CLARIDGE HEALTHCARE CENTER
For profit - Corporation
231 Beds
Independent
Data: November 2025
3 Immediate Jeopardy citations
Trust Grade
0/100
#493 of 665 in IL
Photo by Claridge Healthcare
Photo by Claridge Healthcare
Photo by Claridge Healthcare
1 / 5 photos
Last Inspection: June 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Claridge Healthcare Center has received an F grade, indicating poor quality and significant concerns about resident care. Ranking #493 out of 665 facilities in Illinois places it in the bottom half, and #20 out of 24 in Lake County suggests only a few local options are better. While the facility is showing improvement, reducing issues from 25 in 2024 to 5 in 2025, it still has serious concerns, including critical incidents where residents received incorrect diets, resulting in hospitalization and choking risks. Staffing is a relative strength, with a good turnover rate of 6%, and RN coverage exceeds 94% of state facilities, which is beneficial for monitoring resident health. However, the facility also has high fines totaling $237,307, indicating some compliance problems that families should consider when making their decision.
- Trust Score
- F
- In Illinois
- #493/665
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ✓ Good
- 6% annual turnover. Excellent stability, 42 points below Illinois's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- $237,307 in fines. Lower than most Illinois facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 55 minutes of Registered Nurse (RN) attention daily — more than average for Illinois. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 65 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 26%
Review needed
25 → 5 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 25 issues
2025: 5 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Low Staff Turnover (6%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (6%)
42 points below Illinois average of 48%
Facility shows strength in quality measures, staff retention, fire safety.
The Bad
1-Star Overall Rating
Below Illinois average (2.5)
Significant quality concerns identified by CMS
Federal Fines: $237,307
Well above median ($33,413)
Significant penalties indicating serious issues
The Ugly 65 deficiencies on record
3 life-threatening 2 actual harm
Sept 2025
1 deficiency
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
Accident Prevention
(Tag F0689)
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 implement interventions for a resident at risk for elo...
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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 implement interventions for a resident at risk for elopement to elope from the facility. These failures resulted in R1 eloping from the facility and being found walking in the road of a heavily traveled highway. This applies to one of three residents (R1) reviewed for safety in the sample of three. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 9/7/25 when staff were unable to locate R1 inside the facility. V2 (Director of Nurses) was notified of the Immediate Jeopardy on 9/12/25 at 9:50 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 9/12/25, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-servicing training. Findings IncludeThe facility's initial incident report sent to the IDPH (Illinois Department of Public Health) showed R1 was observed through a window in the facility parking lot on 9/7/25 at approximately 8:00 AM. Staff went outside to look for the resident and were unable to locate the resident. The report showed staff called the local police department at 8:16 AM. The report showed R1 was found by local police and returned to the facility at 9:55 AM. R1's face sheet printed on 9/11/25 showed diagnoses including but not limited to psychosis, malnutrition, physiological condition, insomnia, and need for personal care. The same face sheet showed R1 has resided on the second floor of the dementia unit since admission in May of 2024. R1's facility assessment dated [DATE] showed severe cognitive impairment and the ability to walk independently with staff supervision. R1's elopement risk assessment dated [DATE] showed R1 was not physically able to leave the building and was not confused or disoriented (conflicts with the facility assessment). On 9/11/25 at 9:45 AM, R1 was seated in an upright chair in the hallway, directly outside of his room. R1 was pleasantly confused and could not provide any details regarding his elopement. R1 answered yes or no to all questions in a nonsense manner. On 9/11/25 at 9:50 AM, V3 (Licensed Practical Nurse) stated R1 recently went onto the elevator alone and went outside. V3 stated he was trying to look for his mother. The elevator has a key card needed to open the doors but sometimes it doesn't work if the battery is low. V3 said sometimes the doors don't close right away and residents can slip out onto the elevator. V3 said we try to always have someone right by the doors to watch for that. I guess no one was watching the day R1 got out. On 9/11/25 at 10:00 AM, V1 (DON-Director of Nurses) stated she was at the facility the morning R1eloped. R1 said the second-floor nurse (V4) called her and said R1 was observed by V5 (CNA-Certified Nurse Aide) alone outside. V1 said she ran outside but did not see any sign of R1. V1 said she drove her car around the neighborhood then called 911 about 15 minutes later. V1 said R1 can walk without assistance, does not understand English, and is very confused. V1 said she spoke with a local police officer at a nearby gas station. She was told they were in the process of searching the neighborhood for R1 too, so she returned to the facility. V1 said she began looking inside parked cars and came upon a visitor sitting in his car. V1 said the visitor told her he saw a resident come outside and walk behind the building, toward a wooded area. V1 said she searched there and still could not locate R1. V1 said multiple police officers and dogs arrived and continued to search the area. V1 said she received a phone call approximately one hour and forty minutes later that R1 had been found. V1 said the second-floor dementia unit is a locked unit and everyone needs a key card to activate the security pad for the elevator. The security pad was not working last Sunday (9/7) and that is the only way R1 could have got outside. It has been broken a couple of weeks now. V1 said currently, she sits at the nurse's station and watches the elevator when staff aren't there. V1 said she should have been watching the elevator when R1 got out, but she was up and down on other floors that morning. The visitor that observed R1 wandering in the parking lot was attempted to be interviewed but could not be reached during this survey. On 9/11/24 at 10:52 AM, V4 (RN-Registered Nurse) stated she was notified that R1 was outside of the building alone by V5 (CNA) during the breakfast meal on 9/7/25. V4 stated she ran to a window and saw R1 wandering in the parking lot. V4 said she immediately called the DON and reported the elopement. V4 said no one was watching the second-floor elevator or the first-floor front desk. V4 stated the elevator usually needs a key card to open the doors but it hasn't been working for a few weeks. V4 said there is usually a receptionist at the front door, but no one was working that day. V4 said we are supposed to have someone watching the doors to keep residents from getting out. V4 said R1 must have just pushed the elevator, got on, and walked out the front door all by himself. R1 is not fully alert or oriented. He does not speak English and only understands yes or no questions. On 9/11/25 at 11:08 AM, V5 (CNA) said she was feeding a resident breakfast on Sunday in a second-floor room when she looked out the window and observed R1 outside. V5 said she immediately notified V4 (RN). V5 said R1 appeared confused and was wandering around the parking lot. V5 said the key card for the second-floor elevator hasn't been working for a while. On 9/11/25 at 11:25 AM, V2 (Assistant Director of Nurses) stated she was just arriving to the facility on Sunday when the police were leaving. V2 said she was told R1 had got out and the police eventually located him near the intersection of a large, local hospital. V2 said she did the incident investigation and interviewed R1with a translator. R1 said he was trying to find his mother. V2 said R1 is on a lot of psychiatric medications and has a pretty low cognitive status. V2 said her investigation results showed R1 opened the elevator and got on it alone. V2 said she was sure he was able to get on it alone. V2 verified the key card was not working and hadn't worked for almost a month. V2 said a front desk person doesn't start until 9 AM each day and the front door is unlocked around 6 or 7 AM daily. On 9/11/25 at 11:45 AM, V6 (Elevator Security Vendor) stated he has worked on the facility's second floor card access system for years. V6 said he was at the facility a few weeks ago and told staff the system has failed. It is a 30 plus year old system and it can't be patched back together anymore. V6 said the electronic key card system control board can't be repaired anymore. V6 said he repeatedly sent a quote for a new system and never heard anything back until this past Sunday (9/7, day of the elopement). That was when his emails were finally acknowledged, and they agreed to go ahead to fix the system. V6 said right now the second-floor elevator is a fail safe set up which means it will still open when the key card is not working. That prevents anyone from getting trapped in case of an emergency. V6 said right now, anyone can get on or off that elevator. There is no security system in place. V6 said we are still waiting on the parts to be shipped in. The facility provided a quotation invoice dated 8/18/25 from V6's security company. The quote stated, Replace card access system that controls the elevator buttons on the 2nd floor and the stairwell door on that floor. System has to be designed as fail safe. Needs to be interfaced with the existing fire alarm system for emergency release. The quote was blank under the client signature date section. The facility provided a receipt dated 9/9/25 (two days after R1 eloped) showing a downpayment for the 2nd floor elevator was processed by V6's security company. On 9/11/25 at 1:00 PM, V7 (Maintenance Staff) stated the second-floor security pad hasn't been working for a couple of weeks now. V7 said an outside company does all the repairs on that. The outside company has been notified, and the part is on order. It won't be here for several more days. On 9/12/25 at 10:57 AM, V9 (local police officer) stated he got a call on 9/7/25 related to a missing elderly person from the subject facility. It was reported the resident had dementia. V9 said he responded to the call along with several colleagues. The DON (V1) said she called us about 10 to 15 minutes after realizing the resident was missing. V9 said they checked the immediate area with trained dogs. V9 said he went inside and asked V1 how did this happen. V1 answered the missing resident resides on the second floor and the security pad system was broke. She was in the process of trying to get it fixed. V9 said R1 was only found after a random passerby saw him walking in the road. She thought he looked confused or lost so she called the local police department and reported it. That police department responded to the area and sent out notice of a missing person too. V9 said that is when we realized that sounded like our guy. V9 said he took R1 back to the subject facility and V1 confirmed his identity. V9 stated there was no one manning the front desk and he could not find any staff when he initially arrived. V9 stated he rode the elevator up to the second floor with V1. At no time did V1 need a key card to operate the elevator up or back down. V9 stated fellow co-workers mentioned later to him that they have responded to calls in the past at the same facility. Co-workers said they have never needed anything special to go on or off the dementia unit floor. V9 said there are railroad tracks right behind the facility that run all the way parallel to the busy highway, where R1 was found. V9 said they were so worried R1 may be hit by a train that they called the railroad line and confirmed none were scheduled for that day. V9 said the area where R1 eventually was found was by the same tracks. V9 said R1 was found in the road walking the wrong way in traffic. The road is a heavily traveled four lane highway. V9 stated it is the facility's job to keep these people safe and if someone gets out like that, they are not doing their job. The local police department's report dated 9/7/25 and authored by V9 stated R1 was located at 9:35 AM and the exact address of the intersection was provided in the report. The report showed R1 was walking southbound IN the northbound lanes. A google map search from the facility to the intersection showed it was an approximately two-mile walk. On 9/11/25 and 9/12/25, this surveyor was able to freely exit the second-floor dementia unit during the entire survey without using any key card security device. R1's care plan showed a focus area for risk for wandering/elopement due to an elopement event on 9/7/25. The initiation date and interventions were dated 9/8/25. The facility's undated Missing Person/Elopement Policy states: Safety of all residents is the primary care standard at (subject facility). Impaired judgement, perception, and thought processes of cognitively impaired persons make the residents at a higher risk for elopement into unsupervised or unsafe areas. Precautions, procedures, staff, and visitor education have been put in place to maximize resident safety. The Immediate Jeopardy that began on 9/7/25 was removed on 9/12/25 when the facility took the following actions: 1. The facility policy on Elopement Risk: The Policy and Procedure for Elopement Risk residents will be used to identify the potential for residents to exit unsupervised from the facility. The Elopement Risk Assessment will be completed by Social Service Department upon admission, quarterly and with change of condition. This policy has been revised on September 12, 2025. 2. R1. Social Service Unauthorized Departure / Elopement Risk Assessment has been done on 9/8/2025. R1 had a room change to room [ROOM NUMBER] (closer to nursing station) to close monitor. On 9/7/2025, R1 was placed on hourly safety checks. 3. All residents at risk will be reviewed and a revision of the Elopement Book and care plan update will be completed by the Social Service Department. Residents with Elopement Risk will be monitored on an individualized basis dependent on their risk assessment. Social Service will do continued education for all staff on elopement risk residents and any changes to the care plan will be done at the time the elopement risk book is updated with any changes in residents' appearance and condition. This will be completed by September 16, 2025.4. Starting today nonscheduled floor staff have been assigned to stay at the 2nd floor desk to monitor the elevator and to prevent residents from entering the elevator. The nonscheduled staff will be required to fill in a sign-in sheet to ensure the area is covered 24 hours a day. This process will continue until the repair of the elevator safety system has been completed. The elevator repair time is estimated for the week of September 15, 2025. 5. On September 12, 2025, in-services began on the Elopement Risk policy and procedures and elopement risk book to educate all staff including nursing (Nurses and CNAs), Administration, Front Desk, Dietary, Activities, Housekeeping, Maintenance and Laundry. The above staff will continue to be in-serviced on following the Elopement Risk policy and procedures, the Elopement Risk book, and the plan for nonscheduled staff monitoring the elevator. This will be completed prior to the start of their shift, via group in-service or one on one in-service, by nursing administration. All in-servicing will be completed by September 16, 2025.6. Effective today random audits of the sign-in logs will be completed every shift by the DON or her designee. This process will continue until the elevator security system is fixed. The Medical Director has been informed and will be involved in the Quality Assurance. Progress will be reviewed and discussed at the quality assurance meeting to ensure corrections are achieved and permanent.
Sept 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure a resident was free from resident-to-resident physical abuse for 1 of 7 residents (R4) reviewed for abuse in the sample of 7. Finding...
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Based on interview and record review the facility failed to ensure a resident was free from resident-to-resident physical abuse for 1 of 7 residents (R4) reviewed for abuse in the sample of 7. Findings Include:On 9/2/25 at 12:50 PM, V3 (Assistant Director of Nursing) said there was an altercation that had just occurred between two residents {R4 and R5} and one of the residents was punched in the face and was just sent to the hospital because he had a small laceration on the side of his eye.R4's face sheet shows he has diagnoses including Alzheimer's disease, muscle weakness and abnormality of gait and mobility. R4's active care plan last revised on 7/8/25 shows he is alert but confused and forgetful, uses a wheelchair for mobility and his primary language is Spanish. The same care plan also shows that R4 is at risk for abuse due to wandering behaviors and having a cognitive impairment, dementia, with a language barrier. Interventions listed in R4's care plan is for redirecting his behaviors and engaging him in activities.R5's facesheet shows he has a diagnosis of dementia. R5's care plan initiated 7/21/25 shows he is ambulatory and alert but forgetful at times.A Nurses Progress note completed on 9/2/25 at 3:55 PM, by V12 (Registered Nurse) states, resident had physical contact with another resident, separated right away, noted bleeding to his face, completed entire physical exam, 1 cm laceration noted on left temple. sent resident to {local hospital} via ambulance at 12:45 PM.A Social Services note completed by V9 (Social Worker) on 9/2/25 at 5:07 PM states, Around 12:10 pm, this writer responded to a call for help from {R5's} room made by CNA (Certified Nursing Assistant) (V13). Upon arrival, this writer observed that the resident {R4} was being physical attacked by another resident {R5} on the floor. CNA and maintenance staff were attempting to separate the residents, this writer also intervened, but the aggressor continued hitting until staff successfully separated them and moved each resident to different rooms.On 9/2/25 at 1:17 PM, V12 said around 12:10 PM she heard screaming and ran towards the sound and found R4 and R5 in a physical altercation and R4 was being hit by R5. V12 said R4 has wandering behaviors and propels himself into other resident rooms all the time. V12 said both residents have dementia, and R4 also has a language barrier so he does not always understand what people are saying to him.On 9/2/25 at 1:22 PM, V13 said she heard yelling and when she got to the room, she found R4 and R5 in an altercation and grabbing at each other and she yelled for help. V13 said she attempted to separate the residents and did not physically see R5 hit R4 but R4 had blood on the side of his face after. V13 said R4 does wander around the unit in his wheelchair and needs redirecting. On 9/2/25 at 1:25 PM, V14 (Lake County Sheriff Officer) was interviewing R5 and came out of the room and said from what he gathered happened was that R4 had went into R5's room and was going through drawers. R5 wanted R4 out of his room and was yelling for him to get out of here, R4 did not leave and R5 ended up hitting R4. V14 said R4 then grabbed R5's shirt and it continued to escalate.On 9/2/25 at 1:27 PM, R5 said he hit R4 because he would not leave his room. R5 said he comes into the room all the time and this time he was not leaving so I hit him yes, and I meant to.On 9/2/25 at 1:30 PM, R7 (R5's roommate) said he did not see the altercation happen because he was at lunch, but he heard the yelling. R7 said the other guy (R4) comes into our room all the time and eats jelly off my nightstand, usually he leaves on his own. An incident/occurrence report form dated 9/2/25 shows that R4 returned to the facility on 9/2/25 at 4:00 PM, he was stable and had steri strips to his left temple, the local hospital had completed a CT/computed tomography scan of the spine and head which were negative for any bleed or fractures, R4 did not require sutures to the laceration. Hospital documents show R4 was diagnosed with a facial contusion. On 9/3/25 at 8:45 AM, R4 was sitting in the dining area at a table, his left eye was dark purple and very bruised around the eye socket. The sclera of his eye was red in color, and he had several steri strips to the outer temporal area of the left eye. R4 said, I am okay. When this surveyor attempted to talk to him. He also said no when asked if his eye was hurting him. On 9/3/25 at 8:47 AM, V20 (CNA) said she was here the day prior when the altercation happened. V20 said staff were in the dining room feeding residents and V5 came into the room saying someone needs to get him out of my room. V20 said she told another CNA to go see what was going on and the next thing she knows it had escalated, and they were fighting. V20 said R4 goes in and out of the other resident rooms frequently but will usually come right out because he is confused about which room is his.On 9/3/25 at 11:07 AM, V1 (Administrator) said when a resident hits another resident it is abuse.The facility provided Abuse Prevention Program policy last revised on 7/30/12 shows that the facility will prevent abuse, neglect and theft by establishing a sensitive and secure environment and all residents have the right to be free from abuse. The policy describes physical abuse as hitting, slapping, pinching, kicking or controlling behaviors.
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 F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure a resident was free from misappropriation of resident property for 1 of 4 residents (R1) reviewed for misappropriation in the sample ...
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Based on interview and record review the facility failed to ensure a resident was free from misappropriation of resident property for 1 of 4 residents (R1) reviewed for misappropriation in the sample of 7. Findings Include:An Illinois Department of Public Health Investigation Report completed by V3 (Assistant Director of Nursing) on 8/21/25 shows that R1 had reported that $300 was missing from her wallet. The report shows that R1 had taken a nap between 1:30-5:00 PM and when she woke up to take her medication, she noticed her wallet was not secured and the envelope she had inside it with her money was gone. The report shows that R1 is alert and oriented x 4 and cooperative.A Nursing Progress Note completed by V17 (Registered Nurse) on 8/20/25 at 10:30 PM for R1 states, Resident reported to nursing assistant that she lost $300.00 between 1 PM and 5 PM. R1's Social Service Notes for 8/21/25 show that V9 (Social Worker) went to meet with R1 on 8/21/25 at 9:30 AM, a room search was completed, and the money was not located. The police were contacted and came to the facility to interview the resident. A second social service note completed by V22 (Social Worker) on 8/21/25 at 8:18 PM, shows that R1 told V22 that she seldom leaves her room, and her wallet was inside her walker. V22s note shows R1 said she takes her walker everywhere with her even to the bathroom. R1 did not verbalize any suspects to V22 based on the progress note. On 9/2/25 at 8:38 AM, R1 was in her room, her walker which has a seat you can lift and store items underneath it was at her bedside. The top drawer of her dresser was noted to have a silver lock on it. R1 told this surveyor that she is very hard of hearing, and she must read lips to communicate. She said on 8/20/25 she had her wallet closed and inside her walker hidden under some other items she keeps in there. R1 had approximately $300.00 inside and she knows exactly what denominations of bills they were 3- $50.00 dollar bills, 4- $20.00 dollar bills, 3- 5.00 bills and a few $1.00 bills. R1 said she had taken money out of her account back in May to go out with her niece and she also takes $30.00 a month out of the account managed by the facility. R1 also said she had received $50.00 cash in the mail from her cousin for her recent birthday. R1 said she has not been out of the facility beside one doctor appointment since May 2025. R1 said she had taken a nap on 8/20/25 from about 1-5 PM. When she woke up, she noticed that the side of her walker seemed to be bulging out, so she opened the storage seat and her wallet, which was buried under other items, was sticking out and not closed. R1 said she opened the wallet up and all that was left was $3.00. R1 said she immediately panicked and began looking for her CNA that evening (V19), but V19 was on break so she waited for her to return from break and then told her about her missing money. R1 also said she seldom leaves her room and if she does her walker goes with her. R1 said she does have a locked drawer, but she had been keeping the wallet in her walker because nothing like this has ever happened before and she was too trusting. R1 was interviewed again by this surveyor on 9/3/25 at 10:20 AM and she described all the same events with her missing money.On 9/2/25 at 3:10 PM, V19 said R1 did report to her that she had money missing from her wallet. V19 confirmed that R1 seldom leaves her room and if she does her walker goes with her. V19 said R1 is alert and oriented and hard of hearing and if she is asleep, she would not hear someone enter her room. V19 said on the floor R1 resides on they do not have wandering residents. V19 said she went and told her nurse (V17) that evening about the missing money. On 9/3/25 at 8:08 AM, V11 (Administrator Assistant/ Business Office) said I did give money to R1 and brought in a transaction report showing R1's account that the facility manages. The report showed that R1 had taken out cash withdrawals of $30 on 5/6/25, 6/30/25, 7/4/25 and 8/21/25 and a cash withdrawal of $150 on 5/20/25. V11 said she encourages residents to not keep that much cash on them and knew that R1 had taken $150.00 out in May to go shopping with family so she waited until right before they were going to go to give her the money. V11 verified it was possible for R1 to have had that much cash on her possession. On 9/3/25 at 8:15 AM, V3 said she was alerted to R1's missing money on 8/21/25 and they did do a room search and the money was not located. V3 said R1 is deaf and does read lips and if someone came into her room while she was asleep, she would not hear them. V3 confirmed that R1 does not go out of the facility very often and that she is alert and oriented. V3 also confirmed when she interviewed R1 on 8/21/25 that her account of what cash she had, and the events matched what R1 reported to this surveyor. On 9/3/25 at 11:07 AM, V1 (Administrator) said they encourage residents to not have that much cash on them. V1 said he is highly upset that R1 had her cash taken from her and that they facility does not have cameras to identify who may have done it.The facility provided Abuse Prevention Program policy last revised on 7/30/2012 shows residents have the right to be free from misappropriation/theft and any missing money should be treated as theft until there are clear indications the property was mislaid or lost by means other than theft.
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 ensure the abuse coordinator was immediately notified of an allegation of misappropriation of resident property for 1 of 5 residents (R1) re...
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Based on interview and record review the facility failed to ensure the abuse coordinator was immediately notified of an allegation of misappropriation of resident property for 1 of 5 residents (R1) reviewed for abuse reporting in the sample of 7. Findings Include:An Illinois Department of Public Health Investigation Report completed by V3 (Assistant Director of Nursing) on 8/21/25 shows that R1 had reported that $300 was missing from her wallet.A Nursing Progress Note completed by V17 (Registered Nurse) on 8/20/25 at 10:30 PM for R1 states, Resident reported to nursing assistant that she lost $300.00 between 1 PM and 5 PM. On 9/2/25 at 3:10 PM, V19 said R1 did report to her that she had money missing from her wallet. V19 said she went and told her nurse (V17) that evening about the missing money. On 9/2/25 at 12:45 PM, V3 said she was not alerted to R1's missing money until 8/21/25 and when an allegation is made staff should notify an administrator or V1(Administrator and abuse coordinator) immediately. On 9/2/25 at 3:02 PM, V17 said he was alerted by a CNA, V19 the evening of 8/20/25 that R1 had money missing from her wallet but it was getting late in the evening, so he did not call anyone he just left a message to pass on in report to have social services see her the next day. V17 said he knows that you should call the abuse coordinator right away for any abuse allegations, but he thought they should wait to see if the money turns up. On 9/3/25 at 11:07 AM, V1 (Administrator) said staff are required to report to the abuse coordinator or a member of management who would then call the abuse coordinator immediately for any allegations of theft, misappropriation, abuse etc. V1 said waiting until the next day is not acceptable. The facility provided Abuse Prevention Program policy last revised 7/30/2012 shows that any allegations of abuse or mistreatment including misappropriation of property should be reported to a supervisor who should immediately report it to the administrator.
Jun 2025
1 deficiency
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to have a system in place for monitoring resident room temperatures during hot weather. This applies to 4 of 5 residents (R1-R4) r...
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Based on observation, interview and record review the facility failed to have a system in place for monitoring resident room temperatures during hot weather. This applies to 4 of 5 residents (R1-R4) reviewed for comfortable room temperatures in the sample of 5.
The findings include:
On 6/24/25 at 9:20 AM V2 (Director of Nursing) stated, I have a guy that comes everyday to check on the temperatures but with this heat it just can't keep up. He is here now. I have pictures. V2 then showed Surveyor a picture, with no date or time, of a thermometer on the wall at the nurse's station on the second floor. The picture shows the thermometer at 70 degrees Fahrenheit (F).
On 6/24/25 at 9:40 AM V5 (Heating and Cooling Representative) stated, I come in every morning at 7 AM to check. There are 2 condensers and there seems to be an obstruction in one of them- one of the condensers is not as cold as it should be. I ordered the parts, but it will take 2-3 days to get them. Then it is a 2-day job to fix it. It is blowing cold air but not cold enough. One is 50 degrees (F) and the other is about 65 degrees (F).
V2 stated, We turned on the AC (Air Conditioning) about 2 weeks ago. It was working fine. We have not seen any temperatures of 80 or 90 degrees (F). We are not checking room temperatures. We just have the thermometers at the nurse's stations. Yesterday morning we noticed it was hot. I went through and turned on all the units (in the rooms) because they were all off. We have not been recording the temperature checks.
On 6/24/25 at 9:45 AM the thermometer on the third floor read 74 degrees F. There was a digital thermometer next to it showing 78 degrees F.
On 6/24/25 at 9:50 AM R1 stated, It is too hot and very humid. I think with this heat the AC is struggling to keep up.
At 9:55 AM R2 stated, I get cold at night but sometimes it is really hot. They are good about giving us water. The temperature really varies.
At 10:00 AM V6 (Registered Nurse) stated, The temperature is definitely better today than it was the last few days.
At 10:05 AM R3 stated, Maybe a little hot in here, but they got the fans and it is better than yesterday.
