What is ARC AT NORMAL's CMS rating?

ARC AT NORMAL has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Does ARC AT NORMAL have any serious inspection findings?

Yes, ARC AT NORMAL has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 73 total deficiencies from recent inspections.

What are the staffing levels at ARC AT NORMAL?

ARC AT NORMAL has a one-star staffing rating from CMS with 0.44 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is ARC AT NORMAL located?

ARC AT NORMAL is located in NORMAL, IL. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does ARC AT NORMAL have?

ARC AT NORMAL has 141 certified beds.

Who owns ARC AT NORMAL?

ARC AT NORMAL is a for profit - limited liability company facility and is part of the ARCADIA CARE chain.

Is ARC AT NORMAL safe?

ARC AT NORMAL has documented safety concerns including a substantiated abuse finding on record, 1 immediate jeopardy citation. Families should ask about corrective actions taken.

Do nurses at ARC AT NORMAL stick around?

ARC AT NORMAL has average staff turnover at 43%, which is typical for the nursing home industry.

Was ARC AT NORMAL ever fined?

Yes, ARC AT NORMAL has been fined $192,219 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is ARC AT NORMAL on any federal watch list?

No, ARC AT NORMAL is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at ARC AT NORMAL?

Medicare inspectors have found 73 deficiencies at ARC AT NORMAL: 1 critical, 8 serious, 64 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting ARC AT NORMAL?

Families visiting ARC AT NORMAL should ask about what corrective actions were taken after fines, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does ARC AT NORMAL compare to other nursing homes?

ARC AT NORMAL has a 1-star overall rating, which is below average compared to other nursing homes in IL. Families should carefully review inspection findings and consider alternatives.

ARC AT NORMAL | 0/100 (Grade F)

Sept 2025 3 deficiencies

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility repeatedly failed to ensure residents' right to be free from physical abuse of...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility repeatedly failed to ensure residents' right to be free from physical abuse of R8 by R9, R5 by R4, R12 by R11, and R13 by R9. R5, R8, R12 and R13, are four of 20 residents reviewed for abuse on the sample list of 25. Findings include:1.) R8's Minimum Data Set (MDS) dated [DATE] documents R8's Brief Interview of Mental Status (BIMS) score of six, out of a possible 15, indicating severe cognitive impairment . R8's same MDS documents R8 has had no delusions or hallucinations, and no behaviors directed towards self or others.R9's MDS dated [DATE] documents the following: R9's BIMS score of three out of a possible 15, indicating severe cognitive impairment. R9's same MDS documents R9 has had no delusions or hallucinations, and no behaviors directed towards self or others.The Facility Reported Incident (FRI) of 7/5/25/2601647 documents: Resident to Resident Physical Assault. The same FRI report documents the following: On 7/5/25 at 8:20 AM, (V4, Certified Nursing Assistant/CNA) was pushing (R25)'s wheelchair down the hall. (R8) was in (R8)'s wheelchair in the middle of the hall. (V4, CNA) went to move (R8) to the side, and while (V4, CNA) was moving (R8), (R9) approached (R8), and made contact with (R8)'s face.The facility Illinois Department of Public Health Initial dated 7/5/25, and corresponding Final Abuse Investigation Report, Resident to Resident Physical dated 7/10/25 documents the following conclusion:1. Based on the results of the investigation, the facility has found the following: a. Resident (R8) was seated in (R8's) wheelchair in the [NAME] unit hallway. b. Resident (R9) was observed walking by Resident (R8) and made contact with the left side of (R8's) face. c. Resident (R8) stated she was not upset by the alleged occurrence. (R8's interview was conducted 7/7/25, two days after the physical abuse occurred. R8's BIMs score documented above indicates R8 has severe cognitive impairment)d. Resident (R9) does not recall the alleged occurrence. (R9's interview was conducted 7/7/25, two days after the physical abuse occurred. R9's BIM's score documented above indicates R9 also has severe cognitive impairment).On 9/5/25 at 9:30 am V4 CNA stated V4 was the CNA that witnessed R9 hit R8 in the face. V4, CNA stated (R9) smacked (R8) in the face, hurting her eye. I (V4, CNA) immediately separated them and reported to the (V1, Administrator/Abuse Prevention Coordinator. (R9) was a one-on-one (individual staff supervision) the rest of the day. (R8)'s face was not red but her eye was, probably because she was rubbing it. I could tell it hurt but she couldn't verbalize that. I told the nurse (unidentified) right away. We monitored her the rest of the day for any signs of injury. It did not seem to bother her later. Her face never got red. The nurse did a skin assessment on both (R9) and (R8). (R9) never even realized what he did, I guess. It was deliberate and for no reason. (R8) did not provoke him (R9) in any way. He just walked right up to her, and slapped her. On 9/5/25 at 12:05 pm V1, Administrator/Abuse prevention Coordinator reviewed R8 and R9 abuse allegation investigation documented above and confirmed R9 intentionally slapped R8 in the face.2.) R4s Minimum Data Set (MDS) dated [DATE] documents the following: R4's Brief Interview of Mental Status (BIMS) score of three out of a possible 15, indicating severe cognitive impairment.The same MDS documents R4 has had no delusions or hallucinations, and no behavior directed towards self or others, during the seven day lookback period.R5's MDS dated [DATE] documents R5's BIMS score of 14 out of a possible 15, indicating no cognitive impairment.R5's same MDS documents R5 has had no delusions or hallucinations, and has had no behaviors directed towards self or others during the seven day lookback period.The Facility Reported Incident (FRI) of 8/17/25/2601814 documents: Resident to Resident Physical Assault. The same FRI report documents the following: On 8/17/25 R2 was sitting in front of the menu board making it difficult for residents to exit the dining room. (R5) told (R4) to move out of the way and then (R4) swatted at (R5) making contact with (R5's) arm.The facility's Illinois Department of Public Health Initial Report dated 8/17/25 and corresponding Final Abuse Investigation Report, Resident to Resident Physical dated 8/21/25 documents the following conclusion: 1. Based on the results of the investigation, the facility has found the following: a. Resident (R4) was observed sitting in front of the menu board after the Sunday afternoon church service. b. Resident (R5) believed (R4) was blocking the hallway and told her (R4) to move. c. Resident (R4) reached out and made contact with (R5's) arm in response to being told to move.On 9/02/25 at 2:50 pm V10, Social Service Designee/Dementia Unit stated V10 completed the psychosocial assessments on R4 and R5 after the resident-to-resident altercation. V10 stated on 8/17/25, R4 had hit R5 with a book.On 9/5/25 at 11:07 am (R5) stated (R4) is always out to get me. She is always making snide remarks and thinks people are talking about her. I just stay clear of her. The day we were coming out of church, I was talking to (V26, R20's Family Member). (R4) was stopped in front of us. I told (V26) to tell her (R4) to get out of our way. (R4) backed her wheelchair up. She (R4) raised her arm up and swung so fast, I couldn't block her. She (R4) hit me (R5) across the chest and my arm with her bible. It was a black, heavy book. (V28, Activity Assistant) immediately moved (R4) out of the way and went down the hall. I was fine physically. It only hurt a minute. It did not stay red long. She isn't that strong, just mean.(chest and arm). I was just (expletive) it happened is all. I (R5) stay clear of her (R4) as much as possible. I have not had anything like that happen again.On 9/5/25 at 10:58 am V28, Activity Assistant stated I was talking to a(unidentified family member) right after the church activity. I heard (R5) say to (R4) 'Do not hit me'. I turned around immediately and could see (R4's) pull back her hand real fast. I went over immediately and separated them. I did not actually see her hit (R5). (R5) said she did, though. (R5) said she asked (R4) to move because she was blocking the residents trying to leave the activity. I could see (R4) was holding up traffic coming out of church service. I took (R4) to the nurse's station for close observation. I told (V29, Licensed Practical Nurse) the nurse. She called the Administrator ( V1, Abuse Prevention Coordinator) and went to do a did skin check on (R5). I know (R20)'s (V26, Family Member) was pushing (R20's) wheelchair and saw the altercation too. (R5) is alert and oriented. She can tell you exactly what happened. (R4) is mostly confused. She can carry on a conversation but as far as recollecting anything, I am sure she can't. (R4) has a lot of paranoia. She often tells other people, including (R5) to quit talking about her. Other than brief remarks, I have never seen either of them get physical. That day was a first, and I believe (R4) did hit (R5).On 9/5/25 at 12:05 pm V1, Administrator/Abuse prevention Coordinator reviewed R4 and R5 abuse allegation investigation documented above and confirmed R4 intentional hit R5 with a book.3.) R11's Minimum data Set (MDS) dated [DATE] documents R11's Brief Interview of Mental Status (BIMS) score as 00 (Zero) out of 15, indicating severe cognitive impairment.R11's same MDS documents the following: R11 has had no hallucinated or delusions.The same MDS documents R11 has had physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) that occurred 4-6 days of seven the look back period, R11 has had verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) that occurred 4-6 days of seven the look back period, and other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) that occurred 4-6 days of seven the look back period.R11 same MDS R11 has had behaviors of 'rejecting evaluation or care' that occurred 4-6 days of seven the look back period and has had behavior of wandering that occurred 4-6 days of seven the look back period.R12's MDS dated [DATE] documents R12's BIMS score as 04 (four) out of a possible 15, indicating severe cognitive impairment.R12's same MDS documents: R12 has had no delusions or hallucinations and has had no physical behaviors, .R12 same MDS documents R12 has had verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) that occurred one to three days in the lookback period of 7 days, and other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) that occurred 4-6 days in the lookback period of seven days.The Facility Reported Incident (FRI) of 7/02/25/2601326 documents: Resident to Resident Physical Assault. The same FRI report documents the following: On 7/2/25 (R12) attempted to help (R11) with (R12's) Bingo card. (R11) then pushed (R12's) hands away from the Bingo card and then (R11) made contact with (R12's) forehead with the Bingo card.The facility's Illinois Department of Public Health Initial Report dated 7/02/25 and corresponding Final Abuse Investigation Report, Resident to Resident Physical dated 7/07/25 documents the following conclusion:1. Based on the results of the investigation, the facility has found the following: a. Residents (R12) and (R11) were seated side by side during the Bingo activity. b. Resident (R11) was observed moving Resident (R12's) hands from her Bingo card and then made contact (R12's) head using the Bingo card. c. Resident (R12) does not recall the alleged occurrence. d. Resident (R11) does not recall the alleged occurrence.On 9/3/25 at 12:00 pm V21, Activity Assistant / Legacy Dementia Unit stated V21 was present and observed (R11) haul off and hit (R12) in the head with the bingo card. It was deliberate. He (R12) is always trying to help other residents with something. (R11) can get agitated with a flip a switch. We are careful with making sure she is not setting to close to anyone. That day during Bingo, (R12) went over to (R11). He invaded her space, and she let him know, she didn't' not want his help. It was a second or two later she (R11) hit him (R12) in the head. It was not an accident by any stretch of the imagination. It stunned (R12) but did not leave a mark. I was right there, and could not prevent the altercation. Knowing (R11), I was immediately going to separate them to prevent it. I just was not fast enough. I separated them right after the fact. I told the nurse what happened and was present when she called ( V1, Administrator/ Abuse Prevention Coordinator).On 9/5/25 at 12:05 pm V1, Administrator/Abuse prevention Coordinator reviewed R11 and R12's abuse allegation investigation documented above and confirmed R11 intentional hit R12 on the head with a bingo card. 4.) R9's Minimum data Set ( MDS) dated [DATE] documents the following: R9's Brief Interview of Mental Status (BIMS) score of three of a possible 15, indicating severe cognitive impairment. R9's same MDS documents R9 has had no delusions, hallucinations or behaviors directed towards self or others.R13's MDS dated [DATE] document R13's BIMS score of nine out of a possible 15, indicating moderate cognitive impairment.R13's same MDS documents R13 has had no hallucinations, no delusions no behaviors of any type, during the seven day look back period.The Facility Reported Incident (FRI) of 6/18/25/2594972 documents: Resident to Resident Physical Assault. The same FRI report documents the following: On 6/18/25 (R9) tossed a fork on the floor. (R13) then propelled self (herself) over to retrieve the fork from the floor. (R9) told (R13) to go away and get out of there. (R9) then reached out and made contact with (R13's) arm.The facility's Illinois Department of Public Health Initial Report dated 6/18/25 and corresponding Final Abuse Investigation Report, Resident to Resident Physical dated 6/24/25 documents the following conclusion: 1. Based on the results of the investigation, the facility has found the following: a. Resident (R9) was observed tossing a fork on the floor. b. Resident (R13) was observed retrieving the fork from the floor and telling Resident (R9) to go away'' and get out of here. c. Resident (R9) was then observed reaching out and contacting Resident (R13) arm. d. Resident (R13) does not recall the alleged occurrence. e. Resident (R9) does not recall the alleged occurrence. On 9/5/25 at 10:45 m V27, Certified Nursing Assistant (CNA) stated It was a couple months ago. I witnessed (R9) throw a fork on the floor. (R13) wheeled her wheelchair over to picked it up. (R9) grabbed her wrist. She screamed and said it hurt at the time. After a few minutes, she had forgotten about it . The nurse (unidentified) did a skin assessment and there was nothing there. It was on a weekend or second shift. We separated the residents. We reported immediately, after we made sure the residents were safe. We told (V2, Director of Nursing/DON) because (V1, Administrator/Abuse prevention Coordinator) was not here. The (V2,DON) reported to (V1,Administrator/Abuse Prevention Coordinator). (R9) was anxious before and after that. We did a one on one with him the rest of the shift.On 9/5/25 at 12:05 pm V1, Administrator/Abuse prevention Coordinator reviewed R9 and R13's abuse allegation investigation documented above and confirmed R9 intentional made contact with R13's arm.The facility policy Abuse prevention and Reporting-Illinois dated 09/2024 documents the following: Guidelines:This facility affirms the right of our residents to be free from abuse, neglect, exploitation,misappropriation of property, deprivation of goods and services by staff or mistreatment. This facilitytherefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment ofresidents. In order to do so, the facility has attempted to establish a resident sensitive and residentsecure environment. The purpose of this policy is to assure that the facility is doing all that is within itscontrol to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivationof goods and services by staff and mistreatment of residents.The same policy documents:Definitions: Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial well-being. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. An example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her each, as opposed to a resident with a neurological disease who has involuntary movements (e.g., muscle spasms, twitching, jerking, writhing movements) and his/her body movements impact a resident who is nearby. Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment The same policy documents: Resident-to-Resident Abuse (any type): A resident-to-resident altercation should be reviewed as a potential situation of abuse. Not all resident-to resident altercations result in abuse. For example, infrequent arguments or disagreements that occur during the course of normal social interactions (e.g., dinner table discussions) would not necessarily constitute abuse but should be investigated to make this determination. Resident-to-resident altercations that include any willful action that results in physical injury, mental anguish or pain must be reported in accordance with regulations.

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately encode minimum data sets for antipsychotic medications a...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately encode minimum data sets for antipsychotic medications and falls, and failed to complete the correct minimum data set for a discharged resident. These failures affect two residents (R6 and R1) out of thirteen reviewed for minimum data sets on a sample list of 25.Findings include: 1. R6's Physician Order Sheet dated [DATE] documents R6 has a physician order to receive the antipsychotic medication Quetiapine in a dose of 100 milligrams daily, an order initiated on [DATE], the day of R6's admission to the facility. R6's Medication Administration Record dated for [DATE] documents R6 received this antipsychotic medication as ordered. R6's admission Minimum Data Set, dated [DATE] section N0450 documents R6 did not receive antipsychotic medications since admission to the facility. This section, when coded as affirmative, serves as a prompt for further questions about required dosage reduction attempts On [DATE] at 3:40 PM, V16, Minimum Data Set Coordinator, stated she was aware R6 takes Quetiapine and must have been in a hurry to make a mistake coding the wrong section at the bottom of the page for R6. V16 further stated she would need to submit a correction for R6's Minimum Data Set. 2. R6's Nursing Progress Note dated [DATE] at 9:30 PM documents R6 was found on the floor of her own room at 9:00 PM stating she had fallen off of the bed, hit her shoulder, was complaining of right shoulder pain, and stating needed to go to the hospital. This note further documents R6 left the facility with emergency medical technicians to go to the hospital at 9:22 PM. R6's Nursing Progress Note dated [DATE] at 2:58 AM documents R6 had returned to the facility from the hospital with a diagnosis of a right humerus fracture which was immobilized. R6's Care Plan for a focus area of ADL (activities of daily living) self-care deficit dated as initiated [DATE] documents R6's right shoulder fracture as a contributing factor. The facility's Fall Investigation Report dated as initiated [DATE] with an initial report to IDPH [DATE] and final report dated [DATE], includes R6's Nursing Progress Notes from [DATE] and [DATE], R6's Care Plan revisions, and x-ray reports documenting a displaced fractured right humerus. R6's admission Minimum Data Set, dated [DATE] section J1800 and J1900 documents R6 had experienced 1 fall with an injury that was not a major injury since her admission to the facility. Section J1900 clarifies injuries not considered major include skin tears, abrasions and bruises, while major injuries include fractures. On [DATE] at 3:40 PM, V16, Minimum Data Set Coordinator, stated when she coded the section for R6's falls she had obtained her information from the facility's risk management section of the electronic medical records which listed R6's injuries as swelling and edema and had no further revisions. V16 clarified she was aware R6 went to the hospital but missed the part about a fracture. V16 further stated she had missed a lot of things on the Minimum Data Set for R6 and would need to submit a correction. 3. R1's Minimum Data Set, dated [DATE] for Death in Facility documents R1 expired on [DATE] in the facility. R1's State of Illinois Certificate of Death certified [DATE] documents R1 expired [DATE] at 9:40 PM at (local hospital). On [DATE] at 11:58 AM and 1:10 PM, V16, Minimum Data Set Coordinator, stated R1 was discharged to the hospital but was never admitted to the hospital and so R1 was still considered to be a resident of the facility when he expired, and that was why V16 completed a ‘Death in Facility' assessment. At 1:40 PM, V16 referenced the Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument 3.0 Users Manual dated from [DATE] (current Minimum Data Set manual) which documents (page 31) The Death in Facility assessment must be encoded when a resident dies in the facility or while on a leave of absence. This same manual (page 35) defines a leave of absence to include, IF the resident was in a hospital for observation for less than 24 hours, AND the hospital does not admit the resident. This same manual (page 32) documents a Discharge Minimum Data Set must be completed If a resident has a hospital observation period for greater than 24 hours, regardless if the hospital admits the resident. R1's Nursing Progress Note dated [DATE] documents R1 was sent to the emergency room at 12:45 PM on this date. At 2:50 PM on this same date, R6's Nursing Progress Note documents a facility nurse received an update from the hospital that R1 was pending an admission to an ICU (intensive care unit) bed. On [DATE] at 1:40 PM, V16 agreed from 12:45 PM on [DATE] until 9:40 PM on [DATE] was something like 32 hours, more than the 24 hours referenced in the Minimum Data Set manual. V16 stated the appropriate Minimum Data Set to complete for R1 would have been a Discharge with Return Anticipated and she would need to submit a corrected Minimum Data Set for R1.

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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

Based on interview and record review the facility failed repeatedly to maintain complete and accurate medical records for two of 14 residents (R2 and R14) reviewed for accuracy of medical records on t...

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Based on interview and record review the facility failed repeatedly to maintain complete and accurate medical records for two of 14 residents (R2 and R14) reviewed for accuracy of medical records on the sample list of 25.Findings include: 1.) R2's Physician Order Sheet dated 9/1/25 documents the following diagnosis and medication order: Ativan (name brand), ( antianxiety- Lorazepam) Oral Tablet 0.5 MG (Milligrams), Give 0.5 mg by mouth (PO) every 8 (eight) hours as needed (prn) for anxiety/agitation related to Anxiety Disorder, Unspecified for 14 months (inaccurate duration, exceeds the 14 day limit for prn anti-anxiety medication). Start date 07/29/25, end date of 9/26/26 (two-thousand twenty-six). R2 ‘s Consent dated 7/29/25, is incomplete, as it does not document the duration of time for Lorazepam 0.5 mg by mouth (PO) every 8 (eight) hours as needed (prn) for anxiety. R2's (Private Company) Psychiatry Note dated 8/22/25 documents the following: Type of Visit: Follow-up Visit :Chief Complaint: Per staff, patient exhibits agitation, aggression, and behavioral changes. The same (Private Company) Psychiatry Note documents the following a current medication list with no changes to the physician ordered Ativan ordered 7/29/25. R2's current medication list documents the same error in the duration of Ativan prn which exceeds the 14 days. The note documents R2's Ativan PRN (as needed ) order as follows: Lorazepam 0.5 mg PO q (every) 8 hrs (hours) PRN X (times )14 days, end dated 9/29/26 (two-thousand twenty-six). The documented Ativan order has the correct 14 day duration, but also documents inaccurately, the end date which is incongruent with the end date of a 14 month duration. R2's electronic Medication Administration Record (MAR) dated 9/1/25- 9/30/25 continued unrevised, with the same 7/29/25 Ativan PRN order that should have been replaced or discontinued on 8/11/25, after the 14-day required limit. R2's MAR dated 8/1/25 – 8/31/25 documents R2 was administered one dose of Ativan 0.5 mg on 8/29/25, (18 days after R2's Ativan was due to be revised or discontinued on 8/11/15). On 9/3/25 at 2:35 pm V2, Director of Nursing (DON) confirmed R2's electronic medical records. V2, DON stated R2's Physician Ordered for Ativan 'was a transcription error and should have been caught before the order went unrevised for the additional 23 days. V2 then clarified the order should not have exceeded 14 days. The documented 14 months was triggered in error. This error resulted in the wrong duration of 14 months documented throughout R2's chart ( included above) and R2's Ativan 0.5 mg dose being administered on 8/29/25, when the Ativan should have been discontinued or revised on 8/11/25. The facility policy “ Psychotropic Medication- Gradual Dosage Reduction” dated 04/2025 documents the following: “Purpose: To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected: condition as per current standards of practice and are-prescribed at the lowest therapeutic dose to treat such conditions. The plan to alternatives to psychotropic medication and/or use of psychotropic shall be incorporated into the care plan with suitable goals and approaches. This will be initiated by the resident's needs/ problems, goals and approaches as it relates to the use of psychotropic drug use.” The same policy Psychotropic Medication- Gradual Dosage Reduction document: PRN (as needed) Psychotropics: “PRN hypnotic, antianxiety or antidepressant medications shall not be used beyond 14 days unless the prescribing practitioner indicates the clinical rationale for extended use and the expected duration for PRN use of the medication. The duration of use should not extend beyond 6 (six) months unless re-evaluated by the attending physician or prescribing practitioner and clinical rationale is provided.” 2. R14's Hospital Progress Notes dated for 8/9/25 through 8/25/25 documents R14 had experienced a urinary tract infection from the multi-drug resistant bacteria Klebsiella. These progress notes document R14 was simultaneously experiencing sepsis and a bacterial infection of his left knee hardware, all treated with the intravenous antibiotics Cefepime and Ceftriaxone. R14's Hospital Discharge Orders dated 6/26/25 document R14 was to continue the intravenous antibiotic Ceftriaxone daily beginning on 8/27/25, the day after R14's return to the facility as R14 had received a dose for 8/26/25 at the hospital. R14's Medication Administration Record dated for August 2025 does not document administration of Ceftriaxone to R14 on 8/27/25, 8/28/25, and 8/29/25. This lack of administration was noted as blank spaces where the administering nurse should place their initials when the medication was administered. On 9/3/25 at 9:40 AM, V2, Director of Nursing, stated he was the administering nurse as the intravenous medications are administered by a Registered Nurse. V2 stated he did administer the intravenous antibiotic and did not go into R14's record to document the administration. R14's Medication Administration Record dated for September 2025 did not document the administration of R14's intravenous antibiotic Ceftriaxone for 9/3/25, leaving R14's antibiotic administrations undocumented for a total of 4 out of 7 days between 8/27/25 through 9/3/25. On 9/5/25 at 1:45 PM, V2 again stated he had administered R14's intravenous antibiotic on 9/3/25 and had not gone into R14's record to document the administration.

Jun 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect two residents' (R1, R10) from physical abuse for two of eig...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect two residents' (R1, R10) from physical abuse for two of eight residents reviewed for physical abuse in a sample list if 15. Findings Include: Facility Abuse Prevention and Reporting policy effective 09/2024, documents this facility affirms the right of their residents to be free from abuse, neglect, exploitation, misappropriation of property, and deprivation of goods and services. This policy documents abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. The same policy documents physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. The policy documents as part of the resident's life history on the admission assessment, comprehensive care plan, and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, history of trauma or misappropriation of resident property, who have needs, triggers and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis and update as necessary. The same policy documents on page two the definition of Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means (21 0 ILCS 45/1-103). Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident (42 CFR 483.5). This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial wellbeing. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish (42 CFR Interpretive Guidelines). The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. (42 CFR 483.5). An example of a deliberate (willful') action would be a cognitively impaired resident who strikes out at a resident within his/her reach. On 06/24/25 R10's care plan review documents R10's admission to the facility on 6/14/2023 with the following diagnoses: Atherosclerotic heart disease of native coronary artery without angina pectoris, and unspecified lack of expected normal physiological development in childhood. On 06/24/2025 R11's care plan documents R11's admission to the facility on [DATE] with the following diagnoses: Vascular dementia, severe, with agitation, Autistic disorders and Dysphagia. On 06/24/2025 at 1:00 pm R10 stated on an unknown date that R11 struck R10 on the top of right-hand causing pain and redness and that staff applied an ice pack to the area to alleviate the pain. On 06/25/2025 at 11:55 am V3 (Activity Director) stated V3 was in her office in the activity room, when V3 heard yelling out and came out of the office noting R10 and R11 were very close together and R10 was trying to get up. V3 stated V3 did not see R11 strike R10, but R10 stated he was struck by R11. On 06/24/25 at 09:15 am V1 (administrator) confirmed on 06-17-2025 the facility submitted a final report documenting R11 struck R10 with a hand on the hand on 06/13/25. On 06/24/2025 at 09:15 am V1 provided a police report dated 06/13/25 documenting the Normal Police department had been notified of an aggravated battery incident at the facility. On 06/25/2025 at 1:55 pm V1 provided a written witness statement from V3 documenting that upon exiting the office in the activity room, V3 witnessed R10 and R11 waving their arms around. Example 2 On 06/18/25 R1's care plan review documents R1's admission to the facility on [DATE] with the following diagnoses: Unspecified dementia, severe, with other behavioral disturbance, and major depressive disorder. On 06/18/25 R2's care plan review documents R2's admission to the facility on 9/25/2024 with the following diagnoses: Dementia in other diseases classified elsewhere, moderate, with other behavioral disturbance, Cognitive communication deficit, and Dysphagia. On 6/18/25 V5 (Assistant Director of Nursing) provided witness statements documenting V4 witnessed R1 walked over and stood near R2. R2 then reached out and scratched R1 with her (R2) fingernails. V4 stated that R1 did not provoke R2. On 06-13-2025 V1 (Administrator) provided a final summary of events to the department documenting V4 witnessed R2 scratching R1 in the hand.

Jun 2025 2 deficiencies 2 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Quality of Care (Tag F0684)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain medical evaluation and treatment following a resident's fall...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain medical evaluation and treatment following a resident's fall. This failure resulted in R2 experiencing aches, sharp pains, and a significant decline in cognitive, continence, and ambulatory status. R2 was one of three residents reviewed for accidents on a sample list of three. Findings include: R2's Census Detail dated [DATE] documents R2 was admitted to the facility [DATE], hospitalized from [DATE] through [DATE], re-admitted to the facility [DATE], and expired [DATE]. R2's Medical Diagnoses List dated [DATE] documents R2 had health conditions upon her admission including Malnutrition, History of Transient Cerebral Ischemia, and Chronic Kidney Disease. This same Diagnoses List documents, after R2's re-admission on [DATE], R2's diagnoses included a Displaced Right Femoral Neck Fracture, and Acute Respiratory Failure. R2's Nursing Progress Notes dated [DATE] document R2 experienced a fall in her room while ambulating with her walker and began complaining of new onset of pain R2 described initially as an ache. R2's Nurses Notes dated [DATE] and [DATE] document R2 had subsequent pain complaints described as sharp, and with numerical rating of 2 and 3. On [DATE] at 11:55 AM, V5, Licensed Practical Nurse, stated she had taken care of R2 after the fall, that R2 was alert and was telling staff about her pain. V5 additionally stated she had noted R2 was having right hip pain and was also walking funny on [DATE] and [DATE]. V5 then stated R2 was also experiencing a new onset of increased confusion on [DATE]. V5 concluded by stating she did not notify R2's physician until [DATE] when the physician ordered x-rays for R2. On [DATE] at 2:33 PM, V10, Certified Nursing Assistant, stated that on the weekend of [DATE] and [DATE], R2 was lying in bed moaning, complaining of pain, and sleeping a lot. V10 further stated R2 was incontinent of bowel and bladder, which was a change for R2 since prior to the fall R2 could take herself to the bathroom, and was complaining of increased pain in her right hip when V10 was turning and positioning R2 to change R2's soiled depends and linens. R2's Radiology Report dated [DATE] documents R2 experienced a displaced right femoral neck fracture. R2's Hospital History and Physical dated [DATE] documents R2's abnormal laboratory values mimicking a heart attack and low oxygen levels were the result of R2's fall and the increased physical bodily oxygen demands resulting in a low oxygen level. This History and Physical documents R2 received a computed tomography of the right hip and R2's fracture was described as an impacted fracture displaced superiorly (broken smaller pieces around the fracture and the lower portion of the broken bone was moved upwards). This History and Physical documents R2 was to be placed as non-weight bearing status. R2's Minimum Data Set (MDS) dated [DATE] documents R2 had a Brief Interview for Mental Status (BIMS) score of 12, rating R2 as cognitively intact. This MDS documents R2 had no limitations in range of motion in any of her four extremities, only required set up assistance to accomplish daily living activities such as eating, toileting, ambulation over 150 feet with a walker, upper and lower body dressing, donning footwear, and personal hygiene. R2's MDS dated [DATE] documents R2 had a BIMS score of 1, rating R2 as severely cognitively impaired. This MDS documents R2 had an impairment in range of motion of one lower extremity, and was dependent upon staff to accomplish all daily living activities. There was no evaluation of R2 ambulatory status in this MDS due to R2 being placed as non-weight bearing status.

