LINCOLN VILLAGE HEALTHCARE
For profit - Limited Liability company
126 Beds
GENERATIONS HEALTHCARE
Data: November 2025
Trust Grade
0/100
#566 of 665 in IL
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Lincoln Village Healthcare has received a Trust Grade of F, indicating significant concerns and poor performance among nursing homes. Ranking #566 out of 665 facilities in Illinois places it in the bottom half of state options, and it is the lowest-ranked facility in Logan County. The facility's conditions are worsening, with the number of issues increasing from 16 in 2024 to 29 in 2025, reflecting a trend of declining care quality. Staffing is a major weakness here, with a low rating of 1 out of 5 stars and a concerning turnover rate of 69%, significantly higher than the state average, which means many staff members do not stay long enough to build relationships with residents. On the other hand, while the RN coverage is average, there are serious deficiencies that have been identified. For example, residents experienced significant pain due to the failure to administer prescribed opioid medications and the facility did not promptly notify physicians regarding medication refills, leading to unrelieved suffering for multiple residents. Additionally, there were issues with not properly documenting the risks related to residents' skin conditions, which could potentially lead to further complications. Overall, families should be cautious and weigh these serious issues against any potential positives when considering this facility for their loved ones.
- Trust Score
- F
- In Illinois
- #566/665
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 69% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $87,478 in fines. Lower than most Illinois facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 33 minutes of Registered Nurse (RN) attention daily — about average for Illinois. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 74 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 15%
Review needed
16 → 29 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 16 issues
2025: 29 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Illinois average (2.5)
Significant quality concerns identified by CMS
Staff Turnover: 69%
23pts above Illinois avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $87,478
Well above median ($33,413)
Moderate penalties - review what triggered them
Chain: GENERATIONS HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (69%)
21 points above Illinois average of 48%
The Ugly 74 deficiencies on record
7 actual harm
Sept 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to protect a wound from insect contamination and failed to provide appr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to protect a wound from insect contamination and failed to provide appropriate physician ordered wound care leading to a decline in the Resident's physical well-being for one of three Residents (R1) reviewed in sample of five. This failure resulted in R1 requiring emergent transport to the local hospital and hospitalization. Findings include:The Facility Pressure/Skin Breakdown-Clinical Protocol Policy, reviewed 1/2025, documents: document the individual's significant risk factors; nurse must document/report a full assessment of skin condition; identify factors contributing or predisposing Residents for skin breakdown such as co-morbidities; document signs/symptoms of infection, skin condition assessment and the impact of co-morbid conditions on wound healing; and the physician will authorize pertinent orders related to wound treatments.The Facility Resident Rights for People in Long-Term Care Facilities, dated 11/2018, documents: the Facility must provide services to keep your physical and mental health, at their highest practical levels; and the Facility must be safe, clean, comfortable and homelike.The Facility Licensed Practical Nurse/LPN Job Description, undated, documents: to provide nursing care to Residents under the supervision of a Registered Nurse/RN and in accordance with federal, state and Facility standards; responsible for administering medications, performing treatments, monitoring Resident's health status and supporting the overall care plan to promote optimal health outcomes; administer treatments as prescribed in accordance with Facility policies and state regulations; monitor Resident's health status, observe for changes in condition and promptly report finding to the Registered Nurse or Physician; follow infection prevention and control procedures; maintain a safe environment for Residents; and comply with all state, federal and Facility regulations.R1's Physician Order Report, dated 8/1/25 through 8/31/25, documents diagnoses including Chronic Osteomyelitis, Anxiety, Anemia, Type Two Diabetes Mellitus with other skin complications, Atherosclerotic Heart Disease, Chronic combined Systolic and Diastolic (Congestive) Heart Failure, Alcohol dependence with withdrawal, Hypertension and Hyperlipidemia. The Physician Order Report documents Physician orders for: arterial ultrasound to bilateral feet for non-healing wounds (dated 7/24/25); Enhanced Barrier Precaution (dated 7/23/25); Left Foot and Right Foot cleanse with wound cleanser, dry well, apply skin barrier to necrotic areas, place topical medication (Calcium Alginate) to open area on Left Posterior Ankle and Right Medical Second Toe and Great Toe, and cover with dry dressing (Army Battle Dressing/ABD and Kerlix) every day (start date 7/1/25 and end date 8/4/25); and Bilateral Foot wounds topical medication (betadine) and open to air every day (start date 7/25/25 and end date 9/4/25). The Physician Order Report does not document a dry dressing order for 8/7/25 or 8/8/25.R1's Treatment Administration Record/TAR, dated 8/1/25 through 8/31/25, documents an order to R1's Right Foot and Left Foot to cleanse area with wound cleanser, dry well, apply skin barrier to necrotic areas, place topical medication (Calcium Alginate) on open area between right medial second toe and great toe and Left Posterior Ankle) and cover with dry dressing (ABD and Kerlix wrap) every shift (start date 7/1/25 and end date 8/4/25).R1's Treatment Administration Record/TAR, dated 8/1/25 through 8/31/25, documents an order to R1's bilateral food wounds for topical medication (Betadine) and open to air every day (start date 7/25/25 and end date 9/4/25). R1's Nursing Progress Note, dated 8/8/25 at 4:10 am, documents that R1 requires staff assistance with transfers, does not like to get out of bed, appetite poor and refused shower.On 8/8/25 at 6:00 am, V6's (Licensed Practical Nurse/Wound Nurse) Nursing Progress Note documents myiasis (maggots/larva) observed in the wound bed during treatment and located primarily in the base of the wound, within necrotic tissue. R1 was transported to the local emergency department ([NAME]).On 8/8/25 at 6:06 am, V6's (Wound Nurse) Nursing Progress Note documents R1 being transferred to the local hospital ([NAME]) by Emergency Services for evaluation due to complications related to bilateral foot wounds.R1's Nursing Note, dated 8/8/25 at 10:30 am, documents R1 being transferred from the local hospital ([NAME]) to a larger area hospital ([NAME]).R1's Nursing Note, dated 9/4/25 at 12:36 pm, documents hospital ([NAME]) report to the Facility for R1's return from the hospital back to the Facility. R1 was admitted to the larger area hospital ([NAME]) on 8/9/25 for a Urinary Tract Infection, Sepsis and Osteomyelitis. R1 underwent a Right above-the-knee amputation on 8/20/25, was placed on a feeding tube, insertion of an indwelling urinary catheter. On 9/2/25 R1 became unresponsive and a stroke alert was initiated, then R1 was recommended for Hospice services. R1's Paramedic Report/EMS, dated 8/8/25 at 7:21 am, documents that EMS was dispatched for complaints of foot ulcers with maggots. Staff (V6/LPN Wound Nurse) reported that V6 had started to change R1's foot dressings, approximately 30 minutes prior, and R1's diabetic ulcers were covered in maggots. R1 stated that R1 had the diabetic ulcers since approximately January or February (2025) and the Facility changed the dressings approximately one time a week, and the Facility did not notify R1 of the condition of R1's feet. R1 was transported to the local hospital ([NAME]).R1's local Hospital Triage notes ([NAME]) dated 8/8/25 at 6:37 am, documents R1 presented with Right Foot and Left Foot wounds and that when the Nursing Home staff attempted to redress the wounds, maggots were found in R1's Right Foot wound. Antibiotic was initiated for the infected wounds and an indwelling urinary catheter was placed. The Hospital Triage notes document that on 8/8/25 at 2:29 pm R1 was transported to a larger hospital ([NAME]) for treatment.R1's Hospital Notes ([NAME]), dated 9/2/25, document that when R1 presented to the Emergency Department for bilateral foot wounds, one of which was found to have maggots. The Hospital notes document that R1 had a new diagnoses including Right Above-the-Knee amputation.R1's Nursing Notes, dated 8/4/25, do not document V8 (Licensed Practical Nurse/LPN) applying a dry dressing to R1's Right Foot drainage.On 9/9/25 at 2:01 pm, V5 (Former Infection Preventionist) stated, (V6/Former Wound Nurse) told me that when (V5) was doing (R1's) Right Foot treatment, that (V6) found a ton of maggots in it. Apparently, the wrong treatment was also on it. (V8/Licensed Practical Nurse) did the dressing prior to (V6) doing it and put a dry dressing (Kerlix) on it because (V8) said that (R1's) Right Foot had drainage. (R1) was sent out immediately to the local hospital ([NAME]) for the maggots, and was then transported to a larger hospital ([NAME]) for admission.On 9/10/25 at 10:12 am, V6 (Former Wound Nurse/LPN) stated, I came in around 3:00 am on 8/8/25 to do an entire facility skin sweep and around 5:00 am, when I started to do the treatment on (R1's) right foot it had a dry dressing (Kerlix) wrapped around it. I knew this was the wrong treatment, because (V10/Wound Physician) had just changed the foot treatments a few days prior, on 8/4/25, to Betadine topical and leave open to air, so I was immediately concerned when I saw that. Then I began to remove the Right Foot dressing and immediately saw that the Right Foot was covered with over fifty maggots. Honestly, I had never seen that before and I kind of freaked out. I have no knowledge on treating maggots and I was not sure if we even had the right supplies. I tried to call (V5/Infection Preventionist) but could not get ahold of (V5), because I think(V5) was still sleeping. So I called the Physician and ended up sending (R1) out by ambulance to the hospital in [NAME]. Once (R1) got there, they sent (R1) to the big hospital in [NAME].On 9/9/25 at 1:26 pm, V10 (Wound Physician) stated, I understand that (R1) had multiple maggots in (R1's) Right Foot wound a few days after I had just seen (R1) on 8/4/25, and changed the Right Foot treatment order to Betadine and open to air because it was dry eschar at that time. I saw no signs of infection at that time. The only way the maggots would have approved is if they would have been medical maggots ordered by a physician. I did not get notified by the Facility of (R1's) Right Foot drainage and I did not order a dressing on the Right Foot for the drainage. The Facility could have called and sent me pictures or used telehealth (video calls) to notify me of the change. I cannot verify that the wound should or should not have been covered again at this point. I am not sure that (R1's) Primary Physician was notified of the change in the wound or exactly ordered the dressing.
Jul 2025
15 deficiencies
2 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 F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to administer prescribed opioid medications to keep resid...
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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 administer prescribed opioid medications to keep residents' pain controlled, failed to perform pain assessments and implement pain relieving interventions while the residents were not receiving their prescribed pain relieving opioid medications, and failed to notify the physician of the need for a opioid medication refill order and complaints of increased pain for three of three residents (R2, R14, and R22) reviewed for pain in the sample of 30. These findings resulted in R2 experiencing restlessness and unrelieved pain after seven days of going without his prescribed opioid medication, R14 experiencing excruciating and stabbing unrelieved pain to the lower back, and R22 experiencing unrelieved severe pain to the lower back and legs.Findings include:The facility's Pain Management Policy, dated 1/2025, documents Purpose: To establish a program with a multi-level approach to pain management to assist the facility in delivering safe, individualized pain care. Policy: It is the policy of the facility to facilitate resident safety, independence, promote resident comfort, preserve and enhance resident dignity and facilitate life involvement. The purpose of this policy is to accomplish the goals through an effective pain management program. Definition: The facility will utilize a consistent pain assessment. The resident's descriptive words regarding the quality, duration, and location of pain will be used to evaluate the pain and to identify changes in pain. When the resident is unable to describe pain, physical signs such as grimacing, body posturing/protecting, vital sign changes, and changes in behavior and mood will be used to determine the presence of pain. Standards: 1. Pain assessment protocol may be initiated under any of the following situations: Any indication of pain based on the Pain Assessment performed for each resident at the time of admission, quarterly and with any condition change associated with the potential of pain, when the Minimum Data Set triggers an indication of pain (section J2, J3), Resident received routine pain medication and/or pain is not controlled, a change in a resident condition occurs to require pain control, A significant increase in the need for use of as needed use of pain medication, and a change in pain identification related to behavior, cognition or mood. 5. An interdisciplinary process and care plan will be developed and implemented based on the assessed findings, pain rating scale, and pain relieve strategies (interventions). 7. Care plans will be reviewed and updated each time the resident's pain management plan is found not to be effective and at least each quarterly care conference. 11. Documentation of assessments and the resident's response to the pain management plan will be made with each assessment. 12. The resident's physician will be notified of the resident's complaints of pain which are not relieved by comfort measures, including pain medications.The facility's Physician Orders policy dated 1/23/25 documents, Nursing staff will follow physician orders. In an event where a resident refused medication, or mediation is not available physician or nurse practitioner will be notified.1. R2's admission Care Plan dated 7/3/25 documents, (R2) is at risk of complaints of chronic pain related to infection/inflammatory reaction due to internal fixation with removal of hardware and pressure ulcers. (R2) has narcotic and non-narcotic pain medications orders prn (as needed). Approach: Administer medications as per orders. Evaluate/record/report effectiveness and any adverse side effects.R2's current Physician Order Report documents R2 was admitted on [DATE] with the diagnoses of a Pressure Ulcer of the right hip, Osteomyelitis, Pressure ulcer of the left hip, Pressure Ulcer of the right buttock, Contracture of Right Hip, Contracture of the right knee, Contracture of right lower leg muscle, Infection and inflammation reaction due to internal fixation device, and Anxiety Disorder. This same Physician Order Report documents, Start Date 6/30/25 (Admission) Hydrocodone-Acetaminophen (Norco) 10-325 mg (milligrams) one tablet every eight hours as needed.R2's Pharmacy Packing Slip dated 7/7/25 documents R2's Hydrocodone/Acetaminophen 10-325 mg 30 tablets was not delivered until 7/7/25 (seven days after R2 was admitted to the facility).R2's Medication Administration Records (MARs) dated 6/30/25 through 7/7/25 document R2 did not receive any Norco as ordered during this timeframe. R2's Electronic Health Record does not include documentation of R2's Physician (V30) being notified of the need for a prescription to fill R2's Norco, or documentation of pain relieving interventions utilized while R2 was not receiving his Norco as ordered from 6/30/25 through 7/7/25.R2's Progress Notes dated 7/5/25 at 3:45 PM and signed by V28 (Agency RN/Registered Nurse) documents, (R2) alert with confusion. Very confused on (R2's) whereabouts and day to day things. (R2) very restless at times. (R2) throws his legs and upper half of body out of the bed. Staff repositioned (R2) very frequently. (R2) is however contracted. (R2) has legs drawn up in a fetal position. (R2) frequently yells out for someone to get the people out of there while he points at his window. Will continue to monitor and follow current plan of care.On 7/15/25 at 1:35 PM R2 was lying in a low bed with the head of the bed up 90 degrees. R2 had multiple bruises to the right lower arm and a four by four bandage to the right lower arm. R2 had pressure ulcers to the right and left hip and right buttock. R2's legs were drawn up into a fetal position. R2 had facial grimacing and when asked if R2 was in pain R2 replied, Yes.On 7/16/25 at 9:50 AM V27 (CNA/Certified Nursing Assistant Manager) stated, On 7/5/25 around 2:25 PM (V28/Agency RN/Registered Nurse) was working and told me (R2) seemed to be in pain and had no medication. I called (V3/Prior Director of Nursing) and (V3) said she would take care of getting (R2's) pain medication.On 7/16/25 at 1:00 PM V28 (Agency RN) stated, I was working on 7/5/25 and it seemed throughout the shift that (R2) could not get comfortable. I looked at (R2s) MAR and noticed (R2) did not have Norco. (V27) called (V3) and (V3) was supposed to take care of getting (R2's) Norco. (R2's) Norco never did come in that day.On 7/16/25 at 1:30 PM V24 (Director of Rehabilitation) stated, I have worked with (R2) in therapy since (R2's) admission. It seems like (R2) is in a lot of pain most often when (R2) is being moved. (R2) is very contracted and has a lot of wounds. (R2) does not talk much but does say ouch whenever I roll (R2) or move (R2's) legs. I think moving (R2's) legs agitates (R2's) hip pain.On 7/18/25 at 11:10 AM V30 (R2's Physician) stated, (R2) absolutely should not go without his Norco. With all (R2's) illnesses and wounds, going without Norco would cause (R2) severe pain. There is no reason for any of my residents to be without their pain medications. The facility should have gotten ahold of me immediately to get (R2's) Norco ordered. I am always available by phone call and fax.2. R14's MDS (Minimum Data Set) assessment dated [DATE] documents R14 is cognitively intact. R14's Nursing Home Visits dated 319/25 and 4/9/25 and signed by V30 (R14's Physician) document, Chronic Pain: On Norco and Ibuprofen. R14's current Care Plan documents, Problem: Pain (R14) is at risk for chronic pain related to spinal stenosis. (R14) is no routine narcotic pain medication and PRN (as needed) non-narcotic medication for pain. 2/9/25 history of fracture o lumbar vertebrae. Goals: (R14) will verbalize reduction of pain. Approach: Administer medications as ordered. Monitor and record effectiveness. Report adverse side effects. Assess past effective and ineffective pain relief measures. Problem: (R14) has been asking for more pain medications, asking other nurses for pain \medications and telling other staff that (R14) did not get his pain medications. Approach: Nursing staff will give (R14) a sticky note of times he takes his schedules pain medications at the beginning of each shift.R14's Physician's Order Report dated 6/15/25 through 7/15/25 document R14 has the diagnoses of Spinal Stenosis of the Lumbosacral Region and Low Back Pain. This same Physician's Order Report documents, Start Date 10/16/23: Hydrocodone-Acetaminophen (Norco) 5-325 mg two tablets every six hour for low back pain. Start Date 9/1/23 Pain Scale/Evaluation every shift. Pain Scale 0-10. 0=No pain. 1=Mild Pain of uncomfortable/annoying. 4=Moderate Pain that is distressing/miserable. 10=Excruciating Pain that is the worst possible and interferes with the ability to carry on with daily routine, socialization, or sleep.R14's MARs dated 5/1/25 through 7/15/25 documents R14 did not receive his schedule Norco 5-325 mg as ordered on 13 occasions due to the Norco being unavailable.R14's MARs dated 5/1/25 through 7/15/25 document on 5/23/25 during the R14 was rating his back pain at a level 7 on a 0-10 pain scale. According to R14's MARs R14 did not receive his Norco 5-325 mg as ordered on 5/23/25 at 8:00 AM, 2:00 PM, or 8:00 PM and on 5/23/25 R14 was rating his back pain at a level 7 on a 0-10 scale.R14's MARs dated 5/1/25 through 7/15/25 document on 6/15/25 during the entire day R14 was rating his back pain at a level 7 on a 0-10 pain scale and on 6/16/25 during the night R14 was rating his back pain at a level 10 on a 0-10 pain scale. According to R14's MARs R14 did not receive his Norco 5-325 mg as ordered on 6/15/25 at 8:00 PM or 6/16/25 at 2:00 AM.R14's Electronic Medical Record does not include any pain relieving interventions, physician's notification, or comprehensive pain assessments after the 13 occasions between 5/1/25 through 7/15/25 when R14 did not receive his Norco as prescribed.On 7/15/25 at 10:05 AM R14 was walking with a walker in the dining room. R14 stated, The facility runs out of my Norco every month. I was an iron worker and hurt my back years ago. I have been on Norco for the pain in my lower back and was seeing a specialist for the pain. When I don't get my scheduled Norco I have excruciating, stabbing pain to my lower back. The pain keeps me awake. I really wish the facility would get this fixed, so I do not have to go without the Norco.On 7/16 /25 at 10:30 AM V2 (Director of Nursing) stated, (R14) did not get his Norco as ordered on 13 occasions between 5/1/25 through 7/15/25. (R14) has a lot of back pain and should not go without his scheduled Norco.On 7/16/25 at 1:20 PM V1 (Administrator-In-Training) stated, I was made aware that (R14) was running out of his Norco frequently. I know (R14) needs his Norco for lower back pain and should not ever run out of Norco.On 7/16/25 at 2:00 PM V19 (Regional Nurse Consultant) stated, (R14) has not had a comprehensive pain assessment completed since 5/13/25. V19 verified (R14) should have had a comprehensive pain assessment completed anytime (R14) went without his ordered Norco and was experiencing pain.On 7/18/25 at 11:00 AM V20 (R14's Family Member) stated, I know agency nurses do not get (R14's) medication refills done on time. (R14) has always had chronic pain and was a construction worker and hurt his back by following out of a third floor window of a building. (R14) has had multiple back surgeries. (R14) is usually out of his pain medications on the weekends and calls me when (R14) does not get his pain medication because he is having pain. If (R14) misses even one dose of Norco (R14) is in pain.On 7/18/25 at 11:10 AM V30 (R14's Physician) stated, (R14) should never have to go without his Norco. (R14) is dependent on the Norco and needs the Norco routinely to control his back pain. The facility should get ahold of me before (R14's) Norco runs out.3. R22's current Pain Care Plan documents R22 has complaints of chronic pain due related to osteomyelitis, pressure ulcer to the right ischium, tear of the hamstring tendon, and peripheral vascular disease, and is receiving hospice services for pain control management. This same care plan documents R22's pain medications should be administered as ordered and R22 will verbalize reduction of pain and/or show no signs of non-verbal pain.R22's current Physician Order Report documents R22 has the diagnoses of strain of muscle of the fascia and tendon of the posterior muscle group at right thigh level and malignant neoplasm of the large intestine and receives hospice services. This same Physician Order Report documents the following orders, Start Date 6/10/25 pain scale/evaluation every shift. Start Date: 7/7/25 MS Contin (Morphine) tablet extended release 15 mg twice daily at 8:00 AM and 8:00 PM.R22's Physician's Order dated 6/26/25 documents an order to increase R22's Hydrocodone/Acetaminophen from 5-325 mg every four hours to 10-325 mg every four hours and then discontinue on 7/7/25.R22's Medication Administration Record dated 6/10/25 through 7/15/25 documents R22's MS Contin 15 mg was not received on 7/7/25 at 8:00 AM or 8:00 PM due to the medication being unavailable.R22's Medication Administration Record dated 6/10/25 through 7/7/25 documents R22's Hydrocodone/Acetaminophen from 10-325 mg was not received as ordered on 15 occasions due to the Hydrocodone/Acetaminophen being unavailable.R22's Electronic Medical Record documents R22's last Comprehensive Pain Assessment was completed 6/26/25.On 7/16/25 at 11:00 AM R22 was lying in bed. R22 stated, I have cancer, and I hurt all over. I do not like to complaint. I have had pain all over and especially in my lower back and legs. I had no idea I was out of my pain medication. That would explain why I was hurting so bad.On 7/18/25 at 10:30 AM V12 (Hospice RN/Registered Nurse) I was not aware that (R22) was not getting his Hydrocodone/Acetaminophen 10mg-325 mg as ordered or his MS Contin 15 mg for two doses. I made (R22's) Hydrocodone/Acetaminophen 10mg-325 mg scheduled around the clock due top (R22) having wound pain, back pain, arm pain, and leg pain. It is unacceptable for (R22) to go without pain medication and (V9/Hospice Physician) was not notified. (V9) should have been notified so me or (V9) could have reached out to the pharmacy to make sure (R22) was getting his medication or we would have ordered something else to control (R22's) pain until the Hydrocodone/Acetaminophen and MS Contin was received.
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
Pharmacy Services
(Tag F0755)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement a process for the timely ordering and reorde...
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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 process for the timely ordering and reordering of medications, failed to notify the physician of the need for opioid analgesic medications and anti-anxiety medication prescription refill orders, failed to notify the physician of the need for an alternative to ordered Ozempic, and failed to obtain physician ordered opioid analgesic medications, anti-antianxiety medication, and weight-loss medication from the pharmacy for four of four residents (R2, R14, R18, and R22) reviewed for pharmacy services in the sample of 30. These findings resulted in R2 experiencing restlessness, increased anxiety, and unrelieved pain after seven days of going without his prescribed opioid medication and anti-anxiety medication, R14 experiencing excruciating and stabbing unrelieved pain to the lower back and withdrawal symptoms, and R22 experiencing unrelieved severe pain to the lower back and legs. Findings include: The facility's Controlled Substance Prescription Pharmacy Policy, dated 10/25/2014, documents Policy: Before a controlled drug can be dispensed, the pharmacy must be in receipt of a clear, complete, and signed written prescription from a person lawfully authorized to prescribe. To facility effective communication, documentation, and aide in prevention of medication errors, medication orders should be clear and concise and free of potentially dangerous abbreviations. Procedures: A. Elements of a controlled substance prescription: 12) Manual signature of prescriber. C. The prescriber and/or nurse are contacted for direction when delivery of a medication will be delayed, or the medication is not or will not be available. E. New Controlled Substance Prescriptions: 1) For emergency-controlled substance orders, the nurse will review the Emergency Kit list for available medications prior to contacting the prescriber. The nurse will communicate to the prescriber the emergency medications available to provide appropriate care to the patient. 4) In order to communicate Controlled II orders orally/verbally between the prescriber and pharmacist, the prescription must meet DEA's (Drug Enforcement Administration) criteria of an emergency situation. Conformance with such criteria must be discussed between the prescriber and pharmacist and documented on the prescription: a. Immediate administration of the controlled substance is necessary for proper treatment of the intended ultimate user. b. No appropriate alternative treatment is available, including administration of a drug which is not a controlled substance under Schedule II; AND c. It Is not reasonably possible for the prescriber practitioner to provide written prescription to be present to the person dispensing the substance prior to dispensing. 4) Only after verifying that the above communication has occurred and the pharmacy and facility receive a complete prescription, the nurse reviews the Emergency Kit List to assess the contents. After finding the medication list, the nurse unlocks the container seal and removes the required medication if it is available in the emergency kit. If the medication is not available in the emergency kit, the nurse contacts the pharmacy using the afterhours emergency number(s) if necessary. (See IC5: Emergency Pharmacy Service and Emergency Kits). The United States Food and Drug Administration Safety Communication Website article dated 4-9-19 documents, Opioid's are a class of powerful prescription medicines that are used to manage pain when other treatments and medicines cannot be taken or are not able to provide enough pain relief. Patients taking opioid pain medicines long-term should not suddenly stop taking your medicines without first discussing with hour health care professional a plan for how to slowly decrease the dose of the opioid and continue to manage your pain. Even when the opioid dose is decreased gradually, you may experience symptoms of withdrawal. Rapid discontinuation can result in uncontrolled pain or withdrawal symptoms. These include serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide. 1. R2's admission Care Plan dated 7/3/25 documents, (R2) is at risk of complaints of chronic pain related to infection/inflammatory reaction due to internal fixation with removal of hardware and pressure ulcers. (R2) has narcotic and non-narcotic pain medications orders prn (as needed). Approach: Administer medications as per orders. Evaluate/record/report effectiveness and any adverse side effects.R2's current Physician Order Report documents R2 was admitted on [DATE] with the diagnoses of a Pressure Ulcer of the right hip, Osteomyelitis, Pressure ulcer of the left hip, Pressure Ulcer of the right buttock, Contracture of Right Hip, Contracture of the right knee, Contracture of right lower leg muscle, Infection and inflammation reaction due to internal fixation device, and Anxiety Disorder. This same Physician Order Report documents, Start Date 6/30/25 (Admission) Hydrocodone-Acetaminophen (Norco) 10-325 mg (milligrams) one tablet every eight hours as needed.R2's admission Physician's Orders dated 6/30/25 document, Lorazepam 0.5 mg twice daily as needed for Anxiety.R2's Pharmacy Packing Slip dated 7/7/25 documents R2's Lorazepam 0.5 mg 28 tablets was not delivered until 7/7/25 (seven days after R2 was admitted to the facility).R2's Pharmacy Packing Slip dated 7/7/25 documents R2's Hydrocodone/Acetaminophen 10-325 mg 30 tablets was not delivered until 7/7/25 (seven days after R2 was admitted to the facility).R2's Medication Administration Records (MARs) dated 6/30/25 through 7/7/25 document R2 did not receive any Norco as ordered during this timeframe. R2's Electronic Health Record does not include documentation of R2's Physician (V30) being notified of the need for a prescription to fill R2's Norco or R2's Lorazepam, or documentation of pain relieving interventions utilized while R2 was not receiving his Norco as ordered from 6/30/25 through 7/7/25.R2's Progress Notes dated 7/5/25 at 3:45 PM and signed by V28 (Agency RN/Registered Nurse) documents, (R2) alert with confusion. Very confused on (R2's) whereabouts and day to day things. (R2) very restless at times. (R2) throws his legs and upper half of body out of the bed. Staff repositioned (R2) very frequently. (R2) is however contracted. (R2) has legs drawn up in a fetal position. (R2) frequently yells out for someone to get the people out of there while he points at his window. Will continue to monitor and follow current plan of care.On 7/15/25 at 1:35 PM R2 was lying in a low bed with the head of the bed up 90 degrees. R2 had multiple bruises to the right lower arm and a four by four bandage to the right lower arm. R2 had pressure ulcers to the right and left hip and right buttock. R2's legs were drawn up into a fetal position. R2 had facial grimacing and when asked if R2 was in pain, R2 replied, Yes.On 7/16/25 at 9:50 AM V27 (CNA/Certified Nursing Assistant Manager) stated, On 7/5/25 around 2:25 PM (V28/Agency RN/Registered Nurse) was working and told me (R2) seemed to be in pain and anxiety and had no medication. I called (V3/Prior Director of Nursing) and (V3) said she would take care of getting (R2's) pain medication.On 7/16/25 at 1:00 PM V28 (Agency RN) stated, I was working on 7/5/25 and it seemed throughout the shift that (R2) could not get comfortable. (R2) was seeing things and very fidgety and anxious. I looked at (R2s) MAR and noticed (R2) did not have Norco. I also did not have (R2's) Lorazepam to give (R2) to help with his restlessness. (V27) called (V3) and (V3) was supposed to take care of getting (R2's) Norco. (R2's) Norco never did come in that day.On 7/18/25 at 11:10 AM V30 (R2's Physician) stated, (R2) absolutely should not go without his Norco or Lorazepam. With all (R2's) illnesses and wounds, going without Norco would cause (R2) severe pain. There is no reason for any of my residents to be without their pain medications. The facility should have gotten ahold of me immediately to get (R2's) Norco ordered. I am always available by phone call and fax to get the prescription to pharmacy.2. R14's MDS (Minimum Data Set) assessment dated [DATE] documents R14 is cognitively intact. R14's Nursing Home Visits dated 319/25 and 4/9/25 and signed by V30 (R14's Physician) document, Chronic Pain: On Norco and Ibuprofen. R14's current Care Plan documents, Problem: Pain (R14) is at risk for chronic pain related to spinal stenosis. (R14) is no routine narcotic pain medication and PRN (as needed) non-narcotic medication for pain. 2/9/25 history of fracture o lumbar vertebrae. Goals: (R14) will verbalize reduction of pain. Approach: Administer medications as ordered. Monitor and record effectiveness. Report adverse side effects. Assess past effective and ineffective pain relief measures. Problem: (R14) has been asking for more pain medications, asking other nurses for pain \medications and telling other staff that (R14) did not get his pain medications. Approach: Nursing staff will give (R14) a sticky note of times he takes his schedules pain medications at the beginning of each shift.R14's Physician's Order Report dated 6/15/25 through 7/15/25 document R14 has the diagnoses of Spinal Stenosis of the Lumbosacral Region and Low Back Pain. This same Physician's Order Report documents, Start Date 10/16/23: Hydrocodone-Acetaminophen (Norco) 5-325 mg two tablets every six hour for low back pain. Start Date 9/1/23 Pain Scale/Evaluation every shift. Pain Scale 0-10. 0=No pain. 1=Mild Pain of uncomfortable/annoying. 4=Moderate Pain that is distressing/miserable. 10=Excruciating Pain that is the worst possible and interferes with the ability to carry on with daily routine, socialization, or sleep.R14's MARs dated 5/1/25 through 7/15/25 documents R14 did not receive his schedule Norco 5-325 mg as ordered on 13 occasions due to the Norco being unavailable.R14's MARs dated 5/1/25 through 7/15/25 document on 5/23/25 during the R14 was rating his back pain at a level 7 on a 0-10 pain scale. According to R14's MARs R14 did not receive his Norco 5-325 mg as ordered on 5/23/25 at 8:00 AM, 2:00 PM, or 8:00 PM and on 5/23/25 R14 was rating his back pain at a level 7 on a 0-10 scale.R14's MARs dated 5/1/25 through 7/15/25 document on 6/15/25 during the entire day R14 was rating his back pain at a level 7 on a 0-10 pain scale and on 6/16/25 during the night R14 was rating his back pain at a level 10 on a 0-10 pain scale. According to R14's MARs R14 did not receive his Norco 5-325 mg as ordered on 6/15/25 at 8:00 PM or 6/16/25 at 2:00 AM.R14's Electronic Medical Record does not include any pain relieving interventions, physician's notification, or comprehensive pain assessments after the 13 occasions between 5/1/25 through 7/15/25 when R14 did not receive his Norco as prescribed.On 7/15/25 at 10:05 AM R14 was walking with a walker in the dining room. R14 stated, The facility runs out of my Norco every month. I was an iron worker and hurt my back years ago. I have been on Norco for the pain in my lower back and was seeing a specialist for the pain. When I don't get my scheduled Norco I have excruciating, stabbing pain to my lower back. I know when I don't get the Norco because I start to have withdrawals and start feeling sick and jittery. The pain keeps me awake. I really wish the facility would get this fixed, so I do not have to go without the Norco.On 7/16 /25 at 10:30 AM V2 (Director of Nursing) stated, (R14) did not get his Norco as ordered on 13 occasions between 5/1/25 through 7/15/25. (R14) has a lot of back pain and should not go without his scheduled Norco.On 7/16/25 at 1:20 PM V1 (Administrator-In-Training) stated, I was made aware that (R14) was running out of his Norco frequently. I asked (V3/Prior Director of Nursing) sometime around April 10th to start doing narcotic medication audits on every Monday and Friday each week after I was made aware that narcotics were running out and residents were not getting their pain medications as ordered due to not getting renewal prescriptions in time. I wanted (V3) to make sure all residents were getting their narcotic medications as ordered. (V3) did not complete those audits as I instructed. I know (R14) needs his Norco for lower back pain and should not ever run out of Norco. If a resident does not have their narcotic the nurses should know the process and should call the physician immediately to get the prescription and call pharmacy to get a code to get the narcotic out of the facility's back-up supply.On 7/16/25 at 2:00 PM V19 (Regional Nurse Consultant) stated, (R14) has not had a comprehensive pain assessment completed since 5/13/25. V19 verified (R14) should have had a comprehensive pain assessment completed anytime (R14) went without his ordered Norco and was experiencing pain.On 7/18/25 at 11:00 AM V20 (R14's Family Member) stated, I know agency nurses do not get (R14's) medication refills done on time. (R14) has always had chronic pain and was a construction worker and hurt his back by following out of a third floor window of a building. (R14) has had multiple back surgeries. (R14) is usually out of his pain medications on the weekends and calls me when (R14) does not get his pain medication because he is having pain. If (R14) misses even one dose of Norco (R14) is in pain.On 7/18/25 at 11:10 AM V30 (R14's Physician) stated, (R14) should never have to go without his Norco. (R14) is dependent on the Norco and needs the Norco routinely to control his back pain. The facility should get ahold of me before (R14's) Norco runs out.3. R18's MDS assessment dated [DATE] documents R18 is cognitively intact.R18's Physician's Progress Note dated 5/3/25 and signed by V5 (R18's Primary Physician) documents, Chief complaint: (R18) is a [AGE] year-old who is trying to lose weight. (R18) wants to get stronger and hopefully go home. Hopefully will get (R18) started on an agent that will help (R18) lose some weight. Obesity.R18's current Physician Order Report documents R18 has the diagnoses of Severe Morbid Obesity and Type II Diabetes Mellitus. This same Physician Order Report documents, Start Date 6/16/25: Ozempic pen injector 0.25 mg subcutaneous once a day on Wednesdays.R18's Medication Administration Record dated 6/16/25 through 716/25 documents R18 did not receive Ozempic 0.25 mg as ordered on Wednesdays dated 6/18/25, 6/25/25, 7/2/25, 7/9/25, and 7/16/25.R18's Pharmacy Notice of Rejection dated 6/26/25 documents, Ozempic 2mg/3 ml quantity 3 not covered. Reason for denial: (Insurance Plan) requires additional information from medical doctor. Alternative: Trulicity 0.74 m/0.5 ml subcutaneous once a week.R18's Electronic Medical Record does not include notification or follow-up with the physician or pharmacy once insurance rejected to fill R18's Ozempic.On 7/15/25 at 11:00 AM R18 was sitting outside in a wheelchair. R18 stated, (V5/Physician) order me Ozempic so I can get my weight off and get my hip surgery. My insurance will not cover it. I really need it.On 7/16/25 at 9:00 AM V2 (Director of Nursing) stated, I was not aware that (R18) was not getting her ordered Ozempic.On 7/16/25 at 11:12 AM V31 (V5's Registered Nurse) stated, The nursing home has not called or followed up with (V5) to let us know (R18) was not getting Ozempic to get an alternative to (R18's) Ozempic or more information to get (R18's) Ozempic covered by insurance.4. R22's current Pain Care Plan documents R22 has complaints of chronic pain due related to osteomyelitis, pressure ulcer to the right ischium, tear of the hamstring tendon, and peripheral vascular disease, and is receiving hospice services for pain control management. This same care plan documents R22's pain medications should be administered as ordered and R22 will verbalize reduction of pain and/or show no signs of non-verbal pain.R22's current Physician Order Report documents R22 has the diagnoses of strain of muscle of the fascia and tendon of the posterior muscle group at right thigh level and malignant neoplasm of the large intestine and receives hospice services. This same Physician Order Report documents the following orders, Start Date 6/10/25 pain scale/evaluation every shift. Start Date: 7/7/25 MS Contin (Morphine) tablet extended release 15 mg twice daily at 8:00 AM and 8:00 PM.R22's Physician's Order dated 6/26/25 documents an order to increase R22's Hydrocodone/Acetaminophen from 5-325 mg every four hours to 10-325 mg every four hours and then discontinue on 7/7/25.R22's Medication Administration Record dated 6/10/25 through 7/15/25 documents R22's MS Contin 15 mg was not received on 7/7/25 at 8:00 AM or 8:00 PM due to the medication being unavailable.R22's Medication Administration Record dated 6/10/25 through 7/7/25 documents R22's Hydrocodone/Acetaminophen from 10-325 mg was not received as ordered on 15 occasions due to the Hydrocodone/Acetaminophen being unavailable.R22's Electronic Medical Record documents R22's last Comprehensive Pain Assessment was completed 6/26/25.On 7/17/25 at 1:00 PM V1 (Administrator-In-Training) verified R22 never received the Hydrocodone/Acetaminophen 10-325 mg as ordered due to the mediation not being delivered from the pharmacy. V1 also verified she was not aware of R22 not receiving the Hydrocodone/Acetaminophen 10-325 mg and should have been informed and the nurses should have notified the physician immediately to get a signed prescription and ensure the medication was received. V1 verified R22 did not receive the first two doses of MS Contin 15 mg due to the medication being unavailable.On 7/18/25 at 10:30 AM V12 (Hospice RN/Registered Nurse) I was not aware that (R22) was not getting his Hydrocodone/Acetaminophen 10mg-325 mg as ordered or his MS Contin 15 mg for two doses. I made (R22's) Hydrocodone/Acetaminophen 10mg-325 mg scheduled around the clock due top (R22) having wound pain, back pain, arm pain, and leg pain. It is unacceptable for (R22) to go without pain medication and (V9/Hospice Physician) was not notified. (V9) should have been notified so me or (V9) could have reached out to the pharmacy to make sure (R22) was getting his medication or we would have ordered something else to control (R22's) pain until the Hydrocodone/Acetaminophen and MS Contin was received.
