HENRY REHAB AND NURSING
For profit - Corporation
81 Beds
STERN CONSULTANTS
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
48/100
#47 of 665 in IL
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Henry Rehab and Nursing has received a Trust Grade of D, indicating below-average performance with some concerning issues. It ranks #47 out of 665 facilities in Illinois, placing it in the top half, and is the best option out of three in Marshall County. Although the facility's trend is improving, having reduced serious issues from 5 in 2024 to 4 in 2025, it still faces significant challenges, including $206,395 in fines, which is higher than 92% of Illinois facilities. Staffing is a weakness, with a rating of 2 out of 5 stars and a turnover rate of 49%, indicating that staff may not stay long enough to build strong relationships with residents. Specific incidents highlighted include a critical failure to protect vulnerable residents from non-consensual sexual behavior and a serious issue with improper discharge procedures that caused emotional distress for a resident. While there are strengths, such as excellent quality measures, families should weigh these concerns carefully when considering this facility.
- Trust Score
- D
- In Illinois
- #47/665
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 49% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $206,395 in fines. Lower than most Illinois facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 41 minutes of Registered Nurse (RN) attention daily — about average for Illinois. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 27 deficiencies on record. Higher than average. Multiple issues found across inspections.
48/100
Top 7%
Review needed
5 → 4 violations
★★★★★
5.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★★
5.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 5 issues
2025: 4 issues
The Good
-
5-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
Staff Turnover: 49%
Near Illinois avg (46%)
Higher turnover may affect care consistency
Federal Fines: $206,395
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: STERN CONSULTANTS
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 27 deficiencies on record
1 life-threatening 1 actual harm
Apr 2025
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to develop comprehensive care plans for three residents (R6, R22, R31) identified as requiring Contact Precautions of five residen...
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Based on observation, interview and record review the facility failed to develop comprehensive care plans for three residents (R6, R22, R31) identified as requiring Contact Precautions of five residents reviewed for Transmission Based Precautions in a total sample of 22.
FINDINGS INCLUDE:
The facility policy, entitled Comprehensive Care Plan Policy, dated 6/25/2020, documents: An individualized comprehensive care plan that include measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Each resident's comprehensive care plan has been designed to: Incorporate identified problem areas; Incorporate risk factors associated with identified problems.
R6's current Physicians Order Summary Report indicates R6 has diagnoses to include ESBL (Extended Spectrum Beta Lactamase Resistance and Urinary Tract Infection (UTI) and indicates R6 has Infection Precautions-Contact for ESBL in urine. (date initiated 5/16/24).
R22's current Physicians Order Summary Report indicates R22 has diagnoses to include ESBL (Extended Spectrum Beta Lactamase Resistance and Urinary Incontinence and indicates R22 requires Contact Isolation (date initiated 2/6/25).
R31's current Physicians Order Summary Report indicates R31 has diagnoses to include ESBL (Extended Spectrum Beta Lactamase Resistance, Malignant Neoplasm of Unspecified Kidney, UTI, Acute Pyelonephritis, Hydronephrosis with Renal and Ureteral Calculus Obstruction and indicates R31 has Infection Precautions-Contact Isolation every shift for ESBL of urine. (date initiated 6/13/24).
On 4/15/25 and 4/16/25, R6 and R22's room (roommates) and R31's room was noted to have a Contact Precaution sign posted on the door to R6/R22 and R31's rooms.
R6's current Care Plan indicates R6 currently has an alteration to Genitourinary system due to UTI related to antibiotic (Gentamycin) - end date 5/27/24. Date Initiated: 05/17/2024 Revision on: 05/20/2024
R6's care plan does not include a Focus/Problem area for Contact Isolation or identify ESBL as the organism requiring transmission based precautions.
R22's current Care Plan indicates R22 is at risk for urinary incontinence but does not include a Focus/Problem area for Contact Isolation or identify ESBL as the organism requiring transmission based precautions.
R31's current Care Plan indicates R31 has an alteration to her Genitourinary system due to ESBL. Care Plan intervention indicates R31 has Enhanced Barrier Precautions (EBP) in place.
On 4/17/25, at 9:30 am, V1/Administrator, confirmed the facility currently does not have an MDS (Minimum Data Set)/Care Plan Coordinator.
On 4/17/25, at 9:35 am, V1 and V3/ADON (Assistant Director of Nursing)/IP (Infection Preventionist) both acknowledged the care plans should have been developed to include problem area of transmission based precautions and appropriate interventions.
On 4/17/25 V3 confirmed R31 remains in Contact Precautions-not EBP and the care plan needs to be corrected.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to obtain smoking agreements and collect smoking paraphernalia for two (R1, R15) of two residents reviewed for smoking in a sampl...
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Based on observation, interview, and record review the facility failed to obtain smoking agreements and collect smoking paraphernalia for two (R1, R15) of two residents reviewed for smoking in a sample of 22.
Findings include:
The facility policy and procedure titled, Smoking, revised October 1, 2024, documents, Policy- To ensure compliance with regulatory guidelines and safety protocols, the Facility prohibits smoking except for in specifically designated areas. To protect the safety of other residents and employees, the use of medical oxygen is prohibited in smoking areas. Residents deemed to need assistance to smoke should have this designation noted in the care plan. For purposes of this policy, electronic cigarettes Ce-cigarettes, pipes, cigars, and similar paraphernalia are to be treated as cigarettes. Procedure- 1. B. Residents are not permitted to have any smoking paraphernalia in their room or on their person. All smoking paraphernalia should be given to the nursing staff for safekeeping. Nursing staff should maintain records of residents' property and distribute it accordingly. Nursing staff are required to confirm the resident's status in the smoking log before distributing smoking materials to the resident. Residents who have been determined to require supervision must be actively supervised by a staff member while in the designated smoking area. E. Residents must sign a Smoking Agreement as part of the admission process. Smoking Agreements should be amended and re-signed when the resident's smoking status has changed.
R1's admission Record documents R1's date of admission to the facility was 2/26/25 and her diagnoses on admission included: Cerebral Infarction, Major depressive Disorder Recurrent, Insomnia, Depression, Anxiety, Hyperlipidemia, Myocardial Infarction Type 2, and Type 2 Diabetes.
R1's Minimum Data Set assessment, dated 3/6/25, documents R1 has a Brief Interview for Mental Status (BIMS) score of 13/15 indicating cognition intact.
R1's Smoking Evaluation Assessment, dated 3/4/25, documents that R1 is a smoker.
R1's current Care Plan documents R1 is a smoker and Cigarettes (or other smoking materials) and lighter are required to be stored at the nurse's station or med cart.
On 4/15/25 at 1:51pm, R1 stated, I (R1) am a smoker. R1 also stated, I keep my smoking materials with me or in the top drawer of my husbands (R15) dresser in his room. R1's cigarette pack and lighter observed in R1's shirt pocket at this time.
R15's admission Record documents R15's date of admission to the facility was 9/5/24 and his diagnoses on admission included: Cerebral Infarction, Metabolic Encephalopathy, Sepsis, Osteomyelitis, and Nicotine Dependence.
R15's Minimum Data Set assessment, dated 3/11/25, documents R15 has a BIMS score of 13/15, indicating cognition intact.
R15's Smoking Evaluation Assessment, dated 9/6/24, documents that R15 is a smoker.
R15's current Care Plan documents R15 is a smoker and Cigarettes (or other smoking materials) and lighter are required to be stored at the nurse's station or med cart.
On 4/15/25 at 10:53am, R15 stated, I am a smoker and I keep my cigarettes and lighter in the top drawer of the nightstand over there under the television set. R15's cigarette pack and lighter noted in top drawer of nightstand at this time.
On 4/16/25 at 10:39am, R1 and R15's cigarettes and lighters observed in R15's nightstand, top drawer. R1 and R15 also stated they do not remember signing a smoking agreement on admission.
On 4/16/25 at 11:00am, V5 (Licensed Practical Nurse/LPN) stated, There is no designated smoking times for residents, they go when they want if there is staff available to take them. Resident smoking supplies are kept at the nurses station. V5 (LPN) verified that smoking supplies were not at nurses' station and stated, They are usually kept here but I didn't work yesterday so I'm not sure where they are.
On 4/17/25 at 10:00am, V5 (LPN) verified that R1 and R15's cigarettes and lighter were in R15's bedside table, top drawer and V5 (LPN) stated, they (cigarettes and lighter) should be kept at the nurse's station.
On 4/17/25 at 10:14am, V1 (Administrator) stated, resident's cigarettes and lighters are to be kept at the nurse's station when they are not smoking.
On 4/17/25 at 11:30am, V1 (Administrator) stated, Resident smoking agreement is a new form added when policy was revised in October of 2024 and has not been updated in our system. So, neither of our smokers (R1 and R15) have signed one.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on interview, observation, and record review the facility failed to attempt gradual dose reduction for one resident (R15) of five residents reviewed for unnecessary medications in a sample of 22...
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Based on interview, observation, and record review the facility failed to attempt gradual dose reduction for one resident (R15) of five residents reviewed for unnecessary medications in a sample of 22.
Findings include:
The facility's Policy and Procedure, titled Psychotropic Gradual Dose Reduction (GDR), revised 11/5/19, documents, Policy statement- It is the policy of this facility that residents who use psychotropic drugs will receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue the use of these medications. Policy Interpretation and Implementation- 1. Residents who use psychotropic drugs will receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the use of such drugs. 4. Our drug reduction program consists of tapering the resident's daily dose to determine if the resident's symptoms can be controlled by a lower dose or to determine if the dose can be eliminated altogether. Inquiries concerning drug reductions should be referred to the pharmacist, attending physician, psychiatrist, and/or to the director of nursing.
The facility policy, entitled Psychotropic Medication Management, dated 12/4/2019, documents: Documentation within the clinical record to support one or more of the following diagnosis: Schizophrenia, Delusional Disorder, Organic mental syndromes (now called delirium, dementia, and amnesia and other cognitive disorders) with associated psychotic and/or agitated behaviors.
1. R15's admission Record documents R15's date of admission to the facility was 9/5/24 and his diagnoses on admission included: Cerebral Infarction, Metabolic Encephalopathy, Sepsis, Osteomyelitis, Other Specified Depressive Episodes, Anxiety Disorder, and Nicotine Dependence.
R15's Minimum Data Set assessment, dated 3/11/25, Section C documents R15 has a BIMS score of 13/15, indicating cognition intact, Section E documents no behaviors exhibited, and Section N documents R15 currently takes Antidepressant Medications.
R15's Physician Orders, dated 9/5/24, documents R15 takes Bupropion HCL ER (XL) Extended Release 24 Hour 300 milligram (mg) tablet (antidepressant) give one tablet by mouth one time a day related to Other Specified Depressive Episodes and Escitalopram Oxalate/Lexapro 20 mg tablet (antidepressant) give 20 mg by mouth one time a day for antidepressant.
R15's current care plan documents R15 receives antidepressant medications for Depression and has an alteration in behavior related to depression.
R15's Psychotropic Medication Monitoring Assessment, dated 9/5/24, documents R15 takes antidepressant medications of Bupropion ER (Extended Release) 300 mg daily and Escitalopram 20 mg daily.
R15's Behavior- Depression/Withdrawn task documents no behaviors from 3/20/25 to 4/17/25.
R15's psychiatry note, dated 2/15/25, documents, Gradual Dose Reduction (GDR) Lexapro/Escitalopram (antidepressant) 20 mg to 15 mg daily for depression. Continue Bupropion HCL ER (Extended Release) 300 mg daily for depression.
R15's psychiatry note, dated 3/12/25, documents, GDR of Lexapro from 20 mg to 15 mg daily for depression recommended last session but patient is still on Lexapro 20 mg by mouth (po) daily.
On 4/15/25, 4/16/25, and 4/17/25 R15 observed on several occasions calmly sitting in his wheelchair in room watching television.
On 4/16/25 at 2:09 pm, V6 (Social Service Director/SSD) stated, The Director of Nursing/DON, Assistant Director of Nursing/ADON, and me (V6) get the psychiatry notes emailed to us. I (V6) document visit in the nurses' notes and nursing takes care of the recommendations for Gradual Dose Reductions/GDR's.
On 4/16/25 at 2:10 pm, V1 (Administrator) stated, The Director of Nursing/DON monitors psychotropic medications and Gradual Dose Reductions/GDR's. The DON sends recommendations from psychiatric services to the facilities Nurse Practitioner to approve or decline, then documents response and changes orders if approved.
On 4/17/25 at 9:54 am, V1 (Administrator) verified that on 2/15/25 psychiatry recommended to decrease R15's Escitalopram (antidepressant) from 20 milligrams(mg) daily to 15 mg daily and recommendation was not sent to Nurse Practitioner to approve or decline.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to provide a Hospice created Care Plan, visit communication notes and to designate in writing a facility Hospice Coordinator for one resident (...
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Based on interview and record review the facility failed to provide a Hospice created Care Plan, visit communication notes and to designate in writing a facility Hospice Coordinator for one resident (R28) of three residents reviewed for Hospice in the sample of 22.
FINDINGS INCLUDE:
Facility Policy Hospice Care, dated 11/5/2019, document: This facility will work in coordination with the contracted Hospice agency to provide a safe continuum of care for the resident's end of life.
Nursing Facility Hospice, General Inpatient And Respite Care Services Agreement, dated 7/13/21, documents: Services to be Provided by Hospice: Hospice will develop, at the time a resident of the Facility is admitted into Hospice's program, a Plan of Care for the management and palliation of the resident's terminal illness. The Plan of Care will identify the care and services that are needed and will specifically identify which provider is responsible for providing respective functions that have been agreed upon and included in the Plan of Care. The Plan of Care will be updated as often as the patient condition requires, but no less frequently than every fifteen (15) calendar days. A copy of each updated Plan of Care will be furnished to the Facility upon each update, but no less frequently than every fifteen (15) days. Hospice will furnish a copy of each Hospice patient's Plan of Care to the Facility at the time of the resident's admission into the Hospice program.
On 4/16/25, at 3:00 pm, V4/Business Office Manger and V9/Registered Nurse were unable to find the Hospice Company Care Plan at the nurses station where they both stated it would be kept. V4 stated That particular Hospice Company does not leave communication notes They haven't left them for a long time.
No Hospice communication notes were found in R28's electronic medical record or in the binders at nurse station designated for the Hospice Company. There was no designation in writing found indicating who was the facility Hospice Coordinator.
Apr 2024
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy of implementing care plan interventions to preven...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy of implementing care plan interventions to prevent the further decline of pressure ulcers, for one of three residents R100 reviewed for pressure ulcers, in a sample of 31.
FINDINGS INCLUDE:
The facility policy, Skin Prevention, Assessment and Treatment, dated (revised) May 2, 2022 directs staff, Purpose: To identify factors that place the residents at risk for the development of pressure ulcers; To implement appropriate interventions to prevent the development of clinically avoidable wounds; To promote a systemic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown; To promote healing of existing pressure ulcers. Residents identified as high risk should be addressed in the resident's care plan to assure appropriate interventions to manage the risk are implemented. Care Plan interventions include: Wound Consultant review; Registered Dietician review; Nutritional supplement; Encourage or turn and reposition on a resident centered time frame (approximately every 2 hours); Use pillows, pads, etc. to aide in positioning, cushion bony prominence's and elevate heels off surface; Encourage activities such as range of motion, ambulation and exercises as tolerated; Practice good transfer techniques to avoid friction and shearing; Keep linens clean and wrinkle free; Keep skin clean and dry; Incontinent care after each incontinent episode; Provide pressure relieving device or cushion on surfaces as indicated; Inspect skin daily for reddened areas or breakdown; Monitor cast, braces, splints and compression bandages for skin irritation; Encourage to maintain adequate nutrition and hydration; Showers at least two times weekly; Nails maintained to promote cleanliness, prevent infection and enhance sense of wellbeing; Arm sleeves, leg protectors; Pad frequently bumped areas. Wounds are treated and based on the etiology of the wound.