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Deficiency F0697 (Tag F0697)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to manage new onset pain for a resident after a fall. This failure res...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to manage new onset pain for a resident after a fall. This failure resulted in R2 experiencing aches, sharp pains, low oxygen levels, and a significant change in cognitive status. R2 was one of three residents reviewed for accidents on a sample list of three. Findings include: R2's Nursing Notes dated 4/12/25 at 3:25 AM, documents R2 experienced a fall in her room while ambulating with her walker. A subsequent note at 3:27 AM documents R2 was complaining of an achy pain with a numerical value of 2 or 3 out of 10 which was a new onset for R2. R2's Nurses Note dated 4/13/25 at 5:59 PM, documents R2 was complaining of increased sharp pain of her right hip. R2's Medication Administration Record dated for April 2025 documents from 4/1/25 through 4/12/25 day shift, R2 had rated her pain each and every shift as zero. This Record documents on 4/12/25, 4/13/25, and 4/14/25, R2 was rating her pain at 4. R2's Medication Administration Record and Treatment Administration Records dated for April 2025 documents no administration of any type of pain medication nor treatment from the time of R2's fall on 4/12/25 through the time of R2 being sent to the emergency room on 4/14/25. R2's Physician Order Sheet dated 6/13/25 documents none of R2's pain medication orders were initiated prior to 4/18/25 when R2 returned from her hospital admission after R2's fall and fracture on 4/12/25. On 6/12/25 at 11:55 AM, V5, Licensed Practical Nurse, stated she had taken care of R2 after the fall on 4/12/25. V5 stated R2 was alert and was telling staff about her pain. V5 further stated she had noted that R2 was having right hip pain and was walking funny on 4/12/25 and 4/13/25. V5 then stated R2 was also experiencing increased confusion on 4/13/25. V5 concluded by stating she had not notified R2's physician of the increased pain and confusion until 4/14/25 when R2's physician ordered the x-rays and subsequent transfer to the emergency room. On 6/12/25 at 2:33 PM, V10, Certified Nursing Assistant, stated she had provided care for R2 on 4/12/25 and 4/13/25. V10 further stated R2 was lying in bed all weekend moaning and complaining of pain. V10 stated R2 was usually continent of bowel and bladder, and able to take herself to the bathroom walking with a walker. V10 concluded by stating that R2 was incontinent that weekend and was making increased complaints of pain when V10 was turning and repositioning R2 to clean R2's soiled briefs and linens. R2's Radiology Report dated 4/14/25 documents R2 experienced a displaced fracture of the right femoral neck as a result of her fall on 4/12/25. R2's Nurses Notes dated 4/14/25 at 2:18 PM document R2 was sent to the emergency room for further evaluation. R2's Hospital History and Physical dated 4/18/25 documents R2 was admitted to the hospital for pain management, abnormal laboratory values, and surgical orthopedic consult. R2's hospital computed tomography scan dated from 4/14/25 documents R2's right femur fracture was impacted (lots of small pieces of bone) and displaced superiorly (upwards). This History and Physical documents R2's abnormal laboratory values were mimicking of a heart attack and were caused by R2's fall, pain, and increased bodily oxygen demands creating ischemia (lack of blood flow). R2's Minimum Data Set (MDS) dated [DATE] documents R2 had a Brief Interview for Mental Status (BIMS) score of 12, rating R2 as cognitively intact. R2's MDS dated [DATE] documents R2 had a BIMS score of 1, rating R2 as severely cognitively impaired.

May 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to protect the resident's right to be free from physical a...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to protect the resident's right to be free from physical abuse by a staff member for one (R1) of three residents reviewed for physical abuse from a total sample list of nine residents. Findings include: The facility Abuse Prevention and Reporting-Illinois Policy dated 5/2025 documents the facility affirms the right of our residents to be free from abuse. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent abuse by staff and mistreatment of residents. This will be done by identifying occurrences and patterns of potential mistreatment, immediately protecting residents involved in identified reports of possible abuse and implementing systems to promptly and aggressively investigate all reports and allegations of abuse and making the necessary changes to prevent future occurrences and filing accurate and timely investigative reports. Physical abuse is defined in this policy as the infliction of injury on a resident that occurs other than by accidental means including hitting, slapping, pinching, kicking and controlling behavior. R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact. R1's Minimum Data Set, dated [DATE] documents R1 is dependent for toileting care. The facility provided grievance form dated 5/8/25 documents sensitivity to R1's breastbone area due to V3 Certified Nurses Aide (CNA) being too rough with R1. The facility provided schedules document V3 and V4 CNAs worked on 5/6/25 and that V5 CNA worked on 5/8/25. On 5/27/25 at 10:40AM, R1 stated, That day there were two girls in here changing me and (V3 CNA) pushed down here (pointing to her sternum) real hard. R1's sternum appears to be very bony. R1 stated I feel like it was abusive and that other girl just watched her do it, it upset me. On 5/27/25 at 10:00AM, V13 Family Member stated that she was visiting with her grandmother on Wednesday, May 7, 2025 and R1 told her that when two of the girls were changing her yesterday, they were rough with her and hit her on the chest. V13 stated I called the facility and left a message for them to call me back. The next day (V1 Administrator) called me and told me that she had talked with (R1) and she didn't think it was abuse. We met with (V1) and told her what (R1) told us and then she said she would investigate it. On 5/27/25 at 11:52 AM, V5 CNA stated she was told by R1 that an employee had abused her by punching her in the chest. V5 stated She used that word, abused. (R1) seemed to be in her right mind and she asked me what she should do about it. I told her that I would report it to (V1) the Administrator and I did. I don't know what happened from there, I was never asked about it again. On 5/27/25 at 10:35AM, V1 Administrator stated she was told of the incident by V5 CNA on 5/8/25 and that she decided to complete a grievance instead of an abuse investigation. On 5/27/25 at 10:45AM, V4 CNA stated, That day I had (V3 CNA) go in with me to change R1 because she hits sometimes when being changed. When she started hitting, V3 held R1 down with her arms crossed over her chest so that I could change R1. We should have asked R1 to stop, or left and got someone else. I had never seen V3 do that to a resident before. On 5/27/25 at 11:30AM, V1 Administrator stated that the abuse should have been investigated as abuse as soon as V5 CNA reported it to V1 and that Knowing what I know now, it was abusive. On 5/27/25 at 11:45AM, V2 Director of Nursing stated the staff are not trained to grab and hold resident's bodies down so they can change them and that they need further education regarding abuse prevention and the abuse policy.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review the facility failed to report an allegation of abuse to the State Agency in a timely manner for one (R1) of three residents reviewed for abuse from a ...

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Based on observation, interview and record review the facility failed to report an allegation of abuse to the State Agency in a timely manner for one (R1) of three residents reviewed for abuse from a total sample list of nine residents reviewed. Findings include: The facility Abuse Prevention and Reporting-Illinois Policy dated 5/2025 documents the facility affirms the right of our residents to be free from abuse. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent abuse by staff and mistreatment of residents. This will be done by identifying occurrences and patterns of potential mistreatment, immediately protecting residents involved in identified reports of possible abuse and implementing systems to promptly and aggressively investigate all reports and allegations of abuse and making the necessary changes to prevent future occurrences and filing accurate and timely investigative reports. Physical abuse is defined in this policy as the infliction of injury on a resident that occurs other than by accidental means including hitting, slapping, pinching, kicking and controlling behavior. When an allegation of abuse has occurred, the resident's representative and the (State Agency) shall be informed by telephone or fax. (The State Agency) shall be informed that an occurrence of potential abuse, has been reported and is being investigated. The facility provided grievance form dated 5/8/25 documents sensitivity to R1's breastbone area due to V3 Certified Nurses Aide (CNA) being too rough with her. On 5/27/25 at 10:40AM, R1 stated, That day there were two girls in here changing me and (V3) pushed down here (pointing to her sternum) real hard. R1's sternum appears to be very bony. R1 stated I feel like it was abusive and that other girl just watched her do it, it upset me. On 5/27/25 at 10:45AM, V4 CNA stated, That day I had (V3 CNA) go in with me to change (R1) because she hits sometimes when being changed. When she started hitting, (V3) held (R1) down with her arms crossed over her chest so that I could change (R1). We should have asked (R1) to stop, or left and got someone else. I had never seen (V3) do that to a resident before. On 5/27/25 at 11:52 AM, V5 CNA stated she was told by R1 on 5/8/25 shortly after breakfast that an employee had abused her by punching her in the chest. V5 stated I told her that I would report it to (V1 Administrator) and I did. The facility provided abuse investigation documents an initial report of abuse to the state agency on 5/9/25 at 1:27PM. On 5/27/25 at 10:35AM, V1 Administrator stated she chose to fill out a grievance form on 5/8/25 instead of implementing an abuse investigation for R1's allegation of abuse. I didn't turn it into an abuse investigation until I spoke with the family the next day. On 5/27/25 at 11:30AM, V1 Administrator stated the abuse allegation should have been reported as abuse (to the state agency) as soon as V5 CNA reported it to her.

May 2025 2 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Quality of Care (Tag F0684)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow physician orders for one (R1) of three residents reviewed for...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow physician orders for one (R1) of three residents reviewed for physician orders from a total sample list of 103 residents. This failure resulted in R1 being hospitalized with high ammonia levels that could have resulted in permanent harm. Findings include: R1's undated diagnosis sheet includes the following diagnoses: unspecified convulsions, alcohol dependence with alcohol-induced persisting dementia, fracture of right acetabulum, fracture of rib, malnutrition, fracture of anterior wall of right acetabulum, traumatic subarachnoid hemorrhage with loss of consciousness, and diabetes. The facility provided admission/discharge report documents that R1 was admitted to the facility on [DATE]. R1's hospital discharge orders dated 2/21/25 document medications to be continued including: Lactulose 10 gram/15 milliliter (ML) oral solution. Take 30 ML by mouth three times daily. R1's physician orders for February 2025 do not include an order for Lactulose. R1's February 2025 Medication Administration Record does not document that Lactulose was administered. R1's progress notes document on 2/22/25 that R1's mental status is alert and oriented to person, place, time, and situation. R1's progress notes document on 2/23/25 that R1's family member was concerned because R1 was not responding appropriately/like himself and seems extremely weak. R1 was unable to hold his head up and confusion was noted. R1's family member requested that R1 be sent to the emergency department for evaluation and treatment. R1's hospital records dated 2/23/25-3/3/25 document that R1 was admitted to the hospital with Hepatic Encephalopathy with hyperammonemia secondary to not receiving Lactulose at the facility. While hospitalized , R1 received Lactulose in various amounts to bring the ammonia level down with the result of improving mentation. On admission to the hospital on 2/23/25, R1's ammonia level was documented as 116 with significant confusion and decreased to 82 on 3/1/25 with lactulose administration resulting in improved mentation and the recommendation to continue lactulose for ammonia management. On 5/19/25 at 10:30AM, V3 RN (Registered Nurse) stated that she recalled having a conversation with R1's family member regarding not providing R1 Lactulose in the facility and that it was missed because of a system issue with the way that they look at discharge records and that they didn't look at the paper discharge records for R1. The staff are supposed to look at the paper discharge that comes with the resident, as well as the electronic discharge paperwork. On 5/19/25 at 1:10PM, V8 Nurse Practitioner stated that it was her expectation that the facility completed medication reconciliation with the discharge paperwork that comes with the resident from the hospital as soon as the resident arrives at the facility to ensure that nothing has changed. On 5/19/25 at 1:16PM, V7 Discharging Medical Doctor stated that R1 was mentally altered from the ammonia and it could have resulted in a coma. The family and patient told me that (R1) had not received his Lactulose in the facility and this certainly could have permanently harmed him.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review the facility failed to provide the necessary linen supplies for 97(R2, R3, R8-R103) of 103 residents reviewed for linen supplies from a total sample ...

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Based on observation, interview, and record review the facility failed to provide the necessary linen supplies for 97(R2, R3, R8-R103) of 103 residents reviewed for linen supplies from a total sample list of 103 residents reviewed. Findings include: The facility provided grievance dated 3/3/25 documents that resident council complained that whites have been taking too long to come back from the laundry. The response was documented that the delay was due to the elevator not functioning. The facility provided grievance dated 5/5/25 documents that resident council continued to complain that there were no wash cloths or towels for morning care. On 5/19/25 at 2:30PM the west linen room did not contain any washcloths or towels. On 5/19/25 at 2:35PM, the laundry room contained one dryer that appeared to have towels drying in it. V9 CNA (Certified Nurses Assistant) confirmed that no other washcloths or towels could be located in the laundry room. On 5/19/25 at 2:45PM the east linen room contained 6 towels and no washcloths or bed pads. On 5/19/25 at 2:20PM, V12 (CNA) stated that there are never towels and washcloths available for the second shift cares. On 5/19/25 at 2:30AM, V9 (CNA) stated that the facility is usually short of washcloths and towels 2 of 7 day shifts per week and that When we don't have towels and washcloths, we have to use wet paper towels on the resident's faces and bodies. On 5/19/25 at 2:50, V11 (CNA) stated that the facility is short of washcloths and towels every day of the week on the second shift and that she has had to use wet toilet paper to clean residents. On 5/19/25 at 2:55PM, V1 (Administrator) stated that there should always be towels and washcloths available for resident use and that it is not acceptable to use wet paper towels or toilet paper for washing and cleansing. On 5/20/25 at 9:00AM, V13 (Housekeeping Supervisor) stated that she had more towels and washcloths in the basement but no one knew where they were located. I'm having a meeting with my staff tomorrow to address these issues. No, I'm not surprised that they didn't have enough towels and washcloths, I had heard rumblings. The facility census indicates the following residents reside on the impacted wings, R2, R3, R8-R103.

Feb 2025 6 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R10's Minimum Data Set (MDS) dated [DATE] documents the following: R10's Brief Interview of Mental Status score of two (2) ou...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R10's Minimum Data Set (MDS) dated [DATE] documents the following: R10's Brief Interview of Mental Status score of two (2) out of a possible 15, indicating severe cognitive impairment. The same MDS documents R10 had two or more, falls since the last quarterly assessment. R10's Care Plan dated 12/30/24 documents the following: Focus: (R10) is at risk for falls r/t (related /to) dementia, morbid obesity, muscle wasting and difficulty walking. HX (history) of hip FX's (fracture). Interventions include: Apply (name brand non-skid material) on top and under w/chair (wheelchair) cushion. Date Initiated: 07/05/2024. On 2/20/25 at 2:10 PM R10 was seated in his wheelchair bedside. V33, Certified Occupational Therapy Assistant (COTA) and an unidentified Certified Nursing Assistant assisted R10 to a standing position from R10's wheelchair. V30 and V31 (R10's Family Members) entered R10's room as R10 was being assisted. R10 had non-skid material under, but not on the top of his wheelchair cushion. V33, COTA confirmed R10 had no non-skid material on top as his wheelchair cushion. V30 and V31 also noticed R10 did not have the non-skid material on the top of his wheelchair cushion. V30 and V31 both stated the facility is good about notifying them of R10's falls and has notified them R10 has had falls from his wheelchair. On 2/20/25 at 2:50 PM V30 Assistant Director of Nursing reviewed R10's medical record and confirmed R10 is to have non-skid material above and below R10's wheelchair to prevent R10 from sliding out if his wheelchair. Based on observation, interview, and record review the facility failed to complete quarterly fall risk assessments and implement fall interventions and fall prevention measures for three of four residents (R10, R79, R96) reviewed for falls on the sample list of 36. These failures resulted in R79, who is cognitively impaired, falling from a high bed onto the tile floor. R79 was seen in the emergency room and kept for an overnight hospitalization related to the subarachnoid hemorrhage R79 sustained from the fall. Findings Include: The facility's Fall Prevention Program dated October 2024 documents the program's purpose is to assure the safety of all residents in the facility and is to include measures which determine the individual needs of each resident by assessing the risk of falls, implementing appropriate interventions to provide necessary supervision, and using assistive devices as necessary. A Fall Risk Assessment should be performed at least quarterly and with each significant change in mental or functional condition and after any fall incident. Safety interventions should be implemented for each resident identified at risk. The bed should be maintained in a position appropriate for resident transfers. 1. R79's Medical Diagnoses List dated February 2025 documents R79 is diagnosed with Vascular Dementia, Psychotic Disturbance, Anxiety, Alzheimer's Disease, Need for Assistance with Personal Care, Morbid Obesity, Unsteadiness on Feet, Abnormalities of Gait and Mobility, Lack of Coordination, Cognitive Communication Deficit. R79's Physician Order Sheet dated February 2025 documents R79 was prescribed an anti-platelet medication in of March 2024. R79's Minimum Data Set, dated [DATE] documents R79 is severely cognitively impaired and requires staff assistance for transfers, bed mobility, and activities of daily living. R79's Care Plan dated 10/11/24 documents R79 is at risk for falls related to confusion and gait/balance problems. V29's Licensed Practical Nurse (LPN) Progress Note dated 1/31/2025 documents R79 was found on the floor beside her bed at approximately 11:15 PM. R79 was observed with a pool of blood underneath her head. R79's bed was clearly in the up position with the head up in Semi Fowler's position and the lower part bent at the knee area. R79 rated her pain as a 7/10 in her head. Emergency Medical Services were notified and R79 was discharged to the hospital. The cause of the fall was the bed was not in the lowest position. R79 has cognitive limitations due to dementia and immobility. On 2/20/25 at 1:40 PM R79 was sitting in her wheelchair in the television room. R79 had a half dollar sized raised hematoma on the left side of her forehead. R79 also had fading bruises under both eyes and a red fading bruise on the left side of neck. R79 was only alert to person and place. On 2/20/25 at 1:30 PM R79's bed frame was an older bed frame with an air mattress on top. There is an old half metal side rail on the right side of the bed frame. The bed frame, when lowered all of the way, was still about a foot off of the ground. On 2/20/25 at 1:08 PM V27 Certified Nurses Assistant (CNA) stated she put R79 to bed around 9:00 PM on 1/31/25. V27 stated on 1/31/25 R79 had gotten a new air mattress and a new bed frame that was an older model frame. V27 stated she believed part of the reason R79 rolled out of the bed was because of the new air mattress. V27 stated R79 could roll by herself in bed and was confused and needs the assistance of a staff and sit to stand mechanical lift for transfers. Confusion. V27 stated she thought she put the bed in the lowest position after she laid R79 down. However when V27 found R79 on the floor, V27 realized she had not put the bed all the way to the lowest position. On 2/20/25 at 3:29 PM V29 LPN stated the head of R79's bed was up at a 45 degree angle and the bed was also bent at the knees. V29 stated he asked V27 why the bed was like that and she stated so R79 could watch television. V29 also stated R79's bed was not at its lowest position. V29 stated the beds of confused residents should always be at the lowest position but R79's bed was about a foot and a half or two feet off the floor. R79 had blood on her head and on the floor. V29 confirmed R79 has poor safety awareness and would not be aware of where the edge of the bed was if she attempted to turn in bed. V29 also confirmed R79 was in a new air mattress and new bed frame that day for the first time. V29 stated he feels the cause of R79's fall on 1/31/25 was likely R79 trying to adjust herself in bed, then falling head first from the bed due to elevated angle of the head of the bed. V29 confirmed R79's injury risk increased due to the elevated height of the bed at the time of the fall. On 2/21/25 at 9:30 AM V2 Director of Nurses (DON) confirmed there was no quarterly fall risk assessment completed for R79. V2 stated R79 is currently a fall risk and confirmed R79 was a fall risk prior to her fall on 1/31/25 due to her impaired cognition, poor safety awareness, ability to turn and move in bed, and inability to safely transfer on her own. V2 confirmed when R79 was transferred to bed, V27 CNA should have ensured R79's bed was lowered as low as possible and the head of the bed is not elevated. V2 also confirmed on 1/31/25, when R79 fell out of bed and sustained a subarachnoid hemorrhage, R79's bed was not placed in the lowest position and the head of the bed was elevated, increasing R79's risk of injury when she moved in bed and fell out of bed onto the tile floor below. 3. R96 was admitted to the facility on [DATE] with diagnoses including Neurocognitive Disorder with Lewy Bodies, Dementia with behavior disturbances and Hallucinations. R96's Quarterly Comprehensive assessment dated [DATE] documents R96 has severe cognitive impairment and history of falls. R96's Care Plan Dated 10/21/25 documents R96 is at risk for falls related to dementia and cognitive disorder. This same record documents the following fall intervention: [name brand non-skid material] in wheelchair. On 2/19/25 at 2:10 PM, R96's highback wheelchair did not have non-skid material. On 2/19/25 at 2:11 PM, V18 (Certified Nursing Assistant) confirmed R96's highback wheelchair did not have non-skid material in place.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review the facility failed to properly secure R96's indwelling catheter tubing to R96's wheelchair. R96 is one of two residents reviewed for urinary catheter...

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Based on observation, interview and record review the facility failed to properly secure R96's indwelling catheter tubing to R96's wheelchair. R96 is one of two residents reviewed for urinary catheters on the sample list of 36. Findings Include: On 2/18/25 at 12:15 PM, R96 indwelling catheter tubing was dragging on the floor underneath R96 high back wheelchair. On 2/19/25 at 10:32 AM, R96 indwelling catheter tubing was dragging on the floor underneath R96 high back wheelchair. On 02/19/25 at 10:38 AM, V25 (Certified Nursing Aide) confirmed R96's indwelling catheter tubing was hanging underneath R96's highback wheelchair and stated that it should not be dragging on the floor. The facility Catheter Care Policy dated 10/2024 documents the following: to establish guidelines to reduce the risk of or prevent infections in residents with an indwelling catheter. Urinary drainage bags and tubing shall be positioned to prevent either from touching the floor directly.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain comfortable room temperatures for seven of se...

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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 maintain comfortable room temperatures for seven of seven residents (R37, R48, R55, R71, R80, R104, R105) reviewed for comfortable homelike environment on the sample list of 36. Findings Include: Resident Council Meeting Minutes dated 12/2/24 document resident complaints concerning it being too cold in the building. Resident Council Meeting Minutes dated 1/6/25 document resident complaints concerning resident rooms were really cold. Resident Council Meeting Minutes dated 2/3/25 document requests for plastic to be put on windows due to cold temperatures. On 2/18/25 at 11:00 AM the 100 Hallway was much colder than the common areas or other main hallways and dining rooms. On 2/18/25 at 10:35 AM the 101-115 Hallway registered a temperature of 66.2 degrees Fahrenheit (F). On 2/18/25 at 10:37 AM the temperature outside of room [ROOM NUMBER] registered at 65.7 degrees F. 1. R37's Minimum Data Set, dated [DATE] documents R37 is cognitively intact. On 2/18/25 at 11:18 AM R37 stated it is very cold in her room. R37 stated she likes to keep her door closed but it feels like an ice box in her room. R37 stated she isn't sure why the heat doesn't work right but she would like it to be warmer and more comfortable in her room. 2. R48's Minimum Data Set, dated [DATE] documents R48 is cognitively intact. On 2/18/25 at 10:39 AM R48's room registered a temperature of 63.2 degrees F. R48 stated her room was frequently cold and she has to request staff to provide extra blankets or get her a sweater to wear in order to try to stay warm. 3. R55's Minimum Data Set, dated [DATE] documents R55 has a mild cognitive impairment. On 2/18/25 at 11:33 AM R55 stated it has been cold in her room for a few days and when the temperature drops outside it gets too cold in her room and she doesn't want to get out from under the covers. R55 stated she doesn't want to go into her bathroom because it is even colder in there. Her room temperature registered at 66 degrees F. R55 was in bed under three blankets. 4. R71's Minimum Data Set, dated [DATE] documents R71 is cognitively intact. On 2/18/25 at 11:21 AM R71 stated it is very cold in the room today and that is why she is under three big blankets. R71 stated it always get cold when it is very cold outside. R71 stated she is not sure why the facility can't keep it warm in the resident's rooms. 5. R80's Minimum Data Set, dated [DATE] documents R80 is cognitively intact. On 2/18/25 at 11:21 AM R80 stated it gets very cold in her room when the temperature drops outside. 6. R104's Minimum Data Set, dated [DATE] documents R104 is cognitively intact. On 2/18/25 at 11:35 AM R104 stated it is cold in her room and she wears warm clothes, has extra blankets and sometimes wears gloves in order to stay warm. R104 stated she isn't sure why the room can't be maintained at a comfortable temperature. 7. R105's Minimum Data Set, dated [DATE] documents R105 has a mild cognitive impairment. On 2/18/25 at 11:25 AM R105 stated it gets pretty cold in his room when the temperature drops outside. R105 stated he likes to stay in his room and wishes it was warmer in his room. On 2/18/25 at 12:50 PM V11 Maintenance Director confirmed the resident rooms are pretty chilly on very cold days. V11 stated he is aware of the cold temperatures in the resident rooms however V11 confirmed the heating system is a boiler unit and it is running correctly. He stated he took some temperatures in the rooms this morning and the lowest he got was 66 degrees F. V11 stated he just called the heating company and spoke with someone there familiar with this building. They suggested turning on the heating system in the parking garage below the building to see if it would heat up the building floor (concrete) and help warm up the resident rooms. Although he had not tried anything as of yet to warm up the resident rooms, V11 stated he would be turning on the heating system in the parking garage area now to see if it would help. Surveyor temperatures were taken temperatures were taken with a Humidity/Temperature Thermometer-Hygrometer.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R10's Current Diagnoses Sheet documents the following: Alzheimer's Disease With Early Onset, Dementia in Other Diseases Class...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R10's Current Diagnoses Sheet documents the following: Alzheimer's Disease With Early Onset, Dementia in Other Diseases Classified Elsewhere, Moderate With Agitation, Other Abnormalities of Gait and Mobility, and Age-Related Osteoporosis With Current Pathological Fracture, Unspecified Femur, Sequela. R10's Minimum Data Set (MDS) dated [DATE] documents the following: R10's Brief Interview of Mental Status score of two (2) out of a possible 15, indicating severe cognitive impairment. R10's Care Plan dated 12/30/24 documents the following: Focus: (R10) has an ADL (Activities of Daily Living) self-care performance deficit r/t (related/to) dementia, confusion and FX (fracture) to l (left) hip; NWB (No Weight Bearing) to LLE (Left Lower Extremities). Interventions include: BED MOBILITY: The resident requires assist of (2) staff member with bed mobility. The resident uses side rails to maximize independence with turning and repositioning in bed. Date Initiated: 01/14/2024 (thirteen months prior to survey). R10's Quarterly Side Rail assessment dated [DATE] documents R10 does not use side rails, though they are care planned as of 1/14/24. There are no other quarterly side rail assessments until 2/20/25 during this survey. On 2/20/25 at 2:10 pm R10 had bilateral quarter side bedrails attached to R10's bed. On 2/20/25 at 2:50 pm V30 Assistant Director of Nursing confirmed R10 has bilateral quarter side rails but does not have quarterly side rail assessments since 7/31/24. V30 also stated the side rail assessment 7/31/24 is incorrect, because R10 had quarter side rails at that time. 3. R88's Current Diagnoses sheet documents the following: Hallucinations Unspecified, Other Specified Disorders of Muscle, Difficulty In Walking Not Elsewhere Classified, Unsteadiness On Feet, Other Abnormalities Of Gait And Mobility, and a History of Fracture of Unspecified Part Of Neck of Right Femur, Subsequent Encounter For Closed Fracture, With Routine Healing. R88's Minimum Data Set, dated [DATE] documents the following: R88's Brief Interview of Mental Status score of six out of 15, indicating severe cognitive impairment. R88's Care Plan dated 1/5/25 documents the following: Focus: (R88) is at risk for falls (due to) confusion, dementia and wandering. Intervention include: Bed rails for positioning and transfers. Date Initiated: 01/02/2025. On 2/20/25 at 2:25 pm R88 also had bilateral, quarter side bed rails, secured to R88's bed. On 2/20/25 at 2:50 pm V30, Assistant Director of Nursing confirmed R88 has bilateral quarter side rails, but does not have quarterly side rail assessments since 6/4/24. Based on observation, inteview, and record review the facility failed to implement side rails only after completing a side rail assessment and obtaining informed consent for three of three residents (R10, R79, R88) reviewed for side rails on the sample list of 36. Findings Include: The facility's Side Rail/Bed Rail policy dated October 2024 documents the purpose of the policy is to ensure the appropriate, safe and correct installation, use, and maintenance of bed rails. The facility shall ensure that prior to the installation of bed rails, the facility has attempted to use alternatives. After alternatives to bed rails have been attempted and determined that these alternatives do not meet the resident's needs, the facility shall assess the resident for the risks of entrapment and possible benefits of bed rails. After alternatives have been attempted and prior to installation, the facility shall obtain informed consent from the resident or if applicable, the resident representative for the use of bed rails. 1. R79's Medical Diagnoses List dated February 2025 documents R79 is diagnosed with Vascular Dementia, Psychotic Disturbance, Anxiety, Alzheimer's Disease, Need for Assistance with Personal Care, Morbid Obesity, Unsteadiness on Feet, Abnormalities of Gait and Mobility, Lack of Coordination, Cognitive Communication Deficit. R79's Minimum Data Set, dated [DATE] documents R79 is severly cognitively impaired. R79's Care Plan dated 10/11/24 documents R79 has impaired bed mobility and requires assistance of staff members with bed mobility. R79 uses side rails to maximize independence with turning and repositioning in bed. R79's Side Rail assessment dated [DATE] documented side rails were not indicated for R79. On 2/20/25 at 1:30 PM R79's bed frame appeared to be an older bed frame with an air mattress on top. There was an old half metal side rail on the right side of the bed frame next to the wall. There was another half metal side rail laying on the other bed in the room. On 2/21/25 at 9:30 AM V2 Director of Nurses (DON) confirmed R79 had no recent quarterly side rail assessment completed. The last Side Rail Assessment was completed on 7/26/24 and documented side rails were not indicated for R79. V2 stated he completed an assessment last night and determined R79 would benefit from one side rail to assist her with bed mobility. V2 confirmed R79 already had one side rail on her bed prior to this assessment being completed.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review, the facility failed to employ the services of a qualified director of food and nutrition services. This failure has the potential to affect all 105 ...

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Based on observation, interview, and record review, the facility failed to employ the services of a qualified director of food and nutrition services. This failure has the potential to affect all 105 residents residing in the facility. Findings Include: On 02/18/25 at 08:35 am V7, Dietary Manager (DM) was actively supervising dietary staff during breakfast meal service. V7 stated he has worked at the facility, as the dietary manager, since November 2024. V7 DM stated he has not taken the required classes to qualify as the dietary manager. On 2/19/25 at 2:45 pm V14, Regional Dietary Manager confirmed V7 DM has not had the training to qualify as the dietary manager. The facility's Centers for Medicare and Medicaid Services Long Term Care Facility Application for Medicare and Medicaid dated 2/18/25 documents 105 residents reside in 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, interview, and record review, the facility failed to prevent the potential for cross-contamination and food-borne illness, by failing to maintain clean food contact areas, free o...

