OAK PARK OASIS
For profit - Partnership
204 Beds
ICARE CONSULTING SERVICES
Data: November 2025
Trust Grade
0/100
#388 of 665 in IL
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Photo by Oak Park Oasis
Photo by Oak Park Oasis
Photo by Oak Park Oasis
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Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Oak Park Oasis has received a Trust Grade of F, indicating significant concerns about the quality of care provided. It ranks #388 out of 665 nursing homes in Illinois, placing it in the bottom half of facilities in the state, and #125 out of 201 in Cook County, suggesting that there are many better local options. The facility is worsening, with issues increasing from 13 in 2024 to 17 in 2025, and it has a troubling history that includes serious incidents such as a resident suffering a hip fracture due to inadequate supervision and another resident experiencing unaddressed pain for 44 hours before hospitalization. While staffing turnover is below the state average at 39%, the overall staffing rating is poor at 1 out of 5 stars, and the facility has incurred $125,361 in fines, which is average but still concerning. On a positive note, the quality measures rated 5 out of 5 stars, indicating that when care is provided, it can meet high standards, and there is a decent level of RN coverage, which is essential for ensuring residents' well-being.
- Trust Score
- F
- In Illinois
- #388/665
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 39% turnover. Near Illinois's 48% average. Typical for the industry.
- Penalties ✓ Good
- $125,361 in fines. Lower than most Illinois facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 28 minutes of Registered Nurse (RN) attention daily — below average for Illinois. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 57 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 42%
Review needed
13 → 17 violations
★★☆☆☆
2.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 13 issues
2025: 17 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (39%)
9 points below Illinois average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Below Illinois average (2.5)
Below average - review inspection findings carefully
Staff Turnover: 39%
Near Illinois avg (46%)
Typical for the industry
Federal Fines: $125,361
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: ICARE CONSULTING SERVICES
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 57 deficiencies on record
5 actual harm
Aug 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0628
(Tag F0628)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed the facility failed to follow their policy to provide Discharge Instructions and Medica...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed the facility failed to follow their policy to provide Discharge Instructions and Medications to one resident (R1)upon her planned transfer from the facility to another skilled facility. This failure affected 1 of 3 residents reviewed for discharge/transfers.The findings include:R1 admitted to the facility on [DATE] and discharged to another facility on 8/9/25.On 8/13/25 at 12:06PM V3, Restorative Nurse, said R1 had a planned discharge, I was working the cart. V3 said R1's family came and got her. V3 said the Secretary at the front desk told them to speak with a nurse, but the family just took R1. V3 said they did not speak with me. V3 said only the secretary saw the family. At 12:54PM V3 said the admitting facility called me around 12:31PM on 8/9/25, V3 checked her phone for times. V3 said that is when I became aware R1 had left. V3 said they called when R1 arrived saying no medications were sent with R1. V3 said I faxed the paper work to the facility after they called. The family said they spoke with me, but then said I thought it was you. V3 said she didn't know when R1 left so no medication was sent or discharge instructions were given. V3 said she had see R1 sometime after 9:00AM on 8/925 when she administered medications. V3 said R1 was in her room with her suitcase. On 8/13/25 at 2:00PM V5, LPN, said when a resident is a planned discharge we review the discharge instructions and medications with them. We send them the instructions, medication list, and any referrals they might have with them.R1's progress notes dated 8/8/25 states R1 requested to be transferred to another facility. R1's family will transport. On 8/9/25 progress notes at 12:02PM states writer notified via phone that R1 arrived to accepting facility. Nurse did not speak to the family, medication did not go with R1 at the time she left the facility.A Transfer Discharge Report dated 8/8/25 was presented. R1 transferred to another nursing home. Medications are listed. A Discharge Planning Review dated 8/8/25 was presented stating will be returning to the facility she came from before facility.No document presented for R1 has a signature on the day of discharge. No Discharge Instructions with R1 or representative signature was presented.Facility Discharge/Transfer of Resident policy dated 11/18 states in part, purpose to provide safe departure from the facility period to provide for continuity of care and treatment. Provide additional health education or medication instruction information for resident or family as indicated. Have resident or sponsor signed personal inventory of effects form. Heat transfer form accurately and completely including vital signs. Assist resident into wheelchair and escort to vehicle if necessary or assist attendance with transport. Document discharge summary. Include notes on specific instructions given such as medications to resident and responsible parties.
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observations, and record review the facility failed to ensure that resident floors are free from hazards. Wa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observations, and record review the facility failed to ensure that resident floors are free from hazards. Water noted on the floor near door entry ways. Water was observed in a puddle with a white towel over it in R3's room entry way. This failure affected five residents (R3-R7) of 6 residents reviewed for safe environment.The findings include:On 8/13/25 at 10:45AM surveyor walked past R3's room and saw wet floor, towel on the floor near liquid, and no wet floor sign in the room. Air conditioning grill above the wet area near entry door. R3 sitting in her wheelchair in the room.On 8/13/25 at 10:47AM V1, CNA, said I have seen leaking from the ceiling in this room, R4's-R7's. V1 said I saw it a week or two ago. V1 said it was leaking a lot.On 8/13/25 at 10:55AM surveyor walked past R3's room, the floor remains wet with a towel over it. R3 sitting in the wheelchair. R3 pointed to the ceiling air conditioner grill when asked where the water was coming from. R3 said they know about it. It's been like this for a while. V8, ADON, was walking past in the hall and surveyor requested she call maintenance. V6, Administrator, arrived while V8 was placing a wet floor sign and drying the floor with the towel. V6 said maintenance has been working on this. V6 said sometimes the humidity makes it drip. While talking to V6 the grill dripped 2 drops. The water on the floor was approximately 3 floor tiles wide and long.On 8/13/25 at 11:10AM V2, Maintenance, said the air conditioner is working in R3's room making the condensation that is leaking to the floor. V2 said the pipe needs to be opened. V2 said yesterday the leaking was in room [ROOM NUMBER], above R3's room. V2 said I need to clean the main pipe out and put pressure in it, 2-3 times a year. V2 said last week I cleaned it out in the administration office and room [ROOM NUMBER] (currently empty). V2 said today the leak has been in R3's room for about 2 hours. V2 said I have only been working here about 6 weeks and when I asked, no one knew about the pipes needing to be cleaned. V2 said they told me they had not been doing this. V2 said I have been cleaning the pipes as the problems are reported. V2 said the pipes get build up in them and I need flush them with the air compressor. V2 said they get clogged, and the water has no where to go but to leak.On 8/13/25 at 2:03PM R6 said about a week ago the ceiling was leaking, (pointed to ac vent). The floor was getting wet. They had a bucket, but it was overflowing and full. No one was emptying it. The water was spilling onto the floor and it was slippery to walk past.R6 fall risk assessment was completed on 7/14/25 and he is identified at risk for falls due to his unsteady gait and medications.R6's care plan dated 1/25/24 states at risk for falls related to unsteady gait.On 8/13/25 at 2:07PM V9, LPN, said I have seen the dripping from there, indicating the ceiling grill in R6's room. V9 said the CNA and maintenance are in charge of emptying the water bucket. V9 said if there is water on the floor, the residents are at risk for falls. All the residents in that room (R4-R7) ambulate independently and are in and out of the room.On 8/14/25 at 11:56AM V3 said residents with unsteady gait can be ambulating independently. V3 said for all residents we ensure nothing on the floor, nothing in their path, like furniture, other residents, keep paths clear, and spills are supposed to be cleaned up right away. V3 said every week we do team rounding to make sure all rooms are clean and no hazards. V3 said everything in the facility is designed for safety. Census identifies R4-R7 residing in the same room with the leak.Review of work orders first floor on 7/16/25 123 room leaky from AC, please check. 7/11/25 122 room water dripping from the ceiling. [Illegible month] /8/25. 7/24/25 3:55AM room [ROOM NUMBER] ceiling by bathroom (vent) leaking causing huge puddle making hole in the wall bigger. Put something to catch it. 7/24/25 4:20AM room [ROOM NUMBER] leak by bathroom door and head od bed. Garbage bin catching leak now. Undated Rooms 203, 205, 207, and 206 leaking air conditioning condensation. On 8/8/25 room [ROOM NUMBER] water in middle of floor.The facility fall policy dated 2/28/14 states the standard fall safety precautions for all residents in part states the residents environment will be kept clear of clutter Which would affect ambulation and remove hazards.
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 interviews and records reviewed the facility failed to ensure staff followed the facility practice of nurses not leavin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed the facility failed to ensure staff followed the facility practice of nurses not leaving the unit at the end of a shift without a relief. This failure resulted in the unit not having a nurse on unit for at least 1 hour. This failure has the potential to affect 36 residents residing on the unit.The findings include:On 8/13/25 at 12:06PM V3, Restorative Nurse, said on the second floor there is normally 2 nurses, 1 on main unit and 1on pavilion unit. V3 said 8/9/25 there was a call off for day shift I was notified at 8:45AM that there was a missing nurse on 2 main. V3 said I took over the cart about 9:15AM. V3 said I found out because I was coming in as Manager on Duty. V3 said I didn't clock in or out that day. V3 said the off going nurse is supposed to wait until the next nurse comes in before leaving. V3 said V12, LPN, called in. V3 said when I got to the facility the staff told me there was no nurse on 2 main. V3 said the call ins go to the DON or ADON. V3 said the unit was without a nurse for about 2 hours. V3 said CNAs can't pass medications. V3 said I don't even know what time I finished the morning medication pass, we had a code, reports of an alleged smoking violation I had to look into, and the Manager on Duty responsibilities.On 8/13/25 at 1:59PM V7, CNA, said we are supposed to call in 4 hours before our shift. We call into the DON to notify her.On 8/13/25 at 2:00PM V5, LPN, said we give verbal report to the oncoming nurse and we do a narcotic count with them. V5 said we are not supposed to leave the shift without a relief.On 8/13/25 at 12:42PM V6, Administrator, said I was made aware when V3 notified me on 8/9/25 that there was not a nurse for the 2nd floor unit. V6 said V3 took the cart. V3 said calls offs are to go to the on call person and DON. V6 said it is not the facility practice for the nurses to leave before a relief arrives. On 8/14/25 at 9:50AM V6 said we are a skilled nursing facility, we provide nursing care 24 hours a day.On 8/14/25 at 8:02AM V10, LPN, said I was not told there was a call off for the morning of 8/9/25. I was not asked to stay over on 8/9/25.On 8/14/25 at 12:45PM V14, Director of Nursing, said V12 text me last minute on 8/9/25. V14 said it was 6:50something in the morning when she text. V14 said I didn't even hear the text, I didn't know V12 wasn't in the building until V3 notified me. V14 said if I had known, I would have come in and had the nurse wait for me. V14 said call off should be 4 hours before the shift, staff should call the on call number. V14 said this is told to them at hire and is in the handbook. At 12:57PM V14 presented the unit census for 8/9/25 and said the unit has 36 assigned residents for the nurse.Review of time cards includes 8/9/25 V11 clocked in at 7:33AM; V13, LPN, clocked in at 6:51AM; V9, LPN, clocked in at 6:59AM. V12 is designated absent on 8/9/25. V10 clocked out the morning of 8/9/25 at 7:32AM.Review of Controlled Substances Check Form dated 8/9/25 unit 2 Main has no day shift on nurse or off nurse signature.The facility attendance policy in part states it is an employee's responsibility to notify their supervisor promptly of their absence for any scheduled work day. Employees should call at least 4 hours in advance of their scheduled start times.The Facility assessment dated [DATE] identifies on day shift (1st shift) 4 nurses will provide direct care to the residents.
Jul 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
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its Urinary Catheter Care policy to provide ca...
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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 follow its Urinary Catheter Care policy to provide catheter care to residents. This applies to 3 of 4 residents (R2, R3, and R4) reviewed for indwelling catheter care in a sample of 4.1.R2 is an [AGE] year-old female admitted with moderate cognitive impairment as per the MDS dated [DATE]. On 7/16/25 at 9:00 AM, R2 was observed in her bed with an indwelling catheter bag with one-fourth urine placed flat on the bed. On 7/16/25 at 9:03 AM, V3 (Licensed Practical Nurse/LPN) stated that the indwelling catheter bag shouldn't be on the bed to prevent urine backflow, which could cause infection. A review of the indwelling catheter care plan document interventions including to position catheter bag and tubing below the level of the bladder.On 7/16/25 at 11:25 AM, observed V5 (Certified Nursing Assistant/CNA) providing catheter care to R2, who was on a geriatric chair. V5 used soap and water to wipe down the catheter without cleaning the labia. On 7/16/25 at 11:30 AM, V5 stated that she usually cleans the labia when R2 is in bed. V5 added that since R2 was on the chair, it was hard to spread out her legs to clean the labia. 2.R3 is a [AGE] year-old female admitted on [DATE] and having mild cognitive impairment as per the MDS dated [DATE]. On 7/16/25 at 9:10 AM, R3 was in her bed with an indwelling catheter in place, and V4 (Registered Nurse/RN) and V5 were checking R3's catheter. R3 was observed with an indwelling catheter not secured to her thigh with no stat lock or tape in place.3.R4 is a [AGE] year-old male admitted on [DATE] with moderate cognitive impairment as per the MDS dated /16/25. On 7/16/25 at 9:15 AM, observed R4 lying on his bed with a urine leg bag tied to his thigh and without having the catheter secured. On 7/16/25 at 11:45 AM, observed V7 providing catheter care to R4 (uncircumcised). V7 used soap and water to wipe down the indwelling catheter without retracting the foreskin to clean the catheter-meatal junction. On 7/16/25 at 2:00 PM, V2 stated, For uncircumcised male residents, the staff should retract the foreskin to cleanse the catheter-meatal junction while providing the catheter care. For female residents, staff should have clean labia while providing catheter care. The indwelling catheters should be secured to avoid tension, and also the bag should be kept to drain under gravity to prevent urine backflow. The facility presented the Urinary Catheter Care policy (5/14) document:5. Indwelling catheters will be secured to prevent trauma and tension.6. Catheters shall be positioned to maintain a downhill flow of urine to prevent a backflow of urine into the bladder or tubing during transfer, ambulation, and body positioning.16.Male residents who are uncircumcised shall have the foreskin retracted and the catheter-meatal junction cleansed, replacing the foreskin over the penis when the procedure is completed.
Jul 2025
4 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
Accident Prevention
(Tag F0689)
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 provide adequate supervision to a high fall risk resident for one (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate supervision to a high fall risk resident for one (R1) of four residents (R1, R2, R3 and R4) reviewed for falls in the sample of four. This failure resulted in R1's left hip fracture, emergent hospitalization, and subsequent left hip surgery.
Findings include:
R1 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including bit not limited to Ataxia; Epilepsy; Unspecified Abnormalities of Gait and Mobility; Abnormal Posture; Muscle Wasting and Atrophy; Schizoaffective Disorder, Bipolar Type; Schizophrenia; Bipolar Disorder; Essential (Primary) Hypertension; Type 2 Diabetes Mellitus with Diabetic Neuropathy; and Heart Failure.