On 6/24/25 at 10:10 AM the thermometer on the second floor read 70 degrees F. (Same as the picture). The second floor felt cooler than the third floor. The humidity level felt high and the whole building feels damp.
At 10:20 AM R4 stated, It is a little warm in here sometimes but I'm from Texas so it is ok.
On 6/24/25 at 11:00 AM V8 (Admissions Director) stated, I bought a thermometer a long time ago when I was doing the life safety stuff. Let me see if I can find it. V8 returned with a digital thermometer with a long cord and a probe at the end. Surveyor took thermometer to rooms on the second floor and the temperature stayed at 78.8 degrees F with 45% humidity.
On 6/24/25 at 11:45 AM V4 (Maintenance) stated, I have been here for 2 years- helping maintenance. About 2-3 months on my own. I'm not doing air temperature checks- not recording building temps. I don't have a thermometer to check the air temps. Residents and staff have been complaining. I put the fans out. The guy comes and checks the AC in the morning. Asked what temperature he thinks the building should be at V4 stated, 78 degrees (F).
On 6/24/25 at 12:45 PM V3 (Assistant Director of Nursing) stated, I looked at the emergency plan yesterday. If it gets too hot, I would follow the direction of the Administrator (V1). I could not make the decisions myself. I have not seen (V1) yet today. We have a hot weather plan- I know the high-risk residents would be anyone with a respiratory illness. Yesterday it was warm on the third floor, so I closed all the drapes, removed sweaters and blankets and made sure all the units were on.
The facility policy titled Maintenance Services dated 3/20/25 states, The Maintenance Department is responsible for maintaining the building, grounds and equipment in a safe and operable manner always.
The facility policy titled Hot Weather Policy and Procedure states, The following measures are to be taken during periods of excessive heat and/or in the event of a failure in the facility air cooling system to assure the comfort and safety of the residents in the facility. Neither of these policies addresses the need for monitoring and recording the temperatures in the building during days of excessively high heat.
Jun 2024
25 deficiencies
2 IJ (2 affecting multiple)
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0801
(Tag F0801)
Someone could have died · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure dietary staff were supervised and trained by a qualified dietary manager resulting in R6, R53, R21, and R65 receiving ...
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Based on observation, interview, and record review, the facility failed to ensure dietary staff were supervised and trained by a qualified dietary manager resulting in R6, R53, R21, and R65 receiving incorrect physician prescribed diets and resulted in R6 choking, requiring the Heimlich maneuver. R6 required hospitalization for aspiration pneumonia and remains at risk for further episodes of choking and aspiration due to continuing receiving the incorrect diet.
This failure applies to 4 of 4 residents (R6, R53, R21, and R65) reviewed for mechanical soft diets in the sample of 20.
This failure resulted in an Immediate Jeopardy.
The Immediate Jeopardy began on 4/22/24, when the facility failed to ensure residents were served a mechanically soft diet as prescribed by their physician. V1 (Administrator) was notified of the Immediate Jeopardy on 6/4/24 at 2:30 PM. This surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 6/6/24; however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.
The findings include:
On 6/3/24 at 2:05 PM, V4 (Food Service Manager/FSM) stated he has been in his role as food service manager for about three years. V4 only has a food protection manager certification that has expired. V4 is not a certified dietary manager. V4 has not begun the process of signing up to take the certified dietary manager coursework as of 6/3/24. V4 stated that he doesn't always know exactly what to do in his position. There isn't someone on site at all times for him to refer to when he has questions.
V4's provided food protection manager certification shows an expiration date of 4/23/24.
On 6/4/24 at 10:37 AM, V7 (Registered Dietitian/RD) stated that she is contracted to provide 16 hours at the facility per month which mainly includes conducting resident nutrition assessments. V7 has never attended a face-to-face staff meeting with all of the dietary staff but has provided printed information for the staff to review.
On 6/4/24 at 8:44 AM, V9 (Cook) stated she has worked here for about eight years. V9 was trained by V4 (FSM) and former cooks on the job. V9 has a current food protection manager certification. V9 stated that a mechanical soft diet is prepared using a knife and cutting the item into bite-size pieces, roughly the size of the fingernail on a pinky finger. V9 does not use any type of machine or device to prepare the mechanical soft diet. V9 stated chopped meats, cooked vegetables, canned fruit, and fresh fruit are allowed on a mechanical soft diet. V9 stated V7 (RD) does not come to the kitchen and V9 has not received training from V7. Per V9, the most recent in-service provided by V4 was a few months ago and covered being careful to send the correct foods for each resident.
On 6/4/24 at 9:03 AM, V8 (Dietary Aide) stated he reads all of the diet cards during service and notifies the chef as to what to put on each plate. A mechanical soft diet is signified by a green sticker on the diet card. Mechanical soft diets are to receive soft and chopped foods, roughly the size of the fingernail on a pinky finger. V8 stated that residents receiving a mechanical soft diet can receive a lettuce salad as long as the contents of the salad are chopped finely, similar in size to the chopped meats. If tomatoes are a part of the salad, those need to be chopped up as well; they cannot be large pieces.
Facility provided dietary staff certificates indicate that V10 (Dietary Aide), V11 (Dietary Aide), V13 (Dietary Aide), and V14 (Dietary Aide) do not have current food handler's certifications.
V12's (Cook) Food Protection Manager's certificate has an expiration date of 2/13/24 and is not currently active.
R6's current diet card shows R6 should receive a mechanical soft diet.
R6's progress note dated 4/22/24 shows, Writer was called to R6's room, resident was choking. 911 was called. Heimlich maneuver was performed, a piece of tomato was expelled.
On 6/3/24 at 1:02 PM, V5 (LPN) stated that at the time of the choking event, R6 was lying in bed. V5 was called into R6's room by V6 (Certified Nursing Assistant (CNA)). When V5 entered R6's room, R6 was purple and could not speak. V5 initiated the Heimlich maneuver on R6 and a tomato piece, approximately the size of a quarter, came flying out. V5 stated R6 was receiving a mechanical soft diet on 4/22/24 and is still on a mechanical soft diet.
R6's progress note dated 4/28/24 shows, Resident readmitted from local hospital via local paramedics. He was on IV (intravenous) antibiotics to treat aspirated pneumonia while at local hospital . On minced moist diet with thin liquid .
Facility served menu for 4/22/24 shows the meal served for the day includes a tomato wedge, pesto chicken salad, potato chips, marinated cucumber and onion salad, pudding with whipped topping, and a dinner roll.
Facility diet spreadsheet for 4/22/24 shows that a mechanical soft diet should have received a diced tomato rather than a full tomato wedge.
On 6/2/24 at the noon meal, R6 received ham cut into cubes, a baked potato with the skin, spinach, and fresh cantaloupe cut into chunks.
On 6/3/24 at the noon meal, R6 received meat lasagna, California blend vegetables, garlic bread, and apple slices.
R53's physician order sheet dated 10/1/23 shows R53 is on a general diet with mechanical soft texture.
On 6/2/24 at the noon meal, R53 received a whole hot dog on a bun, spinach, and fresh cantaloupe cut into chunks.
On 6/3/24 at 1:43 PM, V7 stated that a hot dog is absolutely not appropriate for a resident on a mechanical soft diet.
R21's current diet card reads, mech soft (mechanical soft).
On 6/2/24 at the noon meal, R21 received ham cut into cubes, a baked potato with skin, spinach, and fresh cantaloupe cut into chunks.
On 6/3/24 at the noon meal, R21 received meat lasagna, California blend vegetables, garlic bread, and apple slices.
R65's physician order sheet dated 10/1/23 shows R65 is on a general diet with mechanical soft texture.
R65's current diet card reads, Regular diet (with no texture modifications).
On 6/2/24 at the noon meal, R65 received a slice of ham, a baked potato with skin, spinach, and fresh cantaloupe.
On 6/3/24 at the noon meal, R65 received meat lasagna, California blend vegetables, garlic bread, and apple slices.
On 6/3/24 at 1:43 PM, V7 (RD) stated that ham would not be the best option for a resident on a mechanical soft diet. The cut-up squares could be a choking problem. She would also recommend they not serve fresh fruit unless they could guarantee it is soft enough for them to eat.
Facility diet spreadsheet for 6/2/24 shows mechanical soft residents should have received ground ham and a chopped baked potato without the skin.
On 6/3/24 at 1:20 PM, V4 (FSM) said the staff should follow the diet spread sheet for altered diets.
On 6/4/24 at 1:13 PM, V29 (Medical Director) stated, They definitely should be serving what is ordered for the resident's diets.
Facility Food and Nutrition Services Diets and Diet Orders, Mechanical Soft Diet policy dated 2017 states, . Procedure: The texture may be altered by one of the following methods: Unless otherwise indicated, meat and meat substitutes will be mechanically ground
On 6/5/24 at 10:40 AM, V29 (Medical Director) stated that he was not familiar with what qualifications a dietary manager requires and he also did not know that V4 (FSM) did not possess the proper qualifications.
Facility provided job description for Director of Food and Nutrition Services dated 2018 states, Qualifications: Certified in food safety through an American National Standards Institute (ANSI) accredited course and has one of the following qualifications: Registered Dietitian, Licensed or Certified Dietitian, Certified Dietary Manager .
The facility presented an abatement plan to remove the immediacy on 6/5/24. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a second revised abatement plan on 6/5/24 and the survey team accepted the abatement plan on 6/6/24.
The Immediate Jeopardy that began on 4/22/24 was removed on 6/6/24 when the facility took the following actions to remove the immediacy:
1. Immediate Recruitment Efforts: We have placed a Certified Dietary Manager (V31) in this position as of 06/04/24. The current Supervisor (V4) will attend a class dated 08/19/24, to renew his Food Safety Manager Certificate. All other dietary staff files will be audited for compliance with the current Food Handler's Certification by Human Resources (V17) by 6/5/24. The Certified Dietary Manager (CDM) (V31) has started the training for dietary staff on 6/5/24. The Registered Dietitian (V7) will continue with the training for proper production and serving of mechanical soft diets on 6/6/24. This process will be completed by 6/6/24. The CDM (V31) will supervise food service production.
2. Enhanced Training Programs: As of 6/5/24 In-servicing and training have begun for dietary staff by the CDM (V31) on providing diet as ordered, communication protocol, review diet, and update orders, in-servicing will continue until all dietary staff is trained before starting their next shift. The ADON (V3) started in-servicing nursing staff on 6/5/24 on monitoring dietary cards to ensure correct food consistency is being served; in-servicing will continue until all nursing staff is trained by 6/13/24. We are enhancing our current training programs to ensure all dietary staff receive continuous education on a yearly basis for food safety, nutritional guidelines, and regulatory compliance. These programs will be provided by our contracted Registered Dietitian (V7) or her designee.
3. Policy Review and Updates: A review of our Dietary Policies and Procedures Manual will be reviewed by the CDM (V31) and our contracted Registered Dietitian (V7) this process will be started on 6/6/24 and continued yearly to ensure they align with State and Federal Regulations. Any necessary updates will be implemented by in servicing the Dietary and Nursing Staff to reinforce our commitment to compliance and high-quality care, this procedure will be given by our contracted Registered Dietitian or her designee.
4. Regular Audits and Monitoring: To prevent future occurrences, we will establish a random weekly audit of 3 meals a week for 90 days done by the CDM (V31); this audit will be focused on food consistency matching the dietary card. This procedure will help us monitor for compliance, identify potential issues early, and take corrective actions promptly.
Results will be reported at QA meeting to ensure ongoing compliance.
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Menu Adequacy
(Tag F0803)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** II. Based on observation, interview, and record review the facility failed to ensure residents receiving a regular texture diet ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** II. Based on observation, interview, and record review the facility failed to ensure residents receiving a regular texture diet received a 3-ounce (oz) portion of sliced ham for the noon meal on 6/2/24. This applies to 4 of 4 residents (R44, R75, R84, R45) reviewed for menus in the sample of 20.
The findings include:
Facility provided Dietary Type Report shows that R44, R75, R84, and R45 all receive a regular texture diet.
On 6/2/24 at 11:27 AM, V12 (Cook) was placing a single slice of sliced ham on each plate receiving a regular texture diet. The slices of ham appeared small. The slices were approximately one quarter inch thick and the size of a three inch by five-inch index card or smaller.
On 6/2/24 at 12:10 PM, V12 finished plating all meals and none of the residents received additional ham during normal meal service.
On 6/2/24 at 12:37 PM, facility provided test tray was received and the portion of ham was similar to the sizes served during lunch.
On 6/2/24 at 12:54 PM, V4 (Dietary Manager) used a calibrated food scale to weigh the ham slice provided on the test tray. The ham slice weighed 1.75 ozs (ounces), providing approximately 88 calories and 11 grams (g) protein. V4 stated the residents were to receive a 3 oz portion of ham, which would provide approximately 150 calories and 20g protein. Residents received approximately 60 calories and 9g less protein than the written menu.
On 6/2/24 at 12:55 PM, V9 (Cook) confirmed that V12 cut the ham into slices to serve for lunch on 6/2/24.
Facility Diet Spreadsheet shows the portion size for the regular texture diet is to receive a 3 oz portion of ham.
On 6/2/24 1:47 PM, R44 said there are sometimes he receives enough food, but he stated the ham received on 6/2/24 was small and he was still hungry after lunch.
On 6/2/24 at 1:58 PM, R84 state that he believes the portion sizes served are small.
On 6/3/24 at 9:05 AM, R75 stated that she does not believe the food portions served are always large enough. R75 was unable to eat the ham on 6/2/24 and was still hungry after the end of the meal. R75 stated there have been other times that she was still hungry after meals and this was not the first time.
I. Based on observation, interview, and record review the facility failed to ensure residents with a history for choking and at risk for choking were served the correct physician prescribed diets. This failure resulted in R6 choking, requiring the Heimlich maneuver, going to the hospital, and being treated for aspiration pneumonia. R6 returned to the facility and continued to be served the incorrect diet putting him at risk to choke again. The facility also failed to ensure R21, R53, and R65 were served the correct physician prescribed diets putting them at risk to choke. This applies to 4 of 20 residents (R6, R21, R53, R65) reviewed for menus in the sample of 20.
These failures resulted in an Immediate Jeopardy.
The Immediate Jeopardy began on 4/22/24 when the facility failed to ensure residents were served a mechanically soft diet as prescribed by their physician. V1 Administrator was notified of the Immediate Jeopardy on 6/4/24. This surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 6/6/24 however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training and staffing levels.
The findings include:
1. R6's progress notes dated 4/22/24 shows, Writer was called to R6's room, resident was choking. 911 was called. Heimlich maneuver was performed, a piece of tomato was expelled.
R6's local hospital records dated 4/22/24 shows, Medical Screening Exam: s/p (status post) reported witnessed chocking [SIC (statement is correct)] event earlier today at 1846 (6:46 PM). Local fire department called by SNF (skilled nursing facility) for witnessed event, Heimlich maneuver perform and fully resolved/signed off at the scene.
R6's progress notes dated 4/28/24 shows, Resident readmitted from local hospital via local paramedics. He was on iv antibiotics to treat aspirated pneumonia while at local hospital . On minced moist diet with thin liquid .
On 6/3/24 at 1:02 PM, V5 Licensed Practical Nurse (LPN) stated, R6 was lying in bed when he choked. It was dinner time, and the CNA (certified nursing assistant/V6) called her into R6's room. R6 was purple and couldn't speak when V5 LPN got into the room. She did the Heimlich maneuver on him and a quarter size tomato came flying out. She couldn't remember what was for dinner that night only that he choked on a tomato. She also stated, his diet has not changed and was on a mechanical soft diet at the time when he choked.
The dinner menu for 4/22/24 (the day R6 choked) shows, tomato wedge, pesto chicken salad, potato chips, marinated cucumber and onion salad, pudding with whipped topping and a dinner roll. The spreadsheet for mechanical soft diet shows, tomato wedge (diced (garnish)) .
On 6/3/24 at 1:43 PM, V7 Dietitian stated, ham would not be the best option for a resident on a mechanical soft diet. The cut-up squares could be a choking problem. She would also recommend they steer away from fresh fruit unless they could guarantee it is soft enough for them to eat.
On 6/4/24 at 9:03 AM, V8 Dietary Aide stated, residents on a mechanical soft diet can receive a salad if it is chopped fine and the tomato is cut small. They should not receive large pieces of tomato. Mechanical soft diets should be soft and chopped up to about the size of a pinky nail.
On 6/2/24, at the noon meal, R6 was served a slice of ham cut into cubes, a baked potato with skin, spinach and fresh cantaloupe cut into chunks. R6 has no teeth.
On 6/3/24, at the noon meal, R6 was served meat lasagna, California blend vegetables, garlic bread and apple slices.
R6's physician order sheet dated 4/28/24 shows, Regular diet, soft & bite sized texture, regular/thin consistency minced and moist diet/thin liquid for dysphagia.
The menu for 6/2/24, at the noon meal shows, orange glazed ham, baked potatoes with sour cream, seasoned spinach, fresh fruit mix and dinner roll. The spreadsheet for mechanical soft diet shows, orange glazed ham: grnd (ground), baked potato: no skin/chopped/add [NAME] (margarine (butter)). The spreadsheet does not show what mixed fruit should be for a mechanical soft diet.
The menu for 6/3/24, at the noon meal shows, home style meat lasagna, Italian blend vegetables, fresh fruit and garlic bread. The spreadsheet for mechanical soft diet shows, they can have what is on the menu however it shows they were to get pineapple with the noon meal instead of fresh fruit. The spreadsheet does not show what a mechanical soft diet should get instead of sliced apples.
R6's diet card shows, mechanical soft diet.
On 6/4/24 at 1:13 PM, V29 (R6's physician/Medical Director) stated, he was aware of him choking during dinner. They definitely should be serving what is ordered for the resident's diets.
R6's medical record does not show any evaluations by a speech therapist for diet recommendations.
2. On 6/2/24, at the noon meal, R53 was served a whole hot dog on a bun, spinach and fresh cantaloupe cut into chunks. R53 also has no teeth and was having a hard time eating the hot dog and cantaloupe.
On 6/3/24, at the noon meal, R53 was served meat lasagna, California blend vegetables, garlic bread and apple slices. R53 was having a hard time eating the apple slices.
R53's physician order sheet dated October 1, 2023, shows, General diet, Mechanical Soft texture, Regular/Thin consistency.
On 6/3/24 at 1:43 PM, V7 Dietitian stated, A hot dog was absolutely not appropriate for a resident on a mechanical soft diet.
R53's current diet card shows, regular diet (not the prescribed diet).
3. On 6/2/24, at the noon meal, R21 was served a slice of ham cut into cubes, a baked potato with skin, spinach and fresh cantaloupe cut into chunks.
On 6/3/24, at the noon meal, R21 was served meat lasagna, California blend vegetables, garlic bread and apple slices.
R21's physician order sheet dated October 1, 2023, shows, NAS (no added salt) diet, Mechanical Soft texture.
R21's current diet card shows, mech soft (mechanical soft).
4. On 6/2/24, at the noon meal, R65 was served a slice of ham, a baked potato with skin, spinach, and fresh cantaloupe.
On 6/3/24, at the noon meal, R65 was served meat lasagna, California blend vegetables, garlic bread and apple slices.
R65's physician order sheet dated October 1, 2024, shows, General diet, Mechanical Soft texture, Regular/Thin consistency.
R65's current diet card shows, Regular diet (not the prescribed diet).
On 6/3/24 at 1:20 PM, V4 Dietary Manager stated, they follow the spreadsheet for altered diets (mechanically soft diets).
The facility's food and nutrition services diets and diet orders policy dated 2017 shows, Diet Standardization: Policy: Food and nutrition services will serve standard diets which correspond to the diet columns on the menu spreadsheet and are based on the nutrition manual for healthcare communities . Procedure: Examples of standard diet orders may include: Mechanical soft: The texture and consistency of the general/regular or therapeutic diet is modified. Food maybe served as ground or chopped. Whole food may only be served if it is soft in consistency.
The facility's food and nutrition services diets and diet orders, mechanical soft diet policy dated 2017 shows, Policy: Food will be provided in a form designed to meet individual needs. The highest practicable level of eating will be provided. The texture of the food may be altered to mechanical soft consistency. Procedure: The texture may be altered by one of the following methods: Unless otherwise indicated, meat and meat substitutes will be mechanically ground. Plain fish fillet may be flaked. Meat loaf without hard crust and soft casseroles may be served intact. Foods commonly avoided are fibrous raw vegetables (such as celery, radishes, cauliflower, broccoli, etc.), whole kernel corn and nuts. If individual tolerance allows, meat and meat substitutes can by chopped by hand. This will be indicated on the tray card.
The facility presented an abatement plan to remove the immediacy on June 5, 2024. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a second revised abatement plan on June 5, 2023, and the survey team accepted the abatement plan on June 6, 2024.
The Immediate Jeopardy that began on April 22, 2024, was removed on June 6, 2024, when the facility took the following actions to remove the immediacy:
1.
Immediate Recruitment Efforts: We have placed a Certified Dietary Manager (V31) in this position as of 06/04/24. The current Supervisor (V4) will attend a class dated 08/19/24, to renew his Food Safety Manager Certificate. All other dietary staff files will be audited for compliance with the current Food Handler's Certification by Human Resources (V17) by June 5, 2024. The CDM (V31) has started the training for dietary staff on 06/05/24. The Registered Dietitian (V7) will continue with the training for proper production and serving of mechanical soft diets on 06/06/24. This process will be completed by 06/06/24. The CDM (V31) will supervise food service production.
2.
Enhanced Training Programs: As of 6/5/24 In-servicing and training have begun for dietary staff by the CDM (V31) on providing diet as ordered, communication protocol, review diet, and update orders, in servicing will continue until all dietary staff is trained before starting their next shift. The ADON (V3) started in-servicing nursing staff on 06/05/24 on monitoring dietary cards to ensure correct food consistency is being served, in servicing will continue until all nursing staff is trained by 6/13/24. We are enhancing our current training programs to ensure all dietary staff receive continuous education on a yearly basis for food safety, nutritional guidelines, and regulatory compliance. These programs will be provided by our contracted Registered Dietitian (V7) or her designee.
3.
Policy Review and Updates: A review of our Dietary Policies and Procedures Manual will be reviewed by the CDM (V31) and our contracted Registered Dietitian (V7) this process will be started on 6/6/24 and continued yearly to ensure they align with State and Federal Regulations. Any necessary updates will be implemented by in servicing the Dietary and Nursing Staff to reinforce our commitment to compliance and high-quality care, this procedure will be given by our contracted Registered Dietitian or her designee.
4.
Regular Audits and Monitoring: To prevent future occurrences, we will establish a Random weekly audit of 3 meals a week for 90 days done by the CDM (V31), this audit will be focused on food consistency matching the dietary card. This procedure will help us monitor for compliance, identify potential issues early, and take corrective actions promptly.
Results will be reported at QA meeting to ensure ongoing compliance.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the Registered Dietician was immediately notified of a signif...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the Registered Dietician was immediately notified of a significant weight loss for a resident receiving enteral feedings. This failure resulted in a delay in a resident (R24) being assessed by the dietician to implement interventions to prevent further weight loss. The facility failed to ensure weekly weights were completed for a resident (R1) on enteral feedings with insidious weight loss. This applies to 2 of 3 residents (R24, R1) reviewed for enteral feedings in the sample of 20.
The findings include:
1. R24's active care plan shows he requires enteral feedings through a Gastrostomy tube (G tube). Hospital records from a local community hospital show he was hospitalized from [DATE] through 3/12/24 for placement of a gastrostomy tube.
R24's nutritional assessment completed by V7 (Registered Dietician/RD) on 3/25/24 show he was re-admitted from the hospital with tube feeding orders for a continuous tube feeding of Glucerna 1.2 at 60 (ml) milliliters per hour. These orders were changed by V7, at the request of the facility, to bolus feedings QID (four times a day).
R24's weight summary shows on 4/1/24, R24's weight was 101.0 lbs. (pounds). On 4/4/24 R24's weight was 91 pounds, a 10 lb., 9.9% weight loss in 4 days. On 4/15/24, R24's weight had dropped from 91 lbs. to 87.8 lbs, another 3.2 lbs in 11 days. R1's nursing progress notes do not show that V7(RD) or V29 (R24's Physician and Medical Director) were notified of R24's significant weight loss.
A Nutrition/Dietary note completed by V7 (RD) on 4/29/24 shows, Patient with significant weight loss noted, 10% in 1 month, Discussed with RN will change to a continuous tube feeding to meet the needs of the patient. A physician's order dated 4/29/24 shows R24's tube feeding was changed from bolus to a continuous feeding of Glucerna 1.2 at 50 ml. per hour.
On 6/4/24 at 10:32 AM, V7 (RD) stated she is only at the facility 16 hours per month. V7 stated she is not immediately notified of weight loss as she finds out by notes left in her mailbox when she comes to the facility. V7 stated she could not recall exactly when she was told of R24's weight loss but she did not see him until 4/29/24 so she assumes it was that day. R24 stated she made immediate changes to the tube feeding orders to be a continuous feeding to try to prevent further weight loss.
On 6/5/24 at 7:50 AM, V2 (Director of Nursing) stated she was aware of R24's weight loss and she expects the nurses to call the Dietician and Physician right away for significant weight loss and to chart that in the resident's medical record. V2 stated she was not aware that V7 (RD) was only contracted to come to the facility 2 times per month.
On 6/5/24 at 10:35 AM, V29 (R24's Physician) stated he was notified of R24's weight loss but not sure of the date. V29 stated he was also unaware that the nursing staff were only leaving notes in the mailbox for V7 (RD) and not calling her to notify her of significant weight loss. V29 state they will have to fix that process because the Registered Dietician should be notified immediately.
On 6/5/24 at 11:41 AM, V16 (Registered Nurse/RN) stated they do not call the Dietician directly they let V3 (Assistant Director of Nursing) know and then put a note in the Dieticians mailbox. V16 stated they should call the residents physician who usually tells them to notify the Dietician.
The facility provided Weight Monitoring policy dated 2017 describes significant weight loss as 5% in one month, 7.5% in 3 months, and 10% in 6 months. The policy shows that the physician and dietician should be notified but fails to indicate a time frame.