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 F0559
(Tag F0559)
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 issue a written notice of room moves for three of four residents (R1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to issue a written notice of room moves for three of four residents (R13, R14, and R27) reviewed for room moves in a sample of 30. Findings include: The facility's Room Changes Policy, dated 1/2025, documents Policy: To make room changes when requested by the resident or as may become necessary to meet the resident's medical and nursing care needs. Policy Specifications: 2. Unless medically necessary for the safety and well-being of the resident(s), a resident will be provided with advance notice of the room change, at least two days before relocation, however, the resident has the right to relocate prior to the expiration of the two-day notice. Such notice will include the reason(s) why the move is recommended. 3. Prior to the room change, the resident, his or her roommate (if any), and the resident's representative will be provided with information concerning the decision to make the room change. 1. R13's current Census Sheet documents R13 had room moves on 2/8/25, 2/13/25, 2/19/25, 3/7/25, and 5/1/25. R13's MDS (Minimum Data Set) Assessment, dated 7/11/25, documents R13 is cognitively intact. R13's Electronic Medical Record does not include a notice of room change issued to R13 for R13's room moves on 2/8/25, 2/13/25, 2/19/25, 3/7/25, and 5/1/25. On 7/16/25 at 11:04 AM R13 stated, I am never made aware of reasons for room moves and they (the facility) make us change rooms a lot. I do not like it.2. R14's current Census Sheet documents R14 moved rooms from the [NAME] Hall to the [NAME] Hall on 5/8/25. R14's MDS Assessment, dated 5/13/25, documents R14 is cognitively intact. R14's Electronic Medical Record does not include a notice of room change issued to R14 or R14's representative. On 7/17/25 at 11:56 AM R14 stated he was never made aware of the reason why they moved him to another room and never received a written notice of room change. 3. R27's current Census Sheet documents R27 moved rooms on 2/1/25, 2/28/25, and 5/19/25. R27's MDS Assessment, dated 7/3/25, documents R27 is cognitively intact. R27's Electronic Medical Record does not include a notice of room change issued to R27 or R27's representative. On 7/17/25 at 11:07 AM V2/Director of Nursing stated R27 is alert and able to answer questions appropriately by shaking his head yes or no.On 7/17/25 at 11:11 AM R27 was asked by this surveyor if he has moved rooms in the facility a few times in the past 6 months. R27 shook is head yes. R27 was asked if they ever let him know the reasons why he was moved rooms and R27 shook his head no. On 7/17/25 at 11:20 AM V6/R27's Family Member stated they called her on one room move (2/28/25) and told her they moved R27 to a different room, but never told her a reason why. V6 stated the facility never let her know about the room moves on 2/1/25 or 5/19/25.On 7/17/25 at 11:24 AM V1/Administrator in Training verified R13, R14, and R27 did have multiple room moves and they (the facility) did not issue any written notice of room moves to R13, R14, R27 or their representatives. V1 stated, I was unaware we were supposed to issue a written notice to the resident or representative of the room moves and the reason we (the facility) are moving the resident(s) to a different room.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
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 notify a resident's responsible party after a significant weight los...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify a resident's responsible party after a significant weight loss was identified for one of four residents (R1) reviewed for notifications of change in a sample of 30.Findings include:The facility's Weight Assessment and Intervention Policy, dated 1/2025, documents The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month- Five percent weight loss is significant; greater than 5% is severe. b. 3 months- 7.5 percent weight loss is significant; greater than 7.5% is severe. c. 6 months- 10 percent weight loss is significant; greater than 10 percent is severe.The facility's Notification of Consumer Change in Condition Policy, dated 1/2025, documents Policy: It is the policy of this facility to promptly notify the consumer, their legal representative(s) and attending physicians of changes in the consumer's health condition. Policy Specifications: To establish guidelines for assuring consumers, their legal representative and attending physicians are informed of changes in the consumer's condition. As per the Guidelines for Reporting to Physicians as per INTERACT Change in Condition Guidelines. Responsibility: Director of Nursing and Licensed Nurses. Standards: 3. Clinical change in condition is determined by consumer visualization, medical record review, clinical assessment findings and care plan review. Review of high-risk clinical issue such as skin breakdown, falls, weight loss, dehydration and others are conducted on a daily basis. 12. Consumer representative(s) notifications and attempts will be made promptly and documented in the nurses' notes. In the event the licensed nurse is unable to contact the consumer's representative, after a reasonable time period, the director of Nursing will be notified.The facility's Notification of Change Guidelines, dated 1/2025, documents Purpose: It is the practice of this facility that changes in a resident condition or treatment are immediately shared with the resident and/or resident representative, according to their authority, and are reported to and consulted with the attending physician. The resident and/or the resident representative will be educated about treatment options and supported to make an informed decision. Responsible Party: Clinical. Physician Notification and Consultation- Notification is provide to residents and/or the resident representative(S) to promote the right to make informed decisions regarding choices for care and treatment while keeping them informed about their current health status.1. R1's Face Sheet, dated 7/16/25, documents R1 is a [AGE] year-old male that admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Cerebral Palsy, Epilepsy, Unspecified Intellectual Disabilities, Hypothyroidism, Bradycardia, and Dysphagia, and Gastrostomy Status Placed 4/30/25.R1's MDS (Minimum Data Set) Assessment, dated 7/1/25, documents R1 had a significant weight loss of five or more percent in one month and/or ten percent or more in six months and is not on a physician-prescribed weight loss regimen.The facility's Weight Variance Report, dated 1/1/25 through 7/9/25, documents R1 weighed 126.2 pounds on 6/3/25 and 109.60 pounds on 7/1/25 indicating R1 had a severe weight loss of 13.2 percent weight loss in one month.R1's Electronic Medical Record does not include notification to V22/R1's Guardian of R1's severe weight loss of 13.2 percent identified on 7/1/25.On 7/15/25 at 9:35 AM V22/R1's Guardian stated she was never notified of R1's significant weight loss identified on 7/1/25 or any weight loss prior to that date. V22 stated, I would have liked to have known about (R1's) severe weight loss. I am very involved in (R1's) care and want him to be able to return to where (R1) lived prior to admitting to (this facility).On 7/15/25 at 10:12 AM V18/Regional Director stated it is the responsibility of the Director of Nursing to notify the family after a significant weight loss is identified. V18 stated, I cannot find any documentation of anyone notifying V22/R1's guardian of R1's significant weight loss identified on 7/1/25.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to protect a resident from staff-to-resident verbal abuse for one of th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to protect a resident from staff-to-resident verbal abuse for one of three residents (R13) reviewed for staff-to-resident abuse in the sample of 30. Findings include:The facility's Abuse Prevention Policy, undated, documents The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of the individual's age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never to be able to see his/her family again.R13's MDS (Minimum Data Set) assessment dated [DATE] documents R13 is cognitively intact.On 7/16/25 at 2:45 PM R13 stated, One night about a month ago a CNA (Certified Nursing Assistant/unknown name) picked up a trash can and wanted to throw it at me and cussed me out. I reported this to (V3/Prior Director of Nursing). (V3) told me she fired the CNA because of abusing me. I felt threatened.On 7/17/25 at 11:00 AM V1 (Administrator-In-Training) stated, I was on maternity leave around a month ago, so (V18/Regional Director) was covering for me. A CNA should not cuss or threaten to throw a trashcan at (R13). (R13) would know if this happened and would know if the CNA still works here. I have not been able to figure out who the CNA was, as (R13) said she no longer works here.
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 F0605
(Tag F0605)
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 consent prior to administering psychotropic medications for o...
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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 consent prior to administering psychotropic medications for one of three residents (R1) reviewed for psychotropic medications in a sample of 30.Findings include:The facility's Psychotropic Medication Policy, dated 2/2014, documents 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: Psychotropic medication shall not be prescribed without the informed consent of the resident, the resident guardian, or other authorized representative.R1's Face Sheet, dated 7/16/25, documents R1 admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Unspecified Intellectual Disabilities and Epilepsy.R1's current Physician Order Sheet documents R1 receives Risperidone (psychotropic medication) 0.5 mg (milligram) tablet twice a day and Clobazam (psychotropic medication) 5mg twice a day.On 7/15/25 at 9:35 AM V22/R1's Guardian stated she never verbally gave consent or signed an informed consent for R1's psychotropic medications.On 7/15/25 at 2:24 PM V1/Administrator in Training stated, We (the facility) could not locate an informed psychotropic consent for (R1). We should have obtained one prior to administering (R1's) psychotropic medication.On 7/17/25 at 10:07 AM V19/Regional Nurse Consultant verified an informed psychotropic consent could not be produced for the use of R1's Psychotropic medication.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to implement their Abuse Policy to immediately report an allegation of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to implement their Abuse Policy to immediately report an allegation of resident abuse to the State Agency and Administrator for one of seven residents (R13) reviewed for Abuse in the sample of 30.Findings include:The facility's Abuse Prevention Policy, undated, documents The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. V. Internal Reporting Requirements and Identification of Allegation: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. In the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence. Reports will be documented, and a record kept of the documentation. Supervisors shall immediately inform the administrator or person designated to act in the administrator's absence of all reports of incidents, allegations or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property. Any allegation of abuse or any incident that results in a serious bodily injury will be reported to the Illinois Department of Public Health immediately, but not more than two hours of allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported withing 24 hours. External Reporting- 1. Initial Reporting of Allegations: When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has been made, the administrator or designee, shall notify Department of Public Health's regional office immediately by telephone of fax. Public health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property has been reported to the administrator and is being investigated. 2. Five-day Final Investigation Report: Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health.R13's MDS (Minimum Data Set) assessment dated [DATE] documents R13 is cognitively intact.On 7/16/25 at 2:45 PM R13 was lying in bed. R13 stated, One night about a month ago a CNA (Certified Nursing Assistant/unknown name) picked up a trash can and wanted to throw it at me and cussed me out. I reported this to (V3/Prior Director of Nursing). (V3) told me she fired the CNA because of abusing me. I felt threatened.R13's Electronic Health Record and the facility's Abuse Investigations do not include evidence of the administrator or the State Agency being notified of R13 alleging a CNA cursed at R13 and threatened to pick up a trash can and throw the trash can at R13.On 7/17/25 at 11:00 AM V1 (Administrator-In-Training) stated, I was on maternity leave around a month ago, so (V18/Regional Director) was covering for me.On 7/17/24 at 11:25 AM V18 (Regional Director) verified V3 did not report R13's allegation that a CNA cursed at R13 and threatened to throw a trash can at R13. V18 stated V3 should have reported the allegation to V18 immediately.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to immediately investigate an allegation of resident abuse for one of s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to immediately investigate an allegation of resident abuse for one of seven residents (R13) reviewed for Abuse in the sample of 30.Findings include:The facility's Abuse Prevention Policy, undated, documents The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. VII. Internal Investigation- 2. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation. 8. Final Investigation Report: The investigator will report the conclusions of the investigation in writing to the administrator or designee within five working days of the reported incident.R13's MDS (Minimum Data Set) assessment dated [DATE] documents R13 is cognitively intact.On 7/16/25 at 2:45 PM R13 was lying in bed. R13 stated, One night about a month ago a CNA (Certified Nursing Assistant/unknown name) picked up a trash can and wanted to throw it at me and cussed me out. I reported this to (V3/Prior Director of Nursing). (V3) told me she fired the CNA because of abusing me. I felt threatened.R13's Electronic Health Record and the facility's Abuse Investigations do not include evidence of an investigation being conducted regarding R13 alleging a CNA cursed at R13 and threatened to pick up a trash can and throw the trash can at R13.On 7/17/25 at 11:00 AM V1 (Administrator-In-Training) stated, I was on maternity leave around a month ago, so (V18/Regional Director) was covering for me.On 7/17/24 at 11:25 AM V18 (Regional Director) verified V3 did not report R13's allegation that a CNA cursed at R13 and threatened to throw a trash can at R13, therefore an investigation has never been done.
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 F0628
(Tag F0628)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to provide residents with a bed hold and written notice of transfer when transferring to the hospital for three of three residents (R3, R13, an...
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Based on interview and record review the facility failed to provide residents with a bed hold and written notice of transfer when transferring to the hospital for three of three residents (R3, R13, and R14) reviewed for hospital transfers in a sample of 30. Findings include: The facility's Transfer and Discharge Policy, un-dated, documents Policy: To assure resident transfers and discharges will be conducted in accordance with residents' rights, physician orders, and in such a manner as to maintain continuity of care for the resident. Policy Specifications: 2. When the facility transfers or discharges a resident under any circumstances, the resident/authorized legal representative must be notified verbally and in writing at least 30 days prior to the intended discharge unless the resident waives the notification period or in an emergency. (including situations where the safety of other residents may be compromised). The facility must also: b. Include a written notice to the resident/authorized legal representative the following. i. reason for transfer/discharge; ii. Effective date of transfer, iii. Location to which the resident will be transferred/discharged ; iv. A statement that the resident has the write to appeal the action to the State; v. the name, address, and telephone number of the State long term care ombudsman; and vi. Any other appropriate advocacy or protective services agency as required by the state. The facility's Bed Hold Policy Notification, undated, documents This Bed Hold Policy will be given to you at the time of admission and a copy will be given to you each time you are transferred from the facility. 1. R3's current Census Sheet, documents R3 was sent to the hospital on 1/13/25 and 7/5/25. R3's medical record did not contain documentation of a written notice of the facility's bed hold policy or notice of discharge was given to R3 or R3's representative for 1/13/25 and 7/5/25. 2. R13's current Census Sheet, documents R13 was sent to the hospital on 6/26/25. R13's medical record did not contain documentation of a written notice of the facility's bed hold policy or notice of discharge was given to R13 or R13's representative for 6/26/25. 3. R14's current Census Sheet, documents R14 was sent to the hospital on 2/9/25. R14's medical record did not contain documentation of a written notice of the facility's bed hold policy or notice of discharge was given to R14 or R14's representative for 2/9/25. On 7/16/25 at 10:30 AM V1/Administrator in Training verified R3 or R3's representative was not given a bed hold or notice of transfer on 1/13/25 and 7/5/25 when transferred to the hospital, R13 or R13's representative was not given a bed hold or notice of transfer on 6/26/26 when transferred to the hospital, and R14 or R14's representative was not given a bed hold or notice of transfer on 2/9/25 when transferred to the hospital. V1 stated When any resident goes out to the hospital, they should receive a bed hold and a written notice of transfer.
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 observation, interview, and record review the facility failed to ensure a resident received a consultation with a lymph...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident received a consultation with a lymphedema specialist and a nephrologist, as ordered by the physician, for one of four residents (R26) reviewed for physician orders in the sample of 30. Findings include:The facility's Physician Orders Policy, dated 1/23/25, documents Procedures: 6. Nursing staff will follow physician orders. In an event where a resident refuses medication or treatment, or medication is not available, Physician or Nurse Practitioner will be notified.The facility's Transportation Policy, dated 6/21/2021, documents Policy: It is the policy of this facility to assist residents in obtaining transportation when necessary for services outside the facility. Standards: 3. Nursing or Social Service personnel or designee shall assist residents in obtaining transportation when it is necessary to obtain medical, dental, diagnostic, or other services outside the facility. Staff shall be familiar with requirements for prior approval from the State Department of Public Aid, as appropriate. 10. If the facility is unable to provide in-house transportation, an outside transport will be sough within a reasonable travel distance.R26's Face Sheet documents R26 was admitted on [DATE] with the following, but not limited to, diagnosis: Lymphedema, Type Two Diabetes Mellitus, Stage Two Chronic Kidney Disease, and Hyponatremia.R26's Physician Order Sheet, dated 4/8/25, documents Start Date 4/8/25: Follow up with nephrologist in one to two weeks for hyponatremia. Start Date 4/8/25: Follow up with outpatient lymphedema clinic.R26's Progress Note dated 5/21/25 at 9:54 AM documents, Reviewed for significant weight gain of 50 pounds past month per fluid status/lymphedema. Good appetite per regular diet with 1500 cc (cubic centimeters) fluid restriction. Nursing to review with physician as need for diuretic. Per staff, not following 1500 cc fluid restriction.R26's Physician's Order dated 5-22-25 documents, Lymphedema clinic consult for evaluation and treatment.R26's Electronic Medical Record does not include evidence of R26 receiving a physician ordered consult with an outpatient lymphedema clinic or a physician ordered follow up with a nephrologist.On 7/17/25 at 9:40 AM R27 was lying in her bed in her room. R27's bilateral lower extremities were swollen, dry, and had multiple dry scabs. R27 stated, I admitted to this facility to get treatment for my lymphedema so I can return home. I have never received my appointment to see a lymphedema specialist or to see my nephrologist and would like to receive them so I can work towards going home.On 7/15/25 at 1:15PM V25/Receptionist stated, I had called a Lymphedema Specialty Clinic to get an appointment for (R27) at some point and the Lymphedema Specialty Clinic stated they needed a referral from a Lymphedema Specialist to be able to see (R27). I let V3/Prior Director of Nursing know what the Lymphedema Specialty Clinic said. I did not hear anymore after that and did not schedule any other appointment for (R27) to go to a Lymphedema Specialty Clinic. I am unaware of (R27) needing a follow up appointment for nephrology.On 7/17/25 at 11:20AM V7/Transportation/Scheduling stated, I am responsible for scheduling appointments and taking residents to their appointments. (V3/Prior Director of Nursing) never let me know that (R27) needed a follow up appointment with a Nephrologist after (R27's) admission to (our facility). That appointment never got scheduled. (V3) did ask me to set up an appointment for (R27) to see a Lymphedema Specialist. I reached out to a few Lymphedema clinics. I got an appointment set up at a clinic, but then they called back and said there is no lymphedema doctor at that clinic and that I would need a referral sent to them by a Lymphedema Specialist for them to see (R27). I let (V3) know this. (V3) told me to search for a Lymphedema Specialist in the area. We (the facility) cannot transport residents over a 50-mile radius due to the transportation van liability. I could not find a Lymphedema Specialist within that radius, so I again let (V3) know. (V3) never let me know anything after that, so (V3) never seen a Lymphedema Specialist.On 7/17/25 at 11:25 AM V1/Administrator in Training verified R27 had never received an appointment to see a Lymphedema Specialist or to see a Nephrologist as physician ordered. V1 stated We (the facility) are getting (R27) set up today to see a Lymphedema Specialist and a Neurologist. (V3/Prior Director of Nursing) did not let me know there was an issue getting (R27) in for her appointments.
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 update a pressure ulcer care plan and implement pressu...
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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 update a pressure ulcer care plan and implement pressure relieving interventions for one of three residents (R1) reviewed for pressure ulcers in the sample of 30.Findings include:The facility's Prevention of Pressure Wounds Policy, dated 1/2025, documents Purpose: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. General Guidelines: 1. Pressure injuries are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. 2. The Most common site of a pressure injury is where the bone is near the surface of the body including the back of the head around th4 ears, elbows, should blades, backbone, hips, knees, heels, ankles, and toes. 5. Once a pressure injury develops, it can be extremely difficult to heal. Pressure injuries are a serious skin condition for the resident. Interventions and Preventative Measures: 1. Identify risk factors for pressure injury development. Additional Factors that Indicate Residents at Risk: The following are additional clinical conditions, treatments, and abnormal lab values that indicate that a resident is at risk for pressure injuries. 1. Impaired/decreased mobility and decreased functional ability; 2. Co-morbid conditions, such as end stage renal disease, thyroid disease, or diabetes mellitus; 6. Cognitive Impairment; 7. And Malnutrition, and hydration deficits. Equipment and Supplies: The following equipment and supplies will be necessary when providing preventive skin care. 1. Tools for assessing skin and pressure injury risk: a. Braden Risk Assessment Form. b. Intervention Preventive Measures.The facility's Skin and Wound Care Management, dated 11/28/2017, documents Guidelines: 8. Preventative measures, such as barrier creams, can be employed to help maintain skin integrity as well as utilization of pressure relieving surfaces, floating heels, protective boots, and use of positioning devices.R1's Face Sheet, dated 7/16/25, documents R1 is a [AGE] year-old male that admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Cerebral Palsy, Epilepsy, Unspecified Intellectual Disabilities, and Hypothyroidism.R1's MDS (Minimum Data Set) Assessment, dated 7/1/25, documents R1 is dependent with all Activities of Daily Living, is at risk for developing pressure ulcers, and has one stage 2 unhealed pressure ulcer.R1's Full Clinical/Body Observation, dated 5/15/25, documents R1 had no skin alterations/pressure ulcers.R1's Braden Scale Pressure Risk Assessment, dated 5/19/25, documents R1 was a very high risk for pressure ulcer development.R1's Initial Wound Evaluation and Management Summary, dated 6/30/25 and signed by V14/Wound Physician, documents Chief Complaint: (R1) presents with a wound on his right posterior heal. Stage two Pressure Wound of the Right, Posterior Heel Partial Thickness: Etiology: Pressure. Stage: 2. Duration: Less than one day. Wound Size: 4.5cm (Centimeters) x 5.0cm x Not Measurable. Exudate: None. Dermis: Open areas with exposed dermis. Blister: Fluid Filled. Additional Care Plan Items. Pressure Off-Loading Boot.R1's Wound Management Detail Report, dated 7/14/25 and signed by V4/Wound Nurse, documents an in house acquired stage two pressure ulcer was identified on 7/1/25 to R1's right heel. This same report documents, Date Observed: 7/14/25. Length 4.5cm (Centimeters) x Width 5.0cm x Depth 0.0cm. Exudate Amount: None. Tissue Type: Closed/Resurfaced.R1's current Care Plan does not document an intervention to apply a pressure relieving off-loading boot to R1's right heel.On 7/14/25 from 1:05 PM through 1:15 PM R1 was sitting in his wheelchair in the dining room. R1's right foot was observed to have a sock on and R1's right heel was resting on his right foot pedal of his wheelchair.On 7/15/25 at 11:32 AM R1 was sitting in the dining room in his wheelchair. R1's right heel observed to have a tennis shoe on and was resting on his right wheelchair foot pedal.On 7/16/25 at 10:12 AM V4/Wound Nurse prepared treatment to R1's right heel. R1's right heel area observed to be approximately a quarter in size. No drainage observed.On 7/16/25 at 12:05 PM V4/Wound Nurse stated, (R1) has a facility acquired pressure ulcer stage 2 to his right heel. (R1's) right heel area was caused by pressure. (R1) should be wearing a pressure relieving boot to his right heel but it sometimes would make his heel slide off his foot pedal. I did not let (V14/Wound Physician) know that we were not following her recommendation to apply a pressure relieving boot to (R1's) right heel. We (the facility) should still be offloading (R1's) heel or applying his pressure relieving boot and haven't been. I am responsible for updating (R1's) skin care plan. I did not update (R1's) skin care plan with new interventions to offload (R1's) heels while in bed or to apply a pressure relieving boot to (R1's) right heel while out of bed to prevent deterioration of the right heel pressure wound and should have.
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
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 monitor an indwelling urinary catheter for urine outpu...
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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 monitor an indwelling urinary catheter for urine output, urine color, and urine consistency, perform a voiding trial as ordered by a physician, follow-up with urology as ordered by a physician, and provide catheter care every shift for one of four residents (R4) reviewed for indwelling urinary catheters in the sample of 30.Findings include:The facility's Urinary Catheter Care Policy, dated 9/2005, documents Purpose: The purpose of this procedure is to prevent infection of the resident's urinary tract. Preparation: 1. Review the residents plan to assess for any special needs of the resident. 7. Maintain an accurate record of the resident's daily output, per facility policy and procedure. Documentation: The following information should be recorded in the resident's medical record- 1. The date and tie that catheter care was given. 2. The name and title of the individual(s) giving the catheter care. 3. All assessment data obtained when giving catheter care. 4. Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor. 5. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain. 5. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting or pain. 6. Any problems or complaints made by the resident related to the procedure. 7. How the resident tolerated the procedure. 8. If the resident refused the procedure, the reason(s) why and the intervention taken. 9. The signature and title of the person recording the data.R4's Hospital Pre-admission Progress Note dated 6/26/25 documents R4 had an indwelling urinary catheter placed on 6/18/25 for the diagnoses of Urinary Retention. ‘R4's Hospital Discharge Orders dated 6/25/25 document Transfer to (facility). Voiding trial in next three to five days. Follow-up with the urology for recurrent urinary retention.R4's current Physician Order Report documents R4 was admitted to the facility on [DATE] with the diagnoses of Urinary Retention.R4's current Care Plan documents, Start Date 6/25/25: (R4) requires an indwelling urinary catheter related to urinary retention. Goal: (R4) will have catheter care managed appropriately as evidenced by not exhibiting signs of urinary tract infection or urethral trauma. Approach: Assess the drainage each shift. Measure and record intake and output. Provide catheter care each shift and as needed.R4's Electronic Health Record dated 6/25/25 (date of admission) through 7/15/25 does not include evidence of R4's intake and output being monitored, R4's urinary catheter drainage being monitored each shift, or R4's urinary catheter care being performed every shift. This same record also does not include evidence of a voiding trial being completed as ordered or a follow-up with urology.On 7/15/25 at 12:20 PM R4 was lying in bed with an indwelling urinary catheter bag hanging on the left side bed frame. R4's urinary catheter tubing had brown dried debris located at the insertion site. R4 stated staff do not clean his catheter tubing daily.On 7/16/25 at 1:00 PM V19 (Regional Nurse Consultant) verified R4's voiding trial and follow-up with urology did not get completed as ordered, and the facility did not monitor R4's intakes and outputs, urinary drainage, or provide urinary catheter care every shift.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to update weight loss care plans with weight loss interventions for two...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to update weight loss care plans with weight loss interventions for two of four residents (R1 and R16) reviewed for significant weight loss in the sample of 30.Findings include:The facility's Weight Assessment and Intervention Policy, dated 1/2025, documents The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month- Five percent weight loss is significant; greater than 5% is severe. b. 3 months- 7.5 percent weight loss is significant; greater than 7.5% is severe. c. 6 months- 10 percent weight loss is significant; greater than 10 percent is severe. Care Planning: 2. Individualized care plans shall address to the extent possible: a. The identified causes of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment.1. R1's Face Sheet, dated 7/16/25, documents R1 is a [AGE] year-old male that admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Cerebral Palsy, Epilepsy, Unspecified Intellectual Disabilities, Hypothyroidism, Bradycardia, and Dysphagia, and Gastrostomy Status Placed 4/30/25.R1's MDS (Minimum Data Set) Assessment, dated 7/1/25, documents R1 had a significant weight loss of 5 or more percent in one month and/or 10 percent or more in 6 months and is not on a physician-prescribed weight loss regimen.The facility's Weight Variance Report, dated 1/1/25 through 7/9/25, documents R1 weighed 126.2 pounds on 6/3/25 and 109.60 pounds on 7/1/25 indicating R1 had a significant weight loss of 13.2 percent weight loss in one month.R1's current Physician Orders documents R1 has a physician order to receive a magic cup (Nutritional Supplement) daily and Prostat (Nutritional Supplement) 30 milliliters twice a day to promote weight/protein status.R1's current Care Plan does not include updated weight loss interventions to prevent further weight loss of a magic cup and Prostat after a significant weight loss was identified on 7/1/25.2. R16's Face Sheet, dated 7/16/25, documents R16 is a [AGE] year-old male that admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Quadriplegia, Cerebral Infarction, Alzheimer's, Type Two Diabetes Mellitus, and Major Depressive Disorder.The facility's Weight Variance Report, dated 1/1/25 through 7/9/25, documents R16 weighed 156.40 on 1/6/25 and 130.40 on 7.3.25 indicating a significant weight loss of 16.6 percent in 6 months and weight 137.60 on 6/2/25 and 130.40 indicating a significant weight loss of 5.2 percent in one month.R16's current Physician Orders documents R16 has a physician order to receive Prostat 45 milliliters (Nutritional Supplements) twice a day and double portions at all meals to promote weight/protein status.R16's current Care Plan documents R16 is at risk for malnutrition. This same plan of care does not document updated weight loss interventions to prevent further weight loss of Prostat 45 milliliters twice a day and double portions at all meals after a significant weight loss was identified on 7/3/25 of 5.2 percent in one month and 16.6 percent in 6 months.On 7/16/25 at 1:19 PM V10/Dietary Manager stated she is responsible for updating dietary care plans for residents who are identified for significant weight losses and have new physician ordered nutritional interventions. V10 verified she did not update R1's nutritional care plan with new nutritional interventions after a significant weight loss was identified on 7/1/25 or R16's nutritional care plan with new nutritional interventions after a significant weight loss was identified on 7.3.25. V10 stated, I should have updated both (R1) and (R16's) nutritional care plan with new physician ordered weight loss interventions when the significant weight losses were identified to prevent further weight loss. I just haven't got that far yet.
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 F0773
(Tag F0773)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to obtain a physician ordered Basic Metabolic Panel for one of five residents (R19) reviewed for laboratories in the sample of 30.Findings incl...
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Based on record review and interview the facility failed to obtain a physician ordered Basic Metabolic Panel for one of five residents (R19) reviewed for laboratories in the sample of 30.Findings include:The facility's Physician Orders policy dated 1/23/25 documents, Nursing staff will follow physician orders.R19's current Physician Order Report documents, Start Date 1/15/25: Basic Metabolic Panel every Wednesday every two weeks.R19's Medical Record dated 1/15/25 documents R19 has only had a Basic Metabolic Panel laboratory obtained on 6/25/25, 7/2/25, 7/4/25, and 7/9/25. On 7/16/25 at 11:00 AM V19 (Regional Nurse Consultant) verified R19 did not have a Basic Metabolic obtained every two weeks as ordered on 1/25/25.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions during direct cares for one of five residents (R22) reviewed for infection control in t...
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Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions during direct cares for one of five residents (R22) reviewed for infection control in the sample of 30.Findings include:The facility's Enhanced Barrier Precautions policy dated 01/2025 documents, Guideline: It is the practice of this facility to implement enhanced barrier precautions for the prevention of transmission of multi-drug-resistant organisms. Enhanced Barrier Precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents know to be colonized or infected with a MDRO (Multi-Drug-Resistant Organism) as well as those at increased risk of MDR acquisition. Implement Enhanced Barrier Precautions for residents with any of the following: Wounds and/or indwelling devices. High-contact resident case activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care.R22's current Physician Order Report documents R22 has the diagnoses of a Colostomy, a Pressure Ulcer of right buttock, and an Indwelling Urinary Catheter.R22's current Care Plan documents, Problem start date 6/10/25: (R22) requires Enhanced Barrier Precautions related to indwelling urinary catheter, colostomy, and open wound on right ischium. Goal: Enhanced Barrier Precautions will reduce the spread of the infectious agent, minimize the transmission of the infection, and reduce the risk of colonization through next review. Approach: Gown and glove use when performing high-contact resident contact activity.On 7/16/25 at 11:00 AM R22 was lying in bed and had an Enhanced Barrier Precautions sign posted on his doorway to his room. V29 (CNA/Certified Nursing Assistant) had gloves on and was emptying stool out of R22's colostomy into a urinal. V29 was not wearing a gown while emptying R22's colostomy bag stool.On 7/16/25 at 12:10 PM V29 stated, I should have worn a gown when emptying the stool out of (R22's) colostomy bag. I guess I just forgot.On 7/16/25 at 12:15 Pm V11 (Infection Preventionist) stated V29 should have worn a gown when emptying R22's colostomy bag.
Jul 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy to ensure resident to resident physical abuse did...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy to ensure resident to resident physical abuse did not occur for one resident (R5) reviewed for abuse in a sample of four.
Findings include:
Facility's Abuse Policy, reviewed 5/19/25, documents: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Abuse means any physical or mental injury or sexual assault inflected upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.
Facility's Initial and Final Reports to (State Department of Public Health) for R4 and R5, dated 5/19/25, document: There was an altercation between R4 and R5. R4 ambulates with his walker and attends activity sessions in the dining room. While R4 was seated with the walker by his side, R5, who propels himself with a wheelchair, entered the dining room and moved R4's walker to provide more space. As soon as R5 moved R4's walker, R4 hit R5's face in attempt to stop him from moving it.
1. R5's diagnoses include: Mantle cell lymphoma, malignant neoplasm of prostate, generalized anxiety disorder, personal history of other venous thrombosis and embolism.
R5's Minimum Data Set/MDS dated [DATE] documents R4 has a BIMS (Brief Interview of Mental Status) of 6 on a scale of 00 - 15 indicating severe impairment. (MDS indicates that on a scale of 0 - 15, 13 to 15 cognitively intact; 8 to 12 moderate impairment; and 0 to 7 severe impairment.)
R5's progress note, dated 5/18/25 documents: (R5) involved in altercation in dining room with another resident (R4) and was struck in the Left cheek.
On 6/27/25 at 1:35pm, R5 stated he did not remember any altercation that he had with R4.
2. R4's diagnoses include: Mild intellectual disabilities, malignant neoplasm of right testis, schizoaffective disorder, major depressive disorder, chronic kidney disease.
R4's Minimum Data Set/MDS dated [DATE] documents R4 has a BIMS score of 15 on a scale of 00 - 15.
R4's current Care Plan documents: Category: Mood State: (R4) exhibiting change in usual behavior as evidenced by increased restlessness, fidgety, lack of initiative/involvement, and being irritated. Category: Behavioral Symptoms: (R4) shows signs of physical aggression when agitated. Threw his television/TV remote at nurse when she was attempting to give him medications. Category: Behavioral Symptoms: (R4) displays verbal behavioral symptoms directed toward others as evidenced by pacing, cursing, and verbally threatening others when he is agitated.:
R4's Progress Note, dated 5/18/25 documents: An altercation occurred in the main dining room between R4 and R5. R4 observed yelling at R5 for allegedly grabbing (R4's) walker. Before staff could intervene, resident swung and struck R5 in the cheek.
R4's 5/19/25 statement regarding the altercation documents: After (V5) grabbed (V4's) walker, I tapped him on his nose very lightly and the nurse got upset.
On 6/27/25 at 1:25pm, R4 stated that he does not recall the 5/18/25 altercation with R5.
On 7/1/25 at 11:35am, V1 Administrator stated that the altercation between R4 and R5 occurred on the weekend during resident activities; stated that the staff who witnessed the altercation (V16 Agency Registered Nurse/RN) assessed both R4 and R5 and found no injuries. V1 stated that (V1) attempted to contact V16 several times for interview but was unable to reach her/V16.
On 7/1/25 at 11:35am, V1 stated, They (R4 and R5) were separated immediately after the incident, we made sure that during activities, make sure the tables had more space between them. R4 does not like his things touched; he hit R5 in the face in the nose area. R4 said his walker was moved and this upset him.
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 interviews and record review, the facility failed to thoroughly investigate an allegation of resident to resident abuse for one resident (R8) reviewed for abuse in a sample of four.
Findings...
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Based on interviews and record review, the facility failed to thoroughly investigate an allegation of resident to resident abuse for one resident (R8) reviewed for abuse in a sample of four.
Findings include:
Facility's Abuse Policy, reviewed 5/19/25, documents: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This will be done by implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences. Reports will be documented, and a record kept of the documentation. VII. 1. All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. 2. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation.
1. R7's Progress Note, dated 6/8/25 at 7:38pm, documents: Resident had incident with roommate. Roommate placed in another room.
2. R8's Progress Note, dated 6/8/25 at 7:34pm documents: Resident had incident with roommate and resident was moved to (another room). Resident okay with move. Skin assessment done and no injuries noted.
There was no other documentation in the Electronic Health Records/EHRs for either R7 or R8 regarding the 6/8/25 incident. (Documentation and staff interviews indicated R7 and R8 were roommates at the time of the 6/8/25 incident.)
On 6/27/25 at 1:40pm, R7 stated that she did not remember details about the incident involving her former roommate (R8). R7 Stated that regarding throwing her meal tray, that she probably threw the tray on the floor; I was pissed, same da*n food all the time.
On 7/1/25 at 11:35am, V1 Administrator stated that the 6/8/25 incident occurred during dinner time in R7 and R8's room; stated that she interviewed both R7 and R8 about the incident but did not document her interviews in the EHRs; and stated that she did not interview staff who were aware of the incident. V1 stated that (V12/LPN) was the night shift nurse for (R7 and R8) but (V1) did not interview V12/LPN.
At this same time, V1 stated there was no other documentation or investigation documentation regarding the incident. V1 stated, I was told that the tray that (R7) threw did not make contact with R8; I was under the impression that I had enough information and did not investigate further.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to document and implement a treatment order for one resident (R3) and failed to follow its policy for labeling and dating wound ...
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Based on observation, interview, and record review, the facility failed to document and implement a treatment order for one resident (R3) and failed to follow its policy for labeling and dating wound dressings after treatments for two (R1, R6) residents reviewed for wound care/treatments in a sample of four.
Findings include:
The facility's Medication and Treatment Orders policy, Revised 7/2016, documents: 3. Drug and biological orders must be recorded on the Physician's Order Sheet in the resident's chart.
The facility's Medication Orders Policy, Revised 11/2014, documents: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. A current list of orders must be maintained in the clinical record of each resident. 6. Treatment Orders - When recording treatment orders, specify the treatment, frequency and duration of the treatment.
The facility's Wound Care Policy, Revised 10/2010, documents: 13. Dress Wound. [NAME] tape with initials, time, and date and apply to dressing.
The facility's Skin and Wound Management Policy, Reviewed 1/2025, documents: 10. Document in the clinical record when treatments are performed.
1. R3's Progress Note Dated 5/12/25 documents: Resident (R3) evaluated during wound care rounds. Rash to chest and abdomen assessed.
R3's Specialty Physician Order (Wound Evaluation and Management Summary Dated 5/30/25) documents: Diagnosis: Scabies. Treatment: Permethrin (Elimite) 5% to whole body for 12 hours. Repeat in seven/7 days.
Review of R3's Electronic Health Record/EHR for May 2025 and June 2025 indicated no treatment order or staff signage for Elimite for R3.
On 7/1/25 at 1:05pm, V2 Director of Nursing/DON verified that R3's Treatment Order for Elimite which was prescribed by V17 Wound Physician was not documented in R3's Physician Orders or in R3's Treatment Administration Record/TAR in the EHR. V2 stated, Apparently he (R3) was not treated with the Elimite.
2. On 6/27/25 at 11:00, R1 noted to have dressings to bilateral heels; dressings are clean, dry and neatly intact. Dressings were not dated. R1's Specialty Physician Wound Evaluation and Management Summary order, dated 6/30/25 documents: Skin prep, alginate calcium once daily and as needed.
On 6/27/25 at 1:55pm, R6 was noted to have dressings to pressure wound of right upper groin; dressings clean, dry and intact; undated. R6's Specialty Physician Wound Evaluation and Management Summary Order dated 5/12/25 documents: Alginate calcium with silver; apply once daily and as needed for 30 days; collagen sheet apply once daily and as needed for 30 days.
On 6/27/25 at 11:35am, V4 Licensed Practical Nurse/LPN/Wound Nurse stated that residents' wound dressings were not labeled and dated; stated that once the staff signage is complete in the Treatment Administration Record/TAR, that is the documentation needed for the wounds.
