HELIA HEALTHCARE OF NEWTON
For profit - Corporation
57 Beds
HELIA HEALTHCARE
Data: November 2025
Trust Grade
30/100
#543 of 665 in IL
Photo by Newton Care Center
Last Inspection: September 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Helia Healthcare of Newton has a Trust Grade of F, indicating significant concerns about the facility's quality of care. Ranked #543 out of 665 nursing homes in Illinois, they are in the bottom half of facilities statewide, although they rank #1 in Jasper County, meaning there are no better local options. The trend is improving, with issues reducing from 19 in 2024 to just 1 in 2025, which is a positive sign. However, staffing is a major weakness, with a poor rating of 1 out of 5 stars and a turnover rate of 61%, much higher than the state average. While the facility has no fines on record, which is a good sign, there have been serious concerns noted, such as a resident experiencing significant weight loss due to inadequate care planning and instances where residents did not receive timely assistance with basic needs. Overall, while there are areas of improvement, potential residents and their families should weigh these strengths against the critical staffing and care deficiencies.
- Trust Score
- F
- In Illinois
- #543/665
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 61% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Illinois facilities.
- Skilled Nurses ○ Average
- Each resident gets 32 minutes of Registered Nurse (RN) attention daily — about average for Illinois. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 32 deficiencies on record. Higher than average. Multiple issues found across inspections.
30/100
Bottom 19%
Needs review
19 → 1 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 19 issues
2025: 1 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: 61%
15pts above Illinois avg (46%)
Frequent staff changes - ask about care continuity
Chain: HELIA HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (61%)
13 points above Illinois average of 48%
The Ugly 32 deficiencies on record
1 actual harm
Feb 2025
1 deficiency
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to provide 8 hours of daily Registered Nurse (RN) coverage. This failure has the potential to affect all 36 residents residing in the facility...
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Based on interview and record review, the facility failed to provide 8 hours of daily Registered Nurse (RN) coverage. This failure has the potential to affect all 36 residents residing in the facility.
Findings include:
On 02/20/2025 at 10:29 A.M. V1 (Administrator) stated she is aware there are a few shifts that did not have 8 hours with a Registered Nurse. V1 stated that V2 (Director of Nursing) has been working weekends to ensure that the facility has RN coverage every shift. V1 stated on 02/16/2025 that V2 was in the building and left for several hours before coming back. V1 stated she did not realize that registered nurse coverage hours had to be consecutive.
On 02/21/2025 at 10:15 A.M. V1 stated that the facility uses several nurses from one shift who keep extending their contract to work for the facility. V1 stated that they have hired a new MDS (Minimum Date Set) nurse who will help cover RN hours when she gets trained. V1 verified the accuracy of the December 2024, January 2025, and February 2025 nursing schedules.
Review of December 2024 Nursing Schedule documents four hours of RN coverage was provided at the facility on 12/07/2024. The same schedule documents two and a half hours of RN coverage was provided by the facility on 12/08/2024, and five hours of RN coverage was provided by the facility on 12/21/2024 and 12/22/2024. Review of Employee Timecard documented on 02/16/2025, V1 clocked in at 5:15 A.M. and out at 8:00 A.M. V1 then clocked in at 11:55 A.M. and out at 6:52 P.M. V1's hours were not consecutive.
The facility provided a Matrix for Providers on 02/20/2025 which documented the facility currently has 36 residents residing at the facility.
Facility policy titled Staffing with no date on it documented under section titled Policy: The Facility provides adequate staffing to meet needed care and services for our resident's population and according to regulatory staffing requirements (CMS, IDPH). Under the section titled Procedure: 2. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. The facility will schedule a registered nurse 8 consecutive hours each day.
Sept 2024
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure assessments were successfully transmitted within 14 days of completion for 1 (R32) of 12 residents reviewed for assessments in the s...
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Based on interview and record review, the facility failed to ensure assessments were successfully transmitted within 14 days of completion for 1 (R32) of 12 residents reviewed for assessments in the sample of 41.
Findings Include:
R32's Face Sheet documented an admission date of 04/29/2024. Diagnoses include, but not limited to dementia, Alzheimer's disease, benign prostatic hyperplasia, and essential hypertension.
On 09/11/2024 at 1:52 PM, V2 (Registered Nurse / Minimum Data Set Nurse) stated R32 had an admission assessment on 05/03/2024 and the discharge assessment was completed on 05/24/2024. V2 stated that she does not have to transmit the MDS because it was a private pay discharge. V2 stated that she did not transmit the assessment as it is not required to be.
On 09/11/2024 at 2:55 PM, V1 (Administrator) stated that she is unfamiliar with the MDS not being transmitted. V1 stated that she will reach out to the corporate office and get the correct information on whether or not the MDS should have been transmitted.
On 09/12/2024 9:45 AM, V2 stated she was inaccurate with what she said on 09/11/2024. V2 stated that she was confused about what type of assessment that it was. V2 stated that she got the private pay and the Medicare Advantage rules confused. V2 stated that she transmitted R32's assessment on 09/11/2024.
On 09/12/2024 at 1:43 PM, V1 stated the facility does not have a policy about MDS. V1 stated the facility follows the RAI manual and the RAI manual is the policy.
On 09/11/2024 at 12:52 PM, R32's MDS (Minimum Data Set) dated 05/24/2024 documented the assessment as complete.
Review of CMS (Centers for Medicare & Medicaid Services) MDS 3.0 NH (Nursing Home) Final Validation Report documented completed submission of R32's 05/24/2024 assessment on 09/11/2024.
RAI Manual Chapter 5, Submission and Correction of the MDS Assessments Nursing homes are required to submit Omnibus Budget Reconciliation Act (OBRA) required Minimum Data Set (MDS) records for all residents in Medicare- or Medicaid-certified beds regardless of the pay source. Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument, including the Care Area Assessment (CAA) Summary (Section V) and all tracking or correction information. Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility has failed to update comprehensive care plans for 2 of 12 residents (R15 and R21) reviewed for care plans in a sample of 41.
The Findings Include:
1. ...
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Based on interview and record review the facility has failed to update comprehensive care plans for 2 of 12 residents (R15 and R21) reviewed for care plans in a sample of 41.
The Findings Include:
1. R15's Face sheet documents an admission date of 2/9/21. R15's Face sheet includes the following diagnosis: major depressive disorder, cognitive communication deficit, depression, unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, vascular dementia with agitation.
R15's Current care plan documents a problem area of falls. The goal for this problem area is that resident will remain free from injury. The approach to this problem area include: therapy to evaluate and treat if POA (Power of Attorney) approves, provide proper well maintained footwear, staff assess pressure alarm is functioning when providing care, lock brakes of wheelchair when resident is not in it, non skid strips placed on the floor next to the bed, observe frequently and place in supervised area when out of bed, resident will be monitored when in the dining room and escorted back to her room when dining is complete, assure resident is wearing eyeglasses and are clean and in good repair, assure the floor is free of glare, liquids, and foreign objects, encourage resident to assume a standing position slowly, give resident verbal reminders not to ambulate/transfer without assistance, keep bed in lowest position with brakes locked, keep call light in reach at all times, keep personal items and frequently used items within reach, leave night light on in room, provide proper maintained footwear, provide environment free of clutter, and provide toileting assistance every 2 hours and as needed.
On 9/11/24 at 2:30PM, V1 (Administrator) stated that R15 should have her call light within reach at all times to call for assistance.
On 9/11/24 at 2:36 PM, V5 (Certified Nurse Assistant/CNA) stated that the family does not like R15 to have a call light due to the risk of her choking herself with the cord. V5 stated that they just check on her more often, that they do not have any other form of call light system for R15 to use.
On 9/11/24 at 2:45 PM, V1 stated that the care plan is not updated to reflect the need for R15 to have an alternate type of call light/alert system to let the staff know assistance is needed, nor is the behavior/request of family in the care plan requesting to not use the standard call light.
2. R21's face sheet documents an admission date of 10/21/2022. The following diagnosis are included on the face sheet: Parkinson's disease, anxiety disorder, depression, and major depressive disorder with psychotic features.
R21's current month physician orders include an order for Seroquel 50 milligram tablet once daily at bedtime with a start date of 4/9/2024.
R21's Current care plan has a problem area category of psychotropic drug use resident receives antidepressant medication. The goal for this problem area is that the resident will not exhibit signs of drug related sedation, hypotension, or anticholigenic symptoms. The approach to this problem area is that they will assess/record effectiveness of drug treatment, monitor signs and symptoms of sedation, hypotension, or anticholinergic symptoms and to monitor resident mood and response to medication.
On 9/13/21 at 12:30 PM, V2 (Minimum Data Set Coordinator/Care Plan Coordinator) stated that the care plan had not been updated to include the anti-psychotic medication that was started on 4/9/24 or any individualized non pharmalogical interventions when behaviors are occurring.
V1 did not provide a care plan policy and procedure on updating comprehensive care plans.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview the facility failed to implement fall precautions by placing the call light within reach for 1 of 2 (R15) residents reviewed for falls in a sample of ...
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Based on observation, record review and interview the facility failed to implement fall precautions by placing the call light within reach for 1 of 2 (R15) residents reviewed for falls in a sample of 41.
Findings Include:
R15's face sheet documents an admission date of 2/9/21. This same document includes the following diagnosis: muscle weakness, other abnormalities of gait and mobility, and vascular dementia.
R15's care plan has a problem area category of falls that has a start date of 8/18/22 and an edited date of 8/27/24. The goal for this problem area with a long term goal target date of 11/29/24 is that the resident will remain free from injury. An approach to this problem area with a start date of 8/18/22 is to keep the call light in reach at all times.
R15's most recent recent quarterly MDS (Minimum Date Set) dated 5/20/24 documents in Section C a BIMS (Brief Interview of Mental Status) of 6, indicating R15 is severely impaired with cognition level. R15's same MDS Section J documents that R15 has had falls since admission/reentry.
On 9/10/24 at 10:30 AM, R15 was observed to be in her recliner and no call light within reach.
On 9/11/24 at 9:30 AM, 11:30 AM, 1:30 PM and 2:32 PM, R15 was observed sitting in her recliner with the call light sitting on top of her personal refrigerator in her room not within reach.
On 9/11/23 at 2:35 PM, V5 (Certified Nurse Assistant) stated that the family does not want R15 to have a call light due to the possibility that she could strangle herself with it. V5 stated that they do not have an alternate source of a call light right now, they just check on her every two hours for sure and then when they are going up and down the hall.
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 record review and interview the facility failed to ensure residents were free from unnecessary medications for 1 of 5 (R2) residents reviewed for unnecessary medications in a sample of 41.
Th...
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Based on record review and interview the facility failed to ensure residents were free from unnecessary medications for 1 of 5 (R2) residents reviewed for unnecessary medications in a sample of 41.
The Findings Include:
R2's Face sheet documents an admit date of 9/6/23 and includes the following diagnosis: vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.
R2's current Physician Order Sheet documents an order for 1 mg (milligram) Risperadol with diagnosis: vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety with a start date of 9/6/2023.
A psychotropic and sedative/hypnotic utilization by resident report provided by V1 (Administrator) dated 9/6/24 documents that R2 started Risperidone 1 mg pm (as needed) on 9/6/23 and is due for a Gradual Dose Reduction (GDR) evaluation on 12/2024. The column labeled Last GDR is blank. On 9/13/24 at 1:30PM, V1 stated at this time there are no other pharmacy reports that show communication to recommend any medication reductions in the medical record.
On 9/13/24 at 11:00 AM, V11 (Pharmacist) stated that he would check to see if there were any previous GDR attempts/recommendations for R2, but his routine is review the GDR's every 5 months to ensure that he catches all the medications to ensure they are reviewed per the Medicare guidelines.
Review of R2's behavior tracking from 8/13/24-9/12/24 provided by V1 has no behaviors occurring. On 9/11/24 at 2:30 PM, V1 stated that all residents are tracked for the same behaviors because the new system does not allow them to individualize them. According to the tracking sheet R12 is tracked for verbal expression of distress, sleep cycle issues, apathetic/anxious/sad appearance, loss of interest, did the resident have any of the following problems or behaviors (PHQ-9-OV) (with no further explanation).