2. R1's Medication Administration Record shows he receives enteral feedings via a G-tube of Jevity 1.2, 300 ml at breakfast and lunch, and 600 ml. at dinner.
R1's 2/12/24 Nutrition note completed by V7 (RD) shows the resident has had a significant weight loss of 8% in 6 months and she recommended weekly weights for 4 weeks to monitor his weight.
R1's Weight Summary report shows on 2/5/24 he weighed 132.0 lbs. but, no further weight is documented until 3/12/24. One month after V7 ordered weekly weights for R24.
On 6/4/24 at 10:32 AM, V7 (RD) stated R1 has a history of refusing the bolus feedings so he can consume his regular diet order. V7 stated she ordered the weekly weights to keep track of his weight and she expects the facility to do the weights when it is ordered.
The facility provided Weight Monitoring policy dated 2017 describes significant weight loss as 5% in one month, 7.5% in 3 months, and 10% in 6 months. The policy shows that the physician and dietician should be notified but fails to indicate a time frame. The policy additional shows that a client's body weight is monitored to maintain acceptable parameters of nutritional status.
CONCERN
(D)
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, interview, and record review the facility failed to ensure a resident, dependent upon staff for cares, had...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident, dependent upon staff for cares, had a call light system in place to meet the needs of the resident. This applies to 1 of 20 residents (R4) reviewed for accommodation of needs in the sample of 20.
The findings include:
R4's Minimum Data Set (MDS) dated [DATE] shows R4 is dependent upon staff for oral hygiene, toileting hygiene, showering/bathing, lower body dressing, personal hygiene, putting on/taking off footwear, rolling left to right in bed, and for all transfers.
On 6/2/24 at 10:51 AM, R4 was lying in bed watching television. R4's call light rope was hanging from a switch above R45's (R4's roommate) bed. R4, although nonverbal, was able to say yes when asked if she had a difficult time asking for help from staff.
On 6/3/24, direct observations from the third-floor nurse's station were made from 12:07 PM until 12:24 PM. During that time, R4 was making intermittent audible verbal sounds at 12:07 PM, 12:10 PM, 12:13 PM, 12:14 PM, 12:17 PM. R4's audible noises became louder and R4 would continue with the noises for roughly 15 seconds at a time. At 12:18 PM, R45 (R4's roommate) returned to the room and stated that R4 makes those noises when she needs help. R45 proceeded to communicate with R4 to determine the level of help she required. During this time, R4's call light was still not within reach.
On 6/3/24 at 12:20 PM, R45 left the room to go alert staff that R4 required assistance.
On 6/3/24 at 12:22 PM, R4's audible noises turned into what sounded like a painful howl. V16 Registered Nurse (RN) entered R4's room at 12:24 PM with another staff member to address R4's needs.
On 6/4/24 at 1:42 PM, V16 RN stated that R4 is nonverbal but will make audible noises when she requires assistance. There are no other ways for R4 to request assistance from staff. V16 stated they have tried using the call light rope and that it should always be within reach but does not know if R4 can use it. V16 is not aware of any other methods for R4 to alert staff when she requires assistance. V16 stated staff would be responsible for checking on R4 more frequently to make sure R4's needs are met.
Facility Call Light, Use of policy dated 7/10 states, . 7. When providing care to residents be sure to position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure a resident was provided privacy during wound dressing changes. This applies to 1 of 20 residents (R6) reviewed for priv...
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Based on observation, interview, and record review the facility failed to ensure a resident was provided privacy during wound dressing changes. This applies to 1 of 20 residents (R6) reviewed for privacy in the sample of 20.
The findings include:
On June 2, 2024, at 11:39 AM, R6 was sitting in his reclining wheelchair in the dining room. V15 Registered Nurse (RN) changed R6's right heel dressing while he was sitting in the dining room. There were approximately 20 residents in the dining room. They could see/watch V15 change his dressing.
On June 2, 2024, at 12:48 PM, R6 was lying in bed. V15 RN was changing the dressing to R6's buttocks. The bedside curtain and door to his room was open. R6 is the first bed in the room. You could see R6 from the hallway.
One June 5, 2024, at 12:36 PM, V3 Assistant Director of Nursing stated, staff should not be doing dressing changes in the dining room, and they need to provide privacy for the residents.
The facility's residents right to personal privacy dated September 1, 2011, shows, Policy: Facility staff must examine and treat residents in a manner that maintains the privacy of their bodies. A resident must be granted privacy when treatments are given . Staff should pull privacy curtains, close doors, or otherwise remove residents from public view and provide clothing or draping to prevent unnecessary exposure of body parts during the provision of personal care and services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure staff-dependent residents were bathed, their na...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure staff-dependent residents were bathed, their nails were cut, and facial hair was groomed for 3 of 20 residents (R1, R24, R64) reviewed for activities of daily living (ADL's) in the sample of 20.
The findings include:
1. On 6/2/24 at 11:39 AM, R24, who is nonverbal, was lying in bed. His nails, on both hands, were approximately 1/2-1 inch in length, with some curling back. R24's shower schedule shows he should receive showers/baths on Monday and Thursday. The facility shower sheets for R24 showed he had a bed bath on 5/6/24 and not again until 6/3/24. R24's active care plan shows he has diagnoses of dementia, communication deficit, and requires extensive to total staff assistance with his Activities of Daily Living.
On 6/2/24 at 11:57 AM, V24 (Certified Nursing Assistant/CNA) stated residents should be given showers or baths 2 times a week, nails should be cut, and facial hair shaved during that time.
On 6/3/24 at 10:10 AM V3 (Assistant Director of Nursing/ADON) was in the room providing cares to R24 with V24. V24 said I thought the nail doctor cuts nails (R24's) nails? V3 ADON replied, No the doctor comes for toenails.
On 6/5/24 at 9:00 AM, R24 was observed to still have long nails.
2. On 6/2/24 at 11:40 AM, R1 was sitting up in a chair in his room. R1 had long stubbly facial hair, and very long nails with a visible black thick substance under the nail beds. R1 said, Yes these nails are very long. I need them cut. The facility shower schedule showed R1 should be given showers on Mondays and Thursdays.
On 6/5/24 at 9:01 AM, R1 was observed to still have long dirty nails and facial stubble.
R1's active care plan shows he has a self-care deficit and requires extensive staff assistance with his ADL's.
3. On 6/2/24 at 10:10 AM, R64 stated she has only gotten one shower since she was admitted about a month ago, and she only got that because her mom came to the facility and threw a fit. The facility shower schedule showed R64 should receive a shower on Mondays and a second shower was not listed for R64. Facility shower sheets indicate that R64 refused a shower on 5/6/24, and 5/13/24 but was given one on 5/20/24, which was her last documented shower.
On 6/5/24 at 9:55 AM, R64 stated she does not and did not refuse to take showers at the facility, she wants showers.
On 6/5/24 10:07 AM, V27 (CNA) stated residents are supposed to receive showers two times a week. V27 stated usually they can get to them on his shift, but he cannot speak for the evening shift.
R64's face sheet shows she was admitted to the facility on [DATE]. R64's active care plan shows she has a self-care deficit and requires staff assistance with ADL's.
The facility provided policy on Nail Care dated July 2010, shows that nails should be kept clean, trimmed and smooth and be completed at bath time or shortly after. The facility's Shower for the Resident policy (undated) does not address a time frame that showers should be given.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure a resident with a skin rash was assessed and failed to ensure a skin treatment was applied according to standards of pr...
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Based on observation, interview, and record review the facility failed to ensure a resident with a skin rash was assessed and failed to ensure a skin treatment was applied according to standards of practice, for 1 of 20 residents (R17) reviewed for quality of care in the sample of 20.
The findings include:
On 6/2/24 at 11:06 AM, R17 stated she has a terrible rash, that has been there for over 2 weeks, on her back and in her groin. R17 proceeded to pull down her pants and show this surveyor the rash, that was bright red in color, between her legs and spreading down both thighs. R17 also pulled up her shirt and showed this surveyor a spotty pinpoint rash on her back with some scabbed areas from itching. In R17's shirt pocket was a bottle of Nystatin powder. R17 stated she has told the nurses about the rashes, but no doctor has seen her. The nurses gave her the powder and told her to put it on herself. R17 stated she told the nurse again today (V16 Registered Nurse) who stated she would come and take a look at it.
On 6/3/24 at 12:32 PM, V16 RN stated she had not been in to see R17's rash yet but she would look at it today and have the wound physician see it as well. V16 said she was not aware of a rash to R17's back. V16 was asked about the Nystatin that was left in R17's room for her to apply herself and V16 stated that should not have happened, the nurses need to apply the powder and assess the rash.
On 6/3/24 at 12:40 PM, R17 stated no one had been in to see her yet, the Nystatin powder was still in R17's shirt pocket.
R17's Treatment Administration Record shows an active order, with a start date of 5/24/24, for Nystatin powder to her groin two times a day. There was no order for an ointment for the rash to R17's back.
The only documented assessment prior to 6/3/24, provided by the facility for R17's rashes, was a nursing note completed by V16 RN on 5/28/24 that states skin check every Tuesday for skin monitoring, redness to groin.
On 6/3/24 at 1:25 PM, V35 (Wound Nurse Practitioner) stated he was not aware of the rashes to R17 until today. V35 believes the rash on R17's back is a form of an allergic reaction, and the rash in her groin is a fungal infection.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure a sacral pressure injury was assessed, reported to the physician, and a treatment for the injury was in place. The faci...
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Based on observation, interview, and record review the facility failed to ensure a sacral pressure injury was assessed, reported to the physician, and a treatment for the injury was in place. The facility also failed to follow physician orders for pressure injuries. This applies to 1 of 3 residents (R6) reviewed for pressure injuries in the sample of 20.
The findings include:
On June 2, 2024, at 11:39 AM, V15 Registered Nurse (RN) was changing R6's right heel dressing. R6 had an approximate 1-inch abrasion to his left knee. V15 RN stated, they are leaving it open to air and then put betadine on it.
On June 2, 2024, at 12:48 PM, V15 RN was changing R6's sacral wound dressing. R6 had a large, ping pong ball size, purple/red open area on his right buttock. He (R6) had the same size/color wound on his left buttock that was connected to the right buttock. V15 RN stated, she first saw the wound on Wednesday of that week. She was waiting for the wound doctor to come in and evaluate the wound. He was supposed to come that day (June 2, 2024) but wasn't coming now. She (V15) stated, the wound was worse than what she saw on Wednesday. There were no physician orders/treatments in place for the wound. She was just putting betadine on it and covering it with a foam dressing.
R6's medical record does not show any assessments of the sacral wound by V15 RN or other nursing staff.
R6's progress notes dated April 28, 2024, shows, Resident readmitted from local hospital . Has skin issues on left knee, right heel, both bottom with form dressings on them .
R6's progress notes dated June 2, 2024, shows, .Wound dr/doctor supposed to come and evaluate the wound today, but he didn't make it. DON/ADON (Director of Nursing/Assistant Director of Nursing) made aware the sacral wound.
R6's Treatment Administration Record (TAR) for the month of June 2024 shows, Left knee, every day shift every Tue, Thu, Sat for treatment, cleanse with normal saline, apply adaptic and foam island (dressing).
R6's TAR for the month of June 2024 shows, Cleanse sacral wound with normal saline and put medi-honey with dry-foam dressing on it every shift until healed . The start date for this physician order is June 3, 2024.
R6's wound doctor evaluation dated June 3, 2024, shows, sacral pressure wound measuring 6 x 6 x 0.3 (6 cm (centimeters) X 6 cm X 0.3 cm) with 50% purple ecchymosis. Date treatment initiated: 6/3/2024.
R6's care plan dated February 25, 2024, shows, The resident may be at risk for skin breakdown related to the following factors which have a causal relationship or complicate the condition: lack of mobility, bowel and/or bladder incontinence, presence of one or more risk factors but no current ulcers, skin problems or lesions. Approaches/Interventions: .Administer prescribed medications and treatments per doctor's orders.
R6's care plan does not address his current pressure injuries.
The facility's management/treatment of pressure ulcer(s) dated November 1, 2012, shows, Purpose: The facility will have protocols in place in the even a newly identified pressure ulcer is noted the direct care staff will initiate an appropriate treatment to the wound until that time it is further assessed by the wound care nurse. Any newly identified pressure ulcer must have treatment initiated at the time of discovery.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to provide restorative services to 2 of 5 residents (R24, R64) reviewed for restorative cares in the sample of 20.
The findings include:
1.) O...
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Based on interview and record review the facility failed to provide restorative services to 2 of 5 residents (R24, R64) reviewed for restorative cares in the sample of 20.
The findings include:
1.) On 6/2/24 at 11:37 AM, R24 who is nonverbal, was lying in bed with contractures noted to both hands. R24's active care plan shows he has diagnoses including dementia and right sided weakness due to a cerebral vascular accident with contractures to his upper body. R24's Restorative Care Plan shows he requires extensive staff assistance with his Activities of Daily Living and should receive PROM (passive range of motion) to his affected extremities for 15 minutes a day. R24's restorative documentation for the last 30 days showed he was provided range of motion for 15 minutes on 8 out of 30 days 5/9/24, 5/10/24, 5/11/24, 5/16/24, 5/20/24, 5/24/24, 5/29/24 and 6/1/24.
On 6/3/24 at 1:42 PM V3 (Assistant Director of Nursing) stated they have a restorative CNA (Certified Nursing Assistant) who should be doing range of motion, and working with residents but he gets pulled to work the floor a lot and then restorative is left up to the CNAs on the floor to complete.
On 6/5/24 at 9:13 AM, V32 (Restorative CNA) stated he just covered another CNA's vacation and was pulled to the floor to work for the last 8 days. V32 stated when he is pulled to the floor, he cannot get his restorative job done and the CNA's have to do their own restorative and that may not always be done.
On 6/5/24 at 9:20 AM, V24 (CNA) stated she tries to do range of motion for R24 but cannot always get to it when she is the only CNA on that hall.
2.) On 6/2/24 at 10:11 AM, R64 stated she was receiving physical therapy however the therapist (V30 Physical Therapist) went out of the country so she was supposed to be walked by the nursing staff but that has not been getting done. R64 additionally stated they are claiming that I always refuse to walk, and I don't. If someone wakes me up, I will go walk with them.
On 6/5/24 at 9:25 AM, R64 stated she was walked by her mom yesterday and when her son comes in, he will also walk her. R64 stated one day last week she was too tired to walk because a medication she was on was making her sleepy and did refuse to go but that was the only time that has happened.
On 6/5/24 at 9:13 AM, V32 (Restorative CNA) stated R64 is supposed to be walked to the bathroom and back, with a walker, and she can do that with stops to rest, but he is not sure if that is being done when he is pulled to work the floor.
On 6/5/24 at 9:35 AM, V27 (CNA) stated he cannot always get time to walk residents when V32 (Restorative CNA) is not there.
R64's Physical Therapy Plan of Treatment shows she was discharged from skilled physical therapy on 5/10/24 but there was no indication on the treatment plan to indicate how often R64 should be walked by the restorative department.
R64's ADL (Activity of Daily Living) record for the month of May shows she was not walked at all.
A restorative care plan was requested for R64, and what was provided by the facility was a self-care deficit care plan which lists range or motion to be done but no mention in that care plan of walking her.
The facility provided Restorative Nursing Program policy (undated) shows that restorative care should be done to prevent a resident from declining. Restorative programs include range of motion, bed mobility and ambulating residents which should be documented daily.
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 ensure residents at risk for falls were supervised and interventions were in place to prevent falls. The facility also failed ...
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Based on observation, interview, and record review the facility failed to ensure residents at risk for falls were supervised and interventions were in place to prevent falls. The facility also failed to ensure residents were transferred in a safe manner. These failures apply to 2 of 20 residents (R21, R65) reviewed for safety/supervision in the sample of 20.
The findings include:
1. On June 2, 2024, at 10:08 AM, R21 was sitting in her wheelchair in the dining room. Her (R21) left eye was yellow/green with sutures to her eyebrow.
R21's incident/occurrence report dated May 26, 2024, shows, Resident fell forward in the bed after night CNA (certified nursing assistant) put her back to bed after falling. Noted bleeding on her left forehead d/t (due to) laceration.
R21's hospital records dated May 26, 2024, shows, she had a fall with a cut on her face. Chin and left eyebrow laceration, stitches or tape. The same records continue to show, Pt (patient) arrives via EMS (emergency medical services) with c/o (complained of) mechanical fall and facial lacerations. Pt resides at the facility assisted living facility with hx (history) of dementia . Per staff at the facility, pt was wheeling herself around in her wheelchair when she struck a corner and fell out of the chair, lacerating her chin and forehead. This occurred at 0700 (7:00 AM) and was unwitnessed but staff heard the fall and assisted the patient up and called EMS.
R21's progress notes dated May 26, 2024, shows, Resident sent out to local hosp.(hospital) for fall and hit her head with bleeding d/t forehead laceration via 911 .
She was diagnosed as below at local hospital; 1. CHIN LACERATION 2. MILD TRAUMATIC BRAIN INJURY
3. PELVIC FRACTURE. She came back from local hosp. after having been 9 stitches done on left forehead without dressings on it.
On June 2, 2023, at 12:58 PM, R21 wandered out of the dining room in her wheelchair and was sitting in another resident's room down the hall. No one was watching her. At 1:29 PM, she tried opening the exit door and set off the alarm. No one was watching her.
On June 3, 2024, at 10:32 AM, R21 was sitting in her wheelchair in the dining room. She was standing up and sitting down. Her wheelchair was not locked. V22 Certified Nursing Assistant (CNA) was in the dining room but attending to another resident. R21 stood up again and realized she couldn't stand well and tried to sit back down but her wheelchair was unlocked so it moved away from her, and she fell on her right side. V22 CNA was on the other side of the dining room. V22 CNA stated, this is why you can't take your eyes off anyone and do games. She also stated, you cannot take your eyes off R21. It is too much for one person. She will stand up and fall.
R21's incident report dated June 3, 2024, shows, Resident was trying to get up from w/c (wheelchair) when she fell and landed on her left side . wheelchair was unlocked.
R21's care plan date-initiated April 9, 2024 shows, The resident is high, risk for falls r/ t (related to) confusion, gait/balance problems, incontinence, psychoactive drug use, unaware of safety needs. Interventions: Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT (interdisciplinary team) as to causes. The care plan has not updated since April 9, 2024.
On June 4, 2024, at 12:25 PM, V4 Assistant Director of Nursing (ADON) stated, she reviews the falls. She reviews them and puts an intervention in place but does not put that information anywhere except her office. She has not added any new interventions for R21. R21 has to be watched. She is everywhere and will stand up and fall.
The facility's falls and fall risk, managing policy dated 2001 shows, Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and Implementation: Prioritizing Approaches to Managing Falls and Fall Risk: 1. The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff my choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once) .
The facility's falls-clinical protocol policy dated 2001 shows, Cause Identification: 1. For an individual who has fallen, staff will attempt to define a possible cause within 24 hours of the fall . Treatment/Management: 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling .
2. On June 3, 2024, at 10:47 AM, V21 CNA transferred R65 from one reclining wheelchair to another reclining wheelchair. R65 did not have a gait belt on. R65 tried to sit down before he got to the chair and almost fell.
R65's care plan last updated December 31, 2023, shows, July 30, 2023, Staff to use gait belt during transfers.
On June 6, 2024, at 12:36 PM, V4 Assistant Director of Nursing stated, staff should be transferring R65 with a gait belt.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure oxygen tubing was dated and failed to change humidifier containers on the oxygen concentrator for 2 of 4 residents (R23...
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Based on observation, interview, and record review the facility failed to ensure oxygen tubing was dated and failed to change humidifier containers on the oxygen concentrator for 2 of 4 residents (R23, R61) reviewed for oxygen administration in the sample of 20.
The findings include:
On 6/2/24 at 10:42 AM, R23 was in bed with a portable oxygen concentrator next to the bed. R23 stated I am not using it right now because they don't change the filter on the back of the machine or the water container. R23's nasal cannula tubing was not dated, and the humidifier container was dated 4/18/24.
On 6/2/24 at 11:10 AM, R61 was in her room with her portable oxygen concentrator running. The nasal cannula tubing was also not dated, and the humidifier container was dated 4/18/24.
Both R23 and R61's May 2024 Treatment Administration Record (TAR) shows their oxygen tubing and humidifier container are to be changed every week on Sundays. R23 and R61's TAR is initialed as the oxygen tubing and humidifiers being changed however the date on the humidifier for both residents was 4/18/24, and the tubing was not dated.
On 6/3/24 at 8:30 AM, V3 (Assistant Director of Nursing) stated the oxygen tubing and humidifiers should be dated and changed weekly.
The facility Oxygen Administration policy dated 2018 shows that humidifiers should be dated and initialed when changed and should be changed according to facility protocol.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to monitor behaviors and provide stimulation for residents with a diagnosis of dementia. This applies to 3 of 3 residents (R21, R...
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Based on observation, interview, and record review the facility failed to monitor behaviors and provide stimulation for residents with a diagnosis of dementia. This applies to 3 of 3 residents (R21, R53, R138) reviewed for dementia in the sample of 20.
The findings include:
1. R21's face sheet list diagnoses to include dementia.
On June 2, 2024, at 10:08 AM, R21 was sitting in the dining room in her wheelchair. There were no activities going on and she was just sitting there. At 11:15 AM, she was trying to leave the dining room. V22 Certified Nursing Assistant (CNA) brought her back into the dining room and put her at the table. At 12:03 PM, she was standing up and down in her wheelchair trying to take food off other resident's trays. She wheeled herself over to the lunch cart and was trying to take food off the cart. At 12:58 PM, she wandered out of the dining room in her wheelchair and was sitting in another resident's room down the hall. No one was watching her. At 1:29 PM, she tried opening the exit door and set off the alarm. No one was watching her.
On June 3, 2024, at 9:17 AM, R21 was sitting in the dining room doing nothing. At 10:21 V22 CNA started playing bingo with other residents. R21 was not offered to play bingo or played bingo. At 10:32 AM, she kept standing up and down. She ended up falling out of her wheelchair, on her right side.
R21's care plan dated August 8, 2023, shows, The resident has impaired cognitive function/dementia or impaired thought processes r/t Dementia, difficulty making decisions, impaired decision-making, long-term memory loss, neurological symptoms.
R21's care plan does not address her behaviors.
2. R53's face sheet list diagnoses to include dementia.
On June 2, 2024, at 10:20 AM, R53 was sitting in a reclining wheelchair in the dining room doing nothing. There were no activities going on and she was just sitting there. She was fidgeting with a blanket and trying to get out of her wheelchair. At 10:59 AM, she was still sitting in the dining room doing nothing trying to get out of her wheelchair. At 12:58 PM and 1:29 PM, she was still sitting in her reclining wheelchair doing nothing. There was staff in the dining room, but they were not engaging with the resident.
On June 3, 2024, at 9:17 AM, R53 was sitting in the dining room in her reclining wheelchair. There were no activities going on and she was just sitting there. At 10:21 AM, V22 CNA started playing bingo with other residents. R53 was not offered to play bingo or played bingo. She continued just sitting in her wheelchair fidgeting with her shoes and trying to get out of her wheelchair.
R53's care plan does not address her dementia or behaviors.
3. R138's face sheet lists his diagnoses to include dementia. His face sheet also shows R138 is a Korean speaking resident.
On June 2, 2024, at 10:08 AM, 10:20 AM, 10:59 AM, 11:38 AM and 12:58 PM, R138 was sitting in a chair in the dining room. He keeps standing up. V22 CNA would tell him to sit back down. There were no activities going on and he was just sitting there doing nothing.
On June 3, 2024, at 9:17 AM, R138 was sitting in a chair in the dining room. There were no activities going on and he was just sitting there. At 10:21 AM, V22 CNA started playing bingo with other residents. R138 was not offered to play bingo or played bingo. He continued just sitting in the chair doing nothing.
R138's medical record does not have a care plan or address his dementia or behaviors.
On June 4, 2024, at 1:58 PM, V22 Certified Nursing Assistant stated, on certain days she tries to do stuff with the residents but it is too much for one person to do. She is trying to watch the residents that are standing up. She has asked for help because it is too much for one person to do.
The facility's dementia-clinical protocol dated 2001 shows, Treatment/Management: 1. For the individual with confirmed dementia, the IDT (Interdisciplinary team) will identify a resident-centered care plan to maximize remaining function and quality of life 4. Direct care staff will support the resident in initiating and completing activities and tasks of daily living. a. Bathing dressing, mealtimes, and therapeutic and recreational activities will be supervised and supported throughout the day as needed
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure medications were dispensed according to standards of practice for 1 of 20 residents (R26) reviewed for pharmacy service...
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Based on observation, interview, and record review the facility failed to ensure medications were dispensed according to standards of practice for 1 of 20 residents (R26) reviewed for pharmacy services in the sample of 20.
The findings include:
On 6/2/24 at 11:52 AM, on R26's bedside table was a pill cup containing 1 blue pill. R26 stated sometimes when he is in the bathroom, they just leave his medication for him to take. R26 was not able to indicate what pill was in the cup or what time it was left for him. R26 took the pill while this surveyor was in the room.
On 6/2/24 at 12:22 PM, V16 (Registered Nurse/RN) stated residents should be supervised taking their medication and R26 does not have an order that he can self-administer his own medication. V16 also stated if the pill was blue, she believes it was probably his Levothyroxine.
On 6/3/24 at 8:30 AM, V3 (Assistant Director of Nursing/ADON) stated medications should not just be left for residents to take they should be supervised.
R26's Physician Order Summary (POS) shows an order for Levothyroxine to be given one time a day and shows no order for him to self-administer his own medications. R26's Medication Administration Summary shows the Levothyroxine is scheduled to be given at 6:00 AM.
The facility provided pharmacy policy titled Medication Administration (undated) shows that residents can only administer their own medication with a physician order and all residents should be observed during medication administration to ensure a resident takes the medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0825
(Tag F0825)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident admitted for therapy services received therapy se...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident admitted for therapy services received therapy services. This applies to 1 of 4 residents (R84) reviewed for therapy services in the sample of 20.
