LEMONT NURSING & REHAB CENTER
For profit - Limited Liability company
173 Beds
EXTENDED CARE CLINICAL
Data: November 2025
Trust Grade
40/100
#377 of 665 in IL
Photo by Lemont Nursing and Rehabilitation Center
Photo by Mark Jurczeski
Photo by Lemont Nursing and Rehabilitation Center
1 / 5 photos
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Lemont Nursing & Rehab Center has a Trust Grade of D, indicating they are below average and have several concerns regarding care and operations. They rank #377 out of 665 facilities in Illinois, placing them in the bottom half, and #123 out of 201 in Cook County, meaning only a few local options are better. The facility is worsening, with issues increasing from 12 in 2024 to 18 in 2025. Staffing is a significant concern, rated at just 1 out of 5 stars with a high turnover rate of 60%, well above the state average of 46%. While they have not incurred any fines, which is a positive aspect, the RN coverage is only average, meaning residents may not receive the attentive care they need. Specific incidents found during inspections highlight serious issues, including a failure to provide a pureed diet for a resident with swallowing problems, leading to significant weight loss, and problems in the kitchen that could lead to foodborne illness, affecting nearly all residents. Overall, families should weigh these strengths and weaknesses carefully when considering Lemont Nursing & Rehab Center for their loved ones.
- Trust Score
- D
- In Illinois
- #377/665
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Illinois facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 28 minutes of Registered Nurse (RN) attention daily — below average for Illinois. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 42 deficiencies on record. Higher than average. Multiple issues found across inspections.
40/100
Bottom 44%
Needs review
12 → 18 violations
★★☆☆☆
2.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 12 issues
2025: 18 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Below Illinois average (2.5)
Below average - review inspection findings carefully
Staff Turnover: 60%
14pts above Illinois avg (46%)
Frequent staff changes - ask about care continuity
Chain: EXTENDED CARE CLINICAL
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (60%)
12 points above Illinois average of 48%
The Ugly 42 deficiencies on record
1 actual harm
Mar 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide documentation of a resident's AD (Advance Directives) to th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide documentation of a resident's AD (Advance Directives) to the ALS (Advance Life Support) paramedics and the hospital during a hospital transfer.
This applies to 1 of 3 residents (R1) reviewed for facility-initiated transfer to the hospital and AD.
The findings include:
The EMR (Electronic Medical Record) showed that R1, a [AGE] year-old with diagnoses that includes acute and chronic respiratory failure, fluid overload, congestive heart failure, dependence on oxygen supplement, asthma, diabetes mellitust type 2, chronic kidney diase, end stage renal disease and dependence on renal dialysis, anemia, cardiomyopathy, aortic valve stenosis, lack of coordination, osteoarthritis, and presence of vascular implants and grafts, R1 was originally admitted to the facility on [DATE]. R1 was sent out to the hospital via 911 on March 11,2025 and returned to facility on March 14, 2025.
The Social Service Notes dated February 28,2025 showed that R1, an African American female who admitted to the facility .primary language is English. (R1's) speech is clear, and her hearing appears adequate. (R1) is alert x3. (R1) is able to understand, as well as be understood Discussed advanced directives. (R1) reported she did not have a POA (Power of Attorney); however, per nursing notes resident's daughters provided POA paperwork and POLST (Practitioner Order Life Sustaining Treatment). (R1) did confirm she would like to be DNR (Do Not Resuscitate).
The MDS (Minimum Data Set) assessment dated [DATE], showed that R1 was cognitively intact with BIMS (Brief Interview Mental Status) score of 15/15.
The POLST form signed by R1 marked with a date of March 19,2019 showed R1's AD wishes as follows: DNR (if patient with no pulse); When not in cardiopulmonary arrest and patient is breathing- Comfort-Focused Treatment: primary goal of maximizing comfort; Relieve pain and suffering through use of medication, by any route, as needed, use oxygen, suctioning, and manual treatment of airway obstruction. Do not use treatments Listed in Full and Selective Treatment unless consistent with comfort goal. REQUEST TRANSPORT TO HOSPITAL ONLY IF COMFORT NEEDS CANNOT BE MET IN CURRENT LOCATION.
The progress notes dated March 11,2025 showed that R1 was sent out to the hospital via 911 due to shortness of breathing. R1 was admitted to hospital's ICU (Intensive Care Unit) with diagnoses of cardiac overload.
The hospital H&P (History and Physical) dated March 11,2025 showed that (R1) to ER (Emergency Room) for worsening SOB (shortness of breathing) over the last 2 hours . Upon arrival, (R1) was in significant amount of distress .admitted to ICU.
The EMR's SS (Social Service) progress note dated March 14, 2025, which was documented by V4 (Social Serve Director) showed that V12 (R1's daughter/POA/Power of Attorney) had requested the facility for a care plan meeting due to multiple concerns. One of the concerns was regarding R1's hospital transfer on March 11,2025.
On March 25,2025 at 11:36 A.M., V4 said that on March 13,2025, she had received an email from V12. V4 added that the email was about V12 asking that a copy of R1's Advance Directives/POLST (Practitioner Order Life Sustaining Treatment) Form be fax immediately to the hospital.
The facility provided the email correspondence between V12 and V4 dated March 13,2025. The email showed that V12 asked V4 Please fax a copy of (R1's) DNR (Do Not Resuscitate form) to .(hospital) .Pursuant to Illinois state law protocols, a copy of the DNR should have been provided to the transporter (ambulance) as well as a copy to the receiving facility .Please confirm once completed.
The facility's concern form dated March 18,2025 showed that V12 was concern that DNR Form/POLST was not sent with (R1) to the hospital.
On March 26,2025 at 4:55 P.M., V9 (LPN/Licensed practical Nurse) said that she sent R1 out to the hospital on March 11,2025 sometime around 10:00 A.M. V9 said that R1 was sent out due to labored breathing, and pulse oxygen level showed an alarming result of 72 % (normal 95). V9 said that she only provided documentation to paramedics of R1's Face Sheet/ and Medication List. V9 added that she did not provide R1's POLST documentation to the paramedics. V9 further said that she was informed by the nurse for the next shift that a POLST copy should be provided to the paramedics who then will provide to the hospital during resident's transfer. V9 said that she was also informed by V2 (Director of Nursing) after V12 had complained that a copy of the POLST was not provided to the paramedics/and hospital. V9 said that she was told that an in-service regarding appropriate documentation forms to be provided during transfer will be given; however, had not receive the in-service up to the current time. V9 also said that she has been working in the facility since July of 2024 and this was not the first time, she had sent a resident to the hospital. V9 said she was not aware that a copy of documentation of AD/POLST was to be provided to paramedics/hospital during transfer.
The EMS (Emergency Medical Services) transport report dated March 11, 2025, showed that 911 was summoned by the facility on March 11,2025 at 8:30 A.M., paramedics were dispatched at 8:31 A.M., en route at 8:33 A.M., with (R1) at 8:39 A.M., and at hospital at 9:08 A.M. The EMS transport report also showed that R1 was in minor distress, with hyperventilation and fluctuation of oxygen saturation level, remained alert and oriented times 4 spheres (name, time place, person). The report also showed NONE for R1's Advance Directives.
On March 25,2025 at 1:30 P.M., V13 (EMS Director) had validated that according to the EMS transport report for R1, none was checked for Advance Directives. V13 also sent a correspondence email dated March 25,2025 that paramedics crew that transported R1 to the hospital were only provided documents that included medication list and a face sheet.
On March 24,2025 at 3:45 P.M., V12 said that facility had not provided a copy of POLST/DNR/Advance Directives to the paramedics and the hospital. V12 said she had sent an email to V4 once she had found out POLST copy was not sent out with R1 at time of transfer. V12 also said that R1 did not coded en route of transfer nor at the hospital. V12 also added it's the ramification of not sending a copy and (R1's) wishes would not be implemented. She (R1) does want a DNR status.
On March 25,2025 at 12:30 P.M., R1 was observed sitting in her wheelchair in her room. R1 was alert and oriented times 3. R1 said that she was sent out to the hospital a week or 2 weeks ago. R1 said her wish was to remain a DNR status.
On March 26,2025, V1 (Administrator) explained the facility's policy and procedure regarding resident transfer to the hospital. V1 said that their policy was to give forms that included face sheet and medication list that was on the POS (Physician Order Sheet).
Feb 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain a resident's urine specimen in a timely manner to rule out a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain a resident's urine specimen in a timely manner to rule out a urinary tract infection.
This applies to 1 of 6 residents (R2) reviewed for quality of care.
The findings include:
R2's Face Sheet showed she was admitted to the facility on [DATE] and her diagnoses include history of UTIs (Urinary Tract Infections), ESBL (extended-spectrum beta lactamase) resistance, acute kidney failure, and anemia of chronic disease.
R2's 1/21/25 nursing progress note from 5:08 PM showed .writer also spoke to resident's daughter [name] who said she talked to her mom and it was disturbing. She noted her mother seems paranoid and just wanted to let writer know. Writer informed daughter of my own interaction with her and daughter believes she could maybe have a UTI because 'this happens when she has a UTI ' Labs ordered to be drawn in the AM, urine to be collected per NP [Nurse Practitioner] .
R2's 1/22/2025 Psychiatric Evaluation progress note from 12:16 PM (written by V7- Psychiatric NP), showed .Obtain a urine sample for urinalysis and culture to rule out a UTI. Will await results to identify reversible causes of confusion and psychosis
R2's 1/23/2025 NP progress note from 7:39 AM showed .LABS: Awaiting UA/CS [urinalysis/culture & sensitivity] results .
R2's 1/25/2025 nursing progress note from 4:47 PM (four days after initial order on 1/21/25) showed Family came in and asked writer if resident UA collection has been done, writer stated that it had been collected but due to the lid of the specimen cup not being tightly secured the urine fell into the bag and the collection was contaminated, writer stated to family that I could straight cath resident and collect another specimen, family stated that they wanted to take her to the ER Resident left facility with family to [local] Urgent Care.
R2's 12/3/2024 MDS (Minimum Data Set) showed she only requires partial/moderate assistance for walking 50 feet, toileting transfers, and toileting hygiene. The same MDS showed she is always incontinent of bladder and bowel.
On 2/4/25 at 3:18 PM, V7 (Psychiatric NP) stated he ordered R2's UA. V7 stated They need to collect it- the resident shouldn't wait for 4 days. R2's current and discontinued orders for January 2025 showed an order for R2's UA/CS was not transcribed until 1/25/2025.
On 2/4/25 at 9:30 AM, V2 DON (Director of Nursing) stated that R2's family took her to urgent care and they did a urinalysis and R2 has a UTI. R2's 1/28/2025 nursing admission note from 5:14 PM showed she returned from the hospital via ambulance with an IV line.
The facility's February 2014 Medication and Treatment Order Policy showed .3. Telephone and/or verbal orders taken by licensed personnel must be promptly recorded on the Physician's Order Sheet in the resident's record
Jan 2025
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
Based on observations, interview and record review, the facility failed to serve pureed diet as ordered by a Physician to a resident (R1) that has had a recent history of swallowing problems. This fai...
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Based on observations, interview and record review, the facility failed to serve pureed diet as ordered by a Physician to a resident (R1) that has had a recent history of swallowing problems. This failure contributed to the resident having a significant weight loss.
This applies to 1 of 3 residents (R1) reviewed for improper nursing in the sample of 6.
The findings include:
R1's EMR (electronic medical records) included diagnoses of osteomyelitis, pressure ulcer of sacral region, stage 4, pressure ulcer of right buttock, stage 4, unspecified severe protein-calorie malnutrition, adult failure to thrive, other cerebral palsy, dysphagia, oropharyngeal phase, anorexia nervosa.
R1's Annual MDS (minimum data set) dated November 06, 2024 showed that R1 was moderately impaired in cognition and was dependent on staff for all ADL's (activities of daily living) including eating.
R1's diet order on POS (Physician Order Summary) showed Pureed diet (start date January 09, 2025).
R1's weight (in lbs/pounds) history in EMR included as follows:
81.8 lbs (January 16, 2025), 89.8 lbs (December 17, 2024), 88.8 lbs (November 25, 2024), 89.6 lbs (October 18, 2024), 88.6 (September 18, 2024), 89.9 (July 14, 2024).
Dietitian progress notes dated January 16, 2025 included the following information in summary: R1's diet order was pureed texture diet with thin liquids and super cereal at breakfast. Weight: 81.8 lbs (January 16, 2025). BMI [Body Mass Index]: 16 which is underweight. Weight loss of 8.9% since December 17, 2025 and 8.7% since October 18, 2025 and is not desired or planned.
On January 16 at 2025 at 10:52 AM, R1 was seen lying in bed in hospital gown. R1 made eye contact and some sounds but did not respond to queries.
On January 16, 2025 at 11:02 AM, V4 CNA (Certified Nursing Assistant) was called to the room to ask about R1's oral intake. V4 stated I am from Agency. I don't know anything about her. The (CNA) students were in here this morning to feed her.
On January 16, 2025 at 12:44 PM, V9 (Student Instructor) stated that she watched the students feed R1, and R1 ate some of the eggs and most of the oatmeal and drank the orange juice. V9 stated She (R1) did not eat the potatoes (hash brown) and sausage.
On January 16, 2025 at 12:36 AM, R1 received a room tray (served by V4) of mechanical soft consistency chicken, regular consistency coleslaw and cornbread and pudding for dessert, and 4 oz/ounces of juice in a glass and 8 oz carton of 2% milk. R1's diet card showed Mechanical Soft consistency. V4 spoon fed R1 and R1 ate 100% of the pudding and drank 100% of juice and most of milk via a straw. On return to the room a few minutes later, V4 remarked that R1 ate all of the pudding and if she (R1) would have received a pureed diet, she would have eaten better.
On January 16, 2025 at 1:00 PM, R1's diet order on POS was checked in the EMR and it showed Pureed diet.
On January 16, 2025 at 1:02 PM, V3 ADON (Assistant Director of Nursing) was shown R1's tray consisting of mechanical soft diet received and relayed that diet order on EMR showed pureed diet and V1 DON (Director of Nursing) was subsequently notified of the same.
On January 16, 2025 at 1:58 PM, V6 (Dietary Manager) stated I got the form today to change the diet from mechanical soft to pureed. Prior to today resident [R1] was getting mechanical soft diet. The nurse brings the diet order change form and put's it in my mailbox and I will update it in the system [computer] before printing the diet cards. V6 stated that he does not recall receiving the diet change slip [from mechanical soft to pureed diet] prior to today.
On January 16, 2025 at 3:00 PM, V2 (DON) stated that if nursing is downgrading the diet, the Physician is notified and then referred to the Speech Therapist. V2 stated that once the diet is downgraded in the POS, the diet order is printed and brought down to the kitchen. V2 stated that she does not know what happens after that. V2 stated that V3 ADON (Assisted Director of Nursing) had put the diet change in the EMR/POS and brought the diet order down to the kitchen.
On January 16, 2025 at 3:04 PM, V3 (ADON) stated that [sometime beginning in the month of January/unknown date] the nurse on duty had come to her office with the V10 NP (Nurse Practitioner) and stated that R1 was not swallowing her medications and feels that the diet should be downgraded. V3 stated that she used her judgement and downgraded the diet to pureed and printed the diet order and placed it on V6's desk. V3 added that she also sent V6 a What's App message (about the diet change) as that is the mode of communication for managers.
On January 16, 2025 at 2:34 PM, V7 (Speech Therapist) stated that she was aware that the nursing downgraded R1's diet to pureed in the beginning of the month. V7 stated that she works three days a week at the facility and sees patients that V8 (Rehab Director) refers her to. V7 stated that V8 put R1 on her schedule to be seen today (January 16, 2025) and she did a swallow evaluation for R1 at the bedside this afternoon. V7 stated that she recommended to keep R1 on the current diet order of pureed consistency with thin liquids. V7 stated that R1 is at risk for aspirating on a mechanical soft diet because of suboptimal positioning. V7 added that while evaluating R1, R1 told her that she had a lot of pain while swallowing.
On January 17, 2025 at 12:24 PM, V12 (Medical Director) stated that he is R1's Primary Care Physician and the staff have been updating him about R1's recent concerns about eating. V12 stated that recently R1 has been eating less as her dysphagia was progressing and the diet was downgraded from mechanical soft to pureed diet. V12 stated that the facility should carry out the order for diet change within the day in 24 hours. V12 stated that R1's oral intake can be affected by dysphagia and pain medications (Morphine). V12 stated that he was notified of R1's weight loss which can be affected by declined oral intake.
Nursing progress notes dated January 15, 2025 included that R1 was not able to tolerate medication and holding her medication in her mouth and the family and MD (Medical Doctor) notified.
NP progress notes dated January 13, 2025 included the following information It was reported by the nurse that the patient was unable to swallow his medications and the patient was ordered speech evaluation and treatment. Her pain medication (Norco by mouth) was discontinued due to swallowing difficulties and Morphine liquid 0.25 ml[Milliliters] q [every] 4 hours was ordered for pain and her diet was downgraded to puree
Nursing progress notes dated January 09, 2025 included R1 holding medication and food in her mouth not swallowing NP, DON and relieving nurse made aware. New order given by NP for speech consultation.
Resident Listing Reports dated January 16, 2025, with current diet orders served in the facility kitchen showed R1's diet order as Mechanical Soft.
Speech Language Pathologist Plan of Treatment bed side swallow evaluation for R1 dated January 16, 2025 for trials of diet consistencies included as follows in summary :
Patient reporting severe pain and unable to reposition to upright position, thus trials completed at about 20-30 degrees. Suspect reduced laryngeal elevation
Thin liquids via straw: mildly delayed oral transit time and no overt signs and symptoms of aspiration, however patient reports pain swallowing and motions to her neck.
Mechanical soft trials noted with prolonged mastication and transit time, as well as observed inadequate mastication of trials and minimal trials attempted due to patient's increased risk of aspiration.
Puree trials via teaspooon: moderately delayed oral transit time .with no overt signs and symptoms of aspiration, however patient continues to report pain swallowing and motions to her neck.
Recommendations for Pureed diet with thin liquids for patient to swallow safetly.
R1's Nutrition care plan revised October 06, 2024 included that R1 benefits from a mechanically altered diet due to dysphagia with interventions for the same included to provide and serve diet as ordered and goal to adhere to diet as ordered by physician through next review 3/11/25.
On January 17, 2025 at 1:59 PM, V2 (DON) stated that the facility does not have a policy for the process of diet order implementation.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observations, interview and record review, the facility failed to provide personal hygiene to a resident that was dependant on care.
This applies to 1 of 3 residents (R1) reviewed for improp...
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Based on observations, interview and record review, the facility failed to provide personal hygiene to a resident that was dependant on care.
This applies to 1 of 3 residents (R1) reviewed for improper nursing in the sample of 6.
The findings include:
R1's face sheet included diagnoses of osteomyelitis, pressure ulcer of sacral region, stage 4, pressure ulcer of right buttock, stage 4, unspecified severe protein-calorie malnutrition, adult failure to thrive, other cerebral palsy, dysphagia, oropharyngeal phase, anorexia nervosa.
R1's Annual MDS (minimum data set) dated November 06, 2024 showed that R1 was moderately impaired in cognition and was dependent on staff for all ADL's (activities of daily living) including personal hygiene.
On 1/16/25 at 10:52 AM, when viewed through the door, R1 was seen lying in bed in hospital gown. Signage on R1's door showed Contact Isolation. V4 (Registered Nurse) who was in the hallway stated that R1 is on contact isolation for MRSA [Methicillin- resistant Staphylococcus Aureus) of wounds and gown and gloves are needed prior to room entry. On entry, R1 made eye contact and some sounds but did not respond to queries. There was a stale odor coming from R1. R1's hair appeared greasy and uncombed. R1's hands appeared contracted and R1 had long jagged fingernails that had blackish substance underneath some of the nails. R1's chin and pillow had remnants of food particles and stains. R1's neck under her chin and upper chest had powdery blackish substance on it.
On January 16, 2025 at 11:02 AM, V4 (Certified Nursing Assistant) was called to the room and shown above observations. V4 stated that she is from agency and not regular staff and has not taken care of R1 before. V4 stated that the student nurses were in R1's room earlier and fed her. V4 stated that she is not sure when the facility staff last cut R1's nails. V4 stated I will get a towel and clean her up and comb her hair.
On January 16, 2025 at 12:44 PM, V9 (Student Instructor) stated that she watched the student feed R1 and had wiped her mouth. V9 added that a towel was placed on R1's chest prior to feeding R1 and therefore did not notice anything on her neck.
Nurse Practitioner's progress notes dated January 13, 2025 included that R1 has contractures and she is dependent on staff for all ADLs.