According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section C, R1 has BIMS (Brief Interview of Mental Status) score of 12 indicating moderate cognitive impairment.
According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section GG, R1 uses a walker as a mobility device and requires supervision or touching assistance during bed-to-chair transfers and walking.
According to R1's Fall Risk Review dated 03/12/2025, R1 is at high risk for falls.
R1's care plan initiated on 12/23/2021 reads in part, (R1) is at risk for falls r/t (related to) confusion, gait/balance problems, poor communication/comprehension, on statin, hypoglycemic and psychotropic medications, unaware of safety needs, vitamin D deficiency, ataxia, DM II with neuropathy. Interventions: Be sure (R1's) call light is within reach and encourage the (R1) to use it for assistance as needed. [NAME] needs prompt response to all requests for assistance; Anticipate and meet the (R1's) needs; Ensure that (R1) is wearing appropriate footwear when ambulating or mobilizing in wheelchair; (R1) needs a safe environment with even floors free from spills and/orclutter; adequate, glare-free light; a working and reachable call light, handrails on walls, personal items within reach.
R1's care plan initiated on 03/21/2023 reads in part, (R1) presents with: Decreased strength., Poor balance., Impaired ambulation., General deconditioning., Symptoms/problems are manifested by increased risk for falls. Interventions: Implement fall precautions per facility protocol (keep areas clear, well lit & accessible).
On 6/30/2025 at 11:48 AM Surveyor observed R1 laying in the bed. R1 clean and dressed appropriate, no shoes observed at this time. R1's room dark, call light out of R1's reach, no clutter observed. R1 said, Yeah I fell, I hurt my hip. I'm not sure when or how it happened. R1 unable to recall circumstances of the incident, sounds confused and forgetful.
On 06/30/2025 at 11:54 AM V6 (Licensed Practical Nurse) said, I wasn't here when R1 fell (04/06/2025). R1 ambulated with a walker, had steady gait back then; however, still required supervision prior to the fall. R1 is forgetful, there are times when you can have a conversation with him and other times when you cannot. R1 forgets to use a call light despite staff reminding him to do it. R1 was moved to a room closer to the nursing station after the fall for easier monitoring.
On 06/30/2025 at 3:23 PM V9 (Registered Nurse) said, I worked on 04/06/2025, I don't remember what shift. I don't remember the time of R1's incident, but I think it was after breakfast. I heard R1 calling for help while I was passing medications. I went up to R1, R1 was sitting on the hallway floor, right by his room, leaning against the wall, with one of his legs stretched forward. R1 said he saw spilled water on the floor and was trying to wipe it. I don't remember if R1 was wearing shoes. R1 was not able to get up on his own. I called someone for help, I don't remember who came, we placed R1 in the wheelchair and put him in the bed. I notified the doctor, who recommend an x-ray. Upon my assessment, R1 was not able to move his left leg and it was in extended position. R1 was in a lot of pain, especially when trying to move his leg. I gave R1 pain medication, but I don't remember if I documented. After I received an x-ray order, I called the diagnostic company, and I was told they'll come out to do an x-ray but didn't say when. I don't remember whether this was a regular or STAT order. I didn't check on R1 nor reassessed R1's pain before the end of my shift. The x-ray company didn't come before I left. I didn't follow up with the diagnostic company. R1 would always use a call light when he needed anything. I don't know why he attempted to get up that day (04/06/2025). R1 would normally walk around the unit, he looked stable. I don't know if he used any mobility devices. R1 was walking like a normal person, so I'm not sure if R1 was at high risk for falls before the incident on 04/06/2025, so I'm not sure if R1 had any fall prevention interventions.
Per record review, V9 (Registered Nurse) was scheduled to work 7:00 AM - 3:00 PM and 3:00 PM - 11:00 PM on the 2 Main unit on 04/06/2025.
On 07/01/2025 at 10:45 AM V7 (Licensed Practical Nurse) said, When I came in to work on 04/07/2025 7:00 AM - 3:00 PM, it was reported to me that R1 fell the day before. I wasn't told any details of the fall. I looked at the report, and it showed that the x-ray was ordered per doctor's order. Once I noticed the diagnostic company didn't come around midday, I called them, and they said they had no order for R1's x-ray. I placed a STAT x-ray order, and they came out after 3:00 PM (04/07/2025). R1 usually wakes up early and walks around with a walker. On 04/07/2025, during my initial rounds, I noticed R1 was in pain and couldn't move his left leg. R1 was not able to get up but wasn't able to rate the pain. I'm pretty sure I gave R1 pain medication and document it in the progress. I was thinking we were just waiting for an x-ray, and everything was arranged. I was trying to keep R1 comfortable, I gave R1 some ice. When I returned to work on 04/08/2025 (7:00 AM - 3:00 PM), I was told that the x-ray showed that he had a fracture, and I was supposed to send him out to the hospital and not wait for the x-ray. R1 was a fall risk resident, and we were supposed to make sure we assist and supervise R1 when he gets in and out of bed and that he has a walker with him. R1 would always use a call light but also, he would try to get up by himself.
On 07/01/2025 at 11:07 AM V2 (Director of Nursing/ Fall Coordinator) said, R1 had a fall in an early April (2025). I received a call from V9 (Registered Nurse) close to 3:00 PM notifying e of R1's fall. V9 (RN) said that R1 had a fall, while he was trying clean up a spilled water in the room. R1 didn't have a walker at the time of a fall. V9 (RN) said that R1 didn't have any injuries but complained of leg pain. V9 (RN) said he gave R1 pain medication and called V13 (Attending Physician) to get an x-ray order. It was a Sunday, so I didn't do anything else in relation to the fall, just spoke to V9 (RN). When I came in on 04/07/2025, V7 (Licensed Practical Nurse) told me that they are still waiting for an x-ray. I advised V7 (LPN) to follow up with the diagnostic company. V7 (LPN) told me that the diagnostic company will be coming in before the end of the day. I don't know what time they came in. When I came into the facility the next day (04/08/2025), I made my rounds and heard that R1 didn't come out of the bad. I had words with V7 (LPN), I told her that when a resident has a change in condition and cannot walk whereas he walked before, nurses should send them out to the hospital. I then started the process of sending R1 to the hospital and he was picked up around 10:20 AM (4/8/2025). R1 was a fall risk resident before the incident (04/06/2025). R1 required constant redirection. One of the issues was that R1 has OCD (obsessive compulsive disorder), trying to clean and rearrange the room all the time. R1 didn't use a call light or ask for assistance. We would find him walk without the walker all the time. R1 was already walking around or stayed in one of the dining rooms; however, Certified Nurse Assistant should monitor residents at least every two hours. R1's fall occurred because R1 was trying to clean up after his roommate and there was spilled water on the floor. R1 has an obsession with cleanliness. One of the reasons why R1 was moved to another room is to make sure the room is clean and close to the nursing station. Surveyor asked if V8 (Certified Nurse Assistant) was the only working CNA despite the need for two CNAs on the on the 2 Main unit on 04/06/2025, V2 (Director of Nursing/ Fall Coordinator) did not confirm nor deny it.
On 07/01/2025 at 12:02 PM V13 (Attending Physician) said, I don't recall getting notified of R1's call, I might have gotten a call. When the facility nursing staff call me, they emphasize if a resident hit the head, vital sign status, how a fall occurred, and based on that I give orders. The first step is in-house diagnostic. If there is a change in resident's mental status, head trauma, loss of consciousness, or complaining of severe pain, I send them out to the hospital. Surveyor asked what some of the signs and symptoms of a broken hip are, V13 (Attending Physician) stated, Some of the signs of broken hip is complaining of pain, bruising, deformity, and affected ROM (range of motion), such as extended leg. The nurse should try to obtain a STAT image order to determine if there is a fracture and need for hospitalization. If a resident has a mild pain, we start at over-the-counter pain medication, if it's excruciating pain we would send them out to the hospital. It a resident has continuous pain, not managed by the over-the-counter medications, they should be sent out to the hospital. Surveyor asked what some are of long-lasting results of a broken hip, V13 (Attending Physician) said, A broken hip with a subsequent surgery would affect a resident acutely, example: bed rest and physical therapy. There could also be long lasting effect, such as chronic pain and change in the ROM (range of motion).
On 07/01/2025 at 12:19 PM V8 (Certified Nurse Assistant) said, On 04/06/2025, R1 was assigned to me. I don't recall R1 falling on my shift (7:00 AM - 3:00 PM). I was the only CNA on the main portion of the second floor on 04/06/2025, normally it's two. We do rounds are at least every two hours. R1 was not monitored in any special way, I don't think he was at risk for fall. I don't remember any special interventions that we had to do for R1. R1 was always adjusting and cleaning his room.
Per record review, V8 (Certified Nurse Assistant) was an only CNA scheduled to work 7:00 AM - 3:00 PM on the 2 Main unit on 04/06/2025.
R1's progress note written by V9 (Registered Nurse) dated 04/06/2025 02:42 PM reads in part, Full body assessment done, no open injuries or active bleeding noted, able to move all extremities but with a lot of pain voiced when moved the left knee and unable to stand up. v/s bp 134/67, r 20 p 71, DON (V2) aware, on call md order Knee x-ray.
R1's progress note written by V7 (Licensed Practical Nurse) dated 04/07/2025 03:38 PM reads in part, (R1) immobile due to pain to injury from recent fall; (R1) unable to come to an upright sitting position without assistance, greenish purple bruise noted on the left hip; pain level 5/10; Ambulatory status pre-change: ambulated with walker; Ambulatory status post-change: non ambulatory due to injury from previous fall.
R1's progress note written by V2 (DON/Fall Coordinator) dated 04/08/2025 09:30 AM reads in part, Manager follow up: Writer made aware by floor nurse that (R1) was observed lying in bed awaiting x ray results, but (R1) continues to c/o pain to Left leg and is not getting out of bed as per his baseline. Writer observed (R1) in room lying in bed stating, it's hard for me to stand up it hurts. Floor nurse made aware and instructed to call MD and have (R1) sent out for further evaluation, no further issues at this time, call remains within reach and resident given pain medication as per MD order. will continue to monitor as needed.
R1's progress note written by V7 (Licensed Practical Nurse) dated 04/08/2025 09:53 AM reads in part, The writer received (R1) in bed complaining of pain in left hip due to recent fall. The resident unable to come to a standing position. Md updated; orders given to send the resident to (local hospital). Currently awaiting transportation to arrive.
R1's progress note written by V7 (Licensed Practical Nurse) dated 04/08/2025 10:20 AM reads in part,
(Local) transportation arrived and transported (R1) via stretcher to (local medical center) per (R1's) request. (R1) received all scheduled medication and prn (pain medication) before leaving the facility and consumed 100% of his breakfast tray. Vitals upon (ambulance) arrival were (blood pressure): 138/76 (pulse): 86 (oxygen): 96% (temperature): 97.7 (pain): 6/10.
Hospital record initiated on 04/08/2025 11:30 AM reads in part, [AGE] year-old male with a (past medical history) of anemia, CAD (coronary artery disease), schizoaffective disorder, bipolar disorder, GERD, epilepsy, hypothyroidism, heart failure, hypertension, T2DM (diabetes mellitus type 2) presented to the ER due to a fall. (R1) unsure when he fell but thinks that he fell on Sunday (04/06/2025) on his left side. Since the fall, (R1) has been having left-sided hip and knee pain as well as adnominal pain. CT of the hip showed a moderately displaced and angulated fracture of the left femoral neck along with enlargement of the left iliac muscle. (R1) was admitted for further management. Left femoral neck hemi-arthroplasty on 04/09/2025. Tolerated procedure well.
The facility Fall policy (no date) reads in part, It is the policy of this facility to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Standards: Safety interventions will be implemented for each resident identified at risk using a standard protocol. Standard Fall/Safety Precautions for All Residents: The resident's environment will be kept clear of clatter which would affect ambulation and remove hazards. Lighting will be appropriate for the time of day and in accordance to the resident's desire and the plan of care; Residents who require staff assistance will not be left alone after being assisted to bathe, shower, or toilet; All nursing personnel will be informed of residents who are at risk of falling. The fall risk classification will be identified on the care plan.
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 timely administer a PRN (as needed) pain medications for post 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 timely administer a PRN (as needed) pain medications for post fall onset of pain for a one of one (R1) resident reviewed for pain in the sample of four. This failure resulted in R1 having ongoing, unaddressed pain for 44 hours before R1 was hospitalized for left hip fracture, and subsequent surgery of the left hip fracture.
Findings include:
R1 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Ataxia; Epilepsy; Unspecified Abnormalities of Gait and Mobility; Abnormal Posture; Muscle Wasting and Atrophy; Schizoaffective Disorder, Bipolar Type; Schizophrenia; Bipolar Disorder; Essential (Primary) Hypertension; Type 2 Diabetes Mellitus with Diabetic Neuropathy; and Heart Failure.
On 6/30/2025 at 11:48 AM Surveyor observed R1 laying in the bed. R1 clean and dressed appropriate, no shoes observed at this time. R1's room dark, call light out of R1's reach, no clutter observed. R1 said, Yeah I fell, I hurt my hip. I'm not sure when or how it happened. R1 unable to recall circumstances of the incident, sounds confused and forgetful.
06/30/2025 11:54 AM V6 (Licensed Practical Nurse) said, If a resident complains of pain and has difficulty moving, I make sure the doctor knows all the details and gives order to send a resident to the hospital for further evaluation.
On 06/30/2025 at 3:23 PM V9 (Registered Nurse) said, I worked on 04/06/2025, I don't remember what shift. I don't remember the time of R1's incident, but I think it was after breakfast. I heard R1 calling for help while I was passing medications. I went up to R1, R1 was sitting on the hallway floor, right by his room, leaning against the wall, with one of his legs stretched forward. R1 said he saw spilled water on the floor and was trying to wipe it. I don't remember if R1 was wearing shoes. R1 was not able to get up on his own. I called someone for help, I don't remember who came, we placed R1 in the wheelchair and put him in the bed. I notified the doctor, who recommend an x-ray. Upon my assessment, R1 was not able to move his left leg and it was in extended position. R1 was in a lot of pain, especially when trying to move his leg. I gave R1 pain medication, but I don't remember if I documented. After I received an x-ray order, I called the diagnostic company, and I was told they'll come out to do an x-ray but didn't say when. I don't remember whether this was a regular or STAT order. I didn't check on R1 nor reassessed R1's pain before the end of my shift. The x-ray company didn't come before I left. I didn't follow up with the diagnostic company. R1 would always use a call light when he needed anything. I don't know why he attempted to get up that day (04/06/2025). R1 would normally walk around the unit, he looked stable. I don't know if he used any mobility devices. R1 was walking like a normal person, so I'm not sure if R1 was at high risk for falls before the incident on 04/06/2025, so I'm not sure if R1 had any fall prevention interventions.