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Based on observation, interview, and record review, the facility failed to prevent the potential for cross-contamination and food-borne illness, by failing to maintain clean food contact areas, free of grease-like substances, rust, dangling strands of accumulated dust-like substance, loose caulking and chipped paint. These failures have the potential to affect all 105 residents residing in the facility. Findings Include: On 2/19/25 at 12:30 pm during the follow- up kitchen tour with V7, Dietary Manager (DM)there was an approximate eight-foot long metal shelf, above the three well sink. The metal shelf above the three well sink had copious amounts of rust and brown and black grease-like debris adhering to the underside surface. Directly below the underside, soiled metal shelf are approximately twenty hanging brackets. There are presumably clean kitchen serving utensils, spoons, tongs, whisk, all hanging in groups from each of these bracket. The three-well sink has loose chipped caulking dangling into the wash and sanitization wells of the sink. There are two electrical outlet boxes on the wall above the three-well sink. Both electrical outlet boxes have thick, grease- like build up and crusted food-like substance adhering to the surface. Adjacent to the three well sink is a metal food preparation table. Approximately four feet above the food preparation table, is a suspended metal pipe. The suspended metal pipe hangs parallel and approximately two feet below the ceiling. The metal pipe is approximately 12 feet long. The metal pipe has a large amount of stringy dust-like substance, hanging strands of two and three inches, directly over the food preparation table. V7, DM stated he had not noticed how dirty these areas were and will make sure they are all cleaned better. The ceiling above this same metal pipe, over the food preparation table has an approximate ten- inch by ten- inch cluster of hanging paint strips that have pulled away from the painted ceiling. V7 stated he will have to get maintenance to fix the paint on the ceiling and the caulking around the three-well sink. V7 confirmed all the soiled areas pose a risk to contaminate food served to the residents from the facility kitchen. The facility General Sanitation Practices policy dated September 2023 documents the following: POLICY: 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. PROCEDURE: 8. Work surfaces will be kept neat and clean during food preparation and service. The department philosophy is Clean as you go. 13. Sanitation is the entire department's responsibility. The facility's Centers for Medicare and Medicaid Services Long Term Care Facility Application for Medicare and Medicaid dated 02/18/25 documents 105 residents reside in the facility.

Dec 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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on interview, and record review, the facility failed to administer intravenous medications as ordered by the physician. This failure affects two residents (R1, R2) out of three reviewed for intr...

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Based on interview, and record review, the facility failed to administer intravenous medications as ordered by the physician. This failure affects two residents (R1, R2) out of three reviewed for intravenous medication administration on a sample of six. Findings include: Medication Administration Policy dated Effective 10/2024 states under section II. ADMINISTRATION OF MEDICATIONS: Medications must be administered in accordance with a physician's order, e.g., the right resident, right medication, right dosage, right route, and right time. R1's medical record documents on 11/7/2024, R1 was admitted to the facility with a diagnosis of ACUTE OSTEOMYELITIS, LEFT ANKLE AND FOOT requiring the treatment of intravenous antibiotics. R1's medical record documents on 11/7/24 at 4:39 PM R1 received the following admission order for: Vancomycin HCl Intravenous Solution (Vancomycin HCl); Use 2250 mg intravenously every 24 hours for osteomyelitis until 11/27/2024 administered daily at 1:00 PM. November 2024 medication administration record (MAR) documents on 11/25/24 at 7:11 PM that V10 nurse administered the intravenous medication 6 hours and 11 minutes after documented physician ordered administration of the medication. Medical record documents on 11/19/2024, R2 was admitted to the facility with a diagnosis of OSTEOMYELITIS requiring the treatment of intravenous antibiotics. Medical record documents On 11/21/24 at 4:32 PM R2 received the following admission order for: Ceftriaxone Sodium Intravenous Solution Reconstituted 2 GM (Ceftriaxone Sodium); Use 2 gram intravenously every 24 hours for sepsis- elbow infection daily at 12:00 PM. On the November 2024 medication administration record (MAR) it is documented that on 11/25/24 at 9:36 PM that V2 administered the intravenous medication 9 hours and 36 minutes after documented physician ordered administration of the medication. On 12/11/24 staffing sheets were reviewed and it is documented that on 11/25/24 there were 2 registered nurses on duty at 2:30 PM. On 12/12/24 at 09:21 AM V2 states on 11/25/24 that V2 Director of Nursing left work early and was unaware that R1's intravenous medication was not given because the nurses did not inform V2 the medication was not given. V2 is unable to recall what time V2 left the building. V2 states on 11/25/24 that V2 left work early, but that R2's intravenous medication was given on time though not documented in the medical record. V2 states V2 logged into the medical chart remotely to document the intravenous medication was given. V2 states it should have been documented on time, and a progress note should have been entered to document the administration of medication on time.

Apr 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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure residents were free from sexual abuse for two of five residents (R1, R2) reviewed for abuse on the sample list of five. Findings In...

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Based on interview and record review, the facility failed to ensure residents were free from sexual abuse for two of five residents (R1, R2) reviewed for abuse on the sample list of five. Findings Include: On 4/29/24 at 8:25 am, V3 (R1's family) stated R2 was roaming the halls and entered R1's room, placed R2's hand on R1's chest and R1's hand on R2's groin, without saying anything. V3 stated R1 started screaming no, no. get out and R2 left the room. V3 explained that R1 was so horrified, R1 didn't say anything about it to anyone until the next day, then R1 reported it to V4 Medical Director. V4 reported it to the facility and at that time, they got the police involved. R1 didn't want to press charges or anything, R1 just wants to forget that it happened. R2's ongoing Diagnosis Listing documents R2 has Metabolic Encephalopathy, Parkinson's, Dementia, and Cognitive Communication Deficit. R1's Progress Notes dated 2/7/24 by V2 DON (Director of Nursing) documents V4 Medical Director came to V2 and reported that while seeing R1, R1 reported that R1 saw a resident (R2) that R1 went to therapy with pass by R1's room in wheelchair so R1 waved at R2. R2 waved back and then entered R1's room. R2 was in a wheelchair and R2 approached R1's bed. R1 stated R2 then touched R1's chest and guided R1's hand to R2's crotch area. R2 then left the room. Upon report, V2 ensured that R1 and R2 were separated. Police was notified and came to the facility. The Police Officer interviewed both R1 and R2. R1 stated that R1 did not want to press charges. Social Services assessed R1. R2 placed on 1:1 observation. Ombudsman notified. R1 is on file for making her own notifications. On 4/29/24 at 10:21 am, V2 confirmed that R1 reported a sexual abuse allegation to V4 back in February 2024. V2 stated according to R1, R2 entered R1's room after R1 waved at R2. R2 approached R1, who was in bed, and placed R2's hand on R1's chest then guided R1's hand towards R2's lap/crotch area. V2 stated R2 has dementia so R2 was not able to recall the incident when V2 talked to R2. V2 explained R2 has never been sexually inappropriate in the past and hasn't been since the incident. V2 believes that R2 mistook R1 for R2's wife, and that R2 did not have any malicious intentions. The facility Abuse Prevention and Reporting Policy dated October 2022 documents this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Sexual abuse is non-consensual sexual contact of any type with a resident. Sexual abuse includes but is not limited to unwanted intimate touching of any kind especially of breast or perineal area.

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to prevent cross contamination of a wound, turn and repos...

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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 prevent cross contamination of a wound, turn and reposition every two hours, document the receipt of wound treatments, and measure and assess wounds upon identification of the wound for three of three residents (R1, R9, and R10) reviewed for pressure ulcers on the sample list of ten. Findings include: The facility Pressure Injury and Skin Condition Assessment Policy dated January 2018 documents a wound assessment will be initiated and documented in the resident's chart when a pressure and/or other ulcers are identified by a licensed nurse. A Wound Assessment for each identified open area will be completed and will include: site location, size, stage of pressure ulcer, odor, drainage, description, and date/initials of the individual performing the assessment. The Physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record after each administration. The facility's Pressure Ulcer Prevention Policy with a revision date of 1/2018 documents dependant residents will be turned and positioned every two hours. 1. R1's care plan with a revision date of 1/2/24 documents R1 requires extensive assistance with bed mobility and is total dependant on staff for personal hygiene. This careplan documents R1 has a pressure sore to the sacrum. On 2/1/24 from 4:45 AM to 6:15 AM, V8 Certified Nurse's Assistant (CNA) was working on the hallway which R1 resides. V8 did not enter R1's room during this time. At 6:00 AM, V8 stated she last checked and repositioned R1 at 4:00 AM. V8 stated the dayshift CNA would be getting her up. V8 left the unit at 6:15 AM. There was not an a Certified Nurse's Assistant working on the hall until 7:17 AM when V13 Certified Nurse's Assistant walked onto the floor. At 7:20 AM, R1 was provided with incontinence cares and repositioning. On 2/1/24 at 7:20 AM, V13 and V14 Certified Nurse's Assistants provided incontinence care to R1. During incontinence care, V13 and V14 removed R1's incontinence brief. A treatment soiled with bowel movement was on R1's sacrum. V13 removed the dressing from R1's sacrum. A four centimeter round full thickness wound was present on R1's sacrum. V13 then took a wet washcloth and cleaned R1's peri-area from the front to the back. When wiping the washcloth became soiled with bowel and urine. V13 wiped over the wound with the soiled washcloth four times contaminating the wound bed. R1's treatment sheet dated 12/1/23 through 12/31/23 includes an order dated 8/19/23 to apply Stimulen External Powder to sacrum topically every day shift and an order dated 6/16/23 to cleanse lower sacrum with normal saline or wound cleanser, sprinkle collagen particles in wound bed cover with alginate calcium, then cover with island dressing once daily. These treatments were not signed out as completed on 12/25/23, 12/26/23, 12/27/23, 12/28/23, 12/30/23, or 12/31/23. On 2/1/23 at 1:03 PM, V16 Licensed Practical Nurse stated she worked on 12/25/23, 12/26/23, 12/27/23, and 12/28/23. V16 stated she completed the treatments to R1's sacrum but must have forgotten to sign them out. V16 stated treatments should be signed out after completed. On 2/1/23 at 2:30 PM, V2 Director of Nursing replied yes when asked if R1 should be checked on and turned and repositioned every two hours. V2 stated incontinence care should be provided without contaminating the wound. V2 stated treatment should be signed off when completed by the nurse. 2. On 2/2/24 at 11:58 AM, scattered pencil eraser sized wounds were present on R9's right and left buttocks and coccyx area. V3 Wound Nurse was present and stated R9's wounds were stage two and three pressure ulcers. R9's admission assessment dated [DATE] documents R9 has skin impairment to the coccyx. This assessment does not document an assessment or measurements for this impairment. R9's medical record does not document an assessment or measurements for the wound to the coccyx. R9's progress notes documents a late entry dated 1/23/24 which states, (R9 )was recently admitted /readmitted to facility with a skin impairment. New wound noted. (R9) was admitted with Wound 1. Wound 1 is a pressure injury. Wound 1 is a stage 3. First observation for wound 1, no reference prior. Wound 1 has no signs and symptoms of infection. Resident does not complain of pain to wound 1. On 2/1/24 at 12:41 PM, V2 DON (Director of Nursing) stated when a wound is observed, the nurses should assess and measure it. 3. On 2/1/24 at 12:12 PM, a half dollar sized black deep tissue injury was present on R10's left heel. R10's ongoing Census Documents R10 was admitted to the facility on [DATE]. R10's admission assessment dated [DATE] documents R10 has a thigh high cast to the left leg and is at risk for skin breakdown, potential shearing. R10's Progress Notes dated 1/30/24 documents R10 returned from orthopedic appointment with a long leg cast with a window on the heel. Weight Bearing As Tolerated to Left Lower Extremity with no direct pressure to ulcer. There is no wound assessment in R10's medical record until 1/31/24, which documents R10 has a new DTI (Deep Tissue Injury) to the left heel measuring 5 cm (centimeters) by 5 cm first observed on 1/30/24. The area is a deep red, maroon/purple in color and skin is intact with no drainage. On 2/1/24 at 12:41 PM, V2 DON (Director of Nursing) stated when a wound is observed, the nurses should assess and measure it, notify the MD (physician) or orders, and make sure it is documented.

Jan 2024 7 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 interview and record review, the facility failed to accurately complete R93's comprehensive assessment. This failure af...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete R93's comprehensive assessment. This failure affects one (R93) of three residents reviewed for accuracy of assessments on the sample list of 48. Findings include: R93's Minimum Data Set, dated [DATE], documents R93 received nutrition via a feeding tube. R93's Physician Orders documents R93 enteral feeds ended in July 2023. On 1/24/24 at 11:05am, V2 Director of Nursing confirmed R93 has not received nutrition via a feeding tube since July 2023.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to initiate a resident Care Plan for Oral Care for one re...

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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 initiate a resident Care Plan for Oral Care for one resident for (R42) of 28 residents reviewed for Care Plans in a sample list of 48. Findings Include: R42's Functional Abilities and Goals admission assessment dated [DATE] documents Oral Hygiene Not Assessed. R42's Minimum Data Set (MDS) dated [DATE] documents R42 is moderately cognitively impaired and requires supervision to assist of one staff to complete ADLs (Activities of Daily Living). On 1/21/24 at 11:00AM R42 was seated in a wheelchair in R42's room. R42 had several front teeth missing and the remaining teeth were visibly crusted with debris. R42 stated I forget to brush my teeth sometimes, but I can eat ok. R42's Care Plan reviewed date 12/18/23 does not include a Care Plan addressing R42's missing teeth or his need for oral care. The facility provided a policy dated 1/2024 for Care Plan Meetings. However, this policy fails to address how the facility ensures individual resident needs are assessed. On 1/24/24 at 12:30PM V2, Director of Nursing stated I can see that (R42) has missing teeth and should have been assessed and have a Care Plan for poor dental health and oral care.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to remain free of a fire hazard for one (R39) of 28 reside...

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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 remain free of a fire hazard for one (R39) of 28 residents reviewed for fire hazards from a total sample list of 48 residents. Findings include: The facility policy, K781, dated 7/1/2023 documents that portable space heaters and like devices are prohibited. R39's Minimum Data Set, dated [DATE] documents R39 as cognitively intact. On 1/21/24 at 9:30AM, R39's room had a space heater in use. The space heater was sitting on the counter, oscillating and blowing toward R39. On 1/21/24 at 9:31 AM V19, R39's Family Member stated it has been in (R39's) room for approximately a week. On 1/21/24 at 10:55AM, V2 Director of Nursing stated, The family brought the space heater into the facility. I told the husband they couldn't have it because it was a fire hazard. 1/21/24 11:00AM, V15 Certified Nursing Assistant stated, It (heater) has been in (R39's) room for about a week and a half. On 1/21/24 at 11:05AM, V1 Administrator said that space heaters are absolutely not allowed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to maintain urinary catheter tubing and collection bag off the floor for one of two residents (R256) reviewed for urinary cathet...

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Based on observation, interview, and record review, the facility failed to maintain urinary catheter tubing and collection bag off the floor for one of two residents (R256) reviewed for urinary catheters on the sample list of 48. Findings include: On 1/21/24 at 12:27pm, R256 was seated in a wheelchair at a dining room table eating lunch. R256's urinary catheter tubing and collection bag were resting on the floor underneath R256's wheelchair. On 1/21/24 at 12:32pm, V3 Infection Preventionist stated R256's urinary catheter tubing and collection bag were absolutely an infection control issue resting on the floor. The facility Urinary Catheter Care Policy dated 3/2024 documents the following: to establish guidelines to reduce the risk of or prevent infections in residents with an indwelling catheter. Urinary drainage bags and tubing shall be positioned to prevent either from touching the floor.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review the facility failed to provide humidification as ordered for oxygen administration for one (R60) of one residents reviewed for oxygenation from a tota...

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Based on observation, interview and record review the facility failed to provide humidification as ordered for oxygen administration for one (R60) of one residents reviewed for oxygenation from a total sample list of 48 residents. Findings include: The facility provided Oxygen and Respiratory Equipment-Changing/Cleaning Policy, dated 8/2023, documents that oxygen humidifiers should be changed weekly or as needed and will be dated when in use. R60's physician orders dated 8/2/2023 document oxygen to be administered at 2.5 liters per nasal cannula with humidification. On 1/21/24 at 9:45AM, R60's oxygen was running at 2.5 liters per nasal cannula and the attached humidification bottle was empty, dated 1/14/24. On 1/21/24 at 12:30PM, R60's oxygen was running at 2.5 liters per nasal cannula and the attached humidification bottle remained empty, dated 1/14/24. On 1/21/24 at 12:31PM, R60 said that she had been asking for a new bottle of water for her oxygen for two days, And I still don't have one.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to maintain comfortable temperatures in a dining room and resident bedroom. These failures affected six residents (R39, R74, R76...

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Based on observation, interview, and record review, the facility failed to maintain comfortable temperatures in a dining room and resident bedroom. These failures affected six residents (R39, R74, R76, R88, R91, R26) of six reviewed for comfortable temperatures on the sample list of 48. 1. On 1/21/24 at 9:30AM, R39's room had a space heater in use. The space heater was sitting on the counter, oscillating and blowing toward R39. On 1/21/24 at 9:00AM, V5, R39's Family Member stated that R39's room was cold and he visits daily. On 1/21/24 at 9:31AM, V19, R39's Family Member stated that they brought in a space heater for R39 approximately a week ago because her room was so cold. On 1/24/24 at 2:00PM, V1 Administrator said that the temperatures in R39's room on both 1/10/2024 and 1/16/2024 were below the acceptable range of 71 to 81 degrees Fahrenheit. The facility provided a temperature log dated 1/10/24 which documents R39's room was at 7:00AM 64.7 degrees Fahrenheit, 8:00AM 64.7 degrees Fahrenheit, 9:00AM 64.9 degrees Fahrenheit, 10:00AM 64.9 degrees Fahrenheit, 11:00AM 65.2 degrees Fahrenheit, 12:00PM 65.2 degrees Fahrenheit, 1:00PM 65.4 degrees Fahrenheit, 2:00PM 65.4 degrees Fahrenheit, 3:00PM 65.6 degrees Fahrenheit, 4:00PM 65.6 degrees Fahrenheit and 5:00PM 65.7 degrees Fahrenheit. The facility provided a temperature log dated 1/16/24 which documents R39's room was at 7:00AM 64.9 degrees Fahrenheit, 8:00AM 65.0 degrees Fahrenheit, 9:00AM 65.2 degrees Fahrenheit, 10:00AM 65.5 degrees Fahrenheit, 11:00AM 65.3 degrees Fahrenheit, 12:00PM 65.8 degrees Fahrenheit, 1:00PM 65.9 degrees Fahrenheit, 2:00PM 66.2 degrees Fahrenheit, 3:00PM 66.2 degrees Fahrenheit, 4:00PM 66.4 degrees Fahrenheit and 5:00PM 66.5 degrees Fahrenheit. 2. On 1/21/2024 at 8:35AM, V5 (R39's family) reported freezing temperatures in the facility. On 1/21/2024 at 8:53AM, the ambient air temperature in the main dining room measured 59.0 degrees Fahrenheit by Illinois Department of Public Health thermometer. At 11:50AM the dining room air temperature felt cold and and felt progressively cooler in the area furthest from the entrance hallway to the dining room. R76 and R88 were seated at a table located closest to the entrance hallway to the dining room and the air temperature at their table measured 59.0 degrees Fahrenheit by Illinois Department of Public Health thermometer. Residents dependent on staff for eating assistance were located in the coldest area of the dining room which measured 53.8 degrees Fahrenheit by Illinois Department of Public Health thermometer. On 1/21/2024 at 12:15PM, V4 (Certified Nurse Aide) was assisting dependent residents in the dining room and stated it's (the dining room) freezing. A stack of blankets was located nearby the dining table where V4 was assisting residents. V4 reported facility staff obtained the blankets in response to resident complaints of being cold and the staff's own initiative to keep residents warm while eating in the dining room. R74 was seated at the table where V4 was assisting dependent residents to eat lunch and R74 had multiple blankets wrapped around R74's upper body and R74's hands appeared clasped together beneath the blankets in front of R74's chest. V4 reported the dining room temperatures have been cold at least since the end of the previous week. On 1/24/2024 at 11:36AM, V22 (R91's family) reported the facility has had issues with heating and reported the facility staff told V22 they couldn't' get the steam up enough to get it (the steam supply source for facility heat) through the entire building. On 1/24/2024 at 11:36AM, R26 reported it's cold in there (the main dining room) and it's been that way all the time. On 1/24/2024 at 12:35PM, R76 and R88 both reported the dining room temperatures have been cold for weeks.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide showers and personal cares for residents depend...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide showers and personal cares for residents dependent on staff for hygiene for eight (R13, R29, R30, R42, R46, R47, R68 and R207) of eight residents reviewed for hygiene on the sample list of 48 residents. Findings include: 1. R29's undated diagnosis sheet documents the following diagnoses: Open Reduction Internal Fixation of Right Femur, Left Bundle Branch Block, Vascular Dementia, Epilepsy, Dysphagia, Mild Intellectual Disability, Abnormality of Gait and Lack of Coordination. R29's Clinical Review dated 1/7/24 documents that R29 requires moderate assistance with personal hygiene. R29's Care Plan dated 12/11/23 documents that R29 requires assistance with personal hygiene. On 1/23/24 at 12:00PM, R29 was sitting at the lunch table and a patch of white hair was observed on R29's chin. R29 then stated, I want them to shave my hair. R68's undated diagnosis sheet documents the following diagnoses: Cerebrovascular Incident, Dysphagia, Autistic Disorder, Muscle Wasting and Atrial Fibrillation. R68's Quarterly Clinical Review dated 1/10/24 documents R68 as dependent for personal hygiene. R68's Care Plan dated 3/2/22 documents that R68 requires extensive assistance for personal hygiene. On 1/21/24 at 12:45PM, R68 was unshaved with approximately one inch hair protruding from his chin and above his lip. On 1/21/24 at 12:46PM, R68 stated he would like to be shaved. On 1/21/24 at 1:00PM, V18 Licensed Practical Nurse stated, Oh yes, (R68) always likes to be shaved. On 1/24/24 at 10:00AM, V1 Administrator said if residents want to be shaved, they should be assisted with shaving. 2. On 1/21/24 at 10:03am, R46 stated R46 has only received two showers since the beginning of the month. R46 appeared unkempt/disheveled with dry skin on face, dirty/uncombed hair and food remnants on clothing. R46's Bathing Report documents facility staff only bathed R46 four times during the past 30 days. R46's Care Plan (current) documents R46 is to be offered two showers per week and dependent on staff for hygiene. R42's Minimum Data Set (MDS) dated [DATE] documents R42 is moderately cognitively impaired and requires supervision to assist of one staff to complete ADLs (Activities of Daily Living). On 1/21/24 at 11:00AM R42 was seated in a wheelchair in R42's room. R42's was unshaven. His beard hair was approximately 1/2 inches long and appeared unkept. R42 stated, I'd like to be shaved. I think I have an electric razor in the drawer. I need some help shaving. They haven't offered me a shave is while. R207's admission assessment dated [DATE] documents R207 requires supervision to partial assistance to complete ADLs (Activities of Daily Living). On 1/21/24 at 11:00AM, R207 was seated in a wheelchair in R207's room. R207 was unshaven. His beard hair was approximately 1/4 inches long and appeared unkept. R207 stated I don't want to be growing a beard, but they haven't helped me shave. On 1/23/24 at 10:00AM V2, Director of Nurse's (DON) stated Residents should be offered assistance with shaving when they get showers or when they prefer to shave. (R42) and (R207) probably need some help shaving. On 1/21/2024 at 9:24AM, R30 reported missing showers four or five times during the past several months and having to repeatedly make requests to staff to receive a shower. R30's bathing record (1/24/2023) documents staff bathed R30 four times total during the previous four weeks and does not document R30 refused any showers during that time period. R30's Care Plan (1/24/2024) documents R30 is dependent on staff for cares and staff should offer R30 two showers per week as R30 tolerates, and as necessary and to provide R30 with a sponge bath when a full bath or shower cannot be tolerated. On 1/24/2024 at 11:00AM, R13 reported not receiving any showers during a a recent two-week period. R13 reported facility staff are not offering showers and R13's shower days are Wednesday and Saturday, but she rarely receives showers on Saturdays. R13 reported the facility does not have enough staff (to provide showers to residents). R13's bathing record (1/24/2023) documents staff bathed R13 three times total during the previous four weeks. R13's Care Plan (1/24/2024) documents R13 is dependent on staff for cares and staff should offer R13 two showers per week as R13 tolerates, and as necessary and to provide R13 with a sponge bath when a full bath or shower cannot be tolerated. On 1/24/2024 at 11:36AM, R47 reported R47 has to repeatedly ask staff to get a shower. R47 reported missing three showers in the past month. R47's bathing record (1/24/2023) documents staff bathed R47 four times total during the previous four weeks. R47's Care Plan (1/24/2024) documents R47 is dependent on staff for cares and staff should offer R47 two showers per week as R47 tolerates, and as necessary and to provide R47 with a sponge bath when a full bath or shower cannot be tolerated. The facility Shower and Tub Bath policy (8/2023) documents a shower, tub bath or bed/sponge bath will be offered according to resident's preference, no less than once per week or according to the resident's preferred frequency and as needed or requested. The facility Complete Bed Bath policy (8/2023) documents a shower, tub bath or bed/sponge bath will be offered according to resident's preferences two times per week or according to the resident's preferred frequency and as needed or requested.

Nov 2023 4 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Deficiency F0694 (Tag F0694)

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 ensure a resident's PICC (Peripherally Inserted Centra...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident's PICC (Peripherally Inserted Central Catheter) infusion line and IV (Intravenous) pump were patent (open and not blocked) and infusing a physician ordered IV antibiotic 24/7 (24 hours a day/seven days a week) for one of two residents (R1) reviewed for PICC lines in the sample of three. These failures resulted in the facility failing to administer R1's physician ordered continuous IV (Intravenous) antibiotic as ordered for the treatment of R1's Sepsis and Epidural Abscess (infection of the spine or skull), R1 experiencing numerous occasions of mental anguish, and R1 experiencing an unwanted visit to the emergency room (ER) room to gain vascular access. Findings include: The facility's Facility Assessment Tool dated 08/2022 through 10/2023 documents, Purpose: The purpose of this assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. (The facility) reviews all referrals. The summary of diagnosis listed below are considered for admission to our facility. We accept residents with a variety of diseases, conditions, physical and cognitive disabilities, or combination of conditions that require complete medical care and management. Diagnosis Summary: Infectious Diseases. Special Treatments: IV Medications. The facility's Resident Care Policy and Procedure Central Venous Access Device and Midline Catheter Care and Management dated 06/2017 documents, Central Venous Access Devices (CVAD), including PICC (Peripherally Inserted Central Catheters), as well as midline catheters will be routinely monitored and cared for following established procedures and guidelines. Licensed practical nurses may monitor central venous access devices and midline catheters for complications. Only registered nurses may change dressings, access ports, change needless connectors, connect administration sets, flush and lock central venous access device lines and midline catheters, perform blood draws for the device, and remove non-tunneled PICC's, CVAD's, and midline catheters. R1's admission Record documents R1 is a [AGE] year-old admitted to the facility on [DATE]. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is cognitively intact. R1's Hospital Discharge summary dated [DATE] documents, You (R1) were here for infection of your neck that was treated with surgery and antibiotics. You were treated with antibiotics and need to be on antibiotics until 12-4-23. Principal Discharge Diagnoses: Sepsis and Epidural Abscess. discharge on IV Nafcillin by PICC placement. R1's Hospital Discharge Transfer Order dated 10-20-23 documents, Nafcillin (Penicillin Antibiotic) 12 grams in 0.9% (percent) 880 ml (milliliters) infusion, infuse 12 grams IV (Intravenous) every 24 hours. R1's Active Order Summary Report documents the following orders: Nafcillin Sodium Intravenous Solution Reconstituted (Nafcillin Sodium) use 12 grams intravenously in the evening related to Extradural and Subdural Abscess. 12 grams in 0.9 % (percent) NaCL (Sodium Chloride) 880 ml (milliliters) to be run over 24 hours. Flush each lumen of PICC line with five ml of normal saline before and after infusion at bedtime. Order date: 10-20-23. R1's Care Plan dated 10-21-23 documents, (R1) has a peripheral midline PICC line to right arm due to Sepsis. Nursing to maintain midline/PICC line per orders. R1's Nursing Note dated 10-27-23 at 1:40 AM and signed by V4 (Agency LPN/Licensed Practical Nurse) documents, IV pump beeping stating air in line. No RN present to maintain line. DON (Director of Nursing/V2) and on-call manager notified of IV pump being shut off due to no RN in building. R1's Nursing Note dated 10-29-23 at 2:17 AM and signed by V7 (Agency LPN) documents, (R1) in bed resting at this time. (R1) has a PICC line and has fluids that should be running, but due to the line having air in it and there is not an RN on staff, (R1) was informed that she could wait till (until) morning or she would be sent to the hospital. (R1) requested to be sent to the ER and this nurse informed on-call and (V2). R1's Emergency Department Notes dated 10-29-23 at 3:53 AM document, Chief complaint: Vascular Access Problem. (R1) is currently living a (nursing home) for septic arthritis that (R1) was diagnosed with approximately one month ago. (R1) sent by nursing home staff due to her PICC not working properly in order for her to receive her nightly medication through her PICC line. (R1) is currently at the facility to receive 24-hour IV antibiotic therapy for septic arthritis. Per (R1) she has not received her antibiotics routinely as scheduled. Call (nursing home) and spoke with nurse (V7/Agency LPN) who advised that (R1) was sent into the emergency department for administration of her antibiotics infusion because he was advised by the nurse manager to do so because there is not a registered nurse in the building. LPN (s) are not allowed to administer medications through PICC line. An RN not on staff until day shift today. R1's Nursing Note dated 11-1-23 at 2:22 AM and signed by V7 (Agency LPN) documents R1's IV PICC line was not running and was displaying air in line. On 11-10-23 at 9:45 AM R1 was sitting in her bed with Nafcillin 12 GM in 0.9 % Normal Saline infusing at 42 ml/hour through a PICC line in the right upper arm. R1 was crying with visible tears and stated, When a RN isn't here, and my machine (IV pump) acts up the staff shut my machine off. I have gone without my antibiotic seven nights now. Two nights I went without it (IV antibiotic) for seven hours. I have had to be sent to the ER on e night just to get the IV restarted. I should not have to be sent out of the facility in the middle of the night just to get my IV fixed and turned back on. I spent over a month in the hospital before coming to this facility. I was very sick, and I have an infection in my blood stream that was caused by an infection in my spine. I do not want to go without my antibiotics and have a set-back. I am afraid I will die without it (antibiotic). I called (V3/Infectious Disease RN) and told her I am afraid, and the facility is not giving me my antibiotic at night. Please help me. On 11-10-23 at 10:00 AM V2 (Director of Nursing) stated, I know (R1) has had air in her IV line and her pump was beeping a couple times on third shift. There was no RN on-site to manage it, so I told the nurses to send her to the ER. We do not have RNs in this building 24/7 (24 hours a day/seven days a week). The IDT (Inter-Disciplinary Team) reviews new admissions together and we knew when we admitted (R1) that she had a PICC line with antibiotics 24/7. On 11-10-23 at 10:35 AM V4 (Agency LPN/Licensed Practical Nurse) stated I was working third shift on 10-27-23 and taking care of (R1). At 1:38 AM that night (R1's) IV pump started to malfunction. (R1) gets a continuous antibiotic through a PICC line. There was no RN on duty to fix the pump and there was air in the line of the tubing. I called (V2/Director of Nursing) to see what I should do. (V2) instructed me to shut off (R1's) pump and wait for a RN in the morning to turn the antibiotic back on. (R1) did not get her antibiotic until after 7:00 AM when V8 (RN) came in and hooked it back up. The entire time (R1's) pump was off, (R1) was crying and afraid she was going to die. R1's mother (V6) even called me and was screaming at me. I was so upset that I quit, and I am not going back to the facility because I do not feel comfortable with taking care of a PICC line without an RN in the building. On 11-10-23 at 10:45 AM V8 (RN) stated, (On 10-27-23) I came in around 7:00 AM and cleared the air out of (R1's) tubing and hooked her IV back up. (R1's) IV antibiotics had been shut off that night because there was no RN working. I have had to turn (R1's) pump on twice when I have gotten here in the morning. On 11-10-23 at 10:50 AM V6 (R1's Mother) stated, (R1) has been really scared living at that facility because there have been multiple nights that her IV pump has been shut off and she has not gotten her antibiotic. (R1) is a very sick girl and has to have antibiotics continuously. (R1) has an infection of her spine. I have spoken to staff multiple times about this issue. I am trying to get (R1) moved to a facility closer to me that has RN's available to manage her IV. On 11-10-23 at 3:55 PM V3 (Infectious Disease RN) stated, I got a call from (R1) a week or more ago. (R1) was crying and telling me she was not getting her antibiotics because there was no RN in the building to manage her PICC line. (R1) told me there were seven nights she has not received her antibiotic. The facility admitted (R1) knowing she needed antibiotics through the PICC line 24 hours a day every day for at least two months. The facility should have made sure there was a RN there to administer and manage (R1's) PICC line and antibiotics. (R1) is septic and has an infection of the spine. (R1) is very ill and has to have her antibiotics around the clock. I have tried to call (V2) for over a week to talk to her about (R1) not getting her antibiotics. (V2) never returned my calls until yesterday. This clinic and V5 (Infectious Disease Physician) should have been notified every time (R1) did not get her antibiotics so we could have monitored (R1's) labs (laboratories) closer and developed a plan. (V5) and this clinic were never notified when (R1) missed her antibiotic. (R1) had to notify us herself. On 11-11-23 at 3:03 PM V7 (Agency LPN) stated, There have been numerous nights that (R1's) IV pump has been beeping and (R1) had air in her IV line. There was no RN in the building, so I have called (V2) and (V2) instructed me to send (R1) to the ER (Emergency Room). (R1) was crying and did not want to go to the ER just to get her IV to work. The second time the paramedics came in and fixed the air in the line, but about an hour after they left the pump started to beep again. I turned the pump off and an RN did not come in to turn in back on until day shift, which was around four hours later, so (R1) did not receive her IV antibiotics. There have been numerous nights (R1's) pump does not work and (R1) does not get her antibiotics and I have had to turn it off. (R1) cries and is afraid she is going to die whenever I have to turn the pump off.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Based on interview and record review the facility failed to notify the physician of a resident not receiving a physician ordered IV (Intravenous) antibiotic medication for one of three residents (R1) ...