R1's restorative care plan initiated May 03, 2023 included that R1 is at risk for deterioration in ADL related to medical diagnosis of Cerebral palsy, osteomyelitis, lack of coordination, adult failure to thrive, and weakness. Interventions included : do not rush resident, allow extra time to complete ADLs, have consistent approach among caregivers.
On January 16, 2025 at 3:02 PM and on January 17, 2025 at 9:27 AM, V2 (Director of Nursing) stated that the CNA's provide ADL care and should provide personal hygiene daily for the residents. V2 stated that R1 is contracted and therefore it is difficult to cut her nails. V2 stated that staff should wipe R1's face off after providing feeding assistance.
Facility policy for ADL effective February, 2023 (2/2023) included as follows:
Guideline: In accordance with the comprehensive assessment, together with respect for individual resident needs and choices, our facility provides care and services for the following activities:
Hygiene: bathing, dressing, grooming and oral care
Our collaborative professional team, together with the resident and/or resident representative:
2. Develop and implement interventions in accordance with the resident's evaluated need, goal for care and preferences and will address the identified limitation in an ability to perform ADLs.
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 F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
Based on observations, interview and record review, the facility failed to serve pureed diet as ordered by a Physician to a resident (R1) that has had a recent history of swallowing problems.
This ap...
Read full inspector narrative →
Based on observations, interview and record review, the facility failed to serve pureed diet as ordered by a Physician to a resident (R1) that has had a recent history of swallowing problems.
This applies to 1 of 3 residents (R1) reviewed for improper nursing in the sample of 6.
The findings include:
R1's EMR (electronic medical records) included diagnoses of osteomyelitis, pressure ulcer of sacral region, stage 4, pressure ulcer of right buttock, stage 4, unspecified severe protein-calorie malnutrition, adult failure to thrive, other cerebral palsy, dysphagia, oropharyngeal phase, anorexia nervosa. R1's Annual MDS (minimum data set) dated November 06, 2024 showed that R1 was moderately impaired in cognition and was dependent on staff for all ADL's (activities of daily living) including eating.
R1's diet order on POS (Physician Order Summary) showed Pureed diet (start date January 09, 2025).
R1's weight (in lbs/pounds) history in EMR included as follows:
81.8 lbs (January 16, 2025), 89.8 lbs (December 17, 2024), 88.8 lbs (November 25, 2024), 89.6 lbs (October 18, 2024), 88.6 (September 18, 2024), 89.9 (July 14, 2024).
Dietitian progress notes dated January 16, 2025 included the following information in summary: R1's diet order was pureed texture diet with thin liquids and super cereal at breakfast. Weight: 81.8 lbs (January 16, 2025). BMI [Body Mass Index]: 16 which is underweight. Weight loss of 8.9% since December 17, 2025 and 8.7% since October 18, 2025 and is not desired or planned.
On January 16, 2025 at 11:02 AM, V4 CNA (Certified Nursing Assistant) was called to the room to ask about R1's oral intake. V4 stated I am from Agency. I don't know anything about her. The (CNA) students were in here this morning to feed her.
On January 16, 2025 at 12:44 PM, V9 (Student Instructor) stated that she watched the students feed R1, and R1 ate some of the eggs and most of the oatmeal and drank the orange juice. V9 stated She (R1) did not eat the potatoes (hash brown) and sausage.
On January 16, 2025 at 12:36 AM, R1 received a room tray (served by V4) of mechanical soft consistency chicken, regular consistency coleslaw and cornbread and pudding for dessert, and 4 oz/ounces of juice in a glass and 8 oz carton of 2% milk. R1's diet card showed Mechanical Soft consistency.
On January 16, 2025 at 1:00 PM, R1's diet order on POS was checked in the EMR and it showed Pureed diet.
Resident Listing Reports dated January 16, 2025, with current diet orders served in the facility kitchen showed R1's diet order as Mechanical Soft.
On January 16, 2025 at 1:58 PM, V6 (Dietary Manager) stated I got the form today to change the diet from mechanical soft to pureed. Prior to today resident [R1] was getting mechanical soft diet. The nurse brings the diet order change form and put's it in my mailbox and I will update it in the system [computer] before printing the diet cards. V6 stated that he does not recall receiving the diet change slip [from mechanical soft to pureed diet] prior to January 16, 2025.
On January 16, 2025 at 3:00 PM, V2 (DON) stated that if nursing is downgrading the diet, the Physician is notified and then referred to the Speech Therapist. V2 stated that once the diet is downgraded in the POS, the diet order is printed and brought down to the kitchen. V2 stated that she does not know what happens after that. V2 stated that V3 ADON (Assisted Director of Nursing) had put the diet change in the EMR/POS and brought the diet order down to the kitchen.
On January 16, 2025 at 3:04 PM, V3 (ADON) stated that [sometime beginning in the month of January/unknown date] the nurse on duty had come to her office with the V10 NP (Nurse Practitioner) and stated that R1 was not swallowing her medications and feels that the diet should be downgraded. V3 stated that she used her judgement and downgraded the diet to pureed and printed the diet order and placed it on V6's desk. V3 added that she also sent V6 a What's App message (about the diet change) as that is the mode of communication for managers.
On January 16, 2025 at 2:34 PM, V7 (Speech Therapist) stated that she was aware that the nursing downgraded R1's diet to pureed in the beginning of the month. V7 stated that she works three days a week at the facility and sees patients that V8 (Rehab Director) refers her to. V7 stated that V8 put R1 on her schedule to be seen today (January 16, 2025) and she did a swallow evaluation for R1 at the bedside this afternoon. V7 stated that she recommended to keep R1 on the current diet order of pureed consistency with thin liquids. V7 stated that R1 is at risk for aspirating on a mechanical soft diet.
Nursing progress notes dated January 15, 2025 included that R1 was not able to tolerate medication and holding her medication in her mouth and the family and MD (Medical Doctor) notified.
Jan 2025
13 deficiencies
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 protect residents' privacy.
This applies to 2 of 2 res...
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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 protect residents' privacy.
This applies to 2 of 2 residents (R61 and R32) reviewed for dignity in a sample of 29.
Findings include:
1. R61 admitted to the facility with diagnoses that includes effusion of the left knee, poly-osteoarthritis, acute kidney disease, dysphagia, anemia, hypertension, gout, and pulmonary edema. R 61's current care plan states he has an ADL (Activities of Daily Living) self-care performance deficit related to impaired gait and requires substantial staff assistance with transfers, bed mobility, and toileting. R61's MDS (Minimum Data Set) dated 1/5/25 shows he is cognitively intact.
On 01/07/25 at 12:21 PM, R61's urine collection bag was hanging on the right side of his bed visible to the hallway.
On 01/07/25 at 12:44 PM, V23 CNA (Certified Nursing Assistant) and a therapist came into room to put R61's pants on. R61's room blinds were left open and visible from the parking lot on the first floor as he was dressed.
On 01/08/25 at 03:14 PM, R61's urine collection bag was hanging on the right side of his bed visible to the hallway. R61 stated he prefers to have his urine collection bag protected from the view of others.
On 01/08/25 at 03:28 PM, V19 CNA removed R61's incontinence brief and left the room to obtain staff assistance to reposition R61 and reapply his incontinence brief. V19 walked out of room, leaving the door open, with R61 naked and exposed from his waist to his ankles. V19 turned back less than a minute later closed the room door but did not cover R61. R61 stated he is left exposed often. He would like to have been covered and not left exposed.
On 01/08/25 at 03:43 PM (15 minutes later), V19 returned with assistance to finish assisting R61.
2. R32 admitted to the facility with diagnoses that includes Parkinson's, dementia, congestive heart failure, acute, left artificial hip joint and dysphagia. R32 physician's orders includes hospice care services and enhanced barrier precautions related to wounds. R32's MDS dated [DATE] indicates she has severe cognitive impairment and is completely dependent on staff for assistance with ADL's.
On 01/07/25 at 04:05 PM, V17 (Hospice CNA) was providing bathing assistance to R32 with the room door opened and no curtain closed around the bed to protect R32 from view. R32, who has severe cognitive impairment, did not verbalize concern with the curtain not being pulled to protect her privacy, but a reasonable person would want their naked body protected from the view of passersby.
On 01/09/25 at 02:22 PM, V2 DON (Director of Nursing) stated curtains should be closed during cares to block the residents from view; urine collections bags should be covered from view; blinds should be closed when care is being provided to residents; and when staff walk away from residents, they should cover them and not leave their genitals exposed.
The facility Resident Rights Guideline states residents have the right to be treated with respect and dignity.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide resident and/or their family/power of attorney (POA) in wri...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide resident and/or their family/power of attorney (POA) in writing the reason residents were transferred to the hospital, and the facility failed to notify the ombudsman of resident hospital transfers.
This applies to 3 of 3 residents (R25, R108 and R136) reviewed for hospitalization in a sample of 29.
The findings include:
1. R108's Emergency Department (ED) hospital record of 11/21/24 shows that R108 was seen at the hospital for Altered Mental Status and Leukocytosis.
R108's progress notes of 11/21/24 at 6:12 PM states that resident was confused and unable to acknowledge nursing staff. Resident's POA was notified and requested for resident to be sent to the hospital. Nurse informed the provider and the Director of Nursing (DON), orders received to send to the ED.
2. R25's ED hospital record of 1/3/25 shows that R1 was seen at the hospital for abdominal pain, ascites, and pneumonia.
R25's progress notes of 12/31/24 at 4:45 PM states that R25 was complaining of severe abdominal and chest pain; R25's abdomen was distended and firm. The physician was notified and ordered to send R25 to the ED. R25' wife was notified of the transfer.
On 1/9/25 at 9:10 AM, V2 (DON) said resident's family are notified of the transfers to hospital, however, there is no written documentation of reason of transfer and that the bed hold policy was provided to the residents and/or their POAs. V2 said that they do not notify the ombudsman of residents' transfers to the hospital. V2 stated the facility does not have a bed hold policy; they have an assessment that is done in the EMR and that is presented to the resident when they leave the facility.
The facility's ECC Bed Hold Policy (undated) states that this form serves as a written information and notice to the resident or legal representative at the time of admission, and in advance of any transfer, and at the time of transfer that specified the duration of the bed hold policy under the Medicare and Medicaid state plan of the facility. The facility permits private pay residents, Medicare-eligible residents and Medicaid-eligible residents whose leaves have exceeded the Medicaid-reimbursed 10 day bed hold period who wish to pay from their own income to hold the bed.
3. R136's Face sheet shows she was admitted to the facility on [DATE]. R136's Change in Condition Evaluation documented on 11/1/24 at 13:33 shows R136 was transferred to the hospital after an unwitnessed fall. On 1/9/25 at 2:13 PM, V2 (DON) said the facility does not have documentation showing R136 or her family were notified in writing of the reason for R136's transfer to the hospital. V2 said the facility did not notify the Ombudsman of R136's transfer to the hospital because V2 stated she did not know the facility was supposed to notify the Ombudsman.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide resident and/or their family/power of attorney (POA) writte...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide resident and/or their family/power of attorney (POA) written documentation of bed hold policy when residents were transferred to the hospital.
The facility also failed to notify the ombudsman of resident transfer to the hospital.
This applies to 3 of 3 residents (R25, R108 and R136) reviewed for hospitalization in a sample of 29.
The findings include:
1. R108's Emergency Department (ED) hospital record of 11/21/24 shows that R108 was seen at the hospital for Altered Mental Status and Leukocytosis.
R108's progress notes of 11/21/24 at 6:12 PM states that R108 was confused and unable to acknowledge nursing staff. Resident's POA was notified and requested for resident to be sent to the hospital. Nurse informed the provider and the Director of Nursing (DON), orders received to send to the ED. The facility was unable to provide documentation that the bed hold policy/assessment form was given to the resident and/or the POA upon transfer to the hospital.
2. R25's ED hospital record of 1/3/25 shows that R25 was seen at the hospital for abdominal pain, ascites and pneumonia.
R25's progress notes of 12/31/24 at 4:45 PM states that R25 was complaining of severe abdominal and chest pain; R25's abdomen was distended and firm. The physician was notified and ordered to send R25 to the ED. R25' wife was notified of the transfer. The facility was unable to provide documentation that the bed hold policy/assessment form was given to the resident and/or the POA upon transfer to the hospital.
On 1/9/25 at 9:10 AM, V2 (DON) said resident's family are notified of the transfers to hospital, however, there is no written documentation that the bed hold policy was provided to the residents and/or their POAs. V2 stated the facility does not have a bed hold policy; they have an assessment that is done in the EMR and that is presented to the resident when they leave the facility.
The facility's ECC Bed Hold Policy (undated) states that this form serves as a written information and notice to the resident or legal representative at the time of admission and in advance of any transfer and at the time of transfer that specified the duration of the bed hold policy under the Medicare and Medicaid state plan of the facility. The facility permits private pay residents, Medicare-eligible residents and Medicaid-eligible residents whose leaves have exceeded the Medicaid-reimbursed 10 day bed hold period who wish to pay from their own income to hold the bed.
3. R136's Face sheet shows she was admitted to the facility on [DATE]. R136's Change in Condition Evaluation documented on 11/1/24 at 13:33 shows R136 was transferred to the hospital after an unwitnessed fall. On 1/9/25 at 2:13 PM, V2 (DON) said the facility does have a Bed Hold Policy Form, but it was not documented for R136's transfer to hospital.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to have an accurate MDS (Minimum Data Set) assessment ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to have an accurate MDS (Minimum Data Set) assessment to document the functional limitation in range of motion (ROM).
This applies to two of the two residents (R66 and R64) reviewed for assessment accuracy in a sample of 29.
The Findings include:
1. R66 is a [AGE] year-old male admitted with an admitting diagnosis, including cerebral infraction and hemiplegia affecting the right dominant side.
On 01/07/25 at 12:03 PM, R66 was observed with his contracted right hand, third and fourth fingers curled and touching his palm.
A review of R66's MDS dated [DATE] documented no impairment with functional limitation in range of motion.
2. On 01/07/25 at 10:18 AM, R64 was observed in her bed with contracted hands, fingers curled and touching her palm.
A review of R64's MDS dated [DATE] documented no impairment with functional limitation in range of motion.
On 01/08/25 at 9:59 AM, V8 (MDS Coordinator) stated, The hand contracture is coded in the functional limitation in ROM. The restorative is the one coding this section and should have been coded accurately to reflect resident status.
On 01/08/25 at 10:40 PM, V2 (Director of Nursing/DON) stated, The MDS assessment should reflect resident status. An inaccurate MDS code can cause a lack of care with residents. The restorative is the one document of the functional limitation in ROM and should have been documented accurately for R64 and R66.
A review of the facility presented Resident Assessment Instrument (RAI) Guidelines document: Ensure timely and accurate submission to avoid penalties and maintain compliance.
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** Based on observation, interview, and record review, the facility failed to implement a physician's order for 1 of 1 residents (R...
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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 a physician's order for 1 of 1 residents (R239) reviewed for quality of care in a sample of 29.
The findings include:
R239 is a [AGE] year old female admitted to the facility on [DATE]th, 2024, with diagnoses including mechanical complications of nephrostomy catheter, calculus of kidney, hydronephrosis with ureteral stricture, urinary tract infection, and urge incontinence.
On 1/7/25 at 2:11 PM, V9 (R239's daughter) said that she had concerns with the staff not changing the dressing to R239's nephrostomy every day. V9 turned R239 on her side and exposed R239's dressing to her nephrostomy. The date on the adhesive dressing showed 1/2/25 (five days earlier). V9 said, See, they are not changing it every day.
On 1/8/25 at 12:04 PM, V6 (Wound Nurse) was preparing to provide wound care for R239. V6 turned R239 on her side, pulled down R239's pants, and opened her brief. Two adhesive dressings were present, one on the coccyx area and one on the right flank area. V6 was asked if R239 had two wounds and V6 said no, that the one adhesive dressing dated 1/2/65 was the dressing for R239's nephrostomy, and the dressing dated 1/6/25 was her pressure wound. The 1/2/25 dressing was observed peeling off at the bottom of the dressing. After V6 provided wound care to R239's pressure wound, she did not provide care to R239's nephrostomy site even after seeing that the dressing was not fully intact.
R239's 11/18/24 Physician's orders showed, Site: Right side of back nephrostomy insertion site. Cleanse wound with Normal Saline or wound cleanser. Pat wound dry. Apply border gauze daily and PRN (as needed) if loose/soiled. Every day shift.
On 1/9/25 at 09:34, V2 (Director of Nursing) said that her expectations are that the nurse change R239's nephrostomy dressing daily as ordered. V2 said this should be done to check the site for infection and to prevent infections.
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 have fall interventions in place for 2 of 5 residents (R3 & R94) who are at risk for falls in a sample of 29.
The findings i...
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Based on observation, interview, and record review, the facility failed to have fall interventions in place for 2 of 5 residents (R3 & R94) who are at risk for falls in a sample of 29.
The findings include:
1. On 01/7/25 at 11:25 AM, R3 was in her room and stated she had a concern with her bed moving when she tries to get into her bed from her wheelchair. R3 said that she grabs the Halo (specialized safety ring attached to the bed frame) at the top of her bed to pull herself up out of her wheelchair and stabilize herself to transfer into her bed. R3 said that every time she does it, her bed moves. The wheels on R3's bed were unlocked at this time and the bed moved easily when pushed. R3 stated she has a history of falling.
R3's diagnoses include difficulty in walking, and lack of coordination. R3's 10/15/24 care plan showed that R3 is at risk for falls with interventions including the resident needs a safe environment.
On 01/09/25 at 09:47 AM, V2 DON (Director of Nursing) said that the wheels on R3's bed should be locked to prevent her from falling.
On 01/09/25 at 10:08 AM V2 (DON) tested R3's bed with R3 present and the bed moved. Additionally, the Halo on the left side of the bed was not secured and spun around when touched.
2. On 01/07/25 at 10:54 AM, R94 was observed in her wheelchair with no shoes on her feet and her socks were not non-skid or non-slip socks. R94 said that she has a history of falls. R94 said that a couple of weeks ago she slipped out of her wheelchair while in her room, and again while in her bathroom she leaned forward while sitting on her wheelchair attempting to pull the bathroom call light and again slipped out of her wheelchair.
R94's diagnoses include history of falls, difficulty in walking, and unsteadiness on feet. R94's 10/15/24 care plan showed that R94 is at a risk for falls with interventions including ensure that R94 is wearing appropriate footwear and follow the facility's fall protocol.
On 01/09/25 at 09:45 AM, V2 (DON) said that R94 should be wearing proper footwear while in the wheelchair.
The facility's Falls Guidelines date 1/2014 showed to consistently identify and evaluate residents at risk for falls to prevent or reduce injuries related to falls. The policy showed that the facility provides an environment that is free from hazards over which the facility has control. The policy showed under Fall Prevention: Identification of hazards and risk factor: Environmental rounds. Fall management: develop and implement interventions.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
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 attempt gradual dose reductions (GDR) for residents taking psychotr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to attempt gradual dose reductions (GDR) for residents taking psychotropic medications.
This applies to 2 of 3 residents (R82 and R109) reviewed for unnecessary medications/psychotropic medications in a sample of 29.
The findings include:
1. Review of R109's Electronic Medical Record (EMR) shows the following diagnoses of traumatic brain injury, dementia, attention deficit hyperactivity disorder, bipolar disorder and major depressive disorder. R109's physician order shows that R109 has the following orders, Citalopram 20 mg give 1 tablet a day for antidepressant, Quetiapine 50 mg, give 1 tablet for bipolar disorder, Trazadone 150 mg give 1 tablet orally at bedtime for depression.
Per the facility's Psychotropic and Sedative/Hypnotic Utilization report, it showed that R109 had GDR done on 4/14/24 for Citalopram 20 mg, Quetiapine 50 mg and Trazadone 150 mg. The next evaluation for GDR was supposed to be in October of 2024; there is no documentation that the GDR was attempted or done in October of 2024. There is also no documentation on behavior monitoring for R109.
On 1/9/25 at 1:17 PM, V2 (Director of Nursing/DON) said GDR are to be done every quarterly and the last GDR for R109 was done in April of 2024, R109 was not evaluated in October. V2 said she does not have documentation of behavior monitoring on R109; she said they switched EMR systems, and nothing transferred into their current EMR system.
2. R82 is an [AGE] year-old female admitted on [DATE] with an admitting diagnosis including psychosis, major depression, and anxiety disorder.
A review of R82's Physician Order Sheet (POS) documents that R82 is getting Lorazepam 1 milligram (mg)/0.5 milliliter (ml) every six hours as needed for anxiety, Olanzapine 5 mg three times a day for psychosis, Trazadone 150 mg at bedtime for depression, and Clonazepam 0.5 mg as needed for anxiety/agitation.