Per record review, V9 (Registered Nurse) was scheduled to work 7:00 AM - 3:00 PM and 3:00 PM - 11:00 PM on the 2 Main unit on 04/06/2025.
On 07/01/2025 at 10:45 AM V7 (Licensed Practical Nurse) said, When I came in to work on 04/07/2025 7:00 AM - 3:00 PM, it was reported to me that R1 fell the day before. I wasn't told any details of the fall. I looked at the report, and it showed that the x-ray was ordered per doctor's order. Once I noticed the diagnostic company didn't come around midday, I called them, and they said they had no order for R1's x-ray. I placed a STAT x-ray order, and they came out after 3:00 PM (04/07/2025). R1 usually wakes up early and walks around with a walker. On 04/07/2025, during my initial rounds, I noticed R1 was in pain and couldn't move his left leg. R1 was not able to get up but wasn't able to rate the pain. I'm pretty sure I gave R1 pain medication and document it in the progress. I was thinking we were just waiting for an x-ray, and everything was arranged. I was trying to keep R1 comfortable, I gave R1 some ice. When I returned to work on 04/08/2025 (7:00 AM - 3:00 PM), I was told that the x-ray showed that he had a fracture, and I was supposed to send him out to the hospital and not wait for the x-ray. R1 was a fall risk resident, and we were supposed to make sure we assist and supervise R1 when he gets in and out of bed and that he has a walker with him. R1 would always use a call light but also, he would try to get up by himself.
On 07/01/2025 at 11:07 AM V2 (Director of Nursing/ Fall Coordinator) said, The nurses should assess residents' pain, establish source, administer a PRN pain medication or order one if there is no order for it, and check within 30 minutes if administered pain medication was effective. If the medication is not effective, nurses should follow-up with a physician. The nurses should sign the medication out in a resident's MAR (Medication Administration Record) or document it in the progress note. The pain should be assessed at the time of a fall or if a resident exhibits pain. Other than that, pain should be assessed every shift and documented in a resident's MAR (Medication Administration Record).
On 07/01/2025 at 12:02 PM V13 (Attending Physician) said, I don't recall getting notified of R1's call, I might have gotten a call. When the facility nursing staff call me, they emphasize if a resident hit the head, vital sign status, how a fall occurred, and based on that I give orders. The first step is in-house diagnostic. If there is a change in resident's mental status, head trauma, loss of consciousness, or complaining of severe pain, I send them out to the hospital. Surveyor asked what some of the signs and symptoms of a broken hip are, V13 (Attending Physician) stated, Some of the signs of broken hip is complaining of pain, bruising, deformity, and affected ROM (range of motion), such as extended leg. If a resident has a mild pain, we start at over-the-counter pain medication, if it's excruciating pain we would send them out to the hospital. It a resident has continuous pain, not managed by the over-the-counter medications, they should be sent out to the hospital.
R1's progress note written by V9 (Registered Nurse) dated 04/06/2025 02:42 PM reads in part, Full body assessment done, no open injuries or active bleeding noted, able to move all extremities but with a lot of pain voiced when moved the left knee and unable to stand up. v/s bp 134/67, r 20 p 71, DON (V2) aware, on call md order Knee x-ray.
R1's progress note written by V7 (Licensed Practical Nurse) dated 04/07/2025 03:38 PM reads in part, (R1) immobile due to pain to injury from recent fall; (R1) unable to come to an upright sitting position without assistance, greenish purple bruise noted on the left hip; pain level 5/10; Ambulatory status pre-change: ambulated with walker; Ambulatory status post-change: non ambulatory due to injury from previous fall.
R1's progress note written by V2 (DON/Fall Coordinator) dated 04/08/2025 09:30 AM reads in part, Manager follow up: Writer made aware by floor nurse that (R1) was observed lying in bed awaiting x ray results, but (R1) continues to c/o pain to Left leg and is not getting out of bed as per his baseline. Writer observed (R1) in room lying in bed stating, it's hard for me to stand up it hurts. Floor nurse made aware and instructed to call MD and have (R1) sent out for further evaluation, no further issues at this time, call remains within reach and resident given pain medication as per MD order. will continue to monitor as needed.
R1's progress note written by V7 (Licensed Practical Nurse) dated 04/08/2025 09:53 AM reads in part, The writer received (R1) in bed complaining of pain in left hip due to recent fall. The resident unable to come to a standing position. Md updated; orders given to send the resident to (local hospital). Currently awaiting transportation to arrive.
R1's progress note written by V7 (Licensed Practical Nurse) dated 04/08/2025 10:20 AM reads in part,
(Local) transportation arrived and transported (R1) via stretcher to (local medical center) per (R1's) request. (R1) received all scheduled medication and prn (pain medication) before leaving the facility and consumed 100% of his breakfast tray. Vitals upon (ambulance) arrival were (blood pressure): 138/76 (pulse): 86 (oxygen): 96% (temperature): 97.7 (pain): 6/10.
R1's April 2025 Medical Administration Record pain assessment shows: 04/06/2025 (evening) pain 3/10; 04/07/2025 (day) pain 4/10; 04/07/2025 (evening) pain 1/10.
R1's progress note written by V7 (Licensed Practical Nurse) dated 04/07/2025 03:38 PM shows R1's pain 5/10.
Absent are any documents to show that R1 received pain medication between 04/06/2025 2:40 PM (time of the incident) and 04/08/2025 10:20 AM (as per progress note) indicating 44-hour delay in pain management.
Hospital record initiated on 04/08/2025 11:30 AM reads in part, [AGE] year-old male with a (past medical history) of anemia, CAD (coronary artery disease), schizoaffective disorder, bipolar disorder, GERD, epilepsy, hypothyroidism, heart failure, hypertension, T2DM (diabetes mellitus type 2) presented to the ER due to a fall. (R1) unsure when he fell but thinks that he fell on Sunday (04/06/2025) on his left side. Since the fall, (R1) has been having left-sided hip and knee pain as well as adnominal pain. CT of the hip showed a moderately displaced and angulated fracture of the left femoral neck along with enlargement of the left iliac muscle. (R1) was admitted for further management. Left femoral neck hemi-arthroplasty on 04/09/2025. Tolerated procedure well.
The facility Pain policy (no date) reads in part, It is the policy of the Nursing Department to respect and support the resident's right to optimal pain management. General Guidelines: A Pain Assessment tool will be used as a guide in determining a resident's pain level in addition to their descriptive words, and/or physical signs and behaviors; Assessments will be performed at the time of admission, quarterly in conjunction with the MDS schedule. admission diagnosis and other events during the resident's stay may initiate additional pain assessments, i.e., post falls or new or increased pain medications; Pain control effectiveness will be measured after PRN pain medication is administered and during each medication pass; Once pain rate scale is determined, all staff members are instructed to use the resident's identified scale for all assessments; Interventions for pain will be balanced with adequate response to provide comfort while maintaining functional status, when possible, in accordance with the residents; Documentation of each pain assessment will be recorded on the Pain Assessment form, in the nurses' notes or on the MAR.
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 F0777
(Tag F0777)
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 diagnostic testing order was carried out and diagnostic test...
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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 diagnostic testing order was carried out and diagnostic testing results were reported in a timely manner for a resident with acute fracture for one of four (R1) residents (R1, R2, R3 and R4) reviewed for diagnostic testing in the sample of four.
Findings include:
R1 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including bit not limited to Ataxia; Epilepsy; Unspecified Abnormalities of Gait and Mobility; Abnormal Posture; Muscle Wasting and Atrophy; Schizoaffective Disorder, Bipolar Type; Schizophrenia; Bipolar Disorder; Essential (Primary) Hypertension; Type 2 Diabetes Mellitus with Diabetic Neuropathy; and Heart Failure.
On 6/30/2025 at 11:48 AM Surveyor observed R1 laying in the bed. R1 clean and dressed appropriate, no shoes observed at this time. R1's room dark, call light out of R1's reach, no clutter observed. R1 said, Yeah I fell, I hurt my hip. I'm not sure when or how it happened. R1 unable to recall circumstances of the incident, sounds confused and forgetful.
06/30/2025 11:54 AM V6 (Licensed Practical Nurse) said, As far as an x-ray service, we use external diagnostic service. When the doctor gives an x-ray order, we call the x-ray company and order an x-ray. If it is a regular order, the company comes out within 24 hours, if it's a STAT order, the company comes out within 2 hours.
On 06/30/2025 at 3:23 PM V9 (Registered Nurse) said, I worked on 04/06/2025, I don't remember what shift. I don't remember the time of R1's incident, but I think it was after breakfast. I heard R1 calling for help while I was passing medications. I went up to R1, R1 was sitting on the hallway floor, right by his room, leaning against the wall, with one of his legs stretched forward. R1 said he saw spilled water on the floor and was trying to wipe it. I don't remember if R1 was wearing shoes. R1 was not able to get up on his own. I called someone for help, I don't remember who came, we placed R1 in the wheelchair and put him in the bed. I notified the doctor, who recommend an x-ray. Upon my assessment, R1 was not able to move his left leg and it was in extended position. R1 was in a lot of pain, especially when trying to move his leg. I gave R1 pain medication, but I don't remember if I documented. After I received an x-ray order, I called the diagnostic company, and I was told they'll come out to do an x-ray but didn't say when. I don't remember whether this was a regular or STAT order. I didn't check on R1 nor reassessed R1's pain before the end of my shift. The x-ray company didn't come before I left. I didn't follow up with the diagnostic company. R1 would always use a call light when he needed anything. I don't know why he attempted to get up that day (04/06/2025). R1 would normally walk around the unit, he looked stable. I don't know if he used any mobility devices. R1 was walking like a normal person, so I'm not sure if R1 was at high risk for falls before the incident on 04/06/2025, so I'm not sure if R1 had any fall prevention interventions.
Per record review, V9 (Registered Nurse) was scheduled to work 7:00 AM - 3:00 PM and 3:00 PM - 11:00 PM on the 2 Main unit on 04/06/2025.
On 07/01/2025 at 10:45 AM V7 (Licensed Practical Nurse) said, When I came in to work on 04/07/2025 7:00 AM - 3:00 PM, it was reported to me that R1 fell the day before. I wasn't told any details of the fall. I looked at the report, and it showed that the x-ray was ordered per doctor's order. Once I noticed the diagnostic company didn't come around midday, I called them, and they said they had no order for R1's x-ray. I placed a STAT x-ray order, and they came out after 3:00 PM (04/07/2025). R1 usually wakes up early and walks around with a walker. On 04/07/2025, during my initial rounds, I noticed R1 was in pain and couldn't move his left leg. R1 was not able to get up but wasn't able to rate the pain. I'm pretty sure I gave R1 pain medication and document it in the progress. I was thinking we were just waiting for an x-ray, and everything was arranged. I was trying to keep R1 comfortable, I gave R1 some ice. When I returned to work on 04/08/2025 (7:00 AM - 3:00 PM), I was told that the x-ray showed that he had a fracture, and I was supposed to send him out to the hospital and not wait for the x-ray. R1 was a fall risk resident, and we were supposed to make sure we assist and supervise R1 when he gets in and out of bed and that he has a walker with him. R1 would always use a call light but also, he would try to get up by himself.
On 07/01/2025 at 11:07 AM V2 (Director of Nursing/ Fall Coordinator) said, The nurse should call the diagnostic company once they receive an order. Next, they should print an order and a resident face shift and get all documents ready. When we call the diagnostic company, we need to specify whether it is a regular or stat order. Regular x-ray is usually done within 24 hours, and STAT should be done with 4 hours.
On 07/01/2025 at 12:02 PM V13 (Attending Physician) said, The nurse should try to obtain a STAT image order to determine if there is a fracture and need for hospitalization.
On 07/01/2025 at 1:40 PM In the follow up interview, V2 (Director of Nursing/ Fall Coordinator) said, If an x-ray order was STAT, it would be indicated on the order, R1's x-ray it was a regular order. If there is an abnormality in the radiology report, the diagnostic company supposed to call the facility; however, all results are posted in the electronic medical record, as the company process them. The nurses should check for any posted results at least once per shift. R1's x-ray result was posted on 04/07/2025 at 5:48 PM, that means, at least night nurse should have caught it. I was never aware of R1's x-ray result. I don't know if any nurses saw the result. It was not reported to me. I don't know if nurses didn't check and were not aware of it or they just didn't report it to nor anyone else. I initiated R1's hospitalization on the morning of 04/08/2025 based on R1's declined condition.
R1's progress note written by V9 (Registered Nurse) dated 04/06/2025 02:42 PM reads in part, Full body assessment done, no open injuries or active bleeding noted, able to move all extremities but with a lot of pain voiced when moved the left knee and unable to stand up. v/s bp 134/67, r 20 p 71, DON (V2) aware, on call md order Knee x-ray.
R1's progress note written by V7 (Licensed Practical Nurse) dated 04/07/2025 03:38 PM reads in part, (R1) immobile due to pain to injury from recent fall; (R1) unable to come to an upright sitting position without assistance, greenish purple bruise noted on the left hip; pain level 5/10; Ambulatory status pre-change: ambulated with walker; Ambulatory status post-change: non ambulatory due to injury from previous fall. New orders: x-ray ordered by writer, currently awaiting x-ray tech to arrive.
R1's progress note written by V2 (DON/Fall Coordinator) dated 04/08/2025 09:30 AM reads in part, Manager follow up: Writer made aware by floor nurse that (R1) was observed lying in bed awaiting x ray results, but (R1) continues to c/o pain to Left leg and is not getting out of bed as per his baseline. Writer observed (R1) in room lying in bed stating, it's hard for me to stand up it hurts. Floor nurse made aware and instructed to call MD and have (R1) sent out for further evaluation, no further issues at this time, call remains within reach and resident given pain medication as per MD order. will continue to monitor as needed.
R1's x-ray physician order dated 04/06/2025 03:20 PM created by V2 (DON/Fall Coordinator) reads in part, x-ray left knee bil.
R1's Radiology Results Report reads in part, Examination Date: 04/07/2025 1:50 PM; Reported Date: 5:48 PM; Procedure: L-HIP W/PELVIS & FEMUR; Interpretation: Impacted transcervical fracture of the left neck with varus deformity.
Hospital record initiated on 04/08/2025 11:30 AM reads in part, [AGE] year-old male with a (past medical history) of anemia, CAD (coronary artery disease), schizoaffective disorder, bipolar disorder, GERD, epilepsy, hypothyroidism, heart failure, hypertension, T2DM (diabetes mellitus type 2) presented to the ER due to a fall. (R1) unsure when he fell but thinks that he fell on Sunday (04/06/2025) on his left side. Since the fall, (R1) has been having left-sided hip and knee pain as well as adnominal pain. CT of the hip showed a moderately displaced and angulated fracture of the left femoral neck along with enlargement of the left iliac muscle. (R1) was admitted for further management. Left femoral neck hemi-arthroplasty on 04/09/2025. Tolerated procedure well.