On 7/2/25 at 10:15am, V4 LPN/Wound Nurse stated that she has been employed at the facility almost a year. V4 stated, I was told by facility staff that this (labeling and dating wound dressings after treatment) was not done at this facility; policy was to document in the TAR only.
May 2025
6 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
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
Based on interview, observation and record review, the facility failed to provide supervision and implement fall prevention interventions to prevent resident falls for two of three residents (R1 and R...
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Based on interview, observation and record review, the facility failed to provide supervision and implement fall prevention interventions to prevent resident falls for two of three residents (R1 and R4) reviewed for falls in the sample of 24. These failures resulted in R1 falling and sustaining an injury to right eyelid and R4 falling and experiencing left hip pain.
Findings include:
The facility's Fall Reduction Program (revised April 2019) documents the following: It is the policy of this facility to have a Fall Reduction Program that promotes the safety of residents in the facility. The program's intent is to assist clinical staff in determining the needs of each resident through the use of standard assessments, the identification of each resident's individual risks, and the implementation of appropriate interventions, supervision, and/or assistive devices deemed appropriate. Quality Assurance will monitor the program to assure ongoing effectiveness. This same policy documents, Safety interventions will be determined and implemented based on the assessed, individualized risks and in accordance with standards of care; interventions to be documented in the resident's care plan. This policy also documents, Examples of Standard Fall/Safety Precautions that May be Applicable: Call lights answered in a timely manner; Supervision of residents who require staff assistance with bathing, showering, or toileting. If resident is not able to maintain proper sitting balance, staff shall remain with resident allowing as much privacy as is safe for the resident.
1. R1's Fall Risk Observation (dated 05/09/25) documents a score of 20, indicating R1 is at high risk for falls.
R1's current Fall Prevention Care Plan documents the following: (R1) is at risk for falling related to polyneuropathy, generalized muscle weakness and cognitive deficit related to progression of Parkinson's. R1's current Functional Status Care Plan documents the following focus: (R1) requires extensive assistance with bed mobility due to weakness related to Parkinson's. R1's Functional Status Care Plan also documents the following intervention currently in place: Never leave (R1) in a position that is unsafe or uncomfortable to him.
R1's Minimum Data Set Assessments (dated 02/11/25 and 05/09/25) document in Section GG, R1 is dependent (helper does all of the effort, or the assistance of two or more helpers is required) in the following areas: Roll left and right, Sit to lying, and Lying to sitting on bed.
R1's Fall Investigation (dated 04/15/25) documents, IDT (Interdisciplinary Team) met to discuss alleged fall. (R1) was receiving cares in bed when CNA (Certified Nursing Assistant) turned away and (R1) rolled out of bed and onto the floor. (R1) has discoloration to right eyelid. Neurological checks initiated. (R1) not complaining of pain at this time. All notifications made, care plan updated. Root cause: Extensive assistance needed for all cares provided while in bed. Intervention: Two staff present during cares in bed at all times.
On 05/14/25 at 11:15 AM, V2 (Director of Nursing) stated that V16 (former Certified Nursing Assistant), Was the only one in with (R1) at the time of his fall. (V16) walked away and left (R1) unattended in his bed to obtain supplies while she was providing cares to him, and he fell out of his bed while he was unattended. (R1) ended up with a black eye. (V16) should not have walked away from (R1) at any time. She knew better than that. She was terminated and no longer works at the facility.
2. R4's current Fall Prevention Care Plan documents the following: (R4) is at risk for falling and repeat falls related to spinal stenosis, generalized edema, history of falls, generalized muscle weakness accompanied by poor safety awareness. This same care plan documents the following fall prevention interventions in place: CNAs (Certified Nursing Assistants) will assist (R4) to the bathroom and back using a wheelchair; Staff will frequently check on (R4) and anticipate her needs.
R4's Fall Investigation (dated 03/14/25) documents the following: (R4) stated she needed to use the bathroom and was in a hurry, so she attempted to get up alone. She lost balance and lowered herself to her knees. (R1) stayed on her knees until CNA (Certified Nursing Assistant) and Nurse entered room and were able to transfer resident back into the bed. No injury. This same investigation documents that R4's call light was on at the time of R4's fall.
On 05/14/25 at 10:00 AM, R4 was sitting in a recliner in her room watching television. When asked about falling in the facility, R4 stated the following: My legs are weak, so I do fall a lot. I'm supposed to ask for help and wait for them to come, but it usually takes too long. There're times I've had an accident in my pants waiting for help to go to the bathroom. I feel like this happens constantly. It takes a really long time for someone to answer the call light at nighttime. I've waited several hours. They try to get to you during the day, but at times you wait 30 to 45 minutes. They definitely need to schedule more nurses and CNAs. R4 was able to recall her 03/14/25 fall and stated the following: I needed to use the bathroom, and I had my call light on. I waited and waited, and no one ever came, so I attempted to get up by myself. That was a mistake because I fell onto my knees. I stayed on my knees for several minutes until someone finally came to help.
On 05/14/25 at 11:25 AM, V2 (Director of Nursing) verified that R4's call light was on at the time of her 03/14/25 fall, and stated staff should be checking on R4 frequently, especially since she is a high risk for falls.
R4's Fall Investigation (dated 04/10/25) documents the following: Resident experienced an unwitnessed fall around 07:30 AM. After the fall, she stated she had left hip pain, and she stated she hit her head. Writer assessed resident after falling. No bleeding, resident alert, neuro (neurological) check done and normal, MD (Medical Doctor) and POA (Power of Attorney) notified. Resident is being sent to ED (emergency department) to be evaluated. This same investigation documents: Resident statement of what happened: I was trying to use the bathroom. This investigation also documents the following conclusion: Root cause: Staff did not follow plan intervention. Staff education and discipline.
On 05/14/25 at 11:30 AM, V2 (Director of Nursing) stated, After (R4's) fall on 04/10/25, (V18, Certified Nursing Assistant) received discipline because she did not check on (R4) frequently. I watched the camera that records the entrance to (R4's) room, and it was an extended period of time before (V18) checked on (R4) since she had last been checked. (R4) is supposed to be checked on frequently, at least every 15 minutes.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to implement all components of their abuse policy for one of four residents (R1) reviewed for abuse in the sample of 24.
Findings include:
Th...
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Based on interview and record review, the facility failed to implement all components of their abuse policy for one of four residents (R1) reviewed for abuse in the sample of 24.
Findings include:
The facility's Abuse Prevention Policy (undated) documents the following Investigation Procedures: The appointed investigator will at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other submitted documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed.
R1's Abuse Investigation (dated 04/21/25) documents an abuse investigation was initiated after R1 verbalized an allegation of physical abuse to V15 (R1's wife). This investigation did not include documentation of any interviews obtained from residents who receive assistance from the same caretakers who provide care to R1.
On 05/14/25 at 03:45 PM, V1 (Administrator) stated she was out of the facility when R1's 04/21/25 Abuse Investigation was conducted, and the investigation was conducted by the individual appointed in her absence. V1 confirmed that all components of the facility's Abuse Policy were not implemented when R1's 04/21/25 Abuse Investigation was conducted and stated resident interviews should have been obtained during the investigation.
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 thoroughly investigate an allegation of physical abuse for one of four residents (R1) reviewed for abuse in the sample of 24.
Findings inc...
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Based on interview and record review, the facility failed to thoroughly investigate an allegation of physical abuse for one of four residents (R1) reviewed for abuse in the sample of 24.
Findings include:
The facility's Abuse Prevention Policy (undated) documents the following Investigation Procedures: The appointed investigator will at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other submitted documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed.
R1's current care plan documents the following focus: (R1) is an adult living with chronic health conditions, challenges, and co-morbidities and symptomatologic factors that require monitoring that put him at risk for abuse. This same care plan also documents the following focus: (R1) displays deficits in cognition, a BIMS (Brief Interview of Mental Status) score of 00.
R1's Abuse Investigation (dated 04/21/25) documents, On 04/21/25, (V15, R1's wife) relayed she was concerned about discoloration to (R1's) eye area. (V15) also stated that (R1) said a man came in his room and did that to him. (V15) added that (R1) was 'trying to get her (V15) out of a locked room' and that is what caused the fall. Investigation was immediately initiated. Staff from night of 04/15/25 were interviewed and did not see any male enter (R1's) room. This same investigation does not include any interviews of residents who reside near R1's room and receive care from the same staff members.
On 05/13/25 at 10:30 AM, V15 (R1's wife) stated, I am a retired nurse, which makes me a mandated reported. He had such a terrible bruise to his eye that it just did not seem consistent with a fall. One day while I was visiting, I asked him how he managed to get a black eye, and he told me that a man had come into his room and hit him. He couldn't tell me exactly when, but it made me concerned. I felt like I had to report it after he said that.
On 05/14/25 at 11:15 AM, V2 (Director of Nursing) stated that R1 is typically confused, but can have moments of lucidity. V2 stated that besides R1, no other residents whose room is located near R1's and receive assistance from the same caregivers were interviewed during R1's 04/21/25 abuse investigation. V2 verified R1's abuse investigation was not thoroughly investigated and stated, Some of the interviewable residents in (R1's) hallway should have been interviewed and those interviews included in the investigation.
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
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to respond to resident call lights in a timely manner for seven of seven residents (R2, R3, R4, R6, R8, R9 and R10) reviewed for ...
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Based on observation, interview and record review, the facility failed to respond to resident call lights in a timely manner for seven of seven residents (R2, R3, R4, R6, R8, R9 and R10) reviewed for call light response time in the sample of 24.
Findings include:
The facility's 'Answering the Call Light' policy (dated August 2008) documents the following: The purpose of this procedure is to respond to the resident's requests and needs; General Guidelines: 8. Answer the resident's call light as soon as possible; Steps in the Procedure: 4. Do what the resident asks of you, if permitted; and, 5. If you have promised the resident you will return .do so promptly.
The Facility Assessment (reviewed 07/30/24) goes on to document: The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required by the (State agency).
The facility's Grievance Log (dated 03/12/25 - 05/12/25) documents the following grievances filed: R9 reported a grievance on 3/27/25, documenting R9, Wants CNAs (Certified Nursing Assistants) to round more and answer call lights faster. R10 also filed a grievance dated 5/6/25, documenting: R10, Wants response time to (call) lights to be more timely.
On 5/13/25 at 10:08 AM, V9 (Certified Nursing Assistant) stated, I feel terrible because these residents have to wait, and sometimes it can be several minutes. We try our best, but there just isn't enough help.
On 05/13/25 at 10:11 AM, V14 (CNA/Certified Nursing Assistant) stated that there are not enough CNAs scheduled to answer call lights timely. V14 stated, It's very overwhelming and sometimes we cannot get all of our showers completed. If we do not get the missed showers made up the next day, we get written up. I work as hard as I can to get to the call lights as soon as possible, but there is only one of me and I cannot be in two places at once.
On 05/13/25 at 01:35 PM, R2 was sitting in a wheelchair in her room watching television. R2 stated, I have been here for several years. It's gotten really bad lately. They need more CNAs. It takes them forever to answer a call light. The other day I sat and waited to get changed (after an episode of incontinence) for an hour and a half.
On 05/13/25 at 01:38 PM, R3 was sitting in her wheelchair conversing with her roommate. R3 stated her biggest concern is the lack of CNAs that the facility schedules. R3 stated, There are only three of them and there used to be more. It can take over an hour for someone to answer a call light. Some CNAs are better than others.
On 5/13/25 at 1:55 PM, R6 was seated in a recliner in her room, alert and awake. R6 activated her call light at 1:58 PM. R6's call light was noted to be in working order and lit up above her door. The call light was also activated at the Nurses Station's call light indicator display board. At 2:19 PM, V3 (RN/Registered Nurse) verified R6's call light had been activated and went to R6's room to answer the call light. R6's call light went unanswered for 21 minutes, from 1:58 PM to 2:19 PM, when this surveyor notified V3, the RN on duty.
R8 communicated using hand gestures in response to this surveyor's inquiries. On 5/13/25 at approximately 1:50 PM, R8 indicated sometimes her call light is answered timely and she receives the care she needed and sometimes there is a long wait for response to her call light.
On 5/13/25 at 1:55 PM, V19 (R8's family member) stated they often have to wait long periods for staff to answer R8's call light. V19 stated, They are very busy.
On 5/13/25, R8's call light was activated at 2:00 PM. R8's call light went unanswered for 10 minutes, until this surveyor notified V5 (LPN/Licensed Practical Nurse) at 2:10 PM that R8's call light was on, and she needed incontinence care.
On 05/14/25 at 10:00 AM, R4 was sitting in a recliner in her room watching television. When asked about falling in the facility, R4 stated the following: My legs are weak, so I do fall a lot. I'm supposed to ask for help and wait for them to come after I use my call light, but it usually takes too long. There're times I've had an accident in my pants waiting for help to go to the bathroom. I feel like this happens constantly. It takes a really long time for someone to answer the call light at nighttime. I've waited several hours. They try to get to you during the day, but at times, you wait 30 to 45 minutes. They definitely need to schedule more nurses and CNAs.
On 5/14/25 at 4:00 PM, R9 stated the facility is, short-staffed, with the, extra CNAs, listed on the daily schedules sent home. R9 stated call lights are left unanswered for long periods and sometimes her requests are not met, stating the CNAs state they, will be back, and do not return.
On 5/14/25 at approximately 10:00 AM, V1, Administrator, stated call lights are to be answered, in five to ten minutes. V1 stated it was unacceptable to leave a call light unanswered for 20 minutes or more.
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
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to remove and discard unlabeled multi-dose insulin vials ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to remove and discard unlabeled multi-dose insulin vials and multi-dose insulin delivery pens from four active medication carts for 17 of 17 residents (R3 through R6, and R12 through R24) reviewed for insulin usage in the sample of 24.
Findings include:
The facility's undated Medication Administration policy documents: Medications shall be prepared and administered only to residents for whom they were ordered .
The facility's Storage of Medications policy (effective 10/25/14) documents the following: All medications dispensed by the pharmacy are stored in the container with a pharmacy label.
On 5/14/25 at 11:35 AM, an unlabeled, multi-dose vial of insulin was stored in the insulin compartment of the top drawer of the active medication cart for Harmony I hall. On 5/14/25 at 11:30 AM, V4 (RN/Registered Nurse) stated she would not use an unlabeled vial of insulin and any insulin pens or vials without an identifying label with the resident's name and the unlabeled, multi-dose should be discarded.
On 5/14/25 at 1:00 PM, an unlabeled, multi-dose insulin delivery pen was stored in the insulin compartment of the top drawer of the active medication cart for Harmony II hall. On 5/14/25 at 1:00 PM, V6 (RN/Registered Nurse) stated she would not use any insulin that was not labeled with the specific resident's name.
On 5/14/25 at 1:15 PM, an unlabeled, multi-dose insulin delivery pen was stored in the insulin compartment of the top drawer of the medication cart for [NAME] and [NAME] halls. On 5/14/25 at 1:15 PM, V5 (LPN/Licensed Practical Nurse) stated an unlabeled insulin vial or delivery pen should not be used for any resident.
On 5/14/25 at 1:25 PM, an unlabeled, multi-dose vial of insulin was stored in the insulin compartment of the top drawer of the medication cart in the respiratory unit. On 5/14/25 at 1:25 PM, V7 (LPN) stated she would not use this vial of insulin, as it was not labeled with a specific resident's name and would discard the vial.
On 5/14/25 at 1:01 PM, V2 (DON/Director of Nursing) stated any insulin vials or pens which are not labeled with the resident's name should be immediately discarded and never used for insulin delivery for any resident nor should it be stored in a medication cart. V2 stated each insulin-dependent resident's specific insulin vials and multi-dose insulin delivery pens are labeled with the resident's name by the pharmacy prior to delivery to the facility. V2 stated Nurses are to notify the Pharmacy when a specific resident's insulin needs to be refilled, and Nurses are not to use any other resident's insulin in place of another resident's insulin.
On 5/15/25, V2 provided a list of all residents in the facility who currently utilize insulin regularly. This list documents the following residents: R3 through R6, and R12 through R24.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to provide adequate staffing to deliver resident cares efficiently and in a timely manner. This failure has to potential to affec...
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Based on observation, interview and record review, the facility failed to provide adequate staffing to deliver resident cares efficiently and in a timely manner. This failure has to potential to affect all 72 residents currently residing in the facility.
Findings include:
The Facility Assessment (reviewed 07/30/24) documents the following: The facility assessment must address or include the facility's resident population, including; but not limited to: Both the number of residents and the facility's resident capacity; The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population. The Facility Assessment goes on to document: The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required by the (State agency).
Daily Staff Assignment posting sheets dated April 15, 2025, through May 12, 2025 documented six CNAs/Certified Nursing Assistants are consistently scheduled to cover the Day shift (6:00 AM to 6:00 PM) and four CNAs are scheduled to cover the Night shift (6:00 PM to 6:00 AM) to carry out resident cares throughout the facility, with a resident census ranging from 72 to 76 residents during this time. The assignment postings included one Extra Aid on day shift and one Extra Aid on Night shift. These extra CNAs names were crossed out and these forms documented went home or sent home and the extra staff member was not to stay and work the shift. This practice consistently left six CNAs on the Day shift and four CNAs to cover the Night shift.
The facility's Grievance Log, dated 2025, documents the following grievances filed: R9 reported a grievance on 3/27/25, documenting R9, Wants CNAs/Certified Nursing Assistants to round more and answer call lights faster. R10 also filed a grievance dated 5/6/25, documenting: R10, Wants response time to lights to be more timely.
On 5/13/25 at 1:55 PM, R6 was seated in a recliner in her room, alert and awake. R6 activated her call light at 1:58 PM. R6's call light was noted to be in working order and lit up above her door. The call light was also activated at the Nurses Station's call light indicator display board. At 2:19 PM, V3 (RN/Registered Nurse) verified R6's call light had been activated and went to R6's room to answer the call light. R6's call light went unanswered for 21 minutes, from 1:58 PM to 2:19 PM, when this surveyor notified V3, the RN on duty.
On 05/13/25 at 10:08 AM, V9 CNA/Certified Nursing Assistant) stated the facility does not staff enough CNAs. V9 stated in the hall she is currently assigned, There are several residents that transfer with (full mechanical lifts) and two CNAs are required to be present when transferring, using a (full mechanical lift). There are three CNAs in this area. The middle CNA has to cover their area, and float to the other two areas to assist. There used to be four CNAs scheduled and they have cut the staffing numbers. I feel terrible because these residents have to wait, and sometimes it can be several minutes. We try our best, but there just isn't enough help.
On 05/13/25 at 10:11 AM, V14 (CNA/Certified Nursing Assistant) stated that there are not enough CNAs scheduled to answer call lights timely. V14 stated, It's very overwhelming and sometimes we cannot get all of our showers completed. If we do not get the missed showers made up the next day, we get written up. I work as hard as I can to get to the call lights as soon as possible, but there is only one of me and I cannot be in two places at once.
On 05/13/25 at 10:30 AM, V15 (R1's spouse) stated the facility needs more staff, They all work very hard. They definitely need a few more CNAs to help out.
On 05/13/25 at 01:35 PM, R2 was sitting in a wheelchair in her room watching television. R2 stated, I have been here for several years. It's gotten really bad lately. They need more CNAs. It takes them forever to answer a call light. The other day I sat and waited to get changed (after an episode of incontinence) for an hour and a half.
On 05/13/25 at 01:38 PM, R3 was sitting in her wheelchair conversing with her roommate. R3 stated her biggest concern is the lack of CNAs that the facility schedules. R3 stated, There are only three of them and there used to be more. It can take over an hour for someone to answer a call light. Some CNAs are better than others.
R8 communicated using hand gestures in response to this surveyor's inquiries. On 5/13/25 at approximately 1:55 PM, R8 indicated sometimes her call light is answered timely and she receives the care she needed and sometimes there is a long wait for response to her call light.
On 5/13/25 at approximately 1:55 PM, V19 (R8's family member) was at the bedside and stated (R8) needs to be changed, She's wet. V19 then stated they often have to wait long periods for staff to answer R8's call light. V19 stated, They are very busy.
On 5/13/25, R8's call light was activated at 2:00 PM. R8's call light went unanswered for 10 minutes, until this surveyor notified V5 (LPN/Licensed Practical Nurse) at 2:10 PM that R8's call light was on and she needed incontinence care.
R8's current Care Plan documents the following interventions to prevent skin issues: Turn and reposition every 2 hours and as needed as tolerated by (R8). Provide incontinence care after each incontinent episode.
R4's Fall Investigation (dated 03/14/25) documents the following: (R4) stated she needed to use the bathroom and was in a hurry, so she attempted to get up alone. She lost balance and lowered herself to her knees. (R1) stayed on her knees until CNA (Certified Nursing Assistant) and Nurse entered room and were able to transfer resident back into the bed. No injury. This same investigation documents that R4's call light was on at the time of R4's fall.
On 05/14/25 at 10:00 AM, R4 was sitting in a recliner in her room watching television. When asked about falling in the facility, R4 stated the following: My legs are weak, so I do fall a lot. I'm supposed to ask for help and wait for them to come, but it usually takes too long. There're times I've had an accident in my pants waiting for help to go to the bathroom. I feel like this happens constantly. It takes a really long time for someone to answer the call light at nighttime. I've waited several hours. They try to get to you during the day, but at times you wait 30 to 45 minutes. They definitely need to schedule more nurses and CNAs. R4 was able to recall her 03/14/25 fall and stated the following: I needed to use the bathroom, and I had my call light on. I waited and waited, and no one ever came, so I attempted to get up by myself. That was a mistake because I fell onto my knees. I stayed on my knees for several minutes until someone finally came to help.
On 05/14/25 at 11:25 AM, V2 (Director of Nursing) verified that R4's call light was on at the time of her 03/14/25 fall, and stated staff should be checking on R4 frequently, especially since she is a high risk for falls.
R4's Fall Investigation (dated 04/10/25) documents the following: Resident experienced an unwitnessed fall around 07:30 AM. After the fall, she stated she had left hip pain, and she stated she hit her head. Writer assessed resident after falling. No bleeding, resident alert, neuro (neurological) check done and normal, MD (Medical Doctor) and POA (Power of Attorney) notified. Resident is being sent to ED (emergency department) to be evaluated. This same investigation documents: Resident statement of what happened: I was trying to use the bathroom. This investigation also documents the following conclusion: Root cause: Staff did not follow plan intervention. Staff education and discipline.
On 05/14/25 at 11:30 AM, V2 (Director of Nursing) stated, After (R4's) fall on 04/10/25, (V18, Certified Nursing Assistant) received discipline because she did not check on (R4) frequently. I watched the camera that records the entrance to (R4's) room, and it was an extended period of time before (V18) checked on (R4) since she had last been checked. (R4) is supposed to be checked on frequently, at least every 15 minutes.
On 5/14/25 at approximately 10:00 AM, V1, Administrator, stated call lights are to be answered, in five to ten minutes. V1 stated a call light should never be left unanswered for 20 minutes or more, That's absurd. V1 stated the facility is staffed according to census and to meet the State Minimum Requirements.
On 5/14/25 at approximately 1:30 PM, V12, CNA, stated he was the CNA for the Respiratory Unit and also assisted the CNA assigned outside of the Respiratory Unit. V12 stated all residents on the Respiratory Unit required full mechanical lift transfers and many residents on each of the other halls required full mechanical lifts, requiring two CNAs to operate and transfer the residents. V12 verified one CNA was assigned to the Respiratory Unit and floated out to assist the other CNAs assigned to a hall outside of the Respiratory Unit.
On 5/14/25 at 4:00 PM, R9 stated the facility is, short-staffed, with the, extra CNAs, listed on the daily schedules sent home. R9 stated call lights are left unanswered for long periods and sometimes her requests are not met, stating the CNAs state they, will be back, and do not return.
On 5/15/25 at approximately 8:25 AM, V6 (CNA/Certified Nursing Assistant Manager and Scheduler) verified when there is an Extra Aide scheduled on the Daily postings, for the day shift (6:00 AM to 6:00 PM) and for the night shift (6:00 PM to 6:00 AM) shifts, they are sent home if the state minimum staffing is met without the extra CNA staff member. V6 stated she was informed by her Corporate that the census determines she cannot staff more than six CNAs on day shift and four CNAs on the night shift. V6 stated, We used to be able to staff eight CNAs on day shift, but now we have to staff with six CNAs on days. V6 stated the Extra Aids staffed on the Daily Staffing Assignment postings were sent home when the facility's staffing, based on resident census, met the State Minimum Requirements.
On 5/15/25 at approximately 10:00 AM, V2 (Director of Nursing) provided a list documenting 31 of 72 residents currently require a full mechanical lift for transfers, and verified the following hallways contain the following amount of residents that utilize a full mechanical lift: five residents residing in the [NAME] Hall; eight residents residing in the Harmony I Hall; eight residents residing in Harmony II Hall; and ten residents residing in the Respiratory Care Unit. V2 stated all of the hallways housing residents who utilize full mechanical lifts are staffed with one CNA, and CNAs assigned to the corresponding halls are expected to assist with a full mechanical lift transfer. V2 stated staffing is based on the facility's census and the facility is staffed to meet and not exceed the State Minimum Requirements. V2 stated that currently, the resident census in the facility is 72, and there are very heavy halls in the facility with the residents requiring a lot of care, including full mechanical lifts. V2 verified the respiratory unit is one of these heavy halls, as well as other halls outside of the respiratory unit. V2 stated most of the residents residing on the respiratory hall are on ventilators and all those residents require full mechanical lifts for transfers. V2 then verified two CNAs are required to safely operate full mechanical lifts.
On 5/14/25 at approximately 3:10 PM, V17 (Corporate Regional Representative) verified the facility is staffed to meet and not exceed the State Minimum Staffing Requirements.
The facility's Census Sheet (dated 05/12/25) documents 72 residents are currently residing in the facility.
Mar 2025
2 deficiencies
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 record review and interview the Facility failed to provide weekly showers for seven of eight Residents (R1, R2, R3, R4,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the Facility failed to provide weekly showers for seven of eight Residents (R1, R2, R3, R4, R5, R7 and R8) reviewed for showers in a sample of nine.
Findings include:
The Facility Shower/Tub Bath Policy, revised 8/2002, documents: the purpose of this procedure are to promote cleanliness, provide comfort to the Resident and to observe the condition of the Resident's skin; the following information should be recorded in the Resident's Activity of Daily Living/ADSL record and/or in the Resident's medical record (date/time of shower/tab bath, name/title of individual who assisted, assessment data, how Resident tolerated, if Resident refused and signature/title of person recording the data); report other information in accordance with Facility policy and professional standards of practice.
The Facility Certified Nursing Assistant/CNA Position Title, undated, documents: assist nursing personnel in providing nonprofessional nursing care and simple technique nursing services; receives assignments; gives general care to Patients/Residents; bathes and dresses Residents; gives grooming care; encourages showers; ensure all Residents are appropriately dressed and well groomed; and responsible for Resident bath sheets.
The Facility Assessment Tool reviewed 1/3/25, documents the Facility will provide bath/showers at least weekly for each Resident and the Facility will provide more frequently by request as needed.
The Facility Shower Schedule, undated, documents scheduled bi-weekly (two times a week showers) for R1, R2, R3, R4, R5, R7 and R8.
1. R1's current Continuity of Care Document/CCD documents that R1 admitted to the facility on [DATE]. R1's Census History (1/1/25 through 3/26/25) documents R1's hospital leave dates (1/25/25 through 1/20/25 and 2/4/25 through 2/8/25). R1's Skin Monitoring/Comprehensive Shower Review document R1 was showered on 2/1/25, 3/18/25 and 3/21/25. The Facility could not provide weekly Shower Review documents for R1 for the entirety of the dates requested 1/1/25 through 3/26/25.
2. R2's current Continuity of Care Document/CCD documents that R2 admitted to the facility on [DATE]. R2's Census History (1/1/25 through 3/26/25) does not document any leaves of absence/discharges from the Facility. R2's Skin Monitoring/Comprehensive Shower Review document R2 was showered on 1/23/25, 1/27/25, 2/24/25, 2/27/25, 3/3/25 and 3/24/25. The Facility could not provide weekly Shower Review documents for R2 for the entirety of the dates requested 1/1/25 through 3/26/25.
3. R3's current Continuity of Care Document/CCD documents that R3 admitted to the facility on [DATE]. R3's Census History (1/1/25 through 3/26/25) does not documents any leaves of absence/discharges from the Facility. R3's Skin Monitoring/Comprehensive Shower Review document R3 was showered on 1/23/25, 1/27/25, 2/24/25, 2/27/25, 3/3/25 and 3/24/25. The Facility could not provide weekly Shower Review documents for R3 for the entirety of the dates requested 1/1/25 through 3/26/25.
4. R4's current Continuity of Care Document/CCD documents that R4 admitted to the facility on [DATE]. R4's Census History (1/1/25 through 3/26/25) does not document any leaves of absence/discharges from the Facility. R4's Skin Monitoring/Comprehensive Shower Review document R4 was showered on 1/9/25, 1/13/25, 1/20/25, 1/28/25, 1/31/25, 2/11/25, 2/14/25, 3/4/25, 3/7/25 and 3/14/25. The Facility could not provide weekly Shower Review documents for R4 for the entirety of the dates requested 1/1/25 through 3/26/25.
5. R5's current Continuity of Care Document/CCD documents that R5 admitted to the facility on [DATE]. R5's Skin Monitoring/Comprehensive Shower Review document R5 was showered on 1/21/25, 1/24/25, 1/28/25, 2/7/25, 2/18/25, 2/25/25, 3/1/25 and 3/21/25. The Facility could not provide weekly Shower Review documents for R5 for the entirety of the dates requested 1/1/25 through 3/26/25.
6. R7's current Continuity of Care Document/CCD documents that R7 admitted to the facility on [DATE]. R7's Census History (1/1/25 through 3/26/25) does not document any leaves of absence/discharges from the Facility. R7's Skin Monitoring/Comprehensive Shower Review document R7 was showered on 1/2/25, 1/4/25, 1/6/25, 1/16/25, 1/20/25, 1/21/25, 1/30/25, 2/14/25, 2/20/25, 2/22/25, 2/25/25, 2/27/25, 3/3/25, 3/6/25, 3/10/25, 3/17/25 and 3/24/25. The Facility could not provide weekly Shower Review documents for R4 for the entirety of the dates requested 1/1/25 through 3/26/25.
7. R8's current Continuity of Care Document/CCD documents that R8 admitted to the facility on [DATE]. R8's Census History (1/1/25 through 3/26/25) documents a hospital leave on 1/1/25 through 1/6/25. R8's Skin Monitoring/Comprehensive Shower Review document R8 was showered on 1/1/25, 1/13/25, 1/27/25, 2/24/25, 2/27/25, 3/3/25, 3/10/25, 3/17/25, 3/20/25 and 3/24/25. The Facility could not provide weekly Shower Review documents for R4 for the entirety of the dates requested 1/1/25 through 3/26/25.
On 3/25/25 at 12:05 pm, R2 (Resident Council President) stated, I am not getting my showers on my scheduled shower days which are Monday and Friday. They tell me that they do not have time, or that they will come back to get me for one, but they never come back. When I first came here and needed more assistance, they would say that I refused my showers, when I really did not.
On 3/26/25 at 9:15 am, R3 stated, I am on hospice care, and I do not like the way the hospice people give me a shower because they squirt me in the head with the water head and no one here checks on my showers or gives me one, so I just wash myself up in my room most times. I really need my hair washed.
On 3/26/25 at 9:08 am, R4 stated, I do not always get my showers when I should.
On 3/26/25 at 9:32 am, R5 stated, Sometimes, I get showers and sometimes I do not, it just depends.
On 3/26/25 at 9:41 am, R8 stated, I do not always get a shower.
On 3/27/25 at 9:32 am, V2 (Director of Nursing) stated, I have not been here that long. We are slowly working on getting better with the shower schedules, they have had some problems. I cannot provide anymore documentation for the Residents showers.
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
Deficiency F0800
(Tag F0800)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the Facility failed to follow their Dietary Menu and provide condiments for six of nine Residents (R1, R2, R4, R5, R6, R7) reviewed for dietary prefe...
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Based on observation, interview, and record review the Facility failed to follow their Dietary Menu and provide condiments for six of nine Residents (R1, R2, R4, R5, R6, R7) reviewed for dietary preferences in a sample of nine.
Findings include:
The Facility Week at a Glance Dietary Menu documents condiments be served with the Breakfast, Lunch, and Supper meals.
The Facility Dietary Purchase Orders, dated 3/3/25, 3/6/25, 3/10/25, 3/13/25, 3/17/25, 3/20/25 and 3/24/25, document one box of sugar substitute/sweetener was received on 3/10/25. No other substitute sugar/sweetener was purchased.
R1's, R2's, R4's, R5's, R6's and R7's Continuity of Care Documents/CCD, document a diagnoses of Diabetes Mellitus.
On 3/25/25 at 12:09 pm, 3/26/25 at 8:35 am, 3/26/25 at 12:20 pm and 3/27/25 at 8:25 am, no substitute sugar/sweetener was available/stocked on the dining room tables, individual serving trays or in the Main Dining Room condiment cart/bar. On 3/26/25 at 8:35 am and 12:20 pm, no substitute sugar/sweetener packets were observed on the room tray carts.
On 3/27/25 at 9:48 am, no sugar substitute sugar/sweetener packets were in the dry storage room storage container. The Facility's dietary supply shipment had just been received and was stacked in the Facility kitchen unpacked. One box of sugar substitute/sweetener was in the shipment.
On 3/25/25 at 12:05 pm, R2 (Resident Council President) stated, There is usually sweetener on the condiment bar in the dining room, but sometimes they run out.
On 3/26/25 at 9:08 am, R4 stated, I use a lot of sweetener and we usually buy extra to keep in my room.
On 3/26/25 at 9:32 am, R5 stated, I buy my own sweetener because they run out.
On 3/27/25 at 9:48 am, V8 (Dietary Manager) stated, I have to order a box of sweetener every week, because we use so much and the Residents hoard the sweetener packets in their rooms. If I run out of product, they will allow me to go to a local store and purchase it, but I did not realize that we were out of the sweetener. V8 verified that no sugar packets were in the storage bin in the dry storage room and that no substitute sugar/sweetener had been received since 3/10/25.
Jan 2025
2 deficiencies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure respiratory equipment was dated, bagged, and kept off the floor per facility policy and professional standards for fou...
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Based on observation, interview, and record review, the facility failed to ensure respiratory equipment was dated, bagged, and kept off the floor per facility policy and professional standards for four (R20, R28, R39, and R125) of six residents reviewed for respiratory therapy in a sample of 26.
Findings include:
A facility procedure titled Respiratory Therapy, dated 11/2017, documents The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Steps in the procedure include, 2. Use distilled water for humidification per facility protocol. 3. [NAME] bottle with date and initials upon opening and discard after twenty four (24) hours. It also documents, e. Change the reservoir every forty-eight (48) hours and disinfect with 2%/percent alkaline glutaraldehyde or sterilize. Additionally, this procedure documents, 7. Change the oxygen cannula and tubing every seven (7) days, or as needed. 8. Keep the oxygen cannula and tubing used prn (as needed) in a plastic bag when not in use.
1. R125's Physician Order Report has an order dated 12/28/24 documenting, Oxygen: change tubing and mask weekly and PRN (as needed). Label. Once a day on (Sunday).
On 01/28/25 at 1:13 PM, R125 was sitting in a recliner in her room with oxygen being administered per nasal cannula from a concentrator with bubble humidity. R125's nasal cannula tubing had no date. R125's reservoir for humidity was dated 12/29/24.
On 01/28/25 at 2:28 PM, V4/Licensed Practical Nurse (LPN)/Infection Preventionist (IP) confirmed R125's oxygen tubing was not dated and R125's humidification reservoir was dated 12/29/24.
On 01/29/25 at 9:23 AM, R125's humidification reservoir was dated 01/28/25 which was written in black marker with the previous 12/29/24 date visible underneath.
On 01/29/25 at 9:53 AM, V4 confirmed the 01/28/25 date was written over the previously marked date of 12/29/24 and stated, I'm so sorry. I will make sure this is changed.
2. On 01/28/25 at 1:19 PM, R39 was sitting in his room with humidified oxygen from a concentrator being delivered per nasal cannula. R39's oxygen tubing or humidification reservoir were not dated. R39's nebulizer mask was tucked into a wheelchair seat in R39's room.
On 01/28/25 at 2:28 PM, V4 LPN/IP confirmed R39's oxygen tubing and humidification reservoir were not dated, and R39 had an order for oxygen.
On 01/29/25 at 9:29 AM, R39's oxygen tubing and humidification reservoir had no dates. R39's nebulizer mask was hanging over a handle of a wheelchair and dangling approximately six inches from the ground, uncovered.
On 01/29/25 at 9:53 AM, V4 confirmed R39's oxygen tubing or humidification had no dates and discarded R39's nebulizer mask. V4 stated any oxygen equipment not being used should be stored in a plastic bag.
3. On 01/28/25 at 1:26 PM, R28 was sitting in a wheelchair in his room with humidified oxygen from a concentrator being delivered per nasal cannula. R28's nasal cannula or humidification reservoir were not dated.
On 01/28/25 at 2:32 PM, V4 LPN/IP confirmed R28's nasal cannula and humidification reservoir had no dates, and R28 had an order for oxygen.
4. On 01/28/2025 at 1:32 PM, R20 was in bed with a CPAP (Continuous Positive Airway Pressure) mask on. R20's concentrator tubing, CPAP tubing, and nebulizer tubing were not dated. There was a gallon of distilled water sitting on the floor in R20's room which was approximately 1/4 full with no date.
On 01/28/25 at 2:28 PM, V4 LPN/IP confirmed R20's tubing's did not have dates, and R20 had an order for the CPAP and nebulizer.
On 01/29/25 at 9:33 AM, R20's distilled water was slightly lower in volume than observations on 01/28/25 and was again sitting on the floor. This gallon of distilled water is now dated 01/27/25 at 1800 (6PM).
On 01/29/25 at 9:53 AM, V4 confirmed R20's distilled water jug should not be sitting on the floor. V4 also stated a nurse added the date yesterday (1/28/25) but she wasn't sure why she dated it 1/27/25.
MINOR
(C)
Minor Issue - procedural, no safety impact
Transfer Notice
(Tag F0623)
Minor procedural issue · This affected most or all residents
Based on record review and interview the facility failed to document in the resident's medical records or provide written notification to residents and/or resident representatives for hospital transfe...
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Based on record review and interview the facility failed to document in the resident's medical records or provide written notification to residents and/or resident representatives for hospital transfer/discharges. This failure has the potential to affect all 73 residents residing in the facility.
Findings include:
The facility Long Term Care Facility Application for Medicare and Medicaid, dated 1/28/25, documents 73 residents reside in the facility.
The facility Transfer and Discharge Policy, dated 1/2024, documents: To assure transfers and discharges will be conducted in accordance with the resident's rights, physician orders, and in such a manner as to maintain continuity of care for the resident; discharges from a skilled nursing facility to a hospital; when the facility transfers or discharges a resident under any circumstance, the resident/authorized legal representative must be notified verbally and in writing in an emergent situation; the facility must include in the written notice to the resident/authorized legal representative the following (reason for transfer, effective date of transfer/discharge, location of discharge/transfer, statement that resident has right to appeal, name/address/telephone number of state Ombudsman; and document the provision of such notice in the resident's clinical record.