The findings include:
R84's Face sheet shows that R84 was admitted to the facility on [DATE] with a primary admitting diagnosis of a right femur fracture.
R84's Care Plan shows the resident has a right hip fracture related to a fall from a car accident.
On 6/2/24 at 2:12 PM, R84 stated he was admitted to the facility following surgery after a car accident. He did not believe he was receiving therapy services. He said that V30 (Physical Therapist) was working with him to exercise his leg before V30 went on vacation. R84 stated that V32 (Restorative Certified Nursing Assistant (CNA)) currently works with him on transfers but does not help him walk. On 6/5/24 at 11:08 AM, R84 stated his goal with therapy is to be able to stand and walk again and discharge back home.
On 6/2/24 at 2:40 PM, V32 (Restorative CNA) confirmed he is only doing transfers with the resident at this time and not walking with the resident. He believed that the resident has been discharged from therapy.
On 6/5/24 at 2:18 PM, V33 (Physical Therapist) stated that she has been filling in for V30 while he is on vacation. V33 has not seen R84 during her time at the facility.
R84's Plan of Treatment for Outpatient Rehabilitation form from 5/10/24 states, Pt (patient) is DC (discharged ) from skilled PT (Physical Therapy) services due to no progress and poor motivation. Pt has been referred to restorative program at this time. Long term goals states, Pt will safely ambulate using RW (rolling walker) x 10 feet .
On 6/6/24 at 8:43 AM, R84 stated that V30 never informed him that he was discharged from therapy services and believed he was still making progress. R84 said that he has not reached his goal of being able to walk.
A physical therapy policy was requested from the facility but was not received prior to the exit date of 6/6/24.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were screened for and received all recommended dose...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were screened for and received all recommended doses of the pneumococcal (pneumonia) vaccine for 2 of 5 residents (R388, R38) reviewed for the vaccine in the sample of 20.
The findings include:
1. R388's immunization record (undated) showed R388 was admitted to the facility on [DATE]. The record showed R388 last received a pneumococcal vaccination on 12/26/2000 which showed R388 was currently eligible for an additional pneumococcal vaccine. R388's medical record was reviewed and showed no documentation R388 was screened for or offered a pneumococcal vaccine upon admission to the facility or at any time during his stay in the facility.
2. R38's immunization record (undated) showed R38 was admitted to the facility on [DATE]. R38's Authorization and Release for Pneumococcal Vaccine form dated 8/25/2023 showed R38 was screened for the vaccine and consented to receive the vaccination. R38's medical records dated 8/25/2023-6/2/2024 were reviewed and showed no documentation R38 was administered the vaccine.
On 6/4/2024 at 10:45 AM, V3 Infection Preventionist confirmed R38 had not received a pneumococcal vaccine in the facility and R388 had not been screened for or offered the vaccine. V3 stated residents should be screened for the pneumococcal vaccine upon admission to the facility. V3 stated, We should probably screen residents for the vaccine at least yearly, but we don't do that. I think we only screen residents when we they get admitted . We don't have a nurse responsible for the immunization program. I don't monitor any of that.
The facility's Influenza and Pneumococcal Immunizations-Residents policy (undated) showed, All residents will receive immunizations that aid in preventing infectious diseases unless medically contraindicated or the resident has already been immunized during this time period . All new residents will be assessed for pneumococcal vaccine status upon admission. Residents without proof of previous pneumococcal vaccination should be offered the pneumococcal vaccine(s) unless contraindicated .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review the facility failed to ensure the residents were provided activities. This appli...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review the facility failed to ensure the residents were provided activities. This applies to 3 of 20 residents (R48, R65, R74) reviewed for activities in the sample of 20.
The findings include:
On June 2, 2024, at 10:11 AM, 11:26 AM, 11:39 AM, 11:46 AM, 12:03 PM and 12:58 PM, R48 and R65 were sitting in the dining room in reclining wheelchairs. There were no activities going on. The television was the only thing on.
On June 2, 2024, at 10:30 AM, R74, the facility's resident council president stated, there isn't any activities. They have to entertain themselves.
On June 3, 2024, at 10:03 AM, R48 and R65 were sitting in the dining room in their reclining wheelchairs. There were no activities going on. The television was the only thing on. At 10:21 AM, V22 Certified Nursing Assistant (CNA) started playing BINGO with the residents that could play (5 residents). R48 and R65 did not play bingo but remained in the dining room watching everyone else play.
On June 4, 2024, at 12:25 PM, V3 Assistant Director of Nursing (ADON) stated, there is no activity director and only 1 activity assistant.
On June 4, 2024, at 1:58 AM, V22 CNA stated, only on certain days they do stuff with the residents. It's too much for one person. She stated, she is trying to watch the residents that stand up and do activities and she can't by herself.
R48's activities quarterly/annual participation review dated March 18, 2024, shows, The resident is alert but not oriented and likes to sit with her peers in the group. She is interested to do building blocks .
R48's activities care plan dated November 30, 2021, shows, Focus: Resident is alert/oriented but confused/forgetful at times with impaired cognition due to Dementia Has interest in religious r/t (related to) programs. Interventions: 2. Encourage to attend/participate in interim activity program as tolerated and increase socialization. 3. Inform the resident when programs of interest occur. Orient to the activity calendar. 5. Offer the resident independent leisure materials with options addressing areas she might like to pursue. 14. Do daily round/short pop-up visit.
R65's care plan dated May 4, 2023, shows, Interventions .The resident needs a variety of activity types and locations to maintain interests.
R74's Minimum Data Set, dated [DATE], shows, he is cognitively intact.
The facility's activity calendar for June 2024 shows, June 2nd: 10:00 AM- Documentary, 1:30 PM Classic Music. June 3rd: 10:00 AM- Exercise, 1:30 PM Rock & Roll. None of these activities were done during the survey.
The facility did not provide an activity policy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure opened, multi-dose bottles of medication, inhalers, and insulin pens were labeled with expiration dates for 4 of 4 resi...
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Based on observation, interview, and record review the facility failed to ensure opened, multi-dose bottles of medication, inhalers, and insulin pens were labeled with expiration dates for 4 of 4 residents (R64, R20, R45, R82) reviewed for medication storage in the sample of 20.
The findings include:
1. R64's June 2024 (physician) Order Summary report showed R64 received Advair Diskus (powder) inhaler, 100-50 mcg (micrograms), one puff, twice a day. The order showed R64 received 30 units of Glargine insulin, subcutaneous (SQ), daily.
R20's June 2024 (physician) Order Summary report showed R20 received Lispro insulin, as per sliding scale instructions, SQ (subcutaneous), four times a day.
R45's June 2024 (physician) Order Summary report showed R45 received Lantus insulin, 25 units, SQ, daily.
On 6/2/2024 at 10:50 AM, the third-floor medication (med) cart was reviewed by this surveyor and V16 Registered Nurse (RN). Upon inspection of the cart, the following medications were found opened and not dated with an opened or expiration date:
a)
A Lantus insulin pen and Advair Diskus inhaler for R64.
b)
A vial of Lispro insulin for R20.
c)
A Lantus insulin pen for R45.
On 6/2/24 at 11:00 AM, V17 RN stated all medication vials/bottles are to be dated when opened so staff know when the medication expires.
2. R82's June 2024 (physician) Order Summary report showed R82 received Latanoprost 0.005% eye drops, one drop to both eyes as needed.
On 6/2/24 at 10:35 AM, the second-floor med cart was reviewed by this surveyor and V15 RN. A medicine cup, containing 6 pills of different sizes and colors was noted in the top drawer of the med cart. When asked about the cup of pills, V15 stated, They have been there since yesterday. I don't know who they are for. They should be labeled with a name, so we know who they are for. One opened/not dated bottle of Latanoprost eye drops for R82 was noted in the cart. When V15 was asked why medications should be dated when opened, V15 stated, I know they should be dated but I'm not sure why.
The facility's Storage of Medications policy dated 10/25/2014 showed, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of supplier . When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new expiration date . The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guideline require different dating .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
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 ensure that a resident with a multi-drug resistant uri...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident with a multi-drug resistant urinary infection was placed on contact isolation. The facility failed to initiate enhanced barrier precautions on residents with a catheter, tube feeding, and/or wounds. These failures apply to 5 of 20 residents (R51, R4, R84, R1, R24) reviewed for infection control in the sample of 20.
The findings include:
1. R51's Order Summary Report shows R51 is receiving Meropenem-Sodium Chloride (intravenous antibiotic), two times a day for a UTI (urinary tract infection). This order was started on 5/29/24.
On 6/3/24 at 8:39 AM, R51's door or room had no signs of contact isolation precautions in place. At 9:09 AM, R51 was lying in bed receiving her scheduled intravenous antibiotic.
On 6/3/24 at 8:26 AM, V3 (Assistant Director of Nursing) stated that R51 had ESBL (extended spectrum beta-lactamase; a multi-drug resistant organism) in the urine and that R51 was not on contact isolation and there is not an isolation cart of sign outside the room to notify staff. V3 stated R51 should be on contact isolation.
Facility Isolation-- Initiating Transmission-Based Precautions policy dated 2009 states, . 1. If a resident is suspected of, or identified as, having a communicable infectious disease, the Charge Nurse or Nursing Supervisor shall notify the DON (Director of Nursing) and/or the NHA (Nursing Home Administrator) and the resident's Attending Physician for appropriate Transmission-Based Precautions.
2. On 6/2/24 at 10:51 AM, R4 was lying in bed with a urinary catheter attached. In the corner of R4's room, next to the head of her bed, a tube feeding bag was suspended from a metal hanger but was not initiated. There were no enhanced barrier precaution signs on the outside of R4's room.
R4's Minimum Data Set (MDS) dated [DATE] shows R4 has an indwelling catheter and receives 51 percent or more of her total calories and fluids through a tube feeding.
3. On 6/2/24 at 1:58 PM, R84 was lying in bed with a urinary catheter attached. No enhanced barrier precaution sign was noted outside of R84's room.
R84's Care Plan shows that the resident has an indwelling catheter.
On 6/3/24 at 8:26 AM, V3 (Assistant Director of Nursing) stated they do not currently have a policy or follow guidance for enhanced barrier precautions.
4.) On 6/3/24 at 10:10 AM, R24 was in bed with his feeding tube infusing into his gastrostomy tube via a pump. R1 who is R24's roommate also had a gastrostomy tube. V3 (Assistant Director of Nursing/ADON) completed a dressing change to R24's stage 2 sacral pressure injury. V24 (CNA) came into the room to assist her with the dressing change. V3 and V24 did not wear gowns during the dressing change (which are required with enhanced barrier precautions). There was no sign on the outside door to indicate either resident was on enhanced barrier precautions and there was no PPE (Personal Protective Equipment) cart outside of the room.
On 6/3/24 at 8:30 AM, V3 stated enhanced barrier precautions are for residents who have catheters, feeding tubes and wounds but the facility has not gotten around to implementing that yet.
On 6/6/24 at 1:10 PM V3 (Assistant Director of Nursing) confirmed the facility does not have an enhanced barrier policy.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0680
(Tag F0680)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to employ a qualified, full time activity director. This ...
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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 employ a qualified, full time activity director. This failure applies to all 84 residents residing in the facility.
The findings include:
The CMS-671 form dated June 2, 2024, shows, there was 84 residents residing in the facility.
On June 2nd and 3rd, 2024, no activities were observed.
On June 2, 2024, at 10:30 AM, R74, the facility's resident council president stated, there isn't any activities. They have to entertain themselves.
R74's Minimum Data Set, dated [DATE], shows, he is cognitively intact.
On June 4, 2024, at 12:25 PM, V3 Assistant Director of Nursing stated, there is no activity director and one activity assistant.
On June 5, 2024, at 9:14 AM, V2 Director of Nursing stated, she does not have a activity director. She has been gone since March 2024. There is only 1 activity assistant for the entire building. She does not have the qualifications of an activity director.
The facility's job description and performance standards for the activity director shows, Purpose of this position: The purpose of this position is to develop and implement an activity program in compliance with requirements to meet residents' needs.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide sufficient nursing staff to meet the needs 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 provide sufficient nursing staff to meet the needs of the residents. This failure has the potential to affect all 84 residents in the facility.
The findings include:
The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 6/2/2024 showed a resident census of 84.
1. R4's Minimum Data Set (MDS) dated [DATE] shows R4 is dependent upon staff for oral hygiene, toileting hygiene, showering/bathing, lower body dressing, personal hygiene, putting on/taking off footwear, rolling left to right in bed, and for all transfers.
On 6/2/24 at 10:51 AM, R4 was lying in bed watching television. R4's call light rope was hanging from a switch above R45's (R4's roommate) bed. R4, although nonverbal, was able to say yes when asked if she had a difficult time asking for help from staff.
On 6/3/24, direct observations from the third-floor nurse's station were made from 12:07 PM until 12:24 PM. During that time, R4 was making intermittent audible verbal sounds at 12:07 PM, 12:10 PM, 12:13 PM, 12:14 PM, 12:17 PM. R4's audible noises became louder and R4 would continue with the noises for roughly 15 seconds at a time. At 12:18 PM, R45 (R4's roommate) returned to the room and stated that R4 makes those noises when she needs help. R45 proceeded to communicate with R4 to determine the level of help she required.
On 6/3/24 at 12:20 PM, R45 left the room to go alert staff that R4 required assistance.
On 6/3/24 at 12:22 PM, R4's audible noises turned into what sounded like a painful howl. V16 Registered Nurse (RN) entered R4's room at 12:24 PM with another staff member to address R4's needs.
2. On 6/2/24 at 11:39 AM, R24, who is nonverbal, was lying in bed. His nails, on both hands, were approximately 1/2-1 inch in length, with some curling back.
R24's shower schedule shows he should receive showers/baths on Monday and Thursday. The facility shower sheets for R24 showed he had a bed bath on 5/6/24 and not again until 6/3/24.
R24's active care plan shows he has a diagnosis of dementia, communication deficit, and requires extensive to total staff assistance with his Activities of Daily Living.
On 6/5/24 at 9:00 AM, R24 was observed to still have long nails.
3. On 6/2/24 at 11:40 AM, R1 was sitting up in a chair in his room. R1 had long stubbly facial hair, and very long nails with a visible black thick substance under the nail beds. R1 said, Yes these nails are very long. I need them cut. The facility shower schedule showed R1 should be given showers on Mondays and Thursdays.
On 6/5/24 at 9:01 AM, R1 was observed to still have long dirty nails and facial stubble.
R1's active care plan shows he has a self-care deficit and requires extensive staff assistance with his ADL's.
4. On 6/2/24 at 10:10 AM, R64 stated she has only gotten one shower since she was admitted about a month ago, and she only got that because her mom came to the facility and threw a fit. The facility shower schedule showed R64 should receive a shower on Mondays and a second shower was not listed for R64. Facility shower sheets indicate that R64 refused a shower on 5/6/24, and 5/13/24 but was given one on 5/20/24, which was her last documented shower.
5. On 6/2/24 at 11:37 AM, R24 who is nonverbal, was lying in bed with contractures noted to both hands. R24's active care plan shows he has diagnoses including dementia and right sided weakness due to a cerebral vascular accident with contractures to his upper body.
R24's Restorative Care Plan shows he requires extensive staff assistance with his Activities of Daily Living and should receive PROM (passive range of motion) to his affected extremities for 15 minutes a day. R24's restorative documentation for the last 30 days showed he was provided range of motion for 15 minutes on 8 out of 30 days 5/9/24, 5/10/24, 5/11/24, 5/16/24, 5/20/24, 5/24/24, 5/29/24 and 6/1/24.
On 6/3/24 at 1:42 PM V3 (Assistant Director of Nursing) stated they have a restorative CNA (Certified Nursing Assistant) who should be doing range of motion, and working with residents but he gets pulled to work the floor a lot and then restorative is left up to the CNAs on the floor to complete.
On 6/5/24 at 9:13 AM, V32 (Restorative CNA) stated he just covered another CNA's vacation and was pulled to the floor to work for the last 8 days. V32 stated when he is pulled to the floor, he cannot get his restorative job done and the CNA's have to do their own restorative and that may not always be done.
On 6/5/24 at 9:20 AM, V24 (CNA) stated she tries to do range of motion for R24 but cannot always get to it when she is the only CNA on that hall.
6. On 6/2/24 at 10:11 AM, R64 said she was receiving physical therapy however the therapist (V30 Physical Therapist) went out of the country so she was supposed to be walked by the nursing staff but that has not been getting done. R64 additionally stated they are claiming that I always refuse to walk, and I don't. If someone wakes me up, I will go walk with them.
On 6/5/24 at 9:25 AM, R64 stated she was walked by her mom yesterday and when her son comes in, he will also walk her. R64 said one day last week she was too tired to walk because a medication she was on was making her sleepy and did refuse to go but that was the only time that has happened.
On 6/5/24 at 9:13 AM, V32 (Restorative CNA) stated R64 is supposed to be walked to the bathroom and back, with a walker, and she can do that with stops to rest, but he is not sure if that is being done when he is pulled to work the floor.
On 6/5/24 at 9:35 AM, V27 (CNA) stated he cannot always get time to walk residents when V32 (Restorative CNA) is not there.
On 6/3/24, during the resident meeting, R11 and R40 each stated there was not always a nurse assigned to the third floor on the night shift (11 PM-7 AM). R11 stated, There are nights we don't have a nurse. I get scared because what if I choke and no one is there to help me? When we don't have a nurse at night, my 6 AM meds (medications) are late. They aren't given until after 7 AM when the day nurse arrives.
On 6/4/24 at 10:00 AM, R28 stated, There has been nights when we haven't had a nurse on the floor. One night I needed a pain pill but there was no one to tell.
On 6/3/24 at 2:00 PM, the facility's nursing schedules dated 5/19/24-6/2/24 were reviewed and showed the following:
a. On 5/19/24 (Sunday), V34 Registered Nurse (RN) was assigned to both the second and third floors of the facility from 11 PM-7 AM. A daily census form dated 5/19/24 showed 1 Nurse (V34) was responsible for 87 residents from 11 PM-7 AM.
b. On 5/20/24 (Monday), No nurse was assigned to the second floor of the facility from 11 PM-7 AM. V2 Director of Nursing (DON) was assigned to the third floor from 11 PM-7 AM. A daily census form dated 5/20/24 showed 1 Nurse (V2 DON) was responsible for 87 residents from 11 PM- 7 AM.
c. On 5/27/24 (Monday), V34 RN was assigned to both the second and third floors of the facility from 11 PM-7 AM. A daily census form dated 5/27/24 showed 1 Nurse (V34) was responsible for 85 residents from 11 PM-7 AM.
d. On 5/28/24 (Monday), V34 RN was assigned to both the second and third floors of the facility from 11 PM-7 AM. A daily census form dated 5/28/24 showed 1 Nurse (V34) was responsible for 86 residents from 11 PM-7 AM.
e. On 6/2/24 (Sunday), No nurse was assigned to the second floor of the facility from 11 PM-7 AM. V34 RN was assigned to the third floor from 11 PM-7 AM. A daily census form dated 6/2/24 showed 1 Nurse (V34) was responsible for 85 residents from 11 PM-7 AM.
On 6/4/24 at 7:43 AM, V19 RN stated, I always work the second floor. We are sometimes short-staffed. There have been nights when I am the only nurse for the whole building . If I work both floors, I don't pass 6 AM meds on the third floor. I don't have time. I will pass PRN (as needed) meds to residents on the third floor if they need them .I tell the CNAs on the third floor to call me if there is an emergency.
On 6/4/24 at 10:07 AM, V16 RN stated, Yes, there have been days that I have come in for day shift and there has not been a night nurse. Sometimes residents haven't gotten their 6 AM meds.
On 6/4/24 at 11:56 AM, V2 DON stated she was responsible for completing the nursing schedule and ensure sufficient staffing. V2 stated she was aware the facility was short-staffed, specifically on nights (11 PM-7 AM). V2 stated, We are supposed to have one nurse assigned to the second floor and one nurse assigned to the third floor on nights. There are nights we only have one nurse for both floors, but I sleep here in case they need anything.
The facility's Facility Assessment Tools revised 7/31/23 showed the second floor and third floors were to each have their own nurse assigned from 11 PM- 7 AM as part of the facility resources needed to provide competent support and care for resident population every day and during emergencies.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to provide medically related social services to meet the needs of the residents. This failure has the potential to affect all 84 ...
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Based on observation, interview, and record review the facility failed to provide medically related social services to meet the needs of the residents. This failure has the potential to affect all 84 residents in the facility.
The findings include:
The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 6/2/2024 showed a resident census of 84.
1. R21's face sheet list diagnoses to include dementia.
On June 2, 2024, at 10:08 AM, R21 was sitting in the dining room in her wheelchair. At 11:15 AM, she was trying to leave the dining room. V22 Certified Nursing Assistant (CNA) brought her back into the dining room and put her at the table. At 12:03 PM, she was standing up and down in her wheelchair trying to take food off other resident's trays. She wheeled herself over to the lunch cart and was trying to take food off the cart. At 12:58 PM, she wandered out of the dining room in her wheelchair and was sitting in another resident's room down the hall. No one was watching her. At 1:29 PM, she tried opening the exit door and set off the alarm. No one was watching her.
On June 3, 2024 at 9:17 AM, R21 was sitting in the dining room doing nothing. At 10:21 V22 CNA started playing bingo with other residents. R21 was not offered to play bingo or played bingo. At 10:32 AM, she kept standing up and down. She ended up falling out of her wheelchair, on her right side.
R21's care plan dated August 8, 2023, shows, The resident has impaired cognitive function/dementia or impaired thought processes r/t Dementia, difficulty making decisions, impaired decision-making, long-term memory loss, neurological symptoms.
R21's care plan does not address her behaviors.
2. R53's face sheet list diagnoses to include dementia.
On June 2, 2024, at 10:20 AM, R53 was sitting in a reclining wheelchair in the dining room doing nothing. She was fidgeting with a blanket and trying to get out of her wheelchair. At 10:59 AM, she was still sitting in the dining room doing nothing trying to get out of her wheelchair. At 12:58 PM and 1:29 PM, she was still sitting in her reclining wheelchair doing nothing. There was staff in the dining room, but they were not engaging with the resident.
R53's care plan does not address her dementia or behaviors.
3. R138's face sheet lists his diagnoses to include dementia. His face sheet also shows R138 is a Korean speaking resident.
On June 2, 2024, at 10:08 AM, 10:20 AM, 10:59 AM, 11:38 AM and 12:58 PM, R138 was sitting in a chair in the dining room. He keeps standing up. V22 CNA would tell him to sit back down. There were no activities going on and he was just sitting there doing nothing.
R138's medical record does not have a care plan or address his dementia or behaviors.
4. On 6/3/24, during the resident meeting, R11, R55, and F74 each stated the facility did not have a full-time social worker. R55 stated, They have a part-time woman that comes a couple of hours in the evening a few days a week, but we hardly ever see her. R55 stated she had an ongoing conflict with her new roommate with no resolution due to no one here to deal with it. R55 stated she needed someone's assistance to help her work with my insurance so I can find a dentist but there's no one to help do that either. R11 stated, I see my counselor (contracted psychiatric social worker) once a week when she comes in but, I have no one to talk to if I am upset and need to talk to someone when she isn't here.
5. R28's Social Service note dated 4/17/24 showed R28 was seen upon admission to the facility by social services. The note showed R28 was admitted to the facility for subacute rehab after a flare-up of her Multiple Sclerosis. R28's medical records dated 4/18/24-6/3/24 showed no other social services notes for R28.
On 6/4/24 at 10:00 AM, R28 stated, I was admitted here for rehab. I have a MS (Multiple Sclerosis) flare-up and broke a rib. The plan was never for me to stay here long term. I have a cat and my own apartment. I need to go home. No one has talked to me about my discharge. I haven't talked to anyone in social services in months.
On 6/3/24 at 8:44 AM, V3 Assistant Director of Nursing (ADON) stated, We have not had a full-time social worker in a long time. We have (V18 part-time Social Services) that comes in a few hours during the evenings, but she is part-time.
On 6/3/24 at 12:12 PM, V18 (part-time Social Services) stated, I work very part-time there. I am under social services, but I am just helping out. I come in for 3-4 hours during the evening; 3-4 days a week. I help do care plans and MDS's (Minimum Data Set), but I am a little behind on the care plans. V18 stated, I don't do any discharge planning. I don't handle grievances unless someone complains to me. I don't do anything with resident council. I don't help set up appointments or counsel residents unless someone stops me when I'm there. I don't do any behavior management counseling unless I see behaviors happening when I'm there. V18 stated R55 did ask her to help R55 find another dentist but told R55 that she does not help with medical referrals. V18 stated, I told her to tell nursing about it.
On 6/3/24 at 11:44 AM, V1 Administrator of the facility stated they had not had a full-time social worker in a while.
On 6/3/24 at 11:47 AM, V2 Director of Nursing stated, We haven't had someone in full-time in Social Services for a long time. V2 stated social services is responsible for handling resident problems, problems with roommates, resident's grievances, help with behavior management, helping schedule and set-up monthly resident council meetings, and doing discharge planning for residents.
On 6/3/24 at 12:15 PM, V17 Human Resources stated the last time the facility had a full-time social services employee was last year. V17 stated, We have never had a Social Service Director that I am aware of. We used to have a consultant for social services but that hasn't been since last year.
On 6/4/24 at 11:05 AM, V17 Human Resources stated, I am responsible for providing the yearly abuse, harassment, and privacy education to our nursing staff. Social services usually does the staff dementia training every year but we don't have anyone in social services to do it.
On 6/4/24 at 8:31 AM, V3 ADON was asked for the facility's grievance logs from 3/1/24-6/4/24. V3 stated, I don't think we have any. We don't have anyone to complete the logs and always follow up on them. That would be done by social services.
A facility form dated 6/4/24 showed no documented grievances from March 2024-June 2024.