On 9/13/24 at 12:30 PM, V9 (Certified Nurse Assistant) stated that R2 has not had any behaviors that he is aware of.
On 9/13/24 at 1:00 PM, V2 (Minimum Data Set Coordinator) stated that R2 used to have behaviors of not having anxiety and eating and drinking all his snack and drinks that family brings in, but they have worked with him and this has all improved. V2 stated that since then he has not really had any behaviors. V2 stated that this is not tracked as a behavior nor is it on his care plan. V2 stated that she cannot find any further documentation regarding any recommendations or attempts at reduction of psychotropic medications.
On 9/13/24 at 1:30 PM, V1 provided a document titled Gradual Dose Reduction Schedule that documented, Antipsychotics and Anxiolytics: During the first year of the use of these drugs in the facility, there should be one attempt to reduce the medication .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate direct care staffing to meet resident's needs. Thi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate direct care staffing to meet resident's needs. This has the potential to affect all 32 residents living at the facility.
Findings include:
1. R7's Face Sheet documented an admission Date of 1/31/20 and listed diagnoses including History of Cerebral Infarction, Chronic Obstructive Pulmonary Disease, and Congestive Heart Failure. R7's Minimum Data Set, dated [DATE] indicated R7 has moderate deficits in cognition and is totally dependent on staff for toileting, showering, and dressing. R7's Care Plan dated 8/27/24 documented a problem area, Resident's ability to perform activities of daily living requires assistance of staff.
On 09/10/24 at 02:11PM, R7 was in his room sitting in his wheelchair watching TV. R7 was alert to person and place but not time. R7 stated he needed to use the bathroom and pushed his call light. After 15 minutes and 46 seconds, V8, Certified Nursing Assistant (CNA), responded and assisted R7 with toileting.
2. R15's Face Sheet documented an admission date of 2/9/21 and listed diagnoses including polyneuropathy, Hypertension, and Dementia. R15's Minimum Data Set, dated [DATE] documented that R15 has severe deficits in cognition and requires substantial assistance from staff for toileting, showering, and dressing. R15's Care Plan dated 8/20/24 documented a problem area, Due to cognitive deficits, (R15) is dependent on staff for meeting his/her emotional, intellectual, physical and social needs.
On 09/11/24 at 11:04 AM, V6, family member of R15, stated when she was visiting on 9/7/24 on day shift, it took an hour to get staff to take V6 to the bathroom. V6 stated on 9/8/24 on day shift, there was one CNA and one nurse to care for the whole building.
On 09/11/24 at 1:13 PM, V7, Licensed Practical Nurse, stated there have been times where it has just been her and one CNA for the whole building on day shift on weekends. She stated there is also an issue at times with there being only one CNA and one nurse on night shift.
On 09/12/24 at 1:16 PM, V9, CNA, stated there are times when there is only one CNA and one nurse for the whole building, and that it can happen on any shift both through the week and on the weekend.
On 09/13/24 at 8:13am, V1, Administrator, stated she is the staff member responsible for scheduling nursing and CNA staff. V1 stated nurses work 12 hour shifts from 6am to 6pm and 6pm to 6am, and CNAs work 8 hour shifts. V1 stated one nurse and 2 CNAs are scheduled each shift. V1 stated there are times when CNA's call in, especially on the 2pm to 10pm shift and 10pm to 6am shift, but coverage can usually be obtained. V1 stated corporate staff have told her one CNA on the 10pm to 6am shift is enough for the current census, and that when the census gets up to 36 she can schedule a total of 3 CNAs either on day shift or evening shift, but not both.
On 9/13/24 at 12:10 PM, V2, Interim Director of Nurses, stated it is her expectation that call lights should be answered within five minutes.
Nursing and CNA Schedules for July, August, and September 2024 documented the following dates with one CNA and one nurse providing care for the entire facility:
7/1/24, 10pm to 6am shift.
7/4/24, 10pm to 6am shift.
7/12/24, 10pm to 6am shift.
7/13/24, 10pm to 6am shift.
7/18/24, 2pm to 10pm shift.
8/2/24, 2pm to 10pm shift.
8/10/24, 6am to 2pm and 2pm to 10pm shifts.
8/18/24, 6am to 2pm shift.
9/8/24, 6am to 2pm shift.
9/9/24, 2pm to 10pm shift.
9/10/24, 2pm to 10pm shift.
The Long - Term Care Facility Application for Medicare and Medicaid provided by the facility with a date of 09/11/2024 documents that 32 residents reside at the facility.
CONCERN
(F)
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 8 hours of daily Registered Nurse coverage. This failure has the potential to affect all 32 residents residing in the facility.
Fin...
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Based on interview and record review, the facility failed to provide 8 hours of daily Registered Nurse coverage. This failure has the potential to affect all 32 residents residing in the facility.
Findings include:
Review of June 2024 Nursing Schedule documents no RN coverage was provided at the facility on 06/19/2024 and 06/29/2024. Review of July 2024 Nursing Schedule documents no RN coverage was provided at the facility on 07/13/2024, 07/14/2024, 07/17/2024, 07/27/2024 and 07/28/2024. Review of August 2024 Nursing Schedule documents no RN coverage was provided at the facility on 08/03/2024, 08/04/2024, 08/17/2024 and 08/18/2024.
On 09/10/24 at 02:01 PM, V1 (Administrator) stated that she is aware there are shifts that have no RN (Registered Nurse) coverage. V1 stated the facility utilizes agency nurses to fill in gaps. V1 stated that she has recently hired RN's and the September schedule has more RN coverage on it.
On 09/13/2024 at 10:47 A.M., V1 stated the facility tries to have RN coverage for all days but it is hard to get RN's to apply. V1 stated that she recently hired more RN's so this should not be an issue moving forward. V1 verified the accuracy of the June 2024, July 2024, and August 2024 nursing schedules.
The Long - Term Care Facility Application for Medicare and Medicaid provided by the facility with a date of 09/11/2024 documents that 32 residents reside at the facility.
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, record review, and interview, the facility failed to store food and maintain the kitchen in safe and sanitary manner to prevent potential contamination. This has the potential to...
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Based on observation, record review, and interview, the facility failed to store food and maintain the kitchen in safe and sanitary manner to prevent potential contamination. This has the potential to all 32 residents residing in the facility.
Findings Include:
On 9/10/24 at 9:45 AM, the initial kitchen tour was completed and the following concerns were noted: the top of the dish machine had a layer of flaky dried matter on top covering the entire surface, a scoop with a handle was found inside the bulk thickener touching the food item, bottom shelves of stainless steel tables were dusty and had old/dried food debris on them, bulk food containers were found to be sticky to touch and dried spills going down the side and food debris on top, a container on the cooks table holding various utensils/seasonings was found to have crumbs and food debris in the bottom, the steam table had dried/black food substance burnt to the bottom of all inserts, the side of the stove was found to have old/dried food spills down the side, the floor under the stove and cooks stainless steel table had spilled food/food debris/paper products underneath them, the floor in the kitchen was upswept with food and paper products scattered everywhere, the stove top is full of old dried spilled food on the burners and under the burners near the flame.
A sample cleaning schedule provided by V4 documents that the following items are to be cleaned after each use: can opener, coffee machine, counters, cutting boards, dining room chairs/tables, dishes, floors, food carts, food preparation appliances, kitchen/dining room floors, mixers, pots/pans, Range/Stove Top, and toaster. Items to be cleaned weekly are: dish machine, oven, garbage containers, garbage disposal, interior of dishwasher, refrigerator, sanitize dining room chairs, storeroom floor and windows. Monthly cleaning schedule includes; clean behind/under major appliances, freezer condenser boils/pans, shelves, stove hood/filters, and vacuum and dust back of appliances. Daily cleaning schedule lists: exterior of dishwasher and appliances, floors, kitchen sinks/faucets, kitchen towels/cloths, microwave and waster disposal.
On 9/10/24 at 11:30 AM, V10 (Cook) was observed to be pureeing the lunch meal. V10 reached into the bulk food thickener and used the scoop without washing his hands or gloves. V10 then set the measuring cup on the table with no clean barrier and then placed the scoop back in the container when he was finished with the pureed pork. At this same time an observation of V10 stirring cherries on the stove with a spatula that he picked up off the stove top burner with no clean barrier between to stir the cherries.
On 9/10/24 at 2:00 PM, V4 (Dietary Manager) stated that they have a cleaning list that is supposed to be completed weekly. V4 stated that for some reason it was not completed this week and she cannot say for sure how long it has been since the stove was cleaned. V4's expectation is that it is cleaned at least once a week. V4 stated that the she will remove the scoops out of the bulk containers and clean them. V4 stated that she will speak with her staff regarding placing food utensils on a clean barrier instead of on a table top and then used to cook the food.
The Long Term Care Applications for Medicare and Medicaid provided by the facility on 9/11/24, documents 32 residents reside in the facility.
May 2024
1 deficiency
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to provide adequate direct care staffing to meet resident's needs. This has the potential to affect all 37 residents living at the facility.
...
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Based on interview and record review, the facility failed to provide adequate direct care staffing to meet resident's needs. This has the potential to affect all 37 residents living at the facility.
Findings include:
On 5/15/24 at 8:30am, V1 (Administrator) stated the current resident census is 37. V1 stated since the facility received a staffing citation from IDPH (The Illinois Department of Public Health) on 4/19/24, the facility signed a contract with a staffing agency. V1 stated the agency currently has nurses available which the facility is utilizing, but no CNAs (Certified Nursing Assistants) are available.
On 5/15/24 at 9:15am, V3 (Power of Attorney/POA) of R1, stated on Tuesday 5/7/24 from about 3:30pm to about 6:00pm, the only CNA working was V11 (CNA). V3 stated during that time, she tried to find V11 for help transferring R1 into the wheelchair from the recliner and back again, but V11 was busy with other residents, and V3 stated she transferred R1 by herself although it takes two people to transfer R1. V3 stated the facility has an ongoing problem with being short staffed. V3 stated because of this, she has decided to have R1 discharged to home with in home care at the end of May 2024.
On 5/15/24 at 10:45am, R4 was alert and oriented. R4 stated there are ongoing issues with staffing. R4 stated call lights can take up to an hour to be answered especially on overnight shift (10pm-6am), and there have been times in past month where only one CNA and one nurse were the only two staff in the building on overnight shift. R4 stated V7 (Registered Nurse [RN]/Minimum Data Set[MDS]/Care Plan Coordinator[CPC]) works as a floor nurse and sometimes as a CNA almost every weekend, in addition to her Monday through Friday job duties.
On 5/15/24 at 11:00am, R2 was alert and oriented. R2 stated call lights take up to an hour especially on evening shift (2:00pm to 10:00pm) and overnight shift on weekends. R2 stated in the past month there have been times on the overnight shift when there is only one nurse and one CNA for the whole building, and she has noticed some of the CNAs working doubles due to the oncoming shift not relieving them.
On 5/15/24 at 11:20am, R3 was alert and oriented. R3 stated she doesn't use the call light so she can't say how long it might take to get answered. R3 stated sometimes on night shift there are only two staff in the building, one CNA and one nurse, and sometimes the CNAs are working doubles because nobody is coming in to relieve them.
On 5/15/24 at 2:20pm, V9 (CNA) stated in the past month, she has at times been the only CNA in the building, usually not for a whole shift but for a partial shift. V9 stated it is very difficult to meet all resident care needs under these circumstances.
On 5/15/24 at 2:40pm, V11 (CNA) stated she has worked at the facility for about 3 weeks. V11 stated on 5/7/24 from 2:00pm to about 5:30pm, she worked alone with V5 (Registered Nurse/RN) because the 2pm to 10pm CNA called in sick. V11 stated it was very difficult to get residents fed, keep them clean and dry, and transfer them with only the help of V5. V11 stated on 5/3/24, she worked from 6:00am to 6:00pm because the evening shift CNA did not show up at 2:00pm.