On 1/29/25 at 1:26 PM, V7 (Regional Director of Operations) stated, I cannot find any written notifications because we are not doing them for any resident when they discharge to the hospital. We got tagged for that a couple of years ago and were doing good with doing them, but we have had turnover in that position and now it seems they have not been getting done again.
Dec 2024
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to notify a family member of a resident fall for one (R1) of three residents reviewed for falls in the sample of eight.
Findings include:
The...
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Based on interview and record review the facility failed to notify a family member of a resident fall for one (R1) of three residents reviewed for falls in the sample of eight.
Findings include:
The facility's Change in a Resident's condition or Status policy and procedure, dated 05/17, documents Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's condition and/or status. Unless otherwise instructed by the resident, the nurse will notify the resident's representative when: The resident is involved in any accident or incident, including injuries of unknown source and There is a significant change in the residents' physical, mental or psychosocial status.
The Fall Event for R1, dated 9/6/24 at 7:15 am, documents R1 self-reported she lost her balance, fell in her room, and hit her head during the night. This Event documents R1 with a knot on mid (middle) occipital region of her head. This Event does not document anyone was notified of R1's fall.
The Progress Note for R1, dated 9/6/24 at 10:51 am, documents V13 (R1's) PCP (Primary Care Physician) was notified of R1's self-reported fall during the night three hours and 36 minutes after R1 reported the fall.
There are no Progress Notes documenting R1's family or representative was notified until 9/7/24 at 1:40 pm. This Progress Note documents V14 RN (Registered Nurse) spoke with V15 (R1's) Family Member, 29 hours after R1 reported she had a fall. (V14 RN) documented she spoke to (V15 R1's Family Member) regarding R1's condition and (V15) states he was not aware of the fall and requested R1 be sent to the hospital for evaluation of Occipital Hematoma, headache, and vision loss of left eye.
The Progress Note for R1, dated 9/7/24 at 2:07 pm, documents (V15/ R1's Family Member) called back requesting he be given the documented times of when he was notified of (R1) falling. (V14 RN) endorsed this task to the manager on call. Manager notifying (V1 Administrator).
On 12/24/24 at 12:03 pm, V1 Administrator confirmed V15 (R1's) Family Member was not notified of R1's self-reported fall on 9/6/24 because at that time R1 was alert, oriented, cognitively intact, and was her own Power of Attorney. V1 Administrator stated if a resident is cognitively intact, they are their own POA and Family Members are not generally notified unless the resident is unable to make decisions for themselves or unable to communicate.
On 12/26/24 at 10:45 am, V16 Regional Director confirmed the facility policy is that family members or emergency contacts are notified of resident falls, injuries or change in condition.
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 implement complete neurological assessments, provide continuous mon...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to implement complete neurological assessments, provide continuous monitoring, and provide timely hospital transfer for one (R1) of three residents reviewed for quality of care in the sample of eight.
Findings include:
The Residents' Rights for People in Long-Term Care Facilities, dated 11/18, documents Your facility must provide equal access to quality care regardless of diagnosis, condition, or payment source. Your facility must provide services to keep your physical and mental health, at their highest practical levels.
The facility's Change in a Resident's condition or Status policy and procedure, dated 05/17, documents the Nurse will notify the resident's attending physician when: the resident has a significant change in status, resident's treatment needs altered significantly, or is necessary or in the best interest of the resident. The nurse will record in the resident's medical record any changes in the resident's medical condition or status; and If a significant change in resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted.
The Face Sheet for R1 includes the following diagnoses: History of cerebral infarction (stroke); Disseminated demyelination (damage to fatty tissue that protects and insulates nerve cells in the brain and spinal cord); Chronic respiratory failure with hypoxia; Congestive heart failure; Atherosclerotic heart disease of coronary artery, and Aortocoronary bypass graft.
The Quarterly Progress Note for R1, dated 10/15/24, documents R1 is cognitively intact and has adequate hearing and vision with the help of glasses at times, is able to walk with use of walker and wheelchair at times.
The Fall Event for R1, documents R1 had an unwitnessed fall on 9/6/24 at 7:15 am in R1's room. The Description of R1's fall is documented as lost balance, hit head, no loc (loss of consciousness). The initial assessment was completed and documents knot on mid occipital (side of the head that processes visual information) region with no other findings and documents None required for Medical Care Provided After The Fall. The interventions and immediate measures taken at the time of the fall are documented as analgesics and increased supervision or monitoring.
The Neurological Flow Sheet documents Neuro Check Time Schedule as: every 15 minutes for one hour; every 30 minutes for two hours; every hour for four hours; every four hours for 24 hours; and every shift for 48 hours. This Neurological Flow Sheet was initiated on 9/6/24 at 7:20 am and is documented up to 9/6/24 at 2:50 pm. There are no neurological checks completed after the 9/6/24 at 2:50 pm.
The Progress Note for R1 dated 9/6/24 at 7:15 am, documents (R1) self-reported that (R1) got up in the middle of the night, it was dark and (R1) lost her balance falling to the floor. (R1) has a knot on mid occipital region. No other injuries noted. (R1) alert and oriented to her norm (normal), neuro (neurological checks) and vitals initiated and unit nurse to notify MD (Medical Doctor).
The Progress Note for R1, dated 9/7/24 at 5:30 am, documents (R1) reported falling to the floor to the morning nurse. Neurological flow sheet is incomplete with no times and only 5 sets of vitals. (R1) has a knot on the mid occipital region. No other injuries noted. This same note documents R1 stated she is in pain and Norco (opioid pain medication) given at 8:30 pm.
The Progress Note for R1, dated 9/7/24 at 1:34 pm, documents (R1) c/o (complained of) complete vision loss in her left eye. (R1) recently had an un-witnessed fall during the night on 9/6/24. (R1) has a hematoma to her occipital lobe. (R1) complained of headache as 10 out of 10.
The Progress Note for R1, dated 9/7/24 at 1:49 pm documents V14 RN notified the on-call manager and called 911 for transport.
The Progress Note for R1, dated 9/7/24 at 6:21 pm, by V14 RN documents Resident being admitted for atherosclerosis of the neck. (R1) will be transferred to (another local hospital).
The facility's Admission/Discharge Report, documents R1 was sent out to the local hospital on 9/7/24 and was readmitted to the facility on [DATE].
The local hospital History and Physical for R1, dated 9/7/24, documents Impression/Plan as: 1. CVA (Cerebrovascular Accident) occipital - (R1) has left-sided blurry vision however she reports she is already improving. CT (computed tomography) head showed hypotensive and right occipital lobe. CTA (computed tomography angiography) with multiple findings as mentioned in HPI (history of present illness). Stroke 1 (emergency stroke level protocol) already on board. We will obtain MRI (Magnetic Resonance Imaging) head. We will obtain TTE (transthoracic echocardiogram). Continue aspirin, Plavix as advised by Stroke 1. Currently does not have any motor deficits. Vascular surgery consultation in am (morning). 2. ACA (aneurysm of the anterior communicating artery) seen on CT Angio (angiogram). Neurosurgery follow up as an outpatient. 3. UTI (urinary tract infection) UA (urinary analysis) from (local hospital) did show WBC (white blood cell) 11-20 with bacteria 4+ and we will put her on ceftriaxone (antibiotic) 1 g (gram) daily. Other comorbidities: Previous history of stroke and CABG (coronary artery bypass graft surgery).
The MRI of the brain for R1, dated 9/8/24 documents Impression: 1. Tiny focus of abnormal diffusion signal within the left occipital cortex most consistent with tiny acute/subacute infarct. 2. Additional extensive chronic small-vessel ischemic and lacunar changes. Sequela of prior infarct right parietooccipital lobe. 3. Parenchymal atrophy. The ventricles are more prominent compared to the sulci which could relate to atrophy but does raise the possibility of normal pressure hydrocephalus.
The Hospitalist Progress Note for R1, documents Impression and Plan as: 1. Cerebrovascular Accident Occipital. Symptoms have significantly improved. MRI (Magnetic Resonance Imaging) shows very small area now. 2. Anterior communicating artery aneurysm small. 3. Suspected UTI (Urinary Tract Infection.
The Stroke Chart Note for R1, dated 9/8/24, documents (R1's) workup is complete. TTE shows EF (ejection fraction) 550% (percent) with no obvious cardiac source of stroke. MRI shows a small, acute infarct in the left occipital lobe, as well as chronic right occipital stroke. This new infarct does not explain left eye vision loss. (R1's) left eye symptoms may thus be due to central/branch retinal artery occlusion. The small left occipital stroke on MRI is very likely due to her extensive atherosclerotic disease of the cerebral vasculature.
The Discharge Plan for R1, dated 9/14/24 documents I was in the hospital because: Occipital stroke.
On 12/24/24 at 1:12 pm, V3 LPN/ADON (Assistant Director of Nursing) stated she was helping the Nurse with paperwork to send R1 to the hospital because R1 to V2 Former DON (Director of Nursing) that she fell going to the bathroom and hurt her tailbone and requested to go to the hospital. V3 LPN stated at the time R1 didn't have a POA, was able to make her own decisions so we didn't call her family. V3 LPN/ADON stated If it wasn't documented then (V15 R1's Family Member) wasn't called. (R1) did not have a POA (Power of Attorney) on file. If someone is alert and oriented, I believe the cut off is 13 out of 15 on BIMS we would not notify the family. V3 LPN/ADON stated family is called Only if the resident is not able to make their own decisions or communicate.
On 12/26/24 at 10:35 am, V1 Administrator confirmed R1 had a fall on 9/6/24, neurological checks were not fully completed for R1, and R1 returned to the facility on 9/14/24 with a diagnosis of Left Occipital Stroke.
On 12/26/24 at 10:40 am, V16 Regional Director confirmed Neurological Checks and vital signs should have been fully completed up to the time of R1's discharge to the local hospital and had they been done may have alerted staff to send R1 to the hospital sooner.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to provide safety during resident cares, keep supplies in reach, and do a thorough fall investigation for one (R6) of three resid...
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Based on observation, interview, and record review the facility failed to provide safety during resident cares, keep supplies in reach, and do a thorough fall investigation for one (R6) of three residents reviewed for fall safety during cares.
Findings include:
The facility's undated Managing Falls and Fall Risk policy and procedures documents Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling.
The facility's undated Resident Rights Statement documents Residents will be cared for in a manner and in an environment that promote maintenance or enhancement of each resident's quality of life, dignity, and aspect in full recognition of his or her individuality.
The facility's undated CNA (Certified Nursing Assistant) job description, documents The primary purpose of this position is to: Assist nursing personnel in providing nonprofessional nursing care and simple technical nursing services under the direction and supervision of an RN (Registered Nurse) or LPN (Licensed Practical Nurse). This policy also documents the CNA will: Ensure that all transfers and lifts are performed with concern for the safety of the resident according to the policies of the facility. Ensure that all CNA care plan approaches and interventions are being utilized as planned; Make sure that necessary supplies are available .; Assists with and/or performs procedures as outlined, with proper instruction and supervision; and Ensure the resident environment is as free from accidents and hazards as is possible. The CNA Orientation documents Training and instruction has been given to the employee regarding the following topics: Perineal Care; Bed Bath; Positioning; Re-directing resident from unwanted or unsafe behavior(s); and Maintaining a safe and hazard-free environment.
The Face Sheet for R6 includes the following diagnoses for R6 as: Contracture of right knee, Contracture of left knee, Vitamin D Deficiency, GAD (Generalized Anxiety Disorder), Frontotemporal Neurocognitive Disorder, Dementia, History of Traumatic Brain Injury, and unspecified Psychosis.
The Quarterly Social Service Note for R6, dated 11/27/24 at 3:35 pm, documents R6 is a long-term resident of facility, has clear speech, adequate hearing, and vision with glasses, able to make her wants and needs known, and able to make simple daily decisions. R6 has a BIMS (Brief Interview for Mental Status) score of 14 out of 15, indicating R6 is cognitively intact.
The most recent Fall Risk assessment for R6, dated 9/19/24 scored R6 as 13 indicating she is a High Risk for falls.
The current Care Plan for R6, documents (R6) has the potential for fall and is at risk for falls r/t (related to) unaware of safety needs, psychoactive drug use, TBI (traumatic brain injury), abnormal posture and has a history of falls. The interventions for R6 include encourage to change position slowly; know R6's habits to anticipate needs; and have commonly used items in reach. R6 requires total staff participation for bathing, incontinence care, and to re-position and turn in bed. This same Care Plan documents to monitor R6 for incontinence, provide peri care and may apply barrier cream.
The Progress Notes for R6 documents the following: 12/18/24 at 8:42 pm (late entry note) Resident fell while being cleaned, hit her head, 911 and family called; 12/18/24 at 8:40 pm, MD (Medical Doctor) notified of fall, order to send resident to ER (emergency room) for evaluation and treatment; and 12/19/24 12:41 am, Resident seen at (local hospital) - has left femur fracture and awaiting ortho (orthopedic) consult.
The Progress Note for R6, dated 12/19/24 at 6:09 am, documents Writer summoned to room by V12 CNA (Certified Nursing Assistant), V12 CNA stated that Resident (R6) fell out of the bed while being changed. V12 CNA stated that (R6) said she hit her head and no bleeding. Writer printed paperwork, called 911 and family, writer entered the room, (R1) observed in a sitting position underneath the bedside table and writer assessed the best of ability w/o (without) moving. (R6) mark noted to center of forehead and took vitals. Awaited paramedics to arrive.
The Fall Event report for R6, dated 12/19/24, documents on 12/18/24 R6 was being assisted with cares by (V12) CNA and during cares R6 fell from her bed onto the floor and R6 reported hitting her head.
The Initial Report sent to the State Agency, dated 12/18/24 at 8:42 pm, documents an investigation was initiated for R6 after a fall from bed. This report documents Resident was reaching for object out of bedside table and rolled out of bed. CNA was present in the room, witnessed the fall. Resident hit her head but did not lose consciousness. R6 was sent to the local hospital emergency room for evaluation.
The Hospital Medical Record for R6, dated 12/18/24, documents R6 was admitted to the local hospital with a left proximal femur fracture. The Hospital Medical Record discharge record documents R6 required a surgical cephalomedullary nailing (a nail is surgically placed into the femur bone) as treatment for R6's femur fracture.
The Facility's Final Report to the State Agency documents R6 with a BIMS (Brief Interview for Mental Status) of 14 out of 15 indicating R6 is cognitively intact with diagnoses of frontotemporal neurological cognitive disorder and has bilateral lower extremity contractures. While CNA was providing care, (R6) reached for the bedside drawer and had episode of leg spasms; slipped from the bed to the floor. Resident immobilized and sent to emergency room. After the initial assessment R6 was diagnosed with a left proximal femur fracture.
On 12/26/24 at 10:10 am, R6 was sitting in a wheelchair in the dining room with her bilateral knees contracted upward. R6 stated one of the CNAs pushed her onto her side, was cleaning her up and R6 fell on the floor. R6 stated she doesn't remember who the CNA was but that the CNA was not holding onto (R6). R6 stated she was sent to the hospital and the x-ray showed (R6) had a broken femur. R6 stated It was so painful. It is better but still causes me pain. R6 stated no one has talked to her about what happened other than this writer.
On 12/24/24 at 11:40 am, V6 LPN (Licensed Practical Nurse) stated she was the nurse on call the night R6 fell. V8 Agency RN (Registered Nurse) reported that R6 was reaching for something in her drawer and rolled right out of bed. V6 LPN stated it was only reported that R6 had hit her head and is why R6 was sent to the hospital. V12 CNA was in the room with R6 when R6 fell.
On 12/26/24 at 10:35 am, V1 Administrator stated she did the investigation for R6's fall. V12 CNA was the CNA providing care when R6 fell. V1 Administrator stated she spoke with V12 CNA who was providing care and R6 reached over to get something out of her nightstand and fell on the floor. V1 Administrator stated she did not interview anyone else, including R6.
On 12/26/24 at 10:40 am, V16 Regional Director educated V1 Administrator that (V1) should always interview the resident when there is a fall, even if (V1) has to go to the hospital to get the interview. V16 Regional Director confirmed V12 CNA should not have turned away from R6.
On 12/26/24 at 1:26 pm, V12 CNA stated she was providing incontinence care to R6 when R6 fell out of bed. V12 CNA stated R6 was lying in bed on her right side, facing the door and V12 was on the opposite side of the bed to R6's back. (V12) stated she cleaned R6 and turned to find R6's barrier cream and when she turned back R6 was falling out of the bed. V12 CNA confirmed (V12) didn't know if R6 was reaching for something or trying to grab onto something due to falling. It happened so fast. V12 CNA stated she did not have her hands on R6 and stated (V12) shouldn't have turned away from R6
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the Facility failed to employee a full time Director of Nursing. This failure has the potential to affect all 75 Residents residing in the Facility.
...
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Based on observation, interview, and record review the Facility failed to employee a full time Director of Nursing. This failure has the potential to affect all 75 Residents residing in the Facility.
Findings include:
The Facility Daily Census Report, dated 12/24/24, documents 75 Residents residing in the Facility.
The Facility Assessment Tool, dated 7/10/24, does not document a Director of Nursing. The Assessment also documents: that a Director of Nursing is needed to provide support and care for Residents; reviews the regulation for the Facility Assessment requirements; the Facility identifies the type of staff members and Nursing Services (Director of Nursing); and the Infection Control Committee is composed of the following personnel (Director of Nursing).
The Facility Director of Nursing Job Summary, update 7/14/20, documents that the Director of Nursing will develop, monitor, and adapt as necessary the Facility's clinical program; keep the Facility prepared for State and Federal Inspections; and participate in the survey process with the Administrator and maintain current Federal and State Regulations.
On 12/24/24 and 12/26/24, during the hours of 8:00 am and 3:00 pm, the Facility did not have a Director of Nursing on staff.
V2's (Former Director of Nursing/DON) written statement, dated 12/10/24, documents, I am resigning effective immediately from my employment opportunity.
On 12/24/24, V3 (Assistant Director of Nursing/ADON) stated, We have been without a 'DON' for a few weeks now. I am a Licensed Practical Nurse/LPN. We do not have a DON right now, so I am helping out.
On 12/24/24, V1 (Administrator in Training) stated, (V2/Former Director of Nursing) just walked off of the job a few weeks ago and we have not had a Director of Nursing since. (V3/ADON) is filling in. I am hoping to get someone interviewed, I have one in mind that lives out of town, but I have not interviewed them yet.
Nov 2024
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
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to prevent misappropriation of controlled substance medications for eight of ten residents (R2, R7, R9, R10, R11, R12, R13, and R...
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Based on observation, interview and record review, the facility failed to prevent misappropriation of controlled substance medications for eight of ten residents (R2, R7, R9, R10, R11, R12, R13, and R14) reviewed for misappropriation of resident medications in a sample of 14.
Findings include:
The facility's Abuse Prevention Policy, undated, documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Definitions: The following definitions are based on federal and state laws, regulations, and interpretive guidelines. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent. Misappropriation of a resident's property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent.
The Final Report sent to the (State agency) (un-dated) documents A night shift nurse (identified as V10/LPN (Licensed Practical Nurse) quit on 10/31/24. (V10) claimed the reason to be is that (V8/RN/Registered Nurse) stole medication. Police Department notified and on scene. (V8) is suspended pending the outcome of the investigation. Occurrence Resolution Immediate investigation initiated. (V8) was identified as nurse alleged for medication theft. (V8) was suspended until further investigation. Facility made several attempts to contact and interview (V8) but was unsuccessful.
V8/RN's License Lookup Detail documents V8 was on probation starting on 9/8/2010 and ending 5/1/2014 due to a conviction relating to controlled substances.
V8/RN's Timecard dated 10/31/24 documents V8 worked on 10/31/24 from 5:43 PM to 6:20 AM.
On 11/22/24 at 8:00 AM, the medication cart on the Respiratory Care Unit contained a locked box containing controlled substance medications including R2's Hydrocodone/Acetaminophen 5-325 mg (milligram) tablets, R7's Oxycodone 5 mg tablets, R9's Hydrocodone/Acetaminophen 5-325 mg tablets, R10's Alprazolam 0.5 mg tablets, R11's Lorazepam 0.5 mg,tablets R12's Lorazepam 0.5 mg tablets, R13's Lorazepam 0.5 mg tablets and Hydrocodone/Acetaminophen 5-325 mg tablets, and R14's Hydrocodone/Acetaminophen 5-325 mg tablets.
On 11/23/24 at 9:06 AM, V10/LPN stated that she quit working at (the facility) because V10 suspected V8/RN was taking residents' medication. Several nights while at work, V10 thought V8's eyes were dilated and that V8 acted different. V10 also stated My mother had a pill addiction, so I know what a pill head looks like. I did not have any proof (V8) was stealing drugs, but I did not want to work around (V8) anymore. V10/LPN stated the Police got hold of her for the investigation and he asked if she had filled out a report and she said no she hadn't, but she would. Police stated don't worry about it I already watched the video surveillance at the nursing home and saw her put seven narcotic pills in her pocket.
On 11/23/24 at 9:30 AM V1 (Administrator) stated the facility had video surveillance the night of 10/31/24 into the morning of 11/1/24 of V8/RN working on the Respiratory Care Unit putting controlled substance medications in her pocket.
This surveyor observed the facility video surveillance at this time and noted the following: On 11/1/24 at approximately 4:32 AM V8/RN was observed standing at the Respiratory Unit's medication cart. V8 parked the medication cart in front of the facility's camera. V8 was observed to open the medication drawer that contained the locked box of controlled substance medications, unlocked the box, then opened the box. V8 then opened the controlled substance narcotic count book that was located on top of the medication cart. V8 was observed flipping each page of the narcotic book slowly while looking both ways down the hallway. From 4:32 AM to 4:34 AM V8 was observed popping out narcotic medications at least four different times from different controlled substance medication cards and sliding the controlled substance medications into her shirt pocket with her right hand. V1/Administrator verified V8 had access to R2, R7, R9, R10, R11, R12, R13, and R14's controlled substance medications and observed V8 putting the pills in her pocket from the surveillance footage.
On 11/23/24 at 10:04 AM, V26/Officer for City stated the alleged perpetrator (V8/RN) got arrested for stealing narcotics (controlled substances) from the facility. V26 stated he is not the one who arrested V8, but he witnessed V8 get arrested.
On 11/25/24 at 9:10 AM, V11 (Local Police Officer) stated, I have arrested (V8/RN) and charged her with forgery, possession of a controlled substance, and theft due to stealing controlled medications from the facility. I watched (V8) take resident medications on video. When I went to arrest (V8) at her house she was extremely high on narcotics and was out of it. (V8) did not even know her cat's name.
Apr 2024
2 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
Incontinence Care
(Tag F0690)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to obtain physician orders for use and care of an indwell...
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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 obtain physician orders for use and care of an indwelling urinary catheter (R1), failed to notify a physician of a resident's abnormal urine laboratory testing results (R1), failed to timely treat a urinary tract infection/UTI (R1), and failed to obtain a physician ordered urine laboratory test (R4) for two of three residents (R1 and R4) reviewed for indwelling urinary catheters and UTIs in the sample of six. These failures resulted in R1 experiencing lower abdominal pain; urine with increased sediment in R1's indwelling urinary catheter tubing and bag; abnormal urine laboratory test results with a delay of physician notification and treatment. R1 was subsequently transferred to two different local area hospitals and admitted to the intensive care unit with a diagnosis of UTI with septic shock.
Findings include:
The facility's Urinary Tract Infections/Bacteriuria revised April 2007 states, 1. As part of the initial assessment, the physician will help identify individuals who have a history of symptomatic urinary tract infections, and those who have risk factors (for example, an indwelling urinary catheter, urinary outflow obstruction, etc.) for UTIs. 2. The staff and practitioner will identify individuals with signs and symptoms suggesting a possible UTI. 1. The physician will order appropriate treatment for verified or suspected UTIs based on a pertinent assessment.
The facility's Lab, Diagnostic Test Results and Change in Resident's Condition-Clinical Protocol (undated) states, Policy: To establish guidelines for physician notifications concerning resident lab and diagnostic test results and change(s) in resident conditions. 1. A licensed nursing will review all diagnostic test results: b. if the staff member who first receives or reviews lab and diagnostic test results is unable to follow the remainder of this procedure (i.e., reporting and documenting the results and their implications), another nurse in the facility should follow and coordinate procedural compliance. 2. The person who is to communicate results to a physician will review and compile the information and be prepared to discuss the following: the individual's current condition and any recent changes in status, including vital signs and mental status; b. major diagnoses, allergies, pertinent current medications, other recent pertinent lab work, actions already taken to address the results and treat the resident, and pertinent aspects of advanced directives; c. Why the test results were obtained, d. How the test results might relate to the individual's current status, treatments, or medications; e. any concerns the physician will be expected to address upon receiving the results. 3. The attending physician is responsible for responding in a timely manner to nurses regarding prompt notification calls or emergencies. The attending physician is also responsible for communicating the results of assessments and medical plans to a licensed nurse when appropriate. 4. Nurses should promptly notify the physician of any significant abnormal laboratory results. In such situations, direct communication with the physician is required and may not be faxed. Prompt calls must be made after office hours or when physician offices are closed. The following symptoms, signs and laboratory values should prompt the nurse to notify the physician as soon as possible: c. any of the following abnormal reports: Positive urine culture > (greater than) 100,000 colonies/ml (per milliliter) of a pathogen only if 1. Resident has symptoms and is not on treatment; or 2. The pathogen is not sensitive to the antibiotic which has been prescribed. 5. If a response from an attending physician concerning abnormal lab results is not obtained, the designated alternate physician should be called. If a response is still not received, the Director of Nursing/Designee should be notified for further instructions. 8. The following documentation should be entered into the resident's clinical record: a. Any calls to and from the physician indicating information conveyed or received, b. All orders taken from the physician or his designee (i.e., physician extender); c. Ongoing conversations with the physician regarding response to notification(s) of changes in condition and/or laboratory/diagnostic test results.
The facility's Urinary Catheter Care Policy revised September 2005 states, The purpose of this procedure is to prevent infection of the resident's urinary tract. General Guidelines are documented as: Should the resident indicate that his or her bladder is full or that he or she needs to void (urinate), report it immediately to your supervisor; Observe the resident for signs and symptoms of urinary tract infection and urinary retention. Report findings to the supervisor immediately; Report to the supervisor any complaints the resident may have of burning, tenderness,
or pain in the urethral area. Documentation: The following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given. 2. The name and title of the individual(s) giving the catheter care. 3. All assessment data obtained when giving catheter care. 4. Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor. 5. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain. 6. Any problems or complaints made by the resident related to the procedure. 7. How the resident tolerated the procedure. 8. If the resident refused the procedure, the reason(s) why and the intervention taken. 9. The signature and title of the person recording the data.
1. R1's Resident Census documents R1 admitted to the facility on [DATE] and was placed on hospital leave on 4/10/24.
R1's admission Minimum Data Set assessment dated [DATE] documents the following: R1 is cognitively intact; R1 has impairment to both upper and lower extremities; R1 is dependent on staff assistance for all activities of daily living (ADLs); and R1 has an indwelling urinary catheter.
R1's admission Bladder Observation dated 3/22/24 documents R1 admitted to the facility with an indwelling urinary catheter.
R1's Care Plan documents the following with a start date of 3/25/24: R1 requires an indwelling urinary catheter; R1 will have catheter care managed appropriately as evidenced by: not exhibiting signs of urinary tract infection or urethral trauma; Change catheter per MD (Medical Doctor) order; Provide Catheter Care during peri-care and as needed; and Report signs of UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain/difficulty urinating, nausea, emesis, chills, fever, low back/flank pain, malaise, foul odor, concentrated urine, blood in urine).
R1's Physician's Order documents a written order dated 4/3/24 and signed by V14 (Advanced Practice Nurse for UA C&S/Urinalysis with Culture and Sensitivity.
R1's Order History documents an order with a start date of 4/4/24 to collect a Urinalysis with Culture and Sensitivity with special instructions as Chronic (Indwelling Urinary Catheter). As of 4/25/24, this same Order History did not document an order for: R1's Indwelling Urinary Catheter, including what size catheter and balloon to be used; Indwelling Urinary Catheter bag changes; or treatment orders for the care of R1's Indwelling Urinary Catheter.
On 4/25/24 at 11:37 AM, V18 (Licensed Practical Nurse) verified R1 did not have orders for R1's Indwelling Urinary Catheter or Catheter Care and should have. V18 stated catheter care is completed minimally on each shift daily and would be on the resident's administration record to be completed each shift and as needed.
As of 4/25/24, R1's medical record did not contain documentation that R1's indwelling catheter care was completed daily.
R1's Resident Progress Notes dated 4/5/24 at 2:55 PM and signed by V7 (Licensed Practical Nurse/LPN) states, UA obtained and sent to (name of local area hospital).
R1's Resident Progress Notes dated 4/8/24 at 2:38 PM and signed by V7 is recorded as a late entry on 4/12/24 at 11:45 AM. This note states, Writer (V7) called (name of local area hospital) lab to obtain UA C&S results that were sent to lab on 4/5/24. (Name of local area hospital) lab faxed preliminary results to writer (V7) and writer (V7) then calls back to (name of local area hospital) lab to get the final result faxed to facility. Writer (V7) then faxed C&S final results to PCP/Primary Care Physician. Awaiting response.
R1's Resident Progress Notes dated 3/22/24-3/30/24 documents R1 with the presence of an indwelling urinary catheter draining yellow urine.
R1's Resident Progress Notes dated 3/30/24 at 10:52 PM documents R1 complained during the shift of R1's indwelling urinary catheter not feeling right. V19 (LPN) attempted to irrigate R1's indwelling urinary catheter without success. V19 replaced R1's indwelling urinary catheter with an immediate return of yellow urine.
R1's Resident Progress Notes dated 4/3/24 and signed by V15 (R1's Physician) states, Assessment: (indwelling urinary catheter) with yellow urine with sediment. This same note states, Plan: UA C+S (Urinalysis Culture and Sensitivity).
R1's Resident Progress Notes dated 4/9/24 at 5:45 AM and signed by V10 (LPN) states, (R1) requesting catheter to be flushed; states he has been feeling some discomfort and pressure in his lower abdomen. Noted to have about 50 cc (cubic centimeters) of urine in the drainage bag. Abdomen distended and hard. Attempt to flush met with resistance. Catheter changed using size 14 fr (french) with 30 cc NS (normal saline). Upon insertion of new catheter, urine return of 1200 cc noted in the drainage bag right away.
R1's Resident Progress Notes dated 4/10/24 at 1:21 PM and signed by V9 (LPN) states, (R1) complained of lower abdomen pain and states he can't pee. Moderate amount of sediment present in the (indwelling urinary catheter tube). Attempted to flush indwelling urinary catheter and was not effective. Changed indwelling urinary catheter #14 30 cc with scant amount of yellow sediment urine. Spoke with V14 (R1's Advanced Nurse Practitioner) and to send to ER (Emergency Room) for evaluation. Call placed to 911 for transport to (name of local area hospital).
R1's Urinalysis Laboratory Result dated 4/5/24 documents the following results: Color: Amber; Appearance: Cloudy (with a normal result being clear); pH (potential of Hydrogen): 9 (with a normal result being 5-7); Leukocyte esterase: 2+ (with a normal result being negative); Nitrite: Positive (with a normal result being negative); Protein: 1+ (with a normal result being negative-trace); [NAME] Blood Cells 6-10 (with normal range being 0-5); Bacteria: 3+. This same lab result contains a handwritten note on the bottom corner that it was sent to V14 and V16 (R1's Physician).
R1's Urine Culture Laboratory Result documents it was collected on 4/5/24 and resulted on 4/8/24. The Final Report states, > (greater than) 100,000 col/ml (colonies per milliliter) Proteus mirabilis. The Sensitivity report of susceptible antibiotics is listed at the bottom of the page.
R1's History and Physical (H&P) from the local area hospital dated 4/10/24 documents R1 presented to a local area hospital from the skilled nursing facility for evaluation of a UTI (Urinary Tract Infection), but R1 was not started on any antibiotics and R1 had complaints of lower abdominal pain. (R1) reports that he has had some abdominal pain the past few days. His blood pressure was on the lower side on arrival with a bp (blood pressure) in the upper 70s. (R1's) labs demonstrated mild leukocytosis and urinalysis consistent with UTI. A CT (Computed Tomography) of (R1's) abdomen and pelvis was performed (on 4/10/24) and demonstrated abnormal appearance of urinary bladder with mucosal hyperenhancement bladder wall thickening, findings of cystitis. This same H&P states, Impression/Plan: Severe Sepsis secondary to complicated UTI (Urinary Tract Infection), Leukocytosis, Sepsis protocol.
R1's Discharge Summary from the local area hospital dated 4/19/24 documents R1 was initially evaluated at a local area hospital closer to the facility and transferred to a second hospital where R1 remained until R1's discharge. R1 was admitted to the Intensive Care Unit/ICU on 4/10/24. R1 was discharged from the hospital on 4/19/24 after a nine-day hospital stay. R1 required blood pressure support medication while in the ICU. R1's significant problems are again stated as: Severe Sepsis (with) shock secondary to complicated UTI and Leukocytosis-Source appears to be r/t (related to) UTI in the context chronic (indwelling urinary) catheter.
On 4/23/24 at 10:06 AM, V20 (R1's Spouse/Power of Attorney) stated that R1 had been complaining about lower abdominal pain and not feeling well for almost a week. V20 stated, I kept pointing out that (R1) had what looked like thick strands of mucous in his (indwelling urinary catheter) tubing and bag and the staff just kept brushing me off. (R1) is immunocompromised and he gets UTIs easily. I knew he was getting an infection, and no one was listening. They were telling me the way his catheter looked was 'expected.' V20 stated V20 was aware a urine sample was taken and V20 reported never being made aware what R1's urine test results were. V20 stated R1 was in the hospital for nine days and discharged to another skilled nursing facility.
On 4/24/24 at 11:59 PM, during a third shift telephone interview with V10 (LPN), V10 stated when V10 came onto shift on 4/8/24, V10 received a report from V7 (LPN) that R1 was complaining of bladder burning and that the V7 had sent R1's UA C&S results to V14 (APN) and V16 (R1's Physician) earlier in the shift with no response. V10 stated that V7 had not received an answer back from V14 or V16 on V7's shift. V10 denied following up with V14 (APN), V15 (R1's Physician) or V16 (R1's Physician) regarding R1's UA C&S results. V10 denied being aware of R1's urine lab test results. V10 stated, I was just told (V7) faxed them. V10 stated during V10's shift, R1 had complained of abdominal pain and that R1 had expressed R1 felt as if R1's indwelling urinary catheter wasn't draining. V10 stated V10 attempted to flush R1's catheter and was not able to, so V10 replaced R1's urinary catheter with a new one. V10 denied speaking to any of R1's physicians or nurse practitioner (V14-V16) regarding R1's complaints of pain, issues with R1's indwelling urinary catheter, or R1's abnormal urine test results during V10's shift.
On 4/24/24 at 2:22 PM, V7 (LPN) stated that V7 was the admitting nurse when R1 arrived at the facility. V7 stated that R1 had an indwelling urinary catheter in place at the time of R1's admission to the facility. V7 stated that V7 recalls V20 stating that R1 goes septic quickly with UTIs. V7 stated that V20 was requesting a urine sample be ordered for R1 as V20 was concerned about R1's urine. V7 stated on 4/5/24, V14 gave a verbal order to obtain a UA C&S and V7 sent the sample out on that same day. V7 stated when V7 returned to work on 4/8/24, V7 followed up with the lab regarding R1's urine C&S results. V7 stated V7 faxed the urine test results to V14 and V16 on 4/8/24. V7 stated V14 and V15 were taking over as primary care of R1, but V16 was still overseeing in the transitional period, so V7 sent the results to both. V7 denied getting a physician response regarding R1's abnormal urine test results and V7 denied speaking with V14, V15, or V16 directly regarding R1's abnormal urine test results. V7 stated V7 faxed the results and nothing further.
On 4/24/24 at 10:30 AM, V9 (LPN) stated that V9 was off work for a couple of days before returning to work on 4/9/24. V9 denied speaking with any physician or getting new orders on 4/9/24 regarding R1's abnormal urine test results. V9 stated V9 was aware R1's test results were faxed to a provider on 4/8/24, but V9 was not aware R1's test results were abnormal requiring a physician response. V9 stated if V9 had been aware of R1's urine test results were positive for a UTI, V9 would have attempted to speak with a physician directly. V9 stated, I would have sent the fax and immediately followed up with a phone call. V9 stated on 4/10/24, V9 was handed R1's UA C&S results and there was a sticky note on the results stating to call R1's daughter. V9 stated the UA was positive for a UTI. V9 stated, I went to (V2/Director of Nursing) and I asked who is taking care of this? V9 stated V14, V15, and V16, but V14 and V15 did not end up coming to the facility on 4/10/24 to see the residents. V9 stated on 4/10/24, R1 was complaining of severe abdominal pain with a lot of sediment in R1's indwelling urinary catheter tubing and bag. V9 stated V9 tried to irrigate R1's catheter and was unable to. V9 stated that V9 then replaced R1's urinary catheter and V9 still did not get much urine return, stating it was mostly sediment. V9 stated V9 asked about bladder scanning R1, but the equipment was broken and not able to be used. V9 stated, I thought ok, it's time to go. V9 stated V14 gave orders for R1 to be transferred to the local area emergency room for evaluation.
On 4/23/24 at 12:57 PM, V2 (Director of Nursing) stated that the facility was in transition between two different lab companies and that in the interim, all lab samples had to be transported to the local hospital to be tested. V2 stated that since the hospital was running the lab tests, the results did not automatically show up in the system at the facility. V2 stated the hospital was not faxing over results once they were available; the facility was having to call to get them causing delays. V2 also stated that V14 and V15 were new providers to the facility and were going to be taking over as primary care for the respiratory care residents, including R1. V2 stated that V16 remained primary in the two-week transitional period while V14 and V15 got to know the residents and meet families. V2 stated V14 ordered the UA C&S on R1 during rounds and that the results were given to V14 and V16 on 4/8/24. V2 stated the nursing staff should have called V14, V15, or V16 to immediately notify of R1's UA C&S results. V2 stated V14 and V15 did not come to the facility on 4/10/24 as originally planned, so R1's urine lab tests were not reviewed then either. V2 stated R1's UA results were positive for a UTI and as soon as the C&S results were available, the nurses should have called to get treatment orders that day. V2 stated R1's UA resulted on 4/5/24 and that on 4/8/24, new orders should have been received based off the culture and sensitivity. V2 verified treatment orders were not obtained at the facility for R1's abnormal urine test results and should have been. V2 verified residents with indwelling urinary catheter should have orders for the catheter indicating the size catheter and balloon to be used and orders for catheter care to be completed. V2 stated the residents' electronic administration record would document the catheter care was completed.