Diagnostic company ordering procedure (no date) reads in part, All non-stat orders are performed the same day, unless requested to be done another day. Results will also be available to you the same day the procedure was performed (please note that this is 100% possible if the orders are placed early, preferably before 5 pm.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to adhere to sanitary requirements by not following its own hair restraints policy when a dietary aide was found not wearing a h...
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Based on observation, interview, and record review, the facility failed to adhere to sanitary requirements by not following its own hair restraints policy when a dietary aide was found not wearing a hair restraint while inside the facility's kitchen. This failure has the potential to affect the quality of food served to all residents at the facility.
Findings include:
On 07/01/2025 at 12:00 PM, This Surveyor visited the facility kitchen to verify if kitchen staff were wearing hair restraints. This Surveyor introduced himself to V14 (Dietary Supervisor). Before entering the kitchen, this Surveyor asked V14 for a hair restraint to wear, was given one, and placed it over his head. Both V14 and this Surveyor then proceeded to enter the kitchen. Upon entering the kitchen, this Surveyor observed V15 (Dietary Aide) to the immediate left, sitting by the wall, and not wearing a hair restraint. This Surveyor then observed V14 instruct V15 to place his hair restraint over his head. V15 was then seen walking outside the kitchen, holding a hair restraint in his hand, then returning to the kitchen a few seconds later, now wearing a hair restraint over his head. This Surveyor then left the kitchen.
On 07/01/2025 at 1:15 PM, V14 told this Surveyor that, technically, V15 was not supposed be without his hairnet in the kitchen. When this Surveyor asked V14 what she meant by, technically, V14 said, it was not correct because I didn't want you to see it. V14 also said that V15 told her he had just sat down in the kitchen because it got hot, then wiped the sweat off his brow, and the hairnet slipped off. V14 reiterated that, technically, V15 was not supposed to be in the kitchen without wearing a hairnet, but because he was hot, she gave him the leeway.
The facility's Hair Restraints policy, dated 2021, states in part, Food and nutrition services employees shall wear hair restraints. The facility's Hair Restraints procedure states in part, hairnets will be worn at all times in the kitchen.
May 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
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 their policy to conduct a contraband search on one (R1) of t...
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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 their policy to conduct a contraband search on one (R1) of three residents reviewed for contraband possession. This failure resulted in R1 falling and hospitalized with a diagnosis of opioid overdose, and laceration of right eyebrow.
Finding include:
On 5/28/2025 at 11:52 AM, V3 (LPN) said that R1 did not fall on V3 shift. V3 said R1 is alert and oriented and makes his needs known. V3 said that R1 has a pass to go with relatives. V3 said that R1 went out with relative today about 8:30 am and was expected to be back to the facility around 2:00 PM. V3 said that the social service told V3 that R1 must be checked by the social service before R1 can get back into R1's room. V3 said that the social services are responsible for checking the residents before the residents return to their rooms.
On 5/28/2025 at 12:04 PM, V4 (LPN) said that when V4 initially rounded on R1, R1 was alert and oriented and conversing. V4 said about less than ten minutes while V4 was walking the hall, V4 saw R1 on the floor in another resident's room. V4 called out to V2 (Director of Nursing) for help. V4 assessed the resident, V4 said that R1 was unresponsive, and 911 was called to transport to ER.
On 5/28/2025 at 12:58 PM, V5 (Director of Social Services) said that R1 has never been out by himself. V5 said R1 is always accompanied by a family and friends. V5 said that R1's family comes and takes R1 out. V5 said that if R1 has not had any visitor to stay with him in the facility, but if he does have a visitor who wants to spend time with him in the facility, V5 said that the visitation will happen in the day room and monitored by the staff. V5 said that V5 was informed that R1 was unresponsive and was sent out to the hospital. Prior to 5/19/2025 incident, V5 said on 4/14/25 V5 observed R1 who appeared to be asleep, upon entering the room and getting closer R1, V5 observed a rolled-up dollar in R1's hand. V5 said that R1 was breathing, V5 shouted out R1's name and received no response. V5 said V5 notified the nurse and V5 removed the dollar from R1's hand, unrolled it and notice a white powdery substance on the dollar. V5 said that R1 was aroused and asked to identify the substance on the dollar in-which R1 refused to do so. V5 said that R1 was asked the question if there was any more of this white powdery substance in R1's possession and R1 stated I don't know what you are talking about. V5 said that R1's living area was searched and there was no contraband found. V5 said that after the incident, R1 was only allowed to go out with responsible party. V5 said that R1's belongings were supposed to be searched upon return from outing. V5 said that social services are supposed to search R1 belongings when he returns from outing. V5 said that V5 was not in the facility when R1 went out on pass on 5/19/2025. V5 said that V5 was not made aware that R1 was back into the facility. V5 said that V5 is not sure if any social worker searched R1 belongings when he returned from pass.
On 5/2 /2025 at 2:17 PM, V2 (Director of Nursing) said that V2 was called down to R1's room in April because resident was sitting in the chair and nodding. V2 said that V1 and V5 informed V2 that a dollar rolled up with white substance was found in R1's hand. V2 said that V2 gave R1 a sternal rub which woke R1 up but R1 continue to go in and out. V2 said that after the incident occurred, R1 was moved to a room closer to the nurses' station so that R1 will be monitored more closely. V2 said R1 was made aware that R1 will have supervised visit only. V2 said that R1's emergency contact was notified that R1 can only have supervised visit. V2 said that R1 also notified that he can only go out with his emergency contact. V2 said that social services are also supposed to search R1 when he returns from the community outing. V2 said that on 5/19/2025, V4 (LPN) came to V2 to talk about R1 staying in another resident's room more frequently than usual. V2 said that V2 came down with V4 to go talk to R1. V2 said that R1 was observed on the floor with face down. V2 said that V2 observed small amount of blood on the floor. V2 said that R1 was unresponsive but was breathing. V2 said that V2 perform sternal rub, V2 said that V2 placed a pillow underneath R1 head and log rolled R1 to observe where R1 was bleeding from. V2 said that R1 was administered with Narcan and 911 was called. V2 said that V2 notified V1 (Administrator), and R1 nephew was called by (V1) to determine if he at any point left R1 alone. V2 said that R1's nephew admitted leaving R1 alone in the car for few minutes while he went to reactivate his phone. V2 said that V1 searched R1 pocket before the ambulance transported him to ER and found a bag of white substance in R1's pocket. V2 said that V2 called the cooperate office and notify them and also notified the IDPH. V2 said that the social service should have searched R1 when R1 returned from outing to the facility. V2 said that the social services failed in that area for not searching R1.
On 5/28/2025 at 3:12 PM, V1 (Administrator) said that V1 was aware of R1 drug abuse incident in April. V1 said R1 was unresponsive, and the facility tried to wake him up and after shaking R1, R1 finally woke up. V1 said that R1 was placed on a pass restriction where R1 was only allowed to go out on pass with his nephew, and random room search to be conducted on him. V1 said that social service will search R1 when he returns from outing. V1 said that on 5/19/2025, R1 went out with his nephew. V1 said that R1's nephew assured the facility that he will keep a close watch on R1. V1 said that it wouldn't have hurt for the social service to search R1 when R1 returned from the outing with the nephew. V1 said that after the incident happened, V1 said that V1 called R1 nephew to ask if R1 was left alone at any time during his outing. V1 said that R1's nephew said that he left R1 alone in the car while he went to a phone store. V1 said that V1 found a packet of white powder in R1 pocket.
R1 is a [AGE] year-old-male admitted on [DATE]. The social service note dated 4/16/2025, indicated that R1 was found unresponsive on 4/14/2025 and a dollar found in R1's hand when unrolled had white powdery substance on the dollar. On 5/19/2025, it was documented that R1 was also found on the floor unresponsive, and when R1 pockets were searched by V1 (Administrator), a bag with white substance in the bag was found in the left pocket. 5/19/2025 nurses note indicated that R1 was transferred to the hospital by 911 attendees. It was also documented that R1 went out on a pass with his nephew earlier on 5/19/2025. R1 after hospital visit summary indicated that R1 admission diagnosis was Opioid overdose, accidental or unintentional, and laceration of right eyebrow.
Facility Policy:
Policy on Contraband Materials, Inspection of Rooms and Use of Recording Devices
Introduction:
This organization reserves the right to conduct inspections if there is reason to suspect/believe that a resident has contraband items/materials in his/her possession.
Procedure
1.
Residents may be asked to empty and show the content of their pockets at any time if reasonable suspicion exists.
2.
Residents may be asked to reach into concealed (Clothing) areas and remove any items and place these items on a horizontal surface. Staff are instructed to have the resident hand items to the staff member or place the items on the horizontal surfaces.
May 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 residents representative psychotropic medications were prescribed. This applies to 1 of 3 residents (R1) reviewed for resident ri...
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Based on interview and record review the facility failed to notify the residents representative psychotropic medications were prescribed. This applies to 1 of 3 residents (R1) reviewed for resident rights in the sample of 4.
The findings include:
On 5/16/25 at 10:37 AM, V9 (R1's Guardian) said the facility reported R1 was receiving psychotropic medications with my knowledge or consent. V9 said she did not consent for him to receive those medications. When she asked the facility why he was on the medications she was told, R1 would be uncontrollable without the medications.
R1's face sheet shows V9 is R1's Guardian.
R1's Physician Order Sheets dated May 2025 shows orders including Haloperidol 5 mg (milligrams) every 6 hours as needed for behavior disturbance and Lorazepam 1 mg every 6 hours as needed for behaviors (both order date of 3/4/25).
R1's Consent for Psychotropic Medications dated 3/5/25 shows Haloperidol 5 mg and Ativan (Lorazepam) 1 mg listed. The informed consent is signed by V3 (ADON) and signed signature above the resident/authorized Representative/Guardian.
On 5/16/25 at 12:10 PM, V3 (Assistant Director of Nursing-ADON) said she over sees psychotropic medications. Consent should be obtained from the resident or resident representative prior to the use of psychotropic medications. At 1:57 PM, V3 said R1 signed his own consent, and she was not aware of R1 having a guardian. V2 (Director of Nursing) confirmed R1 has a guardian, and consents should be signed by the authorized representative.
The facility's undated Psychotropic Drug Therapy Policy states, Psychotropic drug therapy will be used only to treat a specific condition .Obtain informed consent. PSYCHOTROPIC MEDICATION SHALL NOT BE PRESCRIBED OR ADMINISTERED WITHOUT THE INFORMED CONSENT OF THE RESIDENT, THE RESIDENTS GUARDIAN OR OTHER AUTHORIZED REPRESENTATIVE .
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure prescribed medications were administered as ordered for 1 of 3 residents (R2) reviewed for medication administration in the sample of...
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Based on interview and record review the facility failed to ensure prescribed medications were administered as ordered for 1 of 3 residents (R2) reviewed for medication administration in the sample of 4.
The findings include:
R2's Medication Administration Record dated April 2025 shows orders including Benztropine Mesylate 0.5 mg (milligram) give one tablet at bedtime. The M.A.R. shows on 4/10/25 this medication was not administered.
Divalproex Sodium tablet 500 mg ER (extended release) give two tablets at bedtime related to bipolar disorder. The M.A.R. shows this medication was not administered on 4/10/25 and 4/13/25.
Olanzapine 10 mg give one tablet daily for mood disorder. The M.A.R. shows this medication was not administered on 4/10/25.
Trazadone 50 mg give 1.5 tablet daily for insomnia. The M.A.R. shows this medication was not administered on 4/10/25 and 4/13/25.
On 5/16/25 at 9:28 AM, V5 (Registered Nurse) said medications should be administered as ordered. If the medication is given it is documented on the M.A.R. If the M.A.R. shows no entry the medication was not administered.
The facility's undated Medication Administration Policy states, Documentation of medication administration is recorded on the Medication Administration record (MAR) or Treatment Record and includes the date, time and initials of the licensed nurse who administered the medication .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on interview, and record review the failed to ensure stop dates for residents with prn (as needed) psychotropic medications were in place for 2 of 3 residents (R1, R3) reviewed for psychotropic ...
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Based on interview, and record review the failed to ensure stop dates for residents with prn (as needed) psychotropic medications were in place for 2 of 3 residents (R1, R3) reviewed for psychotropic medications in the sample 4.
The findings:
R1's Physician Order Sheets dated May 2025 shows orders including Haloperidol 5 mg (milligrams) every 6 hours as needed for behavior disturbance and Lorazepam 1 mg every 6 hours as needed for behaviors (both order date of 3/4/25).
R3's Physician Order Sheets dated May 2025 shows orders including Lorazepam Injection 0.5 ml every 8 hours as needed for agitation (order date 4/29/25).
On 5/16/25 at 12:10 PM, V3 (Assistant Director of Nursing-ADON) said psychotropics prn medications should have a stop date of 14 days.
The facility's Psychotropic Drug Therapy undated policy states, Psychotropic drug therapy will be used when necessary to treat a specific condition .PRN (as needed) psychoactive medications will be ordered with a time limit of 14 days. After that time, Physicians may re-evaluate and reroder at 14 day intervals. There must be documentation to support the continued use.
Mar 2025
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a clean, comfortable, and homelike environment...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a clean, comfortable, and homelike environment for 9 (R3, R4, R5, R6, R7, R8, R10, R11, and R12) of 12 residents reviewed for environment.
The findings include:
On 3/22/25 at 10:04AM R8's room has four tiles missing from the main room floor. R8 was observed in the bed, opened her eyes but did not respond to the surveyor's question.
On 3/22/25 at 10:06AM R3's room was observed. The top veneer finish lifts off to expose plywood/particle board underneath. A round hole was [NAME] key lock fell out. 2 window curtains in the room, one is hung and can slide to open and close, but second curtain is partially hung. Curtain hooks/clips observed on the window ledge. Trim boards look dirty with discolored, dark black/brown grime. Black, dark, spotted discoloration along floor trim and floor that is along wall. R3 said her window curtains have been like that for a couple weeks. R3 said she is unable to open or close the windows, they stay like that. R3 said the dresser in the room was her room mates, it's been like that for some time. R3 said housekeeping has not been in to clean her room today. R3 said that was my roommate's dresser. R3 showed surveyor her bathroom. R3 turned on the cold-water faucet and then the faucet for hot water. Only a dribble of hot water came out. R3 said it makes it hard to wash up. There are four missing tiles in R3's bathroom. R3 said the floor has a lot of wear and tear, it's been like that so long as I can remember. R3 said some rooms are better than others. R3 said yes, she has reported the faucet, curtain, and tiles, but the staff have a lot to do.
On 3/22/25 at 10:13AM R4-R7 are roommates. Three residents were in the room during observation. No window curtain in the room.
On 3/22/25 at 10:15 R12's room has 1 square tile near bathroom door lifted up and some pieces cracked.