On 5/15/24 at 3:00pm, V5 (RN) confirmed in the past month, CNAs are occasionally working alone for part of a shift until coverage can be found.
On 5/16/24 at 8:40am, V13 (Licensed Practical Nurse/LPN) stated within the past month, there have been overnight shifts with her and one CNA providing care for the whole building.
On 5/16/24 at 8:50am, V14 (RN/Agency Nurse) stated she has only worked at the facility for a few weeks. V14 stated she works the 6:00am to 6:00pm shift. V14 stated there have been occasions on the weekends when she and one CNA were the only staff in the building.
On 5/16/24 at 9:55am, V7 (RN/MDS/CPC) stated in the past month, there have been instances of one nurse and one CNA taking care of the whole building, Maybe not for a whole shift, but part of a shift. V7 confirmed she has also worked shifts as a CNA during that period because coverage could not be found, as well as working her 40 hour a week position as Minimum Data Set/Care Plan Coordinator and recently added duties of Interim Director of Nursing.
On 5/16/24 at 12:55pm, V1 (Administrator) stated she is the staff member responsible for scheduling. V1 stated if residents were truly concerned about staffing they would be filing grievances, and they haven't. V1 stated she believes the facility is meeting minimum staffing requirements. V1 stated she,Tries to schedule 2 CNAs every 8 hour shift and one nurse every 12 hour shift. V1 stated CNAs working alone with one nurse on night shift is not uncommon. V1 stated, If staff call in, we do our best to get coverage. If I can't get coverage there is nothing I can do.We can't mandate staff to work. There is nothing I can do if the staffing agency doesn't have any CNAs. V1 stated she has just hired three new CNAs.
On 5/16/24 at 1:25pm, V2 (Corporate Regional Director of Operations) stated she does not believe there is a problem with staffing at the facility, she Believes there is a problem with the staff and the residents' perception that they need to have more staff. V2 stated the staffing agency with which they have contracted, Have CNAs available but none are willing to come to the facility.
On 5/17/24 at 7:50am, V4 (Ombudsman) stated in the past month, residents have complained about, Call lights taking too long, and the facility being short staffed, both of which are ongoing problems. V4 stated she intends to increase monitoring at the facility in relation to these issues.
Nursing and CNA Schedules for April and May 2024 documented the following dates with one CNA and one nurse providing care for the entire facility:
5/1/24: 2:00pm to 10:00pm
5/3/24: 2:00pm to 10:00pm and 10:00pm to 6:00am
5/7/24: 2:00pm to 6:00pm
5/13/24: 2:00pm to 5:00pm and 10:00pm to 6:00am
A Room Roster dated 5/15/24 documented a total of 37 residents living at the facility.
Apr 2024
10 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
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide twice weekly showers for 3 of 17 dependent residents (R4, R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide twice weekly showers for 3 of 17 dependent residents (R4, R12, R13) reviewed for ADL (Activities of Daily Living) care in the sample of 17.
Findings include:
1. R4's Face Sheet documented an admission Date of 5/31/17 and listed diagnoses including Anxiety Disorder, Hypertension, and Osteoarthritis. R4's Minimum Data Set (MDS) dated [DATE] documented that R4 requires substantial assistance from staff for bathing or showering. March and April 2024 Shower Sheets documented that R4 received showers on 3/2/24, 3/4/24, 4/4/24, 4/8/24, and 4/11/24, with only one shower given on the week of 3/3/24, no showers given on the weeks of 3/10/24, 3/17/24, and 3/24/24, and only one shower given on the week of 3/31/24.
On 4/3/24 at 9:55am, R4 was alert and oriented. R4 stated she is to get a shower twice weekly, and she was to have gotten a shower on 4/1/24 but didn't because there was no hot water on the North Hall where she lives. R4 stated nobody offered to take her to get a shower on the South Hall, they just told her she wouldn't be getting one.
2. R13's Face Sheet documented an admission Date of 3/29/24 and listed diagnoses including Left Femur Fracture with surgical repair following a fall at home. R13's MDS dated [DATE] documented that R13 requires substantial or maximal assistance from staff for bathing or showering. R13's Shower Sheets documented that R13 received showers on 4/8/24, 4/11/24, and 4/15/24, with no showers given on the week of 3/31/24.
On 4/3/24 at 10:05am, R13 was alert and oriented. R13 stated she was admitted to the facility on [DATE] and has not had a shower, bath, or bed bath since her admission, nor had any staff asked her if she wanted one.
3. R12's Face Sheet documented an admission Date of 6/30/21 and listed diagnoses including Congestive Heart Failure, Major Depressive Disorder, and Osteoporosis. R12's MDS dated [DATE] documented that R12 requires substantial or maximal assistance from staff for bathing or showering. March and April 2024 Shower Sheets documented the only showers R12 received during that time were on 3/2/24 and 3/22/24.
On 4/11/24 at 12:20 pm, R12 was alert and oriented. R12 stated there have been issues with her not getting twice weekly showers because they are short staffed.
On 4/4/24 at 3:00pm, V7, Certified Nursing Assistant (CNA), stated staff have problems getting all the showers done due to insufficient CNA staffing. V7 stated residents are to receive a shower or bed bath twice weekly.
On 4/10/24 at 3:00pm, V13, CNA, stated residents who are scheduled for showers on the 2:00pm to 10:00pm shift often do not get them due to being short staffed. V13 stated residents receive showers twice a week.
On 4/11/24 at 10:25am, V6, Ombudsman, stated R12 had complained to V6 about not getting twice weekly showers.
On 4/12/24 at 1:20pm, V1, Administrator, stated there is no problem with residents not getting twice weekly showers but staff may be forgetting to document them.
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 interview and record review, the facility failed to safely transfer a resident requiring the use of a mechanical lift f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to safely transfer a resident requiring the use of a mechanical lift for 1 of 4 residents (R13) reviewed for transfers in the sample of 17.
Findings include:
On 4/4/24 at 12:05pm, V1, Administrator, identified R13 as a resident who requires mechanical lift transfers.
R13's Face Sheet documented an admission Date of 2/6/24 and listed diagnoses including Cervical Spine Fusion following Wedge Compression Fracture. R13's Minimum Data Set, dated [DATE] documented that R13 is dependent on 2 or more staff members for transfers. R13's Physical Therapy Evaluation dated 2/7/24 documented, Patient is bed bound and uses (a mechanical lift) for transfers.
On 4/10/24 at 3:00pm, V13, Certified Nursing Assistant, stated at times there is only one nurse and one CNA per shift, and that V13 has had to do mechanical lift transfers on residents by herself, which she stated is not policy. V13 stated there have been no negative outcomes associated with these transfers.
On 4/11/24 at 12:50pm, R13 was alert and oriented. R13 stated she requires the use of a mechanical lift for transfers. and stated there have been, A few times, that there has only been one staff member doing the transfer. R13 stated there have been no negative outcomes related to these transfers.
The facility's Mechanical Lift Policy dated 9/8/23 stated, Policy: The mechanical lift may be used to lift and move a resident with limited ability during transfer while providing safety and security for residents and personnel. The mechanical lift must be able to accommodate the weight of the resident. A sling assessment should be completed to ensure the proper size sling is used for each resident. The facility uses the International Standards Organization guidelines when choosing a sling. Two staff members are required when transferring a resident with a mechanical lift.
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
Based on observation, interview, and record review, the facility failed to provide nutritional supplements according to physician's orders for four (R3, R14, R15, R16) of four residents reviewed for n...
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Based on observation, interview, and record review, the facility failed to provide nutritional supplements according to physician's orders for four (R3, R14, R15, R16) of four residents reviewed for nutrition in the sample of 17.
Findings include:
On 4/2/24 at 11:45am, lunch trayline was observed. Although the diet cards of R3, R14, and R16 specified they were to be served a liquid nutritional supplement, none was sent on their trays.
During lunchtime dining observation on 4/3/24 at 11:25am, R3, R15, and R16 did not get supplements on their tray.
R3's Face Sheet documented an admission Date of 8/12/23 and listed diagnoses including Atherosclerotic Heart Disease and Hypertension. R3's Physicians Orders listed an order for a liquid nutritional supplement at breakfast and lunch.
R14's Face Sheet documented an admission Date of 1/25/20 and listed diagnoses including Alzheimer's Disease and Hypertension. R14's Physicians Orders listed an order for a liquid nutritional supplement at lunch.
R15's Face Sheet documented an admission date of 3/31/22 and listed diagnoses including Huntington's Disease. R15's Physicians Orders documented an order for nutritionally fortified pudding at lunch.
R16's Face Sheet documented an admission date of 8/8/23 and listed diagnoses including Arthritis and Hypertension. R16's Physicians Orders documented an order for a liquid nutritional supplement at lunch and dinner.
On 4/2/24 at 12:20pm, V5, Dietary Manager, stated the facility received a food order yesterday but they did not get the nutritional supplements they had ordered.
On 4/3/24 at 9:20am, R3 was alert and oriented. R3 stated she was not aware she was supposed to be getting a supplement as she has never gotten one.
On 4/4/24 at 12:05pm at V1, Administrator, stated staff have the ability to take money out of petty cash and go to the store to buy needed food items such as supplements, and they can also prepare liquid supplements using a recipe.
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 observation, interview, and record review, the facility failed to ensure residents are free from significant medication errors for one of four residents (R7) reviewed for medication errors in...
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Based on observation, interview, and record review, the facility failed to ensure residents are free from significant medication errors for one of four residents (R7) reviewed for medication errors in the sample of 17.
Findings include:
R7's Face Sheet documented an admission Date of 1/27/23 and listed diagnoses including Diabetes Type 2 with Diabetic Neuropathy. R7's April 2024 Physicians Orders documented an order for Humalog U-100 Insulin per sliding scale as follows: If blood sugar is less than 60, call the Physician. If Blood Sugar is 200 to 250, give 2 Units. If Blood Sugar is 251 to 275, give 4 Units. If Blood Sugar is 276 to 300, give 6 Units. If Blood Sugar is 301 to 350, give 8 Units. If Blood Sugar is 351 to 400, give 10 Units. To be given three times daily, dose 1 from 6:00am-10:00am, dose 2 from 11:00am-2:00pm, and dose 3 from 3:00pm-6:00pm. The Physicians Orders also documented an order for Insulin Lispro give 12 units three times daily, dose 1 from 6:00am-10:00am, dose 2 from 11:00am-2:00pm, and dose 3 from 3:00pm-6:00pm
On 4/4/24 at from 7:15am to 8:00am, V8, Registered Nurse, was observed passing morning medications for R3, R9, and R10.
On 4/4/24 at 10:30am V8 was observed coming out of R7's room and going to the medication cart in the hall. When the Surveyor asked V8 if she was still passing the morning medications, she acknowledged that she was. V8 stated she had had multiple distractions and therefore morning medication pass was late. V8 stated she had just given R7 her Insulin Lispro, which should have been given between 7:00 to 7:30am during breakfast. V8 stated R7's blood glucose level at 6:00am was 172 so R7 had not required and Humalog per sliding scale. When surveyor asked her what her next step was, she stated I guess I'll do her accucheck and go from there.
On 4/4/24 at 11:25am, V8 stated she called R7's Physician about the late administration of the insulin, and reported R7's blood glucose at 11:15 was 424. V8 stated the physician ordered her to recheck it in one hour and call back for further instructions.
On 4/4/24 at 11:50am, R7 was observed in the dining room eating lunch and was alert and oriented. R7 agreed her morning insulin had been given very late. R7 stated she felt fine and had no negative effects that she was aware of.
R7's Medication Administration Record for April 2024 documented the following:
4/4/24 Lispro insulin administer 12 units subcutaneously before meals, due at 6:00am to 10:00am. Administered Blood sugar before-172.
4/4/24 Lispro insulin administer 12 units subcutaneously before meals, due at 11am to 1pm. Not administered due to late morning administration. Blood sugar before-345.