The facility's Social Service Director (Designee) job description (undated) showed, The purpose of this position is to provide social services to meet the social and/or emotional needs that affect the residents' ability to achieve their highest level of function; participate in the development of residents' comprehensive care plans; develop policies and procedures to provide social services to residents in compliance with federal, state and local regulations The job description showed the Social Service Director was responsible for developing and coordinating family and resident activities designed to promote social interaction . develop one-to-one professional relationships with residents and families as needed for counseling . assess, plan, and document residents' discharge needs . document the social service component of the Comprehensive Care Plan for each resident in a timely manner . refer residents to social, health and community resources and complete accurate documentation in residents' records concerning the results of such referrals .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to ensure a serving spoon was sanitized and air dried to prevent foodborne illness. This has the potential to affect all 82 resid...
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Based on observation, interview, and record review the facility failed to ensure a serving spoon was sanitized and air dried to prevent foodborne illness. This has the potential to affect all 82 residents in the facility receiving food from the kitchen.
The findings include:
The CMS 671 dated 6/2/24 shows there are 84 residents residing in the facility.
On 6/2/24 at 11:53 AM, V12 (Cook) handed V10 (Dietary Aide) a serving spoon that became soiled during service. V10 took the serving spoon to the three-compartment sink, and quickly dipped the spoon through each individual sink. At the sanitizer sink, V10 dipped the spoon a few times, removed the spoon from the sink, and proceeded to dry the spoon with brown disposable paper towels. V10 returned the spoon to V12 and V12 continued to use the spoon for the remainder of service.
On 6/2/24 at 10:01 AM, V4 stated that all dishes are currently being done using the three-compartment sink. The dish machine has been broken for a few years and is not currently in use. When using the three-compartment sink, dishes need to be fully submerged for one full minute in order to sanitize the items. The items then need to be air dried.
Facility Manual Sanitizing in Three-Compartment Sink policy dated 2017 states, A sink with three compartments is used for manually washing, rinsing, and sanitizing utensils and equipment that can be submerged . After washing and rinsing utensils or equipment are sanitized in the third sink by immersion in either: Hot water (at least 171 Fahrenheit (F) for thirty seconds) or chemical sanitizing solution used according to manufacturer's instructions. The most common chemical sanitizers are chlorine, iodine, and quaternary ammonia. The manufacturer's label is referenced for the appropriate concentration of the sanitizing solution and for length of submersion time.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review facility administration failed to manage the facility in manner to effectively meet the needs of the residents.
This failure has the potential to aff...
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Based on observation, interview and record review facility administration failed to manage the facility in manner to effectively meet the needs of the residents.
This failure has the potential to affect all 84 residents in the facility.
The findings include:
The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 6/2/2024 showed a resident census of 84.
1. On June 2, 2024, at 10:11 AM, 11:26 AM, 11:39 AM, 11:46 AM, 12:03 PM and 12:58 PM, R48 and R65 were sitting in the dining room in reclining wheelchairs. There were no activities going on. The television was the only thing on.
On June 2, 2024, at 10:30 AM, R74 the resident council president stated, there isn't any activities. They have to entertain themselves.
On June 4, 2024, at 12:25 PM, V3 Assistant Director of Nursing (ADON) stated, there is no activity director and only 1 activity assistant.
2. On 6/3/24, during the resident meeting, R11, R55, and F74 each stated the facility did not have a full-time social worker. R55 stated, They have a part-time woman that comes a couple of hours in the evening a few days a week, but we hardly ever see her. R55 stated she had an ongoing conflict with her new roommate with no resolution due to no one here to deal with it. R55 stated she needed someone's assistance to help her work with my insurance so I can find a dentist but there's no one to help do that either. R11 stated, I see my counselor (contracted psychiatric social worker) once a week when she comes in but, I have no one to talk to if I am upset and need to talk to someone when she isn't here.
On 6/3/24 at 8:44 AM, V3 Assistant Director of Nursing stated, We have not had a full-time social worker in a long time. We have (V18 part-time Social Services) that comes in a few hours during the evenings, but she is part-time.
3. On 6/3/24, during the resident meeting, R11 and R40 each stated there was not always a nurse assigned to the third floor on the night shift (11 PM-7 AM). R11 stated, There are nights we don't have a nurse. I get scared because what if I choke and no one is there to help me? When we don't have a nurse at night, my 6 AM meds (medications) are late. They aren't given until after 7 AM when the day nurse arrives.
On 6/4/24 at 10:00 AM, R28 stated, There has been nights when we haven't had a nurse on the floor. One night I needed a pain pill but there was no one to tell.
On 6/3/24 at 2:00 PM, the facility's nursing schedules dated 5/19/24-6/2/24 were reviewed and showed the following:
a. On 5/19/24 (Sunday), V34 Registered Nurse (RN) was assigned to both the second and third floors of the facility from 11 PM-7 AM. A daily census form dated 5/19/24 showed 1 Nurse (V34) was responsible for 87 residents from 11 PM-7 AM.
b. On 5/20/24 (Monday), No nurse was assigned to the second floor of the facility from 11 PM-7 AM. V2 Director of Nursing (DON) was assigned to the third floor from 11 PM-7 AM. A daily census form dated 5/20/24 showed 1 Nurse (V2 DON) was responsible for 87 residents from 11 PM- 7 AM.
c. On 5/27/24 (Monday), V34 RN was assigned to both the second and third floors of the facility from 11 PM-7 AM. A daily census form dated 5/27/24 showed 1 Nurse (V34) was responsible for 85 residents from 11 PM-7 AM.
d. On 5/28/24 (Monday), V34 RN was assigned to both the second and third floors of the facility from 11 PM-7 AM. A daily census form dated 5/28/24 showed 1 Nurse (V34) was responsible for 86 residents from 11 PM-7 AM.
e. On 6/2/24 (Sunday), No nurse was assigned to the second floor of the facility from 11 PM-7 AM. V34 RN was assigned to the third floor from 11 PM-7 AM. A daily census form dated 6/2/24 showed 1 Nurse (V34) was responsible for 85 residents from 11 PM-7 AM.
On 6/4/24 at 7:43 AM, V19 RN stated, I always work the second floor. We are sometimes short-staffed. There have been nights when I am the only nurse for the whole building . If I work both floors, I don't pass 6 AM meds on the third floor. I don't have time. I will pass PRN (as needed) meds to residents on the third floor if they need them .I tell the CNA's on the third floor to call me if there is an emergency.
On 6/4/24 at 10:07 AM, V16 RN stated, Yes, there have been days that I have come in for day shift and there has not been a night nurse. Sometimes then residents haven't gotten their 6 AM meds.
On 6/4/24 at 11:56 AM, V2 DON stated she was responsible for completing the nursing schedule and ensure sufficient staffing. V2 stated she was aware the facility was short-staffed, specifically on nights (11 PM-7 AM). V2 stated, We are supposed to have one nurse assigned to the second floor and one nurse assigned to the third floor on nights. There are nights we only have one nurse for both floors, but I sleep here in case they need anything.
4. R6's progress note dated 4/22/24 shows, Writer was called to R6's room, resident was choking. 911 was called. Heimlich maneuver was performed, a piece of tomato was expelled.
On 6/3/24 at 1:02 PM, V5 (LPN) stated that at the time of the choking event, R6 was lying in bed. V5 was called into R6's room by V6 (Certified Nursing Assistant (CNA)). When V5 entered R6's room, R6 was purple and could not speak. V5 initiated the Heimlich maneuver on R6 and a tomato piece, approximately the size of a quarter, came flying out. V5 stated R6 was receiving a mechanical soft diet on 4/22/24 and is still on a mechanical soft diet.
R6's progress note dated 4/28/24 shows, Resident readmitted from local hospital via local paramedics. He was on iv (intravenous) antibiotics to treat aspirated pneumonia while at local hospital . On minced moist diet with thin liquid .
On 6/3/24 at 2:05 PM, V4 (Food Service Manager/FSM) stated he has been in his role as food service manager for about three years. V4 only has a food protection manager certification that has expired. V4 is not a certified dietary manager. V4 has not begun the process of signing up to take the certified dietary manager coursework as of 6/3/24. V4 stated that he doesn't always know exactly what to do in his position. There isn't someone on site at all times for him to refer to when he has questions.
V4's provided food protection manager certification shows an expiration date of 4/23/24.
On 6/6/24 at 10:18 AM, V1 Administrator was asked what his responsibilities were as administrator of the facility. V1 stated, I think of my role as COO (Chief Operating Officer). I overlook the operations of the facility. (V2 Director of Nursing/DON) hires and fires staff. Both (V2) and I are responsible for making sure we have staff in key positions. V1 stated, I am aware we haven't had a full-time social service person in a while. I know (V2) is actively trying to fill that role. V1 stated he wasn't aware that residents' discharge planning, care plans, and grievances weren't being done in a timely manner or done at all due to not having dedicated full-time social services staff. V1 stated he was aware that V4 (Food Service Manager) had been in that role for three years and had never been certified for the position. V1 stated he never gave V4 a deadline as to when he needed to have his Food Service Manager certification. When V1 was asked if he was okay with V4 working in the role as food service manager while not being certified, V1 stated, No I am not okay with (V4) working as the food service manager and not being certified in the role. I can only do so much for this organization. V1 stated R6's April 2024 choking episode had not been reported to him prior to the week of 6/2/24. V1 stated, I should have been notified. I also wasn't aware that the kitchen wasn't serving the right diets until you guys came in for survey. V1 stated he was aware the facility was without an activity director. V1 stated, I leave the hiring and firing of that position (activity director) to (V2 DON). V1 stated he wasn't aware that there had been nights when the facility only had one nurse for the entire building. V1 stated he thought (V2 DON) was taking care of any staffing issues. V1 stated he realized the lack of key staff members and the lack of resident cares associated with a lack of staff falls on him.
On 6/5/24 at 10:40 AM, V29 (Medical Director) stated he was not aware the facility did not have an activity director or full-time social services staff. V29 stated he was not aware V4 Food Services Manager had been working in the role for three years and had never been certified for the role. V29 stated he was not aware there were nights the facility only had one nurse scheduled to care for all of the residents. V29 stated, I speak with (V1 Administrator) at least one-two times a month. He didn't tell me about any of these issues. I didn't know about any of this. He should have people in place to handle this. I just assumed he did.
The facility's Administrator job description (undated) showed, The purpose of this position is to establish and maintain systems that are effective and efficient to operate a facility in a manner to safely meet the residents' needs in compliance with federal, state and local requirements . The job description showed the administrator's responsibilities included, determining the personnel requirements of the facility and hire or arrange for sufficient staff to implement facility policies and procedures . supervise the recruitment, employment, performance, evaluation, promotion, and discharge of all staff . Assume responsibility with department supervisors to implement effective policies to assure adequate staffing to meet facility needs .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Social Worker
(Tag F0850)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to provide/employ a qualified, full-time social worker. This failure has the potential to affect all 84 residents in the facility.
The findings...
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Based on interview and record review the facility failed to provide/employ a qualified, full-time social worker. This failure has the potential to affect all 84 residents in the facility.
The findings include:
The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 6/2/2024 showed a resident census of 84.
The facility's Facility Assessment Tool revised 7/31/23 showed the facility has a maximum bed capacity of 230 beds.
On 6/3/24, during the resident meeting, R11, R55, and R74 each stated the facility did not have a full-time social worker. R55 stated, They have a part-time woman that comes a couple of hours in the evening a few days a week, but we hardly ever see her. R55 stated she had an ongoing conflict with her new roommate with no resolution due to no one here to deal with it. R55 stated she needed someone's assistance to help her work with my insurance so I can find a dentist but there's no one to help do that either. R11 stated, I see my counselor (contracted psychiatric social worker) once a week when she comes in but, I have no one to talk to if I am upset and need to talk to someone when she isn't here.
On 6/3/24 at 8:44 AM, V3 Assistant Director of Nursing stated, We have not had a full-time social worker in a long time. We have (V18 part-time Social Services) that comes in a few hours during the evenings, but she is part-time.
On 6/3/24 at 11:44 AM, V1 Administrator state the facility had not had a full-time social worker in a while.
On 6/3/24 at 12:12 PM, V18 (part-time Social Services) stated, I work very part-time there. I am under social services, but I am just helping out. I come in for 3-4 hours during the evening; 3-4 days a week. I help do care plans and MDS's (Minimum Data Set). V18 stated, I don't do any discharge planning. I don't handle grievances unless someone complains to me. I don't do anything with resident council. I don't help set up appointments or counsel residents unless someone stops me when I'm there. I don't do any behavior management counseling unless I see behaviors happening when I'm there.
The facility's Social Service Director (Designee) job description (undated) showed, The purpose of this position is to provide social services to meet the social and/or emotional needs that affect the residents' ability to achieve their highest level of function; participate in the development of residents' comprehensive care plans; develop policies and procedures to provide social services to residents in compliance with federal, state and local regulations The job description showed the Social Service Director was responsible for developing and coordinating family and resident activities designed to promote social interaction . develop one-to-one professional relationships with residents and families as needed for counseling . assess, plan, and document residents' discharge needs . document the social service component of the Comprehensive Care Plan for each resident in a timely manner . refer residents to social, health and community resources and complete accurate documentation in residents' records concerning the results of such referrals .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to ensure nursing staff received dementia care training and education, annually, as required.
This failure has the potential to affect all 84 r...
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Based on interview and record review the facility failed to ensure nursing staff received dementia care training and education, annually, as required.
This failure has the potential to affect all 84 residents in the facility.
The findings include:
The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 6/2/2024 showed a resident census of 84.
On 6/4/24 at 11:00 AM, the following employee files were reviewed:
1. V22 Certified Nursing Assistant's (CNA) file showed V22 had been employed by the facility since 4/6/2014. V22's file showed V22 had received no dementia education or training in 2023 or 2024.
2. V28's file showed V28 had been employed by the facility since 8/12/1991. V28's file showed V28 had received no dementia education or training in 2023 or 2024.
3. V26's file showed V26 had been employed by the facility since 8/7/2015. V26's file showed V26 had received no dementia education or training in 2023 or 2024.
4. V21's file showed V21 had been employed by the facility since 11/1/2017. V21's file showed V21 had received no dementia education or training in 2023 or 2024.
5. V6's file showed V6 had been employed by the facility since 1/19/2022. V6's file showed V6 had received no dementia education or training in 2023 or 2024.
On 6/4/24 at 11:05 AM, V17 Human Resources stated, I am responsible for providing the yearly abuse, harassment, and privacy education to our nursing staff. Social services usually does the staff dementia training every year but we don't have anyone in social services to do it. V17 confirmed V22, V28, V26, V21, and V6 had not received dementia training or education in 2023 or 2024.
The facility's Facility Assessment Tool revised 7/31/2023 showed the nursing staff education and competencies to be completed, upon hire and as required, included education/training on abuse, resident rights, and dementia care.
Jul 2023
22 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Incontinence Care
(Tag F0690)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to set up a urology appointment for a resident with a supr...
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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 set up a urology appointment for a resident with a suprapubic urinary catheter for (R46) 1 of 4 residents reviewed for urinary catheters in the sample of 20. This failure resulted in R46 suffering from catheter pain, leaking, urinary blockages and infections requiring emergency treatments.
The findings include:
R46's Minimum Data Set assessment dated [DATE] shows that her cognition is intact, and she has an indwelling urinary catheter.
On 7/10/23 at 1:58 PM, the back of R46's pants were wet. R46 said that she has a catheter that causes her constant pain, leaking and burning. R46 said that she is supposed to be seeing a Urologist, but she is waiting on the nurses to set up an appointment.
R46's Nursing notes on 1/29/23 indicates, Resident c/o (complains of) painful burning upon urination and the suprapubic catheter leaking. Noted sediment inside the suprapubic catheter tubing with scant amt (amount) of urine noted called [Urogynecologist] ok to change the catheter and monitor .attempted to change suprapubic catheter and when balloon deflated unable to pull tube out met with much resistance spoke to [Urogynecology Nurse] .she is also aware that she has an appointment February 1 .
R46's Nursing note on 2/1/23 shows, Unable to make appointment due to no transportation Will make new date .
On 2/5/23 R46's Nursing note indicates, Writer reported from a CNA that resident's adult brief was wet with urine when she cleaned the resident no urine output in the bag.
On 2/8/23 R46's Nursing note indicates that the resident complains of moderate pain to suprapubic catheter and vaginal area .[primary doctor] made aware with N.O (Nursing Orders) carried out. Report given to nurse at [local hospital] resident admitted for UTI (urinary tract infection).
No notes were found that her Urogynecology appointment was rescheduled.
R46's Nurses note dated 2/28/23 indicates, Tried to flush suprapubic catheter. Unable to flush, urine has been leaking out from urethra Sent patient to [Local Hospital].
R46's Nurses note dated 3/11/23 indicates, Urine leaking out through urethra, tried to flush suprapubic cath but blocked send resident out to [Local Hospital]
R46's Nurses note dated 3/12/23 indicates that she came back from the hospital after getting her catheter changed with new antibiotic orders for a urinary tract infection.
R46's Nurses note dated 4/8/23 indicates that she complained of blood in her urine, her incontinence brief was saturated with pinkish urine.
R46's Nurses note dated 4/11/23 indicates, Unable to flush suprapubic catheter. Urine leaking out through urethra. Resident sent to [Local Hospital].
R46's Nurses note dated 5/12/23 shows, Suprapubic cath unable to flush. Urine has been leaking out through urethra for few days. Informed [Physician]. Resident went to [Local Hospital].
R46's Nurses note dated 6/23/23 shows, Resident need to change suprapubic catheter and c/o low abd (abdominal) pain. Called [Doctor] and received order to send to ER (Emergency Room) Returned from [local hospital] without change suprapubic catheter, endorse to tomorrow to make appointment (Urology).
R46's Nurses note dated 6/23/23 shows, Called [Urology] office to make appointment, they said they need to fill out [SIC] some paperwork. Will fax to us and remind them need to see MD within 2-4 days.
R46's Nurses note dated 6/30/23 shows, Still waiting for picture ID from former home, and they said they mailed already.
R46's Nursing Notes do not document that she had a clinic visit with a Urologist from 1/29/23 to 7/12/23.
R46's Discharge Instructions from the hospital dated 6/23/23 show that she was diagnosed with a urinary tract infection and needs to see a Urologist in 2-4 days.
On 7/11/23 at 10:25 AM, V7 (Registered Nurse) said that R46 has been to the emergency room multiple times to get her catheter changed due to pain and leaking. V7 said that every time she comes back, they say that she needs to see a Urologist in 2-4 days, but we are waiting on getting a photo ID from her previous facility before we can send the paperwork.
On 7/11/23 at 10:30 AM, R46 said that her catheter is very uncomfortable and painful. R46 said that it makes her cry sometimes and when she is sent to the hospital, all they do is say to see the Urologist. This surveyor asked R46 if she had a photo ID, and the resident took it out of her wallet and gave it to this surveyor. R46 said that no one at the facility has ever asked her for her ID. R46 said if she would have been asked, she would have given it to them.
On 7/12/23 at 1:35 PM, V16 (R46's Physician] said that he is not aware of any current issues that R46 is having regarding her catheter. V16 said that he knows that she has had issues in the past and was sent to the hospital and she should have had a follow up with a Urologist. V16 said that he is not sure if she has seen a Urologist, but he would assume she had seen one in the hospital.
On 7/12/23 at 12:11 PM, V3 (Assistant Director of Nursing) said that she is not sure why R46 has not seen the Urologist yet.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
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 treat a resident in a dignified manner for two of 20 ...
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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 treat a resident in a dignified manner for two of 20 residents (R48, R51) reviewed for dignity in the sample of 20.
The findings include:
1. R48's admission Record shows she was admitted to the facility on [DATE] with diagnoses including alzheimer's disease, altered mental status, anxiety disorder, and major depressive disorder.
On 7/10/23 at 12:10 PM, V4 CNA (Certified Nursing Assistant) was feeding R48 a pureed diet during the lunch meal while she was standing over R48. R48's Physician Orders dated 7/1/23-7/31/23 shows an order for pureed diet.
On 7/11/23 at 1:38 PM, V6 CNA said residents should be fed sitting down.
2. R51's admission Record shows she was admitted to the facility on [DATE] with diagnoses including dementia, and toxic encephalopathy.
R51's Physician Orders dated 7/1/23-7/31/23 shows an order for pureed diet with nectar thick liquids.
On 7/11/23 at 10:51 AM, R51 was sitting next to her spouse that resides at the same facility. R51's spouse was given a cup of lemonade and two Oreos by V4. R51 was not given a snack or a drink. At 11:16 AM, V4 said that snack time was done. At 1:45 PM, V4 said she received the snacks from the kitchen and all the kitchen gave her was lemonade and Oreos nothing for the residents requiring puree diet. At 2:15 PM, V8 Dietary Supervisor said residents that require a puree diet can have applesauce or pudding for snacks. V8 said that the floor CNAs get the snacks from the kitchen, and he was not told that the residents needed a pureed snack.
On 7/11/23 at 10:53 AM, R48 was sitting in the dining room with two table mates. V4 CNA was passing out lemonade and Oreos to the residents for snacks. R48 did not receive a puree snack. R48 was watching her table mates eat their Oreo snacks and then laid her head on the table.
The facility's Dignity policy not dated shows, The facility will promote care for residents in a manner and in an environment that maintains or enhances each resident's self-esteem and self-worth. Promoting resident independence and dignity in dining, such as avoiding day-to-day use of plastic cutlery and paper/plastic dishware, bibs instead of napkins, dining room conducive rot pleasant dining, aides not yelling. Respecting resident's social status, speaking respectfully, listening carefully, treating resident with respect, addressing the resident with a name of the resident's choice, no excluding residents from conversations or discussing residents in community setting.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
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 implement their abuse policy by not investigating and reporting an ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their abuse policy by not investigating and reporting an injury of unknown origin and verbal abuse allegation for two of 20 residents (R82, R46) reviewed for abuse in the sample of 20.
The findings include:
1. R82's admission Record shows he was admitted to the facility on [DATE] with diagnoses including dementia, chronic kidney disease, benign neoplasm of connective and other soft tissue, sebaceous cyst, and osteoarthritis in left knee.
R82's Nurses Notes dated 5/14/23 shows, Resident came back with his son and checked left hand x-ray for swelling. 7:00 PM, writer informed that [R82] had a fracture of index finger, left hand. Doctor made aware.
R82's Nurses notes dated 5/29/23 8:45 PM, shows, Resident placed in bed around 8:00 PM. CNA (Certified Nursing Assistant) noticed right hand was swollen .will order x-ray and will notify doctor.
The facility's Monitoring Flow Sheet for Incident shows on 5/13/23, R82 had swelling to his left hand with a fracture to the index finger. This same flow sheet dated 5/29/23 shows R82 had swelling to right hand and finger.
R82's left hand x-ray report dated 5/14/23 shows, Fracture of the base of the proximal phalanx of the index finger. R82's right hand x-ray dated 5/30/23 shows, Possible fracture of the fifth metacarpal with follow up oblique view for confirmation.
The facility's Abuse investigations were reviewed for the last three months and did not include an investigation for R82's fractures.
On 7/12/23 at 11:27 AM, V1 Administrator said injuries are investigated as potential abuse if the staff does not know where the injury came from. V1 said V3 ADON (Assistant Director of Nursing) does most of the investigating and then she reports the findings to V1. V1 said he was not aware of R82's two fractured fingers. V1 said he should have been notified.
On 7/12/23 at 12:04 PM, V3 said swelling and bruising should be investigated depending on the resident. V3 said fracture of unknown origin should be investigated as potential abuse. V3 said she was aware of one fracture for R82, but not two fractures. V3 said she did not do an investigation on either one of R82's fractures. V3 said R82's fractures should have been investigated and report should have been sent to the state agency.
The facility's Abuse Prevention Program Policy revised July 30, 2012 shows, All allegations of abuse and neglect will be reported immediately to the administrator. All allegations of abuse and neglect will be investigated. Employees are required to report any occurrences of potential mistreatment they observe, hear about, or suspect to a supervisor or the administrator. Supervisors shall immediately inform the administrator or designee of all reports of potential mistreatment. Upon learning of the report, the administrator or designee shall initiate an incident investigation. The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruises, laceration, or other abnormalities as they occur. The investigator will report the conclusions of the investigation in writing to administrator or designee within five working days of the reported incident. The administrator or designee is then responsible for forwarding a final written report of the results of the investigation and of any corrective action taken to the Department of Public Health within five working days of the reported incident. Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Investigation of injuries of unknown source-An injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time.
2. On 7/11/23 at 10:53 AM, V7 (Registered Nurse) and this surveyor were sitting at the nurse's station discussing a resident. R46 walked up to the nurse's station and said, Yesterday when I went to the third floor to play bingo, one of the residents called me a F***ing B***h. I cried and it made me feel sad. R46 said that she wrote a letter to V2 (Director of Nursing) about the incident, but she has not given it to her yet. V7 did not say anything to R46 about the incident. This surveyor then went to the first floor and notified V15 (Receptionist) that V2 needed to go talk with R46 regarding a verbal abuse incident.
On 7/12/23 11:27 AM, V1 (Administrator) said that he is the abuse coordinator and was not aware of an incident regarding verbal abuse that occurred to R46 on 7/11/23.
On 7/12/23 at 11:31 AM, V2 (Director of Nursing) said that she did not speak with R46 on 7/11/23.
07/12/23 at 11:45 AM, V15 said that he immediately paged V2 when he was told the allegation on 7/11/23. V15 said that he told V2 that she needed to go talk to R46 about verbal abuse that occurred. At 1:42 PM, V15 said that it is the policy to notify the DON or ADON right away if he sees or hears about abuse.
The facility's undated Abuse Prevention Policy shows, Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of their age, ability to comprehend, or disability all allegations of abuse and neglect will be reported immediately to the administrator. In the absence of the administrator, he will appoint a designee. All allegations of abuse and neglect will be investigated Employees are required to report any occurrences of potential mistreatment they observe, hear about, or suspect to a supervisor or the administrator Supervisors shall immediately inform the administrator or designee of all reports of potential mistreatment. Upon learning of the report, the administrator or designee shall initiate an incident investigation Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an injury of unknown origin and an allegation of verbal abus...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an injury of unknown origin and an allegation of verbal abuse to the abuse coordinator for two of 20 residents (R82, R46) reviewed for abuse in the sample of 20.
The findings include:
1. R82's admission Record shows he was admitted to the facility on [DATE] with diagnoses including dementia, chronic kidney disease, benign neoplasm of connective and other soft tissue, sebaceous cyst, and osteoarthritis in left knee.