R100's March 2024 Physician Order Sheet documents that R100 was admitted to the facility on [DATE] with the following diagnoses: Alzheimer's Disease, Urinary Tract Infection, Malignant Neoplasm of the Rectum and Diarrhea.
R100's Nursing admission Assessment, dated 3/23/24 and signed by V5/Licensed Practical Nurse includes the following Skin Issues, Left ear, Pressure, 1.3 CM (Centimeters) X 0.3 CM, Stage 1; Right Buttock, Pressure, 5.0 CM X 2.0 CM, Stage 1 and Right Buttock, Pressure, 5.0 CM X 2.0 CM, Stage 1. No admission Care Plan to address R100's admission skin conditions and interventions to prevent further deterioration of R100's skin, is present in R100's medical record.
R100's Care Plan, dated 3/25/24 includes no focus area to address R100's newly acquired pressure ulcer, or interventions to prevent further deterioration of R100's skin.
The facility Weekly Wound Tracking Log, dated 3/25/24 documents, (R100) Pressure wound, Right Buttock, Stage 2, 2.5 CM X 1.5 CM X 0.1 CM, Open (area).
On 4/2/2024 at 1:00 P.M., V4/Care Plan Coordinator verified R100's current Care Plan did not address (R100's) pressure ulcer or include interventions to prevent further deterioration of R100's skin.
On 4/2/24 at 2:40 P.M., V5/Licensed Practical Nurse verified no admission care plan to address (R100's) skin condition on admission was developed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined the facility failed to ensure weights were obtained as ordered for 1 of 1 (R10) resident reviewed for Heart Failure in a sample of 31 residents....
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Based on record review and interview, it was determined the facility failed to ensure weights were obtained as ordered for 1 of 1 (R10) resident reviewed for Heart Failure in a sample of 31 residents.
Findings include:
The Minimum Data Set (MDS) section I documents R10 has an active diagnosis of Heart Failure.
The current care plan documents R10 has an alteration to my cardiac system and to monitor vital signs as ordered and PRN (as needed); expect weight fluctuations due to edema and diuretics (medication that helps reduce fluid in the body).
On 3/11/24, the Physician ordered weights to be conducted daily.
Daily weights were not conducted in March 2024, 6 of 20 days.
On 4/2/24 at 2:00 PM, V2 (Director of Nurses) stated R10's weights were not recorded daily and should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to document target behaviors to warrant the use of Seroquel (antipsychotic medication) for one of two residents (R14) reviewed for...
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Based on observation, interview and record review the facility failed to document target behaviors to warrant the use of Seroquel (antipsychotic medication) for one of two residents (R14) reviewed for antipsychotic medications in the sample of 31.
Findings include:
The facility's Psychotropic Medication Management policy, dated 12/4/19, documents Purpose to provide guidance for the psychopharmacologic drug treatment for a resident with specific conditions, including but not limited to dementia and other cognitive disorders, and/or behaviors as documented in the resident's clinical record. An assessment must be conducted to identify specific behaviors/ symptoms, potential causative factors and recommendations for managing identified behaviors. The physician should evaluate use of antipsychotic medication use if one or more of the following is/are the only indication: Wandering, Poor self-care, Restlessness, Impaired Memory, Anxiety, Depression (without psychotic features), Insomnia, Unsociability, Indifference to surroundings, Fidgeting, Nervousness, Uncooperativeness or Agitated behaviors which do not represent danger to the resident or others.
On 4/1/24 at 10:30 AM R14 was sitting in a wheelchair in her room. R14 was pleasantly confused with conversation and unable to answer questions. R14 was not displaying any behaviors.
On 4/1/24 at 12:00 PM R14 was sitting in dining room at a table being assisted by staff with her meal. R14 was not displaying any behaviors.
On 4/3/24 at 9:45 AM R14 was sitting in her wheelchair in the activity room watching a movie. R14 was not observed displaying any behaviors.
R14's current Physician Order Sheet, dated 4/3/24, documents R14 has an order for Quetiapine Fumarate (Seroquel, antipsychotic medication) 25 milligrams by mouth one times daily related to psychotic disorder with delusions due to known physiological condition. This same order sheets also documents an order for Quetiapine Fumarate 50 milligrams by mouth in the evening related to psychotic disorder with delusions due to known physiological condition.
R14's current Care Plan, dated 3/9/23, documents I currently have acute confusion episodes or delirium due to Dementia and psychotic disorder. I currently have an alteration in my
behavior status related to Dementia/Anxiety/Insomnia/Psychotic Disorder with Delusions. (R14) often wants to speak to her mother and believes staff/residents are her sisters/children. Has a history of being agitated/yelling out/grabbing/pushing staff during cares. It can be very difficult to redirect resident when she is agitated.
R14's electronic behavior monitoring, dated 3/4/24-4/1/24, documents R14 is being monitored daily for behaviors of Agitation/ Restlessness/ Anxious, Confusion/disorganized thinking, Cursing, Depression/withdrawn, Delusion.
On 4/03/24 at 9:35 AM, V7 (Certified Nursing Assistant) stated (R14) mostly has been sleepy lately. She is newly on palliative care. When (R14) does display behaviors, they are of being resistive with cares. She is not a harm to other residents at all.
On 4/03/24 at 9:40 AM, V8 (Licensed Practical Nurse) stated (R14) typically is just resistive to care at times. She can be sassy, her symptoms are that of Dementia. (R14) has no behaviors towards other residents.
On 4/03/24 at 11:54 AM, V2 (Director of Nursing) Confirmed R14's behaviors that are being tracked are those of agitation, restlessness, confusion/disorganized thinking, cursing, depression/withdrawn, and delusion. V2 stated R14's delusions are often thinking staff are family/parents and confirmed R14 is not at risk of harming herself or other residents. V2 confirmed R14's behaviors being tracked are not psychotic in nature and relate back to her diagnosis of dementia.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure Personal Protective Equipment was utilized and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure Personal Protective Equipment was utilized and hand hygiene was performed for 3 of 6 residents (R10, R22 and R27) reviewed for Infection Control Practices in a sample of 31.
Findings include:
The Hand Washing policy dated 11/5/19, documented Hands should be washed before resident care, after resident care.
The Enhanced Barrier Precautions policy dated 3/27/24, documented Are used to prevent transmission of infectious organisms spread by direct or indirect contact with the patient or patient's environment. In addition to residents who have an infection or colonization with CDC (Center for Disease Control)-targeted or other epidemiologically important MDRO when contact precautions do not apply. Hand Washing.
R10 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Atrial Fibrillation, history of Urinary Tract Infection (UTI) with Multi-Drug Resistant Organism and Acute Respiratory Failure.
On 2/14/24, R10's Physician ordered Contact CDC Isolation Precautions d/t (due to) ESBL (Extended-Spectrum beta-lactamase/multi-drug resistant organism) Urine.
On 4/2/24 at 12:00 PM, (R10) was observed to have a Contact Precautions and Enhanced Barrier Precautions signage posted on the door.
On 4/2/24 at 12:00 PM, V6 (Certified Nurse Aide/CNA) was observed assisting R10 with meal setup. V6 was observed to not have any personnel protective equipment donned; exited R10's room without conducting hand hygiene; entered R22's room and assisted R22 and R27 with setting up their meals; exited the room without conducting hand hygiene; re-entered R10's room and exited without conducting hand hygiene and then entered the staff lounge.
On 4/2/24 at 12:20 PM, V2 (Director of Nursing) stated V6 should have donned a gown and gloves while providing care for R10 and conducted hand hygiene before and after exiting room [ROOM NUMBER] and 411.
Jan 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based interview and record review, the facility failed to provide daily housekeeping cleaning services for one resident (R1) of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based interview and record review, the facility failed to provide daily housekeeping cleaning services for one resident (R1) of four residents reviewed for housekeeping in a sample of four.
Findings include:
The facility's Resident Rights Policy and Procedure, Undated, documents: Purpose: To ensure the preservation of every resident's right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. IX. Safe environment. Each resident has a right to a safe clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safety. The facility shall provide: A. A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belonging to the extent possible. B. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.
The facility's Effective Plan for Housekeeping Policy, dated 3/23/23, documents: It is the policy of this facility to provide a clean and sanitary environment. 1. The housekeeping staff will keep the building clean, safe and in orderly condition. This includes all rooms, corridors, attics, basements and storage areas.
The facility's Resident Council Minutes, dated 11/14/23, documents: Housekeeping/laundry: All halls say on weekend their hall or rooms don't get cleaned all the time.
The facility's Resident Council Minutes, dated 12/12/23, documents: Housekeeping: Rooms are not cleaned on weekends, certain housekeepers.
The facility's Resident Council Minutes, dated 1/9/24, documents: Housekeeping: Need toilets to be cleaned, some housekeepers don't even bring cleaner in with them. Would like to see rooms and bathrooms cleaned.
R1's Suggestion/Complaint/Grievance Form, Dated 10/20/23, documents: (My/R1's) room hasn't been cleaned by Housekeeping since October 17, 2023. They have been outside my room every day, sometimes twice, to clean the rooms adjacent to mine but not mine.
R1's Suggestion/Complaint/Grievance Form, Dated 10/20/23, also documents in Section 1 that V17 Housekeeping/Laundry Supervisor spoke with V16 Housekeeping and V9 Housekeeping and both staff admitted to not cleaning (R1's) room.
R1's Minimum Data Set (MDS) dated [DATE] documents R1 has a BIMS (Brief Interview of Mental Status) score of 15. (MDS indicates that on a scale of 0 - 15, 13 to 15 cognitively intact; 8 to 12 moderate impairment; and 0 to 7 severe impairment.)
On 1/25/24 at 1:05pm, V9 Housekeeping stated that she remembers that one day she was called away to clean another's resident's bathroom; and that she did not go back to clean R1's room.
On 1/24/25 at 1:35pm, V16 Housekeeping, stated she cleans rooms five days a week at the facility, and stated that on one occasion (cannot recall the date), (R1's) room did not get cleaned. V16 stated, This was an oversight on my part.
On 1/24/25 at 1:38pm, V17 Housekeeping/Laundry Supervisor stated that all rooms at the facility should be cleaned each day. V17 stated, I talked to my staff to make sure they got (R1's) room each day; they (Housekeeping Staff) have a check off list to use after cleaning each room but they do not always use the check off list but are supposed to.
Jul 2023
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to identify potential triggers for one resident (R35) of five residents reviewed for PTSD (Post Traumatic Stress Disorder) in a total sample of...
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Based on interview and record review the facility failed to identify potential triggers for one resident (R35) of five residents reviewed for PTSD (Post Traumatic Stress Disorder) in a total sample of 22.
Findings Include:
The Facility's Trauma-Centered Care Policy dated, 11/12015, documents It is the policy of this facility that we will create and maintain a safe, calm, and secure environment with supportive care, a system-wide understanding of trauma prevalence and impact, recovery and trauma specific service as needed, and recovery-focused services. As approach that appreciated healing is possible, trauma informed care engages people with histories of trauma, recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in their lives. This approach seeks to shift the paradigm from one that asks What's wrong with you? to one that asks, What has happened to you? Every part of a trauma-informed system's organization, management, and service delivery system is assessed and potentially modified to include a basic understanding of how trauma affects the life of an individual seeking service.
The Facility's Trauma-Centered Care policy also documents the facility routinely assist residents to develop a plan that is designed to prevent and manage a crisis. All staff directly involved in the resident's treatment is informed about the resident plan and how they can support it. The facility has a system in place to identify and implement policies, procedures, environmental conditions, activities, social climate, documentation and treatment practices that promote a safe and secure environment in order to reduce the likelihood of re-dramatization or re-victimization.
R35's undated care plan documents I experienced a traumatic event in my past. childhood trauma and physical abuse. R35's care plan does not include any triggers or approaches for R35.
On 7/27/23 at 9:30 AM V2 (RN DON) stated That (Care Plan) should include approaches specific to (R35's) specific triggers which are also not on the care plan and should be.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the Facility failed to provide hygiene care (showers) for four (R6, R18, R30 a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the Facility failed to provide hygiene care (showers) for four (R6, R18, R30 and R36) of 16 Residents reviewed for hygiene in a sample of 22.
Findings include:
Facility Shower Care Policy and Procedure, revised 11/24/20, documents that it is the practice of this Facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues.
Facility Shower Schedule, effective 3/1/2012, documents that all Residents residing in the Facility are scheduled to receive a shower twice a week.
Facility Certified Nursing Assistant Job Description, documents: this position is to assist the nurses in the providing of Resident care primarily in the area of daily living routine; must be physically and mentally capable of performing routine, repetitive job duties; knowledge of State and Federal Regulations; carry out assignments for resident care including bathing and grooming; and be responsible for the well-being and nursing care of all residents assigned to his/her unit while on duty.
Facility Resident Council Minutes, dated 1/10/23, document: showers (100 Hall) still not being done, they are told by staff that they are short of help; feel nurses spend too much time at nurse's desk; showers (400 Hall) said their showers are better they at least get one shower a week.
Facility Resident Council Minutes, dated 5/9/23, document issues with showers on Second Shift, Residents are told they are too short on staff to do them.
Facility Resident Council Minutes, dated 6/13/23, document issues with showers on second shift are not being done on regular basis and that V2 (Director of Nursing) has talked to staff and shower audits are also in place and being tracked.
Facility Resident Council Minutes, dated 7/11/23, document that showers again have not been done in a timely fashion and that Residents feel that more staff is needed.
R30's Minimum Data Set/MDS, Section G, dated 5/21/23, documents that R30 requires staff assistance with bathing.
R30's current Care Plan documents, requires extensive assistance of one to two staff to provide showers (two times a week) and as necessary.
R36's Minimum Data Set/MDS, Section G, dated 7/20/23, documents that R36 requires staff assistance with bathing.
R6's Current Comprehensive Assessment indicates R6 is cognitively intact and able to make all needs known.
R6's current Care Plan indicates R6 requires assistance with ADL's (Activities of Daily Living).
On 7/27/23, at 1:30 pm, R6 stated, I do not always get my showers and that the CNA's will tell me that they do not have enough time to give them because there is not enough staff.
R6's CNA (Certified Nursing Assistant) Task Documentation, dated 7/2023, indicates R6 was admitted on [DATE] and did not receive a shower on 7/25/23.
R18's Current Comprehensive Assessment indicates R18 has moderate cognitive impairments.
R18's current Care Plan indicates R18 requires assistance with ADL's (Activity of Daily Living) including showering/bathing.
R18's CNA (Certified Nursing Assistant) Task Documentation, dated 7/2023, indicates R18 was admitted to the facility 2/23/23, and received one shower on 7/6/23.
On 7/25/23, at 8:19 am, R36, with oily and unkempt hair, stated, I do not remember when my showers are, and I do not remember the last time I got one. I do not think I get them all the time when I am supposed to.
On 7/26/23, at 9:50 am (during Resident Group Meeting), R24 (Resident Council [NAME] President) stated, There was a problem with the nurses not helping to cover the hallways when the CNA's were in giving showers, so the showers were not getting done all the time and there were not enough CNA's to give showers.
On 7/26/23, at 8:15 am, R195 stated, I am the Resident Council President and there are many people, in the meetings, that complain about not getting their showers when they are scheduled. This has been going on for a few months, we keep complaining and nothing is ever done. I am supposed to get my showers on Monday and Thursday evening, but I do not get them. I like my showers right before I go to bed, and I definitely do not get my showers when they are scheduled.