4/4/24 Lispro insulin administer 12 units subcutaneosly before meals, due at 3pm-6pm. Administered. Blood sugar before-345.
4/5/24 Lispro insulin administer 12 units subcutaneously before meals, due at 6:00am to 10:00am. Administered. Blood sugar before-164.
Nursing Progress Notes documented the following:
04/04/2024 11:26am.Contacted Physician regarding glucose of 424 related to late administration of morning insulin. Received orders to recheck glucose in one hour and call at time for orders.
04/04/2024 12:50pm Glucose 335. Doctor office closed for lunch. Answering service advised to call after 1pm.
04/04/2024 02:41pm Technical difficulties reaching Physicians office. Glucose 345 at this time. Will try to reach Clinic at this time.
04/04/2024 02:50pm. Contacted with Physician regarding glucose of 345. Orders received to administer scheduled insulin and sliding scale insulin to equal 20 units before supper. Will continue to follow.
On 4/11/24 at 9:50am, when asked by the Surveyor to interview V8, V1, Administrator, stated V8 had reported for work that morning to start her shift and had abruptly walked out, thereby terminating her employment.
The facility's Administration Procedures for all Medications Policy stated, Policy: To administer medications in a safe and effective manner. Procedures, C: Review the 5 Rights three times.
Guidance at The National Institute of Health, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2957754/#:~:text=Most%20health%20care%20professionals%2C%20especially,standard%20for%20safe%20medication%20practices. Defines the 'Five Rights' as the right patient, the right drug, the right time, the right dose, and the right route.
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
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to serve the appropriation portions for a lunch meal according to the menu spreadsheet for four (R3, R9, R13, R14) of eight resi...
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Based on observation, interview, and record review, the facility failed to serve the appropriation portions for a lunch meal according to the menu spreadsheet for four (R3, R9, R13, R14) of eight residents reviewed for nutrition in the sample of 17.
Findings include:
On 4/2/24 at 11:45am, lunch service trayline was observed. V4, Cook, stated regular trays were to receive a 4 ounce portion of the ham and augratin potato casserole entree. V4 used a 4 ounce scoop to portion the casserole for R3, R9, R13, and R14's trays.
The Menu Spreadsheet for lunch 4/2/24 for regular texture diets called for the service of an 8 ounce ladle of the ham and potato casserole.
R3's Face Sheet documented an admission Date of 8/12/23 and listed diagnoses including Atherosclerotic Heart Disease and Hypertension. R3's Physicians Orders listed an order for a regular texture diet.
R9's Face Sheet documented an admission Date of 7/15/21 and listed diagnoses including Hearth Failure and Anxiety Disorder. R9's Physicians Orders listed an order for a regular diet.
R13's Face Sheet documented an admission Date of 3/29/24 and listed diagnoses including left femur fracture with surgical repair. R13's Physicians Orders listed an order for a regular diet.
R14's Face Sheet documented an admission Date of 1/25/20 and listed diagnoses including Alzheimer's Disease and Hypertension. R14's Physicians Orders listed an order for a regular diet.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate direct care staffing to meet resident's needs. Thi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate direct care staffing to meet resident's needs. This has the potential to affect all 36 residents living at the facility.
Findings include:
On 4/2/24 at 8:40am, V1, Administrator, stated she is the staff member responsible for scheduling nursing staff. V1 stated that for each 8-hour shift, one nurse and two CNA's (Certified Nursing Assistants) are scheduled. V1 stated on Easter Sunday, 3/31/24 the facility experienced, A staffing situation. V1 stated the two CNAs and one nurse scheduled for 6am to 2pm called in sick. V1 stated she called other CNA and nursing staff and everybody refused to come in except V9, Registered Nurse/Minimum Data Set Coordinator, V1 stated V1 worked as a CNA, although she is not certified, and she and V9 had to perform all resident care from 6:00am to 2:00pm until staff came in to relieve them. V1 denied there were any negative outcomes associated with this event.
On 4/3/24 at 9:55am, R4 was alert and oriented. R4 stated on Easter morning only V1 and V9 were providing care as none of the other staff had showed up. R4 stated she had to have breakfast in bed, which she did not like, because they did not have time to get her up then, and V1 came in after 8:00am to get her dressed. R4 stated there have been Several times, that there has only been one CNA and one nurse in the building to provide care.
On 4/4/24 at 3:00pm, V7, CNA, stated there have been several occasions where he was the only CNA on duty along with one nurse. V7 stated on 3/31/24 he had worked from 6pm on 3/30/24 to 6am 3/31/24. V7 stated staff called in that morning and V1 and V9 had to do all the resident care on day shift. V7 stated staff have problems getting all the showers done due to insufficient CNA staffing.
On 4/10/24 at 3pm, V13, CNA, stated she has been in the facility's employ since 10/4/23 via her high school's vocational work program. V13 stated she works from about 3pm to 9pm. V13 stated there are normally two CNAs and one nurse on evening shift, but there have been times where it was just her and one nurse. V13 stated residents who are scheduled for showers on the 2:00pm to 10:00pm shift often do not get them due to being short staffed.
On 4/11/24 at 9:50am, V1 stated she has been telling corporate staff that the facility needs more staff, and finally last night at 9pm they gave her the ok to start using a staffing agency again. V1 stated they used one in 2023 but as of January 2024 corporate said they couldn't use them anymore due to budget.
On 4/11/24 at 10:25am, V6, Ombudsman, stated residents have complained about the facility being short staffed.
On 4/11/24 at 12:20pm, R12 was alert and oriented. R12 stated she is not getting showers twice a week because the facility is short staffed.
On 4/3/24 at 10:05am, R13 was alert and oriented. R13 stated she was admitted to the facility on [DATE] and has not had a shower, bath, or bed bath since her admission, nor had any staff asked her if she wanted one.
On 4/11/24 at 12:50pm, R2 was alert and oriented. R2 stated there are times when the facility is shorthanded and as a result only one staff member is available to do her mechanical lift transfers.
On 4/12/24 at 9:25am, V11, Housekeeping Supervisor, stated she has witnessed occasions where there has been one nurse and one CNA in the building to take care of all the residents.
On 4/12/24 at 10:15am, V9 corroborated V1's account of 3/31/24. V9 stated that day was, Horrible. V9 stated thankfully with the holiday, several residents went out with their families and/or had family members come in who fed them. V9 stated there are always holes in the schedule as well as frequent call-ins. V9 stated she and V1 did the best they could and managed to get everything done.
On 4/12/24 at 12:35pm, V10, Social Services Designee, stated there are times when one nurse and one CNA are working. V10 stated if corporate staff would let them start using agency staff again, it would not be a problem.
The Staff Schedule for March 2024 documented that on the following dates on the 10pm to 6am shift, only one CNA was working with one nurse: 3/8/24, 3/18/24, 3/28/24, 3/30/24. The schedule further documented that 2 CNAs and one nurse called in for the 6am to 2pm shift on 3/31/24 and V1 and V9 worked the floor.
A Room Roster dated 4/2/24 documented a total of 36 residents living at 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 F0726
(Tag F0726)
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 trained, competent Certified Nursing Assistant (CNA) on 3/31/24. This has the potential to affect all 36 resident...
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Based on interview and record review, the facility failed to provide the services of a trained, competent Certified Nursing Assistant (CNA) on 3/31/24. This has the potential to affect all 36 residents living at the facility.
Findings include:
On 4/2/24 at 8:40am, V1, Administrator, stated on Easter Sunday, 3/31/24 the facility experienced, A staffing situation. V1 stated the two CNAs and one nurse scheduled for 6am to 2pm called in sick. V1 stated she called other CNA and nursing staff and everybody refused to come in except V9, Registered Nurse/Minimum Data Set Coordinator. V1 stated V1 worked as a CNA, although she is not certified as a CAN. V1 stated she and V9 had to perform all resident care duties from 6:00am to 2:00pm. V1 denied there were any negative outcomes associated with this event. V1 acknowledged she performed transfers and incontinence care with no training or experience in personal care. V1 denied feeding residents or assisting with resident medications or treatments.
On 4/3/24 at 9:55am, R4 was alert and oriented. R4 stated on Easter morning only V1 and V9 were providing care as none of the other staff had showed up. R4 stated she had to have breakfast in bed, which she did not like, because they did not have time to get her up then, and V1 came in after 8:00am to get her dressed.
On 4/4/24 at 3:00pm, V7, CNA, stated on 3/31/24 he had worked from 6pm on 3/30/24 to 6am on 3/31/24. V7 stated CNA staff called in that morning and V1 and V9 had to do all the resident care on day shift.
On 4/12/24 at 10:15am, V9 corroborated V1's account of 3/31/24. V9 stated that day was, Horrible. V9 stated thankfully with the holiday, several residents went out with their families and/or had family members come in who fed them. V9 stated she and V1 did the best they could and managed to get everything done and there were no negative outcomes. V9 denied that V1 fed residents or assisted with resident medications or treatments.
An undated CNA Job Description stated, The overall purpose of the Certified Nursing Assistant position is to provide each of the assigned residents with routine daily nursing care and services in accordance with the residents' plan of care. Education and experience requirements: State certification as a Certified Nursing Assistant.
A Room Roster dated 4/2/24 documented a total of 36 residents living at 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 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 full time Director of Nurses/DON. This has the potential to affect all 36 residents living at the facility.
Findi...
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Based on interview and record review, the facility failed to provide the services of a full time Director of Nurses/DON. This has the potential to affect all 36 residents living at the facility.
Findings include:
On 4/2/24 at 8:40am, V1, Administrator, stated V2, former DON, walked out 3/24/24, giving no notice of termination of employment. V1 stated V2 had stated she was tired of having to frequently work the floor as a nurse in addition to her DON duties. V1 stated there have since been no interested applicants. V1 stated the facility's other nurses, as well as corporate staff, have had to take over some of the DON duties. V1 stated V2 acted as the facility's Infection Control Preventionist and no staff has been assigned to take over those duties. V1 stated V2 is still employed by the facility as a PRN (as needed) staff nurse.
On 4/11/24 at 3:30pm, V2 stated she left the position on 3/24/24 because she was tired of not being able to spend time with her family due to her DON duties as well as working the floor when there were call ins. V2 stated she is still employed by the facility PRN as a staff nurse.
On 4/12/24 at 10:15a, V9, Registered Nurse/Minimum Data Set Coordinator, stated she is not sure who is performing the DON duties, but it is not her. V9 stated she is performing her own duties as well as having to work the floor at times, and she has no interest in applying for the DON position due to staffing issues.
An undated DON Job Description documented, The Director of Nursing will recognize and respond to the nursing and health care of residents. This person will effectively manage the nursing department regarding residents, employees, families' visitors, and the public. The Director of Nursing will make prompt and accurate nursing assessment of care and management judgments. This individual will perform the essential functions of the job in a manner which benefits residents of the facility and complies with business necessity without causing undue hardship. The Director of Nursing position will require an individual who is dependable, self-sufficient, and can easily multi-task. Qualified candidates will plan, organize, develop, and direct the overall operation of the nursing department in accordance with local, state, and federal guidelines and regulations. The position is charged with responsibility to ensure the quality of care is delivered consistently to the resident population; and performs related work as required.
A Room Roster dated 4/2/24 documented a total of 36 residents living at 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 interview and record review, the facility failed to provide sufficient kitchen staff to carry out nutrition services on 3/26/24. This has the ability to affect all 36 residents living at the ...
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Based on interview and record review, the facility failed to provide sufficient kitchen staff to carry out nutrition services on 3/26/24. This has the ability to affect all 36 residents living at the facility.