A review of R82's clinical progress note does not indicate any GDR was attempted to decrease the psychotropic medication dose. The review also shows any signed psychotropic medication consent in place for Lorazepam, Olanzapine, Trazadone, and Clonazepam.
On 1/9/25 at 9:32 AM, V2 (Director of Nursing/DON) stated, Our Psychiatrist retired last March, and we haven't attempted any GDR for R82. To avoid unnecessary medication doses, GDR should be attempted quarterly for the resident's benefit.
The facility presented the Behavior and Psychotropic Medication Management Guideline document:
b. For Psychotropic Medications- Gradual Dose Reduction is attempted per regulatory guidelines.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to administer medications as ordered, in ordered dosages. There were 28 opportunities with 2 errors, resulting in a 7.14% error ...
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Based on observation, interview, and record review, the facility failed to administer medications as ordered, in ordered dosages. There were 28 opportunities with 2 errors, resulting in a 7.14% error rate.
This applies to 2 (R51 and R84) of the 5 residents observed in the medication pass.
Findings include:
1. R51's Face Sheet shows diagnoses of dementia, atrial fibrillation, heart failure, cardiac pacemaker, hypertensive heart disease, and atherosclerosis. On 1/8/25 at 8:43 AM, V12 (LPN/Licensed Practical Nurse) administered two Potassium Chloride ER (extended release) 10 meQs (milliequivalents) tablets orally for a total of 20 meQs to R51.
R51's POS (Physician Order Sheet) and MAR (Medication Administration Record) show an order dated/started 9/10/24 for Potassium Chloride 10 meQs ER 1 tablet orally two times a day (9 am and 5 pm).
On 1/8/25 at 1:51 PM, V12 (LPN) said she gave R51 two 10 meQ tabs of potassium chloride, not 1 tab. V12 confirmed that she could see R51's POS showed an order to give one 10 meQ tablet of potassium chloride twice a day, but V12 had a note on the side of the order that said to give two tabs. V12 said she was going to clarify with the doctor how much potassium should be given. V12 said R51 had not had any recent blood work done to check his potassium level. On 1/9/25 at 9:15 AM, V2 (DON/Director of Nursing) said a potassium chloride order should not show two different doses to be administered, and if it does, the nurse should clarify the order with the doctor BEFORE administering the medication. V2 said giving too much potassium can be harmful to the resident's heart.
2. R84's Face Sheet shows diagnoses of chronic kidney disease, dementia, osteoporosis, and retention of urine. On 1/8/25 at 9:08 AM, V13 (LPN) administered Vitamin D3 125 mcg (micrograms) tablet orally to R84.
R84's POS and MAR showed an order dated 9/10/24 for Vitamin D3 50 mcg cap orally one time a day at 9 AM.
On 1/8/25 at 1:59 PM, V13 (LPN) said she gave R84 125 mcg Vitamin D capsule and removed the bottle back out of her medication cart to verify dosage. V13 was then shown the order in R84's chart to compare the order to the dosage on the bottle that was given to R84. V13 confirmed that she gave R84 75 mcgs MORE than the physician ordered dose. On 1/9/25 at 9:15 AM, V2 (DON) said she was not sure if there was harm in giving a resident more Vitamin D3 than prescribed.
Springhouse Nurse's Drug Guide 2007 shows adverse reactions of Vitamin D include arrhythmias, impaired kidney function, bone and muscle pain, and bone demineralization.
R84's Care Plan dated 10/22/24 shows R84 has renal insufficiency related to stage 3 kidney failure.
The facility's policy titled, Administration Procedures for all Medications effective 11/4/14 states, Policy: To administer medications in a safe and effective manner. Procedures: .C. Review 5 Rights (3) times: 1) a. Check MAR/TAR for order .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on observation interview and record review, the facility failed to provide a safe, comfortable, and homelike environment for 1 of 3 residents (R114) who were reviewed for environment in a sample...
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Based on observation interview and record review, the facility failed to provide a safe, comfortable, and homelike environment for 1 of 3 residents (R114) who were reviewed for environment in a sample of 29.
The findings include:
On 01/07/25 at 11:10 AM, R114 was observed in his bed and the bed control was observed wrapped around the Halo (specialized safety ring attached to the bed frame) on the right side of R114's bed. The wires to the cord were exposed about a foot in a half in length and one white wire was broken from the control.
On 01/09/25 at 10:13 AM V2 DON (Director of Nursing) and the State Surveyor went into R114's room, R114 was in his bed, and the bed control was observed wrapped around the Halo on the top right side of R114's bed. V2 unwrapped the bed control and about 2 and ½ feet of the top of the cord was missing the protective plastic covering, exposing all of the wires. The white colored wire was broken away from the control. The bed control was plugged into the outlet. V2 said that the broken bed control was a safety issue.
On 01/09/25 at 09:50 AM V2 said that the residents should not have broken bed controls in their rooms because if they have exposed and or broken wires the resident could get shocked, and the bed control could malfunction. V2 said that her expectations are that staff notify maintenance immediately.
The facility's General Safety Precautions policy dated February 2014 showed that equipment is not to be used if it is not safe. Report all unsafe acts or conditions to the supervisor as soon as practical.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide grooming and hygeine cares for residents w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide grooming and hygeine cares for residents who require staff assistance.
This applies to 5 of 7 residents (R64, R66, R76, R114, and R125) reviewed for activities of daily living (ADL) in a sample of 29.
The Findings include:
1. R64 is an [AGE] year-old female admitted with severe cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. The MDS also documents that R1 is dependent for eating, toileting hygiene, oral hygiene, and personal hygiene.
On 01/07/25 at 10:18 AM, R64 was observed in her bed with contracted hands, fingers curled, and nails about 7 millimeters (mm) past the fingertip, that were dirty with a brownish deposit underneath the nails, which were touching her palm. R64 stated that she wanted to trim her nails, but she couldn't do it alone, and nobody was helping her.
On 1/8/25 at 9:37 AM, R64 was in her bed with a dry, crusty lip peeling off, and the resident was observed licking her dry lips.
2. R66 is a [AGE] year-old male admitted with an admitting diagnosis, including cerebral infraction and hemiplegia affecting the right dominant side. A review of the MDS dated [DATE] documents that R66 has cognition intact. The MDS also documents that R1 requires set-up assistance with eating, partial/moderate assistance with toileting hygiene, and supervision or touching assistance with personal hygiene.
On 01/07/25 at 12:03 PM, R66 was observed with the contracted right hand, having a dirty long nail about 6-8 millimeters past the fingertip with a blackish deposit underneath the nails on the third and fourth fingers. R66 stated that nobody was helping him to cut his fingernails.
On 1/8/25 at 10:40 AM, V2 (Director of Nursing/DON) stated, Certified Nursing Assistants (CNAs) should be doing nail trimming and grooming at least on shower days and as needed. The long nails with contracted hands can cause ulcers. CNAs are also supposed to provide oral care.
A review of the ADL policy (effective 02/2023) document:
Guideline: In accordance with the comprehensive assessment, together with respect for individual resident needs and choices, our facility provides care and services for the following activities: Hygiene: Bathing, dressing, grooming, and oral care.
The facility presented the Nail Care Guidelines (effective 02/23) document: Nail care includes routine cleaning and regular trimming. Proper nail care can help prevent skin problems around the nail bed.
3. On 1/7/24 at 11:10 AM, R114 was observed with long jagged fingernails.
R114's 12/26/24 MDS showed that R114 needs substantial/maximal assistance from staff for personal hygiene and that R114's cognition is severely impaired.
On 01/09/25 at 09:42, AM V2 (DON) said that the staff should be clipping residents nails every day and the residents' nails should be short for infection control and safety, so they don't scratch themselves or others.
4. On 01/07/25 at 01:29 PM R76's nails were observed long, up to 1 inch in length, jagged, nails curling under tips of fingers, and with a brown substance under the nails.
R76's 11/6/24 MDS showed R76 needs substantial/maximal assistance from staff for personal hygiene.
On 01/09/25 at 09:43 AM V2 said that residents should receive nail care as needed.
The facility's Activities of Daily Living (ADL) policy dated 2/2023 showed that the facility provides necessary care and services to ensure that the residents abilities in activities of daily living (ADL) do not diminish . The policy showed that in accordance with the residents' comprehensive assessment the facility provides care and services for: hygiene, mobility, elimination The facility's professional team will implement interventions in accordance with the resident's evaluated needs .
5. On 1/7/25 at 11:34 AM, R125 was in bed watching TV. R125 was noted with several white hair on her chin and her fingernails were long and dirty with black/brownish substance. On 1/9/25 at 11:38 AM, R125 was resting in bed, fingernails still long with black/brownish substance in nail bed. R125 said she would need assistance with getting her nails trimmed.
Review of R125's Electronic Medical Record (EMR) shows the following diagnoses of cerebral infarction, cognitive communication deficit, and lack of coordination. R125's MDS of 12/24/24 shows that R125's cognition is moderately impaired and needs substantial/maximal assistance with personal hygiene.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
11. On 1/7/25 at 2:02 PM, R238 was in her room and on her bed side table was 1 prescription bottle of Miconazole nitrate 2% powder (Antifungal) and 1 prescription bottle of Sodium Chloride 0.65% nasal...
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11. On 1/7/25 at 2:02 PM, R238 was in her room and on her bed side table was 1 prescription bottle of Miconazole nitrate 2% powder (Antifungal) and 1 prescription bottle of Sodium Chloride 0.65% nasal spray. R238 said that she uses the nasal spray twice a day.
A review of R238's Order Summary report did not show any orders for Miconazole Nitrate 2% powder or Sodium Chloride 0.65% nasal spray.
On 1/9/25 at 09:56 AM V2 (DON) said that medications should not be at the residents' bedside
10. On 1/7/25 at 12:38 PM, R287 was observed in bed; R287 had just finished his lunch. On R287's bedside table, there was tube of Glutose 15 (raises low blood sugar), a bottle of Refresh liquid gel (lubricating eye drops), and a bottle of Fluticasone Propionate nasal spray. R287 said the medications were his and he uses them daily.
Review of R287's Electronic Medical Record (EMR) shows the following diagnoses of Chronic Obstructive Pulmonary Disease with acute Exacerbation, dysphagia, Type 2 Diabetes Mellitus, allergic rhinitis and dependence on supplemental oxygen. R287's Minimum Data Set (MDS) of 12/27/24 shows that his cognition is moderately impaired. Review of R287's current physician order shows that he has an order for Fluticasone Propionate Nasal Suspension 1 spray in both nostrils one time a day. R287 does not have an order for the eye drops, or the Glutose 15. R287 does not have an order that states the medications can be stored in the residents' rooms.
On 1/9/25 at 8:49 AM, V2 (Director of Nursing/DON) said they do not have residents that can self-administer their medications and there are no residents that can store medications at their bedside. V2 said there is a risk that residents could be double medicating, or there could be an interaction with the medications that they are providing for the residents, hence they need to be aware of the medications the residents are taking. V2 said there should be a physician order for residents to have medications stored at the bedside, and the residents needs to be assessed in order to store medications at the bedside. The medications would also need to be locked.
The facility's Storage of Medications policy (effective date 10/25/2014) states that medications and biologicals are stored safely, securely, and properly. The medication supply is accessible only by licensed personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.
Based on observation, interview, and record review, the facility failed to safely and securely store all resident medications.
This applies to 11 residents (R64, R108, R74, R120, R37, R43, R72, R82, R5, R287, and R238) reviewed for medication storage in a sample of 29.
Findings include:
On 1/9/25 at 11:34 AM, the medication storage room on V14's (LPN/Licensed Practical Nurse) unit was checked in her presence. Upon entrance into the medication storage room, the medication refrigerator holding resident narcotics was found unlocked (narcotics were not double-locked) and the key to the refrigerator was hanging on a hook inside the medication storage room. V14 (LPN) said that is where the narcotic key is always kept.
The following resident narcotics were found in the unlocked medication refrigerator:
1. R64's 2 vials of Lorazepam 2 mg/mL oral solution.
2. R108's Lorazepam 2 mg/mL oral solution.
3. R74's Lorazepam 2 mg/mL oral solution.
4. R120's Lorazepam 2 mg/mL oral solution.
5. R37's Lorazepam 2 mg/mL oral solution.
On 1/9/25 at 11:41 AM, the medication storage room on V15's (LPN) unit was checked in her presence. Upon entrance into the medication storage room, the medication refrigerator holding resident narcotics was found without a lock on it. The narcotics were not double-locked.
The following resident narcotics were found in the medication refrigerator without a lock on it:
6. R43's Dronabinol 5 mg capsules.
7. R72's Lorazepam 2 mg/mL oral solution.
8. R82's Lorazepam 2 mg/mL oral solution.
9. R5's Lorazepam 2 mg/mL oral solution.
On 1/9/25 at 12:33 PM, V2 (DON/Director of Nursing) said all resident narcotics/controlled substances should be double-locked. V2 said medication refrigerators in medication storage rooms should have a lock on them because they hold controlled substances. V2 said the medication storage room is to be kept locked as well as the medication refrigerator inside the medication storage room. V2 said only nurses should have access to the keys for the medication storage room and the medication refrigerator. V2 said the key in V14's medication storage room is kept hanging on the wall because they only have one key to the refrigerator and never made copies of it for each nurse to have a key.
The facility's policy titled, Controlled Substance Storage effective 10/25/14 states, Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. Procedures: A. The director of nursing, in collaboration with the consultant pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances. Only authorized licensed nursing and pharmacy personnel have access to controlled substances. B. Schedule II- V medications and other medications subject to abuse or diversion are stored in a permanently affixed, double-locked compartment separate from all other medications or per state regulation . If a key system is used, the medication nurse on duty maintains possession of the key to controlled substance storage areas. Back-up keys to all medication storage areas, including those for controlled substances, are kept by the director of nursing or designee .
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** 2. R64 is an [AGE] year-old female admitted with an admitting diagnosis including Gastrostomy Tube (GT) feeding. A review of R64...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R64 is an [AGE] year-old female admitted with an admitting diagnosis including Gastrostomy Tube (GT) feeding. A review of R64's physician order sheet (POS) documented administering feeding with Jevity 1.2 at 50 milliliters per hour (ml/hr) from 7:00 PM to 10:00 AM.
On 1/7/25 at 10:18 AM, R64's entry door was observed with an EBP sign to wear gloves, gown, and mask to provide high-contact resident care activities. No PPE (Personal Protection Equipment) box is available at the door side.
On 1/7/25 at 10:25 AM, observed V4 (CNA) providing incontinent care to R64 without wearing a gown. At 10:27 AM, V5 (LPN) stated that R64 was on EBP due to GT feeding and that staff should wear gloves and a gown while changing the EBP resident.
On 1/8/25 at 10:40 AM, V2 (DON) stated, The CNA (V4) should have worn gown while changing an EBP resident.
On 1/9/25 at 10:30 AM, during an infection control interview, V3 (Infection Preventionist) stated that the staff should wear gloves and a gown when providing high-contact resident care activities to EBP residents.
A review of the facility presented Enhanced Barrier Precaution Guidelines revised on 3/21/24 document:
Enhanced Barrier Precaution refers to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with MDRO (Multi-Drug Resistant Organism) as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices).
2. Initiation of Enhance Barrier Precaution b. Implement enhanced barrier precautions for residents with any of the following: ii indwelling medical devices (eg., central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO.
3. On 1/9/25 at 11:09 AM, R387 was observed in a contact isolation room with signage indicating to wear gowns and gloves to go inside the room. R387 was observed with two visitors sitting in chairs without wearing gowns.
A review of R387's Physician Order Sheet (POS) document: Maintain contact precaution due to ESBL (Extended Spectrum Beta-Lactamase) every shift.
On 1/9/25 at 11:19 AM, V3 (Infection Preventionist) stated that the visitors are supposed to wear a gloves and gown and she will educate the visitors/family.
The facility presented Isolation - Categories for Transmission Based Precaution (effective date: 01/20/24) document:
Contact Isolation: Use PPE appropriately, including gloves and gown. Wear a gown and gloves for all interactions involving contact with the resident or the resident environment. Donning PPE upon room entry and properly discarding before exiting the resident room is done to contain pathogens.
6. On 1/7/25 at 12:56 PM, V11 CNA (Certified Nurses' Assistant) was observed feeding R20 and R29 at the same time, using the same hand, and never cleaning her hands in-between residents. V11 sat in-between R20 and R29. R29 was on V11's right side, and R20 was on V11's left side. V11 used her right hand to feed both R20 and R29 alternating bites between residents, but never cleaning her hands in-between residents.
On 01/09/25 at 09:53 AM, V2 (DON) said that staff should clean their hands in-between feeding residents for infection control.
The facility's Hand Hygiene Guideline dated 08/2024 showed that appropriate hand hygiene is essential in preventing transmission of infectious agents. The policy showed that hand hygiene is essential to prevent the spread of infection from resident to resident. The policy shows that hand hygiene is recommended immediately before touching a resident, after touching a patient or patient surroundings, after contact with blood, bodily fluids, or contaminated surfaces.
4. On 1/7/25 at 10:59 AM, during initial rounds on the 1st floor, V7 (Housekeeping) was observed cleaning R25's room. V7 had on mask and gloves and was going in and out of R25 room while she was cleaning and getting supplies from her cleaning cart outside the room. R25 had Contact Isolation sign on his door, with a PPE (Personal Protective Equipment) supply bin right outside the door. V7 said R25 was on isolation for MRSA (Methicillin Resistant Staphylococcus Aureus); V7 said she should be wearing full PPE while cleaning the resident's room. On 1/8/25 at 10:31 AM, V6 (Wound Care Nurse) was providing wound care treatment to R25's left and right foot. V3 (Infection Preventionist/IP) was assisting V6 with the wound care; during the wound care, V24 (R25's wife) came into the room without full PPE.
Review of R25's Electronic Medical Record (EMR) shows the following diagnoses of sepsis, pneumonitis due to inhalation of food and vomit, ESBL resistance, MRSA, unspecified Escherichia Coli (E. Coli), pressure ulcer of sacral region stage 2, and pressure ulcer of left heel stage 4.
On 1/8/25 at 10:17 AM, V3 (IP) said R25 was on contact isolation for ESBL (enzymes that make some bacteria resistant to many antibiotics) and MRSA in his sputum. V3 said staff should be wearing full PPE (gown, gloves, mask) when they enter R25's room. On 1/8/25 at 11:22 AM, V3 said resident's family members should also be wearing full PPE when they are in contact isolation rooms.
5. On 1/7/25 at 12:03 PM, V4 (CNA) provided incontinent care to R30. V4 informed R30 of the incontinent care, washed hands, put on gloves and gathered supplies. V4 raised R30's bed up, then moved the garbage can from the left side of the bed to the right side of the bed, and informed R30 to turn to her left side, facing the window. V4 removed R30's soiled brief, R30 had a bowel movement. V4 used wipes to clean R30 buttocks, removed the soiled brief and threw the soiled brief in the trash can. The trash can did not have a trash bag. The soiled brief stained the trash can with bowel movement, there was brown streaks in the trash can. V4 changed gloves, used wet wash clothes to clean R30's perineal area and buttocks. V4 changed gloves again and used a dry towel to dry R30's perineal area and buttocks. V4 then repositioned R30 in bed, then put the soiled brief and wipes from the trash can in a trash bag and took the trash out. The trash can still had brown streaks from the soiled brief. V4 did not perform hand hygiene with each glove change.
On 1/9/24 at 9:01 AM, V2 (Director of Nursing/DON) said there should be trash bags in the trash cans for infection control reasons; also there should be hand hygiene with each glove change.
Based on observation, interview and record review, the facility failed to maintain infection control practices that prevent the spread illness and disease.
This applies to 6 of 7 residents (R20, R25, R29, R30, R32, R64 and R387) reviewed for infection control in a sample of 29.
Findings include:
1. R32 admitted to the facility with diagnoses that includes Parkinson's, dementia, congestive heart failure, arthritis, left artificial hip joint and dysphagia. R32 physician's orders includes hospice care services and enhanced barrier precautions related to wounds.
On 01/07/25 at 04:05 PM, R32's bedroom door had EBP (Enhanced Barrier Precautions) signage. There was no PPE (Personal Protective Equipment) located outside of the room or anywhere nearby for entering R32's bedroom. V17 Hospice CNA (Certified Nursing Assistant) was bathing R32 without wearing an isolation gown. V17 had thrown soiled linens on the floor near R32's bed. V17 stated there was no isolation gown available for her use. V17 stated she informed facility staff the prior week that there were no isolation gowns available.
On 01/07/25 at 04:10 PM, V16 (CNA) entered R32's room to assist with bathing and repositioning and did not put on an isolation gown. V16 stated PPE should be located outside of R32's room and she should have worn gloves and a mask for EBP to assist with care.