On 4/24/24 at 11:30 AM, V14 (Advanced Practice Nurse) stated that during rounds on R1 on 4/3/24, it was noted that R1's urine in R1's indwelling urinary catheter bag was yellow and cloudy so V14 ordered a UA C&S to be obtained. V14 stated R1's initial UA result was sent to the wrong doctor as the nurses were not sure where to send results in the facility's transition period of primary care doctors changing. V14 stated, I was not able to be apprised what to do because I did not know. V14 stated V14 never saw the results from R1's 4/8/24 urine culture and sensitivity. V14 stated V14 would have expected to be made aware of R1's abnormal UA C&S result as soon as it was resulted. V14 stated V14 did not round in the facility on 4/10/24. V14 stated R1's UTI would have been easy to treat if V14 had been made aware of R1's lab findings. V14 stated if V14 had been made aware of R1's C&S result on 4/8/24, R1 would have had a full day or two of good relief and that it is possible R1 may not have needed to be sent out to the hospital. V14 stated, With UTI infections, the inflammation in R1's urinary tract is worsened, and antibiotics would have helped decrease that swelling. V14 stated R1's urinary sediment increases problems with obstruction, further leading to the importance of reducing the swelling and getting antibiotics started quickly.
2. On 4/24/24 at 2:56 PM, R4 was lying in bed with R4's eyes closed. R4's indwelling urinary catheter bag was hanging from the left side of R4's bed and was draining clear yellow urine.
R4's current Physician Orders documents an order for an Indwelling Urinary Catheter for a diagnosis of urine retention.
R4's Resident Progress Note dated 4/17/24 at 4:34 PM and signed by V3 (Assistant Director of Nursing) states, V14 (Advanced Nurse Practitioner) was here for weekly rounds and ordered UA C&S (Urinalysis and Culture and Sensitivity). Awaiting Progress Notes from NP (Nurse Practitioner). Order placed in computer.
The facility's Lab Due Report documents a one-time order dated 4/19/24 for R1 for a Urinalysis; Urine Culture to rule out a urinary tract infection.
As of 4/24/24, R4's medical record did not contain a result for R1's 4/19/24 physician ordered UA and C&S.
On 4/24/24 at 2:36 PM, V2 (Director of Nursing) stated, I am not going to lie to you. V3 (Assistant Director of Nursing) placed the order for the UA and C&S to be completed, but it was never done. Whether the lab never picked it up or the staff never collected it, I don't know, but either way, it wasn't done. At this time, V2 verified R4's UA and C&S should have been collected on 4/19/24 and it was not.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to designate an Infection Preventionist onsite, who is responsible for assessing, developing, implementing, monitoring, and managing the Infec...
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Based on interview and record review, the facility failed to designate an Infection Preventionist onsite, who is responsible for assessing, developing, implementing, monitoring, and managing the Infection Prevention and Control Program (IPCP) to prevent and control infections in the facility. This has the potential to affect all 72 residents living in the facility.
Findings include:
The Infection Preventionist Job Summary dated 2/13/20 states, The Infection Preventionist (IP) is responsible for overseeing the infection control program. The IP systematically collects and assesses data in collaboration with the team to provide therapeutic, evidenced based care. The IP works collaboratively with the team to develop plans of care and documents progress toward achieving defined outcomes. This position requires the knowledge of epidemiology and application of public health practices in the facility, with the goal of implementing effective and efficient procedures and policies to combat disease transmission among residents and staff. Responsibilities: 1. Keeping Infection section of EMR (Electronic Medical Record) current on residents with infections, updating weekly and as needed. 2. Tracks and Trends employee related infections. 3. Ensuring assessments are done per program requirements. 4. Assessing and documenting on all infections within Infection Watch. 5. Audits infection control practices on the floor. 6. Monitors immunization process throughout the year on all residents and employees. 7. In-servicing staff on infection control program. 8. Updating all care plans relevant to infections and isolation. 9. Completing MDS (Minimum Data Set Assessment) section pertinent to infections. 10. Communicates with IDT (Interdisciplinary Team) regarding residents with wounds. 11. Evaluated all new admissions/readmissions within 24 hours of admission for any active infections or usage of antibiotics. 12. Completes analysis of information collected regarding infections and presents at QA (Quality Assurance) Meeting.
The Key Personnel List provided by V1 on 4/23/24 is blank in the section titled Infection Preventionist with no staff member named.
On 4/25/24 at 12:17 PM, V1 (Administrator) stated that the previous IP Nurse (V17) no longer works at the facility as of 4/2/24 and that V18 (Licensed Practical Nurse/Wound Nurse) has been V17's back up.
On 4/25/24 at 11:37 AM, V18 stated V17 was the previous IP nurse and V17 no longer works at the facility. V18 stated that while V18 does have a current IP Certificate, V18 has not worked in the IP role in any capacity since V17 left. V18 stated V18 has not been made aware that V18 is acting as the IP nurse in the facility.
The Daily Census Report dated 4/23/24 documents 72 residents currently reside in the facility.
Mar 2024
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to have a Practitioner Order For Life-Sustaining Treatment/ POLST in the Medical Record for one resident (R171) in the sample of 30.
Findings ...
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Based on interview and record review, the facility failed to have a Practitioner Order For Life-Sustaining Treatment/ POLST in the Medical Record for one resident (R171) in the sample of 30.
Findings include:
The Advanced Directives and Care Plan Guidelines dated 11/28/17 documents It is the practice of the facility to establish, implement and maintain written guidelines for advance directives. The resident has the right and the facility will assist the resident to formulate an advance directive to their option. The facility will inform and provide resident with a written description of the facility's practice to implement advance directives. The resident has the right to accept, request, refuse and/or discontinue medical or surgical treatment and to participate in or refuse to participate in experimental research. D. All advance directive document copies will be obtained and located within the medical record. E. The advance directives are present within the medical record for the facility staff and physician.
Findings include:
On 03/25/24 01:28 PM, there was no Advance Directive for R171 found in R171's Electronic Medical Record or in the desk chart.
On 3/25/24 at 1:15 PM, V5 (Licensed Practical Nurse) stated that there is not an Advanced Directive for R171, but V5 knows R171 is on Hospice and with selective treatment. V5 asked Hospice to bring in a copy of R171's Advanced Directive but the facility does not have it yet.
On 3/25/24 at 1:36 PM, V2 (Director of Nursing/DON) stated that the POLST form is not in the Electronic Medical Record or hard chart because it has not been signed by the primary physician. R171 is to be resuscitated but no ventilator or tube feeding.
On 3/26/24 at 8:15 PM, V2 (DON) stated that on 3/22/24 the hospital was asked for a signed copy of R171's Advanced Directive, and they did not send it. The hospital was contacted again on Monday (3/25/24) and the facility still does not have a signed copy. Until the facility has a signed copy of what R171 wants R171 will be a Full Code.
On 3/25/24 at 2:36 PM, V1 (Administrator) stated that until the doctor signs the Advance Directive R171 will be a Full Code.
On 3/26/24 the facility provided R171's POLST dated 3/22/24, that was signed by V8 (R171's Power of Attorney). The POLST documents that R171 wants to be a Do Not Attempt Resuscitation. The POLST form was not signed by R171's Primary Physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to identify and monitor targeted psychotic behaviors to warrant the use of Seroquel (antipsychotic medication) and attempt a gradu...
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Based on observation, interview and record review the facility failed to identify and monitor targeted psychotic behaviors to warrant the use of Seroquel (antipsychotic medication) and attempt a gradual dose reduction of the medication in the past year for one of one resident (R36) reviewed for antipsychotic medications in the sample of 30.
Findings include:
The facility's (undated) Antipsychotic Drug Assessment and Monitoring policy documents Residents receiving antipsychotic medication will be monitored by nursing personnel utilizing a behavior monitoring form (unless the resident has a psychiatric diagnosis). Behaviors must present a danger to the resident and/or others or interfere with the resident's functional ability to warrant medication. Documentation will include: Documentation of each behavior. This policy also documents Criteria for Psycho-pharmacological Drug use: Dose reductions or re-evaluations performed: Antipsychotic drugs, every six months.
The facility's (undated) Psychotropic Medications Policy documents This facility shall ensure that residents do not receive psychotropic drugs unless such therapy is necessary to treat a specific condition and is diagnosed by the attending physician or psychiatric consultant. Attempts will be made to reduce or discontinue use of such medications whenever possible without compromising resident's health and safety, ability to function appropriately, or the safety of others. This policy also documents Behavior monitoring will be conducted and documented by nursing staff on the shift which they occurred on a tracking record. This number is totaled on a monthly basis and may be used to help assess drug effectiveness. If the number of episodes is not lower than the baseline, the physician shall be notified of the lack of improvement. If the number is consistently low, then gradual dose reduction should be attempted.
On 3/25/24 at 10:45 AM, R36 was lying in her bed sleeping. No behaviors observed.
On 3/26/24 at 2:40 PM, R36 was in her bed sleeping. No behaviors observed.
R36's Physician Order Sheet, dated 2/27/24-3/27/24, documents R36 has orders for Quetiapine (Seroquel, antipsychotic medication) 25 milligrams (mg) give one tablet orally to be given with 150 mg to = 175 mg at bedtime, 8:00 PM every day. This sheet also documents R36's linked order for Quetiapine 300 mg give 1/2 tablet (150 mg). Special Instructions: To be given with 25 mg=175 mg at bedtime, 8:00 PM every day.
R36's Care Plan dated 3/26/24, documents R36 has a care plan for receiving a antipsychotic medication but does not include R36's specific behaviors to monitor.
R36's Point of Care history report, dated 2/1/24- 2/29/24, documents R36's is being monitored for mood expressions of distress and did the resident have any problems or behaviors. These reports all document R36 has not had any behaviors.
R36's Pharmacy Note to Prescriber, dated 2/29/24 documents Consider a GDR (Gradual Dose Reduction) for R36's Quetiapine 175 mg (total) at bedtime. This sheet documents V23 (R36's Physician) declined the GDR due to Patient condition is currently stable, dose reduction is contraindicated.
On 3/27/24 at 1:55 PM, V3 (Assistant Director of Nursing) stated the point of care history report for February is what she has for the last three months of behavior tracking. V3 confirmed R36 does not have targeted behaviors to monitor and has not had a gradual dose reduction (GDR) in the past year. V3 stated (R36) is being monitored for any general behaviors she may exhibit. I am not sure why she was originally put on the medication because she was admitted with it. She hasn't shown any behaviors that I am aware in a while. I looked through her notes and cannot see anything specific for behaviors. So, there are no behaviors right now. The pharmacy did recommend a GDR this year, but it was declined by her Primary Physician (V36).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to provide range of motion programming to residents with limitations in range of motion for 7 of 7 (R3, R11, R27, R52, R55, R57, R63) residents...
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Based on interview and record review the facility failed to provide range of motion programming to residents with limitations in range of motion for 7 of 7 (R3, R11, R27, R52, R55, R57, R63) residents reviewed for limited range of motion in a sample of 69 residents.
Findings include:
1. R3's current care plan documented R3 had ADLs (Activities of Daily Living) Functional Status/Rehabilitation Potential is at risk for an ADL self-care performance deficit, unable to come to a sitting position from supine and has an inability to transfer r/t (related to) generalized weakness and Quadriplegia, C5-C7 (Cervical) incomplete.
On 3/26/23 a Physician's Order documented for R3 to maintain current ROM (Range of Motion) via PROM (Passive Range of Motion) exercise program to BLE (Bilateral Lower Extremities) for 15 repetitions as tolerated twice daily.
R3's Point of Care History Restorative Nursing Passive Range of Motion flowsheet lacked documentation PROM was conducted as ordered: in January, 18 of 31 days; in February, 17 of 29 days; and in March, 15 of 25 days.
2. R11's current care plan documented R11 had ADLs Functional Status/Rehabilitation Potential to maintain self-care performance deficit (related to) Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side.
On 11/10/23, the Physician's Orders documented for R11 to maintain current Passive Range of Motion to BLE/BUE's (Bilateral Upper Extremities) for 10 repetitions as tolerated twice daily.
R11's Point of Care History for Restorative Nursing Passive Range of Motion flowsheet lacked documentation PROM was conducted as ordered: in January, 8 of 10 days; in February, 22 of 29 days; and in March, 16 of 25 days.
3. R27's current care plan documented R27 has ADLs Functional Status/Rehabilitation Potential and is at risk for an ADL self-care performance deficit r/t (related to) paraplegia, s/p (status post) trach (tracheostomy) and vent (ventilator), alcohol abuse, spinal fusion in 2018, arthritis, h/o (history of) falls and fractures prior to admission, cervical osteomyelitis with surgery and neurogenic bladder. R27 is at risk for developing contractures related to Dx (diagnosis): Paraplegia.
On 5/25/22 a Physician's Order documented for R27 to maintain current ROM (Range of Motion) to BLE (Bilateral Lower Extremities) via PROM (Passive Range of Motion) exercises for 10 repetitions x 2 sets as tolerated every shift (twice daily).
R27's Point of Care History Restorative Nursing Passive Range of Motion flowsheet lacked documentation PROM was conducted: in January, 23 of 29 days; in February, 28 of 29 days; and in March, 25 of 25 days.
4. R52's current care plan documented R52 had ADLs Functional Status/Rehabilitation Potential related to impaired mobility.
On 2/6/24, a Physician's Order documented for R52 to maintain current ROM to BLE/BUE via PROM exercises for 10 reps as tolerated twice daily.
The Point of Care History for Restorative Nursing Passive Range of Motion flowsheet lacked documentation Passive Range of Motion was conducted as ordered: in February 19 of 22 days; and in March 19 of 22 days.
5. R55's current care plan documented R55 has ADLs Functional Status/Rehabilitation Potential due to impaired mobility secondary to Craniotomy for meningioma. R55 participates in restorative PROM program with total assistance for performance ability.
On 12/6/23, a Physician's Order documented for R55 to receive PROM exercise BID (twice daily) to all extremities 10 reps (repetitions).
R55's Point of Care History Restorative Nursing Passive Range of Motion flowsheet lacked documentation PROM was conducted as ordered: in January, 10 of 19 days; in February, 22 of 29 days; and in March, 19 of 25 days.
6. R57's current care plan documented R57 had ADLs Functional Status/Rehabilitation Potential to maintain current ROM and strength d/t impaired mobility r/t weakness post hospitalization.
On 12/16/23 a Physician's Order documented for R57 to maintain current ROM to BLE/BUE via PROM exercise for 10 reps x 2 sets as tolerated twice daily.
R57's Point of Care History Restorative Nursing Passive Range of Motion flowsheet lacked documentation PROM was conducted as ordered: in January, 14 of 31 days; in February, 21 of 29 days; and in March, 21 of 26 days.
7. R63's current care plan documented R63 had ADLs Functional Status/Rehabilitation Potential related to impaired mobility d/t Anoxic brain damage.
On 11/1/23, a Physician's Order documented for R63 to maintain current ROM to BLE/BUE via PROM exercises for 10 reps x 2 sets as tolerated twice daily.
The Point of Care History for Restorative Nursing Passive Range of Motion flowsheet lacked documentation Passive Range of Motion was conducted as ordered: January, 15 of 31 days; February 19 of 29 days; and March 16 of 25 days.
On 3/25/24 at 1:45 PM, V2 (Director of Nursing) reviewed R3, R11, R27, R52, R57 and R63's records and verbally agreed PROM was not conducted as ordered and should have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
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 a resident with a physician ordered calorie su...
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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 a resident with a physician ordered calorie supplement, care plan weight loss and ensure resident weights were being scheduled and documented for residents with high-risk diagnoses, fluid fluctuation and weight loss for five of eleven residents (R52, R55, R57, R63, R64) reviewed for nutrition in the sample of 30.
Findings include:
The facility's Weight Monitoring Guideline policy, dated 4/6/2018, documents Purpose: The facility measures and records weights to ensure accuracy and provide information for the evaluation of clinical status unless clinically contraindicated with physician justification. To provide guidance on timely consultation and weight parameters. Guideline: Residents will be weighed; documentation will be recorded in (electronic health record): Monthly by the seventh of each month. Anytime as needed with a change in condition or specified by NAR (Nutrition at Risk) committee. As specified by the physician or mid-level practitioner. This policy also documents For residents on daily weights for fluid volume overload prevention and monitoring weight notification parameters should be discussed with the physician and at minimum consultation should be completed with a five pound weight change in one week for residents with heart failure or fluid volume overload risk. Dietician: Review weight reports at least weekly to ensure residents with weight variances of five percent in 30 days and ten percent in six months are reviewed and evaluations for nutritional risk and timely interventions is completed.
The facility's Nutrition (Impaired)/Unplanned Weight Loss policy, dated 12/2017, documents The threshold for significant unplanned and undesired weight loss will be based on the following criteria: One month, five percent weight loss is significant; greater than five percent is severe. Three months, seven and a half percent weight loss is significant; greater than seven and a half percent is severe. Six months, ten percent weight loss is significant; greater than ten percent is severe. This policy also documents The dietician will estimate calorie, nutrient and fluid needs and, with the physician, will identify whether the resident's current intake is adequate to meet his or her needs.
The facility's Care Plan (Comprehensive) policy, dated 10/2022, documents An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and/or psychological needs is developed for each resident. Each resident's comprehensive care plan has been designed to: Incorporate identified problem areas. Reflect treatment goals and objectives in measurable outcomes. Aid in preventing or reducing declines in the resident's functional status and/or functional levels. This policy also documents, Care plans are revised as changes in the resident's condition dictates.
1. R64's electronic weight record, dated 3/28/24, documents R64's weight on 1/3/24 was 150 pounds. The next documented weight was dated 2/1/24 and documents R64 weighed 140 pounds (6.67% severe weight loss in one month). The next documented weight for R64 is dated 3/1/24 and documents R64 weighed 136.4 pounds (9.07% (percent) severe weight loss in three months). No other weights were documented for January, February or March 2024.
R64's Dietary Progress Notes, dated 2/06/2024 at 1:48 PM, and signed by V11 (Registered Dietician) documents (R64) Reviewed for weight loss at one, three, six months with body mass index of 21.38. Diet is regular/mechanical soft with double protein offered for pressure wound status, right hip stage four, which is now infected, antibiotic added. Multivitamin with minerals and Prostat 45 milliliters two times daily in place to aid healing, some improvement noted per recent report. Will request 2.0 supplement (fortified high calorie/high protein drink) 120 milliliters four times daily to provide 960 kilocalories, 40 grams of protein. Will follow up as needed.
R64's Physician Order Sheet, dated 3/26/24, documents an order for 2.0 supplement 120 milliliters four times a day 8:00 AM, 12:00 PM, 4:00 PM, 8:00 PM. This order has a start date of 2/9/24.
R64's Medication Administration Record, dated 2/1/24-2/29/24, does not document and order or administration of R64's 2.0 dietary calorie supplement.
R64's Medication Administration Record, dated 3/1/24-3/26/24, does not document and order or administration of R64's 2.0 dietary calorie supplement.
R64's current care plan, dated 3/12/24, does not document a care plan for R64's weight loss.
On 3/25/24 at 12:33 PM, R64 was sitting in the dining room in a slightly reclined high back wheelchair. R64 was alert, didn't speak and dozed off frequently during conversation. R64's body appeared thin and bony prominences were evident on R64's face, arms, and legs. V12 (R64's Family member) was sitting beside R64. V12 stated she visits the facility every day and stays until after lunch. V12 stated (R64) can feed himself but it makes a bigger mess, so when I am here, I usually feed him.
On 3/27/24 at 11:20 AM, V25 (Licensed Practical Nurse) confirmed R64 has an order for a 2.0 calorie supplement four times a day and it is not on his medication administration record (MAR). V25 stated It looks like when the order was put in, it was placed on the wrong flowsheet. It is ordered but not alerting nurses to the administration and there is no documentation to show if it's being given to R64. Prior to today it was not alerting nurses to administer the supplement.
On 3/27/24 at 11:30 AM, V3 (Assistant Director of Nursing) stated I was not aware that (R64) was not receiving the supplement and that it didn't populate on the MAR until now. We have some education to do on order entry. They (nurses) should be giving those supplements as ordered.
On 3/27/24 at 11:45 AM, V11 (Registered Dietician) confirmed following R64 and making recommendations based on his weight loss. V11 stated Supplements are typically given by the nurse with medication pass. I had not seen that (R64) was not getting his. He should be getting it as ordered to help prevent further weight reduction and overall nutrition. He is a good eater, but he has other health concerns too. With his weight loss I would expect them to be weighing him weekly. A lot of residents with higher risk nutrition needs should have weights more than monthly. Anyone in the building should be weighed at a minimum monthly but those with higher risk concerns should be monitored more frequently.
On 3/27/24 at 1:35 PM, V2 (Director of Nursing) confirmed she was unaware that (R64's) supplement shakes were not being administered. V2 also confirmed R64's weight loss over the past three months was not addressed on his care plan. V2 stated He should be getting those supplements on medication pass and his weight loss should be care planned with weight loss goals and interventions to follow.
2. R52 was admitted on [DATE] with diagnoses of Ventilator Dependence, Tracheostomy, Tube Feedings via Gastrostomy Tube, Dysphagia and Congestive Heart Failure.
On 2/27/24 and 2/29/24, a Physician's Order to conduct weekly weights, no diagnosis noted.
V11's (Registered Dietician) Progress Notes documented 3/5/24 Per latest weight, noted weight loss since changing tube feeding (TF). Loss of 4.6% past week with BMI (body mass index) of 23.93. 3/12/24 Recent weight loss noted and TF adjusted to accommodate. 3/26/24 Feeding increased due to some recent weight loss, will continue to monitor for need to modify.
R52's weight log lacked documentation that weekly weights were conducted 3 out of 7 weeks.
3. R55 was admitted on [DATE] with diagnoses of Protein Calorie Malnutrition, Dysphagia, Tracheostomy, Vitamin-D Deficiency, and assistance with personal cares related to weakness.
R55's current care plan documented R55 requires feeding tube r/t (related to) inability to maintain required nutritional needs by oral intake.
The record lacked a physician's order for monitoring weights.
On 1/19/24, a Physician's Order stated Diet: Mechanical soft, Regular, nectar thick liquids. Not to have any oral intake while on Ventilator.
R55's record noted R55 was hospitalized [DATE] through 11/13/23 and 1/3/24 through 1/12/24.
V11's (Registered Dietician) Progress Note documented 11/16/23 Per readmission review, noted weight loss and low BMI (body mass index) 16.89. Oral and tube feeding nutrition continues but recent diagnosis and treatment for COVID Pneumonia. High nutrition risk per weight loss, low BMI 12/28/23. (R55) is not allowing feeding to run at times. November weight not correct and likely transposed numbers. Physician is concerned resident is not getting adequate nutrition but has noted weight gain since admit in late August. On 1/16/24 Readmit with weight loss noted, was 184 (pounds) on 12/21/23 now 166.4 (pounds). 2/6/24 Per new weight for February, weight is stable since readmit last month. 12/21/23 readmit weight is in question and net loss at 6 months is 2% with BMI of 20.41. Tube feedings reimplemented last month per request due to appetite decline. 3/5/24 Reviewed for triggered weight loss at 3 months.
R55's weight log lacked documentation of a November weight and noted the following fluctuations on 12/21/23, 184 pounds; 1/15/24, 166.4 pounds; 2/1/24, 167 pounds; and on 3/1/24, 173.3 pounds.
4. R57 was admitted on [DATE] with the diagnoses of Ventilator Dependence, Tube Feeding via Gastrostomy Tube, Chronic Systolic Heart Failure, Protein-calorie Malnutrition, Duodenal Ulcer, Vitamin D Deficiency and need for assistance with personal cares.
R57's current care plan lacked documentation of a nutritional deficit.
R57's Physician's Order dated 11/15/23 documented daily weights were to be conducted related to Congestive Heart Failure and on 12/15/23 nothing to eat or drink by mouth.
R57's weight log lacked documentation of daily weights in January, 13 of 31 days; in February, 9 of 29 days; and in March, 10 of 25 days.
5. R63 was admitted on [DATE] with diagnoses of Chronic Systolic Heart Failure, Tracheostomy and Tube Feedings via Gastrostomy Tube.
R63's current care plan documented The use of the Feeding Tube has been assessed to be Unavoidable and is being used as the only source of Nutrition and Hydration. The tube feeding was determined to be medically necessary and the resident is at increased risk for complications: Leaking around the insertion site, Abdominal wall abscess, Erosion at the insertion site, perforation of the stomach or small Intestine with resultant peritonitis, Esophagitis, ulcerations, Strictures tracheoesophageal fistula of the esophagus, Clogging of the tube, nausea, vomiting, inadequate calorie or Protein intake, altered hydration, hypo/hyperglycemia, Altered Electrolyte and nutrient levels, Aspiration Pneumonia and decreased socialization
R63's record lacked a physician's order for monitoring weights and ordered R63 to have no intake by mouth.
V11's Progress Notes documents 12/18/23 Reviewed for weight loss past 2 months. 1/16/24 Per TF review, resident triggers weight loss since admit in October. Weights suspended in November due to COVID-19 but stable past 2 months with BMI 27.93. 2/6/24 Reviewed for weight loss since admit in October, -12.9% with BMI of 27.26. Continues NPO (nothing by mouth) status with TF of Nepro 65 cc x 21 hours, flush 200 cc (cubic centimeters) q (every) 4 hrs. 3/12/24 Reviewed for NPO status and /TF nutrition, with some weight loss past 5 months, -9.9% with BMI of 28.2. 3/6/24 H/O (history of) weight loss since admit in October, -17.5# (pounds). BMI is WNL (within normal limits) per age adjustment at 28. Will increase Prostat to 45 ml (milliliters) x 3 daily to provide 450 kcals (calories), 67gm (grams)protein.
R63's weight log lacked documentation of weekly weights, lacked documentation of a November weight, and noted the following fluctuations on 2/28/23, 160 pounds; 1/9/24 157.7 pounds; 2/1/24 153.9 pounds and 3/1/24, 159.2 pounds.
On 3/27/24 at 11:45 AM, V11 (Registered Dietician) stated A lot of residents with higher risk nutrition needs should have weights more than monthly. Someone with CHF (Congestive Heart Failure) and fluid overload should be a daily or weekly weight. Anyone in the building should be weighed at a minimum monthly but those with higher risk concerns should be monitored more frequently.
On 3/27/24 at 2:15 PM, V2 (Director of Nursing) stated A Resident who is NPO is considered at higher risk (for weight loss) but it also depends on their comorbidities. Tube Feeding Residents can be considered stable if they have not had any weight fluctuations, but any Resident with Congestive Heart Failure should have their weights conducted at least weekly and more often if indicated by fluctuations in weight. I would expect there to be a Physician's Order for the weight monitoring frequency and the care plan should address the risk area.
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 take and record the food temperature of foods on the tray line (steam table); check and record the wash and rinse temperatures...
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Based on observation, interview and record review, the facility failed to take and record the food temperature of foods on the tray line (steam table); check and record the wash and rinse temperatures and the Chlorine level on the dish machine; Check and record the amount of sanitizing solution in the sanitizer bucket; Keep cases of food off of the floor in the kitchen, walk-in cooler and walk-in freezer; Keep thawing raw meat in non-porous containers; store raw eggs on the bottom shelf to prevent contamination of ready to eat foods underneath the raw eggs; label and date all foods stored; use sanitizer wipes to clean the thermometer before and between uses and keep chemicals off of the floor and on shelves six inches off of the floor. This has the potential to affect all 69 residents living in the facility.
Findings include:
Observations of the kitchen were made on 3/24/24 from 10:00 AM to 12:30 PM.
The document, Dietary Daily Rounds Audit, dated, 2021, states, Dry goods storage, all boxes stored six inches off of the floor; Dish machine, temperature accurate and recorded on the log; sanitizer working/accurate/documented; adequate chemicals and test strips; machine gauge working properly; Walk-in Refrigerator: thermometer present and working; boxes stored six inches off the floor; foods properly wrapped, labeled and dated; Walk-in Freezer, boxes stored six inches off the floor; Food Preparation Area: Temperature logs current/any issues.
The document, Tray line Temperature Log, dated 2021, states, All cold foods must read 41 degrees F (Fahrenheit), or below. All hot foods must read 135 degrees F or above.
The document, Organization and Staffing, [NAME] Job Description, dated 2021, states, Take food temperatures and record them.
The document, Reheating, dated 2021, states, Cooked food will be reheated rapidly to an internal temperature of 165 degrees F, for 15 seconds. Temperature of reheated food will be maintained at a minimum internal temperature of 135 degrees F. Food will not be reheated more than once.
On 3/24/24 at 11:45 AM, V13, Cook, was observed taking out turkey from the oven and slicing off some of the meat to puree and grind. The remaining turkey was put back into the oven. The meat was pureed and ground before putting into the warmer. No food temperatures were taken at this time.
On 3/24/24 at 12:10 PM, V13 took the Tray line (steam table) food temperatures, using a stick thermometer. V13 did not sanitize the thermometer before or between uses. The ground turkey tested 110 degrees F. The pureed turkey tested 100 degrees F. V13 was unable to tell what temperature the meat needed to be reheated to, for how long, or how many times food could be re-heated. The tray line temperature logs were requested. V6 stated that they did not take or record tray line temperatures.
The document, Dishwashing Procedure, dated 2021, states, To prevent food borne illness, when testing for chemical sanitizing machines, dip the appropriate chemical sanitizer test strip in the water on the drain board nearest to the opening at the clean end of the dish machine. Dip for one second only, the test strip should turn the appropriate color to indicate 50 ppm, parts per million for chlorine.
The document, Procedure for Cleaning and Sanitizing, dated 7/2015, states, Record dish machine temperatures and chemical saturation ppm, parts per million three times daily using the Dish machine Temperature Log to ensure dishes are sanitized. Notify Maintenance when there is a problem.
On 3/24/24 at 11:20 AM, the gauge on the dishwasher was not working. When questioned, V26, Dietary Worker, stated, I've worked at the facility for the past four days washing dishes and no one told me to check and record the dish machine's wash and rinse temperatures or to check the amount of chlorine. V26 was unaware what the regulatory temperatures or chlorine amount should be or where to find the log to record it on. V6 stated that they did not check and record the wash and rinse temperatures or the chlorine levels on the dish machine. V7, Maintenance Director, was called to the kitchen concerning the gauge that was not working. V7 stated he was unable to replace the gauge as the supplier did not have any working gauges to send to the facility, V7 said he and V6 would monitor the temperature of the dishwasher heat booster to make sure the temperature level was within 120 to 140 degrees F.
The document, Cleaning and sanitizing Equipment/Utensils, dated 2021, states, Moist cloths for wiping food spills on kitchen ware and other food-contact surfaces of equipment shall be clean and rinsed frequently and used for no other purpose. These cloths will be stored in a sanitizing solution between uses.
The document, Sanitation Buckets/Wiping Cloths Food Contact Surfaces and Equipment too Large to Immerse in the Sink, dated 2021, states, Wiping cloths kept in a sanitation bucket containing a solution of water and chemical sanitizer are used to sanitize food contact surfaces and equipment food too large to immerse in the three-compartment sink. Using an appropriate test strip, the strength of the sanitizing solution will be tested each time the sanitation buckets are changed.
The document, Sanitation and Food Safety, dated 2021, states, The (test) strip is dipped into the sanitizing solution and held for the seconds specified on the test kit. Once removed from the sanitizing solution, the strip is compared to the color on the chart. If the color is not within the correct range, adjustment is made until the sanitizing solution is the correct concentration. The test strip results are recorded on the ppm, parts per million, log.
On 3/24/24 at 11:00 AM, requested that the sanitation bucket be tested. V6 stated that the facility uses a product unfamiliar to writer. Inquired how the product was tested. A container of test strips, outdated, was found but only V14, Dietary Worker, was able to explain what the level of sanitary solution should be, stating, It should be blue, which is zero, I know because I worked somewhere else and learned how to check it there. V6 stated that the sanitation solution was not checked and recorded and that she was unaware of information about the solution and how to properly check it's strength. V6 stated they would use chlorine as a sanitary agent until information about testing the current sanitary agent could be obtained.
The document, Storage of Refrigerated Foods, dated 2021, states, Refrigerated food is stored in a manner that ensures food safety and preservation of nutritive value and quality. Refrigerators will be stored with an internal thermometer and monitored. Temperatures will be checked and documented. Prepared foods stored in the refrigerator until service will be covered, labeled and dated with a use by date or expiration date. Raw food is stored below cooked food or ready to eat food. Food stored in refrigerators will be stored on shelves, racks, dollies or other surfaces that facilitate cleaning.
The document, Storage of Frozen Foods, dated 2021, states, Appropriate storage procedures followed are: Food is stored six inches above the floor; food is stored to allow air circulation; Raw frozen meat, poultry or fish are not stored over other foods.
The document, Storage of Dry Goods/Foods, dated 2021, states, Food and supplies will be stored six (6) inches above the floor on clean racks or shelves. Chemicals, including soaps detergents and cleaning compounds will be clearly labeled.
On 3/24/24 at 10:45 AM, a case of raw sweet potatoes was sitting on the floor next to the food preparation table outside of the walk-in cooler.
On 3/24/24 at 10:46 AM, The walk-in cooler did not have an inside thermometer. V6 stated, We use the gauge on the outside of the walk-in cooler. Several cases of food, bread, English muffins; muffin variety; fresh green beans, zucchini, and a five-pound bag of onions were sitting directly on the floor inside the walk-in cooler. V6, Dietary Manager, stated these cases had been delivered four days prior. Cases of raw hamburger and raw sausage in cardboard boxes, not in non-porous containers were sitting on a middle shelf; a case of raw eggs were on a middle shelf, over a case of thawed Health shakes; a canister containing of approximately three pounds of American cheese, and two pounds of white American cheese were not labeled or dated; an open one half, five pound package of shredded cheddar cheese, loosely closed, was not labeled or dated. The walk-in freezer, which is attached to the walk-in cooler, did not have an inside thermometer. V6 stated that the gauge outside the freezer was what was used. The freezer had 15 cases of frozen food .bread, muffins, spinach, broccoli, Brussels sprouts; pork loin; hamburger; mixed vegetables, French fries sitting on the freezer floor. V6 confirmed these were also received four days prior.
On 3/24/24 at 11:35 AM, V6's office had four, five-gallon buckets of dishwasher detergent, six cases of delimer, all sitting on the floor. V6 stated, We need to figure out how to store these.
The Central Management System, CMS, form 671, Long Term Care Facility Application for Medicare and Medicaid, signed by V1, Administrator, on 3/24/24, states there are 69 residents living in the facility.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0847
(Tag F0847)
Minor procedural issue · This affected most or all residents
Based on interview and record review, the facility failed to explain the arbitration agreement to the resident, or their representative in a form or manner they could understand. This had the potentia...
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Based on interview and record review, the facility failed to explain the arbitration agreement to the resident, or their representative in a form or manner they could understand. This had the potential to affect all 69 residents residing in the facility.
Findings include:
On 3/27/24 at 12:43 PM, V21 (Regional Administrator Consultant) stated that there is not an Arbitration Agreement policy.
The Arbitration and Liability Agreement Between Resident and Facility documents This Arbitration and Limitation of Liability Agreement (the Arbitration Agreement) is entered into this ___ day of ______, 20__ by and between ______________ (Facility) and __________ (Resident) and, if applicable, ____________, an individual with the legal authority to make decisions on behalf of Resident such as a Power of Attorney or Guardian (Legal Representative), (referred to singly and collectively as Resident) who are parties to the Contract between Resident and Facility for Resident's care and treatment at Facility (the Residency Contract).
On 3/24/24 at 11:45 AM, V4 (Admissions Coordinator) stated that she tells residents and their family that the Arbitration Agreement means that if there is a disagreement between the facility and resident or their family an arbitrator will work with them all to resolve the dispute. V4 was asked if she told them they were giving up their legal rights to go to court and V4 stated No that was not explained to V4. V4 has been doing her job for three years.
On 3/25/24 at 4:45 PM, V9 (R19's Power of Attorney) stated that there were so many papers to sign V9 is not sure what she was told. V9 also stated I know I would not have signed it had I known I was giving up rights for (R19).
R19's Contract between Resident and Facility, dated 3/8/24, documents that V9 (R19's Power of Attorney) signed the binding arbitration agreement.
On 03/26/24 at 1:12 PM, V15 (R60's Power of Attorney) stated that she was not told anything when she signed the admission papers for R60. It was a rushed process with people standing in the hall and the phone ringing. V15 also stated that if she was told what the Arbitration Agreement meant V15 would not have signed it.
R60's Contract between Resident and Facility, dated 3/5/24, documents that V15 (R60's Power of Attorney) signed the binding arbitration agreement.
On 3/25/24 at 2:27 PM, V8 (R171's Power of Attorney) stated that she is not sure what she was told about the Arbitration Agreement. V8 does not remember being told that they could not sue the facility if the Arbitration Agreement was signed. V8 also stated Although I don't believe in taking anyone to court it would be nice to know what I signed.
R171's Contract between Resident and Facility, dated 3/22/24, documents that V8 (R171's Power of Attorney) signed the binding arbitration agreement.
The facility's Centers for Medicare & Medicaid Services/CMS-671 Long Term Care Facility Application for Medicare and Medicaid signed by V1 (Administrator) and dated 3/25/24 documents 69 residents currently reside in the facility.
Jan 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on interviews and record review, the facility failed to implement the abuse policy for a thorough investigation and suspension of an employee for an allegation of abuse for one resident (R2) of ...
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Based on interviews and record review, the facility failed to implement the abuse policy for a thorough investigation and suspension of an employee for an allegation of abuse for one resident (R2) of three residents reviewed for allegation of abuse in a sample of three.
Findings include:
The facility's (State) Abuse Prevention Policy Dated 10/24/22 also documents: VII. Internal Investigation. 1. All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. 2. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation. Employees of this facility who have been accused of abuse, neglect, exploitation, mistreatment or misappropriation of resident property will be removed from resident contact immediately. The employee shall not be permitted to return to work until the results of the investigation have been reviewed by the administrator and it is determined that any allegation of abuse, neglect, exploitation, mistreatment or misappropriation of resident property is unsubstantiated.
The facility's (State) Abuse Prevention Policy Dated 10/24/22 also documents: VII. Internal Investigation. 1. All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected.
On 1/11/24 at 12:10 pm, V11 Respiratory Therapy Director stated that V8 Power of Attorney/POA to R2 first informed V11 on 1/4/24 that V8 needed to speak to V11; stated that he had concerns about males caring for R2. V11 stated that she immediately went to inform V1 Administrator/Abuse Coordinator who was in a meeting; stated that she notified V2 Director of Nursing/DON at that time.
On 1/10/24 at 1:12 pm, R2 noted to be alert and oriented, was able to talk very low in a whisper due to trache in place. R2 stated that the male staff who entered her room did not say anything to her (R2 was not sure of the date); stated that the male staff looked at her in the face as he touched her breast (R2 showed that the male staff touched her right breast.) R2 stated that (V8 POA) was very upset. R2 stated, This was the first and only time (the male staff) worked with me; this has not happened before.
On 1/11/24 at 10:20 am, V1 Administrator stated that V12 Certified Nursing Assistant/CNA does not usually work on the Respiratory Unit; stated that she viewed the camera for the overnight into Thursday morning of 1/4/24 and viewed V12 CNA going into R2's room around 5:50 am on 1/4/24, and V12 CNA exited R2's room in one to two minutes.
On 1/11/24 at 10:20 am, V1 Administrator stated that she had not talked with V12 CNA about the abuse allegation with R2; stated that she did not schedule V12 CNA on the Respiratory Unit after the incident but did not suspend V12 CNA; and stated that they did not have investigation documentation regarding the incident.