On 3/22/25 at 10:23AM R10's bathroom is observed and the toilet seat has a brown substance smeared on it.
On 3/22/25 at 10:30AM V2 (Certified Nurse Assistant-CNA), said R12 walks into the bathroom and uses the toilet, but she still needs staff assistance with toilet hygiene. V2 said R11 walks around but needs staff assist with toilet cares. V2 said R2 is bed-bound and won't use the bathroom. R2, R10 and R11 are roommates.
On 3/22/25 at 10:40AM V6 (Assistant Administrator) was asked about missing tiles in R12's room. V6 said I don't know what the plan is for flooring. At 10:44AM V6 said if R3's window curtains were up, we could close them, but it is not up (the hanging curtain mentioned above). V6 opened the hot water faucet in R3's bathroom and saw the water trickle. V6 saw the missing floor tiles in the bathroom.
On 3/22/25 at 10:46AM V6 saw R4-R7's room without window curtains and said all rooms should have window curtains.
On 3/22/25 at 10:48AM V3, Housekeeping, said all rooms are swept, mopped, and bathrooms cleaned every day. V3 said I have the 2nd floor until 1:00PM, the other housekeeper called off. V3 said when we do a deep cleaning of a room, we take the window curtains down to wash them. V3 said he has not gotten to clean any rooms on R10's side.
On 3/22/25 V4 (Licensed Practical Nurse-LPN) observed R10's bathroom. V4 said it is not acceptable, housekeeping is responsible to clean it. V4 said we would clean the toilet before using it.
On 3/22/25 at 11:59AM via phone interview, V7 (Housekeeping Director) said the resident rooms are to be cleaned daily. V7 said we should have two housekeepers on each floor. V7 was asked if the housekeepers are expected to use water from the resident sinks to clean. V7 said yes, they need the sink to wet the cloths. V7 said housekeeping should report when a water faucet needs repair. V7 said I take down the window curtains and wash them when we deep clean a room. V7 said we have extra and enough window curtains for all rooms. V7 said I can get curtains from the empty floor and use them in a needed room. V7 said if a curtain falls then housekeeping should fix it. There are communication sheets at each nurses' station for us to let maintenance know if something needs to be fixed, like faucets.
On 3/22/25 at 1:17PM V9 (Maintenance Director) said work order forms are kept at each end of the hall. V9 said we pick them up or staff calls us to let us know of something that needs fixed. V9 said we check daily for hot water, cold water, and air temperatures. V9 said we can replace furniture with furniture from unoccupied floor/room. V9 said I was aware tiles need to be replaced. V9 said there are no tiles here, none are available in the facility to replace. V9 said the CNAs are supposed to let us know if furniture is damaged or if there are plumbing issues, because they would see it during patient care. V9 said we don't check every room everyday for plumbing problems, I have never checked that room. V9 said I don't keep the work request, we take care of the issue and don't keep the paper.
On 3/22/25 at 2:08PM V6 was asked if the staff have a responsibility to make sure the residents have a clean and homelike environment. V6 responded absolutely. V6 was asked if missing curtains, missing floor tiles, feces smeared on toilet seats, and no hot/warm water available meets the criteria of clean and homelike environment. V6 responded absolutely not.
The facility resident rights booklet page 3 states Your facility must be safe, clean, comfortable, and homelike.
Feb 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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify a physician that a resident was not being administered a ste...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify a physician that a resident was not being administered a steroid topical ointment and an immunosupressive medication as ordered and missed 15 doses of the steroid topical ointment and 14 doses of the immunosupressive medication for one out of three residents (R1) reviewed for physician notification in a total sample of three.
Findings Include:
R1 is a [AGE] year old with the following diagnosis: rheumatoid arthritis, dermatomyositis, herpes vesicular dermatitis, and chronic ulcer of skin.
On 2/26/25 at 11:30AM, R1 was only available by phone for interview due to being hospitalized at the time of the investigation. R1 stated R1 does not the get medication for R1's autoimmune disease. R1 was unable to remember the name of the medication but knew it started with an M. R1 reported the medication is supposed to be taken twice a day (once in the morning and once around dinner time) but it is only given usually once a day or not at all. R1 was unable to report the number of doses that were missed but R1 stated it was more than ten a month. R1 was unaware why the medication was not being given as scheduled. R1 stated the medication is used for healing the lesions on R1's hands from the autoimmune disease. R1 stated the lesions are painful but have not gotten any worse from not taking the medication as scheduled.
On 2/26/25 at 12:30PM, V1 (Nurse) stated R1 takes a medication for an autoimmune disease because R1's fingers swell. V1 could not remember the names of the medications, but reported R1 also uses topical creams. V1 denied R1 refusing any medication. V1 reported R1 has a condition that causes swelling and lesions to the hands and fingers. V1 stated medications need to be administered as they are ordered. V1 denied being aware of R1 having multiple missed doses of the topical steroid cream and the immunosupressive medication. V1 reported that if a medication is not signed out on the MAR, then it is considered not to have been given. V1 stated if a resident misses a dose of a medication the physician or the director of nursing are notified, and the nurse follows up with any further orders.
On 2/26/25 at 1:23PM, V2 (DON) stated R1 admitted to the facility with lesions to the hands and arms. V2 could not state what medications R1 was taking for the autoimmune disease. V2 reported all medication should be administered as ordered. V2 stated the nurse should document the medication when it is administered in the MAR. V2 denied R1 making any reports that R1 was not getting the topical steroid cream or the immunosupressive medication. V2 reported a physician needs to be notified when a resident is missing an ordered medication because the physician needs to be aware of what is going on with the resident.
On 2/26/25 at 3:37PM, V6 stated R1 has rheumatoid arthritis and dermatomyositis and both conditions are autoimmune. V6 reported R1 has lesions on both hands and arms due to dermatomyositis. V6 stated the lesions present as swollen, inflamed, sores. V6 reported the physicians at an outside hospital put R1 on the immunosupressive medication and the topical steroid cream. V6 stated the immunosupressive medication helps decrease the swelling and prevent any further lesions from occurring. V6 reported the topical steroid cream helps with inflammation and healing of the lesions. V6 denied making any changes to the medication and reported the physicians at the outside hospital are responsible for managing both medications. V6 stated R1 reported being given medications late, but denied R1 reporting any missed doses of medication. V6 denied being aware of any missed doses of the topical steroid cream or the immunosupressive medication. V6 reported if either medication is not given as ordered the lesions could potentially become worse. V6 reported if a medication is not given for more than one dose as ordered than V6 would expect to be notified by staff to see if there is an alternative medication that should be prescribed instead. V6 stated the physician wants to be aware if R1 is taking the medication or not to see if the medication is working properly with R1's auto immune disease.
The Physician Order Summary documents a medication order for a topical steroid cream (clobetasol) to be applied two times a day for dermatitis and an immunosupressive medication (mycophenolate mofetil) to be given twice a day for rheumatoid arthritis. The topical cream was ordered on 12/23/24 and the immunosupressive medication was ordered on 12/25/24.
The Medication Administration Record (MAR) dated 01/2025 documents the topical steroid cream is to be given at 6 AM and 6 PM and applied to both hands. During 01/2025, six doses were not documented as being administered on the MAR. The following are the dates and times the topical steroid cream was not administered: 1/8/25 at 6AM, 1/8/25 at 6PM, 1/9/25 at 6AM, 1/15/25 at 6AM, 1/27/25 at 6PM, and 1/30/25 at 6PM. The immunosupressive medication is ordered to give three tablets by mouth two times a day at 9 AM and 5 PM. A total of four doses are not documented as being administered during this month. The following are the dates and times the immunosupressive medication was not administered: 1/20/25 at 9AM, 1/27/25 at 5PM, 1/30/25 at 9AM, and 1/30/25 at 5PM.
The Medication Administration Record dated 02/2025 documents eleven doses of the steroid cream were not administered as ordered. The following are the dates and times the topical steroid cream was not administered: 2/10/25 at 6PM, 2/13/25 at 6PM, 2/14/25 at 6PM, 2/18/25 at 6PM, 2/19/25 at 6PM, 2/20/25 at 6AM, 2/20/25 at 6PM, 2/22/25 at 6AM, 2/23/25 at 6PM, 2/24/25 at 6AM, and 2/24/25 at 6PM. It also documents that ten doses of the immunosupressive medication were not administered as order. The following are the dates and times the immunosupressive medication was not administered: 2/4/25 at 5PM, 2/10/25 at 5PM, 2/13/25 at 5PM, 2/14/25 at 5PM, 2/18/25 at 5PM, 2/19/25 at 5PM, 2/20/25 at 9AM, 2/20/25 at 5PM, 2/23/25 at 5PM, and 2/24/25 at 5PM.
The Hospital Records dated 2/3/25 document R1 presented to the hospital with bilateral hand ulcerations, pain, and swelling. Rheumatology was consulted and stated to continue the immunosupressive medication. Plan is to continue the immunosupressive medication and topical steroid cream.
The Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score as 15 (no cognitive impairment).
The policy titled, Medication Administration Policy, dated 08/2015 documents, Policy: Level of Responsibility: . Documentation of medication administration is recorded on the medication administration record or treatment record and includes the date, time, and initials of the licensed nurse who administered the medication . Administration of Medications: Medication must be administered in accordance with a physician's order at his/her discretion, e.g., the right resident, right medication, right dosage, right route, and right time.
The policy titled, Physicians Orders, dated 06/2017 documents, These guidelines are to ensure that: 1. Changes in resident status/condition are assessed and physician notification is based on assessment findings and is to be documented in the medical record. 2. Any orders given by the physician are carried out. Nurse Responsibilities: .6. Medication and/or treatment orders are to be scheduled to MAR/TAR as appropriate .Nursing Documentation: A. Any calls to or from physician will be documented in the nurse's notes, indicating information conveyed and received. B. The nurse shall indicate in the nurse's notes, ongoing conversations with the physician regarding response to notifications of changes in condition, laboratory, etc.
The policy titled, Change in Condition Physician Notification Overview Guidelines, dated 04/2014 documents, . Nurse Responsibilities: The nurse should not hesitate to contact the attending physician anytime for a problem which is in his or her judgment requires immediate medical intervention. The frequency of physician contacts is based on nursing judgment and the following guidelines . Nursing Documentation: A. Any calls to or from physician will be documented in the nurse's notes, indicating information conveyed and received .E. The nurse shall indicate in the nurse's notes, ongoing conversations with the physician regarding response to notifications of changes in condition, laboratory.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer a topical steroid ointment and an immunosupressive medic...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer a topical steroid ointment and an immunosupressive medication as ordered causing the resident to miss 15 doses of the topical steroid ointment and 14 doses of the immunosupressive medication over a two month period for one resident (R1) out of three reviewed for medication administration in a total sample of three.
Findings Include:
R1 is a [AGE] year old with the following diagnosis: rheumatoid arthritis, dermatomyositis, herpes vesicular dermatitis, and chronic ulcer of skin.
On 2/26/25 at 11:30AM, R1 was only available by phone for interview due to being hospitalized at the time of the investigation. R1 stated R1 does not the get medication for R1's autoimmune disease. R1 was unable to remember the name of the medication but knew it started with an M. R1 reported the medication is supposed to be taken twice a day (once in the morning and once around dinner time) but it is only given usually once a day or not at all. R1 was unable to report the number of doses that were missed but R1 stated it was more than ten a month. R1 was unaware why the medication was not being given as scheduled. R1 stated the medication is used for healing the lesions on R1's hands from the autoimmune disease. R1 stated the lesions are painful but have not gotten any worse from not taking the medication as scheduled.
On 2/26/25 at 12:30PM, V1 (Nurse) stated R1 takes a medication for an autoimmune disease because R1's fingers swell. V1 could not remember the names of the medications, but reported R1 also uses topical creams. V1 denied R1 refusing any medication. V1 reported R1 has a condition that causes swelling and lesions to the hands and fingers. V1 stated medications need to be administered as they are ordered. V1 denied being aware of R1 having multiple missed doses of the topical steroid cream and the immunosupressive medication. V1 reported that if a medication is not signed out on the MAR, then it is considered not to have been given.
On 2/26/25 at 1:23PM, V2 (DON) stated R1 admitted to the facility with lesions to the hands and arms. V2 could not state what medications R1 was taking for the autoimmune disease. V2 reported all medication should be administered as ordered. V2 stated the nurse should document the medication when it is administered in the MAR. V2 denied R1 making any reports that R1 was not getting the topical steroid cream or the immunosupressive medication.
On 2/26/25 at 3:37PM, V6 stated R1 has rheumatoid arthritis and dermatomyositis and both conditions are autoimmune. V6 reported R1 has lesions on both hands and arms due to dermatomyositis. V6 stated the lesions present as swollen, inflamed, sores. V6 reported the physicians at an outside hospital put R1 on the immunosupressive medication and the topical steroid cream. V6 stated the immunosupressive medication helps decrease the swelling and prevent any further lesions from occurring. V6 reported the topical steroid cream helps with inflammation and healing of the lesions. V6 denied making any changes to the medication and reported the physicians at the outside hospital are responsible for managing both medications. V6 stated R1 reported being given medications late, but denied R1 reporting any missed doses of medication. V6 reported if either medication is not given as ordered the lesions could potentially become worse.
The Physician Order Summary documents a medication order for a topical steroid cream (clobetasol) to be applied two times a day for dermatitis and an immunosupressive medication (mycophenolate mofetil) to be given twice a day for rheumatoid arthritis. The topical cream was ordered on 12/23/24 and the immunosupressive medication was ordered on 12/25/24.
The Medication Administration Record (MAR) dated 01/2025 documents the topical steroid cream is to be given at 6 AM and 6 PM and applied to both hands. During 01/2025, six doses were not documented as being administered on the MAR. The following are the dates and times the topical steroid cream was not administered: 1/8/25 at 6AM, 1/8/25 at 6PM, 1/9/25 at 6AM, 1/15/25 at 6AM, 1/27/25 at 6PM, and 1/30/25 at 6PM. The immunosupressive medication is ordered to give three tablets by mouth two times a day at 9 AM and 5 PM. A total of four doses are not documented as being administered during this month. The following are the dates and times the immunosupressive medication was not administered: 1/20/25 at 9AM, 1/27/25 at 5PM, 1/30/25 at 9AM, and 1/30/25 at 5PM.
The Medication Administration Record dated 02/2025 documents eleven doses of the steroid cream were not administered as ordered. The following are the dates and times the topical steroid cream was not administered: 2/10/25 at 6PM, 2/13/25 at 6PM, 2/14/25 at 6PM, 2/18/25 at 6PM, 2/19/25 at 6PM, 2/20/25 at 6AM, 2/20/25 at 6PM, 2/22/25 at 6AM, 2/23/25 at 6PM, 2/24/25 at 6AM, and 2/24/25 at 6PM. It also documents that ten doses of the immunosupressive medication were not administered as order. The following are the dates and times the immunosupressive medication was not administered: 2/4/25 at 5PM, 2/10/25 at 5PM, 2/13/25 at 5PM, 2/14/25 at 5PM, 2/18/25 at 5PM, 2/19/25 at 5PM, 2/20/25 at 9AM, 2/20/25 at 5PM, 2/23/25 at 5PM, and 2/24/25 at 5PM.