On 7/26/23, at 9:15 am, V4 (Ombudsman) stated, At this Facility, I get concerns over the Residents not receiving their showers and this has been ongoing for a few months. I think the Facility has trouble and issues with second shift staff.
On 7/26/23, at 1:20 pm, V2 (Director of Nursing) stated, I know that we have had issues with showers, but we have less CNA's (Certified Nursing Assistants) on second shift, and we need more help, but it is hard finding second shift CNA's. I am looking specifically just for a shower aide. I do not have any documentation showing that (R30 and R36) got their twice a week showers.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to offer bedtime snacks to six of nine residents (R7, R24, R37, R38, R41, R195) who attended the Resident group meeting in the sample of 22.
Fi...
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Based on interview and record review the facility failed to offer bedtime snacks to six of nine residents (R7, R24, R37, R38, R41, R195) who attended the Resident group meeting in the sample of 22.
Findings include:
Facility Policy/Nutritional Snacks and Supplements, dated 11/5/2019, documents: Nutritional supplements are available, and will be provided for all appropriate residents by the nursing staff; bedtime snacks will be offered daily; and the nursing staff will deliver the supplements/snacks to residents.
The Facility Week at a Glance Dietary Menu, dated Spring/Summer 2023, documents fruit drink, assorted snacks, cookies, and crackers as the Evening Snack.
Facility Resident Council Minutes, dated 1/10/23, documents, snacks are available in kitchenette, behind nurses' station, you need to ask for them if not offered.
Facility Resident Council Minutes, dated 3/14/23, documents, still not receiving their nighttime snacks (they need to ask for snack if they do not receive one) and still no nighttime snacks.
On 7/26/23, at 9:45 am, R7, R24, R37, R38, R41 and R195 (Resident Council President) stated they were never offered snacks at bedtime and were not aware there were snacks available. All six residents stated they would like a snack to be offered and acknowledged it is a long time between dinner and breakfast and a snack would be helpful.
On 7/25/23, at 8:19 am, R36 stated, I do not ever remember getting offered a snack at night.
On 7/26/23, at 8:15 am, R195 stated, I am the Resident Council President and I have heard complaints that other Resident's do not get offered a snack at night. They do not offer me a snack at night either, and I would like them to ask me if I want one.
On 7/26/23, at 9:50 am, V6 (Activity Director) stated they had been short staffed on evening shift and may not have had time to pass out snacks.
On 7/27/23, at 2:05 pm, V7, CNA (Certified Nurse Assistant) stated she was just arriving for work as she works the evening shift. V7 stated, sometimes there are snacks available, but not always V7 stated, sometimes staff have to go to the Memory Care Unit to get snacks if a resident asks for them. V7 also stated the staff do not offer snacks, Residents have to ask for them.
On 7/27/23, at 10:20 am, V3 (Dietary Manager) stated, The Dietary [NAME] is responsible for bringing out the nighttime snacks and delivering them to the nurses station. Then, at night, it is the CNA's responsibility to offer and pass them to the Residents. We always send out nutritional snacks for the Diabetics, but it is the responsibility of the Nursing Staff to deliver them and offer snacks to other Resident's, with food from the pantry by the Nurse's Station.
On 7/27/23, at 10:10 am, V2 (Director of Nursing) stated, Dietary delivers a tub of snacks at the Nurse's Station and the CNA's (Certified Nursing Assistant's) are responsible for delivering the snacks. We do not offer each individual resident a snack, there is a snack schedule, and each Resident has to be on the list to receive a snack, such as Diabetics. If they are not on the list, the Residents can always ask for a snack, but the CNA's do not offer each individual Resident a snack every night. I have been working on the snack delivery over the last months. I have trouble hiring CNAs on second shift and now I have hired a few more, so hopefully everything on second shift will get better. We have less CNAs on second shift, and we need more help, but it is hard finding second shift CNA's.
Jun 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
Transfer Requirements
(Tag F0622)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to serve an appropriate non-emergent involuntary discharge and allow t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to serve an appropriate non-emergent involuntary discharge and allow the resident and resident's family time to appeal the notice, for one of three residents (R1) reviewed for discharge in the sample of four. This failure resulted in R1 being removed from his environment and suffering psychosocial harm that any reasonable person would after being placed over four and half hours away from his family and friends without notice.
Findings include:
The facility's Transfer/ Discharge policy, dated 11/5/19, documents The interdisciplinary team and or physician, in consult with the resident or his/her power of attorney (POA) for healthcare, may recommend transfers or discharges. All resident transfers and discharges from this facility require notification and/or authorization of the resident or his/her POA for healthcare, and his/her primary physician. In cases of emergencies the nurse on duty may initiate transfer to a hospital or medical center as resident's status and condition warrants it.
The National Institute on Aging online article titled Changes in Intimacy and Sexuality in Alzheimer's Disease, dated 5/17/17 and located at www.nia.nih.gov, documents Hypersexuality: Sometimes, people with Alzheimer's disease are overly interested in sex. This is called hypersexuality. The person may masturbate a lot and try to seduce others. These behaviors are symptoms of the disease and don't always mean that the person wants to have sex.
R1's admission record documents R1 was admitted to the facility on [DATE] with a principal diagnosis of Alzheimer's Disease.
R1's recent Minimum Data Set assessment, dated 4/7/23, documents R1 suffers severe cognitive impairment and requires extensive assistance of one person to transfer, walk and move around the facility in a wheelchair.
R1's Care Plan, dated 2/6/23, documents (R1) does both independent and group activities. Staff will observe and not leave (R1) unattended during activities. R1's Care Plan, dated 12/26/22, documents (R1) has expressed sexual desires. R1's Plan of Care, dated 4/21/23 documents (R1) is at risk for wandering/elopement and (R1's) safety will be monitored every shift by all staff. Interventions: One on one monitoring as necessary, initiated 4/21/23. Targeted one on one supervision, initiated 4/28/23. R1's Care Plan, dated 12/26/23, documents I currently have an alteration in my behavior status related to Alzheimer's, impaired memory/thinking, and increased sexual drive and may exhibit behaviors such as increased confusion, making inappropriate comments or physically attempting to touch staff and residents; will masturbate and is unable to comprehend or remember appropriate behaviors due to his diagnoses. (R1) does get agitated at times with staff and other residents.
R1's Progress Note, dated 5/25/23, document at 11:00 AM IDT (Interdisciplinary Team) met to discuss the physical assault (R1) attempted with a CNA (Certified Nursing Assistant, V11) during transfer and recommends the resident be discharged to accepting facility for the safety of other residents.
R1's Progress Note, dated 5/25/23, documents Administrator (V1) met with resident to discuss the events happening this morning with Activity Director (V15) present. Involuntary discharge was explained and issued to the resident. Resident did not have any questions or concerns.
R1's Notice of Involuntary Transfer or Discharge and opportunity for Hearing for Nursing Home Residents, dated 5/25/23, documents R1 is to be an Emergency transfer or Discharge due to the safety of individuals in this facility is endangered.
On 6/7/23 at 2:09 PM, V11 (Certified Nursing Assistant, CNA) stated The day of the incident, I went in to get (R1) up and when I went to stand him, his hand was out and (R1) tried to kiss me but did not make contact. I got him to the dining room, and I let activities know his behavior and I told the nurse (V7, Licensed Practical Nurse).
On 6/7/23 at 11:34 AM, V8 (CNA) stated I was on the hall with (V11) when she came out of (R1's) room and said (R1) tried to kiss me. That sometimes was a behavior for him. I hadn't seen him try to do that in the last month or so and I did work with (R1) a lot. For his last couple days (in the facility) he was basically one on one monitoring.
On 6/7/23 at 11:20 AM, V7 (Licensed Practical Nurse) confirmed being the nurse for R1 on the day he was discharged . V7 stated (R1) was back in his room after breakfast. The CNA (V11) saw (R1) up in his room and asked if she could help him back to his chair. (R1) held his hand out to (V11) and pulled her in and tried to kiss her, no contact was made. (V11) came out and told me while I was doing medications and I told her make sure to chart it and don't go back in the room without a buddy. I got done with medication pass and was called into (V1's) office and was asked why I didn't report him being sexual inappropriate to them immediately. I said (R1) was not inappropriate to another resident. We as staff are on our own if we get hit or abused. We worry about the residents. I had no idea (R1) was being taken out of here (the facility). I came back the next day and (R1) was gone. I didn't consider the situation an emergency. His wife (R4) is also a resident here.
On 6/7/23 at 12:15 AM, V6 (R1's Family Friend) stated I have called and talked to (R1) since he's been discharged . (R1's) first day he was so confused and didn't know how he got there and why he was there. He said they had a room that (R4, R1's spouse) could come to. (R4) doesn't want to move that far away. We (Friends and Family) don't want that either. It's sinful to take someone who has dementia that far away, over four and a half hours. (R1) is originally from the Peoria area.
On 6/7/23 at 1:20 PM, V12 (R1's family member/ Power of Attorney) stated I am an international airline pilot. I see a statement from (the facility) and of course don't always open the bills right away. Enclosed in one of those was the notice of Involuntary Discharge. I had no idea that was coming. The fact that we didn't talk is the problem. I live in Atlanta. It read that the date he was transferred was the date the letter was signed. I was a part of the admission process. They told me they would provide extra care and as things progressed, they would just up the care with (R1). I was under no direction that they were going to not care for (R1). They have people in the facility in much worse condition than (R1) and so I knew if they are caring for them, they can care for an [AGE] year-old man with severe Alzheimer's. The receiving facility (he transferred to) was just as shocked as me, they didn't know why he was there. I want him back in the facility with his wife (R4). (R4) and (R1) were inseparable. They had vacation houses together. (R4) and (R1) were always together. I just got the sense that they (the facility) were not going to be bothered with (R1's) behaviors. You can't handle this (Hypersexual) old man who's frail and can't get up without help? (R1's) not strong and they are trained to handle him. He is not mean. Inappropriate, maybe, but not uncontrollable. I just want (R1) back there in (the facility). They (R4 and R1) are wondering where each other are.
On 6/8/23 at 10:10 AM, V13 (R1's Physician) stated I was aware of the discharge. I did not hear the details (of the incident) but just that (R1) assaulted a staff member. I did not know (R1) was issued with emergency status discharge. I had no idea they were moving that quickly or trying to get (R1) out that same day. I do not know why it was escalated that quickly, given the situation was not emergent. I was not aware it was an emergency discharge.
On 6/8/23 at 12:10 PM, R4 was sitting in her room reading. R4 stated she knows her spouse (R1) has been transferred far away and she knows the situation but of course she'd rather be in the building together. R4 stated We've have been married a long time and it's a sad situation. (R1) would rather be in the same residence as me too.
On 6/8/23 at 1:00 PM, V1 (Administrator) stated Our basis on reasoning for discharging (R1) was because he made the action of a physical altercation. He didn't make contact but made a physical attempt at a CNA (V11). At that point he no longer was just a verbal threat, he took a step-in action to be physical. He is in an all-male hallway in a smaller facility. He was transferred to the facility that would accept him. I think it's like four hours from here. He was taken that day because it was urgent to get him right out of here with those behaviors. He did not require emergency services or hospitalization.
Apr 2023
4 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to supervise a resident (R1) to ensure residents were pro...
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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 supervise a resident (R1) to ensure residents were protected from non-consensual sexual abuse; failed to complete monitoring documentation of a resident with known sexual behaviors and failed to protect vulnerable cognitively impaired residents (R2 and R4) without the mental capacity to consent to sexual activity from sexual abuse for two of eight residents (R2 and R4) reviewed for abuse in the sample of ten. These failures resulted in R1 engaging in non-consensual inappropriate sexual behavior with R2 and R4. On [DATE], R1 was found with R1's hands down the front of R4's pants. On [DATE], R1 was found with R1's hands massaging R2's groin/vaginal area.
These failures resulted in an Immediate Jeopardy.
While the immediacy was removed on [DATE], the facility remains out of compliance at a Severity Level 2 as the facility continues to in-service current staff and newly hired staff on R1's sexual behaviors and interventions; in-service current staff and newly hired staff on the newly implemented electronic behavior tracking records; and monitor the effectiveness of implemented interventions to protect other residents from R1's sexual behaviors.
Findings include:
The facility's Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, dated 2022, states, Purpose: To ensure that all of (name of skilled nursing facility) residents are free from abuse, neglect, misappropriation of their property and exploitation. Policy: The facility's residents have the right to be free from abuse, neglect, misappropriation of their property and exploitation as defined in this policy. Procedure: III. The Facility shall review altercations from resident to resident as a potential situation of abuse. A. Staff shall monitor for any behaviors that may provoke a reaction by residents or others, which include, but are not limited to: c. Sexually aggressive behavior such as saying sexual things, inappropriate touching/grabbing.
The facility's Elder Justice Act and Reporting Suspected Crimes Against Residents Policy and Procedure, dated 2022, states, To facilitate efforts to prevent, detect, treat, intervene in and prosecute elder abuse, neglect and exploitation and to protect elders with diminished capacity while maximizing their autonomy and their right to be free of abuse, neglect and exploitation. I. Definitions: C. Abuse. a. The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. c. Instances of abuse of all residents, irrespective of any mental or physical condition, that cause physical harm, pain or mental anguish. This includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. i. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual mist have intended to inflict injury or harm. ii. Sexual abuse is non-consensual sexual contact of any type with a resident. There may be some situations in which the psychosocial outcome to the resident may be difficult to determine or incongruent with what would be expected. In these situations, it is appropriate to consider how a reasonable person in the resident's circumstances would be impacted by the incident. k. Abuse includes unwanted sexual contact, which includes but is not limited to: 1. Unwanted touching of the breasts or perineal area; 2. A resident who fondles or touches a person's sexual organs and the resident being touched indicates the touching is unwanted through verbal and non-verbal cues; 3. Sexual activities where one resident indicates that the activity is unwanted through verbal and non-verbal cues 4. Sexual activity or fondling where one of the resident's capacity to consent to sexual activity is unknown; 8. Other unwanted actions for the purpose of sexual arousal or sexual gratification resulting in degradation or humiliation of another resident.
R1's Facesheet documents R1 admitted to the facility on [DATE] with a diagnosis to include but limited to: Alzheimer's Disease.
R1's Minimum Data Set/MDS Assessment, dated [DATE], documents: R1 with moderate cognitive impairment; R1 requires supervision of one person physical assist to ambulate throughout the facility; R1 uses a walker to ambulate; and R1 is not steady with ambulation but is able to stabilize without staff assistance.
R1's Order Recap Report for the dates [DATE]-[DATE], documents orders for: Aripiprazole Tablet Five mg/milligram, Give 0.5 (half) tablet by mouth one time a day for sexual drive for seven days with an order start date of [DATE] and a discontinue date of [DATE]; Aripiprazole Tablet Five mg/milligram, Give 0.5 (half) tablet by mouth one time a day for sexual behaviors with an order start date of [DATE] and an order end date of [DATE]; Escitalopram Oxalate Tablet 10 (ten) mg Give one tablet by mouth one time a day for Depression; sexual urges with an order start date of [DATE] and a discontinue date of [DATE]; and Escitalopram Oxalate Tablet 20 MG Give one tablet by mouth one time a day for sexual urges with an order start date of [DATE] and no end date.