On 1/11/24 at 10:20 am, V1 stated, The only one who said something had happened to R2 was V8 POA. It did not occur to me that anything had happened between V12 CNA and R2.
On 1/11/24 at 11:55 am, V1 Administrator stated that she did not have records of her interviews with residents about the 1/4/24 incident. V1 stated, I did not suspend (V12 CNA); felt there was no need.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interviews and record review, the facility failed to report allegations of abuse to the State Agency for one (R2) of three residents reviewed for abuse in a sample of three.
Findings include...
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Based on interviews and record review, the facility failed to report allegations of abuse to the State Agency for one (R2) of three residents reviewed for abuse in a sample of three.
Findings include:
The facility's (State) Abuse Prevention Policy Dated 10/24/22 documents: Any allegation of abuse or any incident that results in serious bodily injury will be reported to the (State) Department of Public Health immediately, but not more than two hours of the allegation of abuse.
On 1/11/24 at 12:10 pm, V11 Respiratory Therapy Director stated that V8 Power of Attorney/POA to R2 first informed V11 on 1/4/24 that V8 needed to speak to V11; stated that he had concerns about males caring for R2. V11 stated that she immediately went to inform V1 Administrator who was in a meeting; stated that she notified V2 Director of Nursing/DON at that time.
On 1/10/24 at 12:05 pm, V8 Power of Attorney/POA to R2 stated that he visits R2 each day at the facility; that he reported the 1/4/24 incident (male staff touching R2's breast) to (V1 Administrator) the same day R2 told him.
On 1/11/24 at 10:20am, V1 Administrator stated that they did not report this incident to (State) authorities.
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 interviews and record review, the facility failed to do a thorough investigation for an allegation of staff to resident abuse for one resident (R2) of three residents reviewed for abuse in a ...
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Based on interviews and record review, the facility failed to do a thorough investigation for an allegation of staff to resident abuse for one resident (R2) of three residents reviewed for abuse in a sample of three.
Findings include:
The facility's (State) Abuse Prevention Policy Dated 10/24/22 documents: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault including non-consensual or non-competent to consent sexual activity.
The facility's (State) Abuse Prevention Policy Dated 10/24/22 also documents: VII. Internal Investigation. 1. All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. 2. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation. Employees of this facility who have been accused of abuse, neglect, exploitation, mistreatment or misappropriation of resident property will be removed from resident contact immediately. The employee shall not be permitted to return to work until the results of the investigation have been reviewed by the administrator and it is determined that any allegation of abuse, neglect, exploitation, mistreatment or misappropriation of resident property is unsubstantiated.
On 1/11/24 at 12:10 pm, V11 Respiratory Therapy Director stated that V8 Power of Attorney/POA to R2 informed V11 on 1/4/24 that V8 needed to speak to V11; stated that he had concerns about males caring for R2. V11 stated that she immediately went to inform V1 Administrator who was in a meeting; stated that she notified V2 Director of Nursing/DON at that time.
On 1/10/24 at 1:12 pm, R2 noted to be alert and oriented, was able to talk very low in a whisper due to trache in place. R2 stated that the male staff who entered her room did not say anything to her (R2 was not sure of the date); stated that the male staff looked at her in the face as he touched her breast (R2 showed that the male staff touched her right breast.) R2 stated that (V8 POA) was very upset. R2 stated, This was the first and only time (the male staff) worked with me; this has not happened before.
On 1/11/24 at 10:20 am, V1 Administrator stated that she viewed the camera footage for the overnight into Thursday morning of 1/4/24 and saw V12 Certified Nursing Assistant/CNA going into R2's room around 5:50 am and came out of R2's room in one to two minutes.
On 1/11/24 at 10:20 am, V1 Administrator stated that she had not talked with V12 CNA about the 1/4/24 alleged abuse incident; that V12 CNA was called on 1/4/24 but did not answer; and stated that she advised facility staff not to schedule V12 CNA on the hall where R2 resides. V1 Administrator stated that the facility did not have investigation documentation regarding this abuse incident.
Dec 2023
3 deficiencies
2 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 F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to keep a resident's pain in control following a hip fracture with sur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to keep a resident's pain in control following a hip fracture with surgical repair for one of three residents (R1) reviewed for pain management in the sample of six. This failure resulted in R1 experiencing excruciating pain for over 48 hours causing R1 to cry, not eat and scream in distress.
Findings include:
The facility's Pain Management policy dated 5/2017, states It is the policy of this Facility to screen all residents for pain; identify those who are experiencing pain; and assess and develop an effective individualized pain management care plan.
R1's Hospital Discharge Orders dated 11/27/23 at 11:21 a.m., states Start Norco (narcotic pain medication) 7.5/325 mg (milligram) 1-2 tabs every six hours as needed for pain. Stop Norco 5/325 mg 1 tab every twelve hours as needed for pain.
R1's Medication Administration Record dated 11/25/23 through 11/30/23, documents R1 did not get the physician ordered Norco 7.5/325 mg to start on 11/27/23 until 11/29/23 at 2:11 p.m.
R1's Pain Care Plan dated 11/18/23, documents an updated approach on 11/27/23 was implemented for Staff to increase monitoring of pain management (due to) recent right hip surgery. This same Care Plan documents to Administer medication as ordered and monitor for effectiveness of relief, complete pain assessment, notify R1's physician if current pain medication is not effective.
On 12/12/23 at 10:45 a.m., R1 stated she fell and broke her hip on 11/21/23 and had to have the hip surgically repaired. R1 stated she was re-admitted on [DATE] with orders for a new higher dose of Norco (narcotic pain medication) 7.5/325 mg (milligram) 1-2 tablets every six hours as needed for pain. R1 stated for an unknown reason the nurses did not receive the Norco from the pharmacy until 11/29/23 in the afternoon. R1 stated she was in excruciating pain for over 48 hours with no relief and nothing was done about it. R1 stated she didn't want to eat due to the pain. R1 stated she tried to hold still and sleep to keep her hip from hurting. R1 stated it was a long 48 hours. R1 stated she had a mild pain pill ordered but it didn't touch the pain. R1 stated the hospital ordered the increased dose of Norco because of the severe pain she was experiencing after the hip fracture and surgical repair.
On 12/12/23 at 11:00 a.m., R6 stated she has been R1's roommate for a long time and they know each other very well. R6 stated when R1 returned from the hospital on [DATE] she had a lot of pain that progressively got worse as the day went on because she did not receive any pain medications. R6 stated R1 was crying and moaning in pain. R6 stated I tried to get her to eat her meals, but she didn't feel like it. I felt so helpless. The nurses didn't seem too concerned about it for some reason. They said they were working on getting the pain medications delivered yet they didn't come. R6 stated it was the afternoon of 11/29/23 before R1 finally received her prescribed Norco pain medication. R6 stated R1 would try to lie still and sleep to keep from hurting but she would wake up moaning.
On 12/13/23 at 2:10 p.m., V3 (R1's Representative) stated she had spoken to R1 and knew she was in horrible pain since she returned from the hospital, but no one could tell her why her pain medications had not been delivered. V3 stated then on 11/29/23, V2 (Director of Nursing) called and told V3 that there was confusion with R1's name on the prescription and that had to be clarified. V3 stated that was ridiculous to take over 48 hours to clarify the name of a resident that has resided in the same facility for almost four years. V3 stated the nurses gave her a mild pain medication but it was not good enough to help the pain of her hip repair.
On 12/12/23 at 1:00 p.m., V2 DON stated V2 was notified that R1 had not received her Norco as ordered on 11/29/23 when she came in to work. V2 stated she went down to see R1. V2 stated R1 was crying in pain and visibly in distress.V2 stated R1 should have received her pain medication in a timely manner and not gone over 48 hours without her newly ordered Norco for the hip pain. V2 stated the nurses should have intervened and got something done with the pain medications whether it was through the pharmacy or R1's physician. V2 stated R1 should have had her new pain medications from the pharmacy delivered the night of 11/27/23 into 11/28/23. V2 stated the medications could have been ordered emergency service and they would have been at the facility in four hours or less or they could have acquired them from a local pharmacy with a different prescription from R1's physician.
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
Pharmacy Services
(Tag F0755)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure narcotic pain medication was available upon a resident's rea...
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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 narcotic pain medication was available upon a resident's readmission following hip surgery for one of three residents (R1) reviewed for pain in the sample of six. This failure resulted in R1 experiencing excruciating pain for over 48 hours causing R1 to cry, not eat and scream in distress.
Findings include:
The facility's Pharmacy Receiving Controlled Substances policy dated 10/25/2014, states 5) A nurse notifies the pharmacist if controlled substance orders or doses are missing or incorrect.
The facility's Pharmacy Emergency Pharmacy Service and Emergency Kits policy dated 10/25/14, states Emergency pharmacy service is available on a 24-hour basis. Emergency needs for medication are met by using the facility's approved Emergency Medication Kit/Box or by special order from (the pharmacy). (The pharmacy) supplies emergency medications including emergency drugs, antibiotics, controlled substances, and products for infusion in limited quantities in compliance with applicable state and federal regulations to serve the immediate clinical needs of the residents. A. Telephone/fax numbers for emergency pharmacy service are posted at nursing stations. C. The dispensing pharmacy supplies emergency or 'stat' medications according to the dispensing pharmacy provider, noncontract, or infusion therapy products agreement.
R1's Hospital Discharge Orders dated 11/27/23 at 11:21 a.m., states Start Norco (narcotic pain medication) 7.5/325 mg (milligram) 1-2 tabs every six hours as needed for pain. Stop Norco 5/325 mg 1 tab every twelve hours as needed for pain.
R1's Progress Notes dated 11/27/23 at 3:54 p.m., state (R1) returned from (local hospital to the facility) at 12:15 p.m. (R1) returned with a new order for (Norco) 7.5/325 mg 1-2 tabs every six hours for pain.
R1's Progress Notes do not include any further documentation about R1's pain or that R1's Norco 7.5/325 mg had not been received from pharmacy on 11/27/23 per physician orders. R1's progress notes do not document the pharmacy was notified until 11/29/23 at 8:35 a.m.
R1's Progress Notes completed by V2 (Director of Nursing) dated 11/29/23 at 8:35 a.m., state Called (the pharmacy) about (R1's) pain medication. Pharmacy reported the signed (prescription) was in (R1's legal name) and not (R1's nickname). The error has been corrected as of this time. We are unable to pull from the (automated medication dispensing cabinet), therefore, the medication will be (rushed) delivered today. (R1)/Floor nurse were updated.
R1's Progress Notes dated 11/29/23 at 8:46 a.m., states (R1 complains of) pain to right hip (10 on a scale of 10). (R1's as needed) Tramadol (pain medication) and extra strength Tylenol administered by floor nurse.
R1's Progress Notes dated 11/29/23 at 4:47 p.m., states Spoke to (V3/R1's representative) regarding her (new prescription for Norco 7.5/325 mg). Explained to her that the Norco has arrived and R1 has received her first dose around 2:00 p.m. and is able to get it every six hours.
R1's Pain Care Plan dated 11/18/23, documents an updated approach on 11/27/23 was implemented for Staff to increase monitoring of pain management (due to) recent right hip surgery. This same Care Plan documents to Administer medication as ordered and monitor for effectiveness of relief, complete pain assessment, notify (R1's physician) if current pain medication is not effective).
R1's Medication Administration Record dated 11/25/23 through 11/30/23, documents R1 did not get the physician ordered Norco 7.5/325 mg to start on 11/27/23 until 11/29/23 at 2:11 p.m.
The Pharmacy Timeline received from V6 (Pharmacy Director of Nursing), dated 12/14/23, documents the following: Original order for Norco was faxed to pharmacy on 11/28/23 at 1:50 p.m.; The prescription was written for R1's legal name in which the pharmacy had never seen in their system; On 11/28/23 at 10:22 p.m. R1's name was confirmed and the Norco order was processed but missed the 10 p.m. cutoff for delivery that night; On 11/29/23 the facility sent an order to pharmacy for R1's Norco STAT (Immediately) at 8:35 a.m.; R1's Norco was delivered to the facility on [DATE] at 12:49 p.m.
The Pharmacy Packing Slip Proof of Delivery form documents R1's Norco 7.5/325 mg 12 tablets was delivered to the facility on [DATE] at 12:49 p.m.
R1's Controlled Drug Record form documents R1's Norco 7.5/325 mg was started on 11/29/23 at 2:00 p.m.
On 12/12/23 at 10:45 a.m., R1 stated she fell and broke her hip on 11/21/23 and had to have the hip surgically repaired. R1 stated she was re-admitted on [DATE] with orders for a new higher dose of Norco (narcotic pain medication) 7.5/325 mg (milligram) 1-2 tablets every six hours as needed for pain. R1 stated for an unknown reason the nurses did not receive the Norco from the pharmacy until 11/29/23 in the afternoon. R1 stated she was in excruciating pain for over 48 hours with no relief and nothing was done about it. R1 stated she didn't want to eat due to the pain. R1 stated she tried to hold still and sleep to keep her hip from hurting. R1 stated it was a long 48 hours. R1 stated she had a mild pain pill ordered but it didn't touch the pain. R1 stated the hospital ordered the increased dose of Norco because of the severe pain she was experiencing after the hip fracture and surgical repair.
On 12/12/23 at 11:00 a.m., R6 stated she has been R1's roommate for a long time and they know each other very well. R6 stated when R1 returned from the hospital on [DATE] she had a lot of pain that progressively got worse as the day went on because she did not receive any pain medications. R6 stated R1 was crying and moaning in pain. R6 stated I tried to get her to eat her meals, but she didn't feel like it. I felt so helpless. The nurses didn't seem too concerned about it for some reason. They said they were working on getting the pain medications delivered yet they didn't come. R6 stated it was the afternoon of 11/29/23 before R1 finally received her prescribed Norco pain medication. R6 stated R1 would try to lie still and sleep to keep from hurting but she would wake up moaning.
On 12/13/23 at 2:10 p.m., V3 (R1's Representative) stated she had spoken to R1 and knew she was in horrible pain since she returned from the hospital, but no one could tell her why her pain medications had not been delivered. V3 stated then on 11/29/23, V2 (Director of Nursing) called and told V3 that there was confusion with R1's name on the prescription and that had to be clarified. V3 stated that was ridiculous to take over 48 hours to clarify the name of a resident that has resided in the same facility for almost four years. V3 stated the nurses gave her a mild pain medication but it was not good enough to help the pain of her hip repair.
On 12/12/23 at 3:30 p.m., V8 (Pharmacist) stated R1's Norco was not delayed due to the name needing clarified. V8 stated the order wasn't received by pharmacy until 11/28/23 at 1:49 p.m.
On 12/12/23 at 12:45 p.m., V9 (Licensed Practical Nurse) stated she sent R1's Norco order to the pharmacy on 11/27/23 when she was readmitted from the hospital. V9 stated when she got to work on 11/28/23 R1 told her she still had not received her Norco and was in a lot of pain. V9 stated I called the pharmacy and they told me they didn't received the prescription for (R1's Norco) so I had them stay on the phone and verify they got the fax while I was talking to them. I did not have them send it STAT. I probably should have. The Norco should have arrived early morning on 11/29/23 but I guess it still wasn't here when (V2/Director of Nursing) got to work. The nurse on night shift 11/27/23 did not document any attempts to notify the pharmacy that I can see.
On 12/12/23 at 1:00 p.m., V2 stated V2 was notified that R1 had not received her Norco as ordered on 11/29/23 when she came in to work. V2 stated she went down to see R1. V2 stated R1 was crying in pain and visibly in distress. V2 stated R1 should have received her pain medication in a timely manner and not gone over 48 hours without her newly ordered Norco for the hip pain. V2 stated the nurses should have intervened and got something done with the pain medications whether it was through the pharmacy or R1's physician. V2 stated R1 should have had her new pain medications from the pharmacy delivered the night of 11/27/23 into 11/28/23. V2 stated the medications could have been ordered emergency service and they would have been at the facility in four hours or less or they could have acquired them from a local pharmacy with a different prescription from R1's physician.
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
Notification of Changes
(Tag F0580)
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 notify the resident's physician of an ordered pain medication not be...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the resident's physician of an ordered pain medication not being acquired from pharmacy and a resident being in severe pain for one of three residents (R1)reviewed for pain in the sample of six.
Findings include:
The facility's Change in a Resident's Condition or Status policy dated 5/17, states The nurse will notify the resident's physician when: b. There is a significant change in resident's physical, mental or psychological status, c. There is a need to alter the resident's treatment significantly. 5. The Nurse will record in the resident's medical record any changes in the resident's medical condition or status.
R1's Hospital Discharge Orders dated 11/27/23 at 11:21 a.m., states Start Norco (narcotic pain medication) 7.5/325 mg (milligram) 1-2 tabs every six hours as needed for pain. Stop Norco 5/325 mg 1 tab every twelve hours as needed for pain.
R1's Medication Administration Record dated 11/25/23 through 11/30/23, documents R1 did not get the physician ordered Norco 7.5/325 mg to start on 11/27/23 until 11/29/23 at 2:11 p.m.
R1's Pain Care Plan dated 11/18/23, documents an updated approach on 11/27/23 was implemented for Staff to increase monitoring of pain management (due to) recent right hip surgery. This same Care Plan documents to Administer medication as ordered and monitor for effectiveness of relief, complete pain assessment, notify R1's physician if current pain medication is not effective.
On 12/12/23 at 10:45 a.m., R1 stated she fell and broke her hip on 11/21/23 and had to have the hip surgically repaired. R1 stated she was re-admitted on [DATE] with orders for a new higher dose of Norco (narcotic pain medication) 7.5/325 mg (milligram) 1-2 tablets every six hours as needed for pain. R1 stated for an unknown reason the nurses did not receive the Norco from the pharmacy until 11/29/23 in the afternoon. R1 stated she was in excruciating pain for over 48 hours with no relief and nothing was done about it. R1 doesn't know if her physician was notified. R1 stated she didn't want to eat due to the pain. R1 stated she tried to hold still and sleep to keep her hip from hurting. R1 stated it was a long 48 hours. R1 stated she had a mild pain pill ordered but it didn't touch the pain. R1 stated the hospital ordered the increased dose of Norco because of the severe pain she was experiencing after the hip fracture and surgical repair.
On 12/13/23 at 3:00 p.m., V7 (R1's Primary Physician) stated he was not notified that R1 did not receive her Norco 7.5/325 mg as ordered on 11/27/23. V7 stated had he known there was an issue getting the medication there would have been other options they could have tried. V7 stated I could have sent a prescription to a local pharmacy to acquire the medication quickly or tried an alternative medication until the Norco arrived.
On 12/12/23 at 1:00 p.m., V2 (Director of Nursing) stated there was a mix up with R1's Norco on readmission from the hospital on [DATE] and R1 did not receive her Norco until 11/29/23 at 2:00 p.m. V2 stated R1's physician was not notified according to R1's medical record. V2 stated R1 physician should have been notified as soon as the nurses realized R1's Norco was not delivered the night she was readmitted for an alternative or some type of solution.
Nov 2023
1 deficiency
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to ensure a resident was free from misappropriation of a narcotic pain medication for one of three residents (R1) reviewed for misappropriation ...
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Based on observation and interview, the facility failed to ensure a resident was free from misappropriation of a narcotic pain medication for one of three residents (R1) reviewed for misappropriation in the sample of five.
Findings include:
The facility's Abuse Prevention Policy, dated 10/24/22, documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. This policy also documents Misappropriation of Resident Property means the deliberate misplacement, exploitation or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent.
The facility's Controlled Drug Policy and Procedure, dated 5/2017, documents Controlled drugs, as determined by the facility, are counted every shift by the nurse reporting on duty with the nurse reporting off-duty. The inventory of the controlled drugs must be recorded on the narcotic records and signed for accuracy of count.
R1's current Care Plan, dated 10/22/23 documents (R1) was admitted to hospice on 9/1/23 with admitting diagnosis: Malignant neoplasm of unspecified part of unspecified bronchus or lung. This same care plan has a goal that Resident will experience death with dignity and continued pain management daily through next review.
R1's Medication Administration Record (MAR), dated 9/27/23-11/7/23, documents R1 had an order for Hydrocodone/Acetaminophen (Norco, narcotic pain medication) 5/325 milligrams by mouth every four hours as needed. This MAR also documents the only medication administration of Norco during this time span was given to R1 on 10/4/23, 10/7/23 and 10/8/23 (for a total of three tablets given).
The facility's Proof of Delivery pharmacy report, dated 11/8/23, documents the facility was delivered 30 tablets of Norco for R1 on 9/24/23.
R1's initial incident report, dated 11/7/23, documents R1's Norco tablets were unable to be located on 11/7/23.
The facility's Staff Statement, dated 11/9/23, documents V19 (Registered Nurse) stated (on 11/7/23) Hospice nurse (V8) asked the remaining quantity of (R1's) medications. I checked the narcotic drawer and the resident did not have any Norco on hand. I verified the active order. I checked the book for the count sheet, but it wasn't there. I checked the second medication cart for the hall and it wasn't there. I checked the medical records bin and with the medical records office and could not find the count sheet. The hospice nurse stated their records show that on 11/2 (R1) had 24 tablets remaining.
On 11/27/23 at 2:30 PM, V3 (Assistant Director of Nursing) stated I called the (V2, Director of Nursing) on 11/7 and let her know the Hospice nurse (V8) was here and she mentioned that there was a card of Norco that was unaccounted for. They (Hospice) discontinued the Norco order because (R1) was not using it. He no longer has a Norco order. We do not know where the medication went. V3 also stated the facility now counts each narcotic sheet and records it with the daily shift counts but prior to this incident they were not tracking each narcotic card count.
On 11/27/23 at 10:50 AM, V2 (Director of Nursing) confirmed that on 11/7/23 it was discovered R1 was missing the narcotic medication Norco. V2 stated When a PRN (as needed) pain medication runs out the floor nurse calls the Hospice nurse to get the medication refilled. If the card is used up they (nurses) take the count sheet and place it in a bin to be scanned and then medical records puts it into the computer. (R1's) was gone. Both the sheet and the medication. V2 confirmed that the facility was unable to ever locate a narcotic sign out count sheet for the Norco which was delivered on 9/24/23 or the actual Norco tablets for R1 after 11/7/23.
Oct 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to follow its policy to provide timely and palatable supper meals to three residents (R7, R8, R9) reviewed for meals in a sample of six.
Find...
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Based on interview and record review, the facility failed to follow its policy to provide timely and palatable supper meals to three residents (R7, R8, R9) reviewed for meals in a sample of six.
Findings include:
The facility's Food Palatability-Hot Food Temperatures Policy, undated, documents: Policy: The healthcare community prepares and serves food and beverages that is palatable, attractive and at safe and appetizing temperature.
The facility's Dining Room Meal Service Times document: Breakfast 7:30-9am, Lunch 1130-1pm, Supper 430-6pm.
The facility's Resident Council Minutes, documents: 7/30/23 Dietary: Food not hot enough; 8/28/23 Old Business: Meal late on weekends; Dietary: Meals are still not hot; and 9/25/23 Dietary: Meals need to be getting out on time; dinners are getting served at 6:30/7:00pm; no hot plates.
The facility Assessment Tool, dated 12/7/21 documents: Facility serves three meals per day in the main dining and on each floor as needed at 7:30am, 11:00am, and 5:30pm.
The facility's Grievance Log 2023, documents: 8/6/23: Food was late.
On 10/24/23 at 10:45 am, R7 stated Supper meals are sometimes late; used to have it before 6pm; now sometimes 6:30pm and sometimes not hot. I would prefer supper to be earlier, it used to be earlier.
On 10/24/23 at 10:50 am, R9 stated, If supper is at 6pm, we are lucky. Sometimes the night shift and nurses have to pass out the meals. I feel rushed when I get my supper late; would like to go to bed by 7:30 (pm) and watch TV. Rather eat early for supper time; if it is served early, give it time for food to digest.
On 10/24/23 at 1:55 pm, R8 stated, Residents who eat in dining room gets suppers mostly on time; but the halls are hall by hall, and served after the dining room so supper might be late; and today, lunch was also late; it was late and cold.
On 10/25/23 at 9:50 am, V17 Certified Nursing Assistant/CNA Scheduler/Dietary Manager in Training stated, Meals being late and cold, cooks had not been using hot plates and were reeducated to use these; the last manager did not enforce this--so there were issues with food not being as hot as could be.
At this same time, V17 stated, Last night, at supper the last cart went out at 5:40pm, one night recently the last cart went out at 6:10pm and this was late because we had 10 substitute orders to make; and the residents might have gotten meals late.
On 10/25/23 at 9:50 am, V17 also stated, None of the residents on the halls have said they would like to get meals earlier. We would try to accommodate them. We do the dining room trays first, then the halls in order. I was not aware that the halls food trays had not been hot enough; we are using the hot plates now to try to keep the food hot.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
Based on interview and record review the failed to provide sufficient staff for care of its residents on the night shift. This has the potential to affect all 76 residents residing in the facility.
Fi...
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Based on interview and record review the failed to provide sufficient staff for care of its residents on the night shift. This has the potential to affect all 76 residents residing in the facility.
Findings include:
The facility's Staffing Policy, dated 11/2017, documents: Policy: Our facility provides adequate staffing to meet the needed care and services for our resident population. In addition, staffing will meet all operational activities as required; and, Policy Specifications: 2. Certified Nursing Assistants/CNAs are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan.
The Facility Assessment Tool, dated 12/7/21, documents: Staffing Plan. 3.2 Facility checks daily staffing needs based on census, skilled and non-skilled residents. Position: Nurses' Aides: 12 CNAs (Certified Nursing Assistants) 12 hour shifts. Agency Staff: Facility utilizes agency nurses and CNAs to meet daily staffing needs as needed.
The facility's Certified Nursing Assistant Daily Staffing Schedules document: Saturday 9/30/23 6pm to 6am night shift, two CNAs scheduled; Friday 10/13/23 6pm to 6am, only two CNAs scheduled from 8pm to 10pm (with three CNAs scheduled at the other times); Saturday 10/14/23 6pm to 6am night shift, only two CNAs scheduled from 10pm to 3am (with three CNAs schedule at the other times); Friday 10/20/23 6pm to 6am night shift, two CNAs scheduled.
On 10/20/23 at 11:15 am, R10 stated, Sometimes not enough CNAs at night; they call someone in to come in when there are call offs. They don't have the staff now; a lot quit when they took away the covid pandemic pay and pay went down by 4 dollars an hour.
On 10/20/23 at 10:30 am, R9 stated, There is not enough staff on the weekends; Sometimes I will go out to the staff and ask for what I need, if I waited too long.
On 10/20/23 at 10:20 am, V11 Licensed Practical Nurse/LPN, stated there were usually two to four CNAs on his hall at any one-time during day. V11 stated, The past weekend, there were only two CNAs, not enough; two CNAs for 40 residents. Showers need to be done and the other cares; cannot care for residents like they should with only two CNAs.
On 10/20/23 at 10:45 am, V13 Certified Nursing Assistant/CNA, stated that there were usually just two CNAs scheduled for the weekends and they try to get staff to fill in. V13 stated, There are call offs; we were getting bonuses to fill in for working and just switched to some kind of thing to win prizes; might win and might not. This will cause CNAs to maybe not want to fill in.
On 10/20/23 at 12:25 pm, V9 Certified Nursing Assistant/CNA stated: We have no problems on day shift with CNAs; and there is enough other staff to help out. Issues on the night shift; usually odors might be in the morning when short staffed at night; and the night shift don't get anyone up in the a.m. because of being short on staff; and showers would then have to be done on day shift due to there being short on night. I feel bad for the residents; they are not getting the care they need, and day shift have to really run, and play catch up.
On 10/20/23 at 11:30 am, V8 Minimum Data Set/MDS/Care Plan Coordinator stated, We need three nurses and four CNAs on night. Both me and (V5 Registered Nurse/RN/Infection Control Preventionist) come in on our own time on occasion to assist with trays and CNA work and make beds. Many times, on night shift, one Aide in the building; lots of call offs on Fridays; believe it was 10/13/23 there was one CNA, and one came on later. Nursing staffing is okay; CNAs is needing assist. Even if there are staff, they quit; (V1 Administrator) is trying to correct the situation.
On 10/25/23 at 10:55 am, V1 Administrator stated, We are working on getting CNAs and nurses. Agency is utilized. We offer bonuses in emergency situation, if the shift is not filled, then the bonuses should be offered. Should have six CNAs on day shift and three to four at night.
On 10/24/23 at 10:55 am, V17 CNA Scheduler/Dietary Manager in Training stated: Our CNA numbers are dependent on the census and acuity of residents. I try to have three to four CNAs scheduled each night.
On 10/25/23 at 9:50 am, V17 stated that regarding 9/30/23, 10/13/23, 10/14/23 and 10/20/23 when there were only two CNAs scheduled for the 6pm to 6am shift, that she was not able to get a CNA to work the entire shifts for those nights. V17 stated, I did not fill in. I usually do but I had been in the kitchen doing the dishes and assisting in there from 6am to 10pm those days; 16 hours working. Tried to find someone, called and texted everyone; a lot of them do not respond back on their days off.
The Resident Census and Conditions of Residents (Centers for Medicare and Medicaid Services/CMS 672) form, dated 10/20/23, documents 76 residents reside in the facility.
Oct 2023
8 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 resident did not develop a shear pressure inju...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident did not develop a shear pressure injury for one of three residents (R1) reviewed for pressure ulcers in a sample of eight.
Findings include:
A Pressure/ Skin Breakdown- Clinical Protocol dated 1/2017 states, 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.
A Centers for Medicare and Medicaid form 802 documents R1 does not have any pressure injuries.
R1's Minimum Data Set (MDS) assessment dated [DATE] documents R1 is moderately cognitively impaired, requires extensive assistance of two people for bed mobility, is dependent on staff for transfers and personal hygiene; and has functional limitation in range of motion in both lower extremities.
R1's care plan dated 8/17/23 instructs staff to use a wheelchair cushion as a pressure ulcer prevention while R1 is up in the chair.
R1's physician's orders dated 9/2/23 instruct for R1 to use a pressure redistribution cushion when R1 is up in the chair.
R1's Braden Score to predict pressure ulcer risk dated 8/24/23 documents R1 is at moderate risk for developing pressure ulcers because R1 can't always communicate discomfort or the need to be turned, is confined to the bed all or most of the time, is very limited in her ability to change and control her body position, has probable inadequate meal intake, and has a potential problem with friction and shearing because R1 requires moderate to maximal assistance in moving.
R1's Wound Management report dated 8/17/23 to 9/25/23 documents R1 developed a stage 2 pressure ulcer to the coccyx (above the buttocks at the base of the spine) on 8/17/23 which received treatment and was healed by 9/25/23.
R1's Wound Physician's Wound Evaluation and Summary Reports dated 9/11/23 to 10/2/23 document R1's coccyx pressure ulcer had worsened to a stage 3 pressure ulcer, however, that wound healed on 9/25/23. These reports do not document R1 had any other pressure injuries at that time.
On 10/2/23 at 11:30 a.m. R1 was waiting for lunch to be served while seated in a recliner in her room without a pressure redistribution cushion present. At 12:31p.m. R1 was still in the recliner in her room without a pressure redistribution cushion present. At 1:31p.m. R1 was still seated in a recliner in her room without a pressure redistribution cushion present. At 2:00 p.m. R1 was seated in a recliner in her room without a pressure redistribution cushion present and while waiting for lunch to be served. At 3:06 p.m. R1 was still seated in a recliner in her room without a pressure redistribution cushion present. R1's lunch tray was on the table in front of R1. R1 stated she had been sitting in the same position for a long time. R1 stated her buttocks hurt and she had a new sore on it. R1 called the sore a bedsore. At 3:16 p.m. V14 (Certified Nurse Aide/CNA) and V13 (CNA) entered R1's room to transfer R1 back to bed and to provide incontinence care. V14 and V13 applied a safety belt to R1's waist then, using extensive assistance, stood R1 and transferred R1 into bed. V13 and V14 proceeded to remove R1's incontinence brief. When V13 and V14 turned R1 to the left side R1 had an open wound to both her right and left buttock with an additional scabbed brownish area below the wound on the left buttock. V14 stated she thought R1's wounds were new. V14 proceeded to apply a barrier cream over the wounds before reapplying a clean incontinence brief to R1. At 3:30 p.m. V15 (Licensed Practical Nurse) entered R1's room to evaluate R1's wounds. V15 stated that another staff member told her about the wounds that morning but since R1 was sitting up in the recliner, V15 had not assessed the wounds or called R1's physician. V15 proceeded to leave R1's room to look in R1's medical record to see if R1's wounds had been previously documented. When V15 returned to R1's room she stated that R1 previously had a pressure ulcer that was being treated by a wound physician but that wound had healed. V15 proceeded to remove R1's incontinence brief and evaluate and measure R1's new wounds. V15 proceeded to reapply R1's incontinence brief then leave R1's room.
On 10/3/23 at 11:15 a.m. V4 (Wound Nurse) entered R1's room to evaluate R1's new wounds to her right and left buttock. V4 stated that R1's wounds are new pressure wounds which she believes are the result of shearing such as when R1's is pulled across the sheets during repositioning. V4 stated that shearing is considered a type of pressure injury. V4 stated that R1 is supposed to sit on a pressure redistribution cushion when R1 is in the chair to help prevent pressure injuries from occurring. V4 stated she initially evaluated R1's wounds earlier this morning then contacted R1's physician for treatment orders.
V4's progress note dated 10/3/23 at 9:27 a.m. documents V4 evaluated R1's new wounds as shearing to R1's bilateral buttocks which measured 2.5cm (centimeters) x 0.9cm on the right side, and 5.5cm x 2cm on the left.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the wheels of a recliner were locked and a tran...
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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 the wheels of a recliner were locked and a transfer safety belt was used during a resident transfer which affected one of three residents (R1) reviewed for transfers in a sample of eight.
Findings include:
A Transfer-Using a (Transfer Safety) Belt policy dated 5/2017 instructs staff to use safety transfer belts to transfer residents to and from the chair, to the bed, or toilet. This policy states, Nursing assistants will routinely have a gait belt immediately available to them during resident transfer. In addition, this policy instructs staff to ensure wheelchair wheels are locked or otherwise immobile.
R1's Minimum Data Set (MDS) assessment dated [DATE] documents R1 is moderately cognitively impaired, requires extensive assistance of two people for bed mobility, is dependent on staff for transfers and personal hygiene; and has functional limitation in range of motion in both lower extremities.
On 10/2/23 at 11:51 a.m. V11 (Certified Nurse Aide/CNA) and V12 (CNA) were preparing to transfer R2 to bed from the recliner. V11 had a transfer safety belt sticking out from one of her pants pockets. V11 and V12 placed R2's recliner in the feet down position, then without locking the wheels or applying a transfer safety belt around R2's waist, V11 and V12 lifted R2 under her arms to a standing position. R2 was weak and barely able to maintain a standing position even with V11 and V12 holding onto R2. During the process of lifting R2 from the recliner, the recliner began to move backwards away from R2's legs. Using extensive assistance from both V11 and V12, the two CNAs pivoted R2 onto the side of R2's bed before lifting R2's feet onto the bed. V11 and V12 proceeded to provide R2 with incontinence care. Once the care was completed. V11 and V12 placed their arms under R2's arms, then, without applying a transfer safety belt, V11 and V12 stood R2 then pivoted R2 back into the recliner.
On 10/2/23 at 12:00 p.m. V11 verified she did not use a transfer safety belt while transferring R2 from the recliner to the bed stating that she forgot. At 12:05 p.m. V12 verified she did not use a transfer safety belt while assisting V11 to transfer R1 to and from the recliner to the bed stating, I don't have one.
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
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure a resident's perineal area was cleansed from the front to the back for one of three residents (R3) reviewed for inconti...
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Based on observation, interview, and record review the facility failed to ensure a resident's perineal area was cleansed from the front to the back for one of three residents (R3) reviewed for incontinence care in a sample of eight.
Findings include:
A Perineal Care policy dated 8/2008 states, The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. In addition, this policy states, Wash perineal area, wiping from front to back.
On 10/3/23 at 10:12 a.m. V18 (Certified Nurse Aide/CNA) was preparing to provide incontinence care to R3. V18 positioned R3 on her back then removed R3's pants and removed the tapes on either side of R3's incontinence brief. V18 used a wet soapy washcloth to wipe from the back of R3's perineal area to the front. When V18 began cleansing R3's perineal from the back to the front, fecal material could be seen on the washcloth where V18 had dragged the fecal material from R3's buttocks area to the front across R3's urethra to the front of R3's perineal area. At 10:20 a.m. V14 entered R3's room to assist V18 to complete R3's incontinence care. At 10:30 a.m. V18 stated that the proper way to provide incontinence care is to cleanse the perineal area from the front to the back.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to ensure hand hygiene was performed in between tasks during incontinence care for three of three residents (R1, R2, R3) reviewed ...
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Based on observation, interview and record review the facility failed to ensure hand hygiene was performed in between tasks during incontinence care for three of three residents (R1, R2, R3) reviewed for infection control practices in a sample of eight.
Findings include:
A Hand-Washing/Hand Hygiene Policy dated 3/2020 states, It is the policy of the facility to assure staff practice recognized hand-washing/hand hygiene procedures as a primary means to prevent the spread of infections among residents, personnel, and visitors. Alcohol based hand rubs (ABHR) can be used for hand hygiene when hands are not visibly soiled or contaminated with blood or bodily fluids. This policy instructs that when hands are not visibly soiled they may use perform hand hygiene using ABHR in situation that include before direct contact with residents, before moving from a contaminated body site to a clean body site during resident care, before and after putting on and taking off gloves, after contact with a resident's intact skin, after contact with objects in the immediate vicinity of a resident that may be potentially contaminated, after contact with potentially infectious material, and after removing gloves.
A Perineal Care policy dated 8/2008 instructs to remove gloves and wash hands thoroughly following incontinence care and before repositioning covers or making the resident comfortable.
1. On 10/2/23 at 11:51 a.m. R2 was lying in bed when V11 (Certified Nurse Aide/CNA) and V12 (CNA) entered R2's room to provide incontinence care. V11 and V12 applied gloves then removed R2's pants and loosened the tabs on R2's incontinence brief. V12 proceeded to use soapy wash cloths to cleanse R2's front perineal area before rinsing and drying the area. Without changing her gloves or performing hand hygiene, V12 assisted V11 to turn R2 to the right side. V12 proceeded to cleanse, rinse and dry R2's buttocks area. Without removing the soiled gloves or performing hand hygiene, V12 opened a tube of protective cream an applied it to R2's buttocks area, then assisted V11 to apply a clean incontinence brief and R2's clothing. At 12:05 p.m. V12 verified she did not remove her soiled gloves and perform hand hygiene after cleansing R2's front perineal area and before touching R2's bare skin and clothing; after cleansing R2's buttocks, and before applying R2's protective cream, new incontinence brief and clothing.
2. On 10/3/23 at 3:16 p.m. R1 was lying in bed while V14 (Certified Nurse Aide/CNA) and V13 (CNA) applied gloves before providing R1 with incontinence care. V14 and V13 removed R1's incontinence brief then turned R1 to the left side. V14 used disposable wipes and soapy washcloths to cleanse R1's buttocks area. Without changing gloves or performing hand hygiene, V14 assisted V13 to turn R1 onto her back then proceeded to cleanse R1's front perineal area. Without changing her soiled gloves or performing hand hygiene, V14 proceeded to apply R1's clean incontinence brief and adjusted R1's covers and pillows.