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Based on interview and record review the facility failed to notify the physician of a resident not receiving a physician ordered IV (Intravenous) antibiotic medication for one of three residents (R1) reviewed for notification of changes in the sample of three. Findings include: The facility's Medication Errors and Adverse Drug Reaction policy dated 08/2023 documents, All medication, treatment, and drug reactions must be reported promptly. Notify the attending physician or medical director if the attending physician is not available. R1's Active Order Summary Report documents the following orders: Nafcillin Sodium Intravenous Solution Reconstituted (Nafcillin Sodium) use 12 grams intravenously in the evening related to Extradural and Subdural Abscess. 12 grams in 0.9 % (percent) NaCL (Sodium Chloride) 880 ml (milliliters) to be run over 24 hours. Flush each lumen of PICC (Peripherally Inserted Central Catheter) line with five ml of normal saline before and after infusion at bedtime. Order date: 10-20-23. R1's Progress Notes dated 10-27-23, 10-29-23, and 11-1-23 document R1's Nafcillin Sodium Intravenous Solution continuously by PICC line was not infused as ordered and these same notes do not include documentation of physician notification of R1's Nafcillin Sodium not being administered as ordered by the physician. On 11-10-23 at 10:35 AM V4 (Agency LPN/Licensed Practical Nurse) stated I was working third shift on 10-27-23 and taking care of (R1). At 1:38 AM that night (R1's) IV pump started to malfunction. (R1) gets a continuous antibiotic through a PICC line. There was no RN (Registered Nurse) on duty to fix the pump and there was air in the line of the tubing. (V2/Director of Nursing) instructed me to shut off (R1's) pump and wait for a RN (Registered Nurse) in the morning to turn the antibiotic back on. (R1) did not get her antibiotic until after 7:00 AM when V8 (RN) came in and hooked it back up. I did not notify (R1's) physician of (R1) missing her IV antibiotic. On 11-10-23 at 3:55 PM V3 (Infectious Disease RN) stated, I got a call from (R1) a week or more ago. (R1) was crying and telling me she was not getting her antibiotics because there was no RN in the building to manage her PICC line. (R1) told me there were seven nights she has not received her antibiotic. This clinic and V5 (R1's Infectious Disease Physician) should have been notified every time (R1) did not get her antibiotics so we could have monitored (R1's) labs (laboratories) closer and developed a plan. (V5) and this clinic were never notified when (R1) missed her antibiotic. (R1) had to notify us herself. On 11-11-23 at 3:03 PM V7 (Agency LPN) stated, There have been numerous nights that (R1's) IV pump has been beeping and (R1) had air in her IV line. I turned the pump off. One night an RN did not come in to turn it back on until day shift, which was around four hours later. There have been numerous nights (R1's) pump did not work and (R1) did not get her antibiotics and I have had to turn it off. I did not call (R1's) physician when she did not get her IV antibiotics.

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 F0725 (Tag F0725)

Could have caused harm · This affected 1 resident

Based on interview and record review the facility failed to provide sufficient and competent staff (Registered Nurse/RN) to infuse a physician ordered IV (Intravenous) antibiotic 24/7 (24 hours a day/...

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Based on interview and record review the facility failed to provide sufficient and competent staff (Registered Nurse/RN) to infuse a physician ordered IV (Intravenous) antibiotic 24/7 (24 hours a day/seven days a week) and to ensure a resident's PICC (Peripherally Inserted Central Catheter) infusion line and IV (Intravenous) pump remained patent (open and not blocked) for one of three residents (R1) reviewed for adequate staffing in the sample of three. Findings include: The facility's Facility Assessment Tool dated 08/2022 through 10/2023 documents, Purpose: The purpose of this assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility. The facility assessment must address or include the staff competencies that are necessary to provide the level and types of care needed for the resident population. Nursing Services-The facility must have sufficient nursing staff with appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's Central Venous Access Device and Midline Catheter Care and Management policy dated 06/2017 documents, Central Venous Access Devices (CVAD), including PICC lines, as well as midline catheters will be routinely monitored and cared for following established procedures and guidelines. Only registered nurses may change dressings, access ports, change needless connectors, connect administration sets, flush and lock central venous access device lines and midline catheters, perform blood draws for the device, and remove non-tunneled PICC's, CVAD's, and midline catheters. R1's Active Order Summary Report documents the following orders: Nafcillin Sodium Intravenous Solution Reconstituted (Nafcillin Sodium) use 12 grams intravenously in the evening related to Extradural and Subdural Abscess. 12 grams in 0.9 % (percent) NaCL (Sodium Chloride) 880 ml (milliliters) to be run over 24 hours. Flush each lumen of PICC (Peripherally Inserted Central Catheter) line with five ml of normal saline before and after infusion at bedtime. Order date: 10-20-23 (admission to facility). R1's Progress Notes dated 10-27-23, 10-29-23, and 11-1-23 (during the night shift hours of 10:00 PM through 7:00 AM) document R1's Nafcillin Sodium Intravenous Solution continuously by PICC line was not infused as ordered by the physician due to the facility not have a Registered Nurse/RN in the building to manage R1's PICC line and administer R1's Nafcillin Sodium via the PICC line. The facility Nurse Staffing Sheets dated 10-20-23 through 11-10-23 document there was no RN coverage in the building 22 out of the 22 night shifts that R1 received antibiotics through the PICC line. On 11-10-23 at 9:45 AM R1 stated, When a RN isn't here, and my machine (IV pump) acts up the staff shut my machine off. I have gone without my antibiotic seven nights now. Two nights I went without it (IV antibiotic) for seven hours. On 11-10-23 at 10:00 AM V2 (Director of Nursing) stated, I know (R1) has had air in her IV line and her pump was beeping a couple times on third shift. There was no RN on-site to manage it, so I told the nurses to send her to the ER. We do not have RN's in this building 24/7 (24 hours a day/seven days a week). I do not have RN's available for night shift. The IDT (Inter-Disciplinary Team) reviews new admissions together and we knew when we admitted (R1) that she had a PICC line with antibiotics 24/7. On 11-10-23 at 10:35 AM V4 (Agency LPN/Licensed Practical Nurse) stated I was working third shift on 10-27-23 and taking care of (R1). At 1:38 AM that night (R1's) IV pump started to malfunction. (R1) gets a continuous antibiotic through a PICC line. There was no RN on duty to fix the pump and there was air in the line of the tubing. (V2/Director of Nursing) instructed me to shut off (R1's) pump and wait for a RN in the morning to turn the antibiotic back on. I no longer work at the facility. I did not feel comfortable having a resident with a PICC line with an antibiotic infusing, and no RN in the building to monitor or infuse the antibiotic. On 11-10-23 at 3:55 PM V3 (Infectious Disease RN) stated, I got a call from (R1) a week or more ago. (R1) was crying and telling me she was not getting her antibiotics because there was no RN in the building to manage her PICC line. The facility knew when they admitted (R1) that she had orders for continuous antibiotics through the PICC line and need 24 hours a day RN coverage to manage the PICC line. On 11-11-23 at 3:03 PM V7 (Agency LPN) stated, There have been numerous nights that (R1's) IV pump has been beeping and (R1) had air in her IV line. I turned the pump off. There have been numerous nights (R1's) pump does not work and (R1) does not get her antibiotics and I have had to turn it off because there is no RN available in the facility to take care of (R1's) PICC line and I am only an LPN.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

Based on interview and record review the facility failed to infuse a physician ordered IV (Intravenous) antibiotic 24/7 (24 hours a day/seven days a week) for one of three residents (R1) reviewed for ...

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Based on interview and record review the facility failed to infuse a physician ordered IV (Intravenous) antibiotic 24/7 (24 hours a day/seven days a week) for one of three residents (R1) reviewed for medication errors in the sample of three. Findings include: R1's Active Order Summary Report documents the following orders: Nafcillin Sodium Intravenous Solution Reconstituted (Nafcillin Sodium) use 12 grams intravenously in the evening related to Extradural and Subdural Abscess. 12 grams in 0.9 % (percent) NaCL (Sodium Chloride) 880 ml (milliliters) to be run over 24 hours. Flush each lumen of PICC (Peripherally Inserted Central Catheter) line with five ml of normal saline before and after infusion at bedtime. Order date: 10-20-23. R1's Progress Notes dated 10-27-23, 10-29-23, and 11-1-23 document R1's Nafcillin Sodium Intravenous Solution continuously by PICC line was not infused as ordered and these same notes do not include documentation of physician notification of R1's Nafcillin Sodium not being administered as ordered by the physician. On 11-10-23 at 10:35 AM V4 (Agency LPN/Licensed Practical Nurse) stated I was working third shift on 10-27-23 and taking care of (R1). At 1:38 AM that night (R1's) IV pump started to malfunction. (R1) gets a continuous antibiotic through a PICC line. (V2/Director of Nursing) instructed me to shut off (R1's) pump and wait for a RN in the morning to turn the antibiotic back on. (R1) did not get her antibiotic until after 7:00 AM when V8 (RN) came in and hooked it back up. On 11-10-23 at 3:55 PM V3 (Infectious Disease RN) stated, I got a call from (R1) a week or more ago. (R1) was crying and telling me she was not getting her antibiotics. (R1) told me there were seven nights she has not received her antibiotic. (R1) has to get her antibiotic 24 hours a day and cannot miss any doses. This is definitely a significant medication error as (R1) has sepsis and a severe infection to the spine. (R1) has to get her antibiotics or she could relapse and end up back in the hospital. On 11-11-23 at 3:03 PM V7 (Agency LPN) stated, There have been numerous nights that (R1's) IV pump has been beeping and (R1) had air in her IV line. I turned the pump off. One night an RN did not come in to turn it back on until day shift, which was around four hours later, so (R1) did not receive her IV antibiotics. There have been numerous nights (R1's) pump does not work and (R1) does not get her antibiotics and I have had to turn it off.

Aug 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

Based on interview and record review, the facility failed to complete ten of 27 dressing changes to a diabetic ulcer as ordered for one (R1) of three residents reviewed for wound care in a sample of t...

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Based on interview and record review, the facility failed to complete ten of 27 dressing changes to a diabetic ulcer as ordered for one (R1) of three residents reviewed for wound care in a sample of three. Findings include: R1's progress notes dated 6-22-23 document an open area to R1's left ankle was found. R1's July physician order sheet documents cleanse left medial ankle, apply silver hydrogel to wound bed, cover with foam, every day shift for wound healing. This order started on 7-7-23. R1's TAR (Treatment Administration Record) for July and August 2023 documents R1 did not receive his wound treatment on 7-12, 7-14, 7-17, 7-19, 7-21, 7-24, 7-26, 7-28, 7-31 and 8-2-23. R1 was sent to the hospital on 8-3-23. On 8-12-23 at 2:15 pm, V2 Director of Nursing, confirmed there was no documentation that this wound treatment was completed. V2 stated V9, agency nurse, was working those days and responsible for R1's wound care and was asked not to come back to facility due to failure to complete his work. On 8-14-26 at 10:50 am, E6 Wound Nurse stated on several occasions when completing R1's wound treatment, E6 could tell by the dated dressing that the treatment had not been completed the day before as ordered. E6 stated V9 was working the days the treatment not completed. On 8-12-23, V8 Wound Doctor stated he last observed R1's wound on 7-27-23. V8 stated the wound was stable, non healing and without infection. V8 verified the ordered treatment was to be completed every day. The facility's Skin Condition Assessment & Monitoring-Pressure and Non-Pressure policy dated 2023 documents Adherent or semi-permeable membranous dressing used for deriding or healing purposes will be removed at least weekly or more often in accordance with physician's orders. When used, the licensed nurse will document the observation in the treatment administration record and initial the dressing to verify the treatment was performed. Physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record after each administration.

Aug 2023 6 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review, the facility failed to maintain a clean homelike environment for three of three residents six residents (R3, R5, R6) reviewed for environment on the ...

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Based on observation, interview and record review, the facility failed to maintain a clean homelike environment for three of three residents six residents (R3, R5, R6) reviewed for environment on the sample list of six. Findings Include: On 8/9/23 and 8/10/23 from 10:00 am - 2:00 pm, there were two housekeepers in the building working. On 8/9/23 at 12:54 pm, V17 (R3's family) stated housekeeping works hard but there isn't enough of them to keep the place clean. V17 stated R3's floor is sticky with stains. On 8/9/23 at 1:52 pm, V5 Houskeeper stated there are normally two housekeepers on east wing, two on west wing and one on the dementia unit but that V5 was working alone on the wing and has been working alone for over one month. V5 stated V5 is not able to get to every room everyday to clean but tries to at least get to each room to make their beds and pick up the garbage everyday. V5 stated V5 tries her best but it's too much. On 8/9/23 at 2:05 pm, R5 and R6 were sitting in their rooms. Crumbs and wrappers noted on the floor. R5 and R6 both stated housekeeping tries to come in daily to sweep the floor however there has been something sticky on the floor next to the wall for the past three weeks, will pointing to a quarter sized area, red in color, on the floor next to the wall. On 8/9/23 at 2:38 pm, R3's floor had several dark black sticky areas on it. The bathroom floor around the toilet and garbage can was dark gray in color and sticky, to the point were the surveyors shoe was stuck to the floor and when the surveyor went to take a step, the surveyors shoe stayed stuck to the floor. On 8/10/23 at 5:00 am, R3's floor remained in the same condition. On 8/10/23 at 9:00 am, V5 Housekeeper confirmed R3's floor is dirty and sticky and stated V5 hasn't mopped it in days. The facility's August 2023 Housekeeping Schedule documents one - two housekeepers are working daily for the entire building. On 8/10/23 at 9:56 am, V16 Housekeeping/Laundry Supervisor stated the facility is suppose to have five housekeepers total each day but we are short staffed explaining that today there are only two housekeepers in the building, one on east wing and one on west wing. V16 stated when the facility is short like this, V16 instructs the Houskeeper to make sure the beds are made, to clean the bathrooms and make sure nothing is on the floor. V16 and surveyor entered R3's room and V16 confirmed the floor is sticky and dirty and stated the black/gray marks will not come up, all of these floors need to be stripped and waxed. While standing in the room, surveyors shoes stuck to the floor again. V16 and surveyor then entered R5 and R6's room and V16 stated the quarter sized red area on the floor looks like candy. The crumbs and wrappers on the floor from 8/9/23 were still on the floor. The facility Houskeeper Policy dated July 2023 documents the primary purpose of the Housekeeper is to is to perform the day to day activities of the Housekeeping Department in accordance with state, local and federal guidelines and regulations governing our facility to assure that our facility is maintained in a clean, safe, and comfortable manner. Floors are to be cleaned including sweeping, dusting, damp/wet mopping, stripping, waxing, buffing and disinfecting.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to implement their Abuse Prevention and Reporting Policy by failing to complete a thorough investigation for one of three residents (R1) revie...

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Based on interview and record review, the facility failed to implement their Abuse Prevention and Reporting Policy by failing to complete a thorough investigation for one of three residents (R1) reviewed for abuse on the sample list of three. Findings Include: The facility's Abuse Prevention and Reporting Policy dated 10/2022 documents an incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation. Investigation Procedures: the appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident, the resident, if interviewable. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed to determine whether any one has witnessed any prior abuse, neglect, exploitation, mistreatment or misappropriation of resident property by the accused individual. On 8/10/23, the facility's Abuse Investigation file for an abuse allegation between R1 and V18 CNA (Certified Nursing Assistant) does not contain any resident interviews, only staff interviews. On 8/10/23 at 10:18 am, V1 Administrator confirmed V1 was not able to find any resident interviews that were completed for R1 and V18's abuse investigation, and there should have been some completed.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to complete a thorough abuse investigation for one of three residents (R1) reviewed for abuse on the sample list of six. Findings Include: R...

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Based on interview and record review, the facility failed to complete a thorough abuse investigation for one of three residents (R1) reviewed for abuse on the sample list of six. Findings Include: R1's undated Preliminary 24-hour Abuse Investigation Report documents on 7/28/23, R1 reported V18 CNA (Certified Nursing Assistant) was rough during cares. Employee immediately suspended. R1's Final Abuse Investigation Report dated 8/4/23 documents interview statements from R1, V9 CNA, V18 CNA, and V22 CNA but no interview statements from other residents, just a general statement of other alert and oriented residents were interviewed and voiced no similar interactions with (V18). The Alleged Abuse Witness Statements that were provided includes witness statements from an additional four staff between 7/31/23 and 8/1/23 but does not include any resident witness statements. On 8/10/23 at 10:18 am, V1 Administrator confirmed V1 was not able to find any resident interviews that were completed during R1 and V18's abuse investigation and there should have been. The facility's Abuse Prevention and Reporting Policy dated 10/2022 documents an incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation. Investigation Procedures: the appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident, the resident, if interviewable. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed to determine whether any one has witnessed any prior abuse, neglect, exploitation, mistreatment or misappropriation of resident property by the accused individual.

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 F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review, the facility failed to provide services to prevent a decrease in Activities of Daily Living for one of three residents (R3) reviewed for restorative ...

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Based on observation, interview and record review, the facility failed to provide services to prevent a decrease in Activities of Daily Living for one of three residents (R3) reviewed for restorative programs on the sample list of six. Findings Include: On 8/9/23 at 12:54 pm, V17 (R3's daughter) stated when R3 was admitted to the facility, R3 was able to walk better than (V17) could but due to not getting any restorative programs anymore, R3 is now in a wheelchair. R3's MDS (Minimum Data Set) dated 9/15/23 documents R3 has severe cognitive impairments, requires limited assistance of two staff for ambulation in R3's room and is in a walking restorative program seven days a week. On 8/10/23 at 5:00 am, V12 and V13 CNA's (Certified Nursing Assistant's) provided morning cares on R3 and got R3 up out of bed with a full weight bearing mechanical lift. On 8/10/23 at 8:40 am, V14 Restorative/CNA stated V14 use to be a Restorative CNA but now just works the floor as a CNA due to the facility cutting the restorative staff, approximately two weeks ago. V14 explained the facility expects the floor CNA's to do the restorative programs. V14 stated the restorative programs are not being done because the floor staff do not have time to do them. V14 confirmed R3 use to be in a walking restorative and did well, walking to the dining room for each meal but is now in a wheelchair, and does not walk. On 8/10/23 at 11:52 am, V21 CNA stated the CNA's don't have time to do the restorative programs, so they aren't being done. V21 stated, even if we had time, CNA's would need to be educated on them because everyone's program is different and that hasn't happened yet.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review, the facility failed to secure an indwelling catheter per plan of care and failed to keep the indwelling urinary drainage bag off of the floor for thr...

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Based on observation, interview and record review, the facility failed to secure an indwelling catheter per plan of care and failed to keep the indwelling urinary drainage bag off of the floor for three of three residents (R1, R3 and R4) reviewed for catheters on the sample list of six. Findings Include: 1.) On 8/9/23 at 12:54 pm, V17 (R3's family) stated R3 has pulled R3's catheter out three times in the last two months due to it not being secured and the facility not keeping pants on R3. R3's August 2023 Physician Order Sheet documents an order to change the indwelling catheters securement device weekly. R3's Care Plan dated 6/2/23 documents R3 has an indwelling urinary catheter due to obstruction and hematuria with an intervention to ensure catheter tubing is secured with a securement device. On 8/10/23 at 5:00 am, V12 and V13 CNA's (Certified Nursing Assistants) were providing morning cares to R3. R3 was lying in bed with pajama pants on. As soon as V12 and V13 pulled R3's pants down, R3 reached down and started to grab at R3's indwelling catheter. R3 did not have a catheter securement device in place. Both V12 and V13 stated they are unsure if R3 normally has a catheter securement device or not. 2.) R4's August 2023 Physician Order Sheet documents an order to change the indwelling catheters securement device weekly. R3's Care Plan dated 5/17/23 documents R4 has an indwelling urinary catheter due to urinary retention and polyneuropathy with an intervention to ensure catheter tubing is secured with a securement device. On 8/9/23 at 2:00 pm, R4 was sitting up in R4's recliner wearing a leg urinary drainage bag. R4 stated the catheter itself is not secured but the the leg bag is secured. R4 stated at night, facility staff remove the leg bag and then place a regular drainage back on the catheter at the time but that they don't put a securement device on. On 8/10/23 at 5:45 am, R4 was lying in bed with the urinary drainage bag hanging from R4's walker. R4's indwelling catheter did not have a secure device in place . 3) R1's August 2023 Physician Orders document to monitor the indwelling catheters drainage bag location every shift. On 8/9/23 at 3:00 pm, R1 was lying in bed with R1's uncovered urinary drainage bag hanging on the bedframe and resting on the floor. The facility's Urinary Catheter Care Policy date 9/2020 documents Indwelling Catheter urinary drainage bags and tubing shall be positioned as to prevent either from touching the floor directly.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to have sufficient staff to meet the needs for five of si...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to have sufficient staff to meet the needs for five of six residents (R1, R3, R4, R5 and R6) reviewed for staffing on the sample list of six. Findings Include: On 8/9/23 at 12:45 pm, V3 CNA (Certified Nursing Assistant) was working west wing with two other CNA's. V3 stated, this is typical lately, only having three CNA's when we use to have four on this wing. On 8/9/23 at 12:54 pm, V17 (R3's daughter) stated when R3 was admitted to the facility, R3 was able to walk better than (V17) could but due to not getting any restorative programs anymore, R3 is now in a wheelchair. R3's MDS (Minimum Data Set) dated 9/15/23 documents R3 has severe cognitive impairments, requires limited assistance of two staff for ambulation in R3's room and is in a walking restorative program seven days a week. On 8/9/23 at 1:50 pm, V4 LPN (Licensed Practical Nurse) working east wing stated V4 only has four CNA's today when they should have at least five. V4 stated it is very busy with only four CNA's but the nurses try to help out when able. On 8/9/23 at 2:00 pm, R4 stated sometimes you have to wait 30-60 minutes for your tablemate's to get their food due to not having enough staff to serve food, and R4 doesn't like eating in front of R4's tablemate's if they don't have their food. R4 also stated R4 has to wait more than 30 minutes for assistance from staff to get dressed. R4 also explained that R4 use to be in restoratives and the facility no longer does them. R4's MDS (Minimum Data Set) dated 5/11/23 documents R4 is alert and oriented, and in an AROM (Active Range of Motion) restorative six days a week and Dressing restorative seven days a week. On 8/9/23 at 2:03 pm, V6 CNA working east wing stated six CNA's use to work east wing but when the new company took over, a month ago, they cut all of the staffing and now only have five CNA's on the schedule. V6 explained today a staff member had to leave early, leaving on four CNA's and it's too hard. V6 stated R5 and R6, who reside on east wing have really complained about the lack of staff. On 8/9/23 at 2:05 pm, R5 stated R5 does most all ADL's (Activities of Daily Living) independently but requires assistance with getting R5's lower body dressed. R5 stated this morning, R5 had been sitting on the toilet, got R5's self washed up and dressed and then continued to sit on the toilet waiting for staff to come assist R5 with dressing of R5's lower body for an addition 20 minutes or more. R5 stated, I (R5) don't blame (V6) though, (V6) is running (V6's) tail off trying to take care of all of us. At this time, R6 stated it's really bad at night when you have to go to the bathroom and there is no staff to help you. R6 explained the usual wait time to use the bathroom is 30+ minutes and stated last week, after staff finally responded to R6's call light and placed R6 on the bedpan, R6 was left on the bedpan for over three hours. R5's MDS (Minimum Data Set) dated 5/11/23 documents R5 is alert and oriented and required limited assistance for dressing. R6's MDS dated [DATE] documents R6 is alert and oriented and requires extensive assistance for toileting. On 8/9/23 at 2:30 pm, V7 CNA stated V7 works first and second shift on east wing and east wing usually has five CNA's but that is not sufficient to meet the resident needs, we need to have six. Showers are not getting done because we have so many to do in one day and they are so time consuming. On 8/9/23 at 3:00 pm, R1 stated R1 has colon cancer that has metastasized to the lungs so R1 use to be in restorative programs to try and get stronger but R1 isn't doing them anymore and doesn't know why, and is just getting weaker. R1's 5/4/23 MDS documents R1 is alert and oriented and in a PROM (Passive Range of Motion), Dressing and Bed Mobility Restorative seven days a week. On 8/9/23 at 3:15 pm, V9 and V10 CNA's stated they generally work second shift on west wing with three CNA's. V9 stated only the bare minimum gets done; feeding, changing, and putting them to bed. V9 also stated showers, restoratives or any extra walking isn't getting done. V10 agreed with V9's statements On 8/10/23 at 8:40 am, V14 Restorative/CNA stated V14 use to be a Restorative CNA but now just works the floor as a CNA due to the facility cutting the restorative staff, approximately two weeks ago. V14 explained the facility expects the floor CNA's to do the restorative programs. V14 stated the restorative programs are not being done because the floor staff do not have time to do them. V14 confirmed R3 use to be in a walking restorative and did well, walking to the dining room for each meal but is now in a wheelchair, and does not walk. On 8/10/23 at 11:52 am, V21 CNA stated the CNA's don't have time to do the restorative programs, so they aren't being done. V21 stated, even if we had time, CNA's would need to be educated on them because everyone's program is different and that hasn't happened yet.

Jul 2023 4 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a cognitively impaired resident (R2) was free from physical ...

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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 cognitively impaired resident (R2) was free from physical abuse of by another resident (R1). R1 and R2 are two of five residents reviewed for abuse on the sample list of 17. Findings include: A facility abuse investigation witness statement dated 6/18/23 and signed by V17, Activity Aide documents the following: Around or after 11:00 am, I witnessed (R1) kick (R2). (R1) claimed resident (R2) was kicking her (R1), but I didn't see (R2) kicking (R1) She (R2) was just close to (R1), and rocking back and forth. (V16, Activity Aide) separated the two ( R1 and R2) After taking the people (unidentified) to lunch, (V16) alerted the nurse (R33, Licensed Practical Nurse/ LPN) who informed us we needed to call (V1, Administrator/Abuse Prevention Coordinator). R1's Minimum Data Set (MDS) dated [DATE] document the following: R1's Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15, which indicated R1 has no cognitive impairment. R2's MDS dated [DATE] document the following: R2's BIMS score of three out of a possible 15, which indicated R2 has severe cognitive impairment. On 7/18/23 at 12:35 pm R1 stated There is a resident that gets under my skin during activities. I don't know her name, but she is annoying. I (R1) don't remember ever fighting with her. I remember kicking her (R2). She (R2) kicked at me first (R1). I put an end to that immediately. I would not call that a fight. I don't know who said that, but it is not true. I already told the nurse (unidentified)I wasn't fighting, I just didn't want her to kick me. On 7/19/23 at 11:40 am V16, Activity Aide stated It has been a while since this (R1 kicked R2) happened (6/18/23). We (V16) and (V17, Activity Aide) were in the activity room with the residents (unidentified). (R2) was seated next to me (V16) for several minutes, doing activities with us. She (R2) then started moving her wheelchair away from me and in (R1's) direction. (R2) was kind of back and forth. I saw her (R2) get close to (R1). (R1) started yelling and said (R2) kicked her (R1). I told (R1) that if (R2) kicked her it was an accident. (R1) thought (R2) did it on purpose. (V17, Activity Aide) said right away, (R1) kicked (R2) in the leg. (V17) had a better angle than I did and, saw it happen. I just saw (R1) kick towards (R2). Me (V16) and (V17) separated (R1 and R2). I took (R2) and she (V17) took (R1). We reported right away to my boss (V27, Activity Director), the Nurse (V33, Licensed Practical Nurse/ LPN) and (V1, Administrator/ Abuse Prevention Coordinator). Both residents (R1 and R2) seemed fine. (R1) has made snide remarks, but I have never seen her (R1) do anything abusive before. We (V16 and V17) both wrote down our statements and gave them to (V1, Administrator/ Abuse Prevention Coordinator). (V17) is off today, but you can call her (no call back). She will tell you the same thing.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

Based on record review and interview the facility failed to maintain complete medical records for one of five residents (R3) reviewed for abuse on the sample list of 17. Findings include: The facility...