R1's Care Plan documents the following: Focused area with an initiation date of [DATE] that R1 has an alteration in R1's behavior status related to Alzheimer's, Impaired memory/thinking and Increased sexual drive; R1 may exhibit behaviors such as: increased confusion, making inappropriate comments or physically attempting to touch staff, hospice staff, residents; R1 may be unable to comprehend or remember appropriate behavior due to R1's diagnoses; R1 gets agitated at times with staff and other residents; a goal that R1 will not engage in inappropriate sexual behavior; Interventions are documented as My (R1's) behaviors will be monitored every shift and documented with an initiation date of [DATE]; Intervene as Necessary to protect safety of others; R1 has expressed sexual desires with an initiation date of [DATE] and documents interventions as Intervene when risk, resident safety, or the safety of others is involved; Lexapro per MAR (Medication Administration Record) to control sexual urges with a revision date of [DATE]; and R1 is on Psychotropic Medications due to R1's sexual urges; R1's medication was increased on [DATE] for an unusual occurrence on [DATE].
R1's Nursing Progress Note, dated [DATE] at 3:00 PM, states, Sitting out here across from desk. Other resident (unknown) out here as well. He (R1) pulled penis out and started masturbating. Resident (R1) was directed to stop and could do this behavior in his room.
R1's Nursing Progress Note on [DATE] at 1:54 PM documents a new order for Abilify 2.5 milligrams by mouth was received for sexual behaviors from V15 (R1's Hospice Physician).
On [DATE] and [DATE], R1's room was located in the middle of the 400 resident hallway. R7's (female) room was at the end of the 400 hallway and R8's (female) room was directly across the hallway from R1's room.
On [DATE] at 1:35 PM and [DATE] at 2:35 PM, R1 was observed in R1's room. R1's room was located at the very end of the 400 resident hallway, immediately before the outside exit door and furthest from the Nurse's Station. R7's (female) room was located directly across the hall from R1's room.
1. R4's Facesheet documents R4 admitted to the facility on [DATE] with a diagnosis of Schizophrenia.
R4's Care Plan documents the following: R4 is at high risk for Wandering/Elopement; safety will be monitored every shift by all staff; history of wandering, refusal of cares, insomnia, disorganized speech or behavior, difficulty with concentration, compulsive, slowness in activity, delusions, hallucinations; impaired safety awareness and will get close to other residents; and alteration to cognition.
R4's Minimum Data Set/MDS Assessment, dated [DATE], contains a Brief Interview of Mental Status which documents R4 with severe cognitive impairment.
On [DATE] at 10:29 AM, R4 was observed wandering aimlessly around the facility's Memory Care Unit. R4 was unable to answer questions due to R4's mental status.
The facility's Serious Injury Incident Report, dated [DATE], documents this report as an initial and final report that on [DATE] at 11:15 AM, R1 and R4 were in a resident to resident altercation. This same report documents R1 as the perpetrator, R4 as the victim and V8/CNA/Certified Nursing Assistant as a witness. This report states, (V8) alerted (V2/Director of Nursing) that (R1) appeared to have his hand in (R4's) sweatpants. (R1) was sitting at his table in the dining room and (R4) was standing in front of (R1). (V8) separated (R1 and R4) immediately and notified (V2).
R1's Nursing Progress Note on [DATE] at 12:31 PM, states, Hospice/POA/Power Of Attorney/MD/Medical Doctor notified of (R1's) sexual drive change. (R1) monitored in room at this time. Confusion noted. New order received for Abilify x (times) one week to control sexual drive.
R1's Nursing Progress Note on [DATE] at 12:26 PM documents R1's room was moved due to inappropriate behaviors.
V8's written statement, dated [DATE], states, I went to do personal cares on an (unknown) resident in their room. I had (R4) sitting in a chair in TV/Television Room. (R1) was in the dining room. When I came out of the (unknown) resident's room, I heard (R4) saying, 'No Daddy, No Daddy.' When I got to the dining room, (R1) was in his chair still. (R4) was standing in front of (R1) and (R1) had his hand down in (R4's) sweatpants. I said, '(R1) stop. Go to your room.' I took (R4) to the TV room and called (V2) immediately.
R1's MDS/Minimum Data Set/Care Plan Note on [DATE] at 11:15 AM, states, Root Cause: (R4 and R1) both have impaired memory, safety awareness, and impaired decision making capability. Intervention: Separated immediately. (R1 and R4) assessed. New order for (R1) to start Abilify times one week trial for sexual drive/behavioral change. (R1) given more privacy and relocated (off of Memory Care Unit). Continue to monitor behaviors and location as able.
On [DATE] at 12:10 PM, V8 stated that on [DATE], V8 walked out of an (unknown) residents room after providing cares and noticed that R1 had R1's hand at least up to the wrist down inside the front of R4's sweatpants. V8 stated it was unknown if R1 was inside R4's incontinence brief/underwear or not. V8 stated, I heard (R4) saying, 'No daddy. No daddy, stop. Daddy stop.' V8 stated that R4 is confused and wanders throughout the memory care unit. V8 stated that since R1 had admitted to the facility, R1 was having increased behaviors of masturbating. V8 stated that while V8 was providing cares in the unknown resident's room, no other staff members were present on the Memory Care Unit providing supervision of the residents, including R1 and R4.
2. R2's Facesheet documents R2 admitted to the facility on [DATE] with diagnoses to include but not limited to: Severe Vascular Dementia; Disorientation; and Wheelchair Dependency.
R2's Minimum Data Set/MDS Assessment, dated [DATE], contains a Brief Interview of Mental Status which documents R2 with severe cognitive impairment.
R2's Care Plan documents R2 is at risk for behavior symptoms related to Dementia; is difficult to redirect at times of behaviors; Attempts to assist other resident's with cares and difficult to educate and redirect due to cognitive impairment.
R1's Nursing Progress Note on [DATE] at 10:15 PM, states, (R1) was inappropriately groping another resident (R2). Both residents (R1 and R2) separated and (R1) brought down the hall to be observed by staff.
R2's Nursing Progress Note on [DATE] at 10:23 PM, states, (R2) unaware of unusual occurrence. Unable to recall or describe. (R2) had sling positioned in chair, ready to be transferred into bed for evening. Brief, long pants intact.
The facility's Serious Injury Incident Report, dated [DATE], documents a final report that the Perpetrator/R1 and the Victim/R2 were in a resident to resident altercation on [DATE] at 10:25 PM. V5 (Certified Nursing Assistant/CNA) and V6 (CNA) are documented witnesses. This report states, (R1) had inappropriate behavior with (R2) by the nurse's station. (R1 and R2) were separated immediately. Final: (V5) notified (V4/Licensed Practical Nurse) that (R1) appeared to have his hand grabbing/groping (R2's) lap. (V5 and V6) separated immediately. Assessment was performed by (V4).
V5's written statement, dated [DATE], states, I (V5) was at the nurse's station charting before dinner was served. I looked over and noticed (R2) sitting still next to (R1). I sat up to see what they were doing and I noticed (R1) had his hand on (R2's) vaginal area over (R2's) pants massaging the area. Once I realized what was happening between them, I stood up and removed (R2) from the area, while my co-worker (V6) started to remove (R1). Once (R2) was out of the area, (V5 and V6) told (R1) that behavior was inappropriate and moved him away from other female residents and had him sit in the hallway to eat dinner. Both (V5 and V6) informed our nurse (V4).
V6's written statement, (undated) but has an electronic stamp [DATE], states, Last night ([DATE]) I was sitting at the desk charting, when the incident happened. I could not see it happen. Another CNA (V5) seen it. We approached (R1) and said, 'We don't do that, keep your hands to yourself, please.' (R1) was laughing in response and said 'ok'. (R1) was taken down the hall to his room. (R1) finished supper and was (assisted) into bed.
V4's written statement (undated) states, The CNA (V5) came and got me and told me that (R1) had his hands in (R2's) lap grabbing her. We brought the resident (R1) down the hall closer to staff to be monitored.
On [DATE] at 10:41 PM per telephone interview due to third shift hours, V4 stated that V5 had reported to V4 that R1 was being inappropriate with R2 and R1 had touched R2 near R2's vaginal area. V4 stated that R1 was known to masturbate publicly throughout the facility.
R1's Nursing Progress Note on [DATE] at 1:44 PM, states, Verbal consent received for increase in dose of Lexapro to treat sexual urges/behavioral issues. Continue to monitor behaviors.
V14's (R1's Nurse Practitioner) Progress Note, dated [DATE], states, (R1) was having sexual behaviors and masturbating in public. (R1) has also had some inappropriate behaviors toward other residents. Two weeks ago, I changed (R1) from Abilify to Lexapro. Then two weeks later (R1) was increased from 10 milligrams/mg to 20 mg daily.
On [DATE] at 3:27 PM, V5 (Certified Nursing Assistant) stated, (On [DATE]) I was sitting at the Nurse's desk. We keep a balloon on (R2's) wheelchair to help keep track of (R2) because (R2) is so mobile. I noticed (R2's) balloon was not moving which was not normal for (R2), so I sat up to see what (R2) was doing. That's when I noticed that (R1) had his hands in (R2's) pubic region and was massaging the area. We immediately separated the residents and I reported it to my nurse right away. I don't like to think about that happening to (R2).
On [DATE] at 11:03 AM, V1 (Administrator) stated that R1 all of a sudden started masturbating in random places throughout the facility not long after R1 admitted to the facility. V1 stated that R1 has inappropriately touched two residents; R1 had put R1's hand down the front of R4's pants and R1 touched R2's lap area.
On [DATE] at 11:12 AM, V2 (Director of Nursing) stated that on [DATE], around 9:00 or 10:00 in the morning, V2 was reviewing progress note charting from the night before ([DATE]). V2 stated that V2 found a note charted by V4, that R1 had inappropriately groped R2. V2 stated that V2 discussed the incident with the staff members who confirmed the incident. V2 stated that R1 had inappropriately touched another resident (R4) one other time when R1 touched R4's private area back in [DATE] when R1 was a resident on the Memory Care Unit. V2 stated that R1 was placed on psychotropic medications to help manage R1's sexual urges.
As of [DATE], R1's medical record did not contain any behavior tracking logs for [DATE] or [DATE].
R1's behavior tracking log for [DATE] states, Problem: (R1) has a diagnosis of Alzheimer's Disease and increased sexual drive and may exhibit behaviors such as: Physical: Attempting to inappropriately touch staff, hospice staff and residents. Has doubled up fists when agitated at staff and residents. Interventions: 1. Remove resident/R1 from area and put in a quiet area, back to his room, draw curtain. 2. Offer tasks to distract resident from current thoughts, give an activity, snack, or go for a walk. This same form is blank on the dates [DATE]-[DATE]. On [DATE], it is documented a behavior occurred one time.
R1's behavior tracking log for February 2023 states, Problem: (R1) has a diagnosis of Alzheimer's Disease and increased sexual drive and may exhibit behaviors such as: Physical: Attempting to inappropriately touch staff, hospice staff and residents. Has doubled up fists when agitated at staff and residents. Interventions: 1. Remove resident/R1 from area and put in a quiet area, back to his room, draw curtain. 2. Offer tasks to distract resident from current thoughts, give an activity, snack, or go for a walk. This same form documents behaviors occurred on the following dates either all or half the shift: [DATE]; [DATE]; [DATE]-[DATE]; [DATE]; [DATE]; and [DATE]-[DATE]. The following dates are documented that interventions were not effective: [DATE]; [DATE]; [DATE]; and [DATE] and [DATE]. The following dates are documented that interventions were effective and then R1 reverted back to the same behavior: [DATE]-[DATE]; [DATE]-[DATE]. No new or updated interventions are documented as being attempted or implemented.
R1's behavior tracking log for [DATE] states, Problem: (R1) has a diagnosis of Alzheimer's Disease and increased sexual drive and may exhibit behaviors such as: Physical: Attempting to inappropriately touch staff, hospice staff and residents. Has doubled up fists when agitated at staff and residents. Interventions: 1. Remove resident/R1 from area and put in a quiet area, back to his room, draw curtain. 2. Offer tasks to distract resident from current thoughts, give an activity, snack, or go for a walk. This same form documents behaviors occurred on the following dates: [DATE]-[DATE] four times and [DATE] three times with interventions documented as not being effective. No new/different interventions are documented as being attempted or implemented.
R1's behavior tracking log for [DATE] states, Problem: (R1) has a diagnosis of Alzheimer's Disease and increased sexual drive and may exhibit behaviors such as: Physical: Attempting to inappropriately touch staff, hospice staff and residents. Has doubled up fists when agitated at staff and residents. Interventions: 1. Remove resident/R1 from area and put in a quiet area, back to his room, draw curtain. 2. Offer tasks to distract resident from current thoughts, give an activity, snack, or go for a walk. This same form does not document monitoring of R1's behaviors on [DATE]-[DATE], as these areas are blank.
R1's Social Service Behavior Summary dated [DATE] at 12:23 PM, states, SSD/Social Service Director (V16) gathered January's behavior charting. (R1 displayed physical behaviors throughout the month randomly, charting was rarely completed. SSD will continue to follow. In-services were completed and charting should be completed better for this month.
R1's Social Service Behavior Summary dated [DATE] at 12:02 PM, states, SSD gathered February's behavior charting. (R1) displayed physical behaviors half the month with interventions working half the time. Verbal behaviors were displayed a couple days with interventions working. SSD will continue to follow.
R1's Social Service Behavior Summary dated [DATE] at 10:44 AM, states, SSD gathered March's behavior charting. (R1) did display physical behaviors with interventions working occasionally, verbal behaviors were displayed the same as well as the interventions. Interventions generally revert back d/t (due to) his Dementia. SSD will follow.
On [DATE] at 3:30 PM, V2 (Director of Nursing) verified no behavior tracking logs for R1 could be provided for [DATE] or [DATE]. V2 verified the first behavior tracking for R1 was initiated on [DATE]. V2 verified no documentation could be provided to indicate increased monitoring or supervision such as 15 minute checks being initiated for R1 after R1's [DATE] or [DATE] incidents.
On [DATE] at 8:51 AM, V2 stated, I would have expected 15 minute checks to have been implemented for (R1) for at least 24 hours after R1's ([DATE] and [DATE]) incidents. It's hard to check on someone every 15 minutes especially when it gets very busy. I feel like being on 15 minute checks too long, the staff gets desensitized to them.
As of [DATE], R1's medical record did not document 15 minute checks or other increased monitoring was ever completed for R1 after R1's [DATE] or [DATE] resident to resident incidents.
The Immediate Jeopardy began on [DATE] when R1, who has known sexually inappropriate behaviors, engaged in non-consensual inappropriate sexual behavior with R2. R1 was found massaging R2's perineal/groin area with R1's hand. On [DATE], R1 was found with R1's hand down the front of R4's pants.
V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 9:53 AM.
The facility submitted the original Abatement Plan for F600 to the State Agency on [DATE] at 5:14 PM. Revisions was requested on [DATE] at 10:03 AM; 2:51 PM; and 5:02 PM. An amended Abatement Plan was submitted and accepted on [DATE]. On [DATE], the immediacy was not able to be removed because the facility failed to monitor and document R1's behavior each shift as stated in the facility's Abatement Plan and on R1's Care plan and failed to provide documentation that 1:1 monitoring for R1 or R2 was completed after R1 and R2's [DATE] resident to resident incident as stated in the facility's Abatement Plan. An amended Abatement Plan was submitted and accepted on [DATE] at 11:18 AM.
On [DATE] the surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the Immediate Jeopardy:
R1 and R2 were immediately separated and assessed following the [DATE] incident. R2 has expired and is unable to be interviewed/observed.
V16/Social Service Director, V1/Administrator and V2/Director of Nursing had 1:1 visit with R1 and then R2 separately to discuss and assess concerns, needs, feelings - determined both R1 and R2 unaware of situation with no recall of occurrence.