Findings include:
On 4/2/24 at 9:25am, V1, Administrator, stated the facility's long term Dietary Manager died suddenly on 2/15/24. V1 stated her replacement started on 3/28/24. V1 stated in addition to the new Dietary Manager, there are two full time cooks, one morning and one afternoon. V1 stated the kitchen is fully staffed based on their census according to their corporation's guidelines. V1 stated on 3/26/24, Tuesday, one of the cooks called in and the other cook was scheduled to come in at 11:30 and could not come in early, so V1 cooked breakfast that morning. V1 stated she prepared scrambled eggs and provided a choice of cereal as well as donuts, which she stated were not on the menu that day but that combination had been on the menu previously as a Dietician approved meal. V1 stated for lunch she ordered pizza and breadsticks and served chocolate chip cookies which had been the resident choice meal to be served later in the month. V1 stated she checked temperatures of the food for safe holding and serving and documented them according to facility policy, prepared purees according to recipe, and portioned food according to the spreadsheet. V1 stated fluids were provided per resident preference, including thickened liquids following the instructions on the thickener container. V1 acknowledged she did not have certification in food sanitation.
The Menu for 3/26/24 documented that the breakfast meal was to have been choice of cereal, pancakes, scrambled eggs, toast, jelly, margarine,, juice, milk, coffee, and tea. The lunch meal was to have been Mostaccioli, broccoli, garlic toast, and chocolate chip cookie.
The Dietary Schedule dated 3/26/24 documented that the morning cook called out sick and was replaced by V1.
An undated Culinary Associate Job Description stated, To be qualified for this position, you must maintain a current Food Services Sanitation certificate and have one (1) year job related experience including food preparation, full-line menu items and therapeutic diets.
A Room Roster dated 4/2/24 documented a total of 36 residents living at 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 check the dish machine and surface cleaning agent for the correct proportion of a sanitizing agent, failed to maintain equipm...
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Based on observation, interview, and record review, the facility failed to check the dish machine and surface cleaning agent for the correct proportion of a sanitizing agent, failed to maintain equipment, food contact surfaces and storage areas in a clean and sanitary manner, and failed to store foods to prevent potential contamination. This has the potential to affect all 36 residents living in the facility.
Findings include:
On 4/2/24 at 11:15am, all cabinets in the kitchen were noted to be covered on the outside with a layer of grime. The floors throughout the area were sticky and had dried food debris around the and under the stove and under prep tables. The steam table held food debris and grime in its empty compartments. All drawers in the kitchen contained food debris. Shelves under prep tables had a thick layer of grime and also food debris. The cooler doors were dirty and grimy with food debris in the bottom. The microwave was dirty inside and out, the turntable had what appeared to be a layer of baked on oatmeal, and there was food debris under the turntable. There was a grimy open bin on one of the prep tables containing a bag of coating mix, a bag of coconut, and a bag of orange drink mix, all open to air. The coconut bag had food debris on it, the drink mix showed signs of having been wet, and there was food debris in the bottom of the bin. There was a layer of grime, grease, and dried food debris on the stove including rotini pasta pieces. There was a thick layer of grime and food debris on top of the dish machine. There was an open bin of plastic silverware under a prep table, and the shelf it was sitting on was grimy.
On 4/2/24 at 11:18am, V3, Cook, was observed checking the temperature of ham and potato casserole. V3 picked up a thermometer which was sitting on the wooden prep table without its sheath, and without cleansing the thermometer, placed it in the casserole. Upon removing the thermometer, he wiped it clean using the oven mitt he was wearing and placed it back on the prep table. At 11:25am, he placed the thermometer back into the casserole without cleansing it, and again wiped the thermometer on the oven mitt.
On 4/2/24 at 12:55pm, V5, Dietary Manager, was asked by the Surveyor to check the level of sanitizer in the sanitizing bucket which is used for cleaning surfaces. V5 placed a Ph (Potential of Hydrogen) test strip in the water and there was no change in color. The Surveyor asked what that indicated, and what type of chemical is being used for sanitizing surfaces and dishware, and V5 stated she was not sure. The Surveyor then asked for an observation of V5 testing the sanitizer in the dish machine, and V5 stated she was not sure how to do that. V5 stated if there is a kitchen cleaning schedule she does not know where it is.
On 4/2/24 at 1:10pm, V3, Cook, stated he was not sure how to check the dish machine or the sanitizer bucket and stated this is not something he does, and nobody has ever trained him how to do it. V3 stated if there is a kitchen cleaning schedule, he is not aware of it.
On 4/4/24 at 10:10am in the dry food storage area, shelving and floors were noted to be covered with a layer of grime. There was a box of powdered sugar, a bag of corn meal, a box of cornstarch, and box of lasagna noodles all being stored open to air.
An undated Cleaning and Sanitation Policy stated,The kitchen will be maintained in a clean and sanitary condition. The state and/or federal food code will be maintained on file within the food service department,
and will be the basis of all sanitation and food safety practices.
An undated Machine Ware Washing Policy documented, Dishes, glassware, cups, utensils, and other dishware are washed, rinsed, and sanitized after each use. The machine for ware washing will be checked prior to each meal period to ensure it is functioning properly. Employees that use the ware washing machine will be responsible for knowing how to use the machine, document its use, and and properly maintain it after use. Steps include: Check that the wash cycle is maintaining proper temperature. Check sanitizer concentration using appropriate test strips.
A Room Roster dated 4/2/24 documented a total of 36 residents living at the facility.
Feb 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide timely and thorough incontinence care for a dependent resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide timely and thorough incontinence care for a dependent resident who requires assistance with toileting and hygiene for one of four residents (R1) reviewed for incontinence care in the sample of four.
Findings include:
R1's Face Sheet documented an admission date of 1/31/24 and listed diagnoses including Cerebral Infarction, Diabetes Type 2, and Transient Cerebral Ischemic Attacks. R1's 2/5/24 MDS (Minimum Data Set) documented a Brief Inventory for Mental Status Score of 8, indicating R1 has moderate deficits in cognitive functioning. The same MDS documented that R1 is always incontinent of both bowel and bladder and is dependent on staff for toileting and hygiene. R1's Care Plan dated 2/12/24 documented a problem area,Resident experiences bladder and bowel incontinence, with a corresponding intervention, Provide incontinence care after each incontinent episode.
On 2/28/24 at 8:55am, V5, Family Member, stated R1 was admitted to the facility on [DATE]. V5 stated R1 previously had a stroke, has periods of confusion, and is dependent on staff for activities of daily living. V5 stated V5 was informed by V6, Family Member, that when V6 visited R1 on 2/21/24, V6 found R1 lying in her bed, covered with dried feces. V5 stated V6 is R1's Power of Attorney, but they both share responsibility for R1's care.
On 2/28/24 at 10:20am, V1, Administrator, stated on 2/21/24, V6 approached V2, Director of Nurses, on 2/21/24 to say that R1 had been covered in feces. V1 stated V3, R1's CNA(Certified Nursing Assistant) that afternoon, stated to V2 that he did not do mandatory beginning of shift rounds with the outgoing day shift CNA,V4. V1 stated later that afternoon, V3 was written up for not performing his job duties, which V3 refused to sign, and V3 left the facility, upset. V1 stated V3 said V4 had assured him all the residents under her care were clean and dry when she left at 2:00pm. V1 stated when V3 became aware R1 was soiled, he immediately cleaned her up, and R1 got a shower later that afternoon. V1 stated V3 has been employed by the facility since mid December 2023, and there have been no previous issues with his performance.
On 2/28/24 at 10:50am, V2 stated she requires the outgoing and oncoming CNAs to round together at shift change to make sure residents are clean and dry, and V3 admitted he had not done shift change rounds with V4. V2 stated she re-educated V3 and V4 about this requirement. V2 stated she interviewed R1, who did not remember the incident.
On 2/28/24 at 11:30am, R1 was in the dining room awaiting lunch service. R1 appeared adequately groomed and was odor free. R1 was alert only to herself. R1 stated she did not recall the above referenced incident that occurred on 2/21/24.
On 2/28/24 at 11:45am, V6 stated he visited R1 on 2/21/24 at about 4:00pm to 4:15pm. V6 stated when he arrived, R1 had dried feces all over her, the bed, her hands, and the wall and was crying. V6 stated he found V3 and told V3 R1 needed to be cleaned and changed immediately. V6 stated he then informed V7, Minimum Data Set Coordinator, about what happened and that he was very unsatisfied with the care.
On 2/28/24 at 12:50am, V4 stated on 2/21/24 she worked 6:00am to 2:00pm. V4 stated she changed R1 about 1:00pm after R1 had been incontinent of feces. V4 stated at 2:00pm shift change, R1 had again been incontinent of feces and V4 was changing her when V3 came in and helped her. V4 stated she and V3 did not do shift change rounds on anybody but R1.V4 stated although she had not done anything wrong, she got, Talked to about making sure they check and change everybody every two hours.
On 2/28/24 at 1:45pm, V3 stated on 2/21/24 he came in at 2:00pm to cover for another staff member, as V3 usually works 10:00pm to 6:00am. V3 stated when he arrived at 2:00pm, he helped V4 change R1. V3 stated at 4:00pm he went in to check on R1, and found V6 in the room. V3 stated V3 found that R1 had been incontinent of feces and so he changed her. V3 stated the feces was not on the wall or the bed, but there was some on her hands, which he cleaned. V3 stated he then left and went to take care of other residents. V3 stated shortly thereafter,I got pulled into the office by (V2) and (V7), they said there was a complaint that I left (feces) on (R1's) fingers and that (V6) had tried to wipe it off and it was dry. V3 stated he refused to sign the document because he hadn't done anything wrong. V3 stated he left at 5:00pm, not because he was angry, but that was when he was supposed to leave, and he came back at 10::00pm to work his normal shift. V3 stated he did not get re-educated after this incident. V3 stated dependent residents are to be checked and changed every two hours. V3 stated administration has since implemented a shift change check off list which both the outgoing and oncoming CNAs sign off on.
On 2/28/24 at 2:10pm, V6 was again interviewed. V6 stated on 2/21/24, he went into R1's room at about 4:30pm, and nobody was in the room except R1. V6 stated R1 was in bed, with dried feces on her hands, clothes, bed, and the adjacent wall. V6 stated he found V3 and told him R1 needed to be cleaned up. V6 stated he then stepped out into the hall while this took place. V6 stated when he returned to R1's room, V3 was still in the room but had finished cleaning R1. V6 stated R1 still had feces on her shirt, and he had to ask V3 to change it. V6 stated after V3 left, V6 noticed there was still dried feces on R1's hands, so V6 cleaned R1's hands which he stated was difficult since it was dried on. V6 stated, By then they were getting ready to start supper and I guess they were going to be ok with letting her eat supper with feces on hands.
On 2/28/2 at 2:30pm, V7 stated on 2/21/24 at about 4:00pm, she was approached by V6, who stated R1 had a bowel movement and had dried feces on her hands. V7 stated V6 didn't say anything about R1's clothing, bed, or wall being dirty, nor about her hands still being dirty. V7 stated she and V2 then addressed with V3 the importance of between shift rounds, but V3 did not feel he had done anything wrong, and that V3 stated he had been checking on her every two hours and R1 must have been incontinent in between checks.
V3's Employee Disciplinary Action document dated 2/21/24 stated,Resident had dried feces per family. Staff not performing job duties.
A Grievance/Concern/Complaint Form dated 2/21/24 documented,(V6) entered room to find resident had bowel movement and needed cleaned up and showered. Recommendation/Action Taken: Resident cleaned and showered. Staff disciplined related to care concern.
A Toileting Policy dated July 2014 documented,It is the policy of (the facility) to make sure all of our residents toileting needs are met. Procedure: 2. Check each resident at least every two hours and/or as needed and change if found incontinent.
An undated Residents Rights Policy stated, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.
Jul 2023
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to correctly code restraint use for 1 (R11) of 2 resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to correctly code restraint use for 1 (R11) of 2 residents reviewed for Minimum Data Set (MDS) restraint coding in the sample of 21.
Findings Include:
Review of R11's Minimum Data Set, dated [DATE] and documented as being a quarterly review assessment noted in section P0100 Physical Restraints, A. Bed Rail is documented as 1. Used less than daily.
On 07/19/23 at 01:58 PM, R11 was observed lying in bed sleeping. No bed rails or other restraint devices of any kind were observed being utilized or in place on her bed.
Review of R11's current and active Physician Orders documents no order for a bed rail or any other restraint use.