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Based on record review and interview the facility failed to maintain complete medical records for one of five residents (R3) reviewed for abuse on the sample list of 17. Findings include: The facility abuse investigation internal record, titled : Report to Illinois Department of Public Health documents R3 alleged a night shift employee hit R3 in the shoulder on 6/27/23. R3's Electronic Medical Records were reviewed. There was no documentation to indicate R3's alleged physical abuse, a physical assessment, a skin assessment, police, family or physician notification regarding the abuse allegation. On 7/18/23 at 4:05 pm V2, Director of Nursing (DON) confirmed there is no documentation in R3's medical record regarding R3's allegation of physical abuse on 6/27/23, no resident assessment, or notifications related to R3's allegation of physical abuse. V2, DON stated V1, Administrator/Abuse Prevention Coordinator 'is aware'. V2, Director of Nursing stated a late entry (21 days after the allegation), will be put in R3's chart to reflect what happened. Our nurses all know they are supposed to chart incidents, their assessments, and notifications. The facility policy Documentation-Electronic Health Record dated last reviewed March 2023 documents the following: Documentation Guidelines: Entries mad in the electronic health record shall be: * Timely * Accurate * Relevant * Complete ; Late entry documentatation is not encouraged, but in some cases may be necessary. Late entries should be made within 72 hours and will clearly indicated as late entries. Corrections to entries should be made in an addendum note or by striking the incorrect documentation and entering the correct documentation. No entries shall be made in a resident record after discharge.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide dignity while dining, by serving meals in Styrofoam contain...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide dignity while dining, by serving meals in Styrofoam containers with plastic utensils. This failure affected four of four residents (R5, R6, R7, and R8) reviewed for dignity while dining, on the sample list of 17. Findings include: 1.) R6's Minimum Data Set, dated [DATE] documents R6's Brief Interview of Mental Status score of 14 out of a possible 15, which indicates R6 has no cognitive impairment. On 7/18/23 at 11:45 am, R6 stated on Monday 7/17/23 the facility served the meals in Styrofoam containers with plastic utensils. R6 stated R6 was not given a reason. R6 then stated R6 does not like it one bit. 2.) R8's Minimum Data Set, dated [DATE] documents R8's Brief Interview of Mental Status score of 14 out of a possible 15, which indicates R8 has no cognitive impairment. On 7/18/23 at 11:50 am R8 stated plastic utensils were served for a few days when the dishwasher broke down, sometime last month and past this past weekend, maybe Sunday 7/16/23 or Monday 7/17/23. R8 stated R8 does not want plastic utensils and does not like food served in Styrofoam.Food taste different in Styrofoam and is hard to cut- up with plastic silverware in those containers. 3.) R5's Minimum Data Set, dated [DATE] documents R5's Brief Interview of Mental Status score of 14 out of a possible 15, which indicates R5 has no cognitive impairment. On 7/18/23 at 11:55 am R5 stated plastic utensils and Styrofoam containers were used for meal service three or four times in the past month. R5 stated R5 was never told why. R5 stated the food gets soggy and is warm at best in those containers. I don't think for the price we pay, we should have to eat from those containers with plastic utensils. 4.) R7's Minimum Data Set, dated [DATE] documents R7's Brief Interview of Mental Status score of 11 out of a possible 15, indicates R7 had moderate cognitive impairment at the time of this assessment. On 7/18/23 at 12:00 pm R7 stated Styrofoam containers, and plastic forks were used for food, when the dishwasher was out of service for several days, including yesterday. That is ok for hot dogs but not for other meals. Food was mushy, like hog slop and does not stay hot enough then. On 7/18/23 at 12:30 pm V12, Assistant Dietary Manager stated Yes, we have served resident meals in Styrofoam containers and (with) plastic utensils a couple times in the last month. We didn't have a dishwasher. Either the dishwasher was broken, or we didn't have staff to run the dishwasher. We served yesterday in containers (Styrofoam) and (with) plastic ware. On 7/19/23 at 12:28 pm V5, Dietary Manager (DM) stated We had kitchen and dishwashing staff call off (call in to work sick) Monday. We served resident meals in a Styrofoam box with plastic utensils. We did this out of necessity. We had to use the staff we had to serve the residents in a timely manner. I know that is a dignity issues. We had to do it. We have used Styrofoam over the course of the last month, two other times, when the dishwashing machine broke down. There was no evidence that alternative dining options were offered to residents during this time. The facility policy Dignity dated as last reviewed May 2023 documents the following: Guidelines to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The same guidelines direct staff to carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth. The same policy guidelines document maintaining a resident's dignity should include Promoting resident independence and dignity while dining, such as avoiding: Daily use of disposable cutlery and dishware.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to maintain resident personal laundry in a clean manner, ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to maintain resident personal laundry in a clean manner, resulting in a delay in returning resident personal laundry for resident use. This failure affected five of five residents (R5, R6, R7, R8 and R17) reviewed for laundry services on the sample list of 17. Findings include: 1.) R5's Minimum Data Set, dated [DATE] documents R5's Brief Interview of Mental Status score of 14 out of a possible 15, which indicates R5 has no cognitive impairment. On 7/21/23 at 8:10 am R5 stated the laundry department takes too long to bring back clean clothes. Sometimes, a week or two. 2.) R6's Minimum Data Set, dated [DATE] documents R6's Brief Interview of Mental Status score of 14 out of a possible 15, which indicates R6 has no cognitive impairment On 7/21/23 at 8:12 am R6 stated the laundry department can take two or three weeks to return R6's clothes. 3.) R7's Minimum Data Set, dated [DATE] documents R7's Brief Interview of Mental Status score of 11 out of a possible 15, indicates R7 had moderate cognitive impairment at the time of this assessment. On 7/21/23 at 8:14 am R7 stated it takes weeks to get R7's clothes. 4. ) R8's Minimum Data Set, dated [DATE] documents R8's Brief Interview of Mental Status score of 14 out of a possible 15, which indicates R8 has no cognitive impairment. On 7/21/23 at 8:18 am R8 stated currently R8 has two pair of pajama pants she is waiting to come back from laundry. R8 stated it has been close to a months wait. 5.) R17's Minimum Data Set, dated [DATE] documents R17's Brief Interview of Mental Status score of 13 out of a possible 15, which indicates R17 has no cognitive impairment. On 7/21/23 at 8:28 am R17 stated I'm missing two Distillery brand sweat shirts. One had a very nice emblem on it. That one was like new. I have had several pair of sleep pants missing as well. They were sent to laundry three weeks ago. I was told laundry staff are looking for them. On 7/21/23 at 9:10 am, V2, Director of Nursing (DON) toured the clean and soiled laundry rooms. V2, DON confirmed the facility has a backup of resident personal laundry. V2, DON stated she does not know how long it takes for laundry to be returned to residents but believes it takes about three to five days. The facility soiled laundry room had resident personal laundry that accumulated to the following degree: Six, four- feet deep, by five- feet long by four-feet wide, wheeled laundry bins with soiled resident personal laundry clothing. There was a strong foul odor present. The soiled clothes bins were over flowing, piled two feet above the rims of the top of the wheeled laundry bins. The laundry room adjacent to the soiled laundry room had four commercial triple-load clothes washing machines. Three washing machines were actively running, and the fourth washer was out of order. There were four triple load clothes dryers. All were running with facility white linen visible through the glass fronts. There was no laundry staff present. V2, DON stated V32, Laundry Aide comes in to work at 10:00 am. V30, Certified Nursing Assistant was folding resident clothes. The clean side of laundry room adjacent to the clothes dryers had two, approximately six feet long by five feet wide, four- feet deep wheeled bins, filled with resident clean laundry. These bins had clothes stacked two and a half feet higher than the wheeled laundry bin height. The clean side of the laundry room and hallway corridor outside the laundry room had four, six foot long, hanging racks tightly filled to capacity with resident personal laundry. There was also a four foot long by three foot wide, by four-foot-deep bin full of resident peronal laundry. At this time, V2 Director of Nursing (DON) stated this full bin of resident personal laundry contains unlabeled resident personal clothes and some clothes donated by previous residents when they discharged . There were six eight-feet shelves full of clean sheets, towels, and wash clothes. V2, DON stated V2, DON has nothing to do with laundry department staffing. V2, DON stated V1, Administrator will have to speak to staffing in the laundry department. On 7/21/23 at 10:00 am V32, Laundry Aide stated the following: I have worked here five months. We had three people in laundry when I started. Almost all five months we have worked short staffed. V32 further stated, About a month ago, I was the only laundry aide. I worked two weeks totally by myself. This place has over a hundred residents we do laundry for. V32 stated, Sometimes they will come down and let me know when a resident is out of residents' pants. That seems to be the most frequent item (clothing) needed. I got (have) to dig through the dirty bins or find them in the residents' clean laundry. V32 also stated, Many times, I will have unlabeled clothes. I have to take those things to the CNA's. A lot of times they know which resident it belongs to. That extra step takes me away from washing clothes and interrupts delivering laundry to the resident rooms. On 7/21/23 at 10:25 am V1 Administrator stated residents personal laundry needs to be returned to residents in a timely manner and has not been, consistently. V1 confirmed the facility has been working short staff with one full-time (V32) Laundry Aide and one part-time Laundry Aide (V31). V1 stated the facility needs one and a half additional laundry staff to keep up. V1 also stated V28 Housekeeper/ Laundry Supervisor has recently taken responsibility for supervising housekeeping and laundry. V1 stated V28 is currently on a two-week vacation which add to the delay.

May 2023 5 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

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 ensure three of four residents (R1, R4, R5) were not s...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure three of four residents (R1, R4, R5) were not subjected to physical and verbal abuse from another resident (R3) who were reviewed for abuse on the sample list of six. This failure resulted in R1 becoming fearful of R1's safety while at the facility because of R3's physically attacking R1 when R1 is bedbound and unable to defend R1's self. Findings Include: The facility Resident Care Policy and Procedure Regarding Abuse and Neglect, Involuntary Seclusion, Exploitation, Misappropriation of Resident Property, Injuries of Unknown Origin and Social Media dated 3/15/18 documents the following: All residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, and exploitation. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse means the infliction of injury on a resident that occurs, other than by accidental means and the required (whether or not given) medical attention. Physical abuse may include, but is not limited to such acts as: hitting, slapping, kicking, hair pulling and pinching. Verbal abuse means the use by an employee or agent or oral, written or gestured language that includes disparaging and derogatory terms to a resident or within his or her hearing or seeing distance, regardless of the resident's age, ability to comprehend or disability. 1.) On 5/15/23 at 10:10 am, R1's room door had two stop signs adhered on it. R1 was lying in bed and stated R1 has been attacked by R3 who has dementia, while here at the facility. R1 explained R3 used to come into R1's room quiet a bit and when R1 would ask R3 what R3's name is and what R3 wanted, R3 would say Oh, you know who I am, then several months back, R3 came in and started hitting R1. R1 stated R1 reported it and it was already investigated by the facility and IDPH (Illinois Department of Public Health). R1 stated R1 hadn't had any other problems with R3 until a couple of weeks ago. At this point, R1 started to cry and explained, R3 wheeled R3's self into R1's room again and when R1 told R3 to leave, after activating the call light, R3 started pinching R1's right leg, to the point R3 broke the skin. R1 stated R1 tried pushing R3 away and kicking at R3 but that leg doesn't work right, I (R1) have a spacer in that knee and I'm not able to bend it or really even move it, Im pretty much bed bound. R1 stated staff responded to the call light and R1's yells for help and got R3 out of R1's room and R3 hasn't been back since. R1 started to cry again and stated, R1 don't feel safe in the facility with (R3) also being at the facility and close to me (R1) {R3 residents right across the hall from R1}, I'm scare of what (R3) will do next. R1 went on to say, R3 has already attached R1 twice and R1 can't defend R1's self so now R1 has a spray bottle, pointing to a green spray bottle sitting on the over bed table and stated if R3 comes back in here and staff don't respond quickly, R1 can spray R3 with it to try and get R3 to go away; and if that doesn't work, I (R1) have an extending fly swatter that I can use to try it and shoo (R3) away with. R1 explained R1 doesn't want to have to use them but that is the only way R1 can defend R1's self. R1 also stated the one time that R1 has come out of R1's room since the attach was for a care plan meeting and on R1's way back to R1's room, R1 noticed R3 sitting next to the nurses stated. R1 explained, I (R1) started to panic when I (R1) seen (R3). I (R1) tried going quickly past (R3) and even turned my head so (R3) didn't see my face. I (R1) didn't want (R3) to follow me back to my room. R1's MDS (Minimum Data Set) dated 4/15/23 documents R1 is alert and oriented. R3's MDS dated [DATE] documents R3 has severely impaired cognition. The facility's final abuse investigation between R1 and R3 dated 4/25/23 documents R1 stated R3 came into R1's room and requested to be covered up with a blanket and began pinching R1's leg. R1 stated R1 asked R3 to stop and then put on R1's call light. V15 CNA (Certified Nursing Assistant) responded to R1's call light after hearing R1 yelling and removed R3 from the room. At the time V15 responded, R3 was not doing anything but R1 stated R1 was pinched by R3. R3 does not recall the incident due to R3's diagnoses. The facility believes the allegation is substantiated. On 5/15/23 at 1:16 pm, V1 Administrator confirmed R1 has been in an abusive situation while at the facility, more than once, but thinks R1 is confused and that the first situation was not with R1. 2.) The facility's final Abuse Investigation dated 5/7/23 between R3 and R4 documents V17 Housekeeping/Laundry Supervisor witnessed R3 hitting R4 closed fisted with the bottom of R3's hand on R4's arm. When V17 asked R3 what are you doing, R3 then grabbed R4's arms. V18 CNA (Certified Nursing Assistant) also witnessed R3 grabbing R4's arm. Upon completion of the investigation, the facility believes the incident did occur as a result of R3's diagnoses. R3's ongoing Diagnoses List documents R3 has Unspecified Psychosis, Dementia with Behaviors, and Delusional Disorder. R3's MDS (Minimum Data Set) dated 4/5/23 documents R3 has severely impaired cognition. R4's MDS dated [DATE] documents R4 has severely impaired cognition. On 5/16/23 at 9:09 am, V17 stated V17 was coming upstairs from laundry and walked into the east wing lounge area. V17 witnessed R3 hitting R4. V17 stated V17 looked around to see if there was any staff around and there wasn't, so V17 went up to R3 and talked to R3 and rubbed R3's hand trying to calm R3 down and at that time, R3 stopped hitting R4's arm but then tightly grabbed R4's arm. At that point, an unidentified staff member came around the corner, so V17 asked the unidentified staff to take R3 away from R4. The two residents were separated and V17 asked R4 if R4 was okay and R4 replied, yeah, (R3) better be glad that (R3) is a lady. R3 was still irate and trying to grab and hit everyone in R3's reach. On 5/16/23 at 1:15 pm, V1 Administrator stated V1 watched video surveillance of the alleged abuse and the video showed R3 was sitting behind R4 in the lobby area. R3 rolled up to R4, R3 said something, you could see R3's mouth moving but not able to hear anything and then R4 said something back to R3. R4 looked upset and after R4 responded, R3 grabbed R4's arm and started pinching at R4. R3's hand was holding onto R4's arm and then pinching R4's torso area. Then I seen R4 moving R4's arm trying to get it away from R3 and trying to push R3 away. That went on for about 20 seconds then V17 and V18 came into the lobby area and they both separated R3 and R4. V18 moved R3 closer to the nurses station, and V17 was talking to R4. R3 was still upset, and reaching out trying to pinch a staff member that was walking by. Confirmed physical abuse occurred. 3.) On 5/15/23 at 9:50 am, R5 was sitting up in a recliner in R5's room and stated a couple of weeks ago, R5 was asleep in R5's wheelchair in R5's room, with R5's back facing the door when R5 was awoken by someone hitting R5 upside the back of the head and cussing at R5. R5 stated, R5 don't know who it was because they were behind R5 but R5 yelled out, why did you just hit me and several people came to R5's room. R5 reported staff said said it was a female resident, they told me her name but I don't remember who it was but they got her out of here. R5 stated, I (R5) don't know why they {facility} are making such a big deal about it, but then again, I guess people can't just go around and hit others. I (R5) just don't understand why she was cussing at me, I don't cuss so I don't appreciate her cussing at me. R5's Final Abuse Investigation dated 5/3/23 documents R5 reports that R3 smacked the back of R5's head. R5 has a BIMS (Brief Interview for Mental Status) score of 15 {indicating R5 is alert and oriented} and stated that R3 who has a BIMS of 4 {indicating severe cognitive impairments} came into R5's room while R5 was resting in R5's wheelchair and smacked R5 on the back of the head. During medication pass around 2100, V10 RN (Registered Nurse) went into R5's room and saw R3 in R5's room. V10 removed R3 and during that time, R5 reported that R3 smacked R5 on the back of R5's head. The facility believes the incident did occur as a result of R3's diagnoses. On 5/15/23 at 1:02 pm, V1 Administrator confirmed R3 verbally and physically abused R5.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on interview and record review, facility staff did not report an allegation of physical abuse immediately to the administrator for two of four residents (R3, R4) reviewed for abuse on the sample...

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Based on interview and record review, facility staff did not report an allegation of physical abuse immediately to the administrator for two of four residents (R3, R4) reviewed for abuse on the sample list of six. Findings Include: The facility's Abuse investigation for R3 and R4 documents an Initial Report Date of 5/2/23 with a Final Report date of 5/7/23. This investigation documents V17 Housekeeping/Laundry Supervisor witnessed R3 hitting R4's arm closed fisted with the bottom of R3's hand. V17 approached R3 and asked R3 what are you doing and then R3 grabbed R4's arms. This investigation also documents V18 CNA (Certified Nursing Assistant) witnessed R3 grabbing R4's arm after entering the lobby/lounge area. This investigation contained witness statements from V17 and V18, both dated 5/2/23. V17's statement dated 5/2/23 documents V17 came upstairs to the East lobby and witnessed R3 hitting R4 with the bottom of R3's closed fisted hand on R4's right forearm. V17 asked R3 what R3 was doing and then R3 switched from hitting R4 to grabbing R4's right arm tightly. V17 immediately went to separate R3 and R4 with the assistance of an agency nurse (not able to recall name). R3 appeared to be agitated during the time of separation. R3 was redirected and the team was able to get R3 calm. V18's statement documents V18 seen R3 holding onto R4's arm. On 5/16/23 at 9:09 am, V17 confirmed V17 witnessed R3 hitting R4 on a Sunday but doesn't recall the exact date but didn't report it to V1 Administrator until the next morning and at that time, V1 had V17 write up V17's statement and sign it. V17 also stated, after having time to think about it, V17 knows V17 should have reported the incident to V1 the same day but V17 was the only staff working in laundry and was overwhelmed with trying to get everything done and since V17 calmed the situation down, V17 didn't report it the same day. On 5/16/23 at 11:15 am, V1 Administrator stated V17 witnessed R3 hitting R4 on Sunday 4/30/23 but did not reported the incident to V1 until 5/2/23 {2 days later}. V1 explained that V17 had worked the weekend so V17 was off on 5/1/23, so V17 reported it upon returning to the facility on 5/2/23. V1 stated V17 should have reported the abuse allegation to V1 immediately. The facility's Resident Care Policy and Procedures Regarding Abuse and Neglect, Involuntary Seclusion, Exploitation, Misappropriation of Resident Property, Injuries of Unknown Origin, and Social Media dated 3/15/18 documents when a facility employee or agent or covered individual becomes aware of an alleged abuse or neglect of a resident, they shall immediately report the matter to the facility Administrator.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to protect residents from abuse by another resident for three of four residents (R3, R4, R5) reviewed for abuse on the sample list of six. Fi...

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Based on interview and record review, the facility failed to protect residents from abuse by another resident for three of four residents (R3, R4, R5) reviewed for abuse on the sample list of six. Findings Include: The facility's Resident Care Policy and Procedures Regarding Abuse and Neglect, Involuntary Seclusion, Exploitation, Misappropriation of Resident Property, Injuries of Unknown Origin, and Social Media dated 3/15/18 documents if an incident involves suspected abuse, then the charge nurse shall assure that the suspected abuser has no further contact with the resident involved or with any other resident. When an allegation of suspected abuse is received that another resident of the long-term care facility is the perpetrator of the abuse, that resident's condition shall be immediately evaluated to determine the most suitable therapy and placement for the resident, considering the safety of that resident as well as the safety of other residents and employees of the facility. If another resident is the suspected perpetrator of the abuse, then the suspected resident shall be supervised 1:1 or kept physically separate from all other resident's until further orders and the Administrator shall take all steps necessary to protect all residents in the facility from abuse until the alleged perpetrator can be evaluated. The facility's Abuse Investigation between R3 and R5 documents on 4/28/23, R5 reported that R3 entered R5's room and hit R5 upside the back of R5's head and started cussing at R5. The Final Abuse Investigation dated 5/3/23 documents that the abuse was substantiated. The facility's Abuse Investigation between R3 and R4 dated documents on 4/30/23, while in the lounge/lobby, R3 was observed hitting R4's arm with a closed fist. The Final Abuse Investigation dated 5/7/23 documents that the abuse was substantiated. On 5/16/23 at 1:35 pm, V1 Administrator stated R3's level of supervision did not change between 4/28/23 - 5/10/23 when R3 was evaluated by Psychiatric Services except for being in the common area when awake because the facility is not able to provide 1:1 cares. V1 also stated, the reason for R3 being in the common area {lobby/lounge} is so R3 can be monitored by staff but in the case of R3 and R4 on 4/30/23, that didn't occur because staff were not around.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review, the facility did not provide adequate supervision. This failure resulted in one of three residents (R2) reviewed for supervision getting out of a loc...

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Based on observation, interview and record review, the facility did not provide adequate supervision. This failure resulted in one of three residents (R2) reviewed for supervision getting out of a locked dementia unit and being found in the hallway between two locked doors on the sample list of six. Findings Include: On 5/15/23 at 10:30 am, V5 LPN (Licensed Practical Nurse) stated awhile ago, V5 had asked V4 CNA (Certified Nursing Assistant) to do V4's charting as it hadn't been done yet and it was getting close to the end of V4's shift, while V5 went to assist another resident to the bathroom. V5 stated V5 guesses that made V4 mad and V4 neglected the unit by leaving and when doing so, placed (R2) in the long hallway between the main part of the building and the dementia unit. V5 stated V5 don't know what really happened because V5 didn't see anything and by the time V5 was finished toileting the other resident, R2 was already back on the unit. V5 reported that V7 RN (Registered Nurse) called and informed V5 that V7 had seen R2 in the long hallway and that V4 had reported to someone, I don't know if it was V7 or someone else that V4 had placed R2 in the hall. V7 assisted R2 back into the locked unit. On 5/15/23 at 10:40 am, R2 was observed walking unassisted in the dementia unit. At this time, V5 provided the surveyor the code in order to get out of the dementia unit, as the door was locked. On the other side of the door was a long, approximately 68 foot inclining hallway leading to another locked door, which lead to the main facility. R2's MDS (Minimum Data Set) dated 3/29/23 documents R2 has severely impaired cognition and requires supervision with ambulation. R2's Care Plan dated 4/4/23 documents R2 is disoriented to place, has impaired safety awareness, and is an elopement risk. On 5/15/23 at 2:14 pm, V4 stated R2 runs around back there on the unit and is a sweet man. V4 denied putting R2 into the hallway separating the dementia unit and main building, between the two locked doors. V4 also stated V4 has never had a resident follow V4 out the door when leaving the dementia unit explaining, that hallway between the units is long so long, you'd see if someone came out with you. On 5/15/23 at 2:40 pm, V7 RN stated V7 is was unsure of date but one evening around 6:00 pm, when V7 was working on the East Wing, the dementia unit alarm started going off and V4 CNA came through the doors onto east wing. V7 stated V7 thought that it was V4 who had set the door alarm off but stated V4 made a comment that somebody is trying to get out but V4 didn't turn around to assist the person but instead left the unit/facility so V7 went to check who it was. V7 noticed R2 at the top of the ramp (by the door to east) wing and (R2) had already turned around and was heading back down the ramp heading to the dementia unit. V7 stated V7 escorted R2 back to the dementia unit and called V5 to report what had happened. V7 stated V4 did not say V4 put R2 in the hall but for (R2) to have already made it up the long hall/ramp to the east wing in the time that (V4) did, (V4) would have had to have known that R2 was with (V4) or behind (V4), and (V4) didn't take R2 to the unit where (R2) belongs, (V4) just left (R2) locked between the two doors. On 5/16/23 at 11:40 am, V1 Administrator confirmed that if R2 made it up the long inclining locked hallway, V4 would have know that R2 was in the hall with V4, and should not have left R2 in the hallway. V1 explained V4 should have escorted R2 back to the unit and not have let R2 off of the dementia unit due to R2 being an elopement risk and needing supervision.

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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected multiple residents

Based on interview and record review, the facility failed to operationalize their abuse policy for reporting and protection of four out of four residents (R1, R3, R4 and R5) reviewed for abuse on the ...

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Based on interview and record review, the facility failed to operationalize their abuse policy for reporting and protection of four out of four residents (R1, R3, R4 and R5) reviewed for abuse on the sample list of 6. Findings Include: The facility's Resident Care Policy and Procedures Regarding Abuse and Neglect, Involuntary Seclusion, Exploitation, Misappropriation of Resident Property, Injuries of Unknown Origin, and Social Media dated 3/15/18 documents when a facility employee or agent or covered individual becomes aware of an alleged abuse or neglect of a resident, they shall immediately report the matter to the facility Administrator. This policy also documents if another resident is the suspected perpetrator of the abuse, then the suspected resident shall be supervised 1:1 or kept physically separate from all other residents until further orders and the Administrator shall take all steps necessary to protect all residents in the facility from abuse until the alleged perpetrator can be evaluated. 1.) On 5/16/23 at 9:09 am, V17 Housekeeping/Laundry Supervisor stated V17 witnessed R3 hitting R4 on a Sunday but doesn't recall the exact date but didn't report it to V1 Administrator until the next morning and at that time, V1 had V17 write up V17's statement and sign it. V17 also stated, after having time to think about it, V17 knows V17 should have reported the incident to V1 the same day but V17 was the only staff working in laundry and was overwhelmed with trying to get everything done and since V17 calmed the situation down, V17 didn't report it the same day. V17's witness statement was dated Tuesday 5/2/23. On 5/16/23 at 11:15 am, V1 Administrator stated V17 witnessed R3 hitting R4 on Sunday 4/30/23 but did not reported the incident to V1 until 5/2/23 {2 days later}. V1 explained that V17 had worked the weekend so V17 was off on 5/1/23, so V17 reported it upon returning to the facility on 5/2/23. V1 stated V17 should have reported the abuse allegation to V1 immediately. 2.) The facility's Abuse Investigations document confirmed physical abuse between R1 and R3 on 4/20/23 occurring in R1's bedroom, between R3 and R5 on 4/28/23 occurring in R5's bedroom and between R3 and R4 on 4/30/23 occurring in the lounge area with R3 being the aggressor/abuser each time. R3's Psychiatric Services Physician Note dated 5/10/23 documents R3 was seen due to worsening anxiety, poor sleep, and worsening agitation with verbal and physical aggression with no clear triggers. On 5/16/23 at 1:35 pm, V1 Administrator stated after the first abuse allegation between R1 and R3 on 4/20/23, the facility offered to move R1, which R1 didn't want to do so the facility put the stop signs up on R1's door hoping to stop R3 from entering R1's room, that is all we did. V1 then explained that after R3 and R5's incident on 4/28/23, that is when the facility referred to R3 to Psychiatric Services to be evaluated, requested a medication review and got orders for laboratory/urine tests. V1 stated, the biggest issue is (R3's) interactions with other residents was so random, we {facility} kept (R3) in common areas for visual purposes but we {facility}are not set up to be able to do 1:1. V1 explained the facility also placed the initial call to R3's family and requested they come in more often to visit because when family is here, R3 doesn't have these behaviors. V1 stated the diagnostic orders were received but took 6 days to obtain and that it shouldn't have taken that long. V1 also confirmed R3 was not seen by Psychiatric Services until 5/10/23 {12 days after R3 hit R5}. V1 explained after the third abuse incident on 4/30/23 between R3 and R4, the facility requested a care plan meeting, which was held on 5/15/23 {15 days after the incident} and discussed moving R3, and increasing medications based on laboratory results, but the family refused. V1 explained the reason for placing R3 in general areas is so she can be monitored but with the situation between R3 and R4 in the lounge area, that didn't occur because staff were not around. V1 stated R3's level of supervision did not change between 4/28/23 - 5/10/23 when evaluated except for being in common area when awake.

Mar 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to respond timely to an exit door alarm for one of three residents (R1) reviewed for accident hazards on the sample list of three. This failur...

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Based on interview and record review, the facility failed to respond timely to an exit door alarm for one of three residents (R1) reviewed for accident hazards on the sample list of three. This failure resulted in R1 leaving the facility unnoticed. Findings Include: On 3/8/23 at 2:15 pm, V11 Agency LPN (Licensed Practical Nurse) stated on the evening of 2/22/23, V11 was at the nurses station signing in a medication delivery with the Pharmacy Delivery man and there was a door alarm going off. V11 stated V11 didn't check the alarm panel to see what door was alarming but instead asked an unidentified CNA (Certified Nursing Assistant) to take care of the alarm. V11 stated the west lounge exit door had been alarming off and on all evening due to it storming outside and the high winds pushing on the door. V11 explained the unidentified CNA went over to the west lounge exit door, without checking the alarm panel to ensure that was the door that was alarming, and tried to reset the alarm but as soon as the CNA walked away, the alarm started sounding again. V11 stated the CNA returned back to the door, without checking the alarm panel, to reset the alarm but it wouldn't reset. V11 stated as the unidentified CNA then went to check the alarm panel and noticed it was the west dining room door that was alarming. At this point, there was another unidentified CNA that came running down the hall saying we've got an east hall resident out in the parking lot. V11 stated since V11 was on the west hall, V11 was going to finish signing in the medications with the Pharmacy Delivery man and then go out to assist but the unidentified CNA then came back saying it was one of V11's residents that was outside so V11 hurried up and threw the medications in the medication room and followed the unidentified staff outside. V11 explained V11 and the unidentified CNA went down the hallway and out through the breakroom door, into the parking lot to find R1 out in the parking lot. V11 stated there was a visitor in the parking lot that had seen R1 leave the facility through a back door and then came into the facility to alert staff, V11 assumed the visitor had told V15 Agency RN (Registered Nurse) because V15 was already outside with R1 when V11 arrived outside. V11 is not sure how long the door alarm had been sounding and explained, the alarm could have been going off for a long time due to us assuming it was the lounge door due to the storm. On 3/8/23 at 3:07 pm, V15 Agency RN stated V15 was in the breakroom on the evening of 2/22/23 when an unidentified visitor came through the breakroom door and said there is someone laying in the road. V15 went outside and observed R1 lying on the ground behind a vehicle in the staff parking lot behind the building. V15 stated V13 Visitor reported to V15 that V13 observed R1 exit the facility from the [NAME] Dining Room door and walk down the ramp and sidewalk to the parking lot. V13 called out to R1 and asked R1 what R1 was doing and when V13 did that, R1 started running and fell, so that is when V13 sent in the unidentified visitor to report the situation to facility staff. V15 stated R1 was only outside a few minutes before staff responded due to V15 already being in the breakroom. On 3/8/23 at 3:36 pm, V1 Administrator stated when a door alarm goes off, staff need to check the alarm panel and see what door is alarming then go assess the situation to see if someone got out. The alarm is not to be shut off before doing that and if a resident is outside, the alarm is to stay activated until the resident is back inside. On 3/9/23 at 9:30 am, V22 CNA stated V22 was working the evening that R1 got out of the facility. V22 explained V22 heard a door alarm going off but didn't know which door was sounding and didn't check it because V22 was in another resident room. V22 explained V22 then seen other staff run past the door so V22 came out to see what was going on and someone yelled a resident was outside. V22 stated, honestly, we {staff} are kinda numb to the {alarm} sound because the back kitchen door is always going off. The Detailed Patient Activity Report documents that the [NAME] Dining Room exit door was alarming for 10 minutes and 45 seconds. The facility Wandering Resident/Elopement Policy dated October 2011 documents facility staff will insure that all exit alarms are responded to immediately.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review, the facility failed to document an elopement and monitoring for placement and functional status of electronic monitoring devices for two of three res...