On [DATE], V2/Director of Nursing/DON implemented motion alarm at R1's doorway to assist staff in monitoring R1's location. Observations made on [DATE]-[DATE] and 4/20 and [DATE] note motion sensor alarm in place and in functioning working order in R1's room.
On [DATE], R1's Lexapro ordered for sexual urges was increased from 10 milligrams/mg to 20 mg daily by V13/R1's Physician.
All staff educated on appropriate use of R1's motion alarm, completed by V2/DON.
[DATE], Behavior Status Review completed by V3/Assistant Director of Nursing. Medication adjustments continue to be effective,
As of [DATE], Behavior tracking was initiated in the facility's electronic charting system to help differentiate between R1's different targeted behaviors.
On [DATE] and [DATE], R1 was seen by the Psychiatry Company for an initial evaluation and subsequent visit.
On [DATE], Non-pharmacological interventions: offer book to read, turn on music, distraction (games/puzzles), offer assistance to activity room to play bingo added to R1's Care Plan by V2/DON.
All staff educated on Abuse Policy including preventing abuse on [DATE], done by V2/Director of Nursing and V1/Administrator.
All staff notified verbally and/or by mass communication of R1's plan of care on [DATE] by V1 and V2.
[DATE], Audit tool created by V1 to ensure care plans are updated with effective interventions and staff aware of any changes, weekly times four, then monthly times four, then as needed based on QAPI (Quality Assurance and Performance Improvement) Team recommendations.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to immediately report an allegation of sexual abuse to the Administrator/Abuse Coordinator for one (R1 and R2) of five allegations of abuse re...
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Based on interview and record review, the facility failed to immediately report an allegation of sexual abuse to the Administrator/Abuse Coordinator for one (R1 and R2) of five allegations of abuse reviewed.
Findings include:
The facility's Elder Justice Act and Reporting Suspected Crimes Against Residents Policy and Procedure, dated 2022, states, B. The Facility has a duty to report all alleged violations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, as well as the results of all investigations of alleged violations pursuant to 42 CFR 483.12(c). B. Alleged violations under 42 CFR 483.1(c) a. Immediately (for alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) but not later than: i. Two hours if the alleged violation involves abuse or results in serious bodily injury. ii. 24 hours if the alleged violation does not involve abuse and does not result in serious bodily injury. k. Abuse includes unwanted sexual contact, which includes but is not limited to: 1. Unwanted touching of the breasts or perineal area; 2. A resident who fondles or touches a person's sexual organs and the resident being touched indicates the touching is unwanted through verbal and non-verbal cues; 3. Sexual activities where one resident indicates that the activity is unwanted through verbal and non-verbal cues 4. Sexual activity or fondling where one of the resident's capacity to consent to sexual activity is unknown; 8. Other unwanted actions for the purpose of sexual arousal or sexual gratification resulting in degradation or humiliation of another resident.
R1's Nursing Progress Note on 3/7/2023 at 10:15 PM, states, (R1) was inappropriately groping another resident (R2). Both residents (R1 and R2) separated and (R1) brought down the hall to be observed by staff.
The facility's Serious Injury Incident Report, dated 3/8/23, documents a final report that the Perpetrator/R1 and the Victim/R2 were in a resident to resident altercation on 3/7/23 at 10:25 PM. V5 (Certified Nursing Assistant/CNA) and V6 (CNA) are documented witnesses. This report states, (R1) had inappropriate behavior with (R2) by the nurse's station. (R1 and R2) were separated immediately. Final: (V5) notified (V4/Licensed Practical Nurse) that (R1) appeared to have his hand grabbing/groping (R2's) lap. (V5 and V6) separated immediately. Assessment was performed by (V4).
V5's written statement, dated 3/7/23, states, I (V5) was at the nurse's station charting before dinner was served. I looked over and noticed (R2) sitting still next to (R1). I sat up to see what they were doing and I noticed (R1) had his hand on (R2's) vaginal area over her pants massaging the area. Once I realized what was happening between them, I stood up and removed (R2) from the area, while my co-worker (V6) started to remove (R1). Once (R2) was out of the area, (V5 and V6) told (R1) that behavior was inappropriate and moved him away from other female residents and had him sit in the hallway to eat dinner. Both (V5 and V6) informed our nurse (V4).
On 3/28/23 at 10:41 PM per telephone interview due to third shift hours, V4 stated that V5 had reported to V4 that R1 was being inappropriate with R2 and had touched R2 near R2's vaginal area. V4 denied that V4 reported R1 and R2's incident to V1/Administrator/Abuse Coordinator. V4 stated, I charted a progress note and kept an eye on (R1). I did not report it to anyone. They told me the next day that I should have reported the incident immediately.
On 3/29/23 at 3:27 PM, V5 (Certified Nursing Assistant) stated, (On 3/7/23) I was sitting at the Nurse's desk. We keep a balloon on (R2's) wheelchair to help keep track of (R2) because (R2) is so mobile. I noticed (R2's) balloon was not moving which was not normal for (R2), so I sat up to see what (R2) was doing. That's when I noticed that (R1) had his hands in (R2's) pubic region and was massaging the area. We immediately separated the residents and I reported it to my nurse right away. I don't like to think about that happening to (R2). V5 stated, I told my nurse about it and that's it. We were in-serviced that this should have been reported to (V1) immediately.
On 3/28/23 at 11:12 AM, V2 (Director of Nursing) stated that on 3/8/23, around 9:00 or 10:00 in the morning, V2 was reviewing 24 hour charting from the night before (3/7/23). V2 stated that V2 found a note charted by V4, that R1 had inappropriately groped R2. V2 stated that V2 discussed the incident with the staff members who confirmed the incident occurred between R1 and R2. V2 stated that this incident should have immediately been reported to V1 and it was not.
On 3/28/23 at 11:03 AM, V1 (Administrator) stated that staff did not immediately report R1 touching R2 inappropriately on 3/7/23 and should have. We started in-servicing on that right away.
The facility's In-Service Sign-In Sheets, dated 3/9/23 and 3/10/23 documents the audience as All Staff and the topic as: Abuse Reporting; Abuse Prevention; Recognizing Abuse. The attached in-service sheet, dated and initialed by V1 on 3/9/23 states, Any abuse allegations need to be reported to (V1/Administrator/Abuse Coordinator). We only have two hours to report. Example: Inappropriate behaviors sexual or touching needs to be reported. Resident to resident needs to be reported. If you need to separate two residents, call me (V1). We know who has triggers. Move them before the incident happens, get them something to do. Take them to activities. Sit with them for a moment. Ask them to walk with you or go for a ride in wheelchair. These are things that need to happen before an incident occurs. Be proactive verses reactive.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise a resident's plan of care for one of eight residents (R1) re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise a resident's plan of care for one of eight residents (R1) reviewed for care plans in the sample of eight.
Findings include:
The facility's Comprehensive Care Plan policy, revised 6/25/20, states, Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation: 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 3. Each resident's comprehensive care plan has been designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; c. Build on the resident's strengths; d. Reflect treatment goals and objectives in measurable outcomes. 5. Care Plans are revised as changes in the resident's condition dictate.
R1's Facesheet documents R1 admitted to the facility on [DATE] with a diagnosis to include but not limited to: Alzheimer's Disease.
R1's current Order Recap Report documents an order for Escitalopram Oxalate 20 milligram tablet daily for sexual urges with an order start date of 3/11/23 and no end date.
The facility's Serious Injury Incident Report, dated 12/23/22, documents this report as an initial and final report that on 12/23/22 at 11:15 AM, R1 and R4 were in a resident to resident altercation. This same report documents R1 as the perpetrator, R4 as the victim and V8/CNA/Certified Nursing Assistant as a witness. This report states, (V8) alerted (V2/Director of Nursing) that (R1) appeared to have his hand in (R4's) sweatpants. (R1) was sitting at his table in the dining room and (R4) was standing in front of (R1). (V8) separated (R1 and R4) immediately and notified (V2).
The facility's Serious Injury Incident Report, dated 3/8/23, documents a final report that the Perpetrator/R1 and the Victim/R2 were in a resident to resident altercation on 3/7/23 at 10:25 PM. V5 (Certified Nursing Assistant/CNA) and V6 (CNA) are documented witnesses. This report states, (R1) had inappropriate behavior with (R2) by the nurse's station. (R1 and R2) were separated immediately. Final: (V5) notified (V4/Licensed Practical Nurse) that (R1) appeared to have his hand grabbing/groping (R2's) lap. (V5 and V6) separated immediately. Assessment was performed by (V4).
R1's Care Plan documents the following: Focused area with an initiation date of 12/23/22 that R1 has an alteration in R1's behavior status related to Alzheimer's, Impaired memory/thinking and Increased sexual drive; R1 may exhibit behaviors such as: increased confusion, making inappropriate comments or physically attempting to touch staff, hospice staff, residents; R1 may be unable to comprehend or remember appropriate behavior due to R1's diagnoses; R1 gets agitated at times with staff and other residents; a goal that R1 will not engage in inappropriate sexual behavior; Interventions are documented as My (R1's) behaviors will be monitored every shift and documented with an initiation date of 12/23/22; Intervene as Necessary to protect safety of others; R1 has expressed sexual desires with an initiation date of 12/26/22 and documents interventions as Intervene when risk, resident safety, or the safety of others is involved; Lexapro per MAR (Medication Administration Record) to control sexual urges with a revision date of 3/10/23; and R1 is on Psychotropic Medications due to R1's sexual urges; R1's medication was increased on 3/10/23 for an unusual occurrence on 3/7/23.
On 4/14/23 at 2:21 PM, V17 (Activity Director) stated that R1 is an active participant in activities/groups. V17 stated that R1 is invited to attend activities the same as the other residents and that R1 is not on 1:1 activities. V17 stated, (R1) isn't treated differently than any other resident as far activities goes. V17 stated that V17 is aware that R1 has a history of sexually inappropriate behaviors. V17 stated that V17 does not leave R1 alone in activities, V17 puts R1 at group activities with other male residents, and V17 has staff assist R1 to and from activities when needed. V17 stated these extra interventions for R1 should be documented on R1's Care Plan and stated that they are not. V17 stated, I will add them now.
As of 4/14/23 at 12:30 PM, R1's Care Plan did not document interventions to protect other resident's from R1's sexual behavior during Activities.
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
Accident Prevention
(Tag F0689)
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 safely transfer a resident according to their plan of ...
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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 safely transfer a resident according to their plan of care for one of three residents (R6) reviewed for accidents and supervision in the sample of ten.
Findings include:
The facility's Fall Reduction Policy, revised 11/5/19, states, Purpose: To provide an environment that remains as free of accident hazards as possible; To identify residents who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent or minimize fall related injuries.
The facility's Safe Patient Mobility Policy, revised 11/5/19, states, Policy: All lifting, positioning and moving of patients will be done within a defined standard of care for the overall safety of the patient and the health care worker. Purpose: The purpose is to outline a specific standard for lifting, positioning and moving of patients safely and appropriately to prevent injury to healthcare workers and patients. Practice: It is the responsibility of employees to take reasonable care of their own safety, as well as that of their co-workers and patients during patient handling activities. It is preferable that two employees will be present during a transfer to stabilize and support the patient whenever possible to maintain safety. Procedure: b. Patient Lift/ Transfer Procedure: 1. Patient mobility needs are assessed upon admission, prior to performing a lift/transfer/move, every eight hours and on an on-going basis as needed. Types of transferring devices and amount of assistance required will be determined, documented and communicated to all employees taking care of the patient. 2. Prior to using a mechanical lift or transfer device, ensure proper planning for the lift/transfer has been accomplished and request assistance as applicable for any difficult lift/transfer. 3. Have proper equipment or personnel on hand and ensure everyone involved in the task understands his or her role in the transfer, lift, or move.
R6's Facesheet documents R6 admitted to the facility on [DATE] with diagnoses to include but not limited to: Unspecified Abnormalities of Gait and Mobility; Unspecified Lack of Coordination; Cognitive Communication Deficit; Morbid (Severe) Obesity; Muscle Weakness (Generalized); and Repeated Falls.
R6's current Order Summary Report documents orders for Mechanical Lift for Transfers (Brand Name of Total Mechanical Lift) with an order start date of 4/14/23; Monitor Site Hematoma Back of Head/Scalp every shift with an order start date of 4/19/23; Post fall monitoring every shift for three days-if any new injuries post fall place an order for the area of concern and do a progress note with an order start date of 4/19/23; and Eliquis (Anticoagulant) Tablet 2.5 milligram by mouth twice a day for DVT/Deep Vein Thrombosis prevention with an order start date of 10/27/22.
R6's Quarterly Minimum Data Set/MDS Assessment, dated 3/11/23, documents R6 with the following: moderately impaired cognition; requires extensive assistance of two plus persons physical assist for bed mobility, transfers, and toilet use; and when moving from a seated to standing position and moving on and off the toilet, R6 is not steady and only able to stabilize with staff assistance.
R6's Fall Risk Assessment, dated 1/7/23, documents R6 as a moderate fall risk.
R6's current Care Plan documents R6 has had an actual fall due to unaware of safety needs. Falls are documented on 9/24/22, 10/7/22, 10/10/22, 10/14/22, 10/31/22 and 4/18/23. This same Care Plan states, 4/18/23-fall in room; Hematoma to scalp and documents R6 with an alteration to cognition due to memory loss and cognitive communication deficit.
R6's Nursing Progress Note on 12/15/22 at 7:26 PM documents R6 lost consciousness when R6 stood up with two staff member assist.
R6's Nursing Progress Note on 4/18/23 at 2:42 PM documents R6 fell to the floor and sustained a goose egg to the back of R6's head.
R6's Physical Therapy Recertification, Progress Report and Updated Therapy Plan, dated 11/4/22 documents staff provides 100% (percent) assistance for transfers and states, (R6) Difficulty performing transfers d/t (due to) reduced safety awareness, weakness and cognitive status and (R6) unable to perform supported standing d/t LE (lower extremity) weakness, cognitive status and motivation. This same report states, Patient Progress: (R6) Presenting difficulty with improving standing tolerance and functional mobility d/t patient motivation and cognitive status. (R6) frequently is confused and resistive with treatment. Remaining Impairments: Balance Deficits; Decreased Safety Awareness; Strength Impairments; Safety Awareness Deficits; and Postural Alignment/Control.
R6's POC (Point of Care) Response History, dated 4/14/23-4/21/23, states, Task: ADL (Activity of Daily Living)-Transferring (Brand Name of Total Mechanical Lift). The dates 4/14/23-4/15/23 and 4/17/23-4/18/23 documents a sit to stand lift was used with two plus persons physical assist.
The facility's Incident by Incident Type Report, dated 1/21/23-4/21/23, documents on 4/18/23 at 2:30 PM, R6 sustained a staff assisted fall with injury incident.
R6's Incident Report, dated 4/18/23 at 2:30 PM, documents the incident occurred in R6's bedroom. This report states, Nursing Description: (R6) on floor. Lying on his right side Had been transferring with the sit to stand lift. (R6) c/o (complained of) feeling dizzy and then slumped while in lift. (R6's) feet at the base of the lift/his head at the foot of his bed. CNA (Certified Nursing Assistant/V20) said (R6's) head hit the edge of foot board, she (V20) put her hand out to attempt to buffer it. Resident Description: I felt dizzy. Other Info: Was in lift became dizzy and slumped, causing fall. Witnesses: (V20/CNA) 4/18/23 (R6) transferring with sit to stand lift. All of a sudden (R6) slumped down causing to fall. (R6) hit his head on the foot board. I attempted to buffer him hitting his head by putting my hand out onto the foot board.