The Hospital Records dated 2/3/25 document R1 presented to the hospital with bilateral hand ulcerations, pain, and swelling. Rheumatology was consulted and stated to continue the immunosupressive medication. Plan is to continue the immunosupressive medication and topical steroid cream.
The Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score as 15 (no cognitive impairment).
The policy titled, Medication Administration Policy, dated 08/2015 documents, Policy: Level of Responsibility: . Documentation of medication administration is recorded on the medication administration record or treatment record and includes the date, time, and initials of the licensed nurse who administered the medication . Administration of Medications: Medication must be administered in accordance with a physician's order at his/her discretion, e.g., the right resident, right medication, right dosage, right route, and right time.
The policy titled, Physicians Orders, dated 06/2017 documents, These guidelines are to ensure that: 1. Changes in resident status/condition are assessed and physician notification is based on assessment findings and is to be documented in the medical record. 2. Any orders given by the physician are carried out. Nurse Responsibilities: .6. Medication and/or treatment orders are to be scheduled to MAR/TAR as appropriate .Nursing Documentation: A. Any calls to or from physician will be documented in the nurse's notes, indicating information conveyed and received. B. The nurse shall indicate in the nurse's notes, ongoing conversations with the physician regarding response to notifications of changes in condition, laboratory, etc.
Jan 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 interview and record review, the facility failed to follow their abuse policy by not preventing a resident to resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their abuse policy by not preventing a resident to resident physical assault. This affected two of three residents (R1, R2) both reviewed for physical abuse. This failure resulted in R1 being punched in the face and being transferred to the local hospital for evaluation
Findings include:
R1 was admitted to the facility on [DATE] with a diagnosis of heart failure, dementia, schizophrenia, depression and auditory hallucinations. R1's brief interview for mental status score dated 11/8/24 documents score 10/15 which indicates moderate cognitive impairment.
On 12/31/24 at 2:22PM, R1 who was alert and oriented was asked if he recalls the incident with his roommate. R1 said yes. R1 said there was something wrong with the toilet in his room that it wasn't flushing. R1 said R2 punched him in the face two times. R1 was unsure where it happened or why. R1 unable to recall if he went into bathroom with R2. R1 does not recall any injury or any other details.
On 12/31/24 at 2:52PM, V6 (nurse) said she witnessed R2 punching R1 in the face in the hallway. V6 said she immediately went and separated the residents. R2 was upset about something in the bathroom. R2 had hit R1 a couple times in the face. R1 did not hit R2 back. R1 face was red but does not recall any injury.
R2's progress note dated 12/10/24 documents: Writer went to the hallway area and stopped R2 from hitting resident R1 more. Alert and oriented x3. Resident very aggressive and angry and constantly hitting R1.
Facility final abuse report form dated 12/10/24 documents: R2 was using the bathroom, his roommate R1 kept opening bathroom door. R2 exited bathroom and hits R1 in the face below right eye. Staff immediately separate residents. R2 was asked what happened and said R1 keeps messing with him by opening the door while using the bathroom. Both residents assessed for injury with R1 having swelling below right eye and redness to right eye. R2 has diagnosis of hunting's disease and violent behavior. Symptoms include mental confusion, compulsive behaviors, irritability, lack of restraint, anxiety, mood swings as evident by resident becoming irritable and acting impulsively towards his roommate.
R1's hospital record dated 12/10/24 documents eye pain/injury for reported assault.
Facility abuse prevention program policy undated documents: the facility affirms the right for our residents to be free from abuse, neglect, misappropriation of property, corporal punishment, and involuntary seclusion. The facility therefore prohibits the mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrence of mistreatment, abuse or neglect by: implementing systems to investigate all reports promptly and making the necessary changes to prevent further occurrences; identifying occurrences and patterns of mistreatment; establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment. 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 and kicking.
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
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 interview and record review, the facility failed to develop a plan of care for a resident with a history of violent beh...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a plan of care for a resident with a history of violent behavior. This affected one of three residents (R2) reviewed for care plans.
Findings include:
R2 was admitted on [DATE] with a diagnosis of Huntington's disease, violent behavior, brief psychotic disorder and schizoaffective disorder. R2's brief interview for mental status score dated 12/2/24 documents score 14/15 which indicates cognitively intact.
R2's progress note dated 10/11/24 documents: altercation with roommate. Staff attempting to separate, both residents punching at each other but hitting staff. Spitting at each other. R2 held other resident by the neck. R2 was sent to the hospital via petition.
R2's petition dated 10/11/24 documents: R2 physically aggressive towards roommate, fighting and throwing punches to the roommate but punches landed on staff nurse, held his roommate's neck.
R2's hospital record dated 10/11/24 documents: R2 admitted for aggressive behaviors of choking roommate. Per petition, R2 was agitated by roommate and choked and tried to punch roommate.
R2's progress note dated 12/10/24 documents: Writer went to the hallway area and stopped R2 from hitting resident R1 more. Alert and oriented x3. Resident very aggressive and angry and constantly hitting R1.
R2's progress note dated 12/30/24 documents: Resident exhibited aggressive behavior by striking and punching roommate. when approached, he stated, he keeps messing with me.
R2's plan of care reviewed with no intervention documented for behaviors or resident to resident altercations and confirmed with V1(Administrator) and V2(Director of nursing,DON)
On 1/3/25 at 2:28Pm, V2(Director of nursing, DON) said R2 had a care plan for mood or behaviors. V2 said social service is responsible for resident behavior care plans. After a resident-to-resident altercation, a new intervention should be put in place and monitored by staff. V2 was unable to locate any documentation of interventions for R2 after altercations or behaviors.
On 1/3/25 3:37PM, V1 (Administrator) said they were unable to locate any plan of care or documented interventions for R2 behaviors and altercations.
Facility care plan policy undated documents: all residents will have a comprehensive assessment and an individualized plan of care developed to assist them in achieving and maintaining their optimal status.
Nov 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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their abuse and injury of unknown origin policy by not initi...
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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 their abuse and injury of unknown origin policy by not initiating and completing a thorough investigation of an injury of unknown origin reported to the facility by a resident's family member. This failure applied to one (R1) of three residents reviewed for injury of unknown origin investigations.
Findings include:
R1 is [AGE] years of age. Current diagnoses include but are not limited to: Cerebrovascular Disease and Dementia Behavioral Disturbance. R1's MDS Minimum Data Set (Comprehensive Assessment) section C cognitive status dated 10/4/2024 documents a staff assessment indicating R1 being moderately impaired- decisions poor; cues/supervision required.
R1 was admitted to the facility on [DATE] for respite care and was discharged home with family on 10/4/24.
On 11/13/24 at 11:08 AM, interview with V4 LPN Licensed Practical Nurse regarding R1's bruising concern. V4 said, The lady family member said it was something on her arm, it was a bruise that wasn't there before. I didn't get anything in report about it. I called V2 DON down to speak to her family. The family was changing her clothes. The family called me in the room and the bruise was on her left forearm, but it didn't look fresh. She was only here four days, and I didn't get any report that she had an incident or anything. The family was really upset. The family pulled up R1's arm of her shirt to show me the bruise then immediately pulled it down. The family member told me to go get my boss. When V2 came she went into the room with the family, I stayed outside. V2 didn't say anything to me about the bruise when she came out the room. This was my first time taking care of her.
On 11/13/24 at 11:45 AM, interview with V2 DON Director of Nursing regarding R1's bruising concern. V2 said, R1 was here a short time. She was a very feisty lady. She required a lot of monitoring and didn't sleep much. She required a lot of redirection. At times when trying to redirect her she would push you off her or it would take a minute to try to redirect her. Sometimes she would need more Spanish speaking staff to work with her, that's what she preferred. She wasn't very vocal. She had dementia. These are some typical things I'd see with it. When I was called to the room her family was here to pick her up. She said R1 had some discoloration to her arms, I don't remember which one. It looked like a thumb print on the upper arm. The area was maroon in color and when touched R1 didn't grimace or anything. It was about thumb or quarter size, about two sites. I just assessed the area. There was no swelling or pain. I looked at her medications to see if she was on any anticoagulants. I spoke to the family and explained to her R1 was very fragile and that we had to redirect her. The family said R1 didn't come here like that then she quickly took R1 out. I let the nurse know, V4 LPN. I asked the niece what she wanted us to do, and she took pictures. She said she would take R1 home and would follow up with her sister and call me back. The family did call me back but didn't say what she wanted to do with it. I asked V4 if he saw the bruise before, and he said he didn't. I looked at the admission charting and there was nothing observed stating she had any bruising. I asked the CNA (Certified Nurse Assistant); I don't remember who. I asked if she observed R1's bruise, she said no. I also asked the aide that was there 3pm-11pm and 11pm-7am shift but no one saw anything or how it got there. I have documentation of my own. I left it alone because the family never contacted me again. I don't know what else I needed to do. I don't have an investigation. Only from the people that I interviewed. The administrator should have been made aware. It should have been done for an injury of unknown origin.
On 11/13/24 at 12:44 PM, interview with V5 CNA Certified Nurse Assistant regarding R1's bruising concern. V5 said, R1 was here for respite care. I work first shift. I never noticed any bruising, if so, I'd report it to the nurse.
On 11/13/24 at 1:08 PM, interview with V6 CNA Certified Nurse Assistant regarding R1's bruising concern. V6 said, I took care of her the first day she came in. She was feisty and moved quick. She'd snatch herself away if we tried to touch her when redirecting her. I didn't give her a shower; I only had her two days. The last time I saw her she was sitting on her bed with her shirt off. She didn't have any bruises. My coworker and I helped her get a shirt on.
On 11/13/24 at 1:32 PM, interview with V7 CNA regarding R1's bruising concern. V7 said, R1's niece came to take her home. She showed me her arm it had a bruise, but it looked old. She had a quarter size bruise on her arm, I can't remember which one. It was purplish dark, like it was getting old. She was combative. I didn't shower her when she was here.
On 11/13/24 at 3:14 PM, Interview with V10 LPN regarding R1's bruising concern. V10 said, I work night shift. I can't recall any bruising on her. We don't do showers on our shift.
On 11/14/24 at 9:42 AM, interview with V1 Administrator regarding R1's bruising concern. V1 stated, V2 DON was our assistant director of nursing and has been our director of nursing for the last two years. V2 has been trained on the abuse policy back in June of this year. V1 acknowledged any injury of unknown origin is in the abuse policy. V1 stated, I am the abuse coordinator. Any injury of unknown origin we would try to find out the source or how it happened and determine if there is suspicion of abuse. If we suspect abuse, we would conduct an investigation. V2 DON if it was brought to her, she should have let me know. We would take a look at it and decide if we needed to investigate. And we would follow up with the family.
On 11/14/24 at 10:30 AM, Interview with V17 LPN regarding R1's concerns. V17 stated, I'm familiar with R1. Nobody told me about any bruising. I checked whatever was exposed for her. I didn't see anything abnormal or discolorations.
Review of R1's records indicate shower sheets from Monday September 30, 2024, which was given by V9 CNA on the 3PM to 11PM shift. There are no skin issues documented on the shower sheet.
R1 was also scheduled for Thursday October 3, 2024, 3PM to 11PM shift. The shower sheet indicates R1 refused and V4 LPN documented R1 had no skin issues.
V2 DON was inquired of V4 lack of documentation regarding R1 refusing to shower on Thursday October 3, 2024, 3PM to 11PM shift. V2 said, V4 should have documented if R1 refused her shower.
V2 provided typed interviews from other staff all who did not have knowledge of R1's bruising to the arm.
R1's care plan states in part: resident is at increased risk for alteration in skin integrity related to impaired cognition. Interventions: skin will be checked during routine care on a daily basis and during weekly/bi-weekly bath or shower schedule. Any skin integrity issues/concerns will be conveyed to the Charge Nurse for further evaluation and/or treatment changes/new interventions and the medical doctor will be called PRN (as needed). Skin review form will be completed on admission and PRN for any new skin integrity issues.
R1's admission screen dated 9/30/24 by V13 Registered Nurse states in part C. skin integrity 10. Does the resident have impaired skin integrity upon admission. 2. No.
R1's discharge instructions do not document the family member's concern with bruising found on R1 prior to her being discharged . This form was signed by V2 DON Director of Nursing on 10/4/2024.
There is no incident report or documentation in R1's medical record acknowledging R1's bruise found by her family member from V2 DON or nursing staff.
V1 Administrator provided abuse prevention policy training dated 6/6/2024 which indicates V2 DON received training.
The revised 9/9/14 Investigation of Injuries of Unknown Origin states in part:
Policy: To promptly investigate resident injuries of unknown origin.
1.
All staff is responsible for prompt identification and reporting resident injuries to the nurse.
2.
The nurse will immediately evaluate the resident and provide any needed intervention.
3.
Descriptions of the injury, resident status, intervention, and any relevant observations will be documented.
4.
Any needed referrals will be initiated by the nurse.
5.
Any allegations/suspicions of abuse or neglect will be immediately reported to the DON and Administrator.
6.
The DON (Director of Nursing) will notify the Administrator of the injury. Abuse investigation/reporting policies/procedures will be initiated any time an allegation or suspicion of abuse/neglect is involved.
7.
The resident's care plan will be developed and/or updated accordingly.
8.
An accident/incident report is completed.
9.
An analysis of the circumstances is made and an attempt to establish a cause of injury and discussed at safety meetings.
The Abuse Prevention Program Facility Policy states in part:
Policy: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents.
This will be done by establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment; identifying occurrences and patterns of potential mistreatment; implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively, and making the necessary changes to prevent future occurrences; and filing accurate and timely investigative reports.
II. Identification and Internal Reporting A. Identification. The direct care staff is responsible for reporting the appearance of suspicious bruises, lacerations, or other abnormalities of an unknown origin as soon as it is discovered. The report is to be documented on a facility incident report and provided to the nursing supervisor, administrator, or designated individual. Following the discovery of any suspicious bruises, lacerations or other abnormalities of an unknown origin, a nurse shall complete a full assessment of the resident for other bruises, lacerations, or pain. Documentation in the resident's chart should reflect the resident's physical and emotional status as well as any medical and nursing interventions implemented.
B. Internal Reporting. All residents, visitors, volunteers, family members or others are encouraged to report their concerns or suspected incidents of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property to the administrator or an immediate supervisor who must then immediately report it to the administrator or the designated individual in the administrator's absence. Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated. Reports will be documented, and a record kept of the documentation. The resident's physician and representative, if necessary, shall be notified of any incident or allegation of abuse, neglect, exploitation, mistreatment or misappropriation of resident property.