On 01/07/25 at 04:58 PM, V12 LPN (Licensed Practical Nurse) assigned to R32 stated R32's EBP are related to her wounds. Staff are only required to wear an isolation gown when they are doing a dressing change. If the wound is covered and the dressing is intact staff are not required to wear an isolation gown. V12 stated PPE is in the medication room. The medication room is locked, and CNA's do not have access.
On 01/07/25 at 05:03 PM, V18 CNA assigned to R32 stated PPE gown is not required for R32 because although EBP signage is on the door, there were no supplies outside the room for her use and no red biohazard bin near the room door.
On 01/09/25 at 02:22 PM, V2 DON (Director of Nursing/DON) stated R32 in on EBP for her wound and staff should have worn a gown to give her bed bath. V2 stated anytime care is being provided a gown should be worn. V2 stated if there are no supplies available outside the room, the nurse should be giving the CNAs the PPE to use.
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 maintain the kitchen facility in a manner to prevent foodborne illness.
This applies to 128 residents in the facility receiving...
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Based on observation, interview and record review the facility failed to maintain the kitchen facility in a manner to prevent foodborne illness.
This applies to 128 residents in the facility receiving dietary services.
Findings include:
On 01/08/25 10:06 AM V1 Administrator confirmed 128 residents were being served from dietary services on 1/7/25.
1. On 01/07/25 at 10:01 AM, the dry storage contained:
An opened one- gallon jar of mayonnaise dated 12/31/24 labeled refrigerate after opening.
An opened one-gallon bottle of barbeque sauce dated 12/31/24 labeled refrigerate after opening.
An opened 793-gram bag of chocolate pudding and a 24-ounce bag of butterscotch pudding without use by or opened on dates.
Two 6-pound 9-ounce dented cans of yellow cling peaches.
One 6-pound 3-ounce dented can of sauerkraut.
On 01/09/25 at 01:15 PM, V21 (Dietary Director) stated the barbeque sauce and mayonnaise should be refrigerated once opened to prevent the growth of bacteria. Dented cans should be separated and not use because we don't know how deep the dent is or if the can was punctured and leaking. The food could be contaminated, and rust could develop inside of the cans if exposed to air causing illness or medical issues. The shelving in dry storage V21 identified as the location for dented cans did not have dented can signage.
2. On 01/07/25 at 10:13 AM, the plate warmer which was stacked with clean plates, was dirty and covered with crumbs and food splatters.
On 01/09/25 at 01:15 PM, V21 stated, kitchen equipment should be kept clean to prevent cross contamination.
The facility policy Storage and Handling of Cleaned Equipment and Utensils dated June 2023 states the food contact surfaces of equipment are protected from splash, dust and other contamination.
3. On 01/07/25 at 10:14 AM, the walk-in cooler contained:
An opened 25-pound bucket of hard-boiled eggs delivered on 12/24/24. Eggs did not have an opened on or use-by date.
Two pitchers identified by V21 as orange juice, one pitcher identified as cranberry juice and five-liter container identified as fruit punch- none had a label to identify contents or use-by dates.
A 16-quart container with sliced pickles did not have a label to identify contents or any dates.
Five small facility serving cups identified by V21 as vanilla yogurt did not have any labels or dates.
A large piece of meat identified by V21 as a ham roast (which was rewrapped in plastic wrap dated 1/3/5) and a large raw pork loin in factory packaging, were both stored over a box of bagged shredded cabbage and a stalk of celery.
Three 10-ounce packages of corn tortillas and a bottle of pinot grigio. V21 stated the tortillas and wine belongs to staff.
On 01/09/25 at 01:15 PM, V21 stated, employee food items should not be stored with the facility food because we cannot verify the vendor, where it came from or what is in it, and it could be inadvertently served to residents. Meat products should not be stored over vegetables because they could drip blood or juice on them causing illness.
4. On 01/07/25 at 10:37 AM, the walk-in cooler contained:
Two bags of brown liquid without labels or dates.
A bag identified by V21 as chicken patties did not have a label or dates.
An opened bag identified as French fries did not have a label or dates.
An opened 40-ounce bag of onion rings did not have an opened on or use by date.
On 01/09/25 at 01:15 PM, V21 stated it is important to label food items with the contents and dates so that expired food items aren't being served and so that we know what the items contains. Residents who have food sensitivities may have an allergic reaction if they are served food which contents aren't verified.
5. On 01/07/25 at 10:47 AM, a shelf near the stove contained a 32-ounce bottle of disinfectant spray, a 4-ounce bag of disinfectant spray, a four-ounce bag of fryer cleaning pucks, a four-ounce bottle of hand sanitizer and a four- ounce bottle of hand sanitizer.
On a seasoning shelf, an opened 20-ounce bottle of mustard labeled refrigerate after opening.
A large bin of flour with no opened-on or use-by date.
A large bin of sugar with no opened-on or use-by date.
The toaster oven was crusty and greasy. Stored on a shelf under the toaster ovens was a 26-ounce bottle of disinfectant cleaner and a 32-ounce bottle of surface sanitizer.
Four 3.5-gallon containers with items V21 identified as flakes of corn, bran with raisins, crisped rice and O's cereals that were not labeled or dated.
On 01/09/25 at 01:15 PM, V21 stated, cleaning products should not be stored in the food preparation areas when food is being prepared because they could contaminate the food and cause illness or send someone to the hospital.
The facility policy Food Storage dated June 2023 states Refrigerator and freezer temperatures will be monitored twice daily and recorded on temperature monitor logs by culinary personnel. Food and non-food supplies are to be clearly labeled. Leftover foods are labeled, dated immediately placed under refrigeration and used within 72 hours or discarded. No personal food items will be stored with food items.
6. On 01/07/25 at 10:55 AM, V21 tested the sanitizer level in the three-compartment sink. V21 stated the multi-quat sanitizer is automatically measured out and should measure at 50ppm (parts per million). When tested, sanitizer solution in the three-compartment sink measured at 10ppm with test strips with max range of 200ppm.
V22's (Dishwasher) documentation for the sanitizing solution concentration in the three-compartment sink done on 1/7/24 measured 400ppm.
V22 stated he turns the dial on the sanitizing solution and let it run until the water's color turns pink. V22 stated he wrote down the result on the log located in the office.
V21 stated no red disinfecting buckets were in use during the survey. V21 stated they were using no-rinse food safe surface wipes.
On 01/09/25 at 1:15 PM, V21 stated, he purchased the kitchen disinfectant wipes being used in the kitchen instead of the red sanitization bucket. V21 stated there is no facility policy that covers the uses of the disinfecting wipes, and his supervisor did not clear him to use the wipes.
7. The kitchen logs for food temperature, freezer, walk in cooler, sanitizer solution concentration, and dishwasher were reviewed from October 2024 - January 7,2025. The logs reviewed had incomplete documentation daily.
On 01/09/25 at 01:15 PM, V21 stated, food temping is important to make sure food being served is fully cooked and have documentation if someone says it's cold or raw. Checking the cooler and freezer log assures food items are held at the proper temperatures. Assuring the sanitization level makes sure we are cleaning properly.
The facility policy Sanitation and Infection Control dated June 2023 states, monitoring of food temperatures will be recorded throughout food production and delivery. Wiping cloths shall be clean, rinsed frequently in an approved sanitizing solution and shall only be used to wipe food spills and dining tables. Utilize and fill red buckets with sanitizing solution and replace every 2 hours. Sanitizer should read at 200ppm. Three-sink sanitizing method- use a test kit or other device that accurately measures the concentration of the sanitizing solution. The concentration for a multi quat sanitizing solution is 200- 400 ppm. All chemicals and toxic materials shall be stored separately from each other in a place used for no other purpose and away from all food or food contact equipment.
Apr 2024
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to notify the physician of a resident's pain and provide medication as ordered by the physician.
This applies to 1 of 2 residen...
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Based on observation, interview, and record review, the facility failed to notify the physician of a resident's pain and provide medication as ordered by the physician.
This applies to 1 of 2 residents (R65) reviewed for pain management in a sample of 24.
The findings include:
1. R65's Face sheet stated R65 was readmitted from the hospital on March 01, 2024, with diagnoses including encounter for other orthopedic aftercare, local infection of the skin and subcutaneous tissue, unspecified, acquired absence of left foot, encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, non-pressure chronic ulcer of left ankle with unspecified severity, peripheral vascular disease.
R65's 5-day MDS (minimum data set) dated March 7, 2024, showed that R65 was cognitively intact.
R65's POS (Physician Order Sheet) included hydrocodone-acetaminophen 10-325 mg/milligrams [Norco]1 tablet every 4 Hours as needed (start date March 01, 2024).
Physician progress note dated March 28, 2024 (Recorded as Late Entry on April 01, 2024) included as follows: Patient having a lot of pain in his foot as well as bilateral shoulders though bilateral shoulder pain is chronic. Pain management - Reviewed pain relief and side effects of current medications. Recommend continue (gabapentin, hydrocodone-acetaminophen).
On April 01, 2024, at 2:32 PM, R65 was in his room with meal untouched. R65 stated that he is unable to eat as he in a lot of pain. R65 stated I have been asking for pain medications since 8:00 AM this morning. I went to therapy and came back, and my pain is worse. I asked the nurse again a few minutes ago [for pain medications]. She said it hasn't been filled through the normal channels. It happened before. Two weeks ago, when I first got here from the hospital, it took two weeks for them to start giving me medications. When asked what his pain score was on a scale of 1-10, R65 replied 9 and a 1/2 (half).
On April 01, 2024, at 2:42 PM the above information was reported to V6 (Registered Nurse) who was at the nurse's station. V6 stated He's asking for Norco, and he does not have a refill order for it (from Practitioner). I asked V2 (Director of Nursing) for it right away and she said that he needs a script for it and the NP (Nurse Practitioner) is not here. He (R65) says that a few days ago he asked for it and they haven't put the order in yet. This morning before therapy he told me his pain was around 7 and that he needed the pain medications before therapy. He has an order for Tylenol, and I just can't give him that.
On April 01, 2024, at 02:46 PM, V19 (Certified Nursing Assistant) came to the nurse's station and reported to V6 that R65 told her that he is in a lot of pain around his foot and going up his spine and unable to eat his lunch meal.
R65's MAR (Medication Administration Record) showed that R65 started receiving prn (as needed) Norco from March 20, 2024, until March 26, 2024, between 1-2 times daily. The same MAR showed that R65 did not receive Norco from March 26, 2024, until current date (April 2, 2024). The same MAR also had a foot note (by V6) that showed that at on April 1, 2024, at 10:37 AM, the prn order was not administered as drug/item unavailable in cart.
On April 02, 2024, at 9:12 AM, R65 was in his room and stated My pain is still 9 and a 1/2. They still haven't done anything about it. The Tylenol does not help.
On April 02, 2024, at 9:14 AM, the concern about R65's pain was reported to V7 (Licensed Practical Nurse) who was outside R65's door, getting R65's medications ready. V7 searched in the medication cart and stated there is no Norco in here. He R65 told me that his pain was about 9 around 9:00 [AM]. The Pharmacy says that they need a new script.
On April 02, 2024, at 3:32 PM, V2 (Director of Nursing) stated that she learned about R65's pain only that morning and she talked to V14 (Nurse Practitioner) and got a script from her and faxed it to the pharmacy. V2 stated that she can now get the Norco from the electronic medication dispenser to administer to R65. V2 added that prior to getting the script the pharmacy would not give her access to the emergency dispenser.
On April 02, 2024, at 4:02 AM, V14 stated that she wasn't made aware that R65's pain was 9 and a half. V14 stated that if she had known, she would have prescribed something for break through pain. V14 stated that she was only told today that R65 needed a refill for his Norco.
Facility policy titled Pain-Clinical Protocol (Revised August 2008) included as follows:
Monitoring:
1. The staff will reassess the individual's pain and consequences of pain at regular
intervals.
a. For example, review frequency and intensity of pain, ability to perform
activities of daily living (ADLs), sleep pattern, mood, behavior, and
participation in activities.
3. The staff will discuss significant changes in levels of comfort with the Attending
Physician who will adjust interventions accordingly.
a. This may include adjustments of regular and PRN analgesic doses to find the
best combination of effectiveness and tolerable side effects, or possible addition
of non-pharmacological interventions.
Notification:
7. Resident's Physician and resident's family/ responsible party should be notified of
significant changes pertaining to resident's pain level.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
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 monitor clinical condition of a resident upon returning from dialys...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor clinical condition of a resident upon returning from dialysis. The facility also failed to provide clinical documentation of resident's condition during dialysis treatment.
This applies to 1 of 2 residents (R66) reviewed for dialysis in the sample of 24.
The findings include:
R66 is a [AGE] year-old male with medical diagnoses that include acute and chronic congestive heart failure, end stage renal disease, dependence on renal dialysis, morbid obesity, and type 2 diabetes mellitus according to the face sheet.
Review of R66's physician orders showed there was no order for dialysis or for monitoring R66's dialysis access shunt site upon return from dialysis.
On April 3, 2024, at 12:42 PM, V2 (Director of Nurses, DON) stated that R66's order for dialysis was not reactivated. V2 stated she would reactivate them now.
On April 3, 2024, at 3:02 PM, V2 stated the facility does not have any reports from the dialysis company post dialysis sessions and no weights, labs, or communication from the dialysis company. V2 stated that the dialysis company does not send them any reports.
On April 3, 2024, at 3:54 PM, V2 stated the facility does not get any written communication from the dialysis provider. V2 stated she does not get any clinical communication after dialysis from the dialysis company.
On April 3, 2024, at 4:02 PM, V2 handed the surveyor a blank Dialysis Log Profile that she stated she sends with the resident each time. V2 stated, when the dialysis log profile forms don't come back after dialysis, she does not follow up with the dialysis company to find out what occurred during dialysis.
On April 3, 2024, at 4:13 PM, V2 stated that each time R66 comes from dialysis they should be checking, the resident's access site, and the dressing on it. V2 stated she does not know if the assessments are documented because she just reactivated all of the resident's dialysis orders.
On April 3, 2024, at 3:35 PM, V39 (Dialysis RN) stated that she is familiar with R66. V39 stated they do not provide a form to document pre/post dialysis. V39 stated that each facility usually sends the form, and the dialysis company will document on the form. V39 stated she has never received a form from the facility for R66. V39 stated that the facility only sends R66's face sheet and medication list with him. V39 stated their Dietician and the Dietician at the nursing facility follow up with each other regarding the resident's nutrition.
There was no documentation noted in R66's medical record of any assessment after dialysis from March 12, 2024, until April 3, 2023. This documentation was requested, but by the end of the survey, no documentation regarding R66's pre and post dialysis condition was provided.
R66's Dialysis care plan dated April 12, 2023, shows: monitor and report signs of localized infection. Monitor circulation, motion, sensation of extremity with access device every shift. Palpate shunt for thrill site every shift.
The facility did not provide a policy for dialysis care and treatment after being requested. V1 (Administrator) stated on April 3, 2024, at 4:30 PM the facility does not have a policy regarding dialysis care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
3. R32 was admitted to the facility October 12, 2023, with diagnoses including but not limited to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, moo...
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3. R32 was admitted to the facility October 12, 2023, with diagnoses including but not limited to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; and other diagnoses that do not include any psychiatric diagnoses.
According to the discharge report from the hospital where R32 was treated immediately prior to admission to the facility, R32 was not given any antipsychotic medication and had no psychiatric diagnosis.
The POS (physician's order sheet) shows R32 was prescribed quetiapine (antipsychotic medication) 50mg at bedtime, on October 26, 2023. The POS shows as well that quetiapine 25mg TID (three times each day) was added for R32 on February 21, 2024.
The facility Point of Care documentation for the month of October 2023 shows R32 had psychiatric behaviors or changes of mood during that month or any month thereafter including the month of February 2024.
On April 2, 2024, at 4:42pm, V36 (medical Director) stated he was familiar with R32 and did not know why R32 was prescribed quetiapine. V36 stated he would not prescribe quetiapine 50mg for any patient new to the medication and there needs to be a rationale for the use of quetiapine.
The care plan for R32 shows no behavior or diagnosis to be targeted by an antipsychotic medication.
The facility provided a Psychotropic Medication Policy dated February 2014 which shows:
Policy: To establish the process for monitoring the use of and the reduction of doses of psychotropic medications without compromising the resident's health and safety, ability to function appropriately, or the safety of others.
Policy Specifications:
2. Residents shall not be given antipsychotic drugs unless antipsychotic drug therapy is necessary to treat a specific or suspected condition as diagnosed and documented in the clinical record or to rule out the possibility of one of the conditions listed in the guidelines of the recognized external review agencies.
G. Use of Antipsychotic Drugs:
Antipsychotic drugs should not be used unless the clinical record documents that the resident has on of the following specific conditions:
Conditions Other Than Dementia
1.
Schizophrenia
2.
Schizo-affective disorder;
3.
Delusional disorder
4.
Mood Disorders (e.g. Bipolar disorder, severe depression refractory to other therapies and/or with psychotic features);
5.
Schizophreniform disorder;
6.
Tourette's disorder
7.
Nausea and vomiting associated with cancer or chemotherapy;
8.
Hiccups (not induced by other medications)
9.
Medical illnesses with psychotic symptoms (e.g. neoplastic disease or delirium) and /or treatment related top psychosis or mania (e.g. high dose steroids)
Behavioral or Psychological Symptoms of Dementia (BPSD)
1.
Antipsychotic medication may be considered for elderly residents with dementia but only after medical, physical, functional, psychiatric, social and environmental causes have been identified and addressed.
2.
Antipsychotic medications must be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review.
Antipsychotic medication in persons with dementia should not be used if one or more of the following is/are the only indication:
1.
Wandering,
2.
Poor self care
3.
Restlessness,
4.
Impaired memory,
5.
Mild anxiety
6.
Sadness or crying alone that is not related to depression or other psychiatric disorders,
7.
Insomnia
8.
Inattention or indifference to surroundings,
9.
Fidgeting,
10.
Nervousness
11.
Uncooperativeness (e.g. refusal of or difficulty receiving care)
Based on observation, interview, and record review, the facility failed to identify the diagnosis and specific behavior for residents who are prescribed antipsychotic medication.
This applies to 3 of 5 residents (R32, R72, R99) reviewed for psychotropic medications in the sample of 24.
The findings include:
1. R72's Face sheet shows that R72 is a 74 years-old who has multiple medical diagnoses which include parkinson's disease without dyskinesia and neurogenic disorder with lewy bodies, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.
Physician Order Summary (POS) shows multiple medications which include Quetiapine (antipsychotic medication) tablet 25 milligrams (mg) at bedtime.
From April 2, 2024, through April 3, 2024, random observations were conducted on R72 between 9:35 AM through 3:00 PM. R72 was observed in the dining room either sleeping or sitting quietly. There was no behavior noted during observation. R72 was pleasantly confused when surveyor talked to him.
On April 2, 2024, at 2:34 PM, V27 (Certified Nursing Assistant/CNA) stated that R72 displays no behavior except for attempting to stand up occasionally. R72 mumbles to himself, very confused. R72 does not display paranoia, and he has no aggressive behavior.
On April 3, 2024, at 1:40 PM, V29 (CNA) stated that R72 is usually quiet and cooperative.
On April 3, 2024, at 2:09 PM, V40 (Social Service Director) stated that R72 is pleasantly confused, he has no behavior.
On April 4, 2024, at 2:39 PM, V2 (Director of Nursing/DON) stated that R72 has no psychiatric evaluation. The behavioral monitoring is done by the staff, and they record it.
R72's active care which was started on 12/13/2023 with reviewed/revised date of 3/20/2024 shows that R72 receives antipsychotic medication. This same care plan shows multiple approaches which include monitoring R72's behavior and response to medication. However, there was no documented targeted behavior which addressed why R72 needs to use anti-psychotic medication.
R72's Point of Care Mood Category Report dated February to April 2024 does not have observation of any behavior.
2. R99's Face sheet shows R99 is a 82 years-old who has multiple medical diagnoses which include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.
From April 1 through April 4, 2024, multiple random observations were conducted between 9:20 AM though 12:30 PM, R99 was observed sleeping in bed majority of the time.
Physician Order Summary (POS) shows multiple medications which include Quetiapine (antipsychotic medication) 25 mg every morning and 75 mg at bedtime.
Psychiatric evaluation dated 12/13/23 does not have documentation of behavior pertaining to the use of Quetiapine.
On April 3, 2024, at 1:59 PM, V40 (Social Service Director) stated that R99 currently has no behavior but before the use of Quetiapine medication, he was very impulsive, he would try to get out of bed. V40 stated there was no other behavior assessment. R99 was confused, he was unable to participate in the PHQ9 (Patient Health Questionnaire-9) assessment which determines depression and the information for PHQ9 came from the staff. R99 sleeps a lot and had difficulty concentrating.