R82's Nurses Notes dated 5/14/23 shows, Resident came back with his son and checked left hand x ray for swelling. 7:00 PM, writer informed that [R82] had a fracture of index finger, left hand. Doctor made aware. R82's Nurses notes dated 5/29/23 8:45 PM, shows, Resident placed in bed around 8:00 PM. CNA (Certified Nursing Assistant) noticed right hand was swollen .will order x ray and will notify doctor.
The facility's Monitoring Flow Sheet for Incident shows on 5/13/23, R82 had swelling to his left hand with a fracture to the index finger. This same flow sheet dated 5/29/23 shows R82 had swelling to right hand and finger.
R82's left hand x ray report dated 5/14/23 shows, Fracture of the base of the proximal phalanx of the index finger. R82's right hand x ray dated 5/30/23 shows, Possible fracture of the fifth metacarpal with follow up oblique view for confirmation.
The facility's Abuse investigations were reviewed for the last three months and did not include an investigation for R82's fractures.
On 7/12/23 at 11:27 AM, V1 Administrator said he was not aware of the fractures to R82's right and left hand. V1 said he should have been notified.
On 7/12/23 at 12:04 PM, V3 said she was aware of the first finger fracture on R82's hand, but not the second one.
2. On 7/11/23 at 10:53 AM, V7 (Registered Nurse) and this surveyor where sitting at the nurse's station discussing a resident. R46 walked up to the nurse's station and said, Yesterday when I went to the third floor to play bingo, one of the residents called me a F***ing B***h. I cried and it made me feel sad. R46 said that she wrote a letter to V2 (Director of Nursing) about the incident but she has not given it to her yet. V7 did not say anything to R46 about the incident. This surveyor then went to the first floor and notified V15 (Receptionist) that V2 needed to go talk with R46 regarding a verbal abuse incident.
On 7/12/23 11:27 AM, V1 (Administrator) said that he is the abuse coordinator and no one had reported an allegation of verbal abuse for R46. V1 said that all allegations of abuse should be reported to him immediately so an investigation could be started.
On 7/12/23 at 11:31 AM, V2 (Director of Nursing) said that she did not speak with R46 on 7/11/23.
07/12/23 at 11:45 AM, V15 said that he immediately paged V2 when he was told the allegation on 7/11/23. V15 said that he told V2 that she needed to go talk to R46 about verbal abuse that occurred. At 1:42 PM, V15 said that it is the policy to notify the DON or ADON right away if he sees or hears about abuse.
The Facility's undated Abuse Prevention Policy shows, Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of their age, ability to comprehend, or disability .all allegations of abuse and neglect will be reported immediately to the administrator Employees are required to report any occurrences of potential mistreatment they observe, hear about, or suspect to a supervisor or the administrator Supervisors shall immediately inform the administrator or designee of all reports of potential mistreatment .External Reporting of Potential Abuse . If an allegation of abuse or mistreatment is made the resident's representative and the Department of Public Health shall be informed immediately.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to investigate injuries of unknown origin and allegation of verbal abu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to investigate injuries of unknown origin and allegation of verbal abuse for two of 20 residents (R82, R46) reviewed for abuse in the sample of 20.
The findings include:
1. R82's admission Record shows he was admitted to the facility on [DATE] with diagnoses including dementia, chronic kidney disease, benign neoplasm of connective and other soft tissue, sebaceous cyst, and osteoarthritis in left knee.
R82's Nurses Notes dated 5/14/23 shows, Resident came back with his son and checked left hand x-ray for swelling. 7:00 PM, writer informed that [R82] had a fracture of index finger, left hand. Doctor made aware.
R82's Nurses notes dated 5/29/23 8:45 PM, shows, Resident placed in bed around 8:00 PM. CNA (Certified Nursing Assistant) noticed right hand was swollen .will order x-ray and will notify doctor.
The facility's Monitoring Flow Sheet for Incident shows on 5/13/23, R82 had swelling to his left hand with a fracture to the index finger. This same flow sheet dated 5/29/23 shows R82 had swelling to right hand and finger.
R82's left hand x-ray report dated 5/14/23 shows, Fracture of the base of the proximal phalanx of the index finger. R82's right hand x ray dated 5/30/23 shows, Possible fracture of the fifth metacarpal with follow up oblique view for confirmation.
The facility's Abuse investigations were reviewed for the last three months and did not include an investigation for R82's fractures.
On 7/12/23 at 11:27 AM, V1 Administrator said injuries are investigated as potential abuse if the staff does not know where the injury came from. V1 said V3 ADON (Assistant Director of Nursing) does most of the investigating and then she reports the findings to V1. V1 said he was not aware of R82's two fractured fingers. V1 said he should have been notified. V1 said there is no investigation in regard to R82's fractured fingers.
On 7/12/23 at 12:04 PM, V3 said she did not do an investigation on either of R82's fractured fingers. V3 said R82's fractures should have been investigated and report should have been sent to the state agency.
2. On 7/11/23 at 10:53 AM, V7 (Registered Nurse) and this surveyor were sitting at the nurse's station discussing a resident. R46 walked up to the nurse's station and said, Yesterday when I went to the third floor to play bingo, one of the residents called me a F***ing B***h. I cried and it made me feel sad. R46 said that she wrote a letter to V2 (Director of Nursing) about the incident, but she has not given it to her yet. V7 did not say anything to R46 about the incident. This surveyor then went to the first floor and notified V15 (Receptionist) that V2 needed to go talk with R46 regarding a verbal abuse incident.
On 7/12/23 11:27 AM, V1 (Administrator) said that he is the abuse coordinator and was not aware of an incident regarding verbal abuse that occurred to R46 on 7/11/23 so no investigation was initiated.
On 7/12/23 at 11:31 AM, V2 (Director of Nursing) said that she did not speak with R46 on 7/11/23.
07/12/23 at 11:45 AM, V15 said that he immediately paged V2 when he was told about the allegation on 7/11/23. V15 said that he told V2 that she needed to go talk to R46 about verbal abuse that occurred. At 1:42 PM, V15 said that it is the policy to notify the DON or ADON right away if he sees or hears about abuse.
The Facility's undated Abuse Prevention Policy shows, Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of their age, ability to comprehend, or disability All allegations of abuse and neglect will be investigated Supervisors shall immediately inform the administrator or designee of all reports of potential mistreatment. Upon learning of the report, the administrator or designee shall initiate an incident investigation .Residents who allegedly mistreated another resident will be removed from contact with that resident during course of the investigation The administrator or designee will appoint a person to take charge of the investigation .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R16's admission Record shows he was admitted to the facility on [DATE] with diagnoses including dementia, chronic obstructive...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R16's admission Record shows he was admitted to the facility on [DATE] with diagnoses including dementia, chronic obstructive pulmonary disease, and acute kidney failure.
R16's MDS (Minimum Data Set) dated 6/11/23 shows R16 is not cognitively intact. R16 requires extensive assistance with transferring, bed mobility, toilet use, and personal hygiene. R16 is always incontinent of bowel and bladder.
R16's Care Plan dated 6/11/23 shows, The resident is incontinent of bladder and bowel. Administer appropriate cleansing and peri-care after each incontinent episode.
On 7/11/23 at 9:24 AM, R16 was still in bed with the same clothes on as 7/10/23. At 9:33 AM, V6 CNA (Certified Nursing Assistant) asked R16 if he was ready to get out of bed. R16 said, I've been ready. V5 CNA removed R16's incontinence brief. R16's brief was saturated with dark urine and there was loose stool in the back of the brief coming into the front of the brief. V5 CNA said that R16's incontinence brief was last changed on night shift.
On 7/11/23 at 1:38 PM, V6 CNA said incontinence care should be provided at least every two hours in order to protect the resident's skin.
The facility's Activities of Daily Living policy dated 2010 shows, To assist resident in achieving maximum functional ability with dignity and self-esteem. To provide assistance to residents as necessary.
Based on observation, interview, and record review the facility staff failed to ensure residents who require extensive assistance with Activities of Daily Living (ADLs) received timely incontinence care for 2 of 20 residents (R41 and R16) reviewed for ADLs in the sample of 20.
The findings include:
1. R41's Minimum Data Set assessment dated [DATE] shows that she needs extensive assistance with personal hygiene and is always incontinent of urine and stool.
On 7/10/23 at 10:30 AM, R41 was laying in bed. There was a strong urine odor present in the room. R41 said that she asked V6, Certified Nursing Assistant (CNA) to be changed around 7:00 AM but she had not returned yet. R41 said that she was last changed around 12:00 AM.
On 7/10/23 at 11:30 AM, R41 was provided incontinence care by V5 (CNA). At 11:58 AM, V5 said that R41's incontinence brief was saturated with urine and stool. V5 said that her incontinence bed pad and sheets were saturated as well and needed to be changed. V5 said that R41 is not on her assignment but she was helping V6. V5 said that she had not changed R41 any other times on 7/10/23. At 12:10 PM, V6 said that she has not provided incontinence care to R41 at all on 7/10/23.
On 7/11/23 at 1:45 PM, V6 said that all incontinent residents should be checked and changed if needed every 2 hours.
R41's Incontinence Care Plan shows, Administer appropriate cleansing and peri-care after each incontinence episode.
The facility's undated Peri-Care Policy shows, Peri-Care is done daily and prn (as needed) by C.N.A for all residents requiring assistance .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R16's Physician Order dated 7/1/23-7/31/23 shows he was admitted to the facility on [DATE] with diagnoses including dementia,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R16's Physician Order dated 7/1/23-7/31/23 shows he was admitted to the facility on [DATE] with diagnoses including dementia, anemia, high blood pressure, acute kidney failure, urinary retention, both leg cellulitis and an order for compression socks on foot/leg daily on at 8:00 AM and off at 7:00 PM.
On 7/10/23 at 2:00 PM, R16's legs were discolored and had swelling. R16 did not have compression socks on either leg. On 7/11/23 at 9:33 AM, V5 and V6 CNAs got R16 dressed and out of bed for the day. V5 nor V6 placed compression socks onto R16's bilateral legs nor did they offer compression socks.
On 7/11/23 at 1:50 PM, V7 RN (Registered Nurse) said R16 does not use compression socks. V7 said R16 used to, but the order was discontinued. V7 said that the podiatrist is the doctor that ordered the compression socks. V7 looked in R16's room and could not find any compression socks and said she did not know where they were.
On 7/11/23 at 2:01 PM, V5 CNA said R16 does not wear compression socks. V5 said she is very familiar with R16 and R16 just wears regular socks and shoes.
R16's Care Plan dated 6/11/23 shows, administer prescribed medications and treatments per doctor's orders.
Based on observation, interview and record review the facility failed to ensure necessary care and treatment was performed for a resident with leg ulcers and failed to ensure compression stockings were applied for a resident with edema. This applies to 2 of 20 residents (R4, R16) reviewed for quality of care in the sample of 20.
The findings include:
1. R4's face sheet shows she is an [AGE] year-old female with diagnosis including hemiplegia and hemiparesis following intracerebral hemorrhage affecting right dominant side, dysphasia, aphasia following cerebral infarct, vascular dementia, gastrostomy status and non-pressure chronic ulcer of left lower leg.
On 7/11/23 at 9:39 AM, R4 was observed laying in bed. A soiled gauze dressing dated 7/9/23 was observed to her left lower leg and foot. V2 (Director of Nursing) was in the room and said R4's dressing should be changed daily.
R4's Wound Progress note dated 6/26/23 documents she has a chronic ulcer to the left calf with fat layer exposed measuring 15 cm (centimeters) x 20 cm x 0.1 cm with daily treatment orders to cleanse with normal saline apply topical antibiotic ointment and topical steroid and cover with non-adhering dressing and cover with gauze kerlix dressing.
A second ulcer to the left lateral and medial ankle measuring 13 cm x 10 cm x 01.cm with daily treatments orders to cleanse with antimicrobial cleanser and apply topical antibiotic and steroid ointment, cover with abdominal pad, and gauze kerlix dressing.
A third ulcer to her left lateral foot measuring 1cm x 1cm with daily treatment orders to cleanse with antimicrobial cleanser and apply topical antibiotic and steroid ointment, cover with abdominal pad and gauze kerlix dressing.
The facility's Non-Pressure Ulcers Policy dated 9/2012 states, The facility will have in place/processes/procedures that wounds/ulcers are correctly identified and treated as per the specific cause/condition.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to arrange for a resident to see the eye doctor upon resident complaints of being unable to see. This applies to 1 of 20 resident (R62) reviewe...
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Based on interview and record review the facility failed to arrange for a resident to see the eye doctor upon resident complaints of being unable to see. This applies to 1 of 20 resident (R62) reviewed for vision and hearing in a sample of 20.
The findings include:
On 7/11/23 at 1:45 PM R62 stated, I was told I need to see the eye doctor- I didn't know there was an eye doctor that came here. I love to read my books and I can't see and it kind of irritates me. My niece sent me some new books, but I can't see. I told the nurse, and she said I should see the eye doctor and get new glasses. I haven't heard anything more about it.
On 7/11/23 at 2:06 PM V3 (Assistant Director of Nursing) stated, The eye doctor came today because I called him yesterday. I didn't know anything about (R62). He makes his own schedule- if there is an issue then we call him and let him know and he will come in. The nurses will call him- more often than not it will get carried over from day to day to day (on the 24 hours report sheet) until the doctor comes in and then someone may tell him about it. Honestly it could go on for a couple months until he comes in.
On 7/12/23 at 10:00 AM surveyor reviewed the 24 hours report with V3. There was no mention of R62 wanting to see the eye doctor on the report.
On 7/11/23 R62's medical record was also reviewed and showed no documentation of R62 needing to see the eye doctor. R62's progress notes do show that R62 is alert and oriented x3.
On 7/12/23 at 11:56 AM R62 stated, I just can't see. My niece sends me stuff all the time and I want to read the books. I love to read but I just can't see with these glasses.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure pressure ulcer treatment orders were followed and in place for a resident with pressure injuries for 1 of 3 residents (...
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Based on observation, interview, and record review the facility failed to ensure pressure ulcer treatment orders were followed and in place for a resident with pressure injuries for 1 of 3 residents (R26) in the sample of 20.
The findings include:
On 07/10/23 at 9:56 AM, R26 was sitting up in the wheelchair in her room. R26 had compression stockings on her legs and feet and her feet were resting on a folded sheet, flat on the floor.
On 07/10/23 at 12:30 PM, V14 Certified Nursing Assistant (CNA) removed R26's compression hose and there was no dressing on R26's right heel. V14 said R26 doesn't usually have a dressing on her heel.
On 7/10/23 at 1:21 PM, R26 was transferred to bed. V14 CNA removed R26's brief and R26 had a dressing on her sacral area and a red peri-area. V12 Registered Nurse (RN) removed the dressing and cleaned R26's sacral area. R26 had a red, open area on her sacral area. V12 applied honey to the sacral wound and then a pink foam dressing. V12 applied zinc cream over R26's peri-area. V12 said the wound doctor made rounds the day before and the floor nurses are responsible for dressing changes. V12 did not apply a dressing to R26's right heel.
R26's Physician Orders dated 7/1/23 shows cleanse right hell with normal saline, apply betadine paint and foam island dressing change every two days and as needed. Cleanse sacrum with normal saline, apply medihoney and cover with calcium alginate foam island dressing, change every day as needed.
R26's Wound Doctor notes dated 7/9/23 shows Pressure Stage 3 sacral wound-daily and PRN (as needed), clean with betadine, apply gentamicin cover with adaptic or calcium alginate, and foam dressing, treatment has been changed on 7/9/23. Pressure right heel stage 3-clean with normal saline cover with foam island dressing, 3 times per week and prn.
On 07/11/23 at 1:35 PM, V12 RN said the orders should be transcribed from the wound doctor to the physician orders and new treatment orders should be followed. V12 said V3 Assistant Director of Nursing is supposed to do that.
On 07/12/23 at 10:40 AM, V3 stated It's my fault. I was here on Sunday and the Wound Doctor emailed me his notes and I didn't update the treatment orders.
The facility's Management/Treatment of Pressure Ulcer Policy dated 11/1/2012 shows To promote wound healing of pressure ulcers in a timely manner without complications-Successful management of pressure ulcer requires a comprehensive approach including offloading, restoration of circulation, and appropriate dressing.
CONCERN
(D)
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 have fall prevention interventions in place and faile...
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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 have fall prevention interventions in place and failed to safely transfer residents for two of 20 residents (R73, R76) reviewed for safety in the sample of 20.
The findings include:
1. F76's admission Record shows he was admitted to the facility on [DATE] with diagnoses including dementia, dysphagia, major depressive disorder, unsteadiness on feet, cognitive communication deficit, and restlessness and agitation.
R76's MDS (Minimum Data Set) dated 4/22/23 shows R76 is not cognitively intact, requires extensive assistance with one person in transferring and toilet use, and is not steady and only able to stabilize with staff assistance.
R76's Fall Risk Evaluation dated 5/7/23 shows R76 is a high risk for falls.
R76's Care Plan dated 4/22/23 shows R76 is at risk for falls. R76 has an unsteady gait, lower extremity weakness, and cognitive impairment.
On 7/10/23 at 11:23 AM, V5 CNA Certified Nursing Assistant transferred R76 from his wheelchair to the toilet. R76 was not steady. There was a transfer belt around V5's waist. When R76 was finished on the toilet, R76 was attempting to pull up his pants and was unsteady.
The facility's Use of Gait Belt policy and procedure dated 07/10 shows, To assure the safety of the residents and staff when assisting with a transfer or ambulation a gait belt will be used. All residents who require assist with transfers and do not require an electric lift will utilize a gait belt with all transfers.
2. R73's admission Record shows he was admitted to the facility on [DATE] with diagnoses including alzheimer's disease, dementia, major depressive disorder, visual loss, difficulty walking, lack of coordination, and anoxic brain damage.
R73's Fall Risk Evaluation dated 5/7/23 shows he is a high risk for falls.
R73's Care Plan dated 5/7/23 shows R73 is at risk for falls secondary to blindness, dementia, agitation, and difficulty in walking.
On 7/10/23 at 10:45 AM, R73 was sitting in his wheelchair in the dining room. R73 did not have any shoes on or nonskid socks on. R73 had regular socks on. R73 attempted to stand up to wipe off his lap while his wheelchair was sliding back. On 7/11/23 at 11:03 AM, R73 was sitting in the dining room with no shoes on or nonskid socks on. R73 had regular socks on. R73 attempted to stand and had a difficult time trying to stand.
On 7/11/23 at 1:38 PM, V6 CNA said a gait belt should be used when transferring a resident to protect the residents and the staff. V6 said fall prevention interventions include watching the residents and wearing shoes. V6 said she did not know why R73 did not have shoes on.
On 7/11/23 at 2:01 PM, V5 CNA said R73 has slippers, but they don't fit. V5 said R73 does not have tennis shoes.
The facility's Gait Belt (Use of) policy dated 07/10 shows, To assure the safety of the residents and staff when assisting with a transfer or ambulation a gait belt will be used. Equipment: Appropriate footwear.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
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 notify the physician of a significant weight loss, failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed notify the physician of a significant weight loss, failed to ensure residents with a significant weight loss were assessed by a dietitian, and weight loss prevention interventions were implemented for 2 of 9 residents (R3 and R4) reviewed for weight loss in the sample of 20.
The findings include:
On 7/10/23 at 12:00 PM, R3 was in her room eating lunch. R3 ate 50% of her noon meal. R3 appeared very thin.
R3's Monthly Weight/Vital Flow Sheet shows that in January and June 2023, R3 was 89 pounds. R3 was 84 pounds in July (5.62% weight loss in 1 month).
R3's Medication Administration Record shows that Two Cal HN (nutritional supplement)-1 can twice daily was discontinued on 6/28/23.
R3's Clinical Record shows that the last time she was seen by a dietitian was 6/6/22 and R3's weight was 92 pounds.
R3's clinical records do not document that the physician or dietitian was notified of R3's significant weight loss in July. R3's clinical records do not show that additional interventions were tried after discontinuing R3's nutritional supplements.
On 7/12/23 at 12:29 PM, V3 (Assistant Director of Nursing) said that the physician should have been notified when the resident started refusing the supplement and an alternate intervention attempted. V3 said that the physician should have been notified of the significant weight loss as well.
2. R4's face sheet shows she is an [AGE] year-old female with diagnosis including hemiplegia and hemiparesis following intracerebral hemorrhage affecting right dominant side, dysphasia, aphasia following cerebral infarct, vascular dementia, gastrostomy status and non-pressure chronic ulcer of left lower leg.
R4's monthly weight log report
January 2023- 171 lb (pounds)
February 2023- 163 lb
March 2023 - 158 lb
April 2023- 160 lb
May 2023- 157 lb
June 2023- 156 lb
July 2023- 155 lb
The same weight log report shows a blank entry for the date, notification to the physician response and no documentation of the nurse signature for reporting the weight loss.
R4's dietitian referral dated 7/10/23 documents her diet as tube feeding. R4's tube feeding order Jevity 1.5 four times a day. (R4) with weight loss of 9% in seven months.
On 7/10/23 at 10:20 AM, R4 was observed laying in bed with contractors to upper and lower extremities. She was non-verbal and a gastric tube was observed to her abdomen.
On 7/10/23 at 12:02 PM, V10 (Dietitian) said today is her first day at the facility. R4 receives her nutrition thru her gastric tube. She had triggered for weight loss, and it should have been addressed earlier so her feeding could be increased. Residents with tube feedings should be monitored at least monthly.
On 7/10/23 at 3:00 PM, V1 (Administrator) said there has been no dietitian since July 2022.
On 7/10/23 at 2:03 PM, V3 (ADON) said staff should notify the physician and dietitian when residents have weight loss.
R4's medical records shows there were no nutritional assessments performed from August 2022 to June 2023 (11 months).
The facility's Weight Monitoring Policy dated 2017 states, To ensure the client maintains acceptable parameters of nutritional status unless their clinical demonstrates that this is not possible, the client's body weight is monitored .clients are weighed monthly. The monthly weight is compared to the previous weights to determine significant and insidious weight changes .significant weight change is defined as 5% in one month, 7.5% in three months, and 10% in six months. Insidious weight loss is defines as gradual, unintended, progressive weight loss over time .Once a significant weight change has been identified, the director of nursing or person in charge notifies the physician, dietitian, diet technician and the director of food and nutrition services Clinically qualified professionals can initiate interventions prior to assessment of the client's nutrition status by the dietitian .weight committee meetings or nutrition at risk meetings may be held to discuss nutrition status of clients with weight loss or nutrition impairments .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure diet orders were followed for a resident on a tube feeding for 1 of 2 residents (R1) reviewed for tube feeding in the s...
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Based on observation, interview, and record review the facility failed to ensure diet orders were followed for a resident on a tube feeding for 1 of 2 residents (R1) reviewed for tube feeding in the sample of 20.
The findings include:
On 07/10/23 at 10:13 AM, R1 was in bed with his gastric tube feed connected and running at 40 cc/hr. R1 stated I want to eat a sandwich, I don't like pureed food.
On 07/10/23 at 11:48 AM, V10 Dietician said she is going to increase R1's tube feeding rate since he is not eating much of his pureed diet. V10 said R1 told me he doesn't like pureed food and wants a sandwich.
On 07/10/23 at 11:48 AM, R1's lunch tray contained pureed food. R1's dietary card was marked pureed, nectar thick liquids.
On 07/10/23 at 12:35 PM, V14 Certified Nursing Assistant said R1 doesn't like pureed food, and R1 tells her that he wished to take a bite of a sandwich.
On 07/11/23 at 1:35 PM, V12 Registered Nurse said R1 is on a puree diet. V12 stated R1 hasn't been eating because he doesn't like puree, he wants a sandwich. The doctor is following him. I have not seen any issues when he has eaten puree. The doctor's orders for his diet should be followed to help him return to normal eating.
R1's Physician Orders dated 5/20/23 shows diet change to mechanical soft from pureed diet with pleasure food.
R1's Physician Order dated 6/30/23 shows resident may eat soft diet, resident does not have to go to swallow eval (evaluation).
R1's Dietician Referral dated 7/10/23 shows patient visited, states does not want pureed diet, minimal intake noted.
The facility's undated Enteral Nutrition Policy shows enteral tube feeding will be used in accordance with a physicians order to supply partial or total nutritional support for the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure controlled drugs were reconciled and failed to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure controlled drugs were reconciled and failed to ensure medications were administered for 2 of 2 residents (R11, R41) reviewed for medication administration in the sample of 20.
The findings include:
1. On 07/12/23 at 09:43 AM, V12 Registered Nurse reviewed the 3 south medication cart narcotic lock box with this surveyor. R11's Lorazepam 0.5 mg medication card, dispensed on 6/24/23, showed take 1 tablet by mouth three times daily, and contained 14 tabs. R11's Controlled Drug Receipt/Record/Disposition Form dated 6/24/23 showed 15 tabs remaining. V12 said she didn't count the narcotics this am, she had got called in late to work.
On 07/12/23 at 11:00 AM, V3 Assistant Director of Nursing stated I can figure it out why the narcotic count is off. The dose for today was not given this am yet. The nurses should have done a narcotic count at change of shift, the narcotic sheet and medication card should match. I will have to look into this more.
The facility's Administration Procedures for all Medications Policy dated 10/25/14 shows After administration, return to the cart, replace medication containers if multi dose container, and document administration in the Medication. Administration Record and controlled substance sign out record if indicated.
2. R41's Minimum Data Set assessment dated [DATE] shows that she has moderate cognitive impairment. On 7/10/23 at 10:30 AM, R41 was in her room laying in bed. R41 had a medication cup full of medications located on her bedside table. R41 stated, I have no idea when they are from.
On 7/10/23 at 2:15 PM, V13 (Registered Nurse) said that she did not administer R41 her morning medications. V13 said that R41 is not able to self-administer her medications. V13 said that medications should not be left at the bedside especially since it is a dementia unit. On 7/10/23 at 2:15 PM, V2 (Director of Nursing) said that she put the medications on her bedside table this AM, and they are her morning medications.