C. Investigation. As soon as possible after an allegation of abuse, neglect, mistreatment, misappropriation of resident property, or exploitation, the administrator or designee will initiate an investigation into the allegation which may include the following elements: interviewing all persons who may have knowledge of the alleged incident, including, but not limited to: all persons who reported the suspicion, allegation or incident; the alleged victim (if the victim is unable to be interviewed, this shall be documented); the alleged perpetrator (if the alleged perpetrator is a resident who cannot be interviewed, this shall be documented); any witnesses or potential witnesses to the alleged occurrence or incident; any staff having contact with the resident during the period of the alleged incident; roommates, other residents, family or visitors. A review of the medical record, including the care plan; a review of all circumstances surrounding the incident; and physicians will be notified of any incident and any medical treatment will be done as ordered. The investigation shall conclude whether the allegation of abuse, , neglect, mistreatment, misappropriation of resident property, or exploitation, can likely be sustained. Records of the investigation shall be maintained.
IV. Establishing a Resident Sensitive Environment
Concern Identification and Follow-up: Resident and family concerns will be recorded, reviewed, addressed, and responded to using the facility's concern identification procedures. Residents and families will be informed of the facility's concern identification procedures.
Staff Supervision: On a regular basis, supervisors will monitor the ability of the staff to meet the needs of residents, staff understanding of individual resident care needs, and situations such as inappropriate language, insensitive handling, or impersonal care will be corrected as they occur. Incidents short of willful abuse will be handled through counseling, training and if necessary or repeated, the facility's progressive discipline policy.
VI. Internal Investigation of Abuse, Neglect or Misappropriation Allegations and Response. 3. For any other incident or pattern involving reasonable cause to suspect abuse, neglect or misappropriation (210ILCS 30/4), the administrator will appoint a person to gather further facts prior to making a determination to conduct an abuse investigation. An injury should be classified as an injury of unknown source when both of the following conditions are met: -the source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time.
If there is a bruise of unknown origin, the person gathering facts will complete wither the Unusual Occurrence Staff Observation Sheet or the Skin Tear/Bruise of Unknown Origin Investigation.
Oct 2024
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to provide privacy and dignity to residents. This deficiency affects three (R65, R112 and R372) of three residents in a sample of...
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Based on observation, interview, and record review the facility failed to provide privacy and dignity to residents. This deficiency affects three (R65, R112 and R372) of three residents in a sample of 24 reviewed for residents right.
Findings include:
On 10/22/24 at 9:10AM, R372 observed in bed with Foley catheter bag hanging on left side of bed visible when entering the room with no privacy bag covering.
On 10/22/24 at 9:20AM, R112 observed sitting in bed with Foley catheter bag on left side of bed sitting on floor and no privacy bag covering.
On 10/23/24 at 1:23 PM, V14 (Licensed Practical Nurse) did not provide privacy during intravenous medication administration for R112, V14 did not close room door and did not pull privacy curtain.
On 10/23/24 at 1:28PM, R64 observed in bed with no privacy curtain available.
On 10/22/24 at 9:25AM, V14 (Licensed Practical Nurse) verified that R372 did not have a Foley catheter privacy covering bag, V14 said that the Foley catheter bag should have a privacy bag covering in place.
On 10/22/24 at 9:28AM, V14 verified with surveyor that R112 Foley catheter bag was sitting on the floor and that no privacy covering bag was in place. V14 said that Foley catheter bag should not be on the floor and that it should have a privacy bag covering in place.
On 10/22/24 at 11:28AM, V3 (Director of Nursing) said that Foley catheter bags should not be placed on floor and should have privacy bag covering in place.
On 10/23/24 at 1:30PM, V14 said that he should have provided privacy to the resident when administering intravenous medication.
On 10/23/24 at 1:45PM, V14 verified with surveyor that R64 did not have a privacy curtain available V14 said that R64 should have a privacy curtain available for privacy.
On 10/23/24 at 1:47PM, V10 (Housekeeping Supervisor) verified that no privacy curtain available for R64. V10 said that all residents should have a privacy curtain available.
On 10/23/24 at 1:53PM, V3 said that all residents should have a privacy curtain in place and available for resident privacy.
Facility's policy on Resident Rights -revised 11/2018
Policy: Employees shall offer all residents privacy and treat all residents with respect, kindness and dignity. To provide an environment of care that supports a positive self image.
Policy Interpretation and Implementation:
n. Privacy and confidentiality.
ee. The right to an environment that preserves dignity and contributes to a positive self image.
Facility's policy on Dignity-revised 1/2015
Policy: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality.
Responsibilities: All Staff
10. Staff shall promote, maintain, and protect residents privacy, including bodily privacy during assistance with personal care and during treatment procedures.
11. Urinary catheter bags shall be covered.
Facility's policy on Urinary Catheter Care-revised 5/2014
Purpose: To establish guidelines to reduce the risk of, or prevent infections in resident with an indwelling catheter.
Standards:
7. 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
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to ensure the care plan was updated to reduce the risk of falls for one of three residents (R77) reviewed for falls in a sample of...
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Based on observation, interview and record review the facility failed to ensure the care plan was updated to reduce the risk of falls for one of three residents (R77) reviewed for falls in a sample of 24.
Findings include:
On 10/22/2024 at 10:30am R77 was observed in a chair next to the nurse's station.
On 10/22/2024 at 10:33am V24 (Licensed Practical Nurse-LPN) said she is a high fall risk I'm waiting for activity to take her to the dining area.
On 10/24/2024 at 11:00am V28 (Minimum Data Set-MDS Consultant), observed with the surveyor that R77 had a fall on 5/25/2024 sustaining a hematoma and no care plan update, R77 had a fall on 9/10/2024 no injury and no care plan update.
On 10/24/2024 at 11:05am V3 (Director of Nursing-DON) said the MDS coordinator should update the care plan after every fall she resigned last week.
A fall incident report dated 5/25/2024 indicated that R77 had an unobserved fall and sustained a hematoma to forehead and was transferred to the local hospital, no care plan update. On 9/10/2024 R77 had a unobserved fall no injury and no care plan update. An order Summary Report indicated that R77 has a history of falling and an unspecified injury of the head.
Facility Policy:
Care Plan revised 4/27/21 and 3/15/22
Policy:
All residents will have comprehensive assessments and an individualized plan of care developed to assist them in achieving and maintaining their optimal status.
Procedure:
B. When a change occurs in a resident's condition the Care Plan Coordinator is notified by a member of the Interdisciplinary team. The care plan is then reviewed and updated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide nail care to dependent resident. This deficien...
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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 nail care to dependent resident. This deficiency affects one (R110) of three residents in the sample of 24 reviewed for ADL (Activity of Daily Living) care.
Findings include:
On 10/22/24 at 8:50AM, Observed R110's bilateral fingernails with long and dirty. There are with black matter inside the fingernails.
On 10/23/24 at 9:50AM, Observed R110 still with long and dirty fingernails. Showed observation to V23 LPN (Licensed Practical Nurse). V23 said that the CNA (Certified Nurse Assistant) should provide nail care- clean and trim R110's fingernails when providing personal hygiene or bathing/shower. They should check resident fingernails weekly.
On 10/23/24 at 1:38PM, Informed V3 Director of Nursing (DON) of above observation. V3 said that the CNA should check for resident's nails when providing ADLs (Activity of Daily Living) and provide nail care as needed.
R110 is admitted on [DATE] with diagnosis listed in part but not limited to Acute respiratory failure with hypoxia, Tracheostomy status, Reduced mobility, Severe protein calorie malnutrition. Comprehensive care plan indicates that he has ADL self-care performance deficit related to malnutrition, respiratory failure, dysphagia, epilepsy, tracheostomy tube , gastrostomy tube, resident requires substantial to total assist with ADLs.
Facility's policy on ADLs (Activity of Daily Living) indicates:
Purpose: To preserve ADL function, promote independence and increase self-esteem and dignity.
Facility's policy on Care of Nails indicates:
Purpose:
*To provide cleanliness
*To prevent infection
*To promote safety
Procedure:
1. Observed condition of resident nails during each time of bathing.
3. Explain procedure and bring equipment to bedside in shower room.
4. After bathing, use orange stick and clean debris from around and under fingernails
5. Trim fingernails in an oval fashion avoiding tissue after bathing or when needed. Be sure nails are soft before trimming.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow physician order in application for right hand 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 follow physician order in application for right hand splint to resident. This deficiency affects one (R110) of three residents in the sample of 24 reviewed for Restorative Nursing Program.
Findings include:
On 10/22/24 at 8:56AM, Rounds made with V13 Restorative Nurse to R110. Observed R110 lying on bed with tracheostomy tube connected to oxygen concentrator. He does not wear right hand splint.
R110 is admitted on [DATE] with diagnosis listed in part but not limited to Acute respiratory failure with hypoxia, Tracheostomy status, Reduced mobility, Severe protein calorie malnutrition. Active physician order sheet indicates: Primary care physician confirmed order for right hand splint dated 7/30/24. Comprehensive care plan indicates that he has ADL self-care performance deficit related to malnutrition, respiratory failure, dysphagia, epilepsy, tracheostomy tube, gastrostomy tube, resident requires substantial to total assist with ADLs. admission restorative Nursing assessment dated [DATE] and most recent assessment dated [DATE] indicated: A. Range of motion to right wrist and fingers (Flexion and extension)- moderate loss/50% of norm.
On 10/23/24 at 9:40AM, Observed R110 still not wearing right hand splint. R110 said that he does not wear splint on his right hand. V23 LPN said that she has not seen R110 with right hand splint.
On 10/23/24 at 11:29AM, V27 Therapy Director said that they have not received referral from nursing to evaluate R110 for right hand splint. 27 said that they have not evaluated R110 for right hand splint. V27 said that he is not aware that there was an order for right hand splint for R110.
On 10/23/24 at 12:10PM, Informed V13 Restorative Nurse that R110 was observed since yesterday that he was not wearing right hand splint as ordered. R110 said that he does not wear right hand splint. V13 said that R110's right hand splint was ordered and waiting for arrival.
On 10/23/24 at 1:38PM, Informed V3 Director of Nursing (DON) of above observation made. V3 said that they should apply the right-hand splint as ordered by physician. The therapy should be notified of R110's right hand splint order to be evaluated, then R110 will be place on restorative nursing program for the application of right-hand splint.
Facility's policy on physician orders indicates:
These guidelines are ensured that:
2. Any orders given by Physician are carried out.
Facility's policy on Splints/Braces/Devices indicates:
1. A Physician's order is necessary to apply a splint/brace or restorative device. The order should include the application location and time to be worn.
Facility's policy on Restorative Nursing indicates:
Description and rationale:
*To promote each resident's ability to maintain or regain the highest degree of independence as safely as possible
*To promote each resident's highest practicable level of mental, physical and psychosocial functioning
*To prevent further loss of independence
*To promote wellness and prevent debilitation
*Includes, but is not limited to, programs in walking/mobility, dressing and grooming, eating and swallowing, transferring, bed mobility, communication, splint or brace assistance, amputation care and continence program
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 10/22/24 at 9:15AM, R372 observed receiving oxygen via nasal cannula, oxygen nasal cannula tubing was observed with no date.
...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 10/22/24 at 9:15AM, R372 observed receiving oxygen via nasal cannula, oxygen nasal cannula tubing was observed with no date.
On 10/22/24 at 9:16AM, V26 (Certified Nurse Aide) said that no date was observed on oxygen tubing, and it should a label with date on it.
On 10/22/24 at 9:25AM, V14 (Licensed Practical Nurse) said that oxygen tubing should be labeled and dated, V14 verified R372 nasal cannula oxygen tubing did not have a date.
On 10/22/24 at 10:19AM, V4(Assistant Director of Nursing) said she is unaware if oxygen tubing should be labeled. V4 said to refer to facility policy.
R372 admitted to facility on 10/4/24. Diagnosis include but not limited to cellulitis, type 2 diabetes mellitus, essential hypertension, heart failure, anemia. Physician order dated 10/9/24 for Oxygen 1-2 L per nasal cannula as needed for shortness of breath. Care plan dated 10/9/24 Focus: Resident receives oxygen via nasal cannula.
Based on observation, interview, and record review the facility failed to have an order for tracheotomy tube size and oxygen usage in resident chart. The facility failed to ensure to have an accessible spare tracheostomy tube kit in case of emergency /accidental decannulation. The facility failed to ensure oxygen tubing is changed and dated weekly and as needed. This deficiency affects two (R110 and R372) of three residents in the sample of 24 reviewed for Respiratory Care.
Findings include:
On 10/22/24 at 8:50AM, Rounds made with V13 Restorative Nurse to R110. Observed R110 lying in bed with tracheostomy tube connected to oxygen concentrator at 2.5LPM.(liter per minute) Oxygen tubing is not dated. V13 searched the bedside drawer for spare tracheostomy tube set or obturator but unable to locate. V13 said that there should be a spare tracheostomy tube at bedside for in case of emergency.
On 10/22/24 at 11:30AM, Informed V3 DON (Director of Nursing) of above observation made with R110 having no spare tracheostomy tube set at bedside. V3 said that there should be a spare downsize of tracheostomy tube size of R110 at bedside for emergency in case of accidental decannulation.
On 10/24/24 at 10:55AM, V3 DON said that they don't have respiratory therapist that comes to the facility for R110. They don't have policy on respiratory services except for Tracheostomy care. V3 said that there should be an order for tracheostomy tube size in resident chart and oxygen that resident should be receiving. Informed V3 that R110 does not have physician order for size of his tracheostomy tube and oxygen order.
R110 is admitted on [DATE] with diagnosis listed in part but not limited to Acute respiratory failure with hypoxia, Tracheostomy status, Shortness of breath, Gastrostomy, Dysphagia. Acute on chronic congestive heart failure. Active physician order sheet does not indicate size of tracheostomy tube and no order for oxygen usage via tracheostomy.
Facility unable to provide policy on Respiratory services.
Facility's policy on Tracheotomy care indicates:
24. Be sure that a duplicate sterile tracheostomy tube with obturator is available at bedside.
Facility's policy on oxygen equipment indicates:
Objective: To administer oxygen in condition in which infection control is maintained.
Procedure:
4. Oxygen tubing/nebulizer mask will be changed and dated weekly and as needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs. This deficie...
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Based on observation, interview, and record review the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs. This deficiency affects one (R112) of one resident reviewed for intravenous medication administration in a sample of 24 residents.
Findings include:
On 10/23/24 at 1:23 PM, observation made with V14 (Licensed Practical Nurse) for intravenous medication administration for R112, V14 did not perform hand hygiene between change of gloves and before exiting room. V14 did not provide privacy during intravenous medication administration, V14 did not close room door and did not pull privacy curtain.
On 10/23/24 at 1:30PM, V14 said that he should have performed hand hygiene between glove change and provided privacy to the resident when administering medication.