R99's active care which was started on 4/19/2023 with reviewed/revised date of 1/23/2024 shows that R99 is at risk for adverse side effects related to use of psychotropic medications. R99 utilizes antipsychotic medications to assist in managing diagnoses of depression. This same care plan shows multiple approaches which include assessing if R99's behavioral symptoms present a danger to the resident and/or others, intervene as needed, quantitatively and objectively document the resident's behavior. However, there was no documented targeted behavior which addressed why R99 needs to use anti-psychotic medication.
R99's Point of Care Mood Category Report dated February to March, 2024 does not have observation of any behavior.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure that a resident was not given Insulin belonging to another resident and failed to follow the facility's policy regardi...
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Based on observation, interview, and record review, the facility failed to ensure that a resident was not given Insulin belonging to another resident and failed to follow the facility's policy regarding medication administration.
This applies to 1 of 1 resident (R115) reviewed for medication errors in the sample of 24.
The findings include:
On April 2, 2024, at 1:26 PM with V7 (Agency Nurse) outside of R115 room in the doorway, V7 asked R115 what his blood sugar was. R115 stated his blood sugar was 256. V7 stated R115 has an implanted monitor that shows his blood sugar. R115 stated he had lunch about 30 minutes ago. V7 apologized for being late. V7 stated, R115 blood sugar is high, I have to give him insulin. V7 stated she is going to give R115 five (5) units of Insulin Aspart. V7 (agency) looked for insulin in her cart and did not find any insulin and then said the insulin is in another cart. V7 then walked to another cart by the nurses' station and grabbed a box that had R65 name on it and showed it was Aspart Protamine 70/30. Inside the box there was a used multi-dose vial of Insulin Aspart with R380's name on it.
On April 2, 2024, at 1:34 PM, V7 withdrew 5 units of insulin from a used multi-dose vial of insulin Aspart that had R380's name on it and showed it to the surveyor. V7 did not recap the insulin needle and she turned and said she was going to give the insulin to R115. Surveyor asked V7 if she was about to give that now to the R115. V7 stated, Yes. Surveyor asked if V7 should give that insulin that she drew from R380's name on it. Surveyor pointed to the vial that V7 had just drew from that had R380 name on it. V7 stated she should not give insulin she just drew.
R380 was discharged on 1/16/2024 according to her face sheet.
On April 3, 2024, at 12:42 PM, V2 (Director of Nurses, DON) stated that insulins expire 28 days after they are opened.
On April 4, 2024, at 10:57 AM, V2 stated they do not share insulins between patients. On April 4, 2024, at 11:06 AM, V2 stated they don't share insulins between residents because it is an infection control issue. V2 stated insulins are good for 28 days after first use.
On April 4, 2024, at 11:21 AM, V37 (Pharmacist) stated we do not recommend sharing insulins between residents for safety reasons. V37 stated there is always some infection control concern also.
The facility's Expiration dates for certain drugs, biologicals, and records policy show that insulins expire 28 or 42 days after use.
The facility's Medication Administration policy dated 10/25/2014 shows the following:
Preparation 4) FIVE RIGHTS - right resident, right drug, right dose, right route and right time are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication is put away.
a. Check #1 Select the medication - label, container and contents are checked for integrity, and compared against the medication administration record (MAR) by reviewing the 5 Rights.
b. Check #2: Prepare the dose, the dose is removed from the container and verified against the label and the MAR by reviewing the 5 Rights.
c. Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 Rights.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide substitute meals with the same nutrient content.
This applies to 3 of 3 residents (R35, R86, R102) reviewed for dinin...
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Based on observation, interview and record review, the facility failed to provide substitute meals with the same nutrient content.
This applies to 3 of 3 residents (R35, R86, R102) reviewed for dining in the sample of 24.
The findings include:
Facility Fall /Winter menus (week 4) for Monday showed Lemon Baked Fish as the main entree. Production recipe for the same showed to serve 1 filet of fish with a yield of minimum 2 oz (ounce) of protein.
On April 1, 2024, at 12:50 PM, during lunch meal prep in the facility kitchen, V24 (Cook) was seen making grilled cheese sandwiches. V24 placed 2 slices of cheese in between two slices of bread and grilled it. R35, R86 and R102 were served the same on tray line. These residents' meal tickets showed written orders for grilled cheese and V24 stated they had ordered the same as a meal substitute for lemon baked fish.
Facility Production recipe for Sandwich Cheese Grilled included to assemble sandwiches with 2.25 oz of cheese (3 slices of .75 ounces slices of cheese).
On April 03, 2024, at 12:26 PM, V20 (Vice President of Culinary) stated that you need to use 3 slices of cheese to obtain 2 oz protein. V20 added that the meal replacement should have the same equivalent of protein servings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide grooming and hygiene for residents who requir...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide grooming and hygiene for residents who require assistance with ADL (Activities of Daily Living) care.
This applies to 4 of 5 residents (R58, R60, R72, R100) reviewed for ADL care in the sample of 24.
The findings include:
1. R100's Face sheet shows that R100 is a [AGE] year-old who has multiple medical diagnoses which include cerebral palsy and adult failure to thrive. R100's MDS (Minimum Data Set) dated January 30, 2024, showed that R100 was dependent on staff for ADL care.
On April 1, 2024, at 11:53 AM, R100 was resting in bed, she had long dirty fingernails with brown and black unidentified substance underneath the nails, overgrown facial hair which was curling on the chin, uncombed greasy hair, and foul-smelling odor.
On April 2, 2024, at 4:48 PM, R100 was resting in bed. She remained with overgrown nails, facial hair, long dirty fingernails, and a foul-smelling odor. V27 (Certified Nursing Assistant/CNA) stated that R100 needs assistance from staff for hygiene and grooming care.
2. R58's Face sheet shows that R58 is a [AGE] year-old who has multiple medical diagnoses which include parkinson's disease without dyskinesia and corticobasal degeneration. R58's MDS dated [DATE], shows that R58 is alert and oriented and requires substantial to maximal assistance for grooming and hygiene care.
On April 1, 2024, at 3:28 PM, R58 was resting in bed. R58 stated that she has a degenerative disease called corticobasal degeneration which caused the paralysis on the left side of her body. R58 said that it would be nice if the staff could clip her nails and give her a bed bath weekly. R58 also stated this is the second Monday that she has not received a bed bath.
On April 2, 2024, at 3:10 PM, R58 was resting in bed with long dirty fingernails and stated that she still hasn't received a bed bath.
3. R60's Face sheet shows that R60 is a [AGE] year-old who has multiple medical diagnoses which include unspecified secondary parkinsonism. R60's MDS dated [DATE], shows that R60 is alert and oriented and requires supervision or touching assistance for grooming and hygiene care.
On April 02, 2024, at 3:15 PM, R60 was sitting in his wheelchair, he was alert and oriented. R60 stated that it would be nice to have a regular shower, he needs help when he goes to the shower. R60 also said that he has been asking for a shower, but he is told that they don't have enough staff. The last time he had shower was 2 weeks ago.
4. R72's Face sheet shows that R72 is 74 years-old who has multiple medical diagnoses which include Parkinson's disease without dyskinesia and Neurogenic disorder with Lewy bodies. R74's MDS dated [DATE], shows that R72 requires substantial to maximal assistance for grooming and hygiene care.
On April 2, 2024, at 11:11 AM, R72 was sitting in the dining room. R72 had long dirty fingernails with black and brown substance underneath nails, and thick, overgrown nasal hair which was sticking out of his nostrils.
On April 3, 2024, at 12:00 PM, R72 was sitting in his wheelchair remained unkempt and disheveled with long dirty fingernails and long nasal hairs. V29 (CNA) stated today she would give a shower to R72. V29 also stated R72 is usually cooperative and has no behaviors during ADL care.
On April 3, 2024, at 1:25 PM, V29 (CNA) stated she doesn't know how she could trim R72's nasal hair.
On April 3, 2024, at 1:30 PM, V32 (CNA) stated that they don't have a nasal hair trimmer. They will call R72's caregiver to provide a nasal hair trimmer.
On April 3, 2024, at 4:00 PM, V2 (Director of Nursing/DON) stated that showers are scheduled 2 times a week or more often if the resident requests. If the resident refuses the first scheduled shower for the week that is scheduled, they ask the family to assist with encouraging the resident to get a shower. Shaving is to be done with the shower or if there is facial hair visible and in need of being shaved, men may need shaving done daily. Nail care should be provided immediately when noted that the nails are dirty or in need of being clipped or with the weekly shower.
On April 2, 2024, at 2:39 PM, V27 (CNA) stated that residents are scheduled to be given a bed bath or shower twice a week and they document it when they provided it.
On April 2, 2024, around 2:30 PM, V5 (Medical Record Staff) presented a copy of their most recent Bath and Skin Report Sheet (shower/bed bath) sheets which was only for the month of March 2024. V5 stated that she could not find any shower sheet for the month of April for R58, R60, R72, R100.
The March 2024 Bath and Skin Report Sheet shows that the last time the following residents were showered or received bed bath was on 3/17/24 for R100 and 3/18/24 for R58, R60 and R72.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to serve portions for mechanical soft fish as shown on menu spreadsheet.
This applies to 5 of 5 residents (R16, R72, R100, R103, ...
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Based on observation, interview and record review, the facility failed to serve portions for mechanical soft fish as shown on menu spreadsheet.
This applies to 5 of 5 residents (R16, R72, R100, R103, and R175) observed for dining in the sample of 24.
The findings include:
Menu spreadsheet for Fall Winter Menus (cycle day 23) for the mechanical soft diet showed to serve #6 scoop of ground baked fish with 2 oz/ounce gravy.
On April 1, 2024, at 1:03 PM, during tray line service, the residents on mechanical soft diet received two scoops of ground fish served with a red handled spoodle and R16, R 72, R100, R103, R175 received the same. The same residents also did not receive gravy with the flaked fish. No menu spread sheet was seen in the meal service area.
When asked, V8 (Cook) who was on the tray line serving the food, stated that the scoop yields 1 + 1/3rd oz/scoop. This showed that each resident on mechanical soft diet received 2 +2/3 oz/serving of mechanical soft fish. When V8 was shown the menu spreadsheet, he went looking for a #6 scoop and came back and stated that there are none available on hand. V8 also added that he was not aware of the spreadsheet as he usually works on the side of the main cook and just watch, look and see during meal service. V8 also stated that the main cook called off that day.
On April 3, 2024, at 12:33 PM, V20 (Vice President of Culinary) stated that the facility should follow the menu spreadsheet in order to receive the required amount of protein for the meal.
Facility scoop equivalent chart showed that #6=5+1/3 oz.
Facility diet order listing showed that R16, R 72, R100, R103, R175 were on mechanical soft diets.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
4. R104's face sheet included diagnoses of urinary tract infection, site not specified, other specified bacterial agents as the cause of diseases classified elsewhere, enterocolitis due to clostridium...
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4. R104's face sheet included diagnoses of urinary tract infection, site not specified, other specified bacterial agents as the cause of diseases classified elsewhere, enterocolitis due to clostridium difficile, not specified as recurrent.
R104's POS (Physician Order Sheet) showed Contact Isolation for Organism ESBL (extended -spectrum beta-lactamase) in urine.
On April 1, 2024, at around 10:48 AM, R104's room door showed signage for Contact Precautions. The signage included Stop. Contact Precautions. Providers and staff must also put on gown before room entry. Discard gown before room exit.
A plastic container with PPE was stored outside the room. V21 (Housekeeper) was seen going into the room with gloves and cleaned the room and bathroom without wearing disposable gown. R104 was sleeping in her bed.
5. R53's face sheet included diagnoses of urinary tract infection, site not specified, MRSA (methicillin resistant staphylococcus aureus) infection, unspecified site, resistance to vancomycin, resistance to multiple antibiotics.
R53's POS showed Contact Isolation for Organism: VRE (vancomycin-resistant enterococcus) in urine.
On April 1, 2024, at 10:48 PM, R53's room door showed signage for Contact Precautions. A plastic container with PPE was stored outside the room. V21 was seen going into the room with gloves and cleaned the room without wearing disposable gown. R53 was in his room.
6. R26's face sheet included diagnoses of local infection of the skin and subcutaneous tissue, unspecified, Parkinson's disease without dyskinesia, without mention of fluctuations.
R26's POS showed Contact Isolation for Organism MRSA.
On April 1, 2024, at 10:51, R26 room door showed a signage for Contact Precautions. A plastic container with PPE was stored outside the room. V21 was seen going into the room wearing only gloves and without wearing disposable gown to clean the room. R26 was in the bathroom. When asked why she did not don a gown as shown on the signage on doors of the rooms she cleaned, V21 responded that she is not a CNA (Certified Nurse's Assistant) and has not been told about wearing any additional PPE.
On April 1, 2024, at 10:52 PM, V2 (Director of Nursing) stated that V21 should have worn gown and gloves when she cleaned the rooms as organisms from the urine or wound could be anywhere in the room. V2 added that although R26 is on isolation related to MRSA in wound and its contained, a gown and gloves should always be worn on entrance to the room as the signage shows. V2 stated that she will notify the House Keeping Director with the directives.
Based on observation, interview, and record review, the facility failed to follow standard infection control practices with regards to hand hygiene and gloving during provisions of incontinence care. In addition, the facility failed to ensure staff donned full PPE (Personal Protective Equipment) when entering isolation rooms.
This applies to 6 of the 24 residents (R26, R53, R58, R59, R100, R104) reviewed for infection control in the sample of 24.
The findings include:
1. On April 1, 2024, at 2:57 PM, V33 and V34 (Both Certified Nursing Assistants/CNAs) rendered incontinence care to R58 who was wet with urine and had a bowel movement. V34 cleaned R58's peri-area from front to back then she (V34) opened the bathroom door with her soiled gloved hands to wash her gloved hands. After washing her gloved hands and without changing her gloves, V34 continued to clean R58. V33 on the other hand helped to clean the left side of R58's peri-area. After wiping R58, V33 changed her fecal stained gloves and did not perform hand hygiene. Both CNAs then repositioned R58 to the right side. V33 did another round of cleaning/wiping of R58's buttocks area, while wearing the same soiled gloves, then V33 applied barrier cream and incontinence brief to R58.
2. On April 2, 2024, at 11:36 AM, V35 (CNA) rendered incontinence care to R59 who was wet with urine. V35 cleaned R59's perineum from front to back, she (V35) removed the soiled brief and applied a new one and repositioned R59 while wearing the same soiled gloves.
3. On April 2, 2024, at 12:23 PM, V29 and V35 (Both CNAs) rendered peri-care and catheter care to R100. V29 cleaned R100's perineum from front to back including her catheter tube. V29 changed her soiled gloves and did not perform hand hygiene, she then continued to apply a clean incontinence brief and repositioned R100.
The electronic medical record (EMR) shows that R100 is on isolation for MRSA (Methicillin-resistant Staphylococcus-aureus) in the wound.
On April 4, 2024, at 12:16 PM, V2 (Director of Nursing/DON) stated that when staff renders incontinence care, they should perform hand hygiene before and after care, and in between care from dirty to clean tasks. The staff should not wash their soiled gloves. The staff should remove the soiled gloves and perform hand hygiene then wear another set of clean gloves. This should be done to prevent infection.
The Facility's Handwashing/Hand Hygiene Policy with effective date of March 2020 shows:
Policy: It is the policy of the facility to assure staff practice recognized handwashing/hand hygiene procedures as a primary means to prevent the spread of infections among residents, personnel, and visitors.
Policy Specifications:
4. When hands are not visibly soiled, employees may use an alcoholic-based hand rub (foam, gel, liquid) containing at least 60% alcohol in all the following situations:
g. before moving from a contaminated body site to a clean body site during resident care.
h. before and after putting on and upon removal of PPE, including gloves.
m. after removing gloves.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to provide documentation that influenza and pneumococcal vaccines had ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to provide documentation that influenza and pneumococcal vaccines had been offered.
This applies to 5 of 5 residents (R26, R49, R53, R86, R104) reviewed for immunizations in the sample of 24.
The findings include:
1. R86's EMR (Electronic Medical Record) showed R86, age [AGE], admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction, dysphagia, atrial fibrillation, artificial opening of the urinary tract and urinary tract infection.
On April 3, 2024, at 11:20 AM, V4 (IP Nurse) and V2 (DON) stated they were unable to provide documentation of influenza vaccine and pneumococcal vaccines were offered or declined, since admission for R86. V4 stated R86's family requested the vaccines be administered but was unable to provide documentation that the vaccines were administered.
2. R53's EMR showed R53, age [AGE], was admitted to the facility on [DATE], with multiple diagnoses including pneumonia, paroxysmal atrial fibrillation, chronic obstructive pulmonary disease, psoriatic arthritis and history of resistance to multiple antibiotics.
R53's immunization records showed R53 received the PCV 13 (Pneumococcal vaccine 13) vaccine on June 23, 2016. According to the CDC (Center for Disease Control) Pneumonia Vaccine Timing for Adults, adults who received the PCV 13 at any age should receive the PPSV 23 (Pneumococcal Polysaccharide vaccine) if it has been more than one year since last administered.
On April 3, 2024, at 11:20 AM, V4 and V2 stated there was no documentation that R53 had been offered or declined the pneumococcal vaccine.
3. R104's EMR showed R104, age [AGE], was admitted to the facility on [DATE], with multiple diagnoses including metabolic encephalopathy, chronic obstructive pulmonary disease, type 2 diabetes, unspecified dementia and heart failure.
R104's immunization record showed there was no documentation the influenza or pneumococcal vaccines had been administered since admission.
On April 3, 2024, at 11:20 AM, V4 and V2 stated there was no documentation that the influenza and pneumococcal vaccines had been offered or declined since admission.
4. R26's EMR showed R26, age [AGE], was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's disease, heart failure, polyosteoarthritis, polyneuropathy and atrial fibrillation.
R26's immunization record showed R26 had received the pneumococcal vaccine PPSV 23 on January 31, 2023. According to the CDC's Pneumococcal Vaccine Timing for Adults, adults greater than age [AGE], who have already received the PPSV 23 vaccine should be offered the PCV20 vaccine.
On April 3, 2024, at 11:20 AM, V4 and V2 stated there was no documentation that R26 had been offered or declined the pneumococcal vaccine.
5. R49's EMR showed R49, age [AGE], was admitted to the facility on [DATE], with multiple diagnoses including acute diastolic congestive heart failure, epilepsy, obstructive and reflux uropathy, and moderate protein-calorie malnutrition.
R49's immunization record showed R49 last received the influenza vaccine on October 12, 2022, but did not receive the vaccine for the 2023-2024 Flu season. There is no record that the pneumococcal vaccine has been administered.
On April 3, 2024, at 11:20 AM V4 and V2 stated there was no documentation that R49 had been
offered the influenza vaccine for the 2023-2024 Flu season, nor that the pneumococcal vaccine had been offered or declined.
The facility's policy titled Influenza Vaccine dated December 2006, showed 2 residents admitted between October 1st and March 31st shall be offered the vaccine within 5 days of the resident's admission to the facility, and .6. A resident's refusal of the vaccine shall be documented in the resident's medical record.
The facility's policy titled Pneumococcal Vaccine dated December 2006, showed 2. Assessments of pneumococcal vaccination status will be conducted within 5 working days of the resident's admission, if not conducted prior to admission and . 7. Administration of the pneumococcal vaccination or revaccination will be made in accordance with current CDC recommendations at the time of the vaccination and .5 .If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccine.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected most or all residents
2. Facility Mealtimes schedule showed that the variable units would receive breakfast and lunch meals between 8:00-8:30 AM, and 12:00-12:30 PM respectively.
On April 1, 2024, at 12:55 PM, the meal ser...
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2. Facility Mealtimes schedule showed that the variable units would receive breakfast and lunch meals between 8:00-8:30 AM, and 12:00-12:30 PM respectively.
On April 1, 2024, at 12:55 PM, the meal service was noted to start at the facility kitchen. When asked why the meal service was started late, V8 (Cook) stated that it's taking him more time to prepare the meals as I usually work on the side. I am not used to being the lead cook.
On April 1, 2024, at 1:45 PM, V22 (Physical Therapy Assistant) was seen coming to the kitchen and enquiring why the trays are so late. V22 added that she needs to take residents to therapy after lunch and its past the meal schedule time. V9 (Dietary aide) responded to V22 that the 5:00 AM cook called off and a dietary aide also did not show up. V9 stated that she was off and was called to come in and assist.
On April 1, 2024, at 2:15 PM, the last cart was seen taken to the floor.