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Based on observation, interview and record review, the facility failed to document an elopement and monitoring for placement and functional status of electronic monitoring devices for two of three resident (R1 and R2) reviewed for elopement on the sample list of three. Findings Include: On 3/8/23 at 8:30 am, V4 RN (Registered Nurse) stated R1 and R2 have a history of wandering and V4 had heard that both R1 and R2 had recently eloped but doesn't know any details. R1's Progress Notes dated 2/23/23 documents R1 had an electronic monitoring device placed and exit seeking care plan was updated. R2's Progress Notes dated 2/23/23 documents R2 is exit seeking and had an electronic monitoring device placed. There is no documentation in either resident's medical record that R1 and R2 eloped from the facility. On 3/8/23 at 9:05 am, V2 DON (Director of Nursing) confirmed that R1 and R2 had gotten out of the facility, one on the evening of 2/22/23 and the other during the night of 2/22/23-2/23/23, and that is when R1 and R2 had the electronic monitoring devices applied. On 3/8/23 at 9:19 am, R2 was lying in bed with an electronic monitoring device to the left ankle. On 3/8/23 at 9:21 am, R1 was sitting up in a wheelchair in R1's room wearing an electronic monitoring device to the left ankle. On 3/8/23 at 12:47 pm, V2 DON stated on 2/23/23 during the night, V12 MDS (Minimum Data Set) Coordinator was working the floor and reported R2 went outside but was brought back inside by staff. At the time of notification, V2 referred V12 to the facility Wandering Policy and instructed V12 to place an electronic monitoring device onto R2. At this time, V2 confirmed R1 and R2's elopements were not documented in the medical record and stated it was because the policy does not instruct staff to document the elopement in the medical record. On 3/8/23 at 3:07 pm, V15 Agency RN (Registered Nurse) stated on 2/22/23 between 6:30 pm - 7:00 pm, V15 had been in the breakroom when an unidentified person came through the breakroom door and said there is someone laying in the road. V15 explained V15 went outside and seen R1 lying on the ground behind a vehicle in the staff parking lot behind the building. On 3/8/23 at 4:58 pm, V15 stated R1 and R2 should have orders in their medial record to check the electronic monitoring device and it would be signed off in either the MAR (Medication Administration Record) or TAR (Treatment Administration Record). R1 and R2's February and March 2023 Physician Orders do not document an order for placement or monitoring of an electronic monitoring device. On 3/9/23 at 1:10 pm, V2 DON stated an electric monitoring device is considered a treatment for the resident and should have an order for it, as well as it being monitored every shift to ensure placement and every week to ensure function. V2 explained the nurses should be signing out that they are doing those things on the MAR or TAR. At this time, V2 confirmed R1 and R2 do not have orders for the electronic monitoring devices nor are staff signing out that placement and functional status of the electronic monitoring device being checked. The facility Wandering Resident/Elopement Policy dated October 2011 documents Wandering is defined as movement about the area without a fixed goal, and elopement is defined as the slipping away secretly, running away, leaving without accompaniment or knowledge of the staff. Residents with an elopement incident from the facility either on or off the grounds shall be considered at higher risk for further attempts at elopement. These residents will have precautionary measures implemented to prevent repeat incidents of elopement. The resident will wear an alarm bracelet {electronic monitoring device} to alert staff if he/she is trying to leave the facility. The bracelet will be checked weekly to assure that it is functional, and checks will be logged.

Feb 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to implement measures to prevent a resident with known aggressive behaviors (R6) from inflicting physical abuse on another resid...

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Based on observation, interview, and record review, the facility failed to implement measures to prevent a resident with known aggressive behaviors (R6) from inflicting physical abuse on another resident (R5). This failure affects one resident (R5) out of a sample of 5 residents reviewed for allegations of abuse. Findings include: The facility's Resident Roster dated 2/16/23 documents R5 and R6 both reside on the facility's locked dementia care unit. R5's Care Plan dated 2/10/23 documents R5 is at risk for harm, either self-directed or other-directed. R5's Nurses Note dated 2/12/23 at 3:30 pm documents, Resident had contact made to left cheek from another resident at this time. R5's Nurses Note dated 2/12/23 at 4:56 pm documents, Behaviors: yelling out, tearful, repetitive statements and questions, impatient with peers and staff, refusing to use her walker, pacing, anxious, restless. R6's Nurses Note dated 2/12/23 at 3:30 pm documents, Resident made contact with right hand to left cheek of another resident at this time. R6's Nurses Note dated 1/28/23 documents, Behaviors: yelling out, screaming, rude comments, moving chairs in the tv (television) lounge, states everyone is wasting electricity with the lights on, refusing to use walker. R6's Nurses Note dated 1/15/23 documents, Behaviors: yelling out during bingo, rude comments. R6's Nurses Note dated 12/27/22 documents, Behaviors: screaming, yelling out, rude comments, at the activity aid during bingo. R6's Nurses Note dated 10/13/22 documents, Behaviors: combative, resistive, attempting to bite staff, yelling out. R6's Nurses Note dated 9/25/22 documents, Behaviors: yelling out, rude comments, combative and resistive, trying to take roommates items. R6's Nurses Note dated 9/18/22 documents, Behaviors: resident doesn't understand why roommate is in (R6's) room, states roommate is a stranger and does not want roommate in room, if we (staff) don't remove roommate (R6) will kick roommate out. R6's Care Plan dated 1/6/22 documents a goal of, (R6) will not scratch at self or others. R6's Care Plan dated 5/9/22 documents Behavior management, (R6) may refuse cares and to use walker, becomes impatient and demonstrates physical and verbal abusive behaviors. On 2/17/23 at 11:25 am, R5 and R6 were both seated in the dementia care dining area at separate tables. Staff were present conducting the lunch meal service. On 2/17/23 at 11:30 am, V18 Certified Nursing Assistant, stated, I did not witness the actual slap, but I did hear the altercation get started and then I heard the slap. I was here at the nurses station (approximately 25 feet away from the incident). On 2/17/23 at 11:40 am, V19, Certified Nursing Assistant, stated, (R5) was leaning over (R6's) walker and (R6) was getting mad. I looked up just as (R6) was slapping (R5). I was standing at the nurses station when it happened. V19 further stated, I don't think (R6) has any disease that makes (R6) have twitches or involuntary movements. It was an intentional act. On 2/17/23 at 11:45 am, V22, Licensed Practical Nurse, stated, I was not working the day of this incident but I confirm (R6) does not have any conditions which would give (R6) muscle twitches or involuntary movements. On 2/17/23 at 11:50 am, V20, Activity Aide, stated, I did not witness the actual incident because I was passing out cookies, I only became aware of what happened after everybody else (staff) was separating (R5) and (R6), but it all happened during bingo. On 2/17/23 at 2:25 pm, V21, Licensed Practical Nurse, stated, I was working the day of the incident between (R5) and (R6). I was at the nurses station and I saw (R5) leaning over (R6's) walker and bringing it towards (R5's) self. Then (R6) said 'hey that's my walker' and then (R6) smacked (R5) on the face. V21 continued, I witnessed the actual smack. I don't think (R6) has any diagnosis that would give (R6) involuntary twitches (again confirmed by V22), and (R6) didn't slip off the edge of the table and fall into (R5), it wasn't anything accidental. V21 further stated, I talked to (R6) after we separated the two of them and (R6) said 'I smacked (R5) because (R5) was taking my walker.' The facility's Abuse Prohibition Policy dated 3/15/18 documents every resident has the right to be free from abuse, and includes non-accidental acts such as slapping in the definition of physical abuse.

Feb 2023 5 deficiencies 1 IJ

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The failures at this level require more than one deficiency statement. A.) Based on record review and interview the facility fai...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The failures at this level require more than one deficiency statement. A.) Based on record review and interview the facility failed to supervise a resident with suicidal ideation, failed to implement the facility suicide watch policy and failed to initiate care plan interventions after R1 verbalized intentions of killing R1's self. Theses failures resulted in R1 continuing to experience thoughts of self harm and then attempting to strangle R1's self with call light and bed control cords. These failures affect one (R1) of five residents reviewed for accidents in a sample list of 31 residents. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 12/20/22 when R1 made suicidal comments which indicated a plan to use the call light cord to harm himself and the facility did not remove the call light cord nor initiate new Care Plan interventions. V1 Administrator was notified of the Immediate Jeopardy on 1/31/23 at 4:11 PM. The surveyor confirmed by record review, observation and interview that the Immediate Jeopardy was removed on 2/2/23, but noncompliance remains at a level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: a. R1's Nurse Progress Note dated 1/3/23 at 11:34 PM documents Found (R1) in his bed with two call lights and bed control cords wrapped around (R1's) neck. R1's Nurse Progress Note dated 1/4/23 at 7:00 AM documents R1 was sent to the emergency room for psychiatric evaluation. R1's undated Face Sheet documents R1 admitted to facility on 10/6/22 with medical diagnoses of Surgical Aftercare following Surgery on the Nervous System, Spinal Stenosis, Muscle Weakness, Muscle Wasting and Atrophy, Malignant Neoplasm of the Prostate, Rheumatoid Arthritis, Major Depressive Disorder and Anxiety. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. This same MDS documents R1 as requiring extensive assistance of one person for bed mobility, transfers, dressing, and toileting, supervision with eating, and limited assistance of one person for personal hygiene. R1's current Care Plan does not document a focus area, goal nor interventions for risk of abuse. R1's Care Plan documents a focus area of 'Risk for harm to self or others' dated 10/7/23. R1's Care Plan does not document any added interventions from 10/7/22-1/4/23. R1's Nurse Progress Note dated 12/20/22 at 10:55 AM documents (R1) was making suicidal comments, was crying. (R1) wanted to hurt himself with the call button cord. (V18) Licensed Practical Nurse (LPN) went to (R1's) room to check on (R1). (R1) stated 'December was supposed to be my month of healing, my sister canceled my trip to Michigan, the beginning of the year was filled with sadness, loneliness'. (R1) stated 'I am working in therapy, and nothing is working'. (V18) asked (R1) if wanted to hurt himself. (R1) responded 'I feel hopelessness. There is nothing for me here.' R1's Nurse Progress Note dated 12/27/22 at 9:20 PM documents (R1) was really tearful and sad all day. During medication pass (R1) refused medications. (R1) stated 'I do not want my medication, food or water. I am just going to let mother nature take its course with this body'. Encouraged to think positive. (R1) refused and stated, 'just wants to die and wanted to be left alone.' R1's Nurse Progress Note dated 12/30/22 at 8:52 AM documents (V31) (R1's family) called in relation to new referral to see in-house psychiatrist. Questions and concerns addressed. R1's Nurse Progress Note dated 1/2/23 at 7:15 AM documents (R1) lying in bed crying. Stating that this is no quality of life. (R1) stated that he was tired of just taking drugs and not feeling normal. Non-pharmacological interventions: distraction and conversation. Summary: (R1) was wanting to not take medication anymore due to feeling out of sorts. R1's Nurse Progress Note dated 1/3/23 at 11:34 PM documents Found (R1) in his bed with two call lights and bed control cords wrapped around (R1's) neck. (R1) stated this is where all of his problems started, that this is where they will all end. (R1) unhappy about his medical diagnoses, the amount of medication he is taking, not being able to go to his own home, being denied going to his sister's for Christmas. Non-pharmacological interventions: Conversation and distraction. Summary: (R1) made aware of why cords were removed at this time. (R1) does not wish to be sent out to the hospital but also does not have any hope of living at this time. R1's Nurse Progress Note dated 1/4/23 at 7:00 AM documents Spoke with (V1) Administrator and (V1) stated to call the doctor about (R1's) current mood state. Once off the phone with (V1), called the on-call Physician. On call Physician called back and stated (R1) needed to be sent to emergency room for psychiatric evaluation. Family was notified and is ok with sending (R1) out. R1's Nurse Progress Note dated 1/11/23 at 12:33 PM documents (R1) told staff that he did not see any point in living anymore. (R1) states he would like to stop eating and just close his eyes and go to sleep and not wake up. (R1) has one on one in room at this time. R1's Nurse Progress Note dated 1/11/23 at 5:43 PM documents (R1) stated he'd rather die than take those things (medications) that allow us to control him. Summary: (R1) continues to verbalize suicidal thoughts and thoughts of death. R1's Nurse Progress Note dated 1/16/23 at 9:35 AM documents Sent a referral packet to Psychiatric Service on 1/11/23. (R1) was approved and is on the list for counseling services. R1's Electronic Medical Record (EMR) does not document R1 was placed on suicide watch per facility policy and does not document notification to V40 Physician of R1's statements on 12/27/22 and 1/2/23. On 1/27/23 at 11:45 AM V28 Certified Nurse Aide (CNA) stated I am (R1's) CNA today. (R1) is not on any kind of 15-minute checks or continuous observations. Nobody has been watching (R1). I have seen (R1) a couple of times this morning. (R1) has either been in his room or roaming around facility in wheelchair. I think (R1) is in the dining room now. I will have to check. On 1/26/23 at 1:35 PM R1 stated I have had Depression for many years. I have taken medicine for it for many years. I have gotten to the point lately where I just do not want to live anymore. The medicine does not seem to help. I thought December would be better, but I feel worse now than ever. They (staff) told me now I have Parkinson's Disease. Sometimes I just feel like there is no hope. On 1/26/23 at 12:25 PM V2 Director of Nurses (DON) stated (V20) Licensed Practical Nurse (LPN) should have sent (R1) out to the emergency room as soon as she was aware (R1) attempted suicide. Instead of calling the doctor and Power of Attorney (POA), (V20) called (V21) Dementia Coordinator who was the nurse manager on call that night. (V21) instructed (V20) to monitor (R1). I would have sent (R1) directly to the emergency room for evaluation. On 1/27/23 at 1:00 PM V22 Registered Nurse (RN)/Assistant Director of Nurses (ADON) stated I came into work on 1/4/23 and saw the cords sitting on the nurses desk so I asked (V20) what was going on. (V20) told me that (R1) had tried to commit suicide earlier in her shift and she was told by (V21) to remove the cords from (R1's) room so she did. When (V20) told me that I immediately told (V21) to call (R1's) physician, Power of Attorney (POA) and facility Administrator. I told (V21) 'I need you to call right now' and (V21) started making phone calls. We (staff) sent (R1) out to the emergency room for evaluation. On 1/26/23 at 1:30 PM V21 Dementia Coordinator/Nurse Manager stated I was on call the night (R1) attempted suicide. (V20) LPN called me and told me the staff had found (R1) laying in (R1's) bed with all the cords wrapped around (R1's) neck. (V20) told me (R1) was ok so I told (V20) to keep a close eye on (R1) by increasing visual checks. I did not tell (V20) to place (R1) on continuous monitoring or send to the emergency room. I did not notify (V1) Administrator, (V2) Director of Nurses or anyone else. I just told (V20) to make sure nothing was in reach. I should have had (V20) send (R1) out immediately and make all the notifications. (V2) DON brought all the managers together in the conference room on 1/4/23 and inserviced us on what to do when a resident attempts suicide and the suicide watch protocol. On 1/26/23 at 1:45 PM V24 Social Service Assistant (SSA) stated R1 was referred for therapy for Depression after the 1/3/23 attempted suicide. V24 stated We (facility) do have (V25) Licensed Clinical Social Worker come out to facility. (V25) has been coming to facility for over a year to visit with residents. After (R1) attempted suicide we (staff) started doing one to one visits with (R1). (R1) was first seen by (V25) on 1/13/23. (R1) did not see any other therapists or psychiatrists prior to (R1) attempting suicide. We (staff) knew (R1) was depressed because he would cry, refuse medications and make statements about how lonely and sad he was. We (staff) should have gotten (R1) help sooner. On 1/27/23 at 2:45 PM V2 Director of Nurses (DON) stated (R1) does have a history of Depression. (R1) has made comments indicating or stating (R1) wants to kill himself. We (staff) did not respond as we should have. We (staff) should have not given (R1) his call light after he said he wanted to use it to harm himself. We (staff) should have tracked and monitored (R1's) behaviors. We (staff) should have updated (R1's) Care Plan on 12/20/22 after (R1) made the comment that he wanted to use the call light to kill himself. We (staff) should have gotten (R1) a referral for psychiatric services sooner than we did. We (staff) should have placed (R1) on suicide watch after each statement of (R1) wanting to harm himself. The suicide watch policy was completely disregarded. We (facility) have failed (R1) in many ways. We are in the process of fixing those problems but they should have never happened in the first place. The facility policy titled 'Suicidal/Violent Residents' revised 11/01/05 documents Policy: This facility offers initial management stabilization and transfers when needed, to residents with psychiatric emergencies. A psychiatric emergency is an urgent, serious disturbance of behavior, affect, or thought that makes the resident unable to cope with life and/or personal relationships. Psychiatric emergencies may include, but are not limited to overactive, violent or suicidal residents. Verbalization of wishes to die, I wish I was dead, and other remarks or actions leading staff to believe the resident is suicidal will automatically trigger a suicide watch. This will require Physician and Power of Attorney (POA) notification and a every 30-minute charting sequence to be initiated. This will be reevaluated every 12 hours until Physician discontinues such a requirement. Procedure: 6. Facility supervisor in charge will notify (V2) Director of Nurses (DON)/(V1) Administrator. They will instruct the nurse to notify psychiatric hospital to prepare the resident for immediate psychiatric consultation and hospitalization. The Immediate Jeopardy that began on 12/20/22 was removed on 2/2/23 when the facility took the following actions to remove the immediacy. 1. R1 was assessed by V51 Social Service Director (SSD) on 1/31. V51 confirmed on 2/2/23 R1 was assessed on 1/31/23. 2. V2 Director of Nurses (DON) confirmed R1's environmental round was completed on 1/31/23 by DON, V22 Assistant Director of Nurses (ADON), V1 Administrator, and V55 Maintenance Supervisor. 3. V2 DON confirmed V40 Physician and V31 (R1's) Power of Attorney (POA) were notified of increased 15 minutes checks on 1/31/23. 4. V2 DON confirmed a schedule was created and staff were assigned to 15 min checks schedule created on 1/31/23. V2 verified 15 minute checks were documented as starting on 1/31/23 at 6:45 PM. 5. V52 Minimum Data Set Coordinator verified R1's care plan was updated on 2/1/23 by V52. 6. V1 Administrator confirmed the Interdisciplinary Team (IDT) met on 2/2/23 to review care plans for all residents. 7. V51 Social Service Director confirmed an audit of all resident psychosocial assessments was completed and referrals were made as necessary on 2/2/23. 8. V51 confirmed the facility will continue to have ongoing weekly audits for residents with mental health diagnoses or psychotropic medications. V51 confirmed facility started the audits on 1/31/23 and will continue weekly on Thursdays for four weeks. 9. V59 Clinical Educator confirmed V59 completed inservice training for the IDT for proper process for monitoring and documenting behaviors on 2/2/23. 10. V58 Regional Nurse Consultant confirmed all staff present in the facility had been inserviced on depressive symptoms on 1/31/23. V58 confirmed all staff not present in the facility would be inserviced prior to clocking in for their next shift. 11. V58 Regional Nurse Consultant confirmed all staff present in the facility had been inserviced on signs of suicidal behavior on 1/31/23. V58 confirmed all staff not present in the facility would be inserviced prior to clocking in for their next shift. 12. V58 Regional Nurse Consultant confirmed all staff present in the facility had been inserviced on behavior tracking on 1/31/23. V58 confirmed all staff not present in the facility would be inserviced prior to clocking in for their next shift. 13. V58 Regional Nurse Consultant confirmed all staff present in the facility had been inserviced on reporting procedures and enhanced monitoring on 1/31/23. V58 confirmed all staff not present in the facility would be inserviced prior to clocking in for their next shift. 14. V59 Clinical educator and V22 ADON confirmed all audits of residents on psychotropic medications and behavior tracking were completed on 1/31/23. 15. V1 Administrator confirmed the Quality Assurance (QA) team will audit for residents with increased depressive signs and symptoms, new admissions for behavioral care plans and interventions, and behavior weekly for four weeks and that the first audit has been completed. B. Based on record review, observation and interview the facility failed to ensure a resident was properly positioned in a wheelchair and failed to correctly implement a fall intervention for one of five residents (R10) reviewed for accidents on the sample list of 31. Findings include: b.) R10's Face Sheet dated on admission 2/18/2020 documents the following diagnoses: Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, and Osteoporosis Without Current Pathological Fracture. R10's Minimum Data Set (MDS)dated 11/3/22 documents R10 is severely cognitively impaired, totally dependant on two staff for transfers and requires extensive assistance with mobility on unit. R10's Fall incident report investigation, dated 1/4/23 documents the following: Witness statement of what happened written by (V53 Certified Nurses Aide) entered by (V22, Assistant Director of Nursing/ADON) on 1/6/23. While attempting to reposition resident (R10), resident leaned back sliding forward in (the) chair, and staff member lowered resident to the floor. The same report documents: Conclusion, IDT (Interdisciplinary Team) met and reviewed, resident (R10) observed on the floor ROOT CAUSE' slid to the edge of the chair while CNA (V53) was pushing her (R10) back to her room, CNA lowered her (R10) to the ground. 'INTERVENTION' (non-skid material) in wheelchair. The same report documents: Root Cause, Due to resident action or internal factor. On 2/2/23 at 4:10 pm V53, stated I (V53) was the CNA that assisted (R10) the day (1/4/23) she (R10) fell out of the wheel chair. V53 stated the following: It basically happened after lunch. I wasn't the CNA that fed (R10), or cared for (R10), I (V53) was just helping out. I (V53) saw her (R10) awake, out in the lounge on [NAME] hall. I (V53) could see she had slid down in her wheelchair, some. Her (R10's) shoulders were low and up against the wheel chair back. Her (R10) butt must have been closer to the front edge of the seat, than I thought. (R10) was covered in a blanket. Basically, I (V53) could not see how far she (R10) was scooted forward. Basically, I (V53) should have checked (to see how far forward R10 had scooted in the wheel chair). Basically, I started to push (R10's) wheelchair down to her room. (R10) had scooted more, so I hurried to get her back in her (R10's) room. I (V53) was only about one room from hers. I pushed (R10's) wheelchair really fast into her room. I needed to catch her before she fell out (of the wheelchair). I grabbed the back of her waistband and (R10's) shoulder started to lean back farther. By then I was basically at the side of her (R10's) wheelchair. I pushed the wheelchair backwards, out of the way. Basically, (R10) slid the rest of the way to the floor, basically down my leg. (R10) did not have a wheelchair chair cushion in her wheelchair that I saw. It (wheelchair cushion) may have slide out of the wheelchair with her (R10). (R10) does not stand. Her (R10's) cushion may have been under her on the floor, I don't know for sure. I just know it was not in her chair. I went to get (V22, ADON). She (V22, ADON) basically, came and took care of her (R10). On 2/2/23 at 2:40 pm R10 was laying in a low bed with scoop mattress. R10 was pleasantly confused. R10's wheelchair had a 12 inch by 12 inch piece of non-skid material on top of the wheel chair slick, polyester covered cushion. The wheel chair, cushion sat directly on the vinyl wheel chair seat. The wheelchair cushion slid easily front to back and did not have non-skid material. V16, CNA confirmed the non-skid material on the top of the wheel chair cushion and stated I don't know why that (non-skid) is on top instead of under the cushion. It does not stop the cushion from slipping right off the wheel chair. On 2/2/23 at 2:47 pm V22, Assistant Director of Nursing (ADON) assessed R10's wheelchair and stated I don't know a lot about this. I can see this cushion slides all over the place. That doesn't work. The (non-skid material) should be under the cushion I'd say. Or maybe both on top and below the cushion, because R10 does scoot down in her wheel chair.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to protect residents rights to be free from physical and mental abuse b...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to protect residents rights to be free from physical and mental abuse by staff members and a resident for three of five residents (R1, R3, R8) reviewed for abuse in a sample list of 31 residents. Findings include: 1.) R1's undated Face Sheet documents medical diagnoses of Surgical Aftercare following Surgery on the Nervous System, Spinal Stenosis, Muscle Weakness, Muscle Wasting and Atrophy, Malignant Neoplasm of the Prostrate, Rheumatoid Arthritis, Major Depressive Disorder and Anxiety. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. R1's Care Plan does not document a focus area, goal nor interventions for risk of abuse. R1's Electronic Medical Record (EMR) does not document R1's allegation of verbal and mental abuse on 1/19/23. R1's Final Incident Report to Illinois Department of Public Health dated 1/24/23 documents V27 Registered Nurse (RN) witness statement as (R1) reported that (V4) CNA was extremely rude and disrespectful to (R1). (R1) denies physical injuries. After medication pass done (V4) and I discussed situation. (V4) reports '(R1) can move his legs. (R1) just did not want to on purpose.' (V4) did not seem interested in listening. (R1) comforted and encouraged by staff. On 1/26/23 at 2:00 PM R1 stated '(V4) was verbally abusive to me. (V4) yelled at me because I couldn't move my legs fast enough when (V4) was trying to turn me over to change me. (V4) talked to me like a dog, barking orders. (V4) tried to put me to bed with that machine (mechanical lift) and she almost dropped me. I was scared of (V4). (V4) was so hateful calling me names and treating me like I was nothing. I can't remember the names but they were cuss words. R1 stated That girl (V4) came charging into my room in the middle of the night. (V4) rolled me over like she was madder than h***. (V4) wore a blue mask and kept talking into the mask. (V4) had something white sticking out of her ear. I think (V4) was talking on the phone with the device in her ear. (V4) did not care what I said. I was trying to tell (V4) to stop for a second and trying to tell her to take it easy but she just kept throwing me around. (V4) rolled me over so hard I thought I was going to roll off the other side of the bed. (V4) had a very hateful attitude. I was really scared of (V4). (V4) really tore into me. (V4) must have had the worst day and came charging in here (R1 room) and took her anger out on me. I will not allow (V4) in my room again. (V4) was so bitter and hateful. (V4) was like a bad storm ruthless with everything in her path. On 1/26/23 at 9:00 AM V17 Licensed Practical Nurse (LPN) stated (R1) is a very gentle person. (R1) rarely gets upset. (R1) does have Depression but even in those times (R1) knows the crying is due to the Depression. (R1) is alert and oriented and has never been known to fabricate stories. If (R1) accused someone of something, it most likely happened. I would be inclined to believe (R1). (R1) does not make false allegations. On 1/27/23 at 2:30 PM V2 Director of Nurse (DON) stated All of our (facility) residents have the right to be free from being abused. They (residents) are here to live or recover and they (residents) should not have to worry about being treated poorly. (V4) should never have treated anyone like that. I do not blame (R1) for being upset. We (facility) can do better than that. 2.) R8's Minimum Data Set (MDS) dated [DATE] documents R8 as cognitively intact. This same MDS documents R8 as requiring limited assistance with bed mobility, transfers, dressing, toileting, personal hygiene and independent with eating. R8's Care Plan does not document a focus area, goal nor interventions for risk of abuse. R8's Electronic Medical Record (EMR) does not document R8's allegation of verbal on 1/20/23. On 1/31/23 at 9:30 AM (V38) (R8's) Power of Attorney (POA) stated (R8) needed to use the bathroom and some fresh ice water. (V49) came in to (R8's) room and had a bad attitude. (V49) did not help (R8) and then walked out of room. I put on (R8's) call light and (V49) returned to (R8's) room. (V49) told me to shut up right in front of (R8). (V49) yelled at me and (R8). (V49) verbally abuse both of us (R8, V38). I told (V50) nurse about (V49) being verbally abusive to both of us (R8, V38) and (V50) took (V49) CNA off of the hall. On 2/2/23 at 12:00 PM V1 Administrator stated I do not remember exactly which day I got a call from a nurse stating (V49) Certified Nurse Aide (CNA) was being rude to (V38) (R8's) family. The nurse said (V49) was being rude to (V38). On 2/2/23 at 12:35 PM V50 Registered Nurse (RN) stated (V38) came to the nurses desk to complain that (V49) Certified Nurse Aide (CNA) was 'rude' to (V38) and (R8) in (R8's) room. That was on 1/20/23. I remember the date because it is the same date (R8) got a chest X-Ray done. (V38) told me that (V38) asked (V49) CNA to assist (R8) to the bathroom and get (R8) ice water. (V38) told me that (V49) CNA left the room so (V38) activated (R8's) call light and (V49) CNA returned to the room. (V38) told me that (V49) told him to 'shut up' and was progressively yelling at (V38) in front of (R8). I immediately removed (V49) CNA from the resident care areas until I could get direction from (V1) Abuse Coordinator. 3.) R3's undated Face Sheet documents medical diagnoses of Alzheimer's Disease, Aphasia Following Cerebral Infarction and Chronic Atrial Fibrillation. R3's Minimum Data Set (MDS) dated [DATE] documents R3 as having moderately impaired cognition. This same MDS documents R3 as requiring total dependence of two people for bed mobility, transfers and supervision with eating. This same MDS documents R3 as having weakness in both legs, impairment in one upper extremity and uses wheelchair for mobility device. R3's Care Plan does not document a focus area, goal nor intervention for risk of abuse. R3's Final Incident Report to Illinois Department of Public Health dated 1/20/23 documents Date of occurrence as 1/15/23. Date of Initial Report as 1/19/23. Upon completion of this investigation, the facility determined the cause for this resident to resident incident was (R4) becoming upset over (R3) reaching over (R4's) plate and secondary to resident (R3) diagnosis. This same report documents V29 Certified Nurse Aide (CNA) witness statement as I saw (R4) stab (R3) in (R3's) hand. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as severely cognitively impaired. This same MDS documents R4 as requiring limited assistance of one person for bed mobility, transfers, dressing, toileting, personal hygiene and independent with eating. On 1/26/23 at 8:50 AM R4 stated We (R3, R4) were sitting at the same table eating lunch. (R3) kept grabbing me in the arm and trying to pull at my underwear. (R3) would reach across the table to grab me so I took the bottom end of my butter knife and hit (R3) with it. (R3) stopped after that. I guess (R3) didn't like getting hit. I hope it left a bruise. I would do it again if someone grabs me. On 1/26/23 at 9:20 AM V17 LPN stated (R3) has Dementia and can be very grabby at times. (R3) would never be aggressive. (R3) does grab onto other residents at times and sometimes the other residents do not like it but she does not mean any harm by it. (R3) is always smiling and cooperative with staff. On 1/26/23 at 12:25 PM V2 Director of Nurses (DON) stated any resident involved in an altercation should be assessed for pain, any skin injuries and also a psycho-social assessment completed to ensure the safety of the residents. V2 stated the nurse should notify the Physician and Power of Attorney (POA) if applicable. V2 stated (R4) did not injure (R3) when (R4) hit (R3) with the end of the butter knife but that should have never have happened. The staff should have intervened when (R3) was grabbing at (R4's) clothes to prevent that situation from escalating. On 2/1/23 at 2:50 PM V29 Certified Nurse Aide (CNA) stated I was in the dining room feeding another resident when I heard (R4) yelling at (R3). I walked over to their (R3, R4) table but before I could get there (R4) stabbed (R3) in the hand with a butter knife. I separated (R4) from (R3), told the kitchen that (R4) and (R3) could not sit together anymore and then looked at (R3's) hand. (R3) did not appear to have any injury. When I left the dining room, I walked to the nurses station and told (V48) Licensed Practical Nurse (LPN) that (R4) stabbed (R3). I do not know what (V48) did after that. I did not notify (V1) Abuse Coordinator about the incident between (R4) and (R3). I thought just telling the nurse would be enough. I probably should have just taken it to (V1). The facility policy titled 'Resident Care Policy and Procedure Regarding Abuse and Neglect, Involuntary Seclusion, Exploitation, Misappropriation of Resident Property, Injuries of Unknown Origin and Social Media' revised 3/15/18 documents the following: All residents have the right to be free from verbal, physical, sexual, mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful as used in the definition of abuse means that the individual must have acted deliberately, not that the individual must have intended to inflict harm or injury. Mental abuse includes but is not limited to humiliation, harassment, threats of punishment or deprivation or offensive physical contact by an employee. Physical abuse means the infliction of injury on a resident that occurs other than by accidental means and that required (whether or not given) medical attention. Physical abuse may include but not limited to such acts as: hitting, kicking, slapping, hair pulling and pinching, etc Verbal abuse means the use by an employee of oral, written or gestured language that includes disparaging or derogatory terms to a resident or within his or her hearing or seeing distance, regardless of the resident's age, ability to comprehend or disability.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to follow their Abuse policy by failing to immediately report allegatio...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to follow their Abuse policy by failing to immediately report allegations of abuse to the abuse coordinator and by failing to investigate an allegation of abuse for three of five residents (R1, R3, R8) reviewed for abuse in a sample list of 31 residents. Findings include: 1.) R1's Final Incident Report to Illinois Department of Public Health dated 1/24/23 documents V27 Registered Nurse (RN) witness statement as (R1) reported that (V4) CNA was extremely rude and disrespectful to (R1). (R1) denies physical injuries. After medication pass done (V4) and I discussed situation. This same report does not document notification of the allegation of mental and verbal abuse to V1 Administrator. On 1/27/23 at 3:00 PM V1 Administrator stated (V4) CNA should have reported this incident immediately and did not. I have inserviced my staff to report directly to me. There should be no other person staff should report to initially. It is important that the nurse is made aware but I am the Abuse Coordinator and all abuse allegations should be reported to me immediately. This is exactly why those staff are being reprimanded for not following our Abuse policy. I have inserviced regularly on abuse and still can not seem to get my staff to follow the policy. 2.) Facility is not able to provide documentation of an investigation into an allegation of verbal abuse by (V49) Certified Nurse Aide (CNA) to R8 on 1/20/23. R8's Minimum Data Set (MDS) dated [DATE] documents R8 as cognitively intact. On 2/2/23 at 12:35 PM V50 Registered Nurse (RN) stated (V38) came to the nurses desk to complain that (V49) Certified Nurse Aide (CNA) was 'rude' to (V38) and (R8) in (R8's) room. That was on 1/20/23. I immediately removed (V49) CNA from the resident care areas until I could get direction from (V1) Abuse Coordinator. I called (V1) Administrator/Abuse Coordinator who told me that this was a 'he said-she said' situation. I asked (V1) if (V49) CNA should be sent home and (V1) told me to not send (V49) home but to re-assign (V49) to a different area of the building so that is what I did. (V49) CNA finished the shift on another unit. On 2/2/23 at 12:00 PM V1 Administrator stated I do not remember exactly which day I got a call from a nurse stating (V49) Certified Nurse Aide (CNA) was being rude to (V38) (R8's) family. I was going to follow up on this situation but got distracted and was not able to. I would have done an investigation had I not been distracted by other events happening. V1 confirmed the allegation of verbal abuse from V49 towards R8 was never investigated. 3.) R3's Final Incident Report to Illinois Department of Public Health dated 1/24/23 documents Date of occurrence as 1/15/23. Date of Initial Report as 1/19/23. On 1/27/23 at 3:30 PM V30 Registered Nurse (RN) stated I overheard (V29) CNA talking about (R4) hitting (R3) with a knife so I mentioned it to (R3 and R4's) nurse who was sitting at the desk. I can not remember who the nurse was. I did not report this directly to (V1) Administrator because I thought (R3, R4's) nurse would. Apparently (R3, R4's) nurse or (V29) CNA never reported it. On 1/27/23 at 3:05 PM V1 Administrator stated I was not made aware of this allegation of physical abuse until days after it happened. We (staff) determined this happened on 1/15/23 and I was made aware on 1/19/23. That makes me out of compliance. I have inserviced regularly on abuse and still can not seem to get my staff to follow the policy. The facility policy titled 'Resident Care Policy and Procedure Regarding Abuse and Neglect, Involuntary Seclusion, Exploitation, Misappropriation of Resident Property, Injuries of Unknown Origin and Social Media' revised 3/15/18 documents the following: All residents have the right to be free from verbal, physical, sexual, mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful as used in the definition of abuse means that the individual must have acted deliberately, not that the individual must have intended to inflict harm or injury. Reporting: A facility employee or agent or covered individual who becomes aware of alleged abuse or neglect of a resident shall immediately report the matter to the facility Administrator.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to report an allegation of verbal abuse to the state survey agency for ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to report an allegation of verbal abuse to the state survey agency for one of five residents (R8) reviewed for abuse in a sample list of 31 residents. Findings include: On 2/2/23 at 12:00 PM V1 Administrator was not able to provide documentation of an allegation of verbal abuse by (V49) Certified Nurse Aide (CNA) to R8 on 1/20/23. R8's Minimum Data Set (MDS) dated [DATE] documents R8 as cognitively intact. On 2/2/23 at 12:35 PM V50 Registered Nurse (RN) stated (V38) came to the nurses desk to complain that (V49) Certified Nurse Aide (CNA) was 'rude' to (V38) and (R8) in (R8's) room. That was on 1/20/23. I called (V1) Administrator/Abuse Coordinator who told me that this was a 'he said-she said' situation. I asked (V1) if (V49) CNA should be sent home and (V1) told me to not send (V49) home but to re-assign (V49) to a different area of the building so that is what I did. (V49) CNA finished the shift on another unit. On 2/2/23 at 12:00 PM V1 Administrator stated I do not remember exactly which day I got a call from a nurse stating (V49) Certified Nurse Aide (CNA) was being rude to (V38) (R8's) family. I was going to follow up on this situation but got distracted and was not able to. I would have reported this incident initially to Illinois Department of Public Health then done an investigation to determine whether this was a case of abuse or not. V1 confirmed the allegation of verbal abuse from V49 towards R8 was never reported to Illinois Department of Public Health.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide assistance with bathing for four (R3, R5, R9, R10) residents...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide assistance with bathing for four (R3, R5, R9, R10) residents out of four reviewed for Activities of Daily Living in a sample list of 31 residents. Findings include: 1.) R3's Physician Order Sheet (POS) dated January 1-31, 2023 documents a physician order dated 4/5/22 Please ensure shower is completed Tuesday and Friday evenings. R3's Minimum Data Set (MDS) dated [DATE] documents R3 as moderately impaired. This same MDS documents R3 as requiring total dependence of two people for bed mobility, transfers, extensive assistance of two people for dressing and extensive assistance of one for personal hygiene. R3's Electronic Medical Record (EMR) documents showers given on 1/6/23 and 1/20/23 for January 2023. R3's EMR does not document any other showers or bed baths given for the month of January 2023. R3's EMR does not document R3 refusing any bed baths or showers. 2.) R5's Physician Order Sheet (POS) dated January 1-31, 2023 documents a physician order dated 10/25/22 Please ensure shower is completed Tuesday and Friday evenings. R5 Minimum Data Set (MDS) dated [DATE] documents R5 as cognitively intact. This same MDS documents R5 as requiring extensive assistance of one person for bed mobility, transfers, dressing, toileting and personal hygiene. R5's Electronic Medical Record (EMR) documents R5 received only one shower or bedbath instead of two during the weeks of 1/2/23, 1/16/23 and 1/23/23. R5's EMR does not document R5 refusing any bed baths or showers. On 2/2/23 at 1:15 PM R5 stated I do like to take a shower. Sometimes they (staff) miss my showers. I usually get one once per week. They (staff) apologize for not getting to them but they are busy. The girls (staff) are nice to me, I just wish I could get my showers like I should. I do not want to smell. 3.) R9's Physician Order Sheet (POS) dated November 1-30, 2022 documents a physician order dated 10/6/22 Please ensure shower is completed Monday and Thursday day shift. R9's Minimum Data Set (MDS) dated [DATE] documents R9 as cognitively intact. This same MDS documents R9 as requiring extensive assistance of one person for bed mobility, transfers, dressing, toileting, and personal hygiene. R9's EMR documents R9 received only one shower instead of two during the weeks of 10/3/22, 10/10/22, 11/7/22 and 11/14/22. R9's EMR does not document reasons for only one shower being provided during those weeks. 4.) R10's Electronic Medical Record (EMR) documents R10's shower days are Tuesdays and Fridays of every week. R10's Minimum Data Set (MDS) dated [DATE] documents R10 as severely cognitively impaired. This same MDS documents R10 as requiring extensive assistance of two people for bed mobility, dressing, and toileting, total dependence of two people for transfers, and extensive assistance of one person for eating and personal hygiene. R10's Electronic Medical Record (EMR) documents showers given on 1/10/23, 1/17/23 and 1/24/23 for January 2023. R10's EMR does not document any other showers or bed baths given for the month of January 2023. R10's EMR does not document R10 refusing any bed baths or showers for the month of January 2023. On 2/2/23 at 9:00 AM V2 Director of Nurses (DON) stated Every resident is given the opportunity for showers or bed baths twice per week but it is also based on that resident's preference. The Certified Nurse Aides (CNA) staff give the shower and document on a paper sheet that is given to the nurse. The nurse then reviews the shower sheet and either makes sure the documentation is completed or if there is a new skin issue the wound nurse would be notified. Once the nurse reviews the shower sheet, the shower sheet is destroyed. All of the documentation for any resident's shower/bedbath should be in the Electronic Medical Record. V2 confirmed R3, R5, R9 and R10's showers were not given on days that were scheduled with no explanation or refusals by residents. V2 stated Showers are an important part of a resident's hygiene and by our staff not giving showers, the residents are at an increased risk for skin issues or infections.