On 07/20/23 at 11:24 AM, V4 (MDS / Care Plan Coordinator) acknowledges that R11's 6/20/23 MDS did have an error in coding, and R11 does not utilize a bed rail as a restraint. V4 stated she will get the coding error corrected.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to refer a resident for a Level II Preadmission Screening and Resident Review (PASARR) for 1 of 2 residents (R22) reviewed for PASARR's in the ...
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Based on interview and record review the facility failed to refer a resident for a Level II Preadmission Screening and Resident Review (PASARR) for 1 of 2 residents (R22) reviewed for PASARR's in the sample of 21.
Findings Include:
R22's PASARR, as provided by the facility, dated 11/1/19 documents no Developmental Disability or Mental Illness diagnoses during this evaluation, therefore not requiring a level II screening.
Review of R22's Continuity of Care with a created date of July 20, 2023 documents active diagnosis of Delusional Disorders with an effective date of 05/27/2022. This same document also lists a diagnosis of Major depressive disorder, single episode, moderate with an effective date of 06/23/2023. No PASARR re-evaluation is documented as being completed after these diagnoses were added.
On 07/20/23 at 09:28 AM, V5 (Social Services) stated that residents only receive a PASARR screening when they are admitted to the facility, and are not referred back for re-evaluation should new diagnoses be added. V5 confirms that R22 was not referred back for a PASARR Level II screening after a having serious mental disorder diagnoses added.
Review of the facility policy titled Resident Assessment: Coordination with PASARR Program with a revision date of October 2017 stated, 6. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the State mental health or intellectual authority for a level II resident review.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide the required supervision to prevent a fall fo...
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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 provide the required supervision to prevent a fall for 1 of 7 residents (R31) reviewed for falls in the sample of 21.
Findings include:
On 7/28/23 at 12:45pm, R31 was observed in the dining room during lunch service. R31 was in a specialty high backed wheelchair, and was being fed by staff. R31 was noted to be contracted in all limbs and was very spastic, making frequent involuntary jerking movements.
R31's Face Sheet listed an admission Date of 3/31/22, and diagnoses including Huntington's Disease and Dysphagia.
R31's Fall Risk assessment dated [DATE] documented that R31 is at high risk for falls. R31's Minimum Data Sets dated 1/6/23, 4/5/23, and 6/15/23 all documented that R31 requires extensive assistance from at least 2 staff for transfers, locomotion on the unit, and personal hygiene, and is totally dependent on two plus staff for bathing. R31's Care Plan with a start date of 7/11/22 and the most recent review date of 7/19/23 documented, Resident at risk for falls. History of falls. Relies on staff for all transfers. (Specialty) Wheelchair is primary mode of transportation. Primary diagnosis Huntington's disease. She has uncontrolled movement of legs and arms, with a corresponding intervention,Never leave resident unattended in the shower chair, which was added on 1/28/23.
A Nursing Progress Note for R31 dated 1/28/23 documented, At (9:33pm), this nurse was alerted to resident's room by CNA (Certified Nursing Assistant). CNA had just given resident a shower and was needing assistance transferring her to bed from the shower chair. CNA had turned her back on resident long enough to holler out the door and resident tipped shower chair, landing resident on the floor .
A Fall Investigation report for R31 dated 1/28/23 documented,Root Cause Analysis: At (9:33pm) this nurse was alerted to resident's room by CNA. CNA had just given resident a shower and was needing assistance transferring her to bed from the shower chair. CNA had turned her back on resident long enough to holler out the door and resident tipped shower chair, landing resident on the floor. Resident was assessed, no bumps or bruises noted, no shortening or internal/external rotation. Resident was asked if she was okay and she was able to verbalize that she was. When asked if anything hurt she verbalized no .She is in bed now resting comfortably and will continue to monitor. The Investigation documented that physical exam showed no injuries, that R31's vital signs were within normal limits, and that her Primary Care Physician and Power of Attorney were notified.
On 07/21/23 at 08:35 AM, V1, Administrator, stated that after the above referenced fall, staff were re-educated to not leave R31 unsupervised while in the shower chair, and to always have at least two staff members are with R31 during showers.
The facility's Fall Prevention Management Policy dated 3/15/18 documented, It is the policy of (the facility) to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a residents medication regimen was free from unnecessary med...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a residents medication regimen was free from unnecessary medications for one resident of five residents (R4) reviewed for unnecessary medications in the sample of 21.
Findings include:
R4's Face Sheet documented an admission date of 2/1/23, a date of birth indicating R4 is [AGE] years of age, and diagnoses including Hypertension, Diabetes Type 2 and Developmental Disorder of Scholastic Skills, unspecified.
R4's Behavior Tracking for May, June, and July 2023 documented that R4 has displayed no behaviors in that time. R4's July 2023 Physician Order Sheet documented an order for Zoloft 50 mg (milligrams) one tablet daily, Seroquel 25mg one tablet every morning, and Seroquel 50mg one tablet at bedtime, all with a start date of 2/1/23. R4's AIMS (Abnormal Involuntary Movement Scale) dated 5/10/23 documented that R4 is not experiencing any side effects from atypical antipsychotic use.
R4's Psychiatric Initial Diagnostic Interview dated 2/16/23 authored by V7, Advanced Practice Nurse, Psychiatry, documented,(R4) .was admitted to the facility on [DATE] .He has a history of Major Depressive Disorder, as well as a developmental disorder. His sister reports that he is intellectually disabled, she reports this has been (present) his whole life .He is currently on Seroquel 25mg in the morning and 50mg at bedtime .She reports he has been on these medications for years. Assessment: (Diagnoses): Major Depressive Disorder, Recurrent, Unspecified (and) Developmental Disorder of Scholastic Skills .Recommend that he continue his current psychotropic medications. R4's Medical Record documented that R4 saw V7 on 2/23/23, 3/10/23, 3/29/23, 4/27/23, 5/19/23, 6/8/23, and 6/15/23, each evaluation documenting no changes in diagnoses, treatment, or medications.
According to https://pdr.net/drug-summary/Seroquel-quetiapine-fumarate-2185.6108, Indications (for use): Bipolar Disorder Schizophrenia Neurocognitive symptoms associated with Borderline Personality Disorder Refractory Obsessive Compulsive Disorder Refractory Depression. Elderly patients (over 65) may be more sensitive to the sedative, anticholinergic, orthostatic effects, and QT prolongation associated with quetiapine. There was no indication listed for the treatment of behaviors related to Intellectual/Developmental Disability.
On 7/19/23 at 9:45am, R4 was interviewed in his room. R4 was alert and oriented to person place and time. R4 presented as developmentally delayed and with a flattened affect and lack of general fund of knowledge. R4 was pleasant and cooperative with the interview.
On 7/21/23 at 9:32am,V1, Administrator, stated that R4 has displayed no maladaptive behaviors at the facility. V1 stated V7 quit 3 weeks ago and has not yet been replaced. V1 stated V7 was made aware numerous times that R4 did not have diagnoses supporting the use of Seroquel, but V7 stated she did not want to add a mental health diagnosis such as Schizophrenia for R4 as she feared the Department citing a deficiency at F658, which V1 stated V7 felt would reflect negatively on V7.
The facility's Antipsychotic Medication Policy dated October 2017 documented, Antipsychotic medication therapy shall be used only when it is necessary to treat a specific condition, based on a comprehensive assessment of the resident. Only those medications required to treat the resident's assessed condition are being used, reducing the need for and maximizing the effectiveness of medications are important considerations for all residents.
CONCERN
(F)
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 have a Registered Nurse (RN) for at least 8 consecutive hours, 7 days a week. This has the potential to affect all 38 residents who reside ...
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Based on interview and record review, the facility failed to have a Registered Nurse (RN) for at least 8 consecutive hours, 7 days a week. This has the potential to affect all 38 residents who reside at this facility. This past non-compliance occurred between 1/14/23 and 5/20/23.
Findings include:
On 7/20/2023 at 2:00 pm, V6 (Regional Director of Operations) stated that for the following dates in January 2023 (1/14/23 and 1/28/23), February 2023 (2/25/23), and May 2023 (5/20/23) there was no Registered Nurse (RN) coverage for those days.
On 7/20/23 at 2:15 pm, V1 (Administrator) stated that the nursing agency RN's had picked up these shifts to cover the hours and then did not show up for the actual shift. The facility at this time did not have many RN's on staff and many were working on finishing their schooling. As of July 1, 2023 the facility has only RN's on staff with the exception of a new hire (Licensed Practical Nurse) as of 7/20/23.
A facility document titled Resident Census and Condition dated 7/20/23 documents there are currently 38 residents living in the facility.
Prior to the survey date, the facility implemented the following actions to correct the deficient practice:
1. The facility currently has 8 full time RN's, and Minimum Data Set Coordinator (MDS) and the Director of Nursing which are RN's.
2. A Quality Assurance Performance Improvement Meeting was held on 1/26/23 and 4/27/23 to discuss the reason the facility had days of no RN coverage, which included the low amount of RN's on staff and the agency staff not showing up for shifts they had signed up for.
It was determined the facility needed to have more RN's on staff.
3. Schedules show since the last date of 5/20/23 without RN coverage, they have not had this issue. The Licensed Practical Nurses (LPN's) on staff have all became RN's with the exception of a new hire providing more room to schedule a nurse to cover 8 consecutive hours 7 days a week.
Aug 2022
7 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop, revise and/or implement care plan interventio...
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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 develop, revise and/or implement care plan interventions and to follow facility policy to maintain acceptable parameters of nutritional status for 3 of 13 residents (R9, R10, R12) reviewed for weight loss in the sample of 27. This failure resulted in and R9 experiencing an 11.1 percent weight loss in 3 months.
Findings include:
1. R9's Care Plan documents an admission date of 2/21/22 and lists diagnoses including, but not limited to: Alzheimer's disease, unspecified (Primary), Dementia in other diseases classified elsewhere with behavioral disturbance (Admission), Psychotic disorder with hallucinations due to known physiological condition, Restlessness and agitation, Anxiety disorder, unspecified, Essential tremor, Essential (primary) hypertension, Constipation, unspecified, Hyperlipidemia, unspecified, Vitamin D deficiency, unspecified, Mixed incontinence, Personal history of COVID-19, Nausea with vomiting, unspecified.
R9's Minimum Data Set (MDS) dated [DATE], in Section C, documents R9 has a Brief Interview for Mental Status (BIMS) score of 7, indicating R9 can communicate but has impaired cognition and impaired short term and long-term memory. R9's MDS documents in Section G, Eating; R9 is extensive assist of 1 person for eating.
R9's Care Plan also documents a problem category of Nutritional Status with a start date of 8/18/22 and states Resident has experienced weight loss R/T (related to) decreased appetite and dementia. Currently on regular diet with supplements BID (twice per day). Relies on staff for feeding and fluid intake. Other diagnosis that may affect weight loss include agitation, anxiety, essential tremor, age. Approaches dated 8/18/22 include to encourage oral intake of food and fluids, to provide physical assistance for meals and provide supplements as ordered.
There was no reproducible evidence presented from the facility that weight loss had been addressed in R9's care plan as an issue prior to 8/18/22.
R9's Physician's Order for August 2022 documents R9 is to receive a Regular diet and a dietary supplement twice daily at 10 AM and 6 PM. On 08/16/22 between 9:30 AM and 3:00 PM, continuous observation of the cart with R9's dietary supplement was noted by the nurse's station as not being distributed, and R9 was not observed to receive her 10AM dietary supplement.
On 8/16/22 at 12:15 PM, R9 was waiting on her noon tray. At 1:10 PM, R9 received her tray. At this time, R9 was asleep in her recliner and no staff were observed to make sure R9 was awake to eat her noon meal. At 1:20 PM, V9 (Certified Nurse Aide/CNA) came in to assist R9 with her meal. R9 stated the meal was cold and she didn't feel like eating. R9 was not encouraged to eat, offered a different tray, nor offered to reheat the cold food.