On April 2, 2024, at 9:06 AM, R276 was in his room starting to eat his breakfast. R276 stated Look at the time? Breakfast should be served between 7-7:30 [AM]. Yesterday I received lunch after 1:00 PM.
On April 2, 2024, at 9:10 AM, R65 was in his room eating his breakfast. R65 stated They just brought my tray a little while ago. I am a diabetic. If they bring it earlier, I will have a chance to digest my food before I go to therapy at 10:00 AM. Yesterday they brought my lunch tray after 2:00 PM. They call it lunch because it's supposed to be served at noon.
On April 2, 2024, around 4:30 PM, V1 (Administrator) stated that he was aware of the late meal times since last week as he had received complaints from staff about it.
Facility policy titled Mealtimes and Frequency included as follows:
The facility will provide at least three meals at regular times comparable to standard mealtimes in the community or in accordance with the patient'/residents' needs, preferences, requests , and plan of care. Meals will be served in a timely manner to maintain food quality and safe and palatable food temperatures.
Based on observation, interview, and record review, the facility failed to serve meal at the scheduled times.
This applies to all 129 residents that receive food prepared in the facility kitchen.
The findings include:
1. During entrance conference on April 1, 2024, the facility provided information that the census was 129 residents with no residents in house on NPO (nothing by mouth) status.
On April 1, 2024, lunch service began after 1:45pm.
On April 2, 2024, at 1:30pm, residents who are active in the Resident Council, including R51, R7, R26, R45, R50, R93, R95, and R108 met with this writer. During the meeting, R51 stated meals have been served as late as 2 hours after the scheduled time; all the other residents in the meeting affirmed R51's statement. R51 stated it gets quite late in the evening for dinner, as late as 8:00pm.
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 observations, interview and record review, the facility failed to serve foods in a sanitary manner.
This applies to all 129 residents that receive food prepared in the facility kitchen.
The f...
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Based on observations, interview and record review, the facility failed to serve foods in a sanitary manner.
This applies to all 129 residents that receive food prepared in the facility kitchen.
The findings include:
During entrance conference on April 1, 2024, the facility provided information that the census was 129 residents with no residents in house on NPO (nothing by mouth) status.
1. On April 1, 2024, starting at 9:53 AM, during initial tour of facility kitchen, V5 (Medical Records Director) was in the dietary office and stated that she is helping out with the meal tickets as the Dietary Manager is out on medical leave. V5 stated that she does not oversee the other functions in the kitchen.
At the hand washing sink, there was a dirty rag inside the sink. Near the hand washing sink, the clean side of the dish machine area had extensive grime, and unknown debris. Two tray racks with washed glasses were stored over this same soiled area. V12 (Dietary Aide) was seen coming from outside the kitchen and stated that she went to collect the dirty dishes stored in the cart. V12 (not wearing gloves) proceeded to put away the rack with the cleaned glasses which were to be stacked one on top of the other in another area. V12 was notified of contamination risk from going from dirty to clean without washing his hands and also notified of the soiled dish machine area where clean dishes were stored. V12 stated that the night shift staff left it like that.
Near the dish machine, there were multiple washed bowls stored on a free-standing rack with some bowls that were not inverted containing free standing water in them. V13 (Dishwasher) stated that these bowls are used for salad and should have been stored inverted.
Above the dish machine, the ceiling tiles were stained with grayish/brown patches and had one of the tiles come off and tilted in a slant with the area beyond exposed.
The walk-in cooler had extensive debris on the floor under the storage racks. The items on the racks were disorganized with various items randomly placed on the shelves.
In the food prep area, multiple used and dirty rags were seen strewn all over the kitchen counters. Soiled sanitizer buckets were seen in the dish room area.
A free-standing milk refrigerated storage unit had extensive congealed grayish colored spills at the bottom of the refrigerator and had a putrid smell. V8 (Cook) stated that he has only been at the facility for two weeks and does not know what these spills are.
The dry storage area had multiple loafs of bread, rolls and buns stored in tray racks which V8 stated were just delivered that day and would be put away on the bread storage rack. The bread storage rack already had remaining items of bread, rolls and buns stored on them. When asked, how the staff would know which items to use first, cook stated that the manager does not use the first in, first out system and the items that were delivered will just be added on to the shelf based on differentiation of wheat, white bread or rolls and/or buns.
The spoodle and scoop storage units near the tray line serving area contained blackish grime and other dirt like particles. V8 was notified that these serving items are contaminated with the unknown debris and will have to be washed before using them. During tray line service (around 12:55 PM) V8 was seen taking a scoop out of the same storage unit that remained as seen earlier with the unknown contaminants and was again reminded of the earlier notification.
2. On April 2, 2024, at 11:28 AM, V12 was washing pots and pans in the 3 compartment sink. V12 was washing the dishes in the wash sink and rinsing the dishes off in the second sink under running water. Multiple soiled dishes were seen placed in the 3rd sink used for sanitizing. When asked why the 3rd sink with sanitizing solution was not used, V12 stated that the sanitizing sink does not hold water and does not work. V12 then proceeded to fill the 2nd rinse sink with sanitizing solution and put the washed dishes with soap suds and food particles into the sanitizer in the 2nd sink. V13 who was in the area stated that they were supposed to use the 3 sinks to wash, rinse and sanitize respectively.
3. On April 2, 2024, at 11:31 AM, the pureed meal prep of Teriyaki Chicken by V11 (Cook) was observed in the facility kitchen. V11 did not have a recipe in front of her during the pureed preparation. V11 stated that she is preparing for total 10 serving portions. V11 washed hands and put on new gloves and was seen going from one area of the kitchen to the other touching multiple surfaces with gloved hands while getting items ready. V11 pureed an unmeasured amount of cooked chicken and broth in a blender and added a tablespoon of thickener and pureed the mixture. V11 was seen dipping a gloved fingers into the blended product and stirred it and then test the product by rubbing it between her gloved forefinger and thumb. V11 then transferred the product into a container and stated that it is ready for service. V11 covered the pureed mixture with cling wrap and stated that she is going to place it directly on tray line. V11 was also seen touching multiple surfaces including a garbage can prior to applying a cling wrap over the container. When asked if she was going to reheat the pureed item, V11 stated that she is going to put it on the steam table for tray line service. V11 was notified that the pureed product was not safe to serve as she had touched multiple surfaces and touched the pureed mixture with the same gloves. On request, V11 presented the recipe that was placed in a binder.
Recipe for Chicken Teriyaki Pureed Thick included as follows:
1. Measure portions required from the regular prepared recipe.
4. Scrape down sides of food processor with a rubber spatula and process for 30 seconds.
Reheat to 165 degrees Fahrenheit.
CCP [Critical Control Point]: Final internal cooking temperature must reach minimum of 165 degrees Fahrenheit, held for a minimum of 15 seconds.
Facility diet order listing showed that R9, R34, R56, R96, R99, R104 and R277 were on pureed diet.
On April 3, 2024, at 12:26 PM and 1:00 PM, V20 (Vice President of Culinary) stated that the facility should follow the 3 steps of the 3 compartment sink: soak and rinse pots and pans in the wash sink, rinse off in the 2nd rinse sink and sanitize in the 3rd sink with sanitizer for 60 seconds. V20 added that the pureed food should be reheated to 165 degrees Fahrenheit as additional products like thickener and other additives are added to the mixture and the temperature of product tends to be lowered during pureeing process.
Facility Policy titled Sanitation and Infection Control included as follows:
Purpose: The purpose of this policy is to ensure that the culinary experience team members prepare, process, handle, package, transport, display, serve and store foods in a sanitary manner protected from contamination and spoilage; to ensure proper maintenance, disinfecting and sanitizing techniques are followed throughout the department: and to ensure all team members understand and follow infection prevention.
Facility Policy titled Dishwashing and Sanitation included as follows:
Purpose: To properly wash and sanitize is necessary to prevent food-borne diseases. Dishware, pots, pans, or utensils should be thoroughly cleaned and sanitized before use in food preparation or food serving to prevent the spread of food-borne diseases.
Mechanical Dishwashing:
2. Clean dishware and utensils should be kept separate from dirty dishware and utensils.
Manual Dishwashing:
3. Items should be pre-soaked (if necessary) and then scraped free of food debris before placing in wash sink.
5. Items should be washed thoroughly in clean water with detergent solution. Dirty water should be cleaned frequently.
6. Items should be rinsed thoroughly in clean water to remove any remaining food particles or detergent.
Jan 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 a physician-ordered negative pressure wound tr...
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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 physician-ordered negative pressure wound treatment system (wound vac) was placed for a resident with stage 4 pressure ulcers and failed to ensure a resident's stage 4 pressure ulcer was covered.
This applies to 2 of 3 residents (R1, R2) reviewed for pressure ulcers.
The findings include:
1.R1's Face Sheet showed she is a [AGE] year-old resident who was initially admitted to the facility on [DATE]. R1's progress notes showed she was sent to the hospital on 1/17/2024 to facilitate antibiotic treatment due to osteomyelitis and the lack of progressive healing of her wounds. R1's diagnoses include cerebral palsy, severe protein-calorie malnutrition, anorexia nervosa, pressure ulcer of sacral region stage 4, pressure ulcer of right buttock, stage 4 osteomyelitis, and adult failure to thrive. R1's 1/11/2024 Minimum Data Set (MDS) showed her cognition is moderately impaired.
R1's Resident Face Sheet showed she was re-admitted to the facility on [DATE].
R1's January 2024 Physician Order Report showed 1/21/2024 orders for wound vac placement with negative pressure of 125 continuously to her right buttock and sacrum, with special instructions of when seal is broken disconnect wound vac and apply a wet to moist dressing and cover with a dry dressing. The Report showed these orders were discontinued on 1/24/24 (during the survey), then restarted on 1/29/24.
On 1/23/2024 at 11:53 AM (two days after R1's re-admission), R1 was in bed. R1 had severe contractures to all her extremities and was unable to move herself. Her wound vac machine was on top of her nightstand, turned off, and not attached to her wounds. Two boxes of available wound vac supplies were on R1's floor.
On 1/24/2024 at 10:15 AM (three days after R1's re-admission), R1 was in bed and the wound vac machine was still turned off on her nightstand and still not in use. V5 (Registered Nurse/Wound Nurse from a sister facility) came to do the wound care. V5 removed a dressing that had been in place.
On 1/24/24 at 2:25 PM, V6 (Wound Physician) stated if the wound vac seal is broken, or the wound vac is not available, there are alternate orders. V6 stated the wound vac was ordered for controlling drainage and helping with wound granulation. V6 stated R1 should have the wound vac hooked up and functioning and should not be without it for more than two hours.
The negative pressure wound treatment system's undated Quick Reference Guide showed Indications for use- the [brand name] is indicated for use in patients who would benefit from negative pressure wound therapy as the device may promote wound healing by the removal of excess exudates, infectious material and tissue debris . The Guide further showed The [brand name] should remain on for the duration of the treatment. If the patient must be disconnected, the ends of the tubing should be protected using the tethered cap. The length of time a patent may be disconnected for the [brand name] is a clinical decision based on individual characteristics of the patient and the wound. Factors to consider include the location of the wound, the volume of drainage, the integrity of the dressing seal, the assessment of bacterial burden and the patient's risk of infection .
The facility's January 2017 Pressure/Skin Breakdown Clinical Protocol showed 7. The Physician will authorize pertinent orders related to wound treatments, including pressure redistribution surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents .
2. R2's Face Sheet showed R2 is a [AGE] year-old resident admitted to the facility on [DATE] and opted for hospice services on 1/18/24. R2's Face Sheet showed diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and pressure ulcer of sacral region, stage 4. R2's 11/24/23 MDS showed his cognition is severely impaired.
On 1/23/24 at 1:22PM, V2 DON (Director of Nursing) provided wound care for R2's sacral wound with the help of V3 CNA (Certified Nursing Assistant). When V2 opened R2's incontinent brief, no wound dressing was in place or was noted having fallen off in the brief. R2's wound bed was pale and without any granulation tissue.
On 1/23/24 at 1:30 PM, V3 stated when V3 changed him 30 minutes earlier there was no dressing in place. V3 stated she did not know how long R2 was without a wound dressing because she did not assist R2 out of bed that morning.
R2's January 2024 Physician Order Report showed a 1/17/2024 order for Site Sacrum: Cleanse area with [normal saline] pat dry, apply calcium alginate and cover with dry dressing daily and as needed. Once A Day 06:30 AM - 02:30 PM.
Jun 2023
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
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility to ensure residents received timely assistance with incontinenc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility to ensure residents received timely assistance with incontinence care. This applies to 4 of 4 residents (R1, R2, R3, R4) reviewed for incontinence in the sample of 4.
The findings include:
1. On June 6, 2023, at 9:39 AM, R1 was observed laying in bed in a fetal position. A urine odor was present in the room. Surveyor observed a blue line on R1's incontinence brief, indicating the brief was soiled/wet.
On June 6, 2023, at 10:09 AM, V4 (CNA-Certified Nursing Assistant) was observed walking in and out of R1's room without providing care to R1.
On June 6, 2023, at 10:34 AM, surveyor observed V4 walk into R1's room to provide incontinence care. V4 stated she started her shift at 6:30 AM. I did my resident rounds at 6:45 AM and changed [R1] at that time. I have not changed her incontinence brief since that time. She is a heavy wetter. The quilted pad underneath R1 had a dried, circular stain, yellow to brownish in color, approximately three feet in diameter under and around R1. A heavy urine odor was present as R1 was turned from side to side. V4 turned R1 to her side and removed her incontinence brief. The brief was soaked with urine, and a loud thud was heard as V4 dropped the soaked brief into the trash receptacle at R1's bedside. R1's buttocks appeared reddened, with three small open areas noted on R1's coccyx. V4 did not apply barrier cream to R1's buttocks and placed a new incontinence brief. V4 did not change the soiled quilted pad underneath R1 after applying a new incontinence brief. V4 covered R1 with a blanket and left the room.
The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. R1 has multiple diagnoses including, nontraumatic intracerebral hemorrhage, cellulitis of abdominal wall, aphasia, dysphagia, hemiplegia, and hemiparesis following cerebral infarction, difficulty walking, lack of coordination, weakness, presence of a cerebrospinal fluid drainage device, cerebral aneurysm, color cancer, and obstructive hydrocephalus.
R1's MDS (Minimum Data Set) dated February 20, 2023, shows R1 has independent cognitive skills for daily living, is totally dependent on facility staff for transfers between surfaces, toilet use, and bathing. R1 is always incontinent of bowel and bladder.
R1's care plan, initiated February 27, 2023, shows R1 experiences bladder and bowel incontinence related to decreased mobility, subarachnoid intracranial hemorrhage. The goal of R1's care plan is to not exhibit skin breakdown, UTI (Urinary Tract Infection), impaired social interaction, lowered self-esteem secondary to incontinence. A care plan intervention dated February 27, 2023, shows: Provide incontinence care after each incontinent episode.
2. On June 6, 2023, at 9:43 AM, R2 was observed sitting up in bed eating breakfast with the assistance of speech therapy. R2 stated her incontinence brief felt wet but could not remember when she was changed last.
On June 6, 2023, at 10:52 AM, R2 was observed sitting up in the wheelchair in the restroom, and V5 (CNA) was brushing her hair. V5 stated, I started at 6:30 AM. I am agency. I didn't even find out until 7:00 AM who I was assigned to. I did not change her brief from the time I started at 6:30 AM until 10:30 AM, when I got her out of bed and changed her sheets. Her wet brief is in the garbage can next to her bed. V5 showed the incontinence brief in the garbage can was wet with urine.
The EMR shows R2 was admitted to the facility on [DATE]. R2 has multiple diagnoses including, hemiplegia and hemiparesis following cerebral infarction, dysphagia, difficulty in walking, lack of coordination, urine retention, history of falling, dementia, and mood disturbance.
R2's MDS dated [DATE], shows R2 has severe cognitive impairment, requires extensive assistance with toilet use, and is always incontinent of bowel and bladder.
R2's care plan, initiated June 1, 2023, shows R2 is at risk for developing a UTI related to a diagnosis of retention of urine, recent placement of indwelling urinary catheter and its removal, requiring assistance with toileting needs and incontinence of both bladder and bowel. An intervention, initiated June 1, 2023, shows: Provide incontinence care after each incontinent episode and provide prompt incontinence care.
3. On June 6, 2023, at 9:47 AM, R3 was observed laying in bed. R3 had a large growth on the left side of her head, behind her left ear, approximately the size of a baseball. The growth was visibly draining red liquid onto R3's neck and chest. A large gauze dressing was sitting on R3's bed, with copious amounts of bloody drainage noted. An area of wetness, approximately one foot in diameter surrounded R3's head dressing that was lying on the bed. R3's incontinence brief was visibly wet.
On June 6, 2023, at 11:27 AM, V5 (CNA) stated R3 frequently removes her head dressing and puts it on the bed. The soiled head dressing remained on R3's bed, with the area of wetness underneath the dressing still visible. V5 provided incontinence care to R3. V5 stated, This is the first time I am doing incontinence care on R3 since I arrived at 6:30 AM. I told you I am agency. I just have not gotten to it yet. V5 removed R3's incontinence brief. V5 stated the incontinence brief was wet with urine. Surveyor observed V5 use a wet washcloth to clean R3's perineal area, stool was present on the washcloth.
The EMR shows R3 was admitted to the facility on [DATE]. R3 has multiple diagnoses including, cellulitis of the face, dysphagia, squamous cell carcinoma of the skin of the left external auricular canal, diabetes, enlarged lymph nodes, history of falling, cognitive communication deficit, and chronic kidney disease.
R3's MDS dated [DATE], shows R3 has severe cognitive impairment and requires extensive assistance by two facility staff members with toilet use. R3 is always incontinent of urine.
4. On June 6, 2023, at 12:47 PM, R4 was observed laying in bed with a foam wedge between her legs. R4 stated her incontinence brief was wet and the last time she received incontinence care was before her physical therapy session at 10:00 AM. R4 continued to say, I on June 4, 2023, I had a bowel movement in my brief, on two separate occasions that day. I sat in stool for more than three hours each time. I have a long incision from my hip surgery, and I am very worried I will get an infected incision if I sit in stool for that long. I asked the CNA to clean me up, and she said that she was only required to clean me up every two hours by State law. By the time she cleaned me up the sheets were soaked through. It was very upsetting. I saw her working here the next day and I was worried she would take care of me again, but thankfully she did not.
The facility's Resident Grievance/Complaint Form dated June 5, 2023, shows V6 (Daughter of R4) submitted the following grievance to the facility: Daughter voiced resident had full [incontinence brief] and asked to be toileted/changed. [V7] (CNA) states she only needs to change resident every 2 hours according to IDPH (Illinois Department of Public Health).
The EMR shows R4 was admitted to the facility on [DATE]. R4 has multiple diagnoses including, aftercare following joint replacement surgery, presence of bilateral artificial hip joint, abscess of left hip bursa, difficulty walking, lack of coordination, urinary incontinence, and acute osteomyelitis of the left femur.
R4's MDS dated [DATE], shows R4 is cognitively intact, requires extensive assistance with toilet use, and is always incontinent of bowel and bladder.
On June 6, 2023, at 1:09 PM, V2 (DON-Director of Nursing) stated, Residents should receive incontinence care every two hours unless they pull the call light sooner than two hours and request incontinence care.
Feb 2023
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide incontinence care and catheter care in a manner...
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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 incontinence care and catheter care in a manner that would prevent further infection and maintain hygiene.
This applies to 1 of 1 resident (R160) reviewed for incontinence care and urinary catheter care in the sample of 22.
The findings include:
R160 was admitted to the facility on [DATE]. R160 has multiple diagnoses which includes fracture of the right femur, parkinson's disease, and dementia without behavioral disturbance, based on the face sheet.
R160's admission MDS (minimum data set) dated January 16, 2023, showed that the resident is moderately impaired with cognition. The same MDS showed that the resident required extensive assistance with bed mobility, transfer, dressing and personal hygiene.
On January 30, 2023, at 11:23 AM, R160 was observed sleeping in bed. V12 (family) observed at the bedside. R160's privacy bag containing the urinary catheter drainage bag and part of the catheter tubing were observed lying on the floor. V12 stated that R160 was using the indwelling urinary catheter due to urinary retention. V12 added that he was informed by the Nurse Practitioner that R160 had a UTI (urinary tract infection) and was being treated with antibiotics.
R160's progress notes dated January 27, 2023 (1:38 PM) created by the NP (Nurse Practitioner) showed that the resident had urinary retention and UTI based on the bladder scan and urinalysis. The same progress notes showed that the nurse will insert an indwelling urinary catheter and will start R160 on antibiotic therapy.
R160's progress notes dated January 27, 2023 (3:38 PM) showed that an indwelling urinary catheter was inserted due to urine retention.