Dec 2022 17 deficiencies 2 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Quality of Care (Tag F0684)

A resident was harmed · This affected 1 resident

Based on observation, interview and record review, the facility failed to monitor for and notify the physician of changes in weight and edema for a resident with chronic kidney disease, and failed to ...

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Based on observation, interview and record review, the facility failed to monitor for and notify the physician of changes in weight and edema for a resident with chronic kidney disease, and failed to transcribe and complete laboratory testing as ordered for one of one residents (R27) reviewed for edema on the sample list of 46. This failure resulted in R27 having a 13 pound weight gain in one month with increased lower extremity edema which caused pain and a decrease in mobility. This failure also resulted in R27's kidney function deteriorating from a stage 2 to a stage 3B kidney failure. Findings Include: On 12/12/22 at 2:27 PM, R27 was sitting up in the wheelchair with edema to bilateral lower extremities. R27 stated R27's legs are sore due to being more swollen than normal and that R27's socks are cutting into R27's legs. On 12/13/22 at 2:19 PM, edema continues to bilateral lower extremities. On 12/13/22 at 3:12 PM, V17 RN (Registered Nurse) stated R27 has had edema of lower extremities for a couple of years and takes lasix due to kidney failure. V17 checked R27's legs, which were very taunt and shiny. R27 reported to V17 that R27's legs are more edematous than usual and V17 responded it could be due to R27's recent increased weight gain. At this time, V17 also stated R27 had just had laboratory tests completed and would make sure V23 Nephrologist had those results. R27's December 2022 Physician Orders document a diagnosis of Chronic Kidney Disease and localized edema with an order for 1500 ml (milliliter) per day fluid restriction and Lasix {Diuretic} 40 mg (milligrams) twice a day. There is also an order to send laboratory results to V23 however there are no active laboratory orders on the Physician Order Sheet. R27's Care Plan dated 7/6/22 documents R27 has Chronic Kidney Disease and uses diuretics and to monitor for weight gain, edema and monitor lab values. On 12/14/22 at 10:23 AM, R27's legs remain edematous and R27 again stated R27's legs are more sore than usual and that R27 has a hard time propelling R27's wheelchair with R27's feet anymore explaining, I (R27) can do it but it hurts and takes me longer {to get to where I'm going}. R27's ongoing vitals document on 10/1/22, R27 weighed 223.0 pound. On 11/4/22 R27 weighed 238.4 {a 15.4 pound weight gain in one month}, and 236 on 12/1/22. R27's Progress Notes from October - December 12, 2022 do not document any edema, or that the physician was notified of R27's weight gain. On 12/13/22 at 3:47 PM, V2 DON (Director of Nursing) with V8 Regional Nurse Consultant present stated the facility holds monthly weight meetings. At this time, V8 stated R27 flagged for a significant weight gain and explained with any weight gain/loss, the physician should be contacted to see if they want a change in treatment. V8 stated the nurses should have done a comprehensive assessment on R27 for the weight changes, which would have caught the increase in edema, and then updated the primary physician, as well as V23 Nephrologist. V8, after checking R27's progress notes, confirmed there is no documentation of R27's lower extremity edema or weight gain and that the physician was not made aware of R27's change in condition. R27's Laboratory tests dated 12/12/22 document a BUN (Blood Urea Nitrogen) level of 24 milligrams per deciliter(mg/dl) (normal is 9-20), Creatine 1.65 mg/dl (normal is 0.66-1.25), Albumin 3 (grams/deciliter) (normal is 3.5 - 5.0), and EGRF (Estimated Glomerular Filtration Rate) 39 (30-59 indicates stage 3 kidney disease). On 12/14/22 at 11:12 AM, V2 DON with V12 Unit Coordinator present stated V2 is trying to find out where the order for the laboratory tests that were completed on 12/12/22 came from. V2 provided a faxed physician order from V23 that was time stamped on 12/8/22. This order documents labs were ordered on 5/12/22 and expected to be completed on 11/12/22. V2 stated the facility didn't receive those orders until 12/8/22 when it was faxed over, that is why the laboratory tests were ran on 12/12/22. On 12/14/22 at 11:13 AM, V24 (V23's nurse) stated R27 was last seen on 5/12/22 by V23 and received orders at that time for laboratory tests to be completed at 1 month (June 2022), 3 months (August 2022) and 6 months (November 2022). V24 stated the 6 month test was to be due on 11/12/22 and it wasn't done, actually none of the labs were completed, that is why V24 re-faxed over the orders. V24 stated R27 has a follow up appointment on 12/22/22 that V23 needs those results for. V24 stated the last time R27 was seen by V23, R27 was in fluid overload. That is when (V23) put (R27) on the fluid restriction and (R27) was to continue the lasix 40 mg twice a day. V24 stated R27's visit Progress Notes and Orders were sent to the facility with R27 on 5/12/22. V24 stated their is no communication between the facility and V23 in R27's record but if R27 is having increased swelling and increased weight, V23 should have been notified. V23 would have increased R27's diuretics or added a second one like Torsemide, placed on daily weights and been doing increased laboratory tests to monitor R27's kidney function. V24 stated V24 still hasn't received the laboratory results from 12/12/22. On 12/14/22 at 2:25 PM, V2 DON with V1 Administrator present confirmed R27's May 2022 Progress Notes and Orders from R27's appointment with V23 are not in R27's medical record stating, I'm {V2} not sure where the orders went and why they weren't processed except for we {facility} have so much agency. I {V2} don't know what happened or what they {agency staff} did with the paperwork upon (R27's) return on 5/12/22. On 12/15/22 at 9:15 AM, V24 (V23's nurse) reviewed laboratory results from 12/12/22 and stated R27's EGFR went from a 61 in May 2022 to 39 in December 2022 explaining that shows that (R27) went from a Stage 2 to a Stage 3B kidney failure. V24 stated in April 2022 R27 was in the hospital with acute kidney failure due to his kidney's tanking but with hospitalization and changes in treatment, R27's kidney function had improved, that is why (V23) wanted labs at 1 month, 3 months and 6 months; to ensure (R27's) kidney function was stable. V24 stated had the labs been completed as ordered, V23 could have seen when R27's kidney function started to decline again and changed medications at that time. Everyone is different but with his history of kidney failure, and age, I (V24)really don't see (R27's) kidney functioning being able to improved at this time. Some people can remain at a stage 3B for years while others require dialysis in a short amount of time due to the continued decline. V24 also stated, because (R27) wasn't monitored like (R27) should have been, by not completing laboratory tests to ensure kidneys are/were stabilized and functioning as best they could, now (R27's) kidneys have gotten worse again.

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

Based on observation, interviews, and record review the facility failed to prevent a fall by failing to provide supervision, ensure a call light was within reach and failing to ensure a wheelchair cus...

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Based on observation, interviews, and record review the facility failed to prevent a fall by failing to provide supervision, ensure a call light was within reach and failing to ensure a wheelchair cushion was not moveable for one (R59) of seven residents reviewed for falls on the sample list of 46. This failure resulted in R59 falling out of the wheelchair, hitting her head and sustaining a laceration which required emergency medical attention and 25 staples to close the laceration. 1. R59's emergency room report dated 12/12/22 documents R59 presents with complaints of a ground level fall and likely hit her head on the bed frame. This report documents R59 had a large flap laceration to the left mid/frontal scalp region. This report documents the laceration to the head was closed with 25 staples. On 12/12/22 at 2:15 PM, R59 was lying in bed. The top of R59's head had a large U shaped laceration which was closed with staples. R59's Nurse's note dated 12/12/2022 at 10:24 AM documents at 7:15 AM that, (R59) laying on floor on left side at the foot of roommate's bed. Writer noted a large laceration to left side of scalp. Resident was conscious and alert to self. (R59) stated she fell down but was unable to tell writer what she was doing or any other detail regarding the fall. This note documents R59 was sent to the emergency room. On 12/14/22 at 9:11 AM, V22 Certified Nurse's Assistant stated on 12/12/22 around breakfast she was pushing residents to the dining room. When she walked past R59's room she noticed she was lying on her back with her head between the footboard and the wall of R59's roommate's bed. V22 stated R59's was holding her head and was bleeding. V22 stated her wheelchair was at her feet. V22 stated her call light was not in reach. V22 stated R59 can not propel herself in the wheelchair like she could, but will try. V22 stated V22 is not sure who got her up in the chair but she should not be left in the room by herself because she needs supervised once she is up in her chair. On 12/14/22 at 11:15 AM, V12 Restorative Nurse stated R59 is at risk for falls due to having a couple falls in the past. V12 stated she investigated the 12/12/22 fall. V12 stated the cushion in R59's chair was not appropriate because it would slip and slide around when R59 was up in the chair. V12 stated R59 has poor posture combined with the cushion moving. V12 stated she feels the cushion contributed to R59's fall. V12 stated they replaced the cushion after her fall because it put her at greater risk for falling. V12 stated R59 had the cushion for awhile. R59's careplan with a revision date of 8/2/22 documents R59 is at risk for falls and includes an intervention to ensure call light is always within reach.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 12/12/22 at 12:59 PM, R44 was sitting up in a wheelchair without the call light in reach. The call light was attached to t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 12/12/22 at 12:59 PM, R44 was sitting up in a wheelchair without the call light in reach. The call light was attached to the bed, approximately 3 feet away. At this time, V35 (R44's family) was also in R44's room and stated R44 tells me (V35) that (R44) doesn't have (R44's) call light a lot of the time and can't find it because (R44) is blind. 3. On 12/12/22 at 2:22 PM, R43 was lying in bed without the call light. R43's call light was draped across the foot of the other bed in the room, approximately 4 feet away. At this time, R27 (R43's spouse) stated there is no way that R43 could reach the call light because R43 isn't able to get out of the bed independently. Based on observation, interview and record review the facility failed to ensure that the call light response cord was within reach for three of 24 residents (R58, R44, R43) reviewed for accommodation of needs in the sample list of 46. Findings include: The facility's Call Light policy dated 8/1/05 documents, Objective: 1. To respond to resident's requests and needs. Policy: 1. It is the policy of this facility to maintain the highest quality of care for its residents. 7. Make certain call light is within resident's reach before leaving the room. 1.) R58's Order Summary dated 12/14/22 documents diagnoses including Bilateral Primary Osteoarthritis of Knee, Vascular Dementia, Mild, Postlaminectomy Syndrome, Muscle Weakness, Difficulty in Walking and Other Lack of Coordination. R58's Minimum Data Set (MDS) dated [DATE] documents recent spinal surgery and triggered falls to be carried over to the Care Plan. R58's Care Plan dated 11/18/22 documents to assist with ambulation and transfers. On 12/12/22 at 11:07 R58 stated that R58 has to have assistance to walk. R58 stated that R58 needs R58's call light. R58 was sitting in a high back chair on the opposite side of the room as the bed. R58's call light response cord was clipped to the bed and not within R58's reach. At this time V32 Unit Aide was in the hallway and was prompted to give R58 the call light response cord. On 12/14/22 at 2:13 PM, V2 Director of Nursing confirmed R58 should have had the call light response cord in reach before staff left the room.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0602 (Tag F0602)

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 prevent misappropriation of one hundred and thirty thr...

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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 prevent misappropriation of one hundred and thirty three dollars for one (R49) of three residents reviewed for abuse on the sample list of 46. Findings include: R49's Quarterly Minimum Data Set assessment dated [DATE] documents that R49 is cognitively intact. On 12/14/22 at 9:03 AM, R49 stated my wallet was in my drawer and I had $133 dollars in my wallet. R49 pointed across the room and stated it was in the drawer over there. R49 picked up his wallet and opened it and there was no money in the wallet. R49 stated I had not spent my money on anything. I was needing some clothes and when I went and got it out of the drawer and opened my wallet my money was gone. I did not keep my money anywhere but in my wallet and I know for sure I didn't spend it. On 12/14/22 at 9:45 AM, V1 Administrator stated R49 reported that he had $133.00 that went missing. V1 stated R49 told him that he had his money in his wallet and when he looked for it and it was gone. V1 stated R49 is alert and oriented. V1 stated R49 admitted on [DATE] and that R49 has never had any other complaints. V1 stated the facility did a room search to ensure it was not in his room and looked in the laundry downstairs. V1 stated the facility could not find the money.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct care plan meetings with resident's and/or resident represen...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct care plan meetings with resident's and/or resident representative's for two of 46 residents (R44, R100) reviewed for care plans on the sample list of 46. Findings Include: 1.) R44's ongoing census report documents R44 was admitted to the facility on [DATE]. R44's MDS (Minimum Data Set) dated 11/24/22 documents R44 is alert and oriented. On 12/12/22 at 1:11 PM, R44 stated I don't know what you are talking about when asked if R44 was invited to the care plan meetings, and participated in them. At this time, V35 (R44's family) who was in the room with R44 stated V35 gets a letter about the care plan meetings, which were held over the telephone but that R44 was not a part of it. V35 stated she didn't realize R44 could be involved with the care plan meetings. On 12/13/22 at 12:21 PM, V12 Unit Coordinator stated the previous MDS Coordinators were suppose to send the care plan invites to residents and families but since they are no longer employed, the Unit Coordinators will be starting to do them as of next week. V12 also stated residents are suppose to be invited to be involved in the meetings. 2.) R100's ongoing census documents R100 was admitted to the facility on [DATE]. On 12/13/22 at 12:13 PM, V36 (R100's family) stated V36 has not been invited to any care plan meeting but maybe another one of R100's children did. On 12/13/22 at 12:30 PM, V2 DON (Director of Nursing) stated R100 has not had a care plan meeting since being admitted to the facility explaining, V2 knew that the previous MDS (Minimum Data Set) Coordinator's were not doing some parts of their job and therefore are no longer employed with the facility.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review, the facility failed to prevent cross contamination of a pressure ulcer for one of five residents (R43) reviewed for pressure ulcers on the sample lis...

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Based on observation, interview and record review, the facility failed to prevent cross contamination of a pressure ulcer for one of five residents (R43) reviewed for pressure ulcers on the sample list of 46. Findings Include: R43's December Physician Orders document orders for the following pressure ulcer treatments: Right upper lateral ankle wound - cleanse with Normal Saline or Wound Cleanser, apply a mixture of Gentamicin ointment and Santyl {Chemical Debrider} to wound, then cover with thick absorbent gauze pad and secure with gauze wrap daily. Right lateral calf wound - Cleanse with Normal Saline or Wound Cleanser, apply a mixture of Santyl and Gentamicin ointment, cover with calcium alginate and a thick absorbent gauze pad and secure with gauze wrap daily and as needed. R43's Right lateral calf wound Culture dated 10/11/22 documents R43's wound has MRSA (Methicillin-Resistant Staphylococcus Aureus). R43's Wound Physician Notes dated 10/13/22 documents an unstageable (due to necrosis) pressure wound to the right upper calf measuring 6 cm (centimeters) by 4 cm x 0.3 cm, an unstageable (due to necrosis) pressure wound to the right lower calf measuring 3.5 cm by 1 cm by not measurable, and an unstageable (due to necrosis) pressure wound to the right upper lateral ankle measuring 0.8 cm by 0.4 cm by not measurable. On 12/14/22 at 7:03 AM, V18 LPN (Licensed Practical Nurse) and V19 LPN entered R43's room to complete the ordered wound treatments. V18 and V19 both donned a gown and gloves stating R43 has MRSA in R43's calf wound. V18 removed the dressing to the right calf/ankle area, which was saturated with dark tan/red colored drainage, to reveal two wounds:1) a full thickness unstageable pressure wound to the lateral calf measuring approximately 12 cm by 6 cm. The Calf muscles could be visualized. This would contained some yellow slough with granulation tissue. The peri-wound was slightly reddened. 2.) a full thickness pressure ulcer with a beefy red wound bed measuring approximately 0.5 cm by 0.5 cm. This wound was approximately 6 cm below the distal end of the calf wound. The peri-wound was very red. V18 cleansed the calf wound with wound cleanser, then cleaned the ankle wound with wound cleanser. V18 did not changing gloves or complete hand hygiene between cleaning of both wounds. V18 then performed hand hygiene and completed the treatment as ordered. After completion of the dressing change, V18 confirmed V18 did not perform hand hygiene after the cleansing the calf wound and before cleansing the ankle wound and stated, I (V18) just think of them as the same wound. The facility Hand Hygiene Protocol dated 7/26/21 documents hand hygiene means cleaning your hands by using either hand washing with traditional soap and water or antiseptic hand wash, or antiseptic hand rub like an alcohol based hand rub. This Protocol documents hand hygiene should be completed before moving from a soiled body site to a clean body site, after contact with blood, body fluids or contaminated surfaces. On 12/14/22 at 1:12 pm, V2 DON (Director of Nursing) stated V18 should have performed hand hygiene and changed gloves after cleansing the calf wound, prior to cleaning the ankle wound.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review the facility failed to ensure that a knee immobilizer was in place as ordered for one of one resident (R56) reviewed for positioning devices in the sa...

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Based on observation, interview and record review the facility failed to ensure that a knee immobilizer was in place as ordered for one of one resident (R56) reviewed for positioning devices in the sample list of 46. Findings include: R56's Order Summary dated 12/14/22 documents diagnoses including Central Dislocation of Left Hip, Subsequent Encounter, Muscle Weakness, Difficulty in Walking and Diabetes Mellitus. This Order Summary documents an order dated 11/4/22 that it is ok to remove knee immobilizer for bathing and dressing. R56's Therapy Discharge Communication dated 11/9/22 documents to apply splint to left lower extremity, on at all times except during cares and brace on over pants. On 12/12/22 at 10:53 AM, R56 was not in R56's room but R56's knee immobilizer was on R56's bed, not on R56. On 12/12/22 at 1:30 PM, R56 was in the common area in R56's wheelchair. R56's knee immobilizer was still on R56's bed, not on R56's left leg. On 12/13/22 at 10:02 AM, R56's knee immobilizer was on R56's bed, not on R56. On 12/13/22 at 3:06 PM V31, Registered Nurse stated R56's knee immobilizer is supposed to be on R56 all the time. V31 stated the CNAs (Certified Nursing Assistants) put it on R56. V31 stated R56's left hip was popping out of place. On 12/13/22 at 3:10 PM, R56 was in R56's wheelchair in the common area across from the nurse's station and R56 did not have R56's knee immobilizer on R56's left leg. At this time, V40 Activity Aide was painting R56's fingernails and confirmed R56's knee immobilizer was not on R56's left leg. On 12/13/22 at 3:11 PM, R56's knee immobilizer was laying on R56's bed. On 12/14/22 at 8:41 AM, R56 was in bed and did not have the knee immobilizer on R56's left leg. The immobilizer was laying on the other bed in R56's room. On 12/14/22 at 11:55 AM, V25 Physical Therapist stated that R56's knee immobilizer is for left hip dislocation and it is supposed to be on all the time except when dressing and bathing. On 12/14/22 at 12:03 PM, V26 Certified Nursing Assistant stated R56 is supposed to have the knee immobilizer on the left leg, it was a therapy order.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

2.) R27's December 2022 Physician Orders document an order dated 4/11/22 to ensure R27's indwelling catheter tubing is secured with a (catheter securement & stabilization) device. On 12/12/22 at 2:22...