V20's written statement, dated 4/18/23, states, I had (R6) strapped into the sit to stand sitting on the toilet. I lifted (R6) up in the lift to wipe his bottom. (R6) had been talking and alert. As soon as I started to pull the resident's brief and pants up, he stopped talking and began sliding down in the lift. I tried to get (R6) to the wheelchair but then decided it was safer to lower resident to the floor when I couldn't make it to the chair. I had my hands on his back and under his neck as I lowered him to the ground. (R6) started jerking and hit his head off the ground when I was lowering him.
V18's (Licensed Practical Nurse) written statement, dated 4/19/23, states, (R6) fell on 4/18/23 at 2:30 PM. I responded to the call for a nurse. Upon entering (R6's) room, (R6) was lying on his right side, his head at the foot of his bed, his feet at the base of the sit to stand lift. (R6) was talking and his face flushed. He felt a little sweaty but not cool or clammy. Neuro (Neurological) checks and vital signs and his responses were normal limits. (R6) had a small goose egg on the back of his head. (R6) denied having any pain.
On 4/25/23 at 12:58 PM, V3 (Assistant Director of Nursing) that V3 was recently updating residents' transfer status on the Physician Order Sheets. V3 verified that V3 entered R6 to be a total mechanical lift. V3 stated at one point (R6) was either sit to stand or a total lift but (R6) has gotten weaker. V3 stated after R6's 4/18/23 fall, V19 (Physical Therapist) verified R6 should remain a total mechanical lift for transfers.
On 4/25/23 at 1:25 PM, V20 stated, I picked up a 2:00 PM-10:00 PM shift on 4/18/23. I usually work nights. Right at shift change, (R6) had to go to the bathroom. I got report from the day shift CNA and then she was pulled away to go with another aide. I went in (R6's) room and got him hooked up to the lift. I got (R6) to the toilet and then about five minutes later, (R6) had his call light on to get off the toilet. Everyone was giving shift change report or busy. I couldn't find my partner and (R6) was getting agitated, so I went into (R6's) bathroom by myself. We were having a conversation, I was getting him wiped up and pulling his pants up. (R6) then stopped talking. I pulled the lift out of the doorway to get behind (R6) and I was trying to turn the lift to get to (R6's) chair. (R6) was unresponsive and not talking to me. (R6) was sliding down out of the sling and I was having a hard time getting (R6) to the wheelchair. There was no where to go, so I tried to lower (R6) to the ground. (R6's) arms were above (R6's) head and he was sliding through. I was scared his shoulders were going to dislocate, so I lowered the arms of the lift to the halfway down position and then (R6) slid right through. I was trying to lower (R6) gently but (R6) is a very big guy and the fall wasn't graceful at all. (R6) hit his head on the floor. At this time, V20 stated that V20 would check with the previous CNA, the nurse or the POC (Point of Care) charting to see how a resident transfers. V20 verified that V20 should have had two staff members to transfer R6 and to provide after toilet cares.
On 4/25/23 at 1:38 PM, V19 (Physical Therapist) stated that due to R6's cognition status, safety awareness and weakness, R6 should have two staff members present for all mechanical lift transfers and verified R6 should remain a total mechanical lift for all transfers.
On 4/21/23 at 2:37 PM, V9 (CNA) stated that R6 should have two staff members present during R6's transfers. V9 stated, (R6) was standing for too long, passed out and slid out of the sling. For exactly that reason, is why you should always have two people. (R6) is a big guy and it's too much to do alone.
On 4/21/23 at 2:42 PM, R6 was sitting in a wheelchair in R6's bedroom. R6 stated, They told me what happened. I blacked out. I have a sore spot on my (right) elbow and a bump to the back of my head. At this time, R6 rubbed the left posterior portion of R6's head and stated, It's hurts but it gets better each day.
On 4/21/23 at 2:48 PM, V18 (Licensed Practical Nurse) stated that V18 was R6's nurse on 4/18/23 when R6 fell out of the sit to stand sling. V18 stated, (V20) said (R6) slumped and she couldn't hold him up. (V20) said (R6) hit the back of his head during the fall. There was a goose egg to the back of (R6's) head. He was talking when I entered the room. His face was flushed. I notified (R6's) physician. We didn't' send him out. At this time, V18 stated that two staff members should be present for all of R6's transfers. V18 stated, After (R6's 4/18/23) fall, the DON (V2/Director of Nursing) was in-servicing everyone on using two staff members for lift transfers.
On 4/21/23 at 3:05 PM, V2 (Director of Nursing) stated that for residents who use the sit to stand, they must be able to bare their own weight and stand. Two staff members are used ideally.
Feb 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview the Facility failed to provide person centered incontinence care for one at risk incontinent Resident (R1) of three reviewed for incontinence care; pr...
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Based on observation, record review and interview the Facility failed to provide person centered incontinence care for one at risk incontinent Resident (R1) of three reviewed for incontinence care; provide scheduled meal services for two Residents (R1 and R3) of three reviewed for nutritional support and provide a leg brace/assistive device for one Resident (R1) of three reviewed for assistive devices in a sample of three.
Findings include:
Facility Perineal and Incontinence Care Policy and Procedure, revised 9/11/2020, documents to provide cleanliness and comfort to the Resident and prevent skin irritation.
Facility Certified Nursing Job Description, undated, documents: to provide Resident care in areas of Daily Living Routine with grooming, feeding and restorative nursing procedures; show willingness to provide good nursing care; knowledge of Regulations as related to job duties; carry out assignments for Resident care; wash, clean and dry all incontinent Residents; and responsible for the well being and nursing care of Residents.
Facility Meal Time, undated, documents that Breakfast is served at 7:00 am, Lunch is served at 11:00 am and Supper/Dinner is served at 5:00 pm.
1. R1's current Care Plan documents: R1 has an alteration to R1's Musculoskeletal System due to a Right Hip Fracture after a fall in the Facility; encourage good nutrition and hydration; continues to attempt to walk and continues to bend over at the waist to reach the floor, requires one on one to keep brace in place due to residents cognitive disability; alteration to cognition due to Alzheimer's Dementia, impaired decision making, memory loss and impaired communication ability; sometimes understand verbal communication and not able to
communicate my needs; frequent assistance with toileting and anticipate needs as able; take to bathroom as needed; educate on asking staff for help with toileting; anticipate needs with toileting, hydration & snacks as needed; Enhanced diet, Mechanical Soft texture, supplements and nutritional supplement (Medication Pass three times a day) and nutritional deficiency related to poor intakes; and requires limited assistance of one staff for eating, toilet use Perineal care will be done anytime toileting is performed and as needed and continence status is occasionally incontinent of bowel and bladder.
Facility Monthly Weight Record, dated 3/22/22 through 2/15/23, documents R1's weight loss. R1's weight in September 2022 (176.4 pounds), October 2022 (180.4 pounds) and January 2023 (161.4 pounds).
On 2/15/23, at 9:03 am and 10:10 am, R1 was laying in bed, in R1's room, with a strong odor of urine identified at R1's doorway. The back of R1's gray pants, the lower half of the back of R1's shirt and R1's bedding (sheet) was saturated. R1's incontinence brief was soaked in urine. R1 did not have a brace on.
On 2/15/23, at 9:47 am, V4 (Certified Nursing Assistant/CNA) performed R1's incontinence care and stated, (R1) is soaked, she does this a lot, I will change her. (R1) has not had breakfast yet, we usually let her sleep. We just feed her when she wakes up.
On 2/15/23, at 10:16 am, R1 was in the sitting area at the Nurses Station, with blue pants on, feeding self breakfast (scrambled eggs, sausage, oatmeal, orange juice and milk). R1 was not wearing a brace.
On 2/15/23, at 11:18 am, V8 (Dietary Manager) stated, Our meal times are 7:00 am, 11:00 am and 5:00 pm. I knew nothing about (R1) being able to sleep through breakfast. They should let me know that (R1) is doing that, because we need to get her a new tray or reheat the original tray, the food will not be at the right temperature, after it sits for hours.
On 2/15/23, at 10:00 am, V5 (Assistant Director of Nursing/ADON) stated, They came and told us that you found (R1) laying in urine. Her urine has a very strong smell too.
On 2/15/23, at 10:47 am, V2 (Director of Nursing/DON) stated, (R1) has not worn a brace for a long time, it is difficult for the family to get (R1) to follow-up doctor appointments, so we have never been able to follow up on that. I also know that they let (R1) sleep in the morning and (R1) does get breakfast late and often times it is close to lunch time before (R1) gets a breakfast meal. They also let us know that when you were with them, (V4/Certified Nursing Assistant) said that (R1) was found in urine, (R1) is known to urinate frequently and (R1's) urine is very pungent, so she needs changed often.
On 2/16/23, at 12:18 pm, V2 (DON) stated, I am not even sure where (R1's) brace is at. Almost a year ago, we were unable to get (R1) to the doctor and the doctor would not discontinue the brace unless (R1) was seen in the office and we have never been able to get (R1) back to the doctor.
2. On 2/15/23, at 10:01 am, R3 was being transported via wheelchair by a transport company into the front door of the facility. R3 stated, I am hungry, I am ready for breakfast.
On 2/15/23, at 10:09 am, R3 was drinking hot chocolate and stated, They put my order in for my breakfast, I just got back from a doctor's appointment and I did not get breakfast before I left.
On 2/15/23, at 11:25 am, R3 stated, They brought my breakfast tray down and it was oatmeal, two round sausages, coffee cake, orange juice and milk. I did not get scrambled eggs. Now it is lunch time, and I just finished by breakfast. I do not want lunch now.
On 2/15/23, at 11:18 am, V8 (Dietary Manager) stated, (R3) did not get breakfast before (R3) left for a doctor's appointment this morning. I left the cook a note and the cook forgot, but we did save (R1) a tray. They need to remind us, we are old and we forgot. I know that it does mess up (R3's) lunch tray now, we really do apologize.
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the Facility failed to ensure that fall interventions were resident centered for effectiveness for one Resident (R3) and that interventions were imple...
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Based on observation, interview and record review the Facility failed to ensure that fall interventions were resident centered for effectiveness for one Resident (R3) and that interventions were implemented for one Resident (R1) of three Residents reviewed for falls in a sample of three.
Findings include:
Facility Fall/Accident/Incident Protocol Policy and Procedure, revised 8/1/22, documents: it is the policy of the Facility to provide guidelines for the appropriate handling of a resident's fall, accident of incident and that each situation if unique and must be handled in the manner that is most appropriate at the time and for the nature of the change of condition.
1. The Facility Incident by Incident Type Report, dated 2/15/23, documents that R3 sustained an unwitnessed fall on 1/19/23.
Facility Monthly Tracking Form, dated 1/2023, documents that R3 sustained a fall on 1/19/23 at 11:05 am, in R1's room.
Facility Local Health Department Serious Injury Incident Report, dated 1/19/23, documents that R3 sustained a fall on 1/19/23 at 11:05 am. R3 fell from R3's wheelchair while reaching for an object. R3 sustained a left knee supracondylar acute fracture and was transported to the local hospital for evaluation and treatment.
R3's Radiology Patient Report, dated 1/20/23, documents an x-ray of R3's Left Knee and that R3 sustained a superconductor acute fracture.
R3's current Care Plan documents: R3 requires a safe environment and personal items within reach (date initiated: 01/08/2023); education and reminders to communicate needs with staff and education and reminders to lock the brakes on wheelchair prior to standing (date initiated: 01/08/2023).
On 2/15/23, at 11:25 am, R3 stated, I fell from my wheelchair trying to reach for something in my dresser and I could not reach it. My wheelchair would not lock and as I was standing, the wheelchair kept moving backwards and I lost my balance and feel onto my right knee and broke it. They have not done anything to help me.
2. The Facility Incident by Incident Type Report, dated 2/15/23, documents that R1 had falls on 2/2/23 at 10:16 am, 1/10/23 at 8:30 pm, 11/22/22 at 10:15 pm and 11/16/22 at 11:45 pm.
R1's current Care Plan documents: R1 has an alteration to R1's Musculoskeletal System due to a Right Hip Fracture after a fall in the Facility; alteration to cognition due to Alzheimer's Dementia, impaired decision making, memory loss and impaired communication ability; sometimes understand verbal communication and not able to communicate my needs; wear non skid socks or proper footwear; is limited assist of one staff for transferring and dressing. R1's Care Plan also documents that R1 is a high risk for falls, related to strength, balance, cognitive deficit, safety awareness and a history of falls; frequently round and check on resident to anticipate my needs with toileting; educated and reminded to communicate my needs with staff; educated and reminded to lock the brakes on wheelchair prior to standing.
will be educated and reminded to wear appropriate footwear (non-skid socks)
when ambulating or mobilizing in wheelchair.
On 2/15/23, at 9:01 am, R1 had on regular socks, and did not have on proper footwear or non-skid socks.
On 2/15/23, at 10:16 am, R1 was in the sitting area at the Nurses Station and did not have on proper footwear or non-skid socks.
On 2/15/23, at 10:00 am, V5 (Assistant Director of Nursing/ADON) stated, All of (R1's and R3's) fall interventions are on their Care Plan. (R1) and has had a few falls here in the facility. (R3) had not had a fall for quite a while. (R1) is hard to 'keep down' because of (R1's) Dementia. V5 verified that R1 should have on non-skid footwear and that (R3) should have asked for help before standing up for something (R3) could not reach.
Jan 2023
6 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
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 to respond timely to a call light for one of four resident (R4) reviewed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to respond timely to a call light for one of four resident (R4) reviewed for call lights, in a sample of 14.
FINDINGS INCLUDE:
The facility policy, Resident Call Bells, dated November 5, 2020 directs staff, It is the policy of this facility to ensure residents have a functioning call bell to alert staff of their needs, and that calls are responded to timely. Any staff member that hears or sees a call bell on is responsible to answer within a reasonable timeframe.
The facility 11/08/2022 Resident Council Minutes document, Old Business: Long wait on call lights. Was talked to with nursing. New Business: Call lights need to be addressed, too long of a wait time.
The facility Daily Assignment Sheet, dated 1/10/2023 and verified with V3/Assistant Director of Nurses (ADON) as being accurate, document 2 nurses and 2 certified nursing assistants (CNA) scheduled to work in the facility for the night shift. At that time, V3/ADON stated, The CNA scheduled to work on 200 Hall stays on that hall. She can't leave. It's a Locked Unit and there have been a lot of falls down there, recently.
R4's electronic Progress Notes document that R4 was admitted to the facility on [DATE] at 1:15 P.M. with the following diagnoses: Chronic Diastolic Congestive Heart Failure, Acute Kidney Failure, Chronic Respiratory Failure and Spinal Stenosis.
R4's Nursing Progress Notes, dated 1/10/23 at 3:27 P.M. and signed by V3/Assistant Director of Nurses document that R4 was admitted to the facility for Chronic Weakness and Covid Recovery. This same note also documents that R4 is alert and oriented to person, place, time and situation.
On 1/11/23 at 11:30 A.M., R4 was lying in bed tearful and visually upset. At that time R4 stated, I came from a (local) hospital after a prolonged stay for heart failure. I was admitted yesterday (1/10/23) at 1:00 P.M. and laid in the same position for fourteen hours, before being turned on my side for a few brief moments. My bottom was on fire and I was in a lot of pain. I am unable to turn (myself) due to the bed being too small. Last night (I) turned (my) call light on at 3:00 A.M. because I needed to use the urinal. I take two different diuretics. (My call light) didn't get answered until after 4:30 A.M. This facility is very understaffed. The (unnamed) night shift CNA told me she had three hallways to answer call lights on and provide incontinence care (to facility residents) and turn and reposition residents. I haven't slept since I've been here. I am miserable. I'm so afraid I'm going to fall out of this bed. I'm calling an ambulance and I am leaving this place.