3. On 10/3/23 at 10:12 a.m. V18 (Certified Nurse Aide/CNA) was preparing to provide incontinence care to R3. V18 positioned R3 on her back then removed R3's pants and removed the tapes on either side of R3's incontinence brief. V18 used a wet soapy washcloth to wipe from the back of R3's perineal area to the front. When V18 began cleansing R3's perineal from the back to the front, fecal material could be seen on the washcloth where V18 had dragged the fecal material from R3's buttocks area to the front across R3's urethra to the front of R3's perineal area. Once V18 was finished cleansing R3's front perineal area, without removing her soiled gloves or performing hand hygiene, V18 assisted R3 to turn to the right side, then proceeded to cleanse fecal material from R3's buttocks area. At 10:20 a.m. V14 entered R3's room to assist V18 to complete R3's incontinence care. Once V18 finished cleansing R3's buttocks, without removing her soiled gloves or performing hand hygiene, V18 squeezed some protective cream onto her soiled glove then applied it to R3's buttocks area before reapplying R3's clean incontinence brief and reposition R3 and adjusting R3's bed linens.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to have a Dietary Manager to supervise the prevision of meals which has the potential to affect all 82 residents in the facility....
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Based on observation, interview, and record review the facility failed to have a Dietary Manager to supervise the prevision of meals which has the potential to affect all 82 residents in the facility.
Findings include:
A Dietary Management Policy (undated) states, The Dietary Services Department shall be supervised and managed by a duly qualified and experienced Food-Service Supervisor. In addition, this policy states, A dietary management staff member shall be on duty at all times when the department is in operation and is responsible for supervision of all staff on duty.
On 9/2/23 at approximately 9:00 a.m. V2 (Corporate Liaison) stated the facility does not have a Dietary Manager.
A Meal Times policy (undated) documents the facility's noon meal will be served between 11:45 a.m. and 12:30 p.m.
On 10/2/23 at 12:32 p.m. V8 (Prep Cook) was the only staff member in the kitchen and was sorting through resident menus. The kitchen had soiling consisting of paper and food debris covering most of the floor, counter spaces, stove top, and slicer. There were clean dishes stacked on a soiled rack, an opened roll of paper towels above the hand washing station, trash cans were overflowing, food was splashed on the walls above the soiled dish line. There was a steam table containing metal pans full of food for the noon meal. V8 stated she was new to the facility and was learning her duties from the only other person working in the kitchen, V7 (Cook), who had left the kitchen to go outside for a few minutes. When V7 returned to the kitchen, he stated that V7 was the daytime cook. V7 stated that the facility does not have a Certified Dietary Manager to supervise and run the kitchen. V7 proceeded to perform cooking, plating of food, rinsing of noodles, finding plates and utensils, sorting through menus, and loading plates of food into the portable food carts. Food service to the residents seated in the dining room did not begin until approximately 1:12 p.m. and the room trays were not sent out to the resident hallways until approximately 2:16 p.m. On 10/3/23 at 9:03 a.m. V7 and V8 were in the kitchen cleaning up after the breakfast meal was served. V7 stated the kitchen is short staffed and does not have a Dietary Manager to manage the preparation and serving of food. V7 stated there should be four to five people to serve the 82 residents in the facility for breakfast and lunch but there are currently only two. V7 stated that sometimes V5 (Certified Nurse Aide Manager) comes in to help but she is not a Dietary Manager. V7 stated it is chaos in the kitchen trying to teach V8 to do her job, prepare the meals, serve the food, and clean up afterward with so little help. V7 stated the facility needs a dietary manager to make sure enough people are in the kitchen to perform each task and to make sure the meals are on time.
A Resident Census and Conditions of Residents form 672 dated 10/2/23 and signed by V3 (Director of Nurses) documents that at the time of the survey 82 residents resided in the facility.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to have sufficient staff to carry out the meal preparation safely and effectively, keep the kitchen clean and sanitary, and to se...
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Based on observation, interview, and record review the facility failed to have sufficient staff to carry out the meal preparation safely and effectively, keep the kitchen clean and sanitary, and to serve residents' meals on time. These failures have the potential to affect all 82 residents in the facility.
Findings include:
A Dietary Management Policy (undated) states, The Dietary Services Department shall be staffed with the appropriate numbers of properly trained personnel to provide each resident the diet that meets daily nutritional and special dietary needs and to carry out the functions of the dietary service. Personnel shall be scheduled to be on duty sufficient hours to assure proper preparation, serving and sanitation.
A Meal Times policy (undated) documents the facility's noon meal will be served between 11:45 a.m. and 12:30 p.m.
On 10/2/23 at 12:32 p.m. V8 (Prep Cook) was the only staff member in the kitchen and was sorting through resident menus. The kitchen had soiling consisting of paper and food debris covering most of the floor, counter spaces, stove top, and slicer. There were clean dishes stacked on a soiled rack, an opened roll of paper towels above the hand washing station, trash cans were overflowing, food was splashed on the walls above the soiled dish line. There was a steam table containing metal pans full of food for the noon meal. V8 stated she was new to the facility and was learning her duties from the only other person working in the kitchen, V7 (Cook), who had left the kitchen to go outside for a few minutes. When V7 returned to the kitchen, he stated that V7 was the daytime cook. V7 stated that the facility does not have enough staff to cook, clean, organize the kitchen duties, and deliver food on time to residents. V7 stated that sometimes V5 (Certified Nurse Aide Manager) will come into the kitchen to help, however, the kitchen is not V5's normal department. V7 proceeded to perform cooking, plating of food, rinsing of noodles, finding plates and utensils, sorting through menus, and loading plates of food into the portable food carts, all in a hurried manner, walking from one end of the kitchen to the other then turning around again. There were residents seated out in the dining room waiting for their noon meal, however, plates of food were not served in the dining room until approximately 1:12 p.m. and the room trays, for residents who eat in their rooms, were not sent out to the resident hallways until approximately 2:16 p.m. On 10/3/23 at 9:03 a.m. V7 and V8 were in the kitchen cleaning up after the breakfast meal was served. V7 stated the kitchen is short staffed and does not have a Dietary Manager to manage the preparation and serving of food. V7 stated there should be four to five people to serve the 82 residents in the facility for breakfast and lunch but there are currently only two. V7 stated it is chaos in the kitchen trying to teach V8 to do her job, prepare the meals, serve the food, and clean up afterward with so little help. V7 stated that food temperature logs checking the temperature of foods on the steam table prior to serving were not being done and that he does not know where the temperature logbook is kept. V7 stated that several kitchen staff have quit recently and have not been replaced. V7 and V8 both stated it is difficult to continue working in the kitchen at the facility under these conditions. V7 verified that on 10/2/23 residents' meals in the dining room were not served until after 1:00 p.m. and the hall trays were served after 2:00 p.m. which is much later than the posted mealtimes.
On 10/2/23 at 12:29 p.m. R5 was lying in bed with his overbed table in front of R5. R5 stated his lunch should have been delivered by now but that the facility is always late delivering his tray. R5 stated that his lunch tray is often delivered at 2:00 p.m. instead of around 12:00- 12:30 p.m. At 1:26 p.m. R4 was seated in a wheelchair self-propelling out of the dining room and down the hallway. R4 stated that her meal was served very late. R4 stated they are supposed to serve lunch around 12:00 p.m. and that R4 had been waiting in the dining room since before 12:00 p.m. to be served. R4 stated, I finally got my food in the dining room, but it was cold! R4 stated, It's always this way. R4 stated the facility serves residents' their meals late almost every day. At 2:20 p.m. R8 was lying in bed with her lunch tray on a tray table in front of her. R8 stated her lunch was just delivered and it was very late. R8 stated, They are always late! It's a problem!
A Resident Census and Conditions of Residents form 672 dated 10/2/23 and signed by V3 (Director of Nurses) documents that at the time of the survey 82 residents resided in the facility.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected most or all residents
Based on observation interview and record review the facility failed to ensure meals were served on time and as per the scheduled meal times. This failure has the potential to affect all 82 residents ...
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Based on observation interview and record review the facility failed to ensure meals were served on time and as per the scheduled meal times. This failure has the potential to affect all 82 residents in the facility.
Findings include:
A Meal Times policy (undated) documents the facility's noon meal will be served between 11:45 a.m. and 12:30 p.m.
On 10/2/23 at 12:32 p.m. the dining room was full of residents waiting on the noon meal. V8 (Prep Cook) was the only staff member in the kitchen and was sorting through resident menus. V7 (Cook) came into the kitchen from a back room and stated that V7 was the daytime cook. V7 stated that the facility does not have enough staff to cook, clean, organize the kitchen duties, and deliver food on time to residents. V7 stated that sometimes V5 (Certified Nurse Aide Manager) will come into the kitchen to help, however, the kitchen is not V5's normal department. V7 proceeded to perform cooking, plating of food, rinsing of noodles, finding plates and utensils, sorting through menus, and loading plates of food into the portable food carts, all in a hurried manner, walking from one end of the kitchen to the other then turning around again. By the time V7 and V8 started sending plates of food out to the dining room it was approximately 1:12 p.m. The room trays, for residents who prefer to stay in their rooms for meals, were not completed and sent out to the resident hallways until approximately 2:16 p.m.
On 10/2/23 at 12:29 p.m. R5 was lying in bed with his overbed table in front of R5. R5 stated his lunch should have been delivered by now but that the facility is always late delivering his tray. R5 stated that his lunch tray is often delivered at 2:00 p.m. instead of around 12:00- 12:30 p.m. At 1:26 p.m. R4 was seated in a wheelchair self-propelling out of the dining room and down the hallway. R4 stated that her meal was served very late. R4 stated they are supposed to serve lunch around 12:00 p.m. and that R4 had been waiting in the dining room since before 12:00 p.m. to be served. R4 stated, I finally got my food in the dining room, but it was cold! R4 stated, It's always this way. R4 stated the facility serves residents' their meals late almost every day. At 2:20 p.m. R8 was lying in bed with her lunch tray on a tray table in front of her. R8 stated her lunch was just delivered and it was very late. R8 stated, They are always late! It's a problem!
On 10/3/23 at 9:03 a.m. V7 verified that on 10/2/23 residents' meals in the dining room were not served until after 1:00 p.m. and the hall trays were served after 2:00 p.m. which is much later than the posted meal times.
A Resident Census and Conditions of Residents for 672 dated 10/2/23 and signed by V3 (Director of Nurses) documents that at the time of the survey 82 residents resided in the facility.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review the facility failed to ensure the kitchen was clean, without food debris and spills on the floor, the slicer was covered and without food debris cover...
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Based on observation, interview and record review the facility failed to ensure the kitchen was clean, without food debris and spills on the floor, the slicer was covered and without food debris covering the stand, clean dishes were removed from the dish machine area and protected from splashes and food debris, food prep surfaces were clean, the grill was cleaned and free of grease and food debris, individual hand towels were available at the hand washing station, empty and full boxes were kept off the floor, a food temperature log was maintained and food temperatures on the serving steam table were monitored. These failures have the potential to affect all 82 residents in the facility.
Findings include:
A Hot Food Service Temperatures policy dated 5/8/18 states, 2. Food will be held in the steam table at 135F (degrees Fahrenheit) or above during tray assembly. 3. Food temperatures of food being held in the steam table will be recorded.
A Food Services Safety Precautions Policy dated 2/2014 gives as its purpose, To assure that all personnel are aware of food preparation and serving safety precautions when performing tasks associated with position responsibilities. In addition, this policy instructs, 14. Spills should be mopped up immediately and any debris, such as produces, paper, peelings, etc. should be picked up promptly. 15. Dishes, glassware, or other articles should not be stored where food is being prepared.
A Storage of Food and Supplies policy (undated) gives as its purpose, Food and supply storage areas shall be maintained in a clean, safe, and sanitary manner.
A Storage of Dry Goods/Foods policy (undated) states, Food and supplies will be stored six (6) inches above the floor on clean racks or shelves and at least eighteen (18) inches from sprinkler heads.
A Hand-Washing/Hand Hygiene Policy dated 3/2020 states, Facility staff must wash their hands for no less than twenty (20) seconds using antimicrobial or non-antimicrobial soap and water. This policy states that once hands have been washed, Dry hands using a clean towel.
On 10/2/23 at 12:32 p.m. V7 (Cook) and V8 (Prep Cook) were in the kitchen preparing to serve the residents' noon meal. The serving area was just across from the soiled dishes machine. There was dirt, debris, food particles, and pieces of paper covering the floor throughout the kitchen. There was a rack of clean dishes just outside the dish machine on the clean dishes table which were uncovered and with visible wet food particles on the table below the clean dish rack. There were boxes on the floor next to the sink and additional boxes on the floor in the dry food storage room. The grill/ stove top was not being used as V7 and V8 were still reviewing the menus and prepping the steam table, however, there was grease and food debris covering the grill/stove top surface. V8 began scraping food debris from the top of the grill/stove top, stating that the evening staff from the previous day, Didn't clean the grill right. V8 was wearing gloves while preparing food. V8 proceeded to continue to wear the same gloves while he wiped his forehead, pull up his pants and plate residents' food. There was a meat slicer below the food serving area which was uncovered and had large pieces of food debris covering its base. At approximately 1:00 p.m. V5 (Certified Nurse Aide Manager) came into the kitchen to help take food trays to the dining room to serve to residents. V5 walked over to the hand washing station and proceeded to wash her hands. V5 then used her right hand to turn off the faucet then grabbed a roll of opened paper towels which were sitting on the wall above the sink. V5 tore off a few paper towels, placed the roll back on the wall, then dried her hands before standing next to the serving line to wait until plates of food were ready to be served. There was a large drink dispenser on the floor near the stove which was covered with a brown powder. At approximately 1:10 p.m. V7 and V8 began to serve food from the serving line onto plates. Neither V7 nor V8 checked the temperature of the foods on the serving line. There was no food temperature log visible in the kitchen area.
On 10/3/23 at 9:03 a.m. V7 and V8 were in the kitchen cleaning up after the breakfast meal was served. V7 stated the kitchen is short staffed and does not have a Dietary Manager to manage the preparation, serving of food, and cleanliness of the kitchen. V7 stated there should be four to five people to serve the 82 residents in the facility for breakfast and lunch but there are currently only two. V7 stated that sometimes V5 (Certified Nurse Aide Manager) comes in to help but she is not a Dietary Manager. V7 stated it is chaos in the kitchen trying to teach V8 to do her job, prepare the meals, serve the food, and clean up afterward with so little help. V7 stated the facility needs to make sure enough people are in the kitchen to perform each task, make sure the kitchen is clean, and to make sure the meals are on time.
On 10/3/23 at approximately 2:00 p.m. V2 (Corporate Liaison) stated she knows there are problems in the kitchen. V2 stated that last night V1 (Administrator) and some other staff stayed late to attempt to clean up in the kitchen.
A Resident Census and Conditions of Residents form 672 dated 10/2/23 and signed by V3 (Director of Nurses) documents that at the time of the survey 82 residents resided in the facility.
Sept 2023
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure a clean, homelike environment for one of three residents (R1) reviewed for clean, comfortable, homelike environment in ...
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Based on observation, interview and record review, the facility failed to ensure a clean, homelike environment for one of three residents (R1) reviewed for clean, comfortable, homelike environment in the sample of three.
Findings Include:
The facility's Housekeeping Services Policy undated documents it is the policy of the facility to maintain a clean, comfortable and orderly environment in all healthcare and public areas and documents resident rooms are to be maintained in a sanitary manner. This same policy states, 4. The department shall routinely clean the environment of care, using accepted practices, to keep the facility free from offensive odors, the accumulation of dust, rubbish, dirt and hazards.
The facility's Resident Rights Statement undated documents the facility will provide a safe, clean, comfortable and homelike environment.
On 9/2/23 at 12:08 PM, V3 (R1's Family Member) stated there had been a bleach smell outside of R1's room for a few days. V3 stated V3 was informed the room next door to R1's room had mold and needed to be deep cleaned. V3 stated V3 had noticed the closet in R1's room had a discoloration with what appeared to be mold on the ceiling.
On 9/2/23 at 2:30 PM, a tour of R1's room was conducted with V5 (Maintenance Director). R1's closet was in the right-hand corner of R1's bedroom. No closet door or any type of closure was noted on the outside of R1's closet. R1's clothing and personal effects were noted hanging in R1's closet. A wet, musty smell was noted inside the closet area. The entire ceiling of the closet was covered in a flat, powdery, grayish-white colored substance. At this time, V5 stated R1's current bedroom had sat vacant for months prior to R1's admission. V5 stated with the recent extreme hot weather temperatures in the area and the warmer air temperature in the room, condensation likely formed on the walls resulting in a mildew appearance on the walls and ceilings. V5 stated, The room next door just had to be sprayed down with bleach due to the same thing happening. I didn't know this was in here like this. I'd like to bleach it up and we need to move (R1) out of here.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident who requires assistance with activit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident who requires assistance with activities of daily living was showered weekly and failed to ensure a resident's clothing was changed daily for one of three residents (R1) reviewed for activities of daily living/ADLs in the sample of three.
Findings Include:
The facility's Shower/Tub Bath Procedure revised August 2002 documents the purpose of the procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. This same procedure documents the following information should be recorded in the resident's medical record: 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath. 3. All assessment data (e.g., a reddened area, sores, etc. on the resident's skin) obtained during the shower/tub bath. 4. How the resident tolerated the shower/tub bath. 5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data.
The facility's Certified Nursing Assistant Duties, Responsibilities and Essential Functions, undated, documents nursing care responsibilities of assisting residents with ADLs including dressing and assisting residents with bath and shower functions.
The facility's Facility Assessment Tool reviewed 7/31/23 documents Facility provides bath/shower at least weekly for each resident. Facility will provide bath/shower more frequently by request as needed. This same Facility Assessment Tool documents residents are awoken and gotten up for the day per their personal preference and daily schedule.
R1's Resident Face Sheet documents R1 admitted to the facility on [DATE] with diagnoses to include but not limited to status post Lumbar Fusion on 7/20/23; Generalized Muscle Weakness; Difficulty Walking; Lack of Coordination; Reduced Mobility; Need for Assistance with Personal Care; Generalized Osteoarthritis; Cerebral Infarction.
R1's admission Minimum Data Set (MDS) assessment dated [DATE] documents the following: R1 has not exhibited any rejection of care behaviors; R1 requires total dependence of two plus persons physical assist for bathing and dressing.
R1's Nursing admission Note on 8/18/23 documents R1 requires staff assistance with Activities of Daily Living/ADLs.
The facility's 2023 Grievance Log documents a concern/grievance for R1 on 8/29/23 stating Wants (R1) to be added to shower list. This same log documents a resolution date of 8/30/23 which documents R1 was added to the shower list.
The facility's Shower Schedule documents R1 is to be showered twice a week on Tuesday and Fridays.
On 9/2/23 at 12:08 PM, V3 (R1's Family Member) stated that R1 admitted to the facility on [DATE]. V3 stated that R1 was never added to the shower schedule. V3 stated that only after it was brought to the attention of the facility, almost two weeks after R1's admission, was R1 added to the shower schedule. V3 denied that R1 has been receiving showers in the facility. V3 stated the facility has been leaving R1 in the same clothes for days at a time. V3 stated that R1 brought enough clothes to the facility that R1 could change R1's clothes every day for a week. V3 stated that 9/1/23 was the first time V3 had to do R1's laundry since 8/17/23 when R1 admitted to the facility due to R1's clothing not being changed.
On 9/2/23 at 4:00 PM, V3 was present at R1's bedside. R1 was wearing a black short sleeved shirt with a cream-colored cardigan sweater over R1's shoulders. R1 denied receiving a shower in the facility. R1 stated, They don't change my clothes either. That shirt in the laundry basket over there was just taken off me this morning. I had it on for almost three days. At this time, V3 removed R1's shirt from the laundry basket and held it up. V3 stated, We asked them to change (R1) out of this shirt yesterday.
On 9/3/23 at 8:06 AM and 10:02 AM, R1 was in bed. R1 was still dressed in the same black short sleeved shirt from 9/2/23.
On 9/2/23 at 12:48 PM, V2 (Director of Nursing) stated residents are showered twice a week per the facility's shower schedule. V2 stated completed showers are documented on shower sheets. V2 stated resident clothing should be changed daily.
On 9/3/23 at 6:53 AM, V2 (Director of Nursing) stated there are no shower sheets or any other documentation that could be provided indicating R1 had received a shower in the facility since R1's 8/17/23 admission.
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 implement pressure ulcer prevention interventions for ...
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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 pressure ulcer prevention interventions for a resident with known skin impairments, failed to ensure pressure ulcer dressing changes were completed as ordered by the physician, failed to complete weekly wound assessments, and failed to notify the physician of a change in a resident's wound status for two of three residents (R1 and R2) reviewed for pressure ulcers in the sample of three.
Findings include:
The facility's Wound Care Policy, revised May 2017 documents the following: follow physicians' orders for wound care; documentation of wound care must be completed each time the treatment is done on the Treatment Administration Record (TAR); current wound status must be documented no less than once per week and documented in the resident's medical record; wound changes and other pertinent observations must be documented in the nurse's notes as they occur; the physician must be notified of change in the wound status; and the presence of the wound and interventions being done must be addressed in the Care Plan.
The facility's Prevention of Pressure Wounds Policy dated January 2017 states, 5. Once a pressure ulcer develops, it can be extremely difficult to heal. Pressure injuries are a serious skin condition for the resident. 6. The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated and reported to the practitioner, physician, and family and addressed. This same policy documents general preventative measures as the following: for a person in a chair include the use of a foam, gel or air cushion; routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown; immediately report any signs of a developing pressure injury.
The facility's Notification of Resident Change in Condition Policy dated November 2016 documents it is the policy of the facility to notify a resident's attending physician of changes in the resident's health conditions. This same policy documents a licensed nurse shall promptly inform the resident's physician of a significant change in the resident's physical status or a need to alter treatment, such as the need to begin a new form of treatment. This policy states, 3. Clinical change in condition is determined by resident visualization, medical record review, clinical assessment findings and care plan review. Review of high-risk clinical issues such as skin breakdown, falls, weight loss, dehydration, and others are conducted on a daily basis. The policy documents that following the assessment, the attending physician will be promptly notified.
The Facility Assessment Tool reviewed 7/31/23 documents pressure injury prevention and care, skin care and wound care practices are completed to meet residents' needs.
1. R1's Resident Face Sheet documents R1 admitted to the facility on [DATE] with diagnoses to include but not limited to: status post Lumbar Fusion on 7/20/23; Generalized Muscle Weakness; Difficulty Walking; Lack of Coordination; Reduced Mobility; Need for Assistance with Personal Care; Generalized Osteoarthritis; Cerebral Infarction and a stage I sacral pressure ulcer.
R1's admission Minimum Data Set (MDS) assessment dated [DATE] documents the following: R1 has not exhibited any rejection of care behaviors; R1 requires extensive assistance of two plus persons physical assist for bed mobility, total dependence of two plus persons physical assist for transfers; R1 has a pressure ulcer/injury, a scar over a bony prominence; R1 is at risk for developing pressure ulcers/injuries; R1 has unhealed pressure ulcers/injuries. This same assessment documents a skin and ulcer/injury treatment of pressure reducing device for chair.
R1's admission Pressure Sore Risk assessment dated [DATE] documents R1 at moderate risk for developing pressure ulcers. This same assessment documents R1 with very limited bed mobility (unable to make frequent or significant changes independently); confined to bed all or most of the time; and requires moderate to maximum assist in moving.
R1's admission Skin assessment dated [DATE] states, Stage I Pressure Injury/Sacrum 6 cm (centimeters) x (by) 6 cm. No open skin noted at sacral site, no exudate. MD (Medical Doctor) updated; treatment orders received. POA (Power of Attorney/V4) present and aware of current skin condition.
As of 9/2/23 at 12:30 PM, R1's current Physician Order Sheet documents an order to cleanse R1's sacrum with normal saline or wound cleanser, pat dry and apply barrier cream twice a day; 6:00 AM-6:00 PM and 6:00 PM-6:00 AM. This order has a start date of 8/18/23 and no end date.
R1's Treatment Administration Record (TAR) states, Sacrum: Cleanse with Normal Saline or wound cleanser, pat dry and apply barrier cream twice a day. This TAR does not document R1's sacrum wound care was completed on 8/21/23. This TAR documents R1's sacral wound care was only completed one time a day on the following dates: 8/20/23; 8/23/23; 8/26/23; 8/27/23; 8/28/23; and 8/30/23.
On 9/2/23 at 2:15 PM, R1 was placed back into bed from R1's wheelchair via the total mechanical lift by V10 (Certified Nursing Assistant/CNA) and V11 (CNA). No cushion of any kind was noted to the wheelchair that R1 was just removed from. Once in the bed, R1's pants and incontinence brief were removed exposing R1's sacral pressure wound. V12 (Licensed Practical Nurse) was present at R1's bedside during visualization of R1's wounds. R1's left side of the sacrum and spreading across R1's left buttock, was reddened with open skin that was rolling back. R1's right side of the sacrum and spreading across R1's right buttock was bright red with opened skin that was rolling back. The right distal portion of the sacrum contained a dime-sized area that was dark purple in color with red blood on the edges. At this time, V10 and V11 verified no cushion of any kind had been placed in R1's wheelchair when R1 was up in the chair.
On 9/2/23 at 2:58 PM, V12 (Licensed Practical Nurse/LPN), after observing R1's sacral pressure ulcer stated, That looks worse to me. Last time I took care of (R1) it (sacral pressure ulcer) didn't look like that. At this time, V12 stated V12 received R1 from V13 (LPN) at the change of shift.
On 9/2/23 at 3:30 PM, R1 was in R1's bedroom. R1 stated R1 sat up in R1's chair in the morning through the afternoon. R1 denied there being any type of cushion to R1's chair while R1 was sitting up in the chair. R1 stated, My butt was really hurting. R1 stated R1 is useless when it comes to repositioning and stated, I can't do it on my own.
On 9/3/23 at 7:10 AM, via telephone interview, V13 (LPN) stated that V13 took care of R1 on 9/2/23 from 6:00 PM-6:00 AM. V13 stated that during V13's shift, V13 did not assess, cleanse or perform wound care treatment to R1's sacral pressure ulcer. V13 stated that V13 signed the order off on R1's Treatment Administration Record (TAR) because V13 assumed the CNAs would have applied a barrier cream to R1 during incontinence care. V13 stated, I did not ever see (R1's) sacral wound on my shift. V13 verified V13 should have completed R1's wound care as ordered and would notify V7 (Wound Nurse), the physician and V2 (Director of Nursing) of any changes to a resident's wound.
On 9/3/23 at 7:36 AM, V7 (Wound Nurse) stated V7 assessed R1's sacral pressure sores upon R1's admission to the facility. V7 stated R1's wounds were not opened at that time. V7 stated initially, a skin protection barrier cream was appropriate for R1's wound status. V7 stated, (V2 Director of Nursing) called me last night to notify me of the changes that were going on with (R1's) wounds. I came right in to look at it. The wound was worse than when I initially assessed it. V7 stated that R1's wound needs new treatment orders. V7 stated R1's wound status did not just change before V7 was called. V7 stated V13 should have cleansed and assessed R1's wound on V13's shift. V13 stated, They're (nursing staff) are my first eyes on the floor. I depend on them to keep me updated with any changes (with a resident's wound status). I live close. I will come in any time and any day to see a resident if I was needed. At this time, V7 verified new wound treatment orders were obtained from V14 (Wound Physician) and that R1 was added to V14's patient list. V7 stated that the facility has standing orders for skin care. V7 stated these standing orders consist of things like weekly skin checks, turning and repositioning every two hours, pressure reducing mattress and pressure reducing chair cushion. V7 stated R1's standing orders for skin care were not initiated upon R1's admission to the facility and should have been. V7 stated, I don't know how I missed (R1) but I did. V7 stated R1's sacral pressure ulcer should have been assessed weekly and was not and stated that R1 should have had a wheelchair cushion and does not. V7 stated that V7 had to miss work the last week of August and a lot got missed due to V7's unexpected absence.
As of 9/2/23 at 4:00 PM, R1's medical record did not contain documentation that V7 or V17 (R1's Physician) was notified of R1's change in wound status, that weekly wound assessments were completed for R1's sacral wound, that R1's Care Plan documented R1's current wounds or that pressure relieving interventions were implemented for R1.
2. R2's Resident Face Sheet documents R2 admitted to the facility on [DATE] with a diagnosis of a stage IV pressure ulcer to the right buttock.
R2's Pressure Sore Risk assessment dated [DATE] documents R2 is at moderate risk for developing pressure sores.
R2's current Care Plan documents R2 has a stage IV pressure ulcer to the right buttocks. Interventions are documented as to do treatment to affected area as ordered a monitor for signs and symptoms of infection and relay to MD/Medical Doctor accordingly.
R2's current Physician Order Sheet (POS) documents the following orders: Right Buttock: Cleanse with normal saline or wound cleanser, apply Leptospermum Honey and cover with a hydrocolloid once a day on Mondays with an order start date of 8/29/23; Right Buttock: As Needed/PRN cleanse with normal saline or wound cleanser, apply Leptospermum Honey and cover with a hydrocolloid as needed with an order start date of 8/4/23; Right Ischium: Cleanse with normal saline or wound cleanser, apply skin prep and cover with (wound vacuum closure device) once a day on Mondays. Special Instructions: Apply honey and dry dressing if unable to reapply, Notify MD/Medical Doctor with an order start date of 8/29/23; and Right Ischium PRN (as needed): Cleanse with normal saline or wound cleanser, apply Leptospermum Honey and cover with a dry, protective dressing as needed. Special Instructions: Apply if (wound vacuum closure device) malfunctions, notify MD/Medical Doctor or Wound Nurse with an order start date of 8/29/23.
R2's Wound Evaluation and Management Summary signed and dated by V14 (R2's Wound Physician) on 8/28/23 documents R2's Stage IV Pressure Wound of the Right Ischium was evaluated and treated. The Dressing Treatment Plan states, Skin substitute application (Zenith) apply once weekly for seven days: DO NOT REMOVE or disturb the wound bed. Change the secondary dressing(s) with care as per the recommendations. The skin substitute graft will be re-evaluated by the wound physician during the indicated next visit. Single Use NPWT (Negative Pressure Wound Therapy) applied by clinician once weekly for seven days. I applied NPWT on this wound during the visit with the expectation of this treatment being in place for one week at which time it will be re-evaluated.
R2's Wound Evaluation and Management Summary documents R2's wound was assessed with measurements obtained by V14 on the following dates: 7/31/23; 8/7/23; 8/14/23; and 8/28/23. R2's medical record does not contain a weekly wound assessment on 8/21/23.
On 9/3/23 at 9:34 AM, R2 was lying in bed dressed in a night gown. R2 stated R2 had not gotten dressed for the day yet because R2's buttock wound dressings had come off early yesterday evening and no one had placed a new dressing over R2's wounds yet. R2 stated, I am really supposed to have my wounds covered. The nurse last night told me they needed air.
On 9/3/23 at 9:47 AM, R2's wounds were visualized alongside V7 (Wound Nurse). V7 verified R2's right buttocks and right ischium wound were open to air with no dressing in place. V7 stated, There should be a wound dressing over these. At this time V7 stated that each of R2's wound orders have an as needed order so that if it isn't time for the wound dressing to be changed or if R2's wound vacuum dressing fell off, the prn/as needed order allows the nurses to place a dressing over the wound. V7 stated, The prn orders are there to protect the nurses and they aren't even using them. V7 stated that on 8/28/23, V14 placed a wound vacuum to R2's Ischium wound. V7 stated that due to its location, it doesn't always stay sealed, and it comes off. V7 stated that if the wound vacuum were to fall off, it is the expectation that V7 or V14 would be immediately notified, and the prn order would be used. V7 denied being aware that R2's wound vacuum dressing had fallen off. V7 stated, I should have been notified.
As of 9/3/23 at 10:00 AM, R2's Treatment Administration Record (TAR) dated 8/4/23-9/3/23 did not document that any prn/as needed dressing changes were completed for R2.
As of 9/3/23 at 10:00 AM, R2's medical record did not contain documentation that V7 or V14 were notified that R2's wound vacuum dressing had fallen off.
On 9/3/23 at 7:36 AM, V7 (Wound Nurse) verified that R2 was missing a weekly wound assessment on 8/21/23. V7 stated that V7 was off work due to an illness, and no one rounded with V14 in V7's place. V7 stated it was last minute and unexpected for V7 to be off work. V7 verified R2's wound should be assessed weekly, and it was not.
On 9/3/23 at 11:30 AM, V7 stated that V7 called V14 to notify V14 of R2's change in wound dressing status. V7 stated that V14 gave updated wound care orders and that V14 stated V14 had not been notified that R2's wound vacuum dressing had fallen off. V7 verified V14 should have been notified by R2's nurse when R2's dressing originally fell off.
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 F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to stay at a resident's bedside to ensure a resident consumed all of their morning medications during medication pass for one of three residen...
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Based on interview and record review, the facility failed to stay at a resident's bedside to ensure a resident consumed all of their morning medications during medication pass for one of three residents (R1) reviewed for medications in the sample of three.
Findings include:
The facility's Medication Administration Policy updated March 2022 documents residents shall not be left alone until the prepared medications are consumed or refused.
R1's current Medication Administration Record/MAR documents orders for the following medications were scheduled for 8:00 AM on 8/28/23: Aspirin 81 milligrams (mg) once a day; Carvedilol 3.125 mg two tabs twice a day; Coenzyme Q10 100 mg four capsules once a day; Culturelle Capsule 15 billion cell one capsule once a day; Cyanocobalamin 400 micrograms (mcg) once a day; Cyclobenzaprine 10 mg three times a day; Diltiazem Hydrochloride 24 hour extended release 120 mg once a day; Gabapentin 200 mg three times a day; Glipizide 10 mg once a day; Hydrocodone-Acetaminophen Schedule II tablet 5-325 mg one tablet three times a day; Januvia 100 mg tablet once a day; Magnesium Oxide 400 mg tablet once a day; Memantine 10 mg twice a day; Multivitamin-Minerals one tablet once a day; Omeprazole delayed release 20 mg two tablets once a day; Pregabalin Schedule V capsule 25 mg capsule twice a day; and Sennosides-Docusate Sodium 8.6-50 mg two tablets twice a day. This same MAR documents all the above medications were administered by V8 (Licensed Practical Nurse).
On 9/2/23 at 12:08 PM, V3 (R1's Family Member) stated that on 8/28/23 at 11:15 AM, V3 entered R1's room for a visit. V3 stated that on R3's bedside table, there was a medication cup that contained several of R1's morning medications. V3 stated there was not a nurse or anyone else in R1's room at the time or in the hallway near R1's room. V3 stated V3 found R1's nurse (V8/Licensed Practical Nurse) to ask about the medications in the cup. V3 stated V8 verified the medications were R1's morning medications that had not all been taken yet by R1. V3 stated that there was no telling which medications were in the cup and which ones R1 had already taken. V3 stated a pill was found on the floor in R1's room. V3 stated, (R1) takes some of those medications several times a day, so the schedule is all off if (R1) isn't taking them when she is supposed to and then the next nurse gives the second dose too soon.
On 9/2/23 at 12:42 PM, V1 (Administrator in Training) verified that R1's family came to V1 regarding medications being left unattended in R1's room. V1 stated V1 referred R1's family to V18/Assistant Director of Nursing.
On 9/2/23 at 12:48 PM, V18 (Assistant Director of Nursing) verified on 8/28/23, V3 had brought concerns that R1's medications were being left by the nurse (V8) at the bedside without observing R1 consume the medications. V18 stated that V8 was in-serviced on the facility's policy for medication administration. V18 denied that any written communication was completed with V8 regarding the incident.
On 9/2/23 at 12:50 PM, V2 (Director of Nursing) and V18 verified the nurses should not leave medications unattended at a resident's bedside. V2 verified R1 is not assessed for self-administration of medications.
On 9/2/23 at 1:08 PM, V8 (Licensed Practical Nurse) verified that V3 asked about medications being left unattended at R1's bedside. V8 stated V8 did not see R1 take all of R1's morning medications on 8/28/23. V8 stated V8 did not know what medications were remaining in the cup. V8 stated V18 talked with V8 about the incident. V8 verified V8 should have ensured all of R1's medications were consumed prior to V8 leaving R1's room.
As of 9/3/23, R1's medical record did not contain documentation that R1 has been assessed for self-administration of medications.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to provide the services of a registered nurse eight hours a day, seven days a week. This failure has the potential to affect all 79 residents r...
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Based on interview and record review the facility failed to provide the services of a registered nurse eight hours a day, seven days a week. This failure has the potential to affect all 79 residents residing in the facility.
Findings include:
The facility's Staffing Policy dated November 2017 documents the facility will provide adequate staffing to meet the needed care and services for the resident population. This policy also documents that the facility maintains adequate staffing on each shift to ensure that residents' needs and services are met, and documents Licensed Registered Nursing staff are available to provide and monitor the delivery of resident care services and supervision to Certified Nursing Assistants/CNAs and other support staff.
The facility's Facility Assessment Tool reviewed 7/31/23 documents the facility with an average daily census of 82 residents.
The facility's Nurse's Daily Assignment Sheets document the facility did not have eight consecutive hours of registered nurse (RN) coverage in the building to provide services on the following dates: 7/8/23; 7/9/23; 7/13/23; 8/5/23; or 8/6/23.
On 9/3/23 at 10:40 AM, V2 (Director of Nursing) confirmed that the facility was without eight hours of RN coverage on the 7/8/23; 7/9/23; 7/13/23; 8/5/23; or 8/6/23 dates.
The facility's Daily Census Report dated 9/2/23 documents 79 residents currently reside in the facility.
Apr 2023
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain a clean homelike environment for one resident (R19) out of 30 residents reviewed for environment in a sample of 30
F...
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Based on observation, interview, and record review, the facility failed to maintain a clean homelike environment for one resident (R19) out of 30 residents reviewed for environment in a sample of 30
Findings include:
R19's Brief Interview of Mental Status (BIMS) documents a score of 15. A score of 13-15 indicates an individual is cognitively intact.
On 04/16/23 at 8:51 AM, during initial interview of R19, this surveyor stepped on tortilla chips that are on the floor between R19's bed and window. R19 stated, Those are from last night's dinner. Upon further observation of R19's room, the base boarding outside of R19's bathroom is coming off the wall, and there is a hole in the wall above where the base boarding is coming off. In the middle of the room, there are what appear to be four strips of left-over glue residue from something that was adhered to the floor and what appears to be tan-colored paint spots on the floor in the entryway. R19 nodded not when asked if he felt as though his room had been cleaned.
The facility's dinner menu for 4/15/22 documents Chicken taco salad and tortilla chips.
On 04/17/23 from 6:00 am and 1:00 PM, intermittent observations made throughout the day of R19's room. The tortilla chips that were observed on the floor on 4/16/23 are still on the floor between R19's bed and window.