R9's Weight Record documents the following weights: 131.2lbs (pounds) on 6/1/22, 127.4lbs on 7/1/22, and 116.6lbs on 8/11/22. This documents a 14.6 pound weight loss since June 2022, which calculates to an 11.1% weight loss in 3 months.
R9's Registered Dietician Note dated 8/18/22 documents: Current weight of 117# (pounds) is down 10#-1 mo, down 18#-3 mo, down 8#-5 mo. Res is within weight standards per BMI (Body Mass Index) of 21.32. No recent labs. No open skin areas per report. Resident is on regular diet and meal intake average varies. Receives supplement 2x daily. Recently went hospice care. Related to weight loss and varied intakes, receives super cereal at breakfast. Continue to monitor.
2. R10's Care Plan documents an admission date of 7/26/22 and lists diagnoses including, but not limited to: Alzheimer's disease, unspecified (Primary), Unspecified dementia with behavioral disturbance, Anxiety Disorder, unspecified, Chronic kidney disease, stage 3 unspecified, Transient cerebral ischemic attack, unspecified, Anemia, unspecified, Essential (primary) hypertension, Vitamin D deficiency,
unspecified, Other specified abnormalities of plasma proteins, Nontoxic single thyroid nodule, Mixed hyperlipidemia, Gastro-esophageal reflux disease without esophagitis.
R10's MDS dated [DATE] documents in Section C that R10 has a BIMS score of 5, indicating R10's cognition is severely impaired, and she has short term and long-term memory impairment. This same MDS documents in Section G, Eating, that R10 requires supervision and setup assistance from the staff.
R10's Care Plan also documents a problem category of Nutritional Status with a start date of 7/26/22 and states Resident has experienced weight loss R/T (related to) fair/poor food and fluid intake. Currently on mechanical soft diet. Receives supplements. Has own teeth. Relies on staff for set up and cueing during meals. Other factors include dementia, anemia, GERD, age. Approaches dated 7/26/22 include to Provide setup help and cueing assistance for meals encourage oral intake of food and fluids, and provide supplements as ordered.
On both 8/15/22 and 8/16/22 at 12:30 PM, R10 was observed sitting in her recliner asleep, with her noon meal tray on the bedside table that had been placed in front of her. R10's meal tray sat in front of R10 for over 40 minutes during continuous observation and no staff went into R10's room to wake her up and encourage R10 to eat her lunch. R10's tray went back to the kitchen untouched both days on 8/15/22 and 8/16/22.
R10's Weight Record documents the following weights: 125lbs in February 2022, 121lbs on 4/1/22, 118lbs on 5/1/22, 118.6lbs on 6/1/22, and 115lbs on 7/1/22. These records document that R10 had a 6lb weight loss in 4 months and a 10lb weight loss since February 2022 (8% loss in 6 months).
3. R12's Care plan documents an admission date of 5/14/21 and lists diagnoses including, but not limited to: Parkinson's disease (Primary), Unspecified dementia with behavioral disturbance (Admission), Unspecified macular degeneration, Depression, unspecified, Hallucinations, unspecified, Essential (primary) hypertension, Unspecified glaucoma, Anemia, unspecified, Other constipation, Nausea.
R12's MDS dated [DATE] documents in Section C that R12 has a BIMS score of 8, indicating R12 can communicate, but has impaired short term and long term memory. This same MDS documents in Section G, Eating, that R12 is extensive assist of 1 person with her meals.
R12's Care Plan also documents a problem category of Nutritional Status with a start date of 8/18/22 and states Resident has experienced weight loss. Currently on mechanical soft diet with supplements. Has dentures. Relies on staff for food and fluid intake. Other factors may include poor intake, Parkinson's, dementia, glaucoma, macular degeneration, depression, hallucinations, hypoparathyroidism, anemia. Approaches dated 8/18/22 include to encourage oral intake of food and fluids, to provide physical assistance for meals and provide supplements as ordered.
There was no reproducible evidence presented from the facility that Nutritional Status had been addressed in R12's care plan as an issue prior to 8/18/22.
On 8/16/22 at 1:00pm, R12 received her noon (lunch) tray. V9 (Certified Nurse Aide/CNA) was assisting R12 to eat, but R12 stated she didn't like the food because it was cold. R12's food was not offered to be re-heated, and she didn't receive another tray. R12 only ate 35% her noon meal.
On 8/16/22 at 1:25 PM, V9 and V10 (CNAs) both stated they try to pass out the trays as soon as they come out, and it takes a long time to assist residents who need to be fed or encouraged to eat their meal. V10 stated when there are only 2 people passing out trays and assisting with the meals, it's hard to get everyone fed before their food is cold, and it takes time to go to the kitchen for another tray.
On 8/18/22 at 2:30 PM, V1 (Administrator) stated she was wanting to get staff members who weren't Certified Nurse Aides or Nurses trained so they could assist with the meals. V1 stated it's hard for just 2 or 3 Certified Nurse Aides to get all of the feeding assistance done. V1 stated if other staff members could assist with the mealtimes, the residents who need help with their meals would receive that service efficiently, and the meals wouldn't be cold.
The facility's undated policy on Assistance with Meals documents in line #3. Residents Requiring Full Assistance: a. Nursing staff will remove food trays from the food cart and deliver the trays to each resident's room. b. Nursing staff will feed those residents needing full assistance. c. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity. Line #5. For all residents, hot foods shall be held at a temperature of 136 degrees or above until served. Cold foods shall be held at 40 degrees or below until served. Nursing and Dietary Services will establish procedures such that delivery of food to serving areas accommodates this requirement.
The facility's policy on Weight Management Program dated 7/2014 documents under Policy; It is the policy of the facility to manage resident weight through prevention, assessment, and implementation and evaluation of interventions. Line #2; On the first through the fifth days of the month the Certified Nurses Aide will take the weights for all monthly weights. Weekly weights will be obtained for any resident determined by the Weekly committee. Line #10; The Director of Nursing or his/her designee will list all residents who have had a weight loss or gain greater than five pounds, poor intake, pressure ulcers, chewing or swallowing problems, receive tube feedings, all new admissions, all readmissions, or abnormal lab results will be given to the registered dietician for assessment and recommendations.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to follow the physician ordered diet for three (R1, R15 and R34) of 12 residents in a sample of 27.
Findings Include:
The facilit...
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Based on observation, interview and record review, the facility failed to follow the physician ordered diet for three (R1, R15 and R34) of 12 residents in a sample of 27.
Findings Include:
The facility diet spreadsheet dated, Cycle Day: 9, Monday 06/06/2022 documents: Regular diet: oven baked fish 1 fillet, parsley noodles 4 ounces, tossed salad 1 cup, breadstick 1 each and strawberry ice cream 1 each. Mechanical soft diet: ground oven fish #6 (4.75 ounces) scoop with 2 ounces gravy, parsley noodles 4 ounces, shredded lettuce 1 cup, breadstick 1 each, strawberry ice cream. The Pureed diet: Pureed fish #8 scoop, pureed parsley noodles #8 scoop (0.5 cup), pureed green beans #16 scoop (2 ounces), pureed bread 2/3 slice and vanilla pudding #8 scoop.
On 08/15/22, in reference to the menu above dated 06/06/22, V8 (Dietary Manager) stated that it is the correct menu, it is on the next cycle of the menu, that is why the date is not correct, it has not been updated.
The recipe #681 documents: fish oven baked ground: 2. Remove amount of cooked fish and place in a food processor. Grind to desired texture. 3. Serve a #6 scoop (4.75 ounces) with 2 ounces gravy.
1. R1's Physician Order Sheet dated 08/01/22 documents: Diet: Regular, Consistency: Pureed, Fluid consistency: Regular with a start date of 06/10/2022.
On 08/15/22 at 12:05 PM, R1 received puree diet did not receive any pureed bread or pudding.
On 08/15/22 at 12:10 PM, V19 (Cook) stated she did not give R1 the pudding because she received a nutritional ice cream and V19 did not realize R1 was supposed to get both.
On 08/15/22 at 12:10 PM, V8 (Dietary Manager) stated, the pureed bread and pudding were missed for R1, they will send them out shortly.
2. R15's Physician Order Sheet dated 08/01/22 documents: Diet: Regular, Consistency: Mechanical Soft, Fluid consistency: Honey with a start date of 06/14/2022.
On 08/15/22 at 12:05 PM during kitchen observation, V8 (Dietary Manager) used a fork to cut up a breaded fish patty into pieces approximately 0.5 inches by 1.0 inches for R15's lunch. R15 then received that breaded fish patty for lunch.
3. R34's Physician Order Sheet dated 08/01/22 documents: Diet: LCS (Low Concentrated Sweets), Consistency: Mechanical Soft, Fluid consistency: Thin with a start date of 07/01/2022.
On 08/15/22 at 12:05 PM during kitchen observation, V8 (Dietary Manager) used a fork to cut up a breaded fish patty into pieces approximately 0.5 inches by 1.0 inches for R34's lunch. R34 then received that breaded fish patty for lunch.
On 08/18/22 at 11:10 AM, V7 (Minimum Data Set/Care plan coordinator) stated, meat cut up with a fork into pieces, including 1 inch by 1 inch pieces is the same as the mechanical soft diet.
On 08/18/22 11:10 AM V1 (Administrator) stated, meat cut up with a fork into pieces, including 1 inch by 1 inch pieces is the same as the mechanical soft diet.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on interview, observation, and record review the facility failed to provide food at palatable, hot temperatures for 4 (R15, R29, R31 and R3) of 4 residents reviewed for cold food in a sample of ...
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Based on interview, observation, and record review the facility failed to provide food at palatable, hot temperatures for 4 (R15, R29, R31 and R3) of 4 residents reviewed for cold food in a sample of 37.
Findings include:
On 08/16/22 at 9:30 PM - 10:30 AM, during resident council meeting R15, R29, R31 and R3, all alert and orientated, stated, the food is cold, especially at breakfast.
The Summer 2022 Regular Week 2 menu for 08/16/22 documents: Teriyaki Chicken, white rice, sugar snap peas, wheat bread, peanut butter brownies and margarine.
On 08/16/22 at 11:00 AM, the surveyor's metal stemmed digital thermometer was calibrated using the ice point method.
On 08/16/22 at 1:05 PM, a test tray was received off of the hall cart and was temped with the metal stemmed thermometer. The chicken was 98.0 degrees Fahrenheit, the rice was 98.1 degrees Fahrenheit, and the peas were 100.1 degrees Fahrenheit. All items on the plate tasted cold.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to ensure residents were offered snacks and that snacks were distributed per the facility policy for 4 (R15, R29, R31 and R3) of 4...
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Based on observation, interview and record review the facility failed to ensure residents were offered snacks and that snacks were distributed per the facility policy for 4 (R15, R29, R31 and R3) of 4 residents reviewed for providing snacks in a sample of 37.
Findings include:
On 08/15/22 at 9:30 AM, the snack cart was observed behind the nurse's station with an uncovered pitcher of water, an uncovered pitcher of tea, an undated plate of cut up sandwiches and some small bowls of grapes.
On 08/15/22 at approximately 3:00 PM the snack cart was taken back to the kitchen without ever leaving the nurse's station. All food items still appeared to be present on the cart except for half a sandwich, which R18 came to the nurse's station and asked for at 2:15 PM.
On 08/16/22 at 9:30 AM, the snack cart was observed behind the nurse's station with an uncovered pitcher of water, an uncovered pitcher of tea, an undated plate of cut up sandwiches and some small bowls of cake.
On 08/16/22 at approximately 3:00 PM, the snack cart was taken back to the kitchen without ever leaving the nurse's station with all food items appearing untouched.
On 08/16/22 between 9:30 AM and 3:00 PM, continuous observation of the snack cart revealed no snacks being distributed to residents in their rooms.
On 08/17/22 at 9:30 AM the snack cart was located behind the nurse's station with an uncovered pitcher of water, an uncovered pitcher of tea, an undated plate of cut up sandwiches and some small bowls of cake.
On 08/17/22 at approximately 3:00 PM the snack cart was taken back to the kitchen without ever leaving the nurse's station. All items were still intact, appearing untouched.