R160's active orders shows an order dated January 27, 2023, for Macrobid (Antibiotic) 100 mg, 1 capsule twice a day, until February 2, 2023.
On February 1, 2023, at 9:58 AM, R160 was observed in bed, alert, oriented and verbally responsive. R160 observed with an indwelling urinary catheter in place without an anchor device or leg strap. V22 (wound care nurse) was about to provide treatment to R160's pressure injuries. V22 turned R160 on her left side. R160 had a very small amount of stool. V22 was observed with gloved hands cleaning R160's anal and bilateral buttock areas and then proceeded to apply a new disposable brief. V22 proceeded to provide treatment to R160's sacral and right buttock areas and then turned the resident on her back and fastened the disposable brief. During the observation of incontinence care, V22 did not clean R160's front perineal area, including the urinary catheter insertion site and urinary catheter tubing. While R160 was being turned and repositioned during the incontinence care and wound treatment, pulling of the indwelling urinary catheter was observed.
R160's active care plan initiated by the facility on February 1, 2023, shows that the resident requires an indwelling urinary catheter related to urinary retention. The same care plan shows multiple approaches which includes, Provide catheter care daily and prn (as needed).
On February 1, 2023, at 11:04 AM, V22 (wound care nurse) acknowledged that she did not clean the front perineal area including the catheter insertion site and catheter tubing. V22 stated, I should have done hygiene to prevent potential infection.
On February 1, 2023, at 11:34 AM, V2 (Director of Nursing) stated that the privacy bag containing the drainage bag and tubing should not be placed on the floor to prevent potential infection and for infection control. V2 stated that during bowel incontinence care, the resident's perineal care which includes the front and back should be cleaned, as well as the catheter insertion site and the catheter tubing to maintain hygiene and to prevent potential infection. V2 added that a device to anchor the indwelling urinary catheter should be used to prevent pulling of the urinary catheter from the insertion site.
The facility's urinary catheter care policy and procedure dated September 2005 showed, The purpose of this procedure is to prevent infection of the resident's urinary tract. The policy and procedure showed in-part under general guidelines, 8. Provide perineal care to the incontinent resident to prevent skin rashes and breakdown, 11. Be sure that catheter tubing and drainage bag are kept off the floor and 15. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh). The same policy and procedure showed in-part under steps in the procedure, 7. Wash the resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry and 15. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward.
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 that a physician's order was obtained for a resident who was using oxygen.
This applies to 1 of 1 residents (R100) revie...
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Based on observation, interview and record review the facility failed to ensure that a physician's order was obtained for a resident who was using oxygen.
This applies to 1 of 1 residents (R100) reviewed for oxygen therapy in the sample of 22.
The findings include:
R100 has multiple diagnoses which includes pleural effusion, dependence on supplemental oxygen, hypoxemia, thrombocytopenia, and history of pneumothorax, based on the face sheet.
R100's admission MDS (minimum data set) dated December 11, 2022, shows that the resident is cognitively intact. The same MDS shows that R100 required extensive assistance from the staff with most of her ADL (activities of daily living).
On January 30, 2023, at 12:01 PM, R100 was in bed, alert, oriented and verbally responsive. R100 had shortness of breath and was observed breathing through her mouth. R100 verbalized that she was having a problem breathing. R100 observed with oxygen via nasal cannula ongoing at 4 liters/minute, using an oxygen concentrator. The oxygen tubing and humidifier were both dated January 29, 2023. According to R100, she uses her oxygen continuously for a very long time since admission at the facility. V4 (LPN/Licensed Practical Nurse) was informed of R100's shortness of breath. V4 checked R100's oxygen saturation and registered at 93% with the heart rate of 97.
R100's active physician orders as of January 30, 2023, showed no order for oxygen administration.
R100's progress notes dated January 30, 2023 (1:44 PM) created by V4 showed documentation that the resident was observed with shortness of breath during repositioning, was mouth breathing and was using abdominal muscles to breath at times while on oxygen via nasal cannula at 4 liters/minute. The same progress notes showed that R100's oxygen saturation was checked four times with results within normal limits and no discoloration to the nail beds was documented. Further review of R100's January 29 through 30, 2023 progress notes showed no evidence that the physician was informed of the resident's shortness of breath and the need to administer oxygen at 4 liters/minute.
R100's active care plan initiated on December 6, 2022, shows that the resident requires oxygen therapy to relieve hypoxia related to cirrhosis of liver with ascites. The same care plan shows multiple approaches which includes, Administer oxygen as ordered.
On February 1, 2023, at 12:07 PM, V2 (Director of Nursing) stated that she reviewed the order for R100. According to V2, I'm not seeing the order referring to the oxygen therapy. V2 added that if R100 has been using oxygen, it should be ordered.
On February 1, 2023, at 2:44 PM, V2 stated that she had checked the oxygen order for R100. According to V2, R100 used to have an order for oxygen but was discontinued because the resident was not using it. However, when R100 started using the oxygen, the staff did not get a new order from the Physician. V2 stated that she does not know when R100 started using the oxygen again, after it was discontinued because there was no documentation in the resident's records.
The facility's policy and procedure regarding oxygen administration dated March 2004 showed, The purpose of this procedure is to provide guidelines for safe oxygen administration. The same policy and procedure showed in-part under preparation, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of 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
Based on observation, interview and record review the facility failed to ensure that blister packs of prescribed controlled medications are maintained intact to ensure safe and effective use of contro...
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Based on observation, interview and record review the facility failed to ensure that blister packs of prescribed controlled medications are maintained intact to ensure safe and effective use of controlled medications.
This applies to 1 of 1 residents (R27) reviewed for controlled medications in the sample of 22.
The findings include:
On February 1, 2023, at 12:20 PM the medication cart review was performed with the nurse on duty, V19 (LPN). During the medication cart review it was noted that R27 had a blister pack of Tramadol HCL (hydrochloride) 50 mg (milligram), dispensed by the pharmacy on January 16, 2023, originally containing 30 tablets which were individually numbered on the package. It was noted on the Controlled Drug Receipt/Record/Disposition Form that no doses had been administered. However, the reverse side of the blister pack showed that dose #13 was punched and taped over with white bandage tape. V19 stated the package should not be taped closed after opening. V19 stated the dose should have been wasted by two nurses.
On February 1, 2023, at 12:35 PM, V3 (Assistant Director of Nursing) arrived on the unit, and observed the Tramadol HCL blister pack with the tape over the back of dose #13. V3 explained, No that should never happen .it should be wasted by two nurses.
The facility's policy, Controlled Substance Disposal (dated June 18, 2019) stated, When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It is destroyed in the presence of two licensed nurses, or pharmacist and nurse, and the disposal is documented on the accountability record/book on the line representing that dose.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete and submit MDS (minimum data set) assessments within the r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete and submit MDS (minimum data set) assessments within the required timeframe.
This applies to 7 of 7 residents (R34, R47, R49, R56, R61, R67 and R73) reviewed for completion and submission of Resident Assessments in a sample of 22.
The findings include:
1. R34's electronic record for the MDS 3.0 Resident Assessments showed under status, Production accepted with warning for the resident's quarterly MDS dated [DATE]. This quarterly MDS had the ARD (assessment reference data) of November 30, 2022, and the assessment completion date was January 30, 2023.
On February 1, 2023, at 11:25 AM, V11 (Regional Operations Consultant) presented documentation and verbally verified that based on the MDS report, R34's quarterly MDS dated [DATE], had the warning indicating that the assessment was submitted late.
Review of the MDS report provided by V11 showed that the November 30, 2022, quarterly assessment was submitted by the facility on January 30, 2023. The report showed, Warning Assessment Completed late: (assessment completion date) is more than 14 days after (assessment reference date).
2. R47's electronic record for the MDS 3.0 Resident Assessments showed under status, Production accepted with warning for the resident's quarterly MDS dated [DATE]. This quarterly MDS had the ARD of December 20, 2022, and the assessment completion date was January 30, 2023.
On January 31, 2023, at 4:00 PM, V11 presented documentation and verbally verified that based on the MDS report, R47's quarterly MDS dated [DATE] had the warning indicating that the assessment was submitted late.
Review of the MDS report provided by V11 showed that the December 20, 2022, quarterly assessment was submitted by the facility on January 30, 2023. The report showed, Warning Assessment Completed late: (assessment completion date) is more than 14 days after (assessment reference date).
3. R49's electronic record for the MDS 3.0 Resident Assessments showed under status, Production accepted with warning for the resident's quarterly MDS dated [DATE]. This quarterly MDS had the ARD of September 19, 2022, and the assessment completion date was October 10, 2022.
On January 31, 2023, at 2:14 PM, V11 presented documentation and verbally verified that based on the MDS report, R49's quarterly MDS dated [DATE] had the warning indicating that the assessment was submitted late.
Review of the MDS report provided by V11 showed that the September 19, 2022, quarterly assessment was submitted by the facility on October 10, 2022. The report showed, Warning Assessment Completed late: (assessment completion date) is more than 14 days after (assessment reference date).
4. R56's electronic record for the MDS 3.0 Resident Assessments showed under status, Production accepted with warning for the resident's quarterly MDS dated [DATE]. This quarterly MDS had the ARD of December 7, 2022, and the assessment completion date was January 27, 2023.
On January 31, 2023, at 2:13 PM, V11 presented documentation and verbally verified that based on the MDS report, R56's quarterly MDS dated [DATE], had the warning indicating that the assessment was submitted late.
Review of the MDS report provided by V11 showed that the December 7, 2022, quarterly assessment was submitted by the facility on January 27, 2023. The report showed, Warning Assessment Completed late: (assessment completion date) is more than 14 days after (assessment reference date).
5. R61's electronic record for the MDS 3.0 Resident Assessments showed under status, Production accepted with warning for the resident's annual MDS dated [DATE]. This annual MDS had the ARD of December 7, 2022, and the assessment completion date was January 26, 2023.
On January 31, 2023, at 2:11 PM, V11 presented documentation and had verbally verified that based on the MDS report, R61's annual MDS dated [DATE], had the warning indicating that the assessment was submitted late.
Review of the MDS report provided by V11 showed that the December 7, 2022, annual assessment was submitted by the facility on January 26, 2023. The report showed, Warning Assessment Completed late: (assessment completion date) is more than 14 days after (assessment reference date).
6. R67's electronic record for the MDS 3.0 Resident Assessments showed under status, Production accepted with warning for the resident's quarterly MDS dated [DATE]. This quarterly MDS had the ARD of September 15, 2022, and the assessment completion dated was September 30, 2022.
R67's electronic record for the MDS 3.0 Resident Assessments showed under status, Production accepted with warning for the resident's quarterly MDS dated [DATE]. This quarterly MDS had the ARD of December 12, 2022, and the assessment completion date was January 28, 2023.
On January 31, 2023, at 2:12 PM, V11 presented documentation and verbally verified that based on the MDS report, R67's quarterly MDS dated [DATE], and December 12, 2022, had the warnings indicating that the assessments were submitted late.
Review of the MDS report provided by V11 showed that the September 15, 2022, quarterly assessment was submitted by the facility on September 30, 2022. The report showed, Warning Assessment Completed late: (assessment completion date) is more than 14 days after (assessment reference date). Further review of the MDS report provided by V11 showed that the December 12, 2022, quarterly assessment was submitted by the facility on January 28, 2023. The report showed, Warning Assessment Completed late: (assessment completion date) is more than 14 days after (assessment reference date).
7. R73's electronic record for the MDS 3.0 Resident Assessments showed under status, Production accepted with warning for the resident's admission MDS dated [DATE]. This admission MDS showed that R73 was admitted to the facility on [DATE], with the ARD of January 18, 2023, and the assessment completion date was February 1, 2023.
On February 1, 2023, at 12:40 PM, V11 presented documentation and had verbally verified that based on the MDS report, R73's admission MDS dated [DATE], had the warning indicating that the assessment was submitted late.
Review of the MDS report provided by V11 showed that the January 18, 2023, admission assessment was submitted by the facility on February 1, 2023. The report showed, Warning Assessment Completed late: For this admission assessment, (completion date) is more than 13 days.
On February 1, 2023, at 8:39 AM, V2 (Director of Nursing) stated that she is the nurse that signs all the MDS's for completion at the facility. V2 stated that she expects the MDS completion and submission of all required MDS to be within 14 days from the assessment reference date. V2 was asked about the late completion and submission of the above residents. V2 had no response.
The CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual dated October 2019 showed in-part, under timeliness criteria, Long-term care facilities participating in the Medicare and Medicaid programs must meet the following conditions: Completion timing - For all non-admission OBRA (Omnibus Budget Reconciliation Act) and PPS (Prospective Payment System) assessments, The MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD), For the admission assessment, the MDS completion date must be no later than 13 days after the entry date. The same RAI 3.0 Manual showed under assessment transmission, Comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date. All other MDS assessments must be submitted within 14 days of the MDS completion day.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. On 1/30/23 at 2:51 PM, R64 was in bed, reaching and unable to reach the bedside table on which was a water cup. R64 was obser...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. On 1/30/23 at 2:51 PM, R64 was in bed, reaching and unable to reach the bedside table on which was a water cup. R64 was observed disheveled with matted wild hair, teeth caked with food material and flaky material gather about the eyes. R64 was wearing a hospital gown. R64 said, I want water. I can't reach it.
According to R64's facility medical record, R64 was on contact isolation precautions in the room since returning from the hospital on [DATE]. For this reason, staff must don personal protective equipment before entering the room. The same facility records show R64 to have a brain tumor.
According to R64's most recent comprehensive assessment, dated 1/3/23, R64 needs assistance for personal hygiene including tooth brushing, and is unable to participate in bathing, fully dependent on assistance for bathing. The same assessment shows R64 does not resist care.
On 1/30/23, at 2:55 PM, V2 (Director of Nurses) entered R64's room and became very still. V2 stated, We will get her cleaned up right away.
Based on observation, interview, and record review the facility failed to assist residents identified as needing assistance with oral and personal hygiene.
This applies to 6 of 6 residents (R50, R64, R96, R106, R162 and R163) reviewed for ADL (activities of daily living) in the sample of 22.
The findings include:
1. R106 has multiple diagnoses which includes displaced intertrochanteric fracture of the left femur, lack of coordination, weakness, and glaucoma, based on the face sheet.
R106's admission MDS (minimum data set) dated December 18, 2022, shows that the resident is cognitively intact. The same MDS shows that R106 required total assistance from the staff with regards to personal hygiene.
On January 30, 2023, at 11:06 AM, R106 was sitting in her bed. R106 was alert and verbally responsive. R106 observed with accumulation of long curling chin hair. R106 stated that she wanted the staff to remove her chin hair. V2 (Director of Nursing) was made aware of R106's facial hair and the resident's request to have it removed.
R106's active care plan initiated on December 12, 2022, shows that the resident is at risk for deterioration in ADLs related to left femur fracture, impaired mobility and weakness. The same care plan shows multiple approaches which includes, Provide assistance for ADLs.
2. R162 has multiple diagnoses which includes fracture of the right shaft of the humerus, nondisplaced fracture of the right radius, right elbow effusion, weakness, and lack of coordination, based on the face sheet.
R162's admission MDS dated [DATE], shows that the resident is cognitively intact. The same MDS shows that R162 required extensive assistance from the staff with regards to personal hygiene.
On January 30, 2023, at 12:10 PM, R162 was in bed, alert, oriented and verbally responsive. R162 was observed with a hard cast on her right arm. R162 was observed with long and jagged fingernails. R162 stated that she had asked the staff to trim her fingernails, about a week ago but was told that they do not have any nail clippers. R162 stated she wanted to have her fingernails trimmed. R162 stated, it bothers me that it is too long, but they do not have any nail clippers. V4 (LPN/Licensed Practical Nurse) was made aware of R162's fingernails and the resident's request for it to be trimmed.
R162's active care plan initiated on January 20, 2023, shows that the resident is at risk for deterioration in ADLs related to humerus fracture and impaired mobility. The same care plan shows multiple approaches which includes, Provide assistance for ADLs.
3. R163 has multiple diagnoses which includes dementia without behavioral disturbance, lack of coordination and weakness, based on the face sheet.
R163's admission MDS dated [DATE], shows that the resident is severely impaired with cognition. The same MDS shows that R163's personal hygiene activity occurred only once or twice with one staff physical assistance.
On January 30, 2023, at 11:00 AM, R163 was observed in bed, alert and verbally responsive. R163 was observed with accumulation of facial hair on her chin. R163 stated, I am embarrassed. I hope they can shave it for me. V2 (Director of Nursing) was made aware of R163's facial hair and the resident's request to be shaven.
R163's active care plan initiated on January 26, 2023, shows that the resident is at risk for deterioration in ADLs related to weakness and decreased endurance. The same care plan shows multiple approaches which includes, Provide assistance for ADLs.
4. R50 has multiple diagnoses which includes closed fracture of the right femur, type 2 diabetes mellitus, rheumatoid arthritis, lack of coordination and weakness, based on the face sheet.
R50's admission MDS dated [DATE], shows that the resident is cognitively intact. The same MDS shows that R50's personal hygiene activity occurred only once or twice with one staff physical assistance.
On January 30, 2023, at 11:38 AM, R50 was observed in bed, alert and verbally responsive. R50 was observed with an accumulation of long, curling facial hair on her chin and on the side of her lips. R50 stated that she wanted the staff to remove her facial hair. V5 (CNA/Certified Nursing Assistance) was made aware of R50's request to have her facial hair removed.
R50's active care plan initiated on November 29, 2023, shows that the resident is at risk for deterioration in ADLs related to right femur fracture, arthritis and impaired mobility. The same care plan shows multiple approaches which includes, Provide assistance for ADLs.
5. R96 has multiple diagnoses which includes, intertrochanteric fracture of the left femur, ORIF (open reduction interval fixation), weakness, and hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, based on the face sheet.
R96's significant change in status MDS dated [DATE], shows that the resident is moderately impaired with cognition. The same MDS shows that R96 required extensive assistance from the staff with regards to personal hygiene.
On January 30, 2023, at 11:50 AM, R96 was sitting in his bed, alert and verbally responsive. R96 was observed with an accumulation of long facial hair. R96 stated that he wanted to be shaved. V4 (LPN) was made aware of R96's facial hair and the resident's request to be shaved.
R96's active care plan initiated on November 12, 2023, shows that the resident is at risk for deterioration in ADLs related to left femur fracture, impaired mobility and weakness. The same care plan shows multiple approaches which includes, Provide assistance for ADLs.
On February 1, 2023, at 8:42 AM, V2 (Director of Nursing) stated that it is part of the nursing care and service to remove resident's unwanted facial hair and to clean and trim their fingernails. V2 stated that she expects the nursing staff to shave resident's unwanted facial hair especially for females and to trim and clean fingernails for proper hygiene.
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 follow menu spreadsheet to serve the portions as shown for all consistency diets.
This applies to 13 of 13 residents (R1, R6,...
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Based on observation, interview, and record review, the facility failed to follow menu spreadsheet to serve the portions as shown for all consistency diets.
This applies to 13 of 13 residents (R1, R6, R12, R21, R34, R60, R73, R91, R92, R94, R96, R360, R361) observed for meal service in the sample of 22.
The findings include:
On January 30, 2023, at 12:30 PM, the lunch meal service was observed in the facility kitchen. The Week at a Glance main menu for the lunch meal for 1/30/23 included Tasty Meat Sauce, Rotini Pasta, Roasted Broccoli, Tropical Fruit Mix.
V8 (Dietary Manager) stated that the meat sauce and pasta were prepared mixed together and will be served as such. V8 added that for the pureed meal, mashed potatoes were substituted for rotini pasta and tomato puree substituted for roasted broccoli as the broccoli was used up over the weekend.
V9 (Cook) was seen plating the food from the steam table. V9 did not have a menu spread sheet in the area. The pasta and meat sauce mixture were served using a 4 oz ladle for the residents on regular and mechanical soft diets. On the tray line, R1, R6, R12, R21, R73, R91, R94, R96, R360 and R361 meal trays were observed to receive one 4 oz scoop of the meat and pasta mixture.
For the pureed diets, V9 used a #12 scoop to serve each item of pureed meat, mashed potato and pureed tomato respectively and R34, R60 and R92 meal trays were observed to receive the same. V9 stated that #12 scoop is equivalent to 4 ounces.
The daily spreadsheet (Week 3 Monday) showed that the regular and mechanical soft consistency diets will be served a 4 oz/ounce ladle = 2 oz/ounce protein of Tasty Meat Sauce with 3/4th cup of Rotini Pasta. The same spreadsheet showed that the pureed diets will be served #8 scoop of pureed meat sauce, # 6 scoop of pureed Rotini pasta, and # 8 scoop of roasted broccoli.