On 7/12/23 at 12:11 PM, V3 (Assistant Director of Nursing) said that when a nurse administers medications, they should always observe the resident taking the medications to ensure that they received them.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to ensure a resident's liquid Morphine (Schedule II Controlled Substance) was stored in a separately locked, permanently affixed c...
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Based on observation, interview and record review the facility failed to ensure a resident's liquid Morphine (Schedule II Controlled Substance) was stored in a separately locked, permanently affixed compartment for storage of controlled drugs for 1 of 1 resident (R5) reviewed for medication storage in the sample of 20.
The findings include:
On 7/11/23 at 10:00 AM, R5's liquid Morphine was located sitting on a shelf in an unlocked refrigerator in the second-floor medication room.
On 7/12/23 at 12:11 PM, V3 (Assistant Director of Nursing) said that if a controlled substance needs to be refrigerated, it should be kept inside a locked refrigerator in the locked medication room. V3 said that all controlled substances should always be double locked. V3 said that the refrigerators used to have locks on them. V3 said that when they switched to a different pharmacy last year sometime, the refrigerators all got replaced and a lock was never added to them.
The facility's Storage of Medications Policy revised on 5/1/18 shows, Controlled substances that require refrigeration are stored within a locked box within the refrigerator or a locked refrigerator .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
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 assist a resident who is having mouth pain in making 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 assist a resident who is having mouth pain in making a dental appointment for 1 of 20 residents (R41) reviewed for dental services in the sample of 20.
The findings include:
R41's Minimum Data Set Assessment (MDS) dated [DATE] shows that she was admitted to the facility on [DATE]. R41's MDS dated [DATE] shows that she has moderate cognitive impairment, uses a wheelchair for mobility, has obvious or likely cavities or broken natural teeth and has mouth or facial pain, discomfort, and difficulty with chewing.
On 7/10/23 at 10:30 AM, R41 had reddened gums and chipped teeth. R41 said that she has had discolored gums and mouth pain for months. R41 said that she has told multiple nurses about the pain, but no one has helped with setting her up with a dental appointment. R41 said that she has not seen the dentist since admission.
On 7/11/23 at 10:18 AM, V7 (Registered Nurse) said that R41 has been complaining of mouth pain for more than a few months. V7 said that R41 does not have any dental appointments set up.
On 7/12/23 at 11:06 AM, V15 (Receptionist) said that it is the nurse's responsibility to set up outside doctor appointments and then he schedules the transportation for the resident. V15 said that he has not set up any transportation for R41 this year.
R41's Pain Care Plan dated 5/14/23 shows that she has mouth pain.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents received all recommended doses of the Pneumonia Vac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents received all recommended doses of the Pneumonia Vaccine. This applies to 2 of 5 residents (R13, R66) reviewed for vaccinations in the sample of 20.
The findings include:
R13's medical record shows that she was admitted to the facility on [DATE]. R13's medical record shows that she gave consent to receive the Prevnar 13 vaccine on 4/9/2021. R13's Immunization Record shows that she received the Pneumovax 23 vaccine on 4/12/21 but there is no documentation of R13 ever receiving the Prevnar 13 vaccine.
R66's medical record shows he gave consent for the Prevnar 13 on 4/9/2021. R66's Immunization Record shows that he received the Pneumovax 23 on 4/13/21. There is no documentation showing that R66 ever received the Prevnar 13 vaccine.
On 7/11/23 at 10:24 AM V3 (Assistant Director of Nursing) stated, for Pneumonia they do a consent on admission. I am not as familiar with that as I am influenza, it is probably not tracked very well. I know I have a log; I have to find it. V3 stated there is an immunization log in each chart though. It depends on which one they need; we would get it from the pharmacy. It is not tracked as well as influenza.
The facility policy entitled Influenza and Pneumococcal Immunizations- Residents dated 3/23/21 states, All residents will receive immunizations that aid in preventing infectious diseases unless medically contraindicated or the resident has already been immunized during this time period. 4. All new residents will be assessed for pneumococcal vaccine status upon admission, 5. Residents without proof of previous pneumococcal vaccination should be offered the pneumococcal vaccine(s) unless contraindicated.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure oxygen was administered in a manner to prevent infection for 4 of 4 residents (R58, R26, R1, R338) reviewed for oxygen ...
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Based on observation, interview, and record review the facility failed to ensure oxygen was administered in a manner to prevent infection for 4 of 4 residents (R58, R26, R1, R338) reviewed for oxygen in the sample of 20.
The finding include:
1. On 07/10/23 at 10:09 AM, R58 was in bed sleeping. R58 had a nasal cannula on, delivering oxygen. The oxygen tubing was not labeled, and the humidifier bottle was dated 6/5.
R58's Physician Orders for July 2023 shows Oxygen titrated up to 4 Liters/minute per nasal cannula continuously.
2. On 07/10/23 at 12:30 PM, R26 was sitting up in her wheelchair eating lunch. R26 had a nasal cannula on delivering oxygen. There was no date on the oxygen tubing or the humidifier bottle.
R26's Physician Orders for July 2023 shows Oxygen at 2-4 Liters/minute via nasal cannula continuous. Change humidifier weekly on Sunday, Change nasal cannula weekly on Sunday.
3. On 07/10/23 at 12:27 PM, R1 was in bed and had a nasal cannula on delivering oxygen. There was no date on the oxygen tubing or the humidifier bottle.
R1's Physician Orders for July 2023 shows Change nasal cannula and humidifier weekly every Sunday.
4. On 07/11/23 at 1:35 PM, R338 was in bed sleeping with a nasal cannula on delivering oxygen at 3.5 liters. There was no date on the oxygen tubing or humidifier bottle.
R338's Physician Orders for July 2023 shows Oxygen at 2-4 liters/minute per nasal cannula. Change humidifier, nasal cannula/mask weekly.
On 07/11/23 at 1:40 PM, V12 and V13 Registered Nurse said oxygen tubing is changed weekly by night nurse and signed off in the Treatment Administration Record. V12 and V13 said the tubing and humidifier bottles should be labeled with the date it was changed.
On 07/12/23 at 10:40 AM, V3 Assistant Director of Nursing, said there is no specific policy for oxygen tubing/humidifier and the oxygen tubing and humidifier bottle is changed weekly for infection control.
The facility's Oxygen Administration Policy dated 7/10 does not address changing oxygen or humidifier bottles.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to administer medications at the ordered time and ordered dosages. There were 28 opportunities with three errors resulting in a 1...
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Based on observation, interview and record review, the facility failed to administer medications at the ordered time and ordered dosages. There were 28 opportunities with three errors resulting in a 10.71% error rate. This applies to 2 of 3 residents (R41 and R43) observed in the medication pass.
The findings include:
1. R41's July Physician's Order Sheet (POS) shows orders for: Ferosul 325 milligrams (mg)-Take 1 tablet by mouth once daily with breakfast and Senna 8.6 mg-Take 2 (17.2 mg) by mouth twice daily for small bowel obstruction/increase bowel regimen.
On 7/11/23 at 9:24 AM, V7, Registered Nurse (RN) gave R41 her 9:00 AM medications. V7 administered Senna 8.6 mg-one tablet and omitted Ferrous Sulfate 325 mg.
2. R43's July POS shows an order for: Fish Oil 1000 mg-Take 1 capsule by mouth once daily.
On 7/11/23 at 9:28 AM, V12 (RN) administered R43's Fish Oil 1200 mg.
On 7/12/23 at 12:11 PM, V3 (Assistant Director of Nursing) said that a nurse should compare the medication administration record to the medication being provided. V3 said that the nurse should verify that they are giving the correct medication, correct dosage and at the correct time to the correct resident. V3 said that all medications should be given at the ordered time.
The facility's July, 2010 Medication Administration Policy shows, Medication must be administered in accordance with the orders, including any required time frame The individual administering medications must check the label three times to verify the right medication, right dosage, right time and right method of administration before giving the medication.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to ensure the dishes were sanitized after washing in the 3-compartment sink. This has the potential to affect all 88 residents in...
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Based on observation, interview, and record review the facility failed to ensure the dishes were sanitized after washing in the 3-compartment sink. This has the potential to affect all 88 residents in the facility.
The findings include:
The CMS 672: Resident Census and Conditions Report dated 7/11/23 shows the current facility census as 88 residents.
On 7/10/23 at 9:50 AM during the initial kitchen tour the sanitizer in the 3-compartment sink was checked as staff were observed washing dishes. The strip registered as 0- minimal sanitizer present.
At 9:55 AM, V8 (Dietary Manager) drained the water from the sink and new water with sanitizer was added to the sink. The water was tested again, and the strip measured 150ppm (Parts per million). V8 stated that he just got that sanitizer this morning because they were out, and it is a different sanitizer than they are used to, and they did not use enough in the 20 gallon sink. V8 also stated that the dishwasher has not been working (broken for the last year) so all dishes are being done by hand. V8 stated that the dishes are washed, rinsed, and then left in the sanitizer water for 15 seconds.
The Commercial Sanitizer Label on the bottle of sanitizer states, Immerse pre-cleaned glassware, dishes, silverware, cooking utensils and other similar sized food processing equipment in a solution of one ounce per gallon of water for at least 60 seconds .
The undated facility policy entitled, Manual Sanitizing in Three-Compartment Sink states, After washing and rinsing utensils and equipment are sanitized in the third sink by immersion in either: Chemical sanitizing solution used according to manufacturer's instructions .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure a facility wide assessment was reviewed and updated at least every year. This failure has the potential to affect all 88 residents r...
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Based on interview and record review, the facility failed to ensure a facility wide assessment was reviewed and updated at least every year. This failure has the potential to affect all 88 residents residing in the facility.
The findings include:
The facility's Resident Census and Conditions of Residents (CMS-672) form dated 7/10/23 shows the facility census is 88.
On 7/12/23 at 12:08 PM, V1, Administrator, said he is responsible for the facility assessment. V1 said the facility assessment has not been updated since 3/19/21. V1 said he knows it needs to be updated and it just has not been done.
The Facility Assessment provided by the facility shows the most recent date it was reviewed was 3/11/21. An Addendum to the Facility Assessment Tool shows a revision date of 3/19/21.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to have a written QAPI plan and failed to show evidence of an ongoing QAPI Program.
This has the potential to affect all 88 residents in the f...
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Based on interview and record review the facility failed to have a written QAPI plan and failed to show evidence of an ongoing QAPI Program.
This has the potential to affect all 88 residents in the facility.
The findings include:
On 7/12/23 at 10:00 AM V1 (Administrator) stated, We use to have meetings every Thursday and that kind of fell by the wayside. I know it is important and I am not going to lie to you, but it has just kind of fallen by the wayside. We have QA (quality assurance) meeting every quarter. For example, we know that falls is a big thing. When we are out on the floor, we are all looking at that. When we have a meeting, I get the minutes from the last meeting, and I try to remind everyone what we talked about at the last meeting. I am a numbers guy. V3 (Assistant Director of Nursing) is the solution person. I can look at something and see that it has gone up 20%- they need to be able to tell me why. Or if something has gone down then they need to say if something is working or not and why. We put a lot of faith in V3 and sometimes she just says, I don't know. I appreciate the importance of the whole thing and the sensitivity of it. Surveyor asked for meeting minutes (to assure compliance) and meeting sign in sheets. V1 stated, I will see what V9) Human Resources) can come up with. Surveyor requested a copy of the facility QAPI Plan and V1 stated they did not have one.
On 7/12/23 at 12:27 PM V9 presented a Quality Assurance binder and stated, There are no minutes for April 2023. It was a short meeting as we had an emergency going on in the building. In January 2023, I wasn't here. I know that V1 takes notes, but he hasn't typed them up yet.
The QA Meeting Attendance Sheet dated 4/20/23 shows that V1 did not attend the meeting.
The CMS 672: Resident Census and Conditions Report dated 7/11/23 shows the current facility census as 88 residents.
During the annual survey on 7/12/23 the facility showed deficient practice related to resident rights, abuse, resident assistance with activities of daily living, wound care, weight loss, resident safety, medication administration, medication storage and infection control.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R16's admission Record shows he was admitted to the facility on [DATE] with diagnoses including dementia, anemia, and acute k...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R16's admission Record shows he was admitted to the facility on [DATE] with diagnoses including dementia, anemia, and acute kidney failure.
On 7/11/23 at 9:33 AM, V5 and V6 CNA (Certified Nursing Assistants) provided incontinence care to R16. R16's incontinence brief was saturated with dark urine and had a large amount of semi liquid stool in it. V5 removed R16's incontinence brief, touched R16's body to turn him, V5 wiped the large amount of stool from R16's buttocks and noticed that R16 had loose stool in his groin. V5 touched R16's body to turn him back onto his back and proceeded to wipe the stool from his groin area. V5 placed a new brief under R16, touched the handrail, R16's arm, R16's clean pants and the stand lift controls. V5 did not change her gloves or perform hand hygiene.
5. R76's admission Record shows he was admitted to the facility on [DATE] with diagnoses including dementia, dysphagia, major depressive disorder, unsteadiness on feet and cognitive communication deficit.
On 7/10/23 at 11:23 AM, V5 CNA removed R76's incontinence brief. There was urine and a small amount of stool in the brief. R76 urinated in the toilet. V5 wiped R76's front peri area and buttocks. V5 then placed a clean brief onto R76 and touched his body to help him sit back down into his wheelchair. V5 did not change her gloves or perform hand hygiene.
On 7/11/23 at 1:38 PM, V6 CNA said she performs hand hygiene and changes her gloves when she is done cleaning up the resident or if bowel movement gets on them.
The facility's Hand Washing and Hand Hygiene policy dated 07/10 shows, To ensure appropriate hand hygiene which is essential in preventing transmission of infectious agents. Hand hygiene must be performed after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn.
Based on observation, interview and record review the facility failed to develop and maintain an Enhanced Barrier Precautions Policy and Procedure, failed to develop, and maintain a Water Management Plan to detect and prevent water borne pathogens, and failed to have a system in place for tracking and trending any infections in the facility. The facility also failed to ensure that staff change their gloves and wash their hands while providing care to residents to prevent cross contamination. This has the potential to affect all 88 residents in the facility.
The findings include:
1. On 7/11/23 at 10:30 AM V3 (Assistant Director of Nursing) stated, I just learned about that- enhanced Barrier Precautions so I am not too familiar with it, I don't really know too much about that.
When the County came in just recently, they mentioned that to me. That was the first time I really heard about it. V3 stated for certain procedures for certain residents you need to wear personal protective equipment (PPE) for them, like catheters or wounds.
The CMS 672: Resident Census and Conditions Report dated 7/11/23 shows the current facility census as 88 residents. This report also shows that there are five residents with indwelling catheters, three residents with pressure ulcers, two residents receiving tube feedings and one resident receiving Intravenous Therapy. None of these residents had Enhanced Barrier Precautions in place during this survey.
2. On 7/11/23 at 10:58 AM, V1 (Administrator) stated, We use a (Local Water Technology Company) for water testing every year. They are due to come this month. I am not sure if we have a policy or not, I just make sure the water testing is done.
On 7/11/23 V1 provided an invoice showing the last time water testing done was last done on 7/14/22.
On 7/12/23 at 3:30 PM V1 stated that he was sure the facility had blueprints of the building, but he wouldn't know where to find them. V1 also confirmed that the facility did not have a written Water Management Plan to detect potential areas of concern for water borne pathogens.
3. On 7/11/23 at 10:25 AM V3 stated, When an antibiotic is ordered the nurse fills out a form and then I put it on the tracking form. V3 was asked what was done with the tracking form and V3 stated, I just put it on there. If something stands out, then I look into it. There is an infection thing in QA (Quality Assurance). I run through the log and the lab will talk about their part. That is done every 3 months. We will notice if there has been a lot of urinary tract infections or upper respiratory infections but that is only done every 3 months.
The facility Infection Control Log for April, May and June 2023 shows only resident name, room, admit date , infection onset date, date (infection) cleared, and antibiotic used for most infections. Of the 38 infections recorded over the 3-month period reviewed there are only four that show the organism causing the infection and only two shows the resident risk factors for the development of infection.
There is no analysis of the data collected on the Infection Control Log.
The facility policy entitled Infection Control- Data Collection and Surveillance dated 3/27/09 states, Analyze the data to identify trends. Compare the rates to previous months in the current year and to the same month in previous years to identify seasonal trends.
May 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure a resident was free from physical abuse for 1 of 4 residents (R2) reviewed for abuse in the sample of 5.
The findings i...
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Based on observation, interview, and record review the facility failed to ensure a resident was free from physical abuse for 1 of 4 residents (R2) reviewed for abuse in the sample of 5.
The findings include:
On 5/1/23 at 10:05 AM, R2 was observed sitting in his wheelchair at the dining room table, playing Bingo. R2 was observed with a yellowish bruise on his cheek under his right eye.
The facility's Incident/Occurrence report dated 4/24/23 shows R2 had a witnessed, resident to resident contact with his roommate R3 and sustained a bruise to his right eye. This same report shows V6 Certified Nursing Assistant (CNA) stated R2 walked into his room to use the bathroom, when R3 slapped R2 causing R2's glasses to hit him in the right side of the face, resulting in a bruise. R2 is alert and oriented to person, place, and time. Ice pack applied immediately and separated from R3.
On 5/1/23 at 10:40 AM, R2 was observed (touching his cheek) stated That guy who was in that room (pointing to room incident occurred in), he hit me! He didn't give me a reason, he just hit me. I walked into my room, and he hit me.
On 5/1/23 at 10:42 AM, V6 CNA stated she was sitting in the dining room in clear view of room R2's room. V6 stated she saw R2 walk into his room and then came out holding his right eye and saying R3 (roommate) punched him. V6 stated R3 came to the doorway of the room, told R2 not to come in the room and then threw R2's clothes into the hall and slammed the door. V6 stated R2 had a mark on his face below his right eye.
On 5/1/23 at 12:06 PM, V7 Licensed Practical Nurse stated V6 told her that R2 went into his room and R3 slapped R2 in the face knocking R2's glasses off and causing a bruise. V6 stated R2 and R3 were separated, and she assessed both residents. V6 stated R3 would not respond to her questions and just had a blank stare. V6 stated she called the doctor and got orders to send R3 out involuntary for evaluation. V6 stated R2 had a bruise under his right eye and ice was applied.
On 5/1/23 at 10:07 AM, R3 was in a private room, dressed and in bed. R3 stated Please leave me alone, I don't want to talk to you unless you are a psychiatrist!
The facility's Abuse Prevention Program Facility Policy dated 7/3/2012 shows This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion.
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 F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to ensure residents diets, weights and interventions wer...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to ensure residents diets, weights and interventions were monitored for residents with weight gain and insidious weight loss which includes 2 of 4 residents (R1, R4) reviewed for nutritional status in a sample of 5.
The findings include:
R1's Facility assessment dated [DATE] showed R1 is a cognitively impaired resident admitted to the facility with diagnoses which included: dementia, hypertension, mild protein-calorie malnutrition, Wernicke's encephalopathy, schizoaffective disorder, and limitation of activity due to disability.
R1's Monthly Weight Flow Sheet showed R1's weight increase from May 2022 to May of 2023 was 76 pounds. This flow sheet showed R1 was 170 pounds in January of 2022.
R1's Physician Order Sheet showed R1 has an order for a regular consistency diet with double portions at lunch.
On 5/1/23 at 12:30 PM, R1 ate 100 percent of his noon meal. R1 stated he is a good eater and eats everything that is put in front of him.
R1's undated Tray ticket showed R1 has double portions for breakfast, lunch, and dinner.
R1's Care Plan revised on 3/5/23 showed initial concerns for weight loss. R1's Care Plan copy showed an initial date of 8/4/21 with revisions through 3/5/23. Interventions for weight loss included double portions.
On 5/1/23 at 12:25 PM, V7 Licensed Practical Nurse stated for the last few months R1's increase in weight was noticed. V7 stated I contacted the Director of Nursing about his noted increase in weight. I would have contacted the dietitian, but we have not had one in the facility for a while.
R4's Facility assessment dated [DATE] showed R4 is a cognitively impaired resident admitted to the facility with diagnoses which included: dementia, anemia, hypertension, hypo-osmolality, and hyponatremia.
R4's Weight Flow Sheet showed R4's weight in November of 2022 was 102 pounds, and R4's weight on 5/1/23 was 91.6 pounds which is a 10.2% weight loss in 6 months.
On 5/1/23 at 10:15 AM, V11 Registered Nurse stated V13 Restorative Aide does the monthly weights and reports the numbers to the nurses. V11 stated R4 had been losing weight for a while. V11 stated we usually contact the physician and the dietitian for noted weight loss. V11 stated we have not had a dietitian to notify for a while now. V11 stated she was not sure how long the facility has not had a dietitian.
On 5/1/23 at 9:45 AM, V14 [NAME] President for Dietitian Agency stated the contract with the facility was dissolved in July of 2022 when the dietitian had medical issues and stopped working. V14 stated they had no replacement dietitian in July, and still have no new dietitians to start a new contract with the facility. V14 stated a dietitian should be monitoring weights, ordering diets, assessing food allergies, assessing residents' nutritional needs, calculating tube feedings, and making recommendations for residents' nutritional needs.
The facility's Weight Monitoring Policy dated 2017 showed a registered dietitian is an integral part in monitoring weights, providing recommendations for weight changes, and initiating interventions to promote nutritional health for residents.
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 F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to ensure the facility employed/contracted a registered dietitian which applies to all 83 residents residing in the facility.
The Facility Rost...
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Based on interview and record review the facility failed to ensure the facility employed/contracted a registered dietitian which applies to all 83 residents residing in the facility.
The Facility Roster dated 4/30/23 showed the facility census of 83 residents with three residents in the hospital.V4 Assistant Director of Nursing confirmed the census was still 83 on 5/1/23.
On 5/1/23 at 9:20 AM, V2 Director of Nursing and V4 stated the facility did not currently have a Registered Dietitian.
On 5/1/23 at 1:30 PM, V9 Dietary Supervisor stated they did not have a Registered Dietitian working in the facility.
On 5/1/23 at 9:45 AM, V14 [NAME] President for Dietitian Agency stated the contract with the facility was dissolved in July of 2022 when the dietitian had medical issues and stopped working. V14 stated they had no replacement dietitian in July, and still have no new dietitians to start a new contract with the facility. V14 stated in November of 2022 our agency provided a separate service to review the facility's menus. This service does not look at any resident information with the menu reviews.
The facility's Weight Monitoring Policy dated 2017 showed a registered dietitian is an integral part in monitoring weights, providing recommendations for weight changes, and initiating interventions to promote nutritional health for residents.
Apr 2023
1 deficiency
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 F0885
(Tag F0885)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to ensure residents and resident representatives were informed of a COVID-19 outbreak when the facility had a new positive COVID-19 staff or re...
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Based on interview and record review the facility failed to ensure residents and resident representatives were informed of a COVID-19 outbreak when the facility had a new positive COVID-19 staff or resident which applies to all 83 residents.
The findings include:
The facility's Roster printed on 4/3/23 showed the facility census was 83 residents.
The facility's COVID-19 Line List, printed on 4/3/23, showed the facility has had four COVID-19 outbreaks since 12/1/22. The facility is currently in outbreak status which started on 3/20/23 when V4 Registered Nurse (RN) tested positive for COVID-19.
On 4/3/23 at 11:30 AM, V2 Director of Nursing stated the previous Activity Director (V10) was the person who sent out emails to resident's families when there was COVID in the building. V2 stated V10 no longer works in the facility.
On 4/3/23 at 11:45 AM, V3 Assistant Director of Nursing stated after V10 left the facility and does not have anyone assigned to notify families of new COVID cases.
On 4/3/23 at 12:15 PM, V9 Human Resources/Medical Records stated V10 resigned.
The facility's COVID-19 Policy revised on 12/21/22 showed the facility needs to notify residents and resident representatives when resident or staff have a new positive COVID results (initiates or extends outbreak).
Nov 2022
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure home health care services were arranged for a resident prior ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure home health care services were arranged for a resident prior to discharge. This applied to 1 of 3 residents (R1) reviewed for discharge planning in the sample of 4.
The findings include:
On 11/17/22 at 10:00 AM, R1 stated, The discharge was a 'total mess'. I needed home health services for my catheter and not all the paperwork was sent over to the home health agency. No one told me home health was waiting for the paperwork until after I was discharged . I called V6 (Social Service Assistant), and she told me the home health agency was waiting on the paperwork from V8. I had a problem with my catheter leaking at home. I had to go to the emergency room for my catheter and if I had home health, they could have taken care of the issue.
On 11/17/22 at 9:08 AM, V4 (RN) stated, [R1] was discharged to an independent living facility and needed home health services. [R1] was alert and dependent on staff for transfers and had a foley catheter. She had a referral for home health on discharge and as far as I know everything was set up when she discharged . [V6 (Social Service Assistant)] should have set up home health for [R1]. It's important for residents to have those services set up before they are discharged so they have everything at home.
On 11/17/22 at 11:17 AM, V6 (Social Service Assistant) stated she thought R1's home health was set up, she faxed over the paperwork, .but after [R1] was discharged they home health agency called and said they needed more paperwork. I'm new and doing my best.
On 11/17/22 at 10:15 AM, V3 (ADON) stated, Nursing gets the order for home health and social services should fax and arrange the services before a resident is discharged . Home health should be set up prior to discharge so they have the services they need at home. The home health agency was waiting on the doctor's notes for [R1]. [R1] needed assistance with transferring and nursing care for her catheter. [R1] should have not been discharged until those services were arranged.
R1's face sheet shows she is a [AGE] year-old female with diagnoses including multiple sclerosis, type 2 diabetes, urine retention, neuromuscular dysfunction of the bladder and anxiety.
R1's Minimum Data Set assessment dated [DATE] shows she's cognitively intact, total dependent with two persons assist with transfers and has an indwelling catheter.
R1's Physician Order Sheets dated through September 2022 shows an order on 9/20/22 to discharge home and referral for home health.
R1's Post Discharge Form dated 11/2/2022 documents she is being discharged home with the home health services. R1 needs assistance with activities of daily living and foley catheter care daily and foley catheter change monthly.
R1's Social Service progress note dated 11/2/2022 documents, Discharge Summary; [R1] was discharged to independent living .support services in place, home health still waiting for face-to-face encounter documentation from [V8 (Physician)] .