On 08/17/22 between 9:30 AM and 3:00 PM there were no observations of residents being taken snacks to their room.
On 08/16/22 between 9:30 AM and 10:30 AM, during resident council meeting R15, R29, R31 and R3, all alert and orientated, stated, they do not get snacks. R15, R29, R31 and R3 stated the staff are usually too busy and they have not received any snacks since they have had Covid-19 in the facility again.
On 08/18/22 at 11:00 AM V10 (Certified Nurse Aide) stated, she is not really for sure when snacks are to be given to the residents, she believes maybe 9:30 AM and 2:00 PM, she has not taken the cart down the hall or went down the hall and asked the residents about snacks, she is not sure who does it.
The Facility policy titled, Meal Service & Snack Times dated December 2016 documents: Dietary shall be responsible for all food preparation including snacks and shall deliver meals (with assigned assistance) to the residents or to the nursing units. Snacks shall be delivered to the nursing units by dietary personnel. Nursing shall be responsible for distributing snacks to the residents. Procedure(s) 3. Snacks shall be provided at: 10:00 AM, 2:30 PM and 7:00 PM.
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 interview, observation and record review the facility failed to ensure dishes in the dishwasher were being properly sanitized. This has the potential to affect all 37 residents residing in th...
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Based on interview, observation and record review the facility failed to ensure dishes in the dishwasher were being properly sanitized. This has the potential to affect all 37 residents residing in the facility.
Findings include:
On 08/15/22 at 10:55 AM, V19 (Cook) stated she did not know how to check the sanitizer in the dish machine. V19 asked V8 (Dietary Manager) how to test the sanitizer and V8 handed her the quaternary ammonia test strips and told her how to test it. After three attempts of trying to test it, V19 was asked what kind of sanitizer the machine used and what kind of test strip she was using. V19 (Cook) read the label stating sodium hypochlorite and realized the test strips and sanitizer where not compatible. After finding the correct strips, tested the sanitizer in the machine and it read 20 parts per million (PPM) Chlorine.
On 08/15/22 at 10:58 AM, V8 (Dietary Manager) stated she checked the machine this morning and it read 100 ppm Chlorine.
On 08/15/22 at 11:40 AM, V20 (Cook) started doing dishes again and when asked to check the sanitizer in the dish machine, she stated she did not know how. V8 (Dietary Manager) told her how to do it and handed her the quaternary ammonia test strips. After attempting to test it three times, V20 was asked what kind of sanitizer the machine used and what kind of test strip she was using. V20 read the label stating sodium hypochlorite and realized the test strips and sanitizer where not compatible. After finding the correct strips, V20 tested the sanitizer in the machine and it read 20 ppm Chlorine.
On 08/15/22 at 11:45 AM, V20 started doing dishes again and eight more racks of dishes were washed and put away, including the food processor.
On 08/15/22 at 12:57 PM, V8 (Dietary Manager) stated she tested the machine that morning and it tested 100 ppm (while pointing to the 100 color area on the quaternary ammonia test strip). After being told by surveyor the dish machine uses a chlorine based sanitizer, so that was not the correct test strip, V8 (Dietary Manager) said, oh, I will call the dish machine guy tomorrow.
On 08/15/22 at 1:00 PM, V20 (Cook) started doing dishes again.
On 08/15/22 at 1:15 PM, V1 (Administrator) stated that is not good, especially with having Covid-19 in the building, she assumed the dietary staff was checking the machine every day. She will go into the kitchen and see what can be done about sanitizing the dishes.
The www.FDA.gov/FDAFoodCode2017 documents: 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization - Temperature, pH, Concentration, and Hardness. A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under 7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, and shall be used as follows: (A) A chlorine solution shall have a minimum temperature based on the concentration and PH of the solution as listed in the following chart; chlorine sanitizer: Concentration range mg/l (ppm) 50-99 with a minimum temperature of 100 degrees Fahrenheit.
The facility Resident Census and Condition of Residents dated 08/15/22 documents 37 residents residing in the facility.
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 interview, observation and record review, the facility failed to utilize Personal Protective Equipment (PPE) in accorda...
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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 utilize Personal Protective Equipment (PPE) in accordance with professional standards of practice and failed to utilize and/or correctly apply approved disinfectants to prevent the spread of Covid-19. This has the potential to affect all 37 residents that reside at the facility.
Findings Include:
On [DATE] at 9:00 AM, V2 (Director of Nursing) provided the Facility document titled, Daily Census Report: [DATE] this document was marked with the Covid-19 residents and date of positivity by V2. This list documented that R2, R16 and R32 were positive for Covid-19.
On [DATE] at 11:35 AM, V7 (Minimum Data Set Coordinator/Care Plan Coordinator) was assisting delivering residents lunch trays with her N95 respirator on. The bottom strap of the N95 mask was not worn properly, as the bottom strap was hanging down in front of her mask.
On [DATE] 11:46 AM, V7 (Minimum Data Set Coordinator/Care Plan Coordinator) was still wearing her N95 mask improperly with the bottom strap hanging down in front of her mask and entered R16's room. R16's door had signage posted to indicate it was a Covid-19 positive resident's room, documenting contact and droplet transmission-based precautions should be utilized. V7 then entered R32's room, which also had signage posted on the door to indicate it was a Covid-19 positive resident's room, also documenting contact and droplet transmission-based precautions should be utilized. V7 also did not change the N95 upon exiting R16's room, or don a surgical mask over the N95 prior to entry of either room.
On [DATE] at 11:10 AM, V1 (Administrator) stated, all infection control measures are supposed to be followed and all staff members are to wear their N95 properly, covering both their nose and mouth, with both straps behind the head. V1 (Administrator) stated, all personal protective equipment (PPE) should be doffed upon exiting any Covid-19 positive room.
According to https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/use-n95-respirator.html#:~:text=Put%20on%20the%20N95&text=Place%20the%20N95%20under%20your,Do%20not%20crisscross%20the%20straps How to Use Your N95 Respirator updated [DATE], step 3 documents the following: Pull the top strap over your head, placing it near the crown. Then, pull the bottom strap over and place it at the back of your neck, below your ears. Do not crisscross the straps. Make sure the straps lay flat and are not twisted.
On [DATE] at 1:45 PM, R2's door had signage posted to indicate it was a Covid-19 positive resident's room, documenting contact and droplet transmission-based precautions should be utilized. V12 (Housekeeping) was in R2's room wiping down surfaces, spraying door handles and mopping the floor of R2's room. The surfaces that were sprayed were wet approximately 3 minutes. The disinfectants utilized for surfaces and the floor were located on the housekeeping cart and were noted to be Expose and Diversey Revive plus SC.
On [DATE] at 2:10 PM V12 (Housekeeping) stated, she uses Expose (EPA 70627-6) to wipe down surfaces including door handles, beds, and light switches. V12 said she will leave the disinfectant on the surface for approximately 5 minutes and then wipe the surface off. She further stated she uses Diversey Revive plus SC on the floors and will leave it on for a couple minutes when she mops. V12 stated she has not been trained with contact times for Covid-19.
The EPA N List (www.epa.gov/Nlist) documents: Expose (EPA 70627-6) as having a 10-minute contact time to kill Coronavirus, and the Diversey Revive plus SC was not registered as an EPA N listed cleaner for Coronavirus.
The facility document titled Infection Prevention and Control Program Policies and Procedures: General Statement dated [DATE] documents: The organization has made a commitment to prudent infection prevention and control measures by promoting the concept of compassionate, common sense resident and patient care, with an emphasis on cleanliness and infection prevention strategies. This organization has an established infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. We strive to implement evidenced based approaches to infection prevention.
The facility policy titled, Covid-19 Resident Monitoring, Assessment and Management Policy dated [DATE] documents: Planning: The administrator will create a plan to isolate infected residents to 1 area of the facility. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19. The facility should have designated staff to care for residents on the Covid-19 unit when the time comes. In the event of a facility outbreak, the administrator/designee will institute outbreak management protocols. The facility will document efforts to obtain necessary PPEs and supplies. If this occurs the nurse must- place the resident in contact/droplet isolation and close the door (If safe to do so).All staff must wear full PPE. Isolation signage and supplies should be placed outside of resident room. If testing results are positive, the resident must be moved to a Covid-19 designated area. Staff/Resident Management: Place residents in private rooms on standard, contact, droplet precaution and keep resident room door closed. Cohort residents identified with Covid-19 confirmation, Implement consistent assignment of employees and allow only essential staff to enter rooms/wings with appropriate PPE and respiratory protection. PPE includes: gloves, gown, N95 and eye protection will be used. Eye Protection that covers both the front and sides of the face. Remove before leaving resident room. Reusable eye protection will be cleaned and disinfected according to manufacturer's recommendation.
The Resident Census and Conditions of Residents dated [DATE] documents 37 residents residing at the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
Based on observation, record review and interview, the facility failed to provide a safe, functional and sanitary environment for the folding and storage of clean clothes. This has the potential to af...
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Based on observation, record review and interview, the facility failed to provide a safe, functional and sanitary environment for the folding and storage of clean clothes. This has the potential to affect all 37 residents residing at the facility.
Findings Include:
On 08/18/22 at 2:15 PM during inspection of the laundry facility, the room was noted to be rectangular with the washers and dryers on the opposite wall from the entrance. There were clean clothes noted across from the washers and dryers, as well as on the wall next to the entrance. Directly above the washers was a 6 foot by 6 foot hole in the drywall ceiling. Insulation was observed hanging down from the hole. There was visible mold on the insulation. There were dust and drywall particles falling onto the floor from the ceiling. Above the entrance there was another 3 foot by 4 foot hole in the ceiling with insulation and mold hanging down. There was a lot of airflow from the air conditioner vents blowing the drywall particles and insulation around the room. The residents clothes were exposed to these dust particles, insulation and mold.
On 08/18/22 at 2:15 PM during the above inspection of the laundry facility, V17 (Laundry) stated the holes in the ceiling have been there for a couple months, they started out much smaller but keep getting bigger. When it rains, hard water does come inside. V17 stated she had moved inside the facility to fold the clean clothes, but with Covid-19 in the facility she had to move back out to the laundry facility.
The Resident Census and Conditions of Residents dated 08/15/22 documents 37 residents residing at 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
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Illinois facilities.
Concerns
- • 32 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade F (30/100). Below average facility with significant concerns.
- • 61% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 30/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Helia Healthcare Of Newton's CMS Rating?
CMS assigns HELIA HEALTHCARE OF NEWTON 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 Helia Healthcare Of Newton Staffed?
CMS rates HELIA HEALTHCARE OF NEWTON's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 61%, which is 15 percentage points above the Illinois average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 71%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Helia Healthcare Of Newton?
State health inspectors documented 32 deficiencies at HELIA HEALTHCARE OF NEWTON during 2022 to 2025. These included: 1 that caused actual resident harm and 31 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Helia Healthcare Of Newton?
HELIA HEALTHCARE OF NEWTON 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 HELIA HEALTHCARE, a chain that manages multiple nursing homes. With 57 certified beds and approximately 33 residents (about 58% occupancy), it is a smaller facility located in NEWTON, Illinois.
How Does Helia Healthcare Of Newton Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, HELIA HEALTHCARE OF NEWTON's overall rating (1 stars) is below the state average of 2.5, staff turnover (61%) is significantly higher than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Helia Healthcare Of Newton?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.
Is Helia Healthcare Of Newton Safe?
Based on CMS inspection data, HELIA HEALTHCARE OF NEWTON has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Illinois. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Helia Healthcare Of Newton Stick Around?
Staff turnover at HELIA HEALTHCARE OF NEWTON is high. At 61%, the facility is 15 percentage points above the Illinois average of 46%. Registered Nurse turnover is particularly concerning at 71%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Helia Healthcare Of Newton Ever Fined?
HELIA HEALTHCARE OF NEWTON has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Helia Healthcare Of Newton on Any Federal Watch List?
HELIA HEALTHCARE OF NEWTON 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.