Facility Scoop Equivalent size chart that was near the tray line station showed that #6=6 oz, #8=4 oz, #12=2-1/2 oz.
This showed that the above residents on regular and mechanical soft diets received only 4 oz of meat sauce pasta mixture when they should have received 4 oz of meat sauce and 3/4th cup of pasta. It also showed that the above residents on pureed diets received only 2-1/2 oz each of meat, mashed potato and tomato pureed instead of 4 oz of pureed meat sauce and tomato respectively and 6 oz of mashed potato.
On January 30, 2023, at 12:42 PM, V8, who was standing in the area, was asked why V9 used different scoop sizes instead of as shown on the spread sheet. V8 responded that V9 is new and has been in training only for 2 weeks and is not familiar with the spread sheets yet.
On February 1, 2023, at 1:49 PM, V10 (Dietitian) stated that the facility should be having the menu spreadsheet in front of them before starting tray line service to verify the scoop sizes to be used and the menu spreadsheet should be followed.
Facility Diet Order listing report showed that R1, R6, R73, R91, R94, R360, R361 were on regular consistency diets, R12, R21, R96 were on mechanical soft diets and R34, R60 and R92 were on pureed diets.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to prepare pureed pineapples according to recipe to conserve nutritive content.
This applies to 10 of 10 residents (R20, R26, R...
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Based on observation, interview, and record review, the facility failed to prepare pureed pineapples according to recipe to conserve nutritive content.
This applies to 10 of 10 residents (R20, R26, R28, R34, R46, R47, R56, R60, R80, R92) reviewed for pureed diets in the sample of 22.
The findings include:
Facility Diet Order listing report showed that R20, R26, R28, R34, R46, R47, R56, R60, R80, and R92 were on pureed consistency diets.
On January 31, 2023, at 10:25 AM, V9 (Cook) was observed preparing pineapple tidbits in a blender in the facility kitchen. V9 was not following a recipe and had already started the process when observed. V9 was seen adding several spoonful's of thickener (about 1/4 cup) from a plastic bin into a pureed pineapple mixture in the mixer that appeared watery in consistency. V9 ran the motor several more times in the blender and then opened it and added the rest of the thickener (about 3-4 spoonful's) from the container into the pureed mixture and stirred it. V9 then stated that he needs more thickener and was seen going into the storeroom to refill the container. V9 came back again and added several spoonful's (about 1/4 cup) of thickener into the pureed mixture and ran the blender motor again. When V9 opened the blender, the mixture resembled a thick pudding. When V9 was asked why he added so much thickener, V9 responded that he had initially added the fruit with the juice into the blender and he added more thickener in order to attain the texture for pureed.
V8 (Dietary Manager) who was in the vicinity in her office was asked to see the recipe for the pureed Pineapple. The recipe titled Pureed Pineapple was found in a binder and showed the following directions:
1) Drain fruit.
2) Measure to determine 1/2 cup portions.
3) Puree fruit in the food processor.
4) Add recommended amount of Instant Thickener per serving.
5) Reprocess for 20-30 seconds. Use scoop size per recipe to provide one serving of fruit.
* Thickener amounts are recommended based on Instant Food Thickener.
The same recipe guidance listed multiple fruit options with the amount of thickener to use for each fruit option based on serving size of fruit used. The recipe did not include pineapple in the list of fruits for amount of thickener to be used per serving. V8 was notified that the pureed pineapple was altered in nutrition with addition of thickener when the recipe did not show the same. V8 stated that she will redo the puree pineapple by following the recipe.
On February 1, 2023, at 9:56 AM, V8 stated that when she re-did the pureed pineapple by following the recipe, it did not require thickener to attain the desired consistency. V8 also stated that during the above-mentioned pureed preparation, V9 had used one ten ounce can of pineapple with the juice and that she used the same amount of pineapple without the juice.
On February 1, 2023, at 1:45 PM, V10 (Dietitian) stated that the facility should be following the recipes during meal preparation for all pureed items which would indicate whether or not to use thickener. V10 stated that the pureed pineapple should resemble apple sauce. V10 stated that she had seen the above initial pureed product made with the thickener while at the facility and it looked more like a pudding.
Facility Policy and Procedure titled Food Preparation included the following:
Policy: Food will be prepared by methods that conserve nutritive value, flavor and appearance.
Procedure: 1. Menus and recipes will be followed when preparing foods.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to prepare pureed pineapple in a sanitary manner.
This applies to 10 of 10 residents (R20, R26, R28, R34, R46, R47, R56, R60, R8...
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Based on observation, interview and record review, the facility failed to prepare pureed pineapple in a sanitary manner.
This applies to 10 of 10 residents (R20, R26, R28, R34, R46, R47, R56, R60, R80, R92) reviewed for pureed diets in the sample of 22.
The findings include:
Facility Diet Order listing report showed that R20, R26, R28, R34, R46, R47, R56, R60, R80, and R92 were on pureed consistency diets.
On January 31, 2023, at 10:25 AM, V9 (Cook) was observed preparing pineapple tidbits in a blender in the facility kitchen. The workstation where the blender was stationed had extensive spills and miscellaneous food particles and debris. V9 was observed wearing gloves and was seen touching the soiled workstation and then opening the blender lid and placing the lid on top of a free-standing cart close by, that was also covered with spills and food particles including cooked chicken pieces and other debris. V9 then used a spatula to stir the pureed pineapple tidbits and placed the spatula on the same free-standing cart with the end part of it slightly elevated on the handle of the cart. The handle of the cart also appeared covered with grayish colored stains from dried spills. V9 kept repeating the process of opening lid, placing it on cart, stirring the pureed mixture with the spatula and keeping it back on the cart while adding more and more thickener to the pureed mixture in between blending the same.
V8 (Dietary Manager) who was in the vicinity in her office was notified about the soiled work area and V8 instructed V9 to clean the area. V9, wearing the same gloves, then brought a clean container and placed it atop the soiled area of the workstation and poured the pureed pineapple into the pan and stated that it was ready for service. V9 took the used blender to the dish machine area and wearing the same gloves, brought back a bucket of soapy water and another bucket of sanitizer and wiped off the workstation areas. Then without changing his gloves, V9 brought back the newly washed blender that still had pureed pineapple inside the lid and stated that he was going to puree the diced chicken. V8 and V9 were notified that the pureed pineapple was not safe to serve due to the above related unsanitary pureed preparation and that the blender was not clean/sanitary to puree the diced chicken.
On February 1, 2023, at 1:48 PM, V10 (Dietitian) stated that the food prep area should be cleaned and sanitized before food preparation.
Facility Policy and Procedure titled Safe Food Preparation included as follows:
Policy: Food will be prepared using safe food preparation techniques.
Purpose: To prevent food borne illness.
Procedure: 7. Prepare foods on surfaces that have been cleaned, rinsed, and sanitized.
Facility Purpose and Procedure titled Disposable Gloves included as follows:
Purpose: To provide a measure of protection in preventing food borne illness.
Procedure: 4. Change gloves when they have become soiled, torn or the task is changed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide residents with immunizations for pneumococcal pneumonia.
Th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide residents with immunizations for pneumococcal pneumonia.
This applies to 4 of 5 residents (R10, R17, R23, and R68) reviewed for pneumococcal vaccinations in a sample of 22.
The findings include:
1. The EMR (Electronic Medical Record) showed R10 was a [AGE] year-old resident admitted to the facility on [DATE], with the multiple diagnoses including COVID-19, chronic congestive heart failure, type 2 diabetes mellitus, and dementia.
The facility document titled INFORMED CONSENT FOR VACCINATIONS revised July 2012, showed R10's POA (Power of Attorney) consented for R10 to receive the pneumococcal vaccine.
On January 31, 2023, at 4:42 PM, V2 (DON/Director of Nursing) said R10 should have received the pneumococcal vaccine before today. V2 continued to say the reason R10 did not receive the pneumococcal vaccine was not because of an inability of the facility to obtain the vaccine, R10 should have received the pneumococcal vaccine by now.
As of January 31, 2023, at 11:33 AM, the facility did not have documentation to show R10 had received a pneumococcal vaccine.
2. The EMR showed R17 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including COVID-19, dementia, type 2 diabetes mellitus with diabetic chronic kidney disease, heart disease, and dementia.
As of February 1, 2023, at 7:21 AM, the facility did not have documentation to show R17 had received a pneumococcal vaccine.
On February 1, 2023, at 10:42 AM, V2 stated R17 just became eligible for another pneumococcal vaccine because it had been five years since her last pneumococcal vaccine.
3. The EMR showed R23 was an [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including hypertension, malignant neoplasm (cancer) of the right breast, and dementia.
Facility documentation showed R23 received the PCV13 (13-valent Pneumococcal Conjugate Vaccine) pneumococcal vaccine on October 11, 2017.
On February 1, 2023, at 1:41 PM, V17 (Regional Nurse Consultant) said the facility follows CDC (Center for Disease Control and Prevention) guidelines for pneumococcal vaccination schedules.
The Facility does not have documentation to show R23 was offered an additional pneumococcal vaccine per CDC (Centers for Disease Control and Prevention) guidelines. Furthermore, there was no documentation to show that R23 or R23's representative/POA was offered information/education regarding the need for an additional pneumococcal vaccine for R23 per CDC guidelines
4. The EMR showed R68 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including hypertension, seizures, and dementia.
Facility documentation showed R68 received the PPSV23 (23-valent Pneumococcal Polysaccharide Vaccine) on October 17, 2018.
The facility does not have documentation to show R68 was offered another pneumococcal vaccine for R68. Furthermore, there was no documentation to show that R68 or R68's representative/POA was offered information/education regarding the need for an additional pneumococcal vaccine for R68 per CDC guidelines
On February 1, 2023, at 3:12 PM, V2 said R68 was not due for another pneumococcal vaccine because it has not been five years since her previous pneumococcal vaccine.
The Pneumococcal Vaccine Timing for Adults on the cdc.gov website, dated April 1, 2022, showed CDC recommends pneumococcal vaccination for adults [AGE] years old and older.
For those who previously received PPSV23 but who have not received any pneumococcal conjugate vaccine, you may administer one dose of PCV15 (15-valent Pneumococcal conjugate vaccine) or PCV20 (20-valent Pneumococcal Conjugate Vaccine). Regardless of which vaccine is used (PCV15 or PCV20): the minimum interval is at least one year.
Pneumococcal vaccine timing for adults who previously received PCV13: CDC recommends one dose of PPSV23 at age [AGE] years or older. Administer a single dose of PPSV23 at least one year after PCV13 was received.
Jan 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure there was accurate and complete documentation in a resident'...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure there was accurate and complete documentation in a resident's medical record.
This applies to 1 out of 3 residents (R1) reviewed for accurate documentation in the sample of 5.
The findings include:
R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease, weakness, atrial fibrillation, obstructive sleep apnea, and localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus.
R1's MDS (Minimum Data Set) dated December 22, 2022, showed R1 was cognitively intact. R1 required one staff's limited assistance for transfers and toilet use.
On January 24, 2023 at 9:20 AM, V4 (R1's family member) stated on January 8, 2023 at approximately 8:30 AM, V8 (Registered Nurse, RN) called and reported when V6 (Certified Nursing Assistant, CNA) was making rounds to get people dressed and up for breakfast, she found [R1] in bed with a gray/purple eye, a bandage on his lip, marks on his chest and that [R1] was not talking, V8 stated to V4 she called the physician, 911, and then she called her (V4) to let her know what was going on. V8 also stated [R1] was lethargic/confused and could not tell what happened.
On January 23, 2023, at 10:00 AM, review of R1's progress notes showed there was no incident note documented by V7 (Nurse) on January 7th or 8th regarding a fall and/or above-mentioned injuries. V1 (Administrator) provided an Event Report documented by V8 on January 8, 2023, at 8:32 AM. On the same Event Report on January 19, 2023, at 10:50 AM, V2 (DON) did some documentation but it could not be determined what was added on January 19, 2023.
On January 24, 2023, at 11:48 AM, V6 (Certified Nursing Assistant, CNA) stated, On the morning [R1] went to the hospital, I went into [R1's] room to get him dressed and ready for breakfast. When I was able to see his face, there was a bandage on his upper lip and a bump above his left eyebrow. I did not see any bruising on his chest, his hands or arms. I called for [V8], she came right away and assessed [R1], took his vital signs, called 911, and then called for [V2].
On January 24, 2023, at 2:20 PM, V8 (RN) stated she worked day shift on January 7 and January 8, 2023, and was assigned to [R1] both days. V8 stated On January 8th, I got report from V7 (RN), but she never mentioned that [R1] had a fall or any other incident. At approximately 7:45 AM, [V6] called out for me and stated [R1] does not look right, I went to the room and right away I noticed a dusky bluish-gray bruise to the left side of his face above and below his eye. I did my assessment right away and [R1] could not tell me where he was, what happened, he didn't even know how he got into bed. He was totally different than the day before. I also noticed he had a bandage over his bottom left side of his lip. I did not remove because I was not sure what was under there. Sometime later that morning, [V4, R1's family member] returned to the facility upset and wanted to know what happened. All I could tell her was that nothing was reported to me that morning by the night shift nurse and there was no documentation in [R1's] chart.
On January 24, 2023, at 12:48 PM, V7 (RN) reported she worked on January 7, 2023, night shift into the morning of January 8, 2023. V7 reported she was in another resident room when V15 (CNA) came to her and reported she had taken R1 to the bathroom and he slid off the toilet. V7 reported it was her mistake that she forgot to document it at the time, but she did a late entry. V7 wasn't sure when she wrote her late entry, but when she did, she reported she gave it to V2 (Director of Nursing/DON).
On January 26, 2023, at 10:57 AM, V1 (Administrator) provided a copy of V7's handwritten progress note. The note was dated by V7 as January 7, 2023, at 2:15 AM, which showed, CNA came to get me, resident on the floor, when I arrived in bathroom, middle of top lip was bleeding. I asked resident what happened, and he said he bit his lip. I cleaned lip, put a bandage on top of his lip. I assisted resident back to bed. No other signs of injury? Checked on resident periodically, resting quietly in bed, responds to verbal commands. V2 (DON) wrote on the bottom of V7's progress note late entry for 1/7 documented 1/9. Late entry was scanned into the computer on January 11, 2023.
R1's progress note dated January 9, 2023, at 10:45 AM was entered as a late entry on January 19, 2023, at 10:49 AM by V2 (DON). The progress note showed Spoke with nurse on duty on January 7, 2023, regarding resident event .
On January 25, 2023, at 10:07 AM, V2 (DON) stated, on Sunday (January 8th), the day shift nurse either called or text me to let me know [R1] was lethargic/slow to respond, he looked like he had had a fall and was going to the hospital. I called [V7] the night shift nurse and [V15] CNA who were working the night of January 7 into the morning of January 8 and left messages for them to call me back. When I spoke to V7, she indicated she did the initial assessment to make sure he was ok before he was moved off the floor, but she did forget to document the incident. V7 should have documented all her assessments. She was asked to write late entry which she did on January 9. It was handwritten and was scanned into the computer under resident documents.
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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to investigate an allegation of physical abuse by a resident, and subsequently failed to report it to the Illinois Department of Public Health...
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Based on interview and record review, the facility failed to investigate an allegation of physical abuse by a resident, and subsequently failed to report it to the Illinois Department of Public Health (IDPH) within the required time frame.
This applies to 1 of 3 residents (R1) reviewed for abuse in a sample of 3.
Findings include:
R1's Face Sheet showed his diagnoses include aphasia following other non-traumatic intracranial hemorrhage, slurred speech, and vascular dementia.
R1's 12/13/2019 care plan indicated R1 is at risk for physical abuse/neglect due to residing at a long-term care nursing facility. R1's care plan does not address any behavior issues.
On 11/17/22 at 1:03 PM, V6 (Case Manager) stated that when she visited the facility on 11/9/2022, R1 had told her a young male hit his head with a closed fist. V6 stated she reported the allegation to the floor nurse V3 LPN (Licensed Practical Nurse) around 12:30PM. V6 stated R1 told her the incident happened the previous Friday (11/4/2022). V6 stated R1 did not tell her what time or where this happened.
On 11/16/22 at 11:43 AM, V3 stated V6 was from the insurance company and that V6 reported R1's allegation to her. V3 stated that on 11/9/2022 before change of shift, [R1] had made an allegation he was hit by a staff member. V3 stated she called V2 DON (Director of Nursing) and reported R1's allegation. V3 stated she could not remember if a male CNA had worked on 11/4/2022 or not, and all I know is that [R1] was claiming he was hit by a CNA at night. V3 stated V2 called the Administrator.
On 11/16/22 at 9:29 AM, R1 stated a young guy hit the left temple part of his head (R1 pointed his hand towards the left side) with the employee's fist and said the man yelled at R1. R1 could not provide a specific date but stated that this happened about two weeks ago. R1 described the staff member as a young, average height, black male. R1 stated he asked a CNA who he could complain to, and nothing happened.
On 11/16/22 At 12:22 PM V2, DON (Director of Nursing) stated that V3 (LPN) told her that the resident bumped his head and that was what she relayed to the Administrator. V2 stated she was not told that R1 was hit, but that today he claimed he was hit, and he described the person that hit him as a black man with shoulder length hair.
On 11/16/22 at 1:10 PM, V1 (Administrator) stated on 11/9/22, R1 had claimed he bumped his head. V1 stated there were no specifics None that were specified to me . no time . no date. V1 stated the allegation was not investigated or reported to IDPH. V1 stated if there is an allegation brought to him, an investigation is initiated, and the initial report is sent to IDPH within two hours. V1 described the investigation process and stated a final report is sent out within five days after the initial is sent to IDPH. V1 further stated that if a resident bumped their head, it should have been documented.
On 11/16/22 at 1:22 PM, V4 RN (Registered Nurse) was interviewed and stated if someone complains they bumped their head, you must assess the resident and notify the medical doctor (MD.) V4 stated that the incident is documented in the progress note and the resident's Power of Attorney is also notified.
R1's progress notes showed the only note for 11/9/2022 was written by V5 (Social Service Assistant) regarding a well-being check. V5's note did not include any information about R1 bumping his head or any notifications to R1's Physician or Power of Attorney.
Under Section V. Internal Reporting Requirements and Identification of Allegations in the facility's October 24, 2022 Abuse Prevention Policy, it showed Employees are required to report any incident, allegation or suspicion or potential abuse they observe, hear about, or suspect, to the Administrator immediately, to an immediate supervisor immediately who must then immediately report to the Administrator .
Under VII. Internal Investigation in the Policy, it showed 2. Any incident or allegation involving abuse .will result in an investigation .
Section VIII. External Reporting showed Initial Reporting of Allegations. When an allegation of abuse has been made, the Administrator .shall notify Department of Public Health's regional office immediately .that an occurrence of potential abuse .has been reported .and is being investigated .
The facility's Initial Report of R1's Reportable Event was sent to the IDPH Regional Office on 11/16/2022 and listed R1 alleged that a staff member provided care that is not consistent with facility standards as the concern.
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
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Illinois facilities.
Concerns
- • 42 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade D (40/100). Below average facility with significant concerns.
- • 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 40/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Lemont Nursing & Rehab Center's CMS Rating?
CMS assigns LEMONT NURSING & REHAB CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Illinois, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Lemont Nursing & Rehab Center Staffed?
CMS rates LEMONT NURSING & REHAB CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 60%, which is 14 percentage points above the Illinois average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 84%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Lemont Nursing & Rehab Center?
State health inspectors documented 42 deficiencies at LEMONT NURSING & REHAB CENTER during 2022 to 2025. These included: 1 that caused actual resident harm and 41 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Lemont Nursing & Rehab Center?
LEMONT NURSING & REHAB CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by EXTENDED CARE CLINICAL, a chain that manages multiple nursing homes. With 173 certified beds and approximately 127 residents (about 73% occupancy), it is a mid-sized facility located in LEMONT, Illinois.
How Does Lemont Nursing & Rehab Center Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, LEMONT NURSING & REHAB CENTER's overall rating (2 stars) is below the state average of 2.5, staff turnover (60%) is significantly higher than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Lemont Nursing & Rehab Center?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.
Is Lemont Nursing & Rehab Center Safe?
Based on CMS inspection data, LEMONT NURSING & REHAB CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Illinois. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Lemont Nursing & Rehab Center Stick Around?
Staff turnover at LEMONT NURSING & REHAB CENTER is high. At 60%, the facility is 14 percentage points above the Illinois average of 46%. Registered Nurse turnover is particularly concerning at 84%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Lemont Nursing & Rehab Center Ever Fined?
LEMONT NURSING & REHAB CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Lemont Nursing & Rehab Center on Any Federal Watch List?
LEMONT NURSING & REHAB CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.