R1's nurses note dated 11/2/2022 documents, Discharge instructions given to [R1], and she is aware home health will follow up.
A copy of the fax sheet dated 11/9/22 (7 days after R1's discharge) sent by V6 (SSA) to the home health agency states under comments/notes, Dr. notes of [R1].
The facility's undated Discharge Planning Policy states, To identify appropriate candidates for inclusion in active discharge planning facilitating the transition to a less structured environment and to coordinate adequate supportive community care services. This nursing facility strong emphasizes preparation and preparedness .to promote a smooth transition from the skilled nursing facility into a community-based living situation arranging home health care services as necessary and ordered by the doctor
May 2022
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure nail care and personal hygiene were completed f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure nail care and personal hygiene were completed for 1 of 22 residents (R72) reviewed for Activities of Daily Living (ADL's) in the sample of 22.
The findings include:
R72's face sheet shows she has diagnoses including: hemiplegia and hemiparesis following cerebral infarction, osteoarthritis, and vascular dementia.
R72's 4/17/22 facility assessment shows she has a cognitive deficit and requires extensive staff assistance with personal hygiene
On 5/9/2022 at 10:17 AM, R72 was sitting up in her room in bed. She had dried food on her chin and around her mouth. Her fingernails were extremely long and had a black substance and what appeared to be food, heavily coating under [NAME] them. R72 yelled to the surveyor that staff do not help her and she was uncomfortable. The surveyor pulled R72's call light and V9 (Certified Nursing Assistant/CNA) and V6 (Registered Nurse/ RN) came into R72's room and re-positioned R72. V6 and V9 both left the room without clearing the food off of R72's face.
On 5/10/2022 at 11:18 AM, V10 (CNA) said that residents are supposed to have their nails cut during shower days and as needed.
On 5/11/2022 at 9:27 AM, V3 (Assistant Director of Nursing) said grooming should be done with showers and as needed. Staff should cut/clean the residents nails if they are dirty or long.
Facility provided shower sheets show R72 receives showers on Thursdays and Sundays. R72's May shower sheets shows she last received a bed bath on 5/5/22 and nail care was not provided.
The facility's 2010 Activities of Daily Living (ADL) policy states, Purpose: 1. To assist resident in achieving maximum functional ability with dignity and self-esteem. 2. to Provide assistance to residents as necessary.
The facility's July 2010 Nail Care policy states, Residents will receive nail care during bath time or immediately after, and PRN {as needed} to ensure nails are clean, trimmed and smooth.
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 observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place for a resident with a pressure ulcer. This apples to 1 of 5 residents reviewed for pressure injuries in a sample of 22.
The findings include:
R42's Face Sheet dated 1/27/22 showed R42 is a [AGE] year old female admitted to the facility on [DATE] with diagnoses which include: dementia and type 2 diabetes.
R42's Facility assessment dated [DATE] showed R42 having severe cognitive impairment, at risk for pressure injuries, and needing extensive two person assistance with bed mobility and transfers.
R42's Braden assessment dated [DATE] showed R42 being at moderate risk for developing pressure injuries.
R42's Physician Wound Notes dated 5/1/22 showed R42 having a deep tissue pressure injury to the right posterior heel with measurements of 3 X 3 X 0 centimeters (cm). Treatment plan preventative measures which include: off load heels with heel protectors or pillow.
On 5/9/22 at 9:50 AM, 11:25 AM, at 1:20 PM R42, and on 5/10/22 at 9:30 AM, R42 was lying in bed with heels directly on mattress. No offloading devices (extra pillows, padded boots, etc) were present during these observations.
On 5/11/22 at 10:45 AM, V3 Assistant Director of Nursing changed R42's dressing. R42's right heel had a blackened area of skin the approximate width of a ping pong ball. V3 stated Certified Nursing Assistants (CNAs) are told by word of mouth (report or by nurse) when a resident would need off loading or boots need to be applied. A resident with heel issues should have heels offloaded.
On 5/11/22 at 11:00 AM, V16 CNA when a resident has skin issues with their feet they need to have their feet offloaded with a pillow under their legs or use padded boots. We (CNAs) get report from the nurses and/or each other to know who needs to have offloading when we round on residents.
R42's Care plan dated 3/6/22 showed R42 is at risk for skin breakdown due to lack of mobility, Diabetic conditions with interventions which include the use of pressure reducing devices and and administer prescribed mediations and treatments per doctor's orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure restorative care was being completed, and faile...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure restorative care was being completed, and failed to ensure assistive devices were implemented for a resident with contractures, for 1of 8 residents (R52) reviewed for restorative services in the sample of 22.
The findings include:
R52's face sheet shows she has diagnoses including: hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting right dominant side, aphasia, and dysphagia.
R52's facility assessment dated [DATE] shows she has a cognitive deficit, and an impairment of her range of motion (ROM) to both her upper and lower extremities.
R52's active restorative care plan shows she is supposed to receive passive range of motion (PROM) to her upper and lower extremities for 15 minutes a day. The same care plan shows she is supposed to have a hand roll in her right hand.
R52's May 2022 Restorative Program Minutes Tracking Sheet shows she did not receive any restorative (PROM) on 5/1/22, 5/6/22, 5/7/22, 5/8/22 and 5/10/22.
On 5/9/2022 at 1:06 PM, R52 was in bed. She had both hands visible on the top of her covers. Her right hand has a contracture, with her fingers folding inward. R52 was asked if she could move her fingers and she replied back by shaking her head no. She had no splint or hand roll in her hand and one was not seen in her room.
On 5/10/22 at 12:22 PM, V8 (Restorative CNA/Certified Nursing Assistant) said R52 is supposed to be receiving (PROM) every day but when he is being pulled to work on the floor she is not getting it. V8 said that R52 is supposed to have a hand roll in her right hand and he is not sure why she doesn't.
On 5/10/2022 at 12:45 PM, V6 (Registered Nurse/RN) said R52 should have a hand roll in her hand. V6 went into R52's room with the surveyor. R52 did not have a hand roll in her hand. V6 looked for a hand roll in the room but was not able to find one. V6 said R52 was recently moved from another room and it may have been left there.
On 5/11/2022 at 9:25 AM, R52 was in her room in bed and had no hand roll in her right hand.
The facility's 2010 Restorative Nursing Policy and Procedure states, To promote each resident's ability to maintain or regain the highest degree of independence as safely possible . Identify residents who currently have splits/braces or previous range of motion programs or those that have actual or potential limitations with ROM and/or pain .Restorative Nursing is available seven days a week and is provided for residents with assessed needs according to program criteria .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident was offered and assisted with e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident was offered and assisted with eating to maintain weight and adequate nutritional intake.
This applies to 1 of 4 residents (R48) reviewed for weight loss in a sample of 22.
The findings include:
R48's Facility admission Record shows that R48 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Fall, and Hypertension.
R48's Monthly Weight/Vital Flow Sheet shows that R48 weighed 120 pounds in March, 113 pounds in April, and 100 pounds in May.
R48's Nutritional Notes dated 4/9/22 state, Resident with 5.8% weight loss after admit. Weight 4/113#, 3/120#. Resident is refusing meal intake and drinking Glucerna 1.2 . Accepting 5 cans at this time to provide 1420 calories, 45 grams of protein and 960 ml. Resident nutritional needs 1530-1785 calories, 51-66 grams of protein and 1530-1785 ml of fluid. Recommend increase Glucerna 1.2 to 6 cans/day and oral fluids 4-5 cups of water or fluid .Stabilize weight desired.
On 5/10/22 at 1:51 PM, V13 (RN) stated, If you give him the food in his hand, he will eat it. He will not eat with a spoon or fork and he will say, no, no, no but if you put it in his hand he will eat it. Same with his medications- if you put them in his hand , he will take them. He drinks 2 Glucernas a day. I know because I see them in the garbage can.
R48's Daily Nurse's Notes documents that R48 has refused to eat solid food since 4/10/22.
On 5/11/22 at 9:49 AM, V2 (Director of Nursing) stated, He is my Brother in law- my sister's husband. He is 93. He did this at home too. He doesn't want to eat. He is confused and has a mind of his own. He was driving and then he had a stroke. He went to the hospital and then he came here. He is mad at me and he is mad at my sister because he is here. He was not eating anything at home either. I was shocked when I heard he ate a Peanut Butter sandwich- he never ate that before in his life. He only wants the drinks he had when he was at home so my sister brought them in for him.
R48's care plan dated 4/9/22 states, The resident may be at risk for weight loss related to : Refuses meals accepts supplements only. The Approaches include: Provide one to one staff intervention/ set-up to promote proper nutritional intake.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure a medication ordered for a particular resident was not administered to another resident for 2 of 2 residents (R61 and R...
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Based on observation, interview, and record review the facility failed to ensure a medication ordered for a particular resident was not administered to another resident for 2 of 2 residents (R61 and R285) reviewed for pharmacy services in the sample of 22.
The findings include:
On 05/09/22 at 09:56 AM, in R61's room was a intravenous (IV) pole. Hanging on the pole was a empty antibiotic bag connected to IV tubing. The antibiotic was ceftriaxone 1 gram (gm). The resident's name on the bag was R285. R285 and R61 resided in different rooms.
On 05/09/22 at 10:20 AM, V4 (Licensed Practical Nurse- LPN) confirmed the resident's name on the antibiotic was not R61's name but was R285's name. V4 said the nurse that administered the medication, Accidentally swapped R61's and R285's antibiotics. V4 said R61 and R285 were on the same antibiotic with the same dose.
R61's Medication Administration Record (MAR) showed R61 had an order for ceftriaxone 1 gm to be given at 06:00 AM and 06:00 PM.
R285's MAR showed R285 had an order for ceftriaxone 1 gm to be given at 09:00 AM.
On 05/09/22 at 12:58 PM, V5 (Pharmacist) said the nurse gave R61 an antibiotic that was intended for R285. V5 said the pharmacy will have to send another dose of antibiotic for R285 to replace the dose given to R61.
On 05/10/22 at 10:46 AM, V6 (Registered Nurse) said residents have there own medications and residents should not receive other residents' medications. V6 said it was a standard of practice to ensure residents have an adequate supply of medications and to prevent medication errors.
The facility's Medication Administration policy dated 7/10 showed, Medications ordered for a particular resident may not be administered to another resident, unless permitted by state law .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) R38's face sheet shows she has diagnoses including: hemiplegia and dysphagia.
R38's prevention of aspiration care plan with...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) R38's face sheet shows she has diagnoses including: hemiplegia and dysphagia.
R38's prevention of aspiration care plan with an effective date of 3/13/22 shows she is at risk for aspiration pneumonia due to a having dysphagia and a CVA (Cerebrovascular accident). The same care plan shows she requires supervision and monitoring during meal times for prevention of food pocketing, drooling, spitting food and coughing.
R38's Aspiration Precautions sheet shows she is on a pureed diet with honey thick liquids, and she requires 1:1 supervised feedings with small bites and a slow rate.
On 5/9/2022 at 1:46 PM V6 (Registered Nurse/RN) said R38 sometimes eats in her room and sometimes eats in the dining room. V6 said we don't always have to feed her we just have to peek in on her.
On 5/10/2022 at 8:42 AM, R38 was alone in her room eating her breakfast tray. On 5/10/2022 at 12:29 PM, R38 was again in her room eating her noon meal with no staff supervising her.
On 5/11/2022 at 10:15 AM, V6 (RN) said R38 had a prior swallowing evaluation which identified she is at risk for aspiration. V6 said R38 is supposed to be being monitored 1:1 during feedings and when she is in the dining room eating she is supervised. V6 said the CNA's should give R38 her tray last when she is eating in her room, and then stay with her.
A copy of R38's swallowing evaluation was requested and was not provided by the facility.
The facility's not dated Aspiration Precautions-Clinical Guideline policy states, These guidelines have been established to: 1. Help identify patients who are at risk for aspiration, as well as aspiration pneumonia and pneumonitis. 2. Provide guidelines to follow to reduce risks of aspiration, as well as the complications of aspiration pneumonia and pneumonitis. 3. Reinforce that prevention is the best strategy. 4. Assist the medical team in placing the patient on Aspiration Precautions ordering appropriate consults, modifying the diets, and monitoring the patient's progress with swallowing and nutrition .
Based on observation, interview, and record review the facility failed to prevent a resident from eloping off of a locked memory unit, failed to supervise a resident at risk for aspiration while eating, and failed to transfer a resident in a safe manner after a fall. This applies to 4 of 22 residents (R10, R62, R38, R48) reviewed for safety in a sample of 22.
The findings include:
1. R10's Facility assessment dated [DATE] showed R10 to be an [AGE] year old, cognitively impaired female admitted on [DATE] with diagnoses which include: dementia, schizophrenia, and Alzheimer's disease.
The facility's Resident Roster printed on 5/9/22 showed R10 is a resident on the second floor locked memory unit.
On 5/9/22 at 9:30 AM, R10 was repeatedly walking with a walker up and down the hall. At 9:55 AM R10 was waiting next to the nurses station by the elevators. V18 Kitchen aide came to the elevator with the dirty meal tray cart and drink cart. V18 used his security access card reader to activate the elevator buttons. V18 got onto the elevator with the carts. R10 asked if she could get on the elevator with him. V18 let R10 onto the elevator without checking with anyone else if R10 could come off the unit.
On 5/9/22 at 9:35 AM, V11 receptionist was redirecting R10 back onto the elevator. V11 confirmed R10 got off the elevator, and V18 was in the elevator with the dirty dining carts. V11 stated residents on the second floor should not be coming off the floor without the nurse and/or other staff knowing they are off the unit. We use the access card for the elevator to come off the unit. The second floor is a locked memory care unit to protect the resident from wandering off and getting hurt. V11 stated R35 is the only resident on the floor whom is allowed off the unit to go to the basement for the vending machines by himself. V11 stated R10 does go out of the facility with her daughter on occasion, but that is not today. V11 stated staff should not be letting residents on the elevator without checking with others first.
On 5/9/22 at 10:15 AM, V4 Licensed Practical Nurse (LPN) stated the second floor is a locked memory unit. Only one resident (R35) goes off the unit by himself to the vending machines and back upstairs. R35 still needs to be let off the unit with the access card by staff to get on the elevator. V4 stated R10 does wander the unit with her walker. R4 stated staff should not be letting second floor residents on the elevator unless it is a planned leave.
On 5/9/22 at 11:30 AM, R10 was sitting on the edge of her bed. R10 appeared to be in a good mood, but very confused. When R10 responded to questions the replies were not associated with the questions. R10 talked to herself repeatedly stating is time to go home?
On 5/10/22 at 1:40 PM, V15 Kitchen Supervisor stated the kitchen staff should not be letting the second floor residents on the elevator unless the care staff knows, and the resident is supposed to be going somewhere like a doctor appointment or out with their family. V15 stated he has worked here a while and knows which residents to watch for, and not let them off the floor. V15 stated he does not remember any direct inservices on resident elopement.
On 5/11/22 at 11:00 AM V16 Certified Nursing Assistant (CNA) stated we do not let the residents get on the elevators. the second floor is a locked unit. Staff need to make sure none of are exit seeking residents try to get on the elevator. We need to double check with the nures if a resident is leaving for an appoitment, and then the resident needs to be escorted downstairs so they do not leave on their own.
The facility's Elopement Policy dated 8/16/2018 showed Purpose: To prevent elopement by appropriately assessing resident risk factors and implementing an effective interventions determined to diminish exit seeking behavior.
2. R62's Facesheet printed on 3/15/22 showed R62 was is an [AGE] year old male admitted to the facility on [DATE] with diagnoses which include: dementia, cerebral infarction.
R62's Facility assessment dated [DATE] showed R62 has severe cognitive impairment, and needs limited one person assistance with eating ADLs (activities of daily living).
On 5/9/22 at 10:00 AM, R62 was sitting in his room watching television. During R62's interview he had excessive drooling and he kept clearing his throat. At 12:05 PM, R62 was eating his lunch in his room by himself. R62's meal ticket showed and order for mechanically soft food. R62 had periodically coughed after taking drinks of liquids. During the continuous observation from 12:05-12:25 PM, none of the staff checked in on R62. At 12:25 PM, R62 had finished his meal, and had pushed the bedside tray away from himself.
On 5/9/22 at 1:45 PM, V4 stated R62 likes to eat his meals in his room most of the time. He likes to eat by himself, and does not like the staff to hover over him. V4 stated R62 is on an altered diet and we need to check in on him during meals.
On 5/9/22 at 11:00 AM, V16 stated R62 does not like the staff to watch him eat so we do periodic checks on him while he is eating.
R62's Order Sheet copied on 5/11/22 showed R62 has a diet order for mechanically soft diet.
R62's Carplan revised on 3/6/22 showed R62 has a problem of altered nutritional status due to chewing problem, mechanically altered diet, prefers to eat in room, dysphagia, and dementia with an approach for set up and supervision.
R62's Swallow Evaluation results dated 2/13/2018 showed R62 had penetration and aspiration of contrast material. R62 has not had another swallow evaluation since 2/13/18 per facility documentation.
The facility's undated Meal Assistance Policy showed Policy Statement: Residents shall receive assistance with meals in a manner that meets the individual needs of each resident.
4. On 5/10/22 at 11:19 AM, R48 was found sitting on the floor- yelling out for assistance. R48 was sitting between the bed and the wheelchair. R48 kept repeating sleepy, sleepy. V13 (RN) entered R48's room grabbed on to R48's left arm and began pulling resident up by his arm. R48 was able to stand on his feet with his knees still bent, V13 grabbed the back of R48's pants and using her hips, pushed R48's hips and sat him on the edge of the bed. V13 then locked the wheelchair and R48 was able to transfer himself back to the wheelchair. R48 began rubbing his left shoulder with his right hand. V13 asked R48 if he had pain- R48 said no but then continued to point to and rub his left shoulder.
On 5/11/22 at 9:49 AM, V2 (Director of Nursing) stated, (R48) is my Brother in law, my sister's husband. He is 93. He is confused and has a mind of his own. I didn't know he fell yesterday. No one told me.
R48's Nurse's Daily Progress Note dated 5/10/22 states, 'Resident quiet and follows commands at times. Had solid food this morning (boiled egg) Taking sips of water bottle and water at the bedside. Compliant with medications this morning. There is no mention of R48's fall.
On 5/10/22 a copy of the incident report related to R48's fall was requested. The facility was unable to provide this document. R48's medical record shows no documentation of R48's fall. There is also no documentation of family notification or physician notification of R48's fall.
R48's Minimum Data Set of 3/24/22 shows that R48 requires extensive assist of 1 person for all transfers.
R48's care plan dated 4/14/22 states, Resident has had a recent fall associated with / possibly caused by: unsteady gait, weakness, agitation, lack of safety awareness. The Approaches include: Communicate with members if the interdisciplinary team to ensure continuity of care. R48's care plan dated 3/24/22 states, Alteration in comfort secondary to pain. The resident's pain appears related to: Arthritis. The Approaches include: Encourage the resident to sit, stand or lie in a comfortable position. Encourage frequent and correct positioning to prevent strain on muscles and joints.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to puree bread for 4 of 4 residents (R21, R285, R42, and R84) reviewed for following the menu in the sample of 22.
The findings...
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Based on observation, interview, and record review, the facility failed to puree bread for 4 of 4 residents (R21, R285, R42, and R84) reviewed for following the menu in the sample of 22.
The findings include:
On 5/9/22 at 11:20 AM, pureed bread was not noted when the noon meal was being plated.
On 5/9/22 at 11:39 AM, V15, Kitchen Supervisor, said they forgot to puree the bread; they are shorthanded.
The facility's menu for 5/9/22 shows Lunch includes Wheat Bread.
The facility's list of residents requiring a pureed diet (dated 5/9/22) includes R21, R285, R42, and R84.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure staff removed PPE (personal protective equipmen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure staff removed PPE (personal protective equipment) when exiting the COVID-19 unit, failed to ensure a COVID-19 positive resident remained isolated, failed to ensure staff wore a N95 mask when cleaning a COVID-19 positive room, and failed to prevent cross contamination by cleaning a COVID-19 positive room then a COVID-19 negative room. This has the potential to effect all 84 residents at the facility.
The findings include:
1. The federal form 672 that was filled out by the facility on 5/11/22 show the facility's census to be 84.
On 05/10/22 at 12:46 PM, V7 (Certified Nursing Assistant- CNA) was in the COVID-19 unit (where COVID-19 positive residents were being taking care of). V7 had on the following personal protective equipment: N95 mask, gloves, eye protection, and a yellow disposable isolation gown. V7 was going in and out of COVID-19 positive resident rooms picking up meal trays. V7 exited the COVID-19 unit. V7 did not remove her PPE. V7 only changed her gloves and entered R285's room to pick up R285's meal tray. V7 had on PPE that was also worn in a COVID-19 positive room when entering R285's room.
On 05/09/22 at 10:20 AM, V4 (Licensed Practical Nurse) said R285 was on isolation to rule out COVID-19. V4 said R285 was a new admission to the facility and was not vaccinated for COVID-19. V4 said R285 did not have COVID-19.
On 05/10/22 at 01:45 PM, V3 (Assistant Director of Nursing) said staff should remove their PPE when exiting the COVID-19 unit.
The facility's Coronavirus/COVID-19 Response Plan, Policy, and Procedure with a review date of 2/22 showed PPE is only worn between residents of the same COVID-19 status.
2. R35's Facesheet dated 5/12/22 showed R35 is an [AGE] year old male with diagnoses which include: dementia and unspecified psychosis.
The facility's COVID-19 Line List printed on 5/11/22 showed R35 tested positive for COVID-19 on 5/10/22 with symptoms of cough, fever, and body aches.
The facility's Floor Roster for 5/11/22 showed R35 was moved to room [ROOM NUMBER] on the COVID-19 positive Red Zone.
On 5/10/22 at 1:05 PM, R35 could be seen through the plastic barrier walking in the hallway of the Red Zone. R35 walked from the Red Zone through the Yellow Zone, out of the COVID-19 unit, and down the hall approximately 50 feet before V19 Housekeeper redirected R35 back onto the COVID-19 unit. R35 was not wearing a mask when he walked of the unit. At that time there were no care staff present at the nurses station or in the hallway monitoring the COVID-19 unit.
On 5/11/22 at 10:00 AM V19 stated R35 needs to stay behind the curtain (plastic barrier) because he has COVID. V19 stated other people do not want to get sick.
On 5/11/22 at 9:45 AM, V2 stated residents who are positive need to be isolated and stay in their rooms. V2 stated R35 wanders. We need to watch him closely to keep him on the COVID unit.
The facility's COVID-19 Policy updated 3/2022 showed Residents with Confirmed COVID-19 .Isolate using transmission-based precautions.
3. On 5/10/22 at 8:53 AM V14( Housekeeper) was cleaning room [ROOM NUMBER]. V14 was wearing only a surgical mask, a face shield and gloves. V14 was not wearing an N95 mask or a gown.
Per the facility census report the 2 residents in room [ROOM NUMBER] both tested positive for COVID 19 in the early morning hours of 5/10/22.
At 8:58 AM, V14 stated that he can't breath while wearing an N95 mask. V14 was asked if he knew that the residents in room [ROOM NUMBER] were positive for COVID 19. Without removing his gloves, V14 took the paper off of his cleaning cart showing which residents tested positive for COVID and realized he had overlooked room [ROOM NUMBER].
On 5/10/22 at 9:00 AM, V2 (Director of Nursing) was asked about the procedures for housekeeping in the rooms with COVID positive residents. V2 stated that she would take care of it.
Surveyor returned to the floor and observed V14 cleaning R55's room, room [ROOM NUMBER]. R55 tested negative for COVID on 5/10/22. V14 was using the same housekeeping cart, mop and cleaning supplies to clean room [ROOM NUMBER] as he had used to clean room [ROOM NUMBER].
The facility policy entitled Covid 19/Coronavirus Response Plan, Policy and Procedure dated March 2022 states, Full PPE (N95 respirator, eye protection, gown, gloves) should be worn by staff care for residents in quarantine or those suspected or confirmed COVID 19. This same policy also stated, The environmental cleaning and disinfection procedures are followed consistently and correctly.
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
- • 6% annual turnover. Excellent stability, 42 points below Illinois's 48% average. Staff who stay learn residents' needs.
Concerns
- • Multiple safety concerns identified: 3 life-threatening violation(s), Special Focus Facility, 2 harm violation(s), $237,307 in fines, Payment denial on record. Review inspection reports carefully.
- • 65 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $237,307 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility is on CMS's Special Focus list for poor performance. Consider alternatives strongly.
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About This Facility
What is Claridge Healthcare Center's CMS Rating?
CMS assigns CLARIDGE HEALTHCARE CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Illinois, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Claridge Healthcare Center Staffed?
CMS rates CLARIDGE HEALTHCARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 6%, compared to the Illinois average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Claridge Healthcare Center?
State health inspectors documented 65 deficiencies at CLARIDGE HEALTHCARE CENTER during 2022 to 2025. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, and 60 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 Claridge Healthcare Center?
CLARIDGE HEALTHCARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 231 certified beds and approximately 76 residents (about 33% occupancy), it is a large facility located in LAKE BLUFF, Illinois.
How Does Claridge Healthcare Center Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, CLARIDGE HEALTHCARE CENTER's overall rating (1 stars) is below the state average of 2.5, staff turnover (6%) is significantly lower than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Claridge Healthcare Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Claridge Healthcare Center Safe?
Based on CMS inspection data, CLARIDGE HEALTHCARE CENTER has documented safety concerns. Inspectors have issued 3 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Illinois. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Claridge Healthcare Center Stick Around?
Staff at CLARIDGE HEALTHCARE CENTER tend to stick around. With a turnover rate of 6%, the facility is 40 percentage points below the Illinois average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 7%, meaning experienced RNs are available to handle complex medical needs.
Was Claridge Healthcare Center Ever Fined?
CLARIDGE HEALTHCARE CENTER has been fined $237,307 across 2 penalty actions. This is 6.7x the Illinois average of $35,452. 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 Claridge Healthcare Center on Any Federal Watch List?
CLARIDGE HEALTHCARE CENTER is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.