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2.) R27's December 2022 Physician Orders document an order dated 4/11/22 to ensure R27's indwelling catheter tubing is secured with a (catheter securement & stabilization) device. On 12/12/22 at 2:22, R27 was sitting up in a wheelchair and stated R27's indwelling catheter was not secured to R27's leg, but it's suppose to be. R27 stated R27 has to keep a hold of it because it has been pulled on in the past and it's not fun. On 12/13/22 at 3:12 PM, R27 stated R27's catheter is still not secured. R27 explained staff have put something on in the past but it doesn't stay on. Again, R27 stated that staff have to be careful with the catheter so that it's not pulled on. At this time, V17 RN (Registered Nurse) confirmed R27's catheter is not secured explaining V17 has tried two different securement devices and they are to be changed weekly and as needed. On 12/14/22 at 6:46 AM, R27 was lying in bed, with the catheter tubing not secured to R27's leg. R27's urinary drainage bag was hanging on bedside table but resting on the floor, without a barrier between the bag and the floor. On 12/14/22 at 7:01 AM, V19 LPN (Licensed Practical Nurse) confirmed R27's catheter tubing was not secured to R27's leg and V18 LPN stated the catheter drainage bag should not be resting on the floor. Based on observation, interview and record review the facility failed to keep the indwelling urinary catheter collection bag and tubing off of the floor, failed to ensure the indwelling urinary catheter tubing was secure, and failed to prevent backflow of urine for two of two residents (R174, R27) reviewed for catheters in the sample list of 46. Findings include: The facility's Catheter Protocol dated 2/1/10 documents, 6. Catheter bags and tubing shall be maintained at a level below the bladder to prevent backflow of urine into the bladder. 7. The collection bag for catheters shall be emptied at least every shift. Care shall be taken to avoid contact of the drainage tube with anything that could contaminate it. 1.) R174's Order Summary Report dated 12/14/22 documents diagnoses including Other Obstructive and Reflux Uropathy, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms and Vascular Dementia. This Order Summary documents an order for an Indwelling Urinary Catheter size 16 French/10cc (cubic centimeters) balloon, change every 30 days. On 12/12/22 at 10:59 AM, R174 was in R174's room in the wheelchair. R174's indwelling urinary catheter collection bag was hanging on the side of the wheelchair and the tubing was laying on the floor. R174 was stepping on the indwelling catheter tubing. On 12/14/22 at 12:59 PM, V26 and V29 Certified Nursing Assistants (CNAs) transferred R174 to the bed using partial weight bearing mechanical lift. After placing R174 in the bed V26 removed R174's slacks and after removing R174's slacks raised the urinary collection bag up above the level of R174's bladder, approximately one foot above, and pulled the bag out of the leg of the slacks. After finishing care, V26 and V29 covered R174 with the blanket and sheet. R174's indwelling urinary catheter tubing was underneath R174's leg laying flat against the bed. At this time V26 stated that V26 was not sure where the tubing should be placed. At this time, V30 Registered Nurse stated that urinary catheter tubing should not be placed under the leg, it should go over the top of it. On 12/14/22 at 2:13 PM, V2 Director of Nursing stated catheter tubing should not be on the floor and the drainage bag is never supposed to be raised above the level of the bladder,

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0802 (Tag F0802)

Could have caused harm · This affected 1 resident

Based on conservation, interviews, and record reviews the facility failed to employ sufficient kitchen staff to ensure the facility could clean the flat ware within enough time to serve meals without ...

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Based on conservation, interviews, and record reviews the facility failed to employ sufficient kitchen staff to ensure the facility could clean the flat ware within enough time to serve meals without the use of plastic utensils for staff convenience. This failure impacts R327, one of 46 residents on the sample list. Findings include: R327's Care Plan initiated 12/5/22 documents the following diagnoses: Parkinson's Disease, Type II Diabetes, and Muscle Weakness. This Care Plan documents (R327) is at risk for nutritional problems related to diagnoses: Failure to Thrive, Parkinson's Disease, Hypertension, Lymphoid, Diabetes Mellitus, and other complicities. On 12/12/22 at 12:00 PM R 327 was seated in his recliner. R327's family member was visiting. R327's lunch tray was delivered to the room. R327 picked up a container of rice pudding and a spoon. R327 had apparent fine tremors to his hands as he scooped the pudding with difficulty to his mouth. R327's family member cut the pork loin on R327's plate. R327's family stated I try to be here at all of his meals, but Saturday evening (R327's) dinner did not get here until 6:45 PM. Then (R327) was given only flimsy plastic silver ware. Bone in chicken was served. I was barely able to cut it up with what was provided. I asked what was going on and was told there was not enough kitchen staff to provide real silver ware. Anyone can see (R327) has trouble eating because of his Parkinson's. I guess I'll have to start carrying in my silver ware. On 12/13/22 at 11:45 AM V5, Dietary Manager stated We have had to use plastic silver ware sometimes. I had call-offs this past Saturday and we had to then. I know that night Dinner was a little late. We serve from 5:00 PM until 6:30 PM. The reason for the plastic silver ware is if we are short staffed we can't get the real silver ware washed in time to keep up with the meal serving. I can see where it may be hard for some residents to use the plastic silver ware. It is flimsy. On 12/13/22 at 12:00 PM V1, Administrator verbalized he was aware of the issue with the plastic flat ware and was working on it.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0847 (Tag F0847)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to state in the arbitration agreement that the agreement can be rescinded within 30 days of signing it and that it is not required to sign an ...

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Based on interview and record review, the facility failed to state in the arbitration agreement that the agreement can be rescinded within 30 days of signing it and that it is not required to sign an agreement for binding arbitration as a condition of admission to, or to continue to receive care at, the facility. They also failed to explain the arbitration agreement in a manner that the resident and their representative understands. This failure affects R15 and R60, two of 46 residents on the sample list. Findings include: The facility's Contract between resident and select facility has no documentation in the arbitration agreement that the agreement can be rescinded within 30 days of signing it, nor that it is not required to sign an agreement for binding arbitration as a condition of admission to, or to continue to receive care at, the facility. R60's admission Contract dated 9/23/22 between R60 and the facility documents V28 (R60's family) signed the admission Contract and initialed the mediation/arbitration section of the binding arbitration. On 12/14/22 at 12:11 PM, V28 stated R60 has been a resident of the facility since the beginning of October 2022 and confirmed that V28 signed the admission contract for R60. V28 also stated V28 had to initial the section of the contract for binding arbitration but that it wasn't explained to V28 and that V28 wasn't given the option of not signing it. R15's admission Contract dated 7/22/21 between R15 and the facility was signed by V33 (R15's family) and the mediation/arbitration section was also separately initialed by V33. On 12/14/22 at 1:30 PM, V33 stated V33 doesn't recall who did the contract with V33 but that it wasn't explained. (V33) was told to just sign and initial all areas. V33 also stated nobody explained the binding arbitration part of the agreement to V33. On 12/13/22 at 10:14 AM, V1 Administrator stated the facility contract contained a binding arbitration agreement included within the admission contract until last week. V1 explained if we get a new admission, that section of the contract will be crossed off until we get new updated copies of the contract and the facility will then have a separate arbitration agreement.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to offer/administer Influenza vaccines for two residents (R17,R38) of 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 offer/administer Influenza vaccines for two residents (R17,R38) of five residents reviewed for immunization in a sample list of 46 residents. Findings Include: 1.) R17's Immunization consent signed by R17 on 9/26/22 documents I have been educated on the risks and benefits of receiving the influenza (flu) vaccine and I do want to be vaccinated annually. R17's immunization flow sheet documents R17 has not received the flu shot. R17's Minimum Data Set (MDS) dated [DATE] documents R17 is cognitively intact. On 12/12/22 at 10:00AM R17 stated I signed my consent for a flu shot, but I haven't got one yet. 2.) R38's Immunization consent signed by R38 on 11/7/22 documents I have been educated on the risks and benefits of receiving the influenza vaccine and I do want to be vaccinated annually. R38's immunization flow sheet documents R38 has not received the flu shot. On 12/14/22 at 10:00AM V7, Infection Preventionist stated Both (R17, R38) have consented for flu shots. We just haven't had time to give all of the flu shots yet. On 12/15/22 at 1:00PM V2, Director of Nursing stated Once a consent for a flu shot is obtained, it should not be weeks until it is administered.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R117's Medication Administration sheet dated 12/1/22 through 12/31/22 documents R117 was admitted on [DATE] and includes an o...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R117's Medication Administration sheet dated 12/1/22 through 12/31/22 documents R117 was admitted on [DATE] and includes an order dated 11/3/22 for Seroquel 100 milligrams (mg) at bedtime and for Ativan 2 mg/milliliter give 0.5 milliliters every one hour for diagnosis of anxiety/agitation. R117's care plan dated 11/3/22 did not contain a care plan for the use of psychotropic medications. On 12/15/22 at 2:30 PM, V2 Director of Nursing stated a psychotropic care plan should have been completed for R117. Based on observation, interview and record review the facility failed to develop comprehensive care plans for four of 24 residents (R56, R58, R174, R117) reviewed for care plans in the sample list of 46. Findings include: The facility's Resident Care Policy and Procedure; Resident Assessment and Care Planning policy with a revised date of November/2017 documents, Each Resident's Care Planning needs will be met as presented in 483.21, Comprehensive Person Centered care planning of the State Operations Manual, Appendix PP. 4. The facility shall develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs, as well as preferences for care an goals. This comprehensive care plan is person centered, and may be the continuation of the baseline care plan established within 48 hours of admission. 5. The facility must evaluate and modify, if necessary, the efficacy and appropriateness of each resident's care plan on at least a quarterly basis, and with a significant change in condition. 1.) R56's Order Summary dated 12/14/22 documents diagnoses including Central Dislocation of Left Hip, Subsequent Encounter, Muscle Weakness and Difficulty in Walking. This Order Summary documents an order that it is ok to remove knee immobilizer for bathing and dressing with a start date of 11/4/22. R56's Minimum Data Set (MDS) dated [DATE] documents R56 has impaired range of motion on one lower extremity. R56's Therapy Discharge Communication dated 11/9/22 documents orders to apply splint to left lower extremity on all times except cares, brace on over pants. R56's Care Plan dated 10/21/22 does not document the use of a knee immobilizer. On 12/12/22 at 1:30 PM, R56 was in R56's wheelchair across from the nurse's station. R56 did not have the knee immobilizer on R56's left leg. On 12/15/22 at 11:15 AM, V12 Restorative Nurse/Unit Director confirmed R56's knee immobilizer is not on the Care Plan and should be on the Care Plan. 2.) R58's Order Summary dated 12/14/22 documents diagnoses including Bilateral Primary Osteoarthritis of Knee, Vascular Dementia, Mild, Postlaminectomy Syndrome, Muscle Weakness, Difficulty in Walking and Other Lack of Coordination. R58's Minimum Data Set (MDS) dated [DATE] documents recent spinal surgery and triggered falls to be carried over to the Care Plan. R58's Care Plan dated 11/18/22 documents to assist with ambulation and transfers. R58's Fall Risk assessment dated [DATE] documents R58 is at high risk for falling. R58's Care Plan dated 11/18/22 does not document R58 is at risk for falls and does not document any interventions to prevent falls. On 12/12/22 at 11:07 AM, R58 was in R58's room sitting in a high back chair with a walker approximately two feet away from R58. R58 stated that R58 has to have help when walking. On 12/15/22 at 11:15 AM, V12 Restorative Nurse/Unit Director confirmed fall risk and interventions were not on R58's Care Plan. 3.) R174's Order Summary dated 12/14/22 documents diagnoses including Other Obstructive and Reflux Uropathy, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms and Vascular Dementia. This Order Summary documents an order for an Indwelling Urinary Catheter size 16 French/10cc (cubic centimeters) balloon, change every 30 days. R174's MDS dated [DATE] documents R174 had an indwelling urinary catheter on admission. R174's Care Plan dated 11/22/22 does not document R174 having an indwelling urinary catheter or any interventions related to the catheter. On 12/12/22 at 10:59 AM, R174 was in R174's room in a wheelchair and the indwelling urinary catheter collection bag was hanging on the side of the wheelchair. On 12/15/22 at 11:15 AM, V12 confirmed R174's indwelling urinary catheter was not on the Care Plan and the catheter should be on the Care Plan with interventions.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5.) R329's Care Plan reviewed 12/6/22 includes the following diagnoses: Major Depression and Anxiety Disorder. R329 has an activ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5.) R329's Care Plan reviewed 12/6/22 includes the following diagnoses: Major Depression and Anxiety Disorder. R329 has an active physician's order for Cymbalta (antidepressant) Capsule Delayed Release Particles 20 Milligrams Give 1 capsule by mouth one time a day, Melatonin (Sleep Aide) Tablet 3 Milligrams Give 1 tablet by mouth at bedtime for sleep, Quetiapine Fumarate (Antipsychotic) Tablet 50 Milligram Give 1 tablet by mouth at bedtime, Ativan (Antianxiety) Tablet 0.5 milligram Give 0.5 milligrams by mouth two times a day. There is no psychotropic medication assessment documented for R329. There is no diagnosis or rationale documented to support the use of an antipsychotic medication. On 12/14/22 at 2:00PM V2, Director of Nursing stated (R329) should have had a baseline psychotropic assessment and the diagnoses Major Depression and Anxiety do not justify the order of an antipsychotic medication. 6.) R38's Care Plan reviewed 11/23/22 includes the following diagnoses: Major Depressive Disorder and Anxiety. R38 has an active Alprazolam (antianxiety) Tablet 0.5 milligram Give 1 tablet by mouth as needed for Anxiety. This order was initiated 11/23/22. There is no documentation to support R38's physician assessed the need for this (antianxiety) medication beyond 14 days. On 12/14/22 at 2PM V2, Director of Nursing stated (R38's) Alprazolam was not reassessed after from 11/23/22 until 12/14/22. I am aware it should have been. 3.) R95's Physician Order sheet documents an order dated 10/27/22 for Cymbalta 60 milligrams by mouth for nerve pain and Depression and an order dated 6/18/22 for Sertraline 200 mg for Major Depressive Disorder. This physician order sheet also included an order dated 6/18/22 for Lorazepam 0.5 mg three times a day for Anxiety Disorder. R95's Quarterly medication assessment dated [DATE] R95's response to the use of psychotropic medications or the date that a reduction was last attempted. The boxes that ask these questions on the assessment are blank. On 12/15/22 at 2:30 PM, V2 Director of Nursing stated the assessments should be complete and identify targeted behaviors, document when a reduction was last attempted and document the residents response to the medication. 4.) R117's Medication Administration Record (MAR) dated 12/1/22 through 12/31/22 documents R117 was admitted on [DATE]. R117's MAR includes an order dated 11/3/22 for Seroquel 50 milligrams (mg) at bedtime for Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. This MAR documents on 12/4/22 R117's Seroquel was increased to Seroquel 100 mg at bedtime for behaviors. This MAR also includes an order dated 11/2/22 for Ativan 2 mg/milliliter give 0.5 milliliter every one hour (PRN) as needed or diagnosis of Anxiety/Agitation. R117's admission medication assessment dated [DATE] does not document the behaviors for which R117 is receiving psychotropic medications. R117's medical record does not include an assessment when R117's Seroquel was increased or documentation of why R117's Ativan was continued past 14 days or the nonpharmacological interventions or behaviors for which the Ativan was given. On 12/15/22 at 2:30 PM, V2 Director of Nursing stated a new order should be obtained when a PRN extends past 14 days or when a medication is increased. Based on observation, interview, and record review the facility failed to complete initial assessments prior to the start of psychotropic medications and quarterly, failed to justify PRN (as needed) psychotropics, failed to identify/track targeted behaviors, failed to document specific diagnosed conditions for psychotropic medications for six residents (R100, R95, R117, R21, R38, R329) of six residents reviewed for Psychotropic medication in a sample list of 46. Findings include: The facility's policy Psychotropic Medication revised 11/2817 states (psychotropic) medications are to be given to treat a specific condition/medical symptom that is diagnosed and documented in the clinical record. Specific condition/medical symptoms are not enough to justify pharmacological use. An evaluation must be done to determine other possible physical, medical, behavioral, psychosocial needs.This policy also states Classifications of medication including: Antianxiety, Hypnotic, antidepressant medication. Initial PRN (as needed) order of above listed medications should not exceed 14 days, unless the attending physician or prescribing practitioner believes that (there is a rationale) to extend beyond 14 days and has documented the rationale and indicated the duration. 1.) R21's ongoing Census documents R21 was admitted to the facility on [DATE]. R21's December 2022 Physician Orders document the following orders: Buspirone {Anxiolytic} 5 mg (milligrams) - one tablet every every morning and two tablets every evening for Anxiety obtained on 12/1/22. Quetiapine {Atypical Antipsychotic} 25 mg - one tablet at bedtime for Major Depression obtained on 5/27/22 with the justification for use changed to Dementia with other Behavioral Disturbances on 11/23/22. Sertraline {Selective Serotonin Reuptake Inhibitor} 50 mg - 3 tablets by mouth one time a day for Depression obtained on 5/28/22. R21's medical record did not contain any psychotropic medication assessments for the Quetiapine at the time of admission, the Sertraline prior to implementing the order, or quarterly for the psychotropic medications. The first Psychotropic Medication Assessment in R21's medical record is dated 6/7/22 documents R21 is taking Quetiapine 25mg at HS (bedtime) for Major Depression. R21 is responding well; does not show any signs/symptoms or adverse reactions to therapeutic dosage of medications. There are no targeted behaviors documented. There is no assessment for the use of the Sertraline. There is no quarterly Psychotropic Medication Assessment for the continued use of R21's Quetiapine or Sertraline in September 2022 in R21's medical record. R21's December 2022 Pyschotropic Medication assessment dated [DATE] documents R21 is being started on Buspirone 5mg every morning and 10 mg every evening for Anxiety but does not document specific targeted behaviors. There is no quarterly Psychotropic Medication Assessment for the continued use of Quetiapine or Sertraline. R21's Care Plan dated 11/28/22 documents R21 is at risk for adverse signs and symptoms related to the use of psychotropic medications for pacing, wandering, disrobing, inappropriate response to verbal communication, and violence/aggression towards staff/others. R21's medical record does not document behaviors for justification of Antipsychotic medication use or tracking identified care planned behaviors. On 12/12/22 at 12:33 pm and 12/14/22 at 9:24 am, R21 was sitting at the dining room table and did not display any behaviors. On 12/14/22 10:06 AM, V2 DON (Director of Nursing) stated when a resident is admitted on psychotropic medications, an assessment should be completed at that time, then quarterly and PRN (as needed) with changes. V2 also stated that behaviors need to be monitored and tracked and those behaviors should be documented in the medical record. 2.) R100's ongoing census documents R100 was admitted to the facility on [DATE]. R100's December 2022 Physician Orders document an order obtained on 11/25/22 for Seroquel {Antipsychotic} 12.5 mg by mouth in the evening for Anxiety and behaviors, which was increased to 25 mg on 12/3/22. R100's Psychotropic Medication assessment dated [DATE] documents Seroquel 12.5mg is being used for Anxiety and behaviors but does not document specific targeted behaviors. R100's Psychotropic Medication assessment dated [DATE] documents the increase in Seroquel to 25 mg for Anxiety and Alzheimer's but does not document specific targeted behaviors. R100's Care Plan dated 11/28/22 documents R100 is at risk for complications related to taking Antipsychotic medications and is at risk for mood problems related to Anxiety and Alzheimer's. This care plan does not document any targeted behaviors. R100's Behavior tracking form from 11/14/22 - 12/13/22 documents the following behaviors: 2 episodes of repetitive movements and 8 episodes of wandering. No other behaviors are documented. On 12/13/22 at 12:36 PM, V2 DON (Director of Nursing) stated wandering and Anxiety is not a reason for an Antipsychotic medication.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

Based on observation, interview and record review, the facility failed to administer medications according to Physician's Orders for three of seven residents (R60, R79, R80) reviewed for medication ad...

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Based on observation, interview and record review, the facility failed to administer medications according to Physician's Orders for three of seven residents (R60, R79, R80) reviewed for medication administration on the sample list of 46 residents. The facility had five errors out of 25 opportunities for a medication error rate of 20%. Findings Include: The facility Medication Administration Policy dated 1/11/10 documents medications will accurately be administered following physician orders. Crush only medications that can be crushed or physician has given orders to crush. 1.) On 12/14/22 at 8:23 AM, V21 LPN (Licensed Practical Nurse) prepared R79's morning medications that included Metoprolol {Beta Blocker} ER (extended release) 50 mg (milligrams) tablet and Potassium 20 meq (milliequivalents) tablet. R79's Metoprolol had a warning on the medication card documenting take with meal or right after. R79's Potassium medication card contained a warning to take with food. After R79's medications were prepared, V21 entered R79's room and R79 was still lying in bed. V21 administered all morning medications including the Metoprolol and Potassium and stated R79 had not had breakfast yet but would be eating shortly. Under constant supervision until 9:07 am {44 minutes later}, R79 remained in R79's room and did not have breakfast delivered to R79. 2.) On 12/14/22 at 12:11 PM, V31 prepared R60's ordered medication that included Neurontin {Gabapentinoids} 300 mg. The Neurontin medication card documents a warning to take whole, do not crush. V31 opened the capsule of Neurontin and mixed the powdered medication in with applesauce and administered it to R60. 3.) On 12/15/22 at 8:09 AM, R80 was sitting at the dining room table eating breakfast. V38 prepared R80's ordered medication that included Levothyroxine {Hormone} 112mcg (micrograms) and Flomax {Alpha Blocker} 0.4 mg (milligrams). The Levothyroxine medication card documents a warning to take medication 30 minutes before meal and the Flomax medication card documents a warning to take whole, do not crush. V38 crushed R80's Levothyroxine and placed the crushed medication into pudding. V38 then opened the capsule of Flomax and included the powdered medication into the pudding, and administered it to R80.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to request a medication refill for one of one resident (R56) reviewed 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 request a medication refill for one of one resident (R56) reviewed for significant medication errors. R56 did not receive 4 of 4 scheduled once weekly doses of diabetes medication as ordered by the physician. Findings include: The facility's Medication Administration policy dated 1/11/10 documents, 17. Missed doses of medication may occur at points in time related to lack of availability by suppliers, drug recalls, etc. In such cases, the facility will notify the contracted back up pharmacy or resident family (in cases where the family is the provider of these medications, such as is common with some insurance and VA {Veterans Administration} medications) for provision to the facility. R56's Order Summary dated 12/14/22 documents diagnoses including Central Dislocation of Left Hip, Subsequent Encounter, Muscle Weakness, Difficulty in Walking and Diabetes Mellitus. This Order Summary documents an order for Trulicity Solution Pen-Injector (Antihyperglycemic) 0.75 mg (milligrams)/0.5 ml (milliliters), inject 0.5 ml subcutaneously once weekly every Sunday for Diabetes. R56's Medication Administration Record (MAR) dated 11/1/22 through 11/30/22 documents the Trulicity was scheduled to be given on 11/20/22 and 11/27/22 and documents to see the Progress Notes. R56's Progress Notes dated 11/20/22 at 9:28 AM, documents medication (Trulicity) was unavailable. R56's Progress Notes dated 11/27/22 at 8:50 AM, documents medication (Trulicity) unavailable. These Progress Notes do not document any Physician notification of R56 not receiving the Trulicity. R56's MAR dated 12/1/22 through 12/31/22 documents the Trulicity was scheduled to be given on 12/4/22 and 12/11/22 and documents to see the Progress Notes. R56's Progress Notes dated 12/4/22 documents the medication (Trulicity) was not available and R56's Progress Note dated 12/11/22 documents the medication (Trulicity) was unavailable. These Progress Notes do not document any Physician notification of R56 not receiving the Trulicity. R56's Minimum Data Set (MDS) dated [DATE] documents R56 is severely cognitively impaired. This MDS documents R56 has an active diagnosis of Diabetes Mellitus. On 12/14/22 at 2:13 PM, V2 Director of Nursing stated if the resident is out of a medication and the pharmacy has not brought the refill, the nurses should get the medication out of the back up supply if it is available. V2 stated if it is not available then it should be obtained from the back up pharmacy which comes from a local pharmacy. On 12/15/22 at 9:17 AM, V3 Assistant Director of Nursing stated regarding R56's Trulicity that it is not on an automatic order so the nurse's have to put in for the reorder after they give it. If it is an agency nurse they may not know that they are suppose to do that. V3 stated if they do an immediate reorder it will be here the next day. V3 confirmed it has been a month since R56 has had the Trulicity. On 12/15/22 at 9:33 AM, V34 Pharmacist stated the last time the Trulicity was ordered and filled was on 11/7/22 and it was not requested again to be refilled until 12/14/22. V34 stated the Trulicity was sent out yesterday (12/14/22). V34 stated the Trulicity comes in one pen which equals one dose so they have to reorder every time they use it. V34 stated the Trulicity is for diabetes, to lower blood sugars. R56's Medication Administration Records dated 11/17/22 through 12/12/22 document R56's blood glucose readings vary from a low of 53 mg/dL (milligrams per deciliter) to 301 mg/dL.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review the facility failed to ensure cooking surfaces and dish storage areas were clean and free of cross contamination prior to continued use. This failure...

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Based on observation, interview, and record review the facility failed to ensure cooking surfaces and dish storage areas were clean and free of cross contamination prior to continued use. This failure had the potential to affect all 121 residents residing in the facility all or most of whom consume food prepared in the facility kitchen. Findings include: On 12/12/22 at 9:05 AM, accumulated black and brown food residue was covering the doors to the oven. The base of the oven was covered with crumbs and food residue. Cooked rice and a large dried area of liquid was on top of the cook top griddle. V5 Dietary Manager stated the rice was from last night's supper. The stove's backsplash had accumulated dried food spattering stuck to it. The plate warmer which was full of plate warmers ready for use and had a thick covering of crumbs and dust. V5 stated stove and plate warmers are used for every meal. V5 confirmed the oven, stove, and plate warmer was dirty and stated those areas needed cleaned. The facility's census and condition report dated 12/12/22 signed by V4 Minimum Data Set Specialist documents there are 121 residents residing in the facility.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected most or all residents

Based on interview and record review the facility failed to hold QAPI (Quality Assurance and Performance Improvement) meetings at least quarterly. This failure has the potential to affect all 121 resi...

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Based on interview and record review the facility failed to hold QAPI (Quality Assurance and Performance Improvement) meetings at least quarterly. This failure has the potential to affect all 121 residents residing at the facility. Findings Include: The facility's Quality Assurance Sign-In Sheets document the facility held a meeting on 5/22/22 to cover the QAPI meeting requirement for January, February, and March of 2022, and a meeting 7/20/22 to cover the QAPI meeting requirement for April, May, and June of 2022. There is no documentation to support a meeting was held to cover the QAPI meeting requirement for July, August, and September of 2022. On 12/14/22 at 11:00AM V1, Administrator stated We were not able to have a QAPI meeting for the months of July, August, and September of 2022. We are working on scheduling one with our Medical Director of October, November, and December 2022. It is the policy of this facility to hold QAPI meeting at a minimum of quarterly. The facility's census and condition report dated 12/12/22 signed by V4 Minimum Data Set Specialist documents there are 121 residents residing and receiving services in the facility.

Nov 2022 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to operationalize their abuse prevention policy by failing to ensure s...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to operationalize their abuse prevention policy by failing to ensure staff report a bruise of unknown origin immediately to the administrator. This failure affects one resident (R1) of three resident reviewed for abuse in the sample of three. Findings include: The facility's Abuse Prohibition Policy dated Revised 3/15/2018, documents employees who have been hired will be oriented on the Abuse Prohibition Policy (on hire and annually); the administrator will in-service all staff on the need to immediately report any signs of abuse; a facility employee who becomes aware of alleged abuse shall immediately report it to the facility administrator; and employees shall identify and report resident bruises to the administrator. R1's Minimum Data Set (MDS) dated [DATE], documents R1 as moderately impaired cognition and requires extensive assistance and total dependency for all activities of daily living. R1 is discharged from the facility and unable to be contacted. The facility's Final Report dated 10/11/22, documents a resident (R1) family member (V16) reported bruising to R1's buttocks and hip area on 10/6/22. R1's Nursing Progress notes dated 10/6/22 at 6:32 PM, documents R1's Power of Attorney V16 came to visit R1 and noticed R1 was wet and R1's gown was dirty and asked V18 Certified Nursing Assistant (CNA) to change R1. While changing R1, V18 CNA and V16 noticed 2 huge bruises on R1's sacral area. Bruise 1 is 42 centimeters (cm) X 17cm, bruise 2 is 34cm X 7cm. V1 Administrator notified. The facility's Investigation Form dated 10/6/22, documents V10 CNA's hand written statement as on 10/6/22 I went to change resident (R1) around 9:30 AM and notice a bruise on left side. During this same investigation, V10 was asked if V10 reported R1's bruise to a nurse and V10 responded: no I was off a few days and figured it was already reported. On 10/18/22 at 11:39 AM, V10 CNA stated I did not report it (bruise on R1) to the nurse when I (V10) saw it because I (V10) figured someone had already reported it. ` On 10/27/22 at 11:07 AM, V1 Administrator stated if a bruise is unknown in origin, it should be reported to the nurse and V1 to investigate for abuse. V1 stated V10 should have reported the bruising on R1 as soon as V10 noticed it.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to immediately report to the administrator an observed bruise on one resident (R1) of three residents reviewed for abuse/bruise in the sample ...

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Based on interview and record review, the facility failed to immediately report to the administrator an observed bruise on one resident (R1) of three residents reviewed for abuse/bruise in the sample of three. Findings include: The facility's Investigation Report dated 10/6/22, documents V10 Certified Nursing Assistant (CNA) observed a bruise on R1's left side at around 9:30 AM on 10/6/22. This same report documents V10 stated V10 did not report the bruise on R1 because I (V10) was off for a days and figured it was already reported. R1's Nursing Progress notes dated 10/6/22 at 6:32 PM, documents R1's Power of Attorney V16 came to visit R1 and noticed R1 was wet and R1's gown was dirty and asked V18 Certified Nursing Assistant (CNA) to change R1. While changing R1, V18 and V16 noticed 2 huge bruises on R1's sacral area. Bruise 1 is 42 centimeters (cm) X 17cm, bruise 2 is 34cm X 7cm. V1 Administrator notified at this time. On 10/27/22 at 11:07 AM, V1 Administrator stated V10 should have reported the bruising on R1 as soon as V10 noticed it. The facility's Abuse Prohibition Policy dated Revised 3/15/2018, documents employees shall identify and report resident bruises to the administrator.

ARC AT NORMAL

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ARC AT NORMAL

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