On 1/12/2023 at 5:41 A.M., V7/Certified Nursing Assistant (CNA) stated, I have been running all night (1/11/23).I am every night. I am the only CNA for three halls. The nurses try and help answer the call lights, but they have their own job to do. We don't have enough help. I am afraid someone is going to get seriously hurt. I was working the first night that (R4) was here. I felt terrible. I just wasn't able to get to (R4). We were so busy. I know he was upset.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect a resident from verbal abuse by a staff member, for one of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect a resident from verbal abuse by a staff member, for one of three residents (R9), reviewed for abuse, in a sample of 14.
FINDINGS INCLUDE:
The facility policy, Residents Right To Freedom From Abuse, Neglect and Exploitation Policy and Procedure, dated 2022 directs staff, The Facility's residents have the right to be free from abuse, neglect, misappropriation of their property and exploitation. Associates must not use verbal, mental, sexual or physical abuse against any resident.
R9's current Physician Order Sheet, dated January 2023 documents that R9 was admitted to the facility on [DATE] with the following diagnoses: Displaced Comminuted Fracture of the Shaft of the Humerus, Acute Pain and Heart Failure.
The un-named, un-dated facility form, signed by V1/Administrator documents, Spoke with (R10) regarding midnight CNA (Certified Nursing Assistant). Unaware of her name, only could state she has glasses and short hair. (R10) heard loud voices. (R10) thought (V13/CNA) said something about peeing. (V8/CNA) came to me regarding what (R10) stated (concerning V13/CNA and R9). She said (V13/CNA) is the night CNA who worked last night (1/5/2023). I sent V16/Social Services Director) down to interview (R10).
On 1/12/23 at 9:26 A.M., V8/Certified Nursing Assistant (CNA) stated, It was last Friday (1/6/23) when (R10) told me he heard a night shift CNA yelling and cussing at (R9) because he had spilled the urine all over the bed and she had to change the bed. I asked him if it was (V13/CNA) and (R10) said yes. (R10) said (V13) was short and had dark hair. That describes (V13). I reported this to V1/Administrator right away. It would have been on 1/6/23 around 10:30 in the morning.
On 1/12/23 at 9:30 A.M., R9 was laying in bed, watching television. At that time, R9 stated, (V13/Certified Nursing Assistant) scares me. (V13) doesn't want to help you and (V13) lets you know. If you put your light on and tell (V13) you have to go to the bathroom, (V13) disappears and never comes back. (V13) scares me. I don't want (V13) in here.
On 1/12/23 at 9:37 A.M., R10 was seated in a chair, in his room. At that time, R10 stated, (V13/CNA) came in our room and was upset because (R9) tried to use the urinal and had spilled it all over the bed. I heard (V13) yelling at (R9), loudly and V13/CNA) was cussing at (R9) and saying, 'Why did you p*ss the f***ing bed. Why didn't you use the F***ing urinal' After that (V13/CNA) got (R9) up in his recliner. At that time, R10 verified he told (V8/CNA) about the incident, the next day.
On 1/12/23 at 9:59 A.M., V1/Administrator stated, It was on (1/6/23), around 2:00 PM (afternoon), (V8/Certified Nursing Assistant) came to me and told me that (R10) told her about an incident involving (V13/Certified Nursing Assistant) and (R9) that happened last night. I sent (V16/Social Services Director) down to talk to (R9 and R10). I didn't think it was abuse. I didn't report it to the Regional Office. (V13/CNA) didn't work after that. I had called (V13) phone and left a message for her to not come to work and to call me. (V13) never has called me. Evidently, she has called the facility to talk to other staff and ask them what was going on, but she hasn't called me back. Since (V13)'s within her probationary period, we just feel that (V13) isn't a good fit for our facility and have terminated (V13's) employment.
On 1/12/23 at 10:20 A.M., V16/Social Services Director (SSD) stated, I interviewed (R10). I can't remember which staff told me about the incident with (R9) and the CNA (V13) that happened on 1/5/23. It was the next day (1/6/23) and (V1/Administrator) told me to go talk to (R9 and R10). It was reported that (V13) was overheard by (R10) yelling and cussing at (R9) because he had spilled his urinal and there was urine all over his bed and when (V13) got (R9) out of bed, (V13/CNA) was rough with (R9), putting (R9) in his recliner. (R10) told me he had told (V8/CNA) that he heard (V13/CNA) come into the room, sometime the previous night and yell loudly at (R9) and cuss at (R9) because (R9) had spilled his urinal all over the bed and (V13) had to change the bed. (R10) also stated he felt (V13) was rough with (R9) and threw (R9) in (R9)'s recliner, so (V13/CNA) could change the bed. When I interviewed (R9) all he would tell me is that no one yelled at him. I reported all of this to (V1/Administrator).
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to implement its abuse policy of recognizing an incident of verbal abuse and immediately reporting the allegation of potential verbal abuse to...
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Based on interview and record review, the facility failed to implement its abuse policy of recognizing an incident of verbal abuse and immediately reporting the allegation of potential verbal abuse to the State Agency, for one of three residents (R9) reviewed for abuse, in the sample of 14.
FINDINGS INCLUDE:
The facility policy, Residents Right To Freedom From Abuse, Neglect and Exploitation Policy and Procedure, dated 2022 directs staff, Staff shall monitor for any behaviors that may provoke a reaction by residents or others, which may include: Verbally aggressive behavior such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group or intimidating. When the facility has identified abuse, the facility will take all appropriate actions including: Reporting the alleged violation and investigation within the required timeframe's to the State Agency.
On 1/12/23 at 9:59 A.M., V1/Administrator stated, It was on (1/6/23), around 2:00 ish (afternoon), (V8/Certified Nursing Assistant) came to me and told me that (R10) told her about an incident involving (V13/Certified Nursing Assistant) and (R9) that happened last night. I sent (V16/Social Services Director) down to talk to (R9 and R10). I didn't think it was abuse. I didn't report it to the Regional Office.
On 1/12/23 at 10:20 A.M., V16/Social Services Director (SSD) stated, I interviewed (R10).I can't remember which staff told me about the incident with (R9) and the CNA (V13) that happened on 1/5/23. It was the next day (1/6/23) and (V1/Administrator) told me to go talk to (R9 and R10). It was reported that (V13) was overheard by (R10) yelling and cussing at (R9) because he had spilled his urinal and there was urine all over his bed and when (V13) got (R9) out of bed, (V13/CNA) was rough with (R9), putting (R9) in his recliner. (R10) told me he had told (V8/CNA) that he heard (V13/CNA) come into the room, sometime the previous night and yell loudly at (R9) and cuss at (R9) because (R9) had spilled his urinal all over the bed and (V13) had to change the bed. (R10) also stated he felt (V13) was rough with (R9) and threw (R9) in (R9)'s recliner, so (V13/CNA) could change the bed. When I interviewed (R9) all he would tell me is that no one yelled at him. I reported all of this to (V1/Administrator).
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to failed to ensure an allegation of potential verbal abuse was reported to the State Agency, for one of three residents (R9) reviewed for abu...
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Based on interview and record review, the facility failed to failed to ensure an allegation of potential verbal abuse was reported to the State Agency, for one of three residents (R9) reviewed for abuse, in the sample of 12.
FINDINGS INCLUDE:
The un-named, un-dated facility form, signed by V1/Administrator documents, Spoke with (R10) regarding midnight CNA (Certified Nursing Assistant). Unaware of her name, only could state she has glasses and short hair. (R10) heard loud voices. (R10) thought (V13/CNA) said something about peeing. (V8/CNA) came to me regarding what (R10) stated (concerning V13/CNA and R9). She said (V13/CNA) is the night CNA who worked last night (1/5/2023). I sent V16/Social Services Director) down to interview (R10).
On 1/12/23 at 9:37 A.M., R10 stated, (V13/CNA) came in our room and was upset because (R9) tried to use the urinal and had spilled it all over the bed. I heard (V13) yelling at (R9), loudly and (V13/CNA) was cussing at (R9) and saying, 'Why did you p*ss the f***ing bed. Why didn't you use the F***ing urinal' After that (V13/CNA) got (R9) up in his recliner. At that time, R10 verified he told (V8/CNA) about the incident, the next day.
On 1/12/23 at 9:59 A.M., V1/Administrator stated, It was on (1/6/23), around 2:00 ish (afternoon), (V8/Certified Nursing Assistant) came to me and told me that (R10) told her about an incident involving (V13/Certified Nursing Assistant) and (R9) that happened last night. I sent (V16/Social Services Director) down to talk to (R9 and R10). I didn't think it was abuse. I didn't report it to the Regional Office.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to meet residents's nursing needs. This failure has the potential to affect all 60 residents ...
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Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to meet residents's nursing needs. This failure has the potential to affect all 60 residents currently residing in the facility.
FINDINGS INCLUDE:
The facility Daily Assignment Sheet, dated 01/07/2023 (Saturday) documents from 6:00 A.M. until 11:00 A.M., the facility had 2 Nurses and 3 CNAs (Certified Nursing Assistants) to care for the facility residents.
The facility Detailed Census Report, dated for the same date, 01/07/2023 documents there were 9 residents in the facility requiring Skilled Care and 51 residents requiring Unskilled Care.
The facility Daily Assignment Sheet, dated 01/10/2023 (Tuesday) documents from 10:00 P.M. until 6:00 A.M., the facility had 2 Nurses and 2 CNAs (Certified Nursing Assistants) to care for the facility residents.
The facility Detailed Census Report, dated for the same date, 01/10/2023 documents there were 10 residents in the facility requiring Skilled Care and 50 residents requiring Unskilled Care.
On 1/11/23 at 10:26 A.M., R1 was seated in a wheelchair in her room, watching television. At that time, R1 stated, This past weekend (January 7,8, 2023) there wasn't enough help in the building and it took a long time (to get) assistance. (I was) told by staff there were only 3 CNAs (Certified Nursing Assistants) and they were doing the best that they could.
On 1/11/23 at 10:40 A.M., R2 was resting in bed. At that time, R2 stated, Staffing could be better, the past weekend it took a long time to get help (from staff).
On 1/11/2023 at 10:30 A.M., R4 was in bed tearful and very upset. At that time, R4 stated, Last night (I) turned my call light on at 3:00 A.M. due to needing the urinal, and it didn't get answered until after 4:30 A.M. This facility is very understaffed. (The) night shift CNA (Certified Nursing Assistant) told (me) she had 3 hallways to answer call lights on and provide incontinence care (for residents) and turn and reposition residents. I haven't slept since I've been here. I am miserable. I'm so afraid I'm going to fall out of this bed. I'm calling an ambulance and I am leaving this place.
On 1/12/2023 at 5:16 A.M., V5/Registered Nurse (RN) stated, We only work (with) 1 to 2 nurses on night shift and usually 2 CNAs. One CNA has to stay back in the Unit (200 Hall). They currently have 7 or 8 residents back there and that leaves 1 CNA to answer call lights and perform care on the other 52 residents. That includes the residents who just came from the hospital who are generally very ill. A nurse is supposed to go back there and relieve the CNA on 200 hall so she can go help the other CNA, but, that is next to impossible for us to go back there. We have so much stuff going on out here, we can't take the time to go back there. I have resident assessments, treatments, medications and all the charting to do. We do not have enough staff to get all of this work done. I have talked to V2/Director of Nurses and (V1) Administrator about it so many times, but nothing ever gets done. We still work short and it is so dangerous. Residents have fallen, incontinence care and showers don't get done.
On 1/12/23 at 5:36 A.M., V6/Certified Nursing Assistant (CNA) stated, I have been an employee here for thirty years. I often time work back on the unit. The night before last (1/10/23) I had 3 three women residents up walking all night. Tonight (1/11/23), I had two women residents up wandering all night. I can't leave the unit and go out and help the other CNA. I feel really bad about it. We do not have enough staff to take care of all of these residents.
On 1/12/23 at 5:47 A.M., V7/Certified Nursing Assistant stated, I have been running all night. I am every night. I am the only CNA for three halls. The nurses try and help answer the call lights, but they have their own job to do. We don't have enough help. I am afraid someone is going to get seriously hurt. I was working the first night that (R4) was here. I felt terrible. I just wasn't able to get to him. We were so busy. I know (R4) was upset.
On 1/12/23 at 1:14 P.M., V10/Certified Nursing Assistant stated, I worked on January 7, 2023. It was a horrible day. There were 2 nurses, until (V12/Licensed Practical Nurse) came in at 11:00 and we had 3 CNAs, until another one came in at 11:00. All we could do was try and keep call lights answered. It was impossible to get anything else done. I felt so bad for the residents. I know I text (V1/Administrator) and (V2/Director of Nurses) about our lack of help and I know the nurses called them also. No one from Administration came in to help us. We did the best we could.
On 1/12/23 at 1:29 P.M., V8/Certified Nursing Assistant stated, Yes, I worked on the seventh (01/07/2023). I came in at 6:00 A.M. and left at 2:00 P.M. I worked between 200 hall and 300 hall. I felt awful. There was no way we could take care of these residents. We did the best we could, but it wasn't enough. Management staff knew the situation we were in and not one of them came in to help us.
On 1/17/23 at 10:35 A.M., V2/Director of Nurses stated, I have been the Director of Nurses for the past year, in this facility. I am responsible for scheduling the nurses and CNAs (Certified Nursing Assistants). I do a monthly schedule, post it and then the Charge Nurse fills out the Daily Assignment Sheet and assigns staff to the hallways. I try and staff 3 nurses on day shift and 6 CNAs. On Second shift, I staff 2 Nurses and 5 CNAs and on Third shift, I staff 2 Nurses and 3 CNAs. That Saturday (January 7, 2023), I had worked late on Friday night. I didn't have enough staff for day shift. I only had 2 nurses for day shift and we ended up with only 3 CNAs. I was the nurse on call and called the (V1/Administrator) and all the other nurse managers, and even called Corporate (Staff) to ask them what to do. I had 1 CNA that finally came in at 10:30 that morning. No one else would come in and work. It was horrible. I don't know how the staff got everything done. I feel terrible for the residents. I know they didn't get the care they deserved.
On 1/17/23 at 12:30 P.M., V12/Licensed Practical Nurse stated, I worked the morning of January 7 (1/7/23). I came in at eleven. It was a horrible day. We did the best we could. It was very difficult to get to all the call lights and to help the residents with toileting. There was no way possible to get everything done that day. The other nurses that were here had called Management Staff and told them of the situation. No Management Staff came in to help us.
The facility Daily Census Report, dated 1/10/23 and provided by V3/Assistant Director of Nurses on 1/11/23 and verified as correct, documents there are 60 residents currently residing in the facility.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure staff wear proper PPE (Personal Protective Equi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure staff wear proper PPE (Personal Protective Equipment) in the facility during a COVID-19 outbreak, and post signage at the facility entrance informing visitors that a staff member and /or resident has tested positive for COVID-19 within the facility.This failure has the potential to affect all 60 residents residing in the facility.
Findings Include:
The facility's Covid-19 policy, with no date, documents, This facility follows current guidelines and recommendations for preventing and managing Coronavirus outbreak in the facility. 14. Appendix H-PPE (Personal Protective Equipment). 14.1. General 1.) All references to face mask must be a well-fitting facemask. 2.Residents suspected or confirmed to have COVID may only be treated by staff with N95 mask. 14.2. Procedure. 1. Resident with suspected or confirmed COVID-19: 1.) If a resident is suspected/symptomatic or confirmed to have COVID-19, Health Care Personnel must wear an N95 respirator, eye protection, gown and gloves for that resident. 2.4 Visitor/Employee Screening: Post visual alerts (signs, posters) at facility entrances. These alerts should include instructions about current IPC recommendations, when to use source control. 2.2 Core Principles of COVID-19
Infection Prevention 1.) Facilities should provide guidance (e.g., posted signs at entrances) about recommended actions for visitors with a positive viral test Covid-19.