On 04/18/23 at 9:51 AM, V22 (Housekeeping Supervisor) verified there are crushed tortilla chips on the floor between R19's bed and window and stated, It's a common occurrence with (R19) to have food on the floor after he eats. I see the crushed tortilla chips. The issue is that we were told we couldn't take a broom into isolation rooms. We used to keep brooms we got from the dollar store in the isolation rooms, but those all disappeared. What we have to do now is use a mop to essentially sweep the floors for any of the isolation rooms. The stuff in the middle of the floor is the left-over glue residue from where they removed the non-slip strips. They're dark from the dirt it collects. The spot in the entryway is actually paint flakes from the door that sticks to the floor. The facility had a crew come in and remodel the other side of the hall, but they didn't get to this side (referring to R19's room) of the hall. There are a few other rooms where they base boarding is coming off like that. It's a pain because particles from the floor will get stuck under them.
On 4/19/23 at 2:15 PM, V1 (Administrator) stated, We're aware of the issues of the base boarding and the holes. We were in the middle of a remodel, but they had to replace the roof and then go to another building. It's been a while since they stopped remodeling the rooms, but there are plans for them to return in July to finish.
The facility's Housekeeping Services policy undated, documents It is the policy of this facility to maintain a clean, odor free, comfortable and orderly environment in all healthcare and public areas, which meet the sanitation needs of the facility and residents' rights for safe, clean, comfortable home-like environment. Standards: 4. The department shall routinely clean the environment of cares, using accepted practices, to keep the facility free from offensive odors, the accumulation of dust, rubbish, dirt and hazards.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide a written notice of transfer for two (R44 and R49) of two residents reviewed for hospitalization in the sample of 30....
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Based on observation, interview, and record review, the facility failed to provide a written notice of transfer for two (R44 and R49) of two residents reviewed for hospitalization in the sample of 30.
Findings include:
1. The Progress Notes for R44, dated 12/19/22 and 1/29/23, document R44 was transferred from the facility to a local hospital for evaluation and treatment.
R44's Medical Record does not contain documentation of R44 or R44's Representative being provided written notice of reason for R44's transfers to the hospital.
2. The Progress Notes for R49, dated 8/2/22, 9/6/22, 11/7/22, 1/30/23, 2/2/23, and 3/8/23, document R49 was transferred to a local hospital for evaluation and treatment.
R49's Medical Record does not contain documentation of R49 or R49's Representative being provided a written notice of reason for R49's transfers to the hospital.
On 4/18/23 at 2:26 pm, V2 (Director of Nursing/DON) stated the Physician, DON, Administrator and Responsible Party are notified if a resident is sent out to a local hospital. V2 DON also stated, We do not put in writing a written reason for transfer that is given to the resident or their family for a resident transfer to the hospital. V2 stated the facility does not have anything other than the Bed Hold policy that is given to the Resident and Resident Representative.
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 complete an admission wound assessment, obtain a phys...
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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 complete an admission wound assessment, obtain a physician's order, and complete treatments for wounds for one resident (R319) of two residents reviewed for wounds in a sample of 30.
Findings include:
R319's medical record documents R319 admitted to the facility on [DATE].
R319's medical record documents diagnoses of peripheral vascular disease, calciphylaxis, diabetes and end stage renal disease.
R319's skin observation dated 4/12/23 documents Open areas: Yes, describe - right hip, right lateral leg, left hip, sacrum, left stump, posterior left leg, right buttock
On 4/16/23 at 8:40 AM, R319 stated, I don't think they're doing all my wound treatments.
On 4/16/23 at 8:43 AM, V8 (Certified Nursing Assistant/CNA) lifted R319's right leg. R319 has a wound to her right distal lateral shin that is not covered, causing fluid to seep from the wound through to the sheet. V8 then pulled back R319's sheet to expose her left leg. R319's left leg has an uncovered wound at the site of her left leg amputation. V8 stated, Sometimes the bandages fall off. There are no bandages noted in R319's bedding or floor. V8 (CNA) stated, She has wounds on her back as well, but I have to have help to roll her.
On 4/16/23 at 9:00 AM, V2 (Director of Nursing/DON) stated, If the bandage comes off, then the nurse should be redoing the wound treatment. It shouldn't be left off.
On 04/16/23 at 1:00 PM, during wound treatment done by V3 (Wound Nurse), R319 observed to have wounds to her mid-thoracic back, right upper buttocks, left upper buttocks, gluteal fold, left posterior superior thigh, left amputation site, right first toe, and right distal lateral shin. V3 verified the wound locations.
R319's medical record dated 4/11/23 documents Pressure ulcer stage four, left later shin 3.5 centimeters (cm), x 2.5 cm x 0.3 cm.
R319's medical record does not document a wound assessment of her mid thoracic back, right upper buttocks, left upper buttocks, gluteal fold, left posterior superior thigh, right first toe, and right distal lateral shin wounds since her re-admission on [DATE].
R319's physician orders sheet (POS) and treatment administration record (TAR) dated 4/11/23 through 4/18/23, does not include an order or treatment for R319's mid thoracic back, gluteal fold, and the right great toe wound.
R319's POS dated 4/11/23 through 4/18/23 documents Cleanse let hip wound with normal saline. Apply normal saline wet to dry dressing every shift, day, night. Cleanse left hip with soap and water, dry well. Apply (foam wound dressing) every shift, night. Cleanse right hip with soap and water, dry well. Apply (foam wound dressing) every shift; night.
R319's TAR dated 4/11/23 through 4/18/23 documents Cleanse let hip wound with normal saline. Apply normal saline wet to dry dressing. Cleanse left hip with soap and water, dry well. Apply (foam wound dressing). Cleanse right hip with soap and water, dry well. Apply (foam wound dressing).
On 4/18/23 11:15 AM V3 (Wound Nurse) verified there is no wound assessment for R319's mid thoracic back, right upper buttocks, left upper buttocks, gluteal fold, left posterior superior thigh, right first toe, and right distal lateral shin wounds and stated, I see her left lateral shin (amputation site) pressure ulcer was completed, but I don't see the rest of her wound assessments since she admitted on [DATE]. I know I did an assessment on them; I'll have to find the sheet I wrote everything on. I just haven't put the assessments in the medical record. They're supposed to be documented under the wound observation to include the location and size upon admission. I'm pretty sure the wounds on her left and right hip have resolved. I'm not sure about the treatments or orders for the other ones. Let me find my assessment sheet and I'll get back to you.
On 4/18/23 12:04 PM, V3 (Wound Nurse) stated, Ok, I found my assessment sheet for R319's wounds. The left and right hip were resolved and not present on admission. The wound on her upper back (mid thoracic back), gluteal fold and right great toe aren't on the TAR because no one put an order in for them. Yes, I see there's an order and treatments have been completed for her right and left hip, but there's no wound there. It was resolved upon her 4/11/23 admission. That's a good question. I don't know why the nurses signed off that they completed treatments for a resolved wound. I didn't put any of the wound orders in because I saw they were already there; I just didn't verify if they were accurate. I'm going to go through all the wound orders now and make sure they're all correct.
On 4/18/23 at 2:07 PM, V2 (DON) stated, We don't have a policy for skin assessments on admission, the nurses have a checklist they use when a resident admits of the assessment to be completed. I know the nurse on shift did not do R319's skin assessment when she admitted and that's why V23 (Assistant Director of Nursing (ADON)) put the orders in and then did the assessment the next day. I can't speak as to why the nurses documented they completed a wound treatment for wounds that were resolved. I wasn't there.
On 4/19/23 at 11:05 AM, V23 (ADON) confirmed she entered the physician orders for R319's wounds on 4/11/23 and stated, I didn't put wound orders in for those (right great toe, gluteal fold, and mid thoracic back) because I put (R319)'s wound orders in based on her hospital discharge orders when she admitted on [DATE] and not from an assessment. The skin observation assessment I did on 4/12/23 was also completed off of the hospital records, but I know (V3, Wound Nurse) also came in behind me and did a full detailed assessment of her wounds.
04/19/23 12:00 PM, V3 (Wound Nurse) stated, The wound treatments you saw me complete, even though we didn't have orders for a few of them, I did based off her orders prior to her going to the hospital on 4/5/23. She had all the same wounds when she admitted as she did prior to going to the hospital, with the exception of her right and left hip wounds resoled. When I spoke to the wound doctor, she told me to just reactivate the old orders for those wounds since the orders didn't change. I went through and fixed all the orders and updated the assessments to reflect the wound's location, size and treatment.
On 4/19/23, R319's medical record documents the following wounds since admission of 4/11/23.
Dermatitis: Left upper buttocks, gluteal fold, left posterior superior thigh.
Arterial Ulcer: Right first toe.
Pressure Ulcer: Left later shin (Amputation site)
Calciphylaxis: Mid thoracic back, right upper buttocks, and right distal lateral shin
The facility's Pressure Ulcer and Wound Prevention/Management Program dated 12/5/06 documents Ensure a resident who has been admitted with pressure ulcers or develops pressure ulcers in-house receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing, when possible .2. Residents will have a head-to-toe skin assessment upon admission, re-admission, at the time of discharge/transfer, and prior to/return from leave of absence by a licensed nurse.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure oxygen concentrators included humidification per physician order for one out of two residents (R28) reviewed for oxyge...
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Based on observation, interview, and record review, the facility failed to ensure oxygen concentrators included humidification per physician order for one out of two residents (R28) reviewed for oxygen in a sample of 30.
Findings include:
R28's physician order sheet dated 9/06/2021 documents Oxygen: Change tubing and humidifier weekly and as needed.
R28's brief interview of mental status (BIMS) documents a score of 15. A score of 13-15 indicates an individual is cognitively intact.
R28's medical record documents diagnoses of chronic obstructive pulmonary disease and chronic respiratory failure with hypercapnia.
On 4/16/23 at 6:33 AM, R28 observed in his room with oxygen tubing in place via nasal cannula and connected to an oxygen concentrator set at 3.0 liters of oxygen per minute. The humidifier bottle is dated 3/26/23 and does not contain water. R28 stated, Yeah, that happens around here. When the water runs out, it causes my nose to dry out.
On 4/16/23 at 7:35 AM, V2 (Director of Nursing/DON) stated, The bubble pack (Humidifier bottle) and tubing gets changed every seven days.
The facility's Oxygen Administration policy revised 3/2004 documents Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure. 3. Humidifier bottle. Steps in the Procedure: 9. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. 11. Periodically re-check water level in humidifying jar. 18. Make sure the humidifier jar is labeled properly.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
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 assess and identify potential triggers for a residen...
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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 assess and identify potential triggers for a resident with a diagnosis of PTSD (Post-Traumatic Stress Disorder) and failed to provide specific personalized interventions for a resident with a diagnosis of PTSD for one of two residents (R36) reviewed for mood and behavior in the sample of 30.
Findings include:
R36's Face sheet documents R36 admitted to the facility on [DATE] with a diagnosis of PTSD (Post Traumatic Stress Disorder).
R36's Antipsychotic Medication Nursing Assessment, dated 2/2/23, documents this is an annual assessment and documents R36's diagnoses of PTSD, Paranoid Personality Disorder, Generalized Anxiety Disorder, and Panic Disorder.
R36's Physician Order Report, dated 4/1/23-4/18/23 documents the following orders: Ativan 0.5 milligram/mg tablet for anxiety with an order start date of 10/10/22; Sertraline 100 mg daily for depressive episodes; Seroquel 200 mg at bedtime for Paranoid Personality Disorder; and Melatonin 3 mg at bedtime for Insomnia.
R36's quarterly Minimum Data Set/MDS Assessment, dated 2/2/23, documents R36 with moderately impaired cognition; Over the 14 days reviewed, R36 has little interest or pleasure in doing things for half or more of the days; trouble falling or staying asleep, or sleeping too much nearly every day; feeling tired or having little energy nearly every day; poor appetite or overeating half or more of the days; trouble concentrating on things, such as reading the newspaper or watching television several days; moving or speaking so slowly that other people could have noticed or the opposite-being so fidgety or restless that you have been moving around a lot more than usual nearly every day; and documents R36 with active diagnoses of PTSD, Anxiety Disorder, Depression, and Schizophrenia.
R36's Behavioral Health Care Note, dated 2/19/21, documents R36 with a diagnosis of PTSD and states, R36 describes delusions of persecution, overall paranoia and suspiciousness, and reports that R36 experiences both auditory and visual hallucinations. R36 endorses daily depressive symptoms, including a depressed mood, feelings of hopelessness/helplessness, tearfulness and negative ruminations. R36 reports ongoing worries related to her delusions, reports a history of trauma that may be related to these delusions.
R36's Behavioral Health Care Note, dated 3/24/21, documents R36 with a diagnosis of PTSD and documents R36 with ongoing psychotic and anxious symptoms. R36 has been suffering from on and off hallucinations, paranoia, and occ. (occasional) aggression toward CNA (Certified Nursing Assistants) during ADL (Activities of Daily Living) care. This same note documents R36 has exhibited poor intake. R36 endorsed psychotic sxs (symptoms) stated, 'There is an evil man who lives here, he tells me to do and say things I shouldn't.' R36 states she hears/sees him more in the afternoon and evening. R36 reports, 'I take meds/medications for nightmares, but the meds feel like they're still there in the morning' also stating she feels tired in the morning. R36 endorsed sxs (symptoms) of PTSD stating her father used to be verbally and physically aggressive with her as a child. R36 states, 'I've been anxious and scared since I was a child.' R36 reports nightmares about her father and another person who she would not discuss. As (R36) spoke about her father, she became tearful and began tightening her grip to the handlebars on the bed with a 'death grip.' R36 endorses panic sxs (symptoms) as well. This same note documents R36 with a Psychiatric Social History of emotional abuse and physical abuse by R36's father and a history of sexual abuse and documents R36 with a history of psychiatric hospitalizations. This note documents a plan for R36's PTSD to continue Zoloft/Sertraline and to continue Psychotherapy and states, Arranging and organizing patient care with providers and facility staff.
On 4/17/23 at 7:41 AM, R36 was observed sitting in a recliner chair in R36's bedroom. R36 was soft spoken, speaking in a whisper. R36 nodded her head yes when asked about R36's diagnosis of PTSD and shook her head no when asked if the facility staff has talked with R36 about R36's PTSD diagnosis. R36 would not state what triggers R36's PTSD stating, I don't know. I am done answering.
On 4/18/23 at 1:45 PM, V9 (Social Service Director) stated V9 not aware of R36's PTSD diagnosis, R36's reason for PTSD or triggers for R36's PTSD. V9 stated that V9 would be the one responsible for knowing this information, communicating with staff, and adding it to R36's plan of care. V9 verified R36's Care Plan did not contain information regarding R36's PTSD triggers or personalized interventions for R36's PTSD diagnosis. At this same time, V2 (Director of Nursing/DON) who present for V9's interview, stated that V2 was not aware of R36's PTSD diagnosis, triggers, or personalized interventions.
As of 4/19/23, R36's current Plan of Care did not contain documentation regarding R36's PTSD diagnosis; An assessment for triggers of R36's PTSD, or personalized interventions for R36's PTSD diagnosis.
The facility's Trauma Informed Care Policy, dated 12/6/16, states, This facility is committed to being a Trauma-Informed organization and recognizes that many individuals may have experienced trauma. This includes people we serve, all staff and other persons who enter the building. It is the intent that staff be informed about the effects and difficulties of psychological trauma and work in an environment which is sensitive to and facilitates recovery from that trauma. Purpose: This policy and procedure describes expectations for the implementation of trauma-informed and trauma-sensitive services. This facility is committed to promoting the health and safety of the persons it serves, with an emphasis on client safety. Definitions: Trauma is defined as an event or ongoing situation that results in extreme stress that overwhelms a person's ability to cope. Trauma impacts people differently. The symptoms that are adaptations to the effects of all traumas is sometimes not recognized as associated with prior trauma by survivors, family members, providers, or agency staff. The cluster of issues, personal adaptations, problems, and symptoms that are commonly seen in these individuals may result in Post-Traumatic Stress Disorder (PTSD), and other mental health conditions including mood, anxiety, personality, and substance use disorders. Trauma refers to the experience that results from an event or a series of events that subsequently causes intense physical and psychological stress reactions. The individual's functioning and emotional, physical, social, and spiritual health can be affected. Some of the most common traumatic experiences include violence, abuse, neglect, disaster, terrorism, and war. People of all ages, ethnic backgrounds, sexual orientations, and economic conditions may experience trauma. Trauma can affect a person's functional ability - including interacting with others, performing at work, and sleeping - and contribute to responses - including isolation, anxiety, substance abuse/ misuse and overeating or under eating - that can increase health risks. Behavioral health service providers can benefit greatly from understanding the nature and impact of trauma and the benefits of a trauma-informed approach. Re-traumatization can occur due to the effects of mistreatment, abuse, neglect, or coercive interventions in the broad context of health services (e.g., outpatient, hospital, residential, employment, or criminal justice setting). Trauma-Informed Services - Are not specifically designed to treat symptoms or syndromes related to sexual or physical abuse or other trauma, but they are informed about, and sensitive to, trauma-related issues present in survivors. A trauma-informed system is one in which all components of a given service system have been considered and evaluated in the light of a basic understanding of the role that trauma plays in the lives of people seeking mental health and addiction services as well as the staff that support them. A Trauma-Informed System of Care uses that understanding to design service systems that accommodate the vulnerabilities of trauma survivors and allows services to be delivered in a way that will minimize and ideally avoid inadvertent re-traumatization. Trauma Specific Services - Designed to treat actual consequences of trauma consistent with the need for respect, information, connection, and hope for clients; the importance of recognizing the adaptive function of symptoms and the need to work collaboratively in a person-directed and empowering way with survivors of abuse. Treatment providers should recognize a person's right to receive services in the most integrated setting in the community. Traumatized individuals seeking help must be given opportunities to be involved as partners in the planning and evaluation of services offered. They should also be given the opportunity to invite and include family and/or friends in that process, as indicated. Procedure: The long-term adverse effects of interpersonal violence, abuse, neglect, and other serious traumatic experiences are seen in people from infancy to old age, across gender, race, culture, socioeconomic status, intelligence, or educational level. However, most people who ask for help for themselves or family members do not usually seek services specifically for trauma-related conditions. Being sensitive to trauma histories will increase positive outcomes for persons we serve. Without addressing underlying trauma issues, we may continue to treat presenting symptoms and/or initiate services, which do not take into account the root cause, therefore delaying recovery. Therefore, it is the intention of this facility to deliver trauma informed services in consideration of the following four (4) assertions: 1) Trauma is central and pervasive. Trauma is central to the development of mental health and addiction problems and impacts many aspects of a person's life. 2) Universal precautions should be taken in working with individuals. An individual should not have to disclose trauma to receive trauma informed services. All individuals should be treated as if they may have experienced trauma. 3) Symptoms and behaviors are often attempts to cope with the trauma. 4) The goal of trauma services is to return a sense of autonomy and control to the individual receiving services. 5) It is also the intention of this facility to deliver trauma informed services within the context of the following six (6) service delivery principles: 1) Establishing a safe environment that feels physically and emotionally safe; and minimizes re-traumatization by being aware of our behavior attitudes. emotions and words and their impact on the individuals that are served. 2) Using an empowerment model of care that promotes and respects individual's choice and control to the best of our ability and recognizes, respects, and builds upon individual's strengths, abilities, and potentials. 3) Supporting the development of healthy relationships that are a vehicle for healing and are nurturing, empathic, authentic, and empowering. 4) Building healthy coping skills through assisting the individual in developing emotional self-awareness, using grounding and self-soothing techniques, and making safe choices. 5) Providing access to trauma specific services and evidence-based programs for adults, children, and families. 6) Ensuring holistic service delivery of trauma services and programs. Trauma-Informed Services within this Long-Term Care Facility: 1) Will provide educational opportunities to inform staff of the need for and concept behind Trauma-Informed services and effects of trauma on persons served. 2) Will include orientation, initial training opportunities, and ongoing training. 3) Will be sensitive to policies and procedures to assess for and avoid re-traumatizing individuals who seek services. 4) Will complete ongoing assessment of services for sensitivity to, and appropriate treatment to, ensure a sense of safety for survivors of trauma. Trauma-Specific Treatment indicates that the facility: 1) Will conduct appropriate assessments to assess for trauma needs. 2) Will emphasize adoption of best practices and Evidence-Based Treatment modalities to facilitate intervention and potential recovery for those with trauma needs. 3) Will seek to involve knowledgeable mental health professionals and the participation of persons served who have lived experiences of trauma, in the areas of systems planning, oversight, and evaluation.
The Residents' Rights for People in Long Term Care Facilities, pamphlet, revised 11/18, states, Your facility must provide equal access to quality care regardless of diagnosis, condition or payment source. Your facility must provide services to keep your physical and mental health, at their highest practical level.
The Social Service Director Job Description, undated, states, Purpose: To provide for the social services needs to adults in long term care/nursing home setting. 1. Direct Service and Programming: Conduct intake interview and assessments; Participate in development and review of care plans, attend, and participate in care plan conferences; Facilitate supportive treatment intervention to maintain or enhance resident's capacity for independent functioning; Conducting skills groups, therapy groups, and individual counseling sessions as assigned; Conduct follow up resident issues as needed. Record Keeping: Maintains concise comprehensive case records by following established agency policies and procedures; Monitors Social Services case records and reporting patterns to ensure that performance standards are met as well to ensure coordination of information/data for QI (Quality Improvement) meetings; Actively contributes and participates in developing and accomplishing local state agency standards
The Psycho-Social or Social Service Aide Job Description, undated, states, The primary purpose of this position is to provide group psychosocial rehabilitation services to adults within a long-term care/nursing home setting. This position participates with the interdisciplinary team to develop, implement and evaluate effective therapeutic services facility programming.
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 residents received medications as physician ordered for one (R58) of one resident reviewed for medication errors in th...
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Based on observation, interview, and record review, the facility failed to ensure residents received medications as physician ordered for one (R58) of one resident reviewed for medication errors in the sample of 30.
Findings include:
The Event Report for R58, dated 4/2/23 documents V15 (LPN/Licensed Practical Nurse) gave an incorrect dose of Doxazosin 2 mg (milligram) to R58 by giving R58 two tablets equally 4 mg. V14 identified the medication error on 4/2/23, approximately 15 hours after the medication error occurred.
On 4/18/23 at 7:25 am, R58 stated V15 (LPN) gave him two blood pressure pills and he should have only gotten one. R58 stated V15 came into his room, handed R58 the medications, and left R58's room. R58 stated his girlfriend took a picture of the medications after V15 left his room because R58 got more pills than he usually did. R58 stated he asked V14 (LPN) the next day what medicines he was supposed to get at 8:00 pm and told V14 he got the wrong medications.
The Physician Order Report for R58, dated 3/19/23 through 4/19/23, lists a Physician order for the antihypertensive medication doxazosin 2 mg (milligram) at bedtime and scheduled for 8:00 pm.
The Progress Note for R58, dated 4/2/23 at 11:30 am, documents Resident (R58) reports that he believes he received the wrong dosage of medication last night (4/1/23). VS (vital signs) this morning was 116/70 (blood pressure), 68 (heart rate). MD (Medical Doctor) notified of possible med (medication) error. N.O. (new order) Continue to monitor BP/HR (blood pressure/heart rate) and for any adverse effects over the next 24 hours. Admin (Administrator) and floor staff aware.
The Progress Note for R58, dated 4/2/23 at 11:56 am, documents (R58) states that he feels fine, no s/s (signs or symptoms) of hypertension or hypotension. Will cont. (continue) to monitor.
On 4/18/23 at 9:23 am, V26 (Pharmacist) stated Doxazosin is a medication used to control and lower blood pressure and if someone received a double dose this is something that needs looked into. The patient may or may not have adverse reactions based on the resident's condition and dosage at the time; however adverse reactions can occur regardless of dosage. V26 stated some adverse reactions of getting too much of the medication could be Hypotension, Orthostatic Hypotension, Dizziness, fatigue, malaise, nausea, sleepiness, edema, headache, or stomach pain. The higher the dose, obviously have higher risk of adverse reactions. V26 confirmed monitoring for condition changes and blood pressure would be recommended.
On 4/18/23 at 8:13 am, V2 (DON/Director of Nursing) stated she was made aware of a medication error for R58 on 4/2/23 around 11:30 am. R58 questioned V14 (LPN) about what medications he was supposed to get at 8:00 pm. V2 stated R58 should have only gotten four medications routinely. R58's girlfriend took a picture of the medicines the nurse gave him and (V2, DON) had the girlfriend send the picture to V2 and after review of R58's physician orders and the bubble medication cards R58 had received two Doxazosin pills and should only have received one. V2 (DON) confirmed the medication error occurred on 4/1/23 at 8:00 pm and was not discovered until 15 hours later on 4/2/23. V2 stated there were no interventions or monitoring of R58 until about 11:30 am the next day because no one knew about it. V2 also stated she was unaware that the nurse left R58's room and did not observe R58 take his medication.
The facility's Medication Administration policy and procedures, effective Date 10/25/2014, documents A. Preparation . 4) Five Rights - Right resident, right drug, right does, 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 put away . 5) Prior to administration, the medication and dosage schedule of the resident's medication administration record (MAR) are compared with the medication label. If the label and MAR are different and the container in not flagged indicating a change in directions or if there is any other reason to question the dosage directions, the physician's orders are checked for the correct dosage schedule . B. Administration . 2) Medications are administered in accordance with written orders of the prescriber . 18) The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR, and action is taken as appropriated.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
5. R19's medical record documents Supra-pubic catheter.
On 4/16/23 at 8:51 AM, R19's observed lying in bed with his catheter bag lying on the floor.
On 04/16/23 at 8:56 AM, V7 (Licensed Practical Nur...
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5. R19's medical record documents Supra-pubic catheter.
On 4/16/23 at 8:51 AM, R19's observed lying in bed with his catheter bag lying on the floor.
On 04/16/23 at 8:56 AM, V7 (Licensed Practical Nurse/LPN) verified R19's catheter bag was lying on the floor and stated, It shouldn't be on the floor.
On 4/18/23 at 9:40 am, V2 (Director of Nursing/DON) stated, Catheters should not being lying on the floor, they should try and put them in a dignity bag and keep them off of the floor.
The Facility Catheter Care, Urinary Policy, revised September 2005, documents: the purpose of this procedure is to prevent infection of the Resident's urinary tract; the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder; and be sure the catheter tubing and drainage bags are kept off of the floor.
Based on observation, interview, and record review, the facility failed to ensure indwelling urinary catheter tubing and urinary drainage bags were kept off the floor for four residents (R19, R61, R62 and R63) and ensure an indwelling urinary catheter drainage bag was maintained below the bladder for one out five residents (R64) reviewed for indwelling urinary catheters in a sample of 30.
Findings include:
1. R63's Physician Order Sheet, dated 3/17/23 through 4/17/23, documents: diagnoses including kidney disease and Urinary Retention; indwelling urinary catheter size of 16 with a ten cubic centimeter/cc balloon; indwelling urinary catheter care (Foley) and catheter change every four weeks; and monitor output every shift.
On 04/16/23 at 06:42 am, R63 was lying in bed and R63's indwelling urinary catheter drainage tubing and drainage bag were laying on floor next to R63's bed, with no dignity bag.
On 4/19/23 at 9:59 am, R63 was in the therapy room and R63's indwelling urinary catheter tubing was lying on the floor.
2. R64's Physician Order Sheet, dated 3/17/23 through 4/17/23, documents: a diagnosis including Urinary Retention; indwelling urinary catheter care (Foley) and catheter change every four weeks; and monitor output every shift.
On 04/16/23 at 06:20 am, R64 was sitting in R64's wheelchair, in the main hallway outside of R64's room, and R64's indwelling urinary catheter drainage tubing and drainage bag were sitting on top of R64's waist/leg/groin area, with no dignity bag.
3. The Physician Order Report for R61, dated 3/19/23 through 4/19/23, documents a Physician order for an indwelling urinary catheter for Hydroureteronephrosis with Urinary Retention. This same report, documents R61 just completed two rounds of intravenous antibiotics for a urinary tract infection on 3/28/23.
The current Care Plan for R61 documents Problem: R61 requires an indwelling urinary catheter r/t (related to) urinary retention. The Goal is documented R61 will have catheter care managed appropriately as evidenced by not exhibiting signs of urinary tract infection or urethral trauma. The Interventions include: Do not allow tubing or any part of the drainage system to touch the floor and Store collection bag inside a protective dignity pouch.
On 4/16/23 at 6:18 am, R61's urinary collection bag was not in a protective dignity pouch, and the indwelling urinary catheter tubing was resting on the floor next to R61's bed.
4. The Physician Order Report for R62, dated 3/18/23 through 4/18/23, documents a Physician order an indwelling urinary catheter for Urinary Retention.
The current Care Plan for R62, documents Problem: R62 requires an indwelling urinary catheter r/t (related to) urinary retention. The Goal is documented R62 will have catheter care managed appropriately as evidenced by not exhibiting signs of urinary tract infection or urethral trauma. The Interventions include: Do not allow tubing or any part of the drainage system to touch the floor and Store collection bag inside a protective dignity pouch.
On 4/16/23 at 6:40 am, R62's urine collection bag was not in a protective dignity pouch and was resting on the floor next to R62's bed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected multiple residents
4. On 4/16/21 at 8:51 AM, R19 lying in bed with bilateral side rails in the raised position.
R19's physician order sheet dated 10/1/21 documents Bilateral Quarter upper side rails for increased indep...
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4. On 4/16/21 at 8:51 AM, R19 lying in bed with bilateral side rails in the raised position.
R19's physician order sheet dated 10/1/21 documents Bilateral Quarter upper side rails for increased independence in bed mobility.
R19's medical record does not document an assessment for alternate interventions prior to the initiation of the bilateral top quarter side rails.
The Facility Proper Use of Beds and Bed Mobility Systems, effective 4/25/15, documents: The purpose of these guidelines is to ensure the safe use of all beds and bed mobility systems as resident mobility aids; Mobility systems are used to assist and increase the Resident's functional status with Activity of Daily Living's as determined by the Interdisciplinary Team; All such devices must be in compliance with the State and Federal guidelines; and Considerations will be incorporated in care planning include considerations for the use of bed mobility systems, contributing factors for the use of bed mobility systems and assistance provided through the use of bed mobility systems.
Based on observation, interview, and record review, the facility failed to conduct an assessment and include alternative interventions attempted prior to initiating the use of side rails for four out of four residents (R19, R33, R58 and R62) reviewed for side rails in the sample of 30.
Findings include:
1. R33's Physician Order Sheet, dated 3/17/23 through 4/17/23, documents an order for bilateral quarterly upper bed rails for increased independence in bed mobility and repositioning.
R33's Side Rails Observations & Consent Form, dated 8/24/21, documents R33's reason for top-half bed rail usage as bed mobility. The form does not document an assessment for alternate interventions prior to the initiation of the bilateral side rails.
On 4/18/23 at 2:10 pm, V1 (Administrator) stated, We do not have any therapy documentation or prior intervention trials that were initiated for (R19, R33, R58 or R62) before their bed rails were initiated. I cannot find any documentation in their charts or the electronic record. We changed our therapy company and I emailed the old company to see if they can find me any alternate trial interventions and they have not been unable to send me any assessments on these residents.
2. On 4/16/23 at 10:00 am, on 4/17/23 at 8:08 am, on 4/18/23 at 8:30 am, and on 4/19/23 at 12:20 pm, R58 was lying in bed with head of bed elevated with upper quarter bed rails in the upright position on R58's bed.
The Physician Order Report for R58, dated 3/19/23 through 4/19/23 does not document a Physician order for the use of bed rails.
R58's Medical Record does not include documentation of a bed rail assessment or entrapment risk assessment being conducted prior to using bed rails; alternatives attempted prior to the use of bed rails; and does not include a physician order or consent for the use of bedrails.
3. On 4/16/23 at 6:20 am, 6:40 am, 10:00 am, on 4/17/23 at 8:15 am, 9:27 am, and on 4/18/23 at 11:23 am, R62 was lying in bed with upper quarter bedrails in the up position on bilateral sides of R62's bed.
The Physician Order Report for R62, dated 3/18/23 through 4/18/23, documents a Physician order as Ok for bilateral 1/4 (quarter) rails to bed to promote bed mobility.
R62's Medical Record does not include any documentation of a bed rail assessment or entrapment risk assessment being conducted prior to using bed rails; alternatives attempted prior to the use of bed rails; and does not include consent for the use of bedrails.
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 date open food items, store dry food on shelves, maintain clean equipment, and clean the kitchen between meals. This has the ...
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Based on observation, interview, and record review, the facility failed to date open food items, store dry food on shelves, maintain clean equipment, and clean the kitchen between meals. This has the potential to affect 64 of the 71 residents residing in the facility.
Findings include:
The facility's Food Storage policy dated 2020 documents Food shall be stored on shelves in a clean dry area free from contaminants.
On 4/16/23 at 7:00 AM, during the initial tour of the kitchen, the following observations were made: The kitchen refrigerator has ranch dressing, salad dressing (mayonnaise), and cottage cheese opened and not dated. The griddle has a black looking sludge along the front of the grease drain as well as food splattered on the side of the warmer sitting next to the griddle. There is dried food on the oven door and on the racks in the plate warmer. The dry storage has nine boxes of food sitting on the floor.
On 04/16/23 at 7:02 AM, V10 (Lead Cook) verified the open food items in the refrigerator and stated, Those should be dated. We'll have to throw them out since they aren't dated.
On 04/16/23 07:04 AM, V11 (Cook) stated, All the boxes on the floor were delivered on Thursday and will be put away on Monday. I know they aren't supposed to be on the floor.
On 04/16/23 11:47 AM, V4 (Dietary Manager) verified that the black substance in front of the griddle is old grease that had not been cleaned between uses, the food on the side of the warmer, the presence of old dried food on the oven door and food on the racks of the plate warmer and stated, I've only been here three weeks, and I started a new cleaning schedule for the kitchen because it wasn't being done daily. As you can see, nothing got cleaned last night. All of this (moving the old grease on the griddle with a spatula) is going to be cleaned today. The food that got delivered should not be sitting on the floor. It has to be six inches off the floor. Like I said, there's a lot of changes that are going to be made since a lot of this did not get done.
On 4/17/23 at 11:20 AM, upon follow up to the kitchen, there is a thick yellow substance on the floor in front of the steam table.
On 4/17/23 at 11:25 AM, V24 (Cook) stated, The yellow stuff on the floor is butter. We put butter on the oatmeal this morning for breakfast. The steam table causes it to spill over onto the floor.
On 4/17/23 at 11:47 AM, V4 (Dietary Manager) stated, The butter shouldn't have been on the floor because they're supposed to clean the kitchen between each meal. I got the grease cleaned off the griddle, but we just haven't had time to get everything cleaned. We have a lot of cleaning to get caught up on. We don't have a policy on cleaning the kitchen. We have a daily cleaning schedule, but obviously it isn't being done. It's one of the things I'm changing. There's no policy on dating open food items because it's part of the sanitation certification. We all know that open food items have to labeled and dated.
The facility census and data reporting sheet dated 4/16/23 documents 71 residents residing in the facility. Of the 71 residents residing in the facility, R13, R22, R44, R49, R60, R61 and R120 are NPO (Nothing by Mouth).
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to wear Personal Protective Equipment (face masks) in co...
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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 wear Personal Protective Equipment (face masks) in compliance with the local Community COVID Outbreak Transmission Rate. This failure has the potential to affect all 71 residents residing in the Facility.
Findings include:
Facility Community Transmission Level Report, dated 4/14/23, documents a community Transmission Level of High.
Facility COVID-19 Source Control and Personal Protective Equipment/PPE Policy and Procedure, undated documents: when the COVID-19 Community Transmission rate is High, source control is recommended for everyone in a health care setting when they are in areas of the health care facility where they could encounter Residents; and when the Community Transmission rate is High, HCP must wear a well-fitted mask at all times while in areas of the facility where they may encounter residents and eye protection should be worn during all resident care.
On 4/16/23 at 5:56 am through 7:20 am, V7 (Licensed Practical Nurse/LPN), V12 (LPN), V13 (LPN), V14 (LPN), V15 (LPN), V16 (LPN), V17 (LPN), V8 (Certified Nursing Assistant/CNA), V18 (CNA), V19 (CNA), V20 (CNA), V21 (CNA), V10 (Lead Dietary Cook) and V11 (Dietary Cook) were standing either in the Harmony One/I Hallway, Harmony Two/II Hallway, [NAME] Hallway or [NAME] Hallway or sitting at the nurses station, with no Personal Protective Equipment (face masks) on.
On 4/16/23 at 8:05 am, V2 (Director of Nursing/DON) stated, No one was wearing face masks this morning, I had to go around and tell everyone to put their face masks on because our County Transmission rate on Thursday (4/13/23) was High.
On 4/18/23 at 9:40 am, V2 (DON) stated I am the person responsible for letting the employees know about the County COVID rate and wearing the proper 'PPE' in regard to masking and face shields. We get the update on Thursday evening, and I update everyone on Friday. I hang a sign in the break room and one on my office door to notify them.
On 4/17/23, V1 (Administrator) stated, All staff should be wearing masks at this time, they should have had them on yesterday morning (4/16/23).
No residents were known to be COVID-19 positive during this survey.
Facility Resident and Conditions Census Report, dated 4/16/23, documents 71 Residents residing in the Facility.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What safeguards are in place to prevent abuse and neglect?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 7 harm violation(s), $87,478 in fines, Payment denial on record. Review inspection reports carefully.
- • 74 deficiencies on record, including 7 serious (caused harm) violations. Ask about corrective actions taken.
- • $87,478 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Lincoln Village Healthcare's CMS Rating?
CMS assigns LINCOLN VILLAGE HEALTHCARE an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Illinois, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Lincoln Village Healthcare Staffed?
CMS rates LINCOLN VILLAGE HEALTHCARE's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 69%, which is 23 percentage points above the Illinois average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 100%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Lincoln Village Healthcare?
State health inspectors documented 74 deficiencies at LINCOLN VILLAGE HEALTHCARE during 2023 to 2025. These included: 7 that caused actual resident harm, 65 with potential for harm, and 2 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Lincoln Village Healthcare?
LINCOLN VILLAGE HEALTHCARE 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 GENERATIONS HEALTHCARE, a chain that manages multiple nursing homes. With 126 certified beds and approximately 76 residents (about 60% occupancy), it is a mid-sized facility located in LINCOLN, Illinois.
How Does Lincoln Village Healthcare Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, LINCOLN VILLAGE HEALTHCARE's overall rating (1 stars) is below the state average of 2.5, staff turnover (69%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Lincoln Village Healthcare?
Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the substantiated abuse finding on record, the facility's high staff turnover rate, and the below-average staffing rating.
Is Lincoln Village Healthcare Safe?
Based on CMS inspection data, LINCOLN VILLAGE HEALTHCARE has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Illinois. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Lincoln Village Healthcare Stick Around?
Staff turnover at LINCOLN VILLAGE HEALTHCARE is high. At 69%, the facility is 23 percentage points above the Illinois average of 46%. Registered Nurse turnover is particularly concerning at 100%. 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 Lincoln Village Healthcare Ever Fined?
LINCOLN VILLAGE HEALTHCARE has been fined $87,478 across 3 penalty actions. This is above the Illinois average of $33,954. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Lincoln Village Healthcare on Any Federal Watch List?
LINCOLN VILLAGE HEALTHCARE 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.