The CDC's COVID-19 Infection Control Guidance-Personal Protective Equipment, dated 9/23/222, documents, HCP (Health Care Professionals) who enter the room of a patient with suspected or confirmed SARS-CoV2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).
The facility's COVID-19 resident tracking log, dated 1/1/2023, documents, R11 tested on [DATE] with a positive result for COVID-19. The log also documents that R11 COVID-19 will be resolved on 1/15/2023.
R11's Progress Notes, dated 1/5/2023 at 2:26 PM, documents,R11 tested positive for Covid. Now on ISO (isolation).
R11's Progress Notes, dated 1/5/2023 at 1:34 PM, documents, LATE ENTRY, Family at bedside; Educated on precautions and PPE. MD (Medical Doctor) notified. POA (Power of Attorney) son in law notified. R11 reassured of safety and continued to be monitored for signs and symptoms. Precautions in place, increase monitoring.
R11's Test Results Form, dated 1/5/2023, documents, R11 test date: 1/5/2023, Reason for test: Outbreak, Test time: 12:30PM. Type of test: COVID-19. Result of Test: Positive.
On 1/12/2023 at 9:30 AM, R11 stated, I tested positive for Covid-19 about a week ago or so. I have been in isolation since that time. I did not feel too bad. I had a sore throat.
On 1/12/2023 at 9:20 AM, V14/ LPN (Licensed Practical Nurse) stated, There is one resident
in room [ROOM NUMBER] that tested Covid-19 positive. I was in the room with R11 the day R11 was tested. We were not told that we had to wear face shields, or goggles, or N95 masks when we are out of her room. Most of us are just wearing a surgical mask.
On 1/12/2023 at 11 AM, V15/CNA (Certified Nursing Assistant) stated, There is a sign on R11's door that tells you what PPE needs to be used for a resident with a positive Covid-19 test. I don't know why the nurses aren't wearing the right PPE.
On 1/12/2023 at 8:30 AM, V3/ADON (Assistant Director of Nurses) stated, There are no Covid-19 positive cases in the facility at this time. Wearing a surgical mask is appropriate.
On 1/12/2023 at 9:45 AM, V1/Administrator stated, R11 doesn't come out of the room. R11 is Covid-19 positive. R11 is in isolation. Staff know they need to be using the appropriate PPE when taking care of R11. They don't need to wear a N95, face shield or goggles when staff is not taking care of R11.
On 1/17/2023 at 10 AM, V3/ADON stated, All staff are wearing the appropriate PPE. The N95 mask, face shield, goggles until R11 gets out of isolation. Which is on 1/20/2023. We were not wearing the appropriate PPE last week, but everyone is now.
On 1/17/2023 at 1 PM, V1/Administrator stated, All staff need to be wearing N95 masks, goggles, and face shields when working. I am aware that staff was not wearing proper PPE. They were just wearing those paper masks. The signage on the facility entrance door was there at one time. I don't know what happens to these signs. They disappear just like the Christmas decorations do. I have another sign on the door. It tells visitors/staff of the positive Covid-19 cases in the facility.
On 1/17/2023 at 11:30 AM, V2/Director of Nurses, stated, If the facility has a positive case of Covid-19. All staff should be wearing the appropriate PPE such as, N95 mask, goggles, and face shields. If you are in R11's room you need to be wearing a gown, also.
On 1/12/2023 at 8:15 AM, prior to entering the facility, it was observed that the facility did not have any signage posted near the entrance to advice staff/or visitors of any Covid-19 positive cases.
On 1/12/2023 at 8:45 AM, and throughout the survey, it was observed that facility staff were not wearing the appropriate PPE for the Covid-19 positive cases.
Jan 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the Facility failed to update resident Care Plans for fall injuries and falls sustained for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the Facility failed to update resident Care Plans for fall injuries and falls sustained for two residents (R2 and R3) of four reviewed for Care Plans.
Findings include:
The Facility Care Plan Policy, revised 6/25/20, documents: an individualized Comprehensive Care Plan that includes measurable objectives and timetable to meet Resident's medical, nursing, mental and psychological needs is developed for each resident; Facility's Care Planning/Interdisciplinary team in coordination with the Resident, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the Resident may be expected to attain; each Resident's Comprehensive Care Plan has been designed to incorporate identified problem areas; incorporate risk factors associated with identified problems; reflect treatment goals; and preventing and reducing the decline in Resident functional status/level.
1. The Facility Incident Report, dated 10/1/22 through 12/27/22, documents that R2 sustained unwitnessed falls without injury on 12/10/22 at 6:15 am, and 12/14/22 at 11:35 pm.
R2's Nursing Notes, dated 12/10/22 through 12/24/22, document that on 12/15/22, at 12:36 am, R2 sustained a fall and was observed on the floor next to the bed on floor mat.
R2's current Care Plan, documents that R2 admitted to the facility on [DATE]. The Care Plan does not document the 12/10/22 or 12/14/22 fall.
2. The Facility Incident Report, dated 10/1/22 through 12/27/22, documents that R3 sustained an unwitnessed fall with injury on 12/17/22.
R3's Nursing Note, dated 12/17/22 at 10:13 pm, documents that the nurse Was at the medication cart and heard a thud and then a scream and moaning. Upon entering (R3's) room, (R3) was found laying on right side with head at the foot of the bed and feet at head of bed on the floor between bed and wall. (R3) had blood on the floor by head, the floor was wet and a crumbled cookie on it. The Nursing Note documents an abrasion approximately five centimeters (5 cm) in length and two centimeters (2 cm) wide including a one centimeter (1 cm) laceration at bottom of abrasion just at the brow.
R3's current Care Plan, does not document the 12/17/22 fall or R3's right eyebrow laceration.
On 12/28/22, at 9:25 am, V2 (Director of Nursing) verified that R2's and R3's Care Plans were current and stated, I have just recently hired a new Care Plan/Minimum Data Set Nurse and Assistant Director of Nursing, so I am hoping to get the Care Plans caught up and make them current. V2 verified that R2 and R3's Care Plans were not updated to reflect the falls.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to monitor post fall neurological checks for four residents (R1, R2, 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 monitor post fall neurological checks for four residents (R1, R2, R3 and R6) and monitor post fall skin alterations (bruising/hematoma/laceration) for three residents (R1, R3 and R6) of four residents reviewed for falls in a sample of six.
Findings include:
Facility Fall/Accident/Incident Protocol Policy and Procedure, revised 2/25/21, documents that a nursing evaluation on all Resident falls, witnessed or unwitnessed; a complete set of vital signs; neurological checks to be initiated with every unwitnessed fall and witnessed fall with head injury; document progress note; obtain complete vital signs including pulse oximetry at a minimum of every shift for seventy-two hours; and document in the chart a minimum of every shift for seventy-two hours.
1. The Facility Incident Report, dated 10/1/22 through 12/27/22, documents that: R1 sustained an unwitnessed fall with injury on 10/15/22 and an unwitnessed fall without injury on 10/18/22.
R1's Medical Record does not define or differentiate two separate skin alterations, and will be referred to as hematoma/bruising, as the same injury from R1's 10/15/22 unwitnessed fall. R1's Medical Record documents the injury from the 10/15/22 fall as hematoma and bruising.
R1's Nursing Note, dated 10/15/2022 at 1:00 am, documents that, Certified Nursing Assistant/CNA was making rounds when she heard a thump. Upon investigation, resident was noted to be on the floor lateral to the bed, laying on her left side, on the window side of the bed. Resident vital signs within normal limit, hand grasp equal, followed commands, tongue thrust equal, hand grasp equal, pupils round and reactive to light accommodation (PERLA), moves all extremities ([NAME]), denies pain. Hematoma to forehead. (R1)is alert and oriented by one, as per usual and states does not know what happened. No other injuries noted. Ice pack applied to forehead.
R1's Nursing Notes, dated 10/18/2022 at 3:11 am, documents, (R1's) Roommate pressed call light, upon entering room observed resident lying on the floor next to bed lying on (R1's) back, (R1) had pull cord for over bed light, (R1) was pulling off and on. Completed head to toe assessment, noted with bruising and black eyes from previous fall.
R1's Unwitnessed Fall Report, dated 10/18/22, documents that R1 sustained an unwitnessed fall and was found lying on floor next to R1's bed. The Report documents that R1 had bruising and black eyes from the previous fall.
R1's current Care Plan, does not document monitoring of R1's hematoma/bruising from the 10/15/22 fall, or seventy-two hour vital signs and/or neurological checks, for the 10/15/22 and 10/18/22 falls.
R1's Physician Order Sheet/POS, dated 10/15/22 through 11/9/22, does not document monitoring of R1's hematoma/bruising that was sustained on 10/15/22. The POS documents that the monitoring of R1's hematoma/bruising was initiated on 10/18/22, three days after R1 sustained the bruising/hematoma. R1's Physician Order Sheet does not document an order for every shift, seventy-two hour vital signs or neurological checks.
R1's Nursing Notes, dated 10/15/22 through 11/9/22, do not document every shift, seventy-two hour post fall vital signs and/or neurological checks or monitoring of R1's hematoma/bruising.
R1's Vital Sign Summary Report, dated 12/28/22, does not document every shift, seventy-two hour vital signs and/or neurological checks, for the period of 10/15/22 through 11/9/22.
R1's Treatment Administration Record/TAR, dated 10/1/22 through 11/9/22, documents an order dated 10/18/22, to begin every shift, monitoring of R1's hematoma/bruising that was sustained on 10/15/22. The TAR also does not document monitoring of every shift, of the hematoma/bruising.
2. The Facility Incident Report, dated 10/1/22 through 12/27/22, documents that R2 sustained unwitnessed falls without injury on 12/10/22 at 6:15 am, and 12/14/22 at 11:35 pm.
R2's Physician Order Sheet, dated 12/10/22 through 12/24/22, does not document an order for every shift, seventy-two hour vital signs or neurological checks.
R2's Nursing Notes, dated 12/10/22 through 12/24/22, document that on 12/15/22, at 12:36 am, R2 sustained a fall and was observed on the floor next to the bed on floor mat. The Nursing Notes do not document every shift, seventy-two hour vital signs or neurological checks for the 12/10/22 or 12/14/22 fall.
R2's Medication Administration Record and Treatment Administration Record, dated 12/10/22 through 12/24/22, does not document an order for every shift, seventy-two hour vital signs or neurological checks.
R2's current Care Plan, does not document the 12/10/22 or 12/14/22 fall, or monitoring of vital signs or neurological checks.
3. The Facility Incident Report, dated 10/1/22 through 12/27/22, documents that R3 sustained an unwitnessed fall with injury on 12/17/22.
R3's Nursing Note, dated 12/17/22 at 10:13 pm, documents that the nurse Was at the medication cart and heard a thud and then a scream and moaning. Upon entering (R3's) room, (R3) was found laying on right side with head at the foot of the bed and feet at head of bed on the floor between bed and wall. (R3) had blood on the floor by head, the floor was wet and a crumbled cookie on it. The Nursing Note documents an abrasion approximately five centimeters (5 cm) in length and two centimeters (2 cm) wide including a one centimeter (1 cm) laceration at bottom of abrasion just at the brow. The Nursing Note documents that neurological checks were initiated.
R3's Nursing Notes, dated 12/17/22 through 12/28/22, do not document every shift, seventy-two hour vital signs or neurological checks. The Nursing Notes do not document monitoring of R3's laceration.
R3's Physician Order Sheet, dated 12/19/22, documents an order dated 12/19/22 at 4:38 pm, to monitor R3's laceration to the right temple, to be completed daily, on day shift, and with a start date of 12/20/22.
R3's Medication Administration Record, dated 12/17/22 through 12/28/22, does not document every shift, seventy two hour vital signs or neurological checks. The Medication Administration Record does not document monitoring of the right eyebrow laceration.
R3's Treatment Administration Record, dated 12/1/22 through 12/28/22, does not document every shift, seventy two hour vital signs or neurological checks. The Treatment Administration Record, dated 12/17/22 through 12/19/22, does not document monitoring of the right eyebrow laceration.
R3's current Care Plan, does not document the 12/17/22 fall, monitoring of vital signs or neurological checks and/or R3's right eyebrow laceration.
4. R6's Nursing Note, dated 12/7/2022 at 8:00 pm, documents that R6 was observed on floor at bedside and R6's Right Hip appears to have some internal rotation and R6 was sent out to the local Emergency Department. R6's Nursing Note, dated 12/8/22, documents that R6 returned back to the facility on [DATE]. R6's Nursing Notes, Medication Administration Record or Treatment Administration Record, dated 12/8/22, through 12/10/22, do not document every shift, seventy-two hour neurological checks from the time R6 returned on back to the facility on [DATE] through 12/10/22. The Facility could not produce neurological checks for 12/8/22 through 12/10/22.
R6's Nursing Progress Note, dated 12/13/2022 at 12:01 am, documents (on 12/12/22), (R6) was heard yelling for help. (R6) was noted to be laying on the floor. R6 sustained a Skin Tear to the right elbow measuring 1.5 centimeter/cm by 0.5 cm that was on top of an existing bruise. R6's Nursing Notes, dated 12/13/22 through 12/20/22, do not document monitoring of R6's 12/13/22 Skin Tear. R6's Medication Administration Record, dated 12/13/22 through 12/20/22, does not document monitoring of R6's 12/13/22 Skin Tear. R6's Treatment Administration Record, dated 12/13/22 through 12/20/22, does not document monitoring of R6's 12/13/22 Skin Tear.
On 12/28/22, at 9:25 am, V2 (Director of Nursing) stated, It does not look like we have any Neuro (Neurological) checks for them and there are none on the Vital Signs Report or in the nursing notes. I also do not see any monitoring of the R1's hematoma, R3's skin laceration or R6's Skin Tear. It should be on the TAR (Treatment Administration Record) if there are not nursing notes.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s), $206,395 in fines. Review inspection reports carefully.
- • 27 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $206,395 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
- • Grade D (48/100). Below average facility with significant concerns.
Bottom line: Trust Score of 48/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Henry Rehab And Nursing's CMS Rating?
CMS assigns HENRY REHAB AND NURSING an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within Illinois, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Henry Rehab And Nursing Staffed?
CMS rates HENRY REHAB AND NURSING's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 49%, compared to the Illinois average of 46%. RN turnover specifically is 60%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Henry Rehab And Nursing?
State health inspectors documented 27 deficiencies at HENRY REHAB AND NURSING during 2023 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 25 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 Henry Rehab And Nursing?
HENRY REHAB AND NURSING 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 STERN CONSULTANTS, a chain that manages multiple nursing homes. With 81 certified beds and approximately 52 residents (about 64% occupancy), it is a smaller facility located in HENRY, Illinois.
How Does Henry Rehab And Nursing Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, HENRY REHAB AND NURSING's overall rating (5 stars) is above the state average of 2.5, staff turnover (49%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Henry Rehab And Nursing?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Henry Rehab And Nursing Safe?
Based on CMS inspection data, HENRY REHAB AND NURSING has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 5-star overall rating and ranks #1 of 100 nursing homes in Illinois. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Henry Rehab And Nursing Stick Around?
HENRY REHAB AND NURSING has a staff turnover rate of 49%, which is about average for Illinois nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Henry Rehab And Nursing Ever Fined?
HENRY REHAB AND NURSING has been fined $206,395 across 2 penalty actions. This is 5.9x the Illinois average of $35,143. 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 Henry Rehab And Nursing on Any Federal Watch List?
HENRY REHAB AND NURSING 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.