On 10/23/24 at 1:52PM, V3 (Director of Nursing) said that LPN (Licensed Practical Nurse) can administer intravenous medications. Also said that V14 should have performed hand hygiene before and after glove usage and before exiting room. V3 said that resident privacy should be provided when administering medications.
On 10/24/24 at 11:25AM, V14 (Licensed Practical Nurse) said that he is not intravenous certified and does not remember when any intravenous medication training was provided.
On 10/24/24 at 12:06PM, V3 (Director of Nursing) said that V14 (Licensed Practical Nurse) should not have administered any intravenous medication without the supervision of a Registered Nurse. V14 should have waited for any available Registered Nurse to administer intravenous medication.
R112 was admitted to facility on 8/21/24. Diagnosis include but not limited to sepsis, acute cystitis with hematuria. Physician order on 10/15/24 for Piperacillin sodium-Tazobectam sodium in Dextrose intravenous solution 3-0.375GM/50ML every eight hours for sepsis for ten days.
Facility's Policy on Intravenous Therapy- revised 7/2014
Purpose:
To establish guidelines to reduce the risk or to prevent infections during the administration of intravenous fluids and/or medications.
Standards:
1. Only Physicians, Registered Nurses or Nurse Practitioners shall insert intravenous.
2. All personnel inserting intravenous or administering intravenous fluids and medications shall have had training in the procedure. The qualifications must include an adequate return demonstration of intravenous skills. Records shall contain evidence of competency.
3. Thorough hand washing shall be performed before and after the insertion.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure completion of infection verification tool upon ...
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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 completion of infection verification tool upon initiation of antibiotic using the McGeer's criteria. This deficiency affects one (R108) of three residents in the sample of 24 reviewed for Antibiotic Stewardship Program.
Findings include:
On 10/23/24 at 12:02PM, V3 Director of Nursing (DON) and V7 Infection Preventionist said that R108 is currently on Cephalexin 500mg(miligram) Two tablets orally twice a day for Cellulitis. Both said that infection verification assessment was not done upon initiation of antibiotic using McGeer's criteria. V3 said that the floor nurse is the one responsible for completing the Mc Geer's criteria/Antibiotic assessment when the nurse received antibiotic order from the physician. Then V7 will review the assessment/criteria is being met for antibiotic usage.
On 10/24/24 at 9:50AM, Observed R108 sitting on bed with right lower leg bandage. He is alert and oriented, able to verbalize needs to staff.
R108 is admitted on [DATE] with diagnosis listed in part but not limited to Cellulitis, Lymphedema, Morbid obesity. Active physician order sheet indicates: Cephalexin oral tablet 500mg give two tablets by mouth two times a day for cellulitis for 15 days started on 10/8/24. Vashe wound external solution 0.033% (Wound cleanser). Apply to right outer calf topically everyday shift for wound care. Cleanse with Vashe. Cover with soaked Vashe, abdominal pads, wrap with kerlix and secure with Ace wrap.
Facility's policy on Antibiotic Stewardship Program indicates:
It is the policy of the facility to ensure that antibiotic Stewardship practiced within the facility in accordance with CMS regulations which will promote appropriate use of antibiotics while optimizing the treatment of infections at the same time reducing the possible adverse events associated with antibiotic use. This is to ensure that the antibiotics prescribed and administered use the guidelines stated in the McGreer's Criteria. The purpose being to ensure that the residents are not subject to the inappropriate use of antibiotics and therefore the resident have improved outcomes with fewer adverse events. Antibiotic Stewardship is part of the Infection Prevention and Control Program.
Procedures:
*The Infection Control Designee/Nurse will document discussion with the physician and or nurse practitioner as indicated related to antibiotic use and the McGreer's Criteria being met.
*The infection Verification Tool will be completed by the nurse upon initiation of antibiotics using McGreer's Criteria.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 10/23/24 at 1:23 PM, observation made with V14(Licensed Practical Nurse) for intravenous medication administration, V14 did n...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 10/23/24 at 1:23 PM, observation made with V14(Licensed Practical Nurse) for intravenous medication administration, V14 did not perform hand hygiene between change of gloves and before exiting room.
On 10/23/24 at 1:45PM, V14 said that he should have performed hand hygiene between change of glove and before exiting resident room.
On 10/23/24 at 1:52PM, V3 (Director of Nursing) said that LPN's (Licensed Practical Nurses) can administer Intravenous medications. Also said that V14 should have performed hand hygiene when changing gloves and before exiting resident room.
On 10/22/24 at 8:30AM during medication pass observation, V14 (Licensed Practical Nurse/LPN) used the blood pressure (BP) machine on a resident. After the task, V14 initially returned the BP machine inside the medication cart. When V14 realized the machine was not cleaned, V14 pulled the BP machine and started to clean and disinfect. V14 used one sheet of the Microdot disinfection wipe. BP machine was visibly wet for about five seconds. V14 said the machine needs to be visibly wet for one minute to disinfect according to the product label.
On 10/22/2024 at 12:20PM, V3 (Director of Nursing) said the BP machine should be cleaned and disinfect between resident used. Staff should follow the contact time for disinfecting according to the product label and recommendation. V3 stated they do not have policy for cleaning and disinfecting blood pressure machine.
Microdot Bleach Wipe Specification:
Direction for Use: It is a violation of Federal Law to use this product in a manner inconsistent with its labeling.
Disinfection:
4. Remove pre-saturated 6 X 6 wipe.
5. Apply towelette and wipe desired surface to be disinfected.
A 30 second contact time is required to kill the bacteria and viruses on the label except a 1-minute contact time is required to kill Candida albicans and Trichophyton interdigitale, and a 3-minute contact time is required to kill Clostridium difficile spores. Reapply as necessary to ensure that the surface remains visibly wet for the entire contact time.
Based on observation, interview, and record review the facility failed to implement enhanced barrier precaution protocol. The facility failed to observe appropriate infection control protocol in handling soiled linens. The facility failed to have measures in place to prevent the growth of legionella and other opportunistic waterborne pathogen in building water system. The facility failed to clean, disinfect medical equipment, and perform hand hygiene during Intravenous medication administration. These deficiencies have the possibility to affect all residents in the facility.
Findings include:
On 10/22/24 at 6:18AM, Observed soiled linens in a green plastic bag on the floor in the hallway outside by room [ROOM NUMBER] and two bags by the therapy room. V14 LPN (Licensed Practical Nurse) said that it should not be placed on the floor, it should be brought to the soiled linen chute.
On 10/22/24 at 6:31AM, V15 CNA (Certified Nurse Assistant) said that soiled linens in green plastic bag should not be placed on the floor, it should be brought directly to the soiled linen chute.
On 10/22/24 at 7:05AM, Observed V16 CNA placed the three soiled linens in green plastic bags on recliner chair and holding a bag while pushing the reclining chair to the soiled linen chute at 1 main unit. V16 said that she uses the recliner chair to transport the soiled linen because they cannot find the soiled linen barrel. V16 CNA does not wear gloves.
On 10/22/24 at 7:11AM, Observed soiled laundry chute at the 1 main unit open with overflowing of soiled linen in green plastic bags. There are four green plastic bags with soiled linen on the floor. The soiled linen barrel/container is overflowing. V17 CNA said the laundry chute is overflowing because of accumulated soiled linens from evening to night shift. She said that laundry staff will come and collect it when they come this morning.
On 10/22/24 at 7:19AM, Observed V18 Housekeeping Aide removing the stacks of soiled linen in green plastic bags inside the laundry chute without wearing gloves. There are loose soiled linens that pulled out from the laundry chute. Once V18 cleared it, he tossed the bags inside the laundry including those bags on the floor. Surveyor introduced self to employee and ask for his name. Employee refused to give his name. Showed to V19 Housekeeping observation made. V19 said that they have only one housekeeper for 7-3 shift and 1pm to 9pm shift. All soiled linens in green plastic bag are piled up at laundry chute at 1 main unit, the CNAs should be bringing the soiled linen to the basement soiled laundry room. V19 said that V18 should be wearing gloves when handling soiled plastic bags.
On 10/22/24 at 8:20AM, Informed above observation to V7 (Infection Preventionist). V7 said that the soiled linens in green plastic bags should not be placed on the floor. Recliner chair should not be used as transport for soiled linen bags. Staff should be using gloves when handling soiled linens. Soiled linen bags should not be piled on the floor, the laundry chute and soiled linen barrel should be closed, and not overflowing. Staff should be observing infection control protocol in handling soiled linens.
On 10/22/24 at 8:33AM, Observed R10's urinal with half-filled urine on top of the bedside tray table next to the water pitcher. V21 CNA said that R10 is continent and uses urinal as she points to R10's urinal on the tray table. V21 left the room, leaving the urinal on the bedside tray table next to water pitcher.
On 10/22/24 at 8:35AM, Informed and showed observation to V7 Infection Preventionist. V7 said that V21 should remove the urinal at R10's bedside tray table for infection control.
On 10/22/24 at 8:50AM, Rounds made with V13 Restorative Nurse to R110. V13 donned gloves. R110 is on enhanced barrier precaution. After checking R110's Gastrostomy Tube site dressing and Low air loss mattress, she removed gloves left the room without performing hand hygiene and went to nursing station.
On 10/22/24 at 8:56AM, V13 said that she is the Restorative nurse and working on the unit because the nurse did not show up. V13 about to start to open her medication cart to start her medication administration when surveyor informed her that she did not perform hand hygiene after removing the gloves when she left R110's room who is on enhanced barrier precaution. V13 said that she forgot to wash her hands after removing her gloves when leaving R110's room. V13 said that she should wash her hands after removing her gloves.
On 10/22/24 at 9:16AM, V10 Housekeeping /Laundry Supervisor said the CNA should put soiled linen bag in laundry chute. It is just normal for the laundry chute to overflow because they only have small laundry chute. He said that no soiled linen bag should be on the floor. If the laundry chute is already overflowing the CNA should bring the soiled linen to the basement soiled laundry room. Rounds made to laundry room where they kept all the clean linen delivered by laundry vendor company. Observed laundry with scattered trashes on the floor- used gloves, plastics bags, cardboard papers, used tissues, etc. V19 Housekeeping aide in the processing of cleaning. V10 said that they should be cleaning after each shift.
On 10/22/24 at 10:30AM, V1 Administrator said that he does not have maintenance in the building.
On 10/22/24 at 2:00PM, V1 Administrator presented copy of water sample testing at boiler room and 1st floor nursing station sink for legionella collected on 7/18/24 with negative results. V1 said that they do the water testing for legionella annually. Surveyor requested for facility's documentation of measures to prevent growth of legionella and other opportunistic waterborne pathogen in the building water system.
On 10/23/24 at 9:54AM, Observed R110 with audible congestion. R110 has tracheostomy connected to oxygen concentrator. V23 LPN preparing to suction R110. After opening, the normal saline solution bottle, V23 LPN removed her gloves, did not perform hand hygiene. She opened the suction kit, took on a glove and put on to her right hand. She started suctioning R110 via tracheostomy tube with no gloves on left hand. After V23 LPN suctioned R110, surveyor informed observation made that she did not perform hand hygiene. V23 said that she forgot. V23 said that she should wear both gloves and performed hand hygiene after gloves removal.
On 10/23/24 at 9:30AM, Follow up with V1 Administrator regarding documentation of monitoring for legionella and other water pathogen. V1 said, he still looking for it.
On 10/23/24 at 2:10PM, Follow up with V1 Administrator regarding documentation of monitoring for legionella and other water pathogen. V1 said, he still looking for it.
On 10/23/24 at 10:00AM, V3 DON ( Director of Nursing) said that they don't need physician order for residents on enhanced barrier precautions.
On 10/24/24 at 2:00PM, V1 Administrator unable to provide documentation of monitoring for legionella and other pathogen.
Facility's policy on Linen and Laundry handling for laundry department indicates:
Purpose: To ensure proper handling of soiled and clean linen and personal laundry to prevent the spread of microorganisms.
Standards:
3. Every effort will made to ensure that soiled articles do not come into contact with the floor, uniforms, furniture, or other areas deemed clean.
6. Laundry personnel shall wear aprons and utility or non-sterile gloves when handling linens soiled with blood or body fluids.
8. Soiled linens and personal linens shall not be placed on the floor during the sorting process.
16. Hands shall be washed immediately in the event of accidental contamination of blood and body fluids and handling soiled linens and laundry.
Facility's policy on Enhance Barrier Precaution (EBP) indicates:
EBP refer to an infection control intervention designed to reduce transmission of multidrug- resistant organism that employs targeted gown and glove use during high contact resident care activities.
EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfers of MDROs to staff hands and clothing.
EBP are indicated for residents with any of the following:
*Wound and or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.
Facility's policy on Hand washing policy indicates:
Purpose: To remove dirt, organic material, and transplant microorganisms which are found on the hands and to reduce the potential of resident morbidity and mortality from nosocomial infection.
Policy: All facility staff will practice hand washing activities with an anti-microbial agent or water-less antiseptic agent in accordance with this policy.
Standards:
d. Immediately after glove removal
g. Before leaving the room of a resident in an isolation room.
Oct 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 a resident from a potential sexual abuse by not monitoring ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect a resident from a potential sexual abuse by not monitoring a resident with a history of wandering from going into other resident rooms. This failure affected one (R1) of three residents reviewed for abuse.
Findings include:
R1 is a [AGE] year-old female who was admitted to the facility 07/13/2021 with diagnosis history of Dementia with behavioral disturbance, Psychosis, Vitamin D Deficiency, Gastroesophageal reflux disease, Dysphasia, Bipolar, and history of falling. On the (MDS) Minimal data Set assessment of 06/24/24 section C the BIMS (Brief Interviewed Mental status) score was 07/15and on MDS of 06/25/24 section GG R1 requires walking supervision or touching assistance.
R2 is a [AGE] year-old male who was admitted to the facility on [DATE] and discharged [DATE] after an allegation of sexual abuse towards R1. R2 has a diagnoses history of Dementia, Hypertensive, Encephalopathy, Cerebral atrophy, Right Inguinal Hernia, and Anemia. On the (MDS) Minimal data Set assessment of 07/10/24 section C the BIMS (Brief Interviewed Mental status) score was 12 /15 and on MDS of 07/1024 section GG R2 requires walking supervision or touching assistance.
On 09/30/24 at 11:19 AM R3 said R1 has a habit of wandering in and out of rooms and did so just a couple of days ago. R3 said on 09/16/24 he was in his room when R1 came in and sat down on R2's bed. R3 said R2 touched R1 inappropriately then wrapped his arms around R1's leg. R3 said he then went straight to the nursing station to call the nurse. R3 said R1 had her brief on but she exposed herself and R2 does not wander around. R3 said, I never seen him touching anyone inappropriate before.
On 09/30/24 at 11:25 AM V5 (Licensed Practical Nurse) said that she was by the nursing station charting, when R3 came in and let her know that R1 wandered into his room, and that R1 was there with R2. V5 requested V6(Certified Nursing Assistant) to go and get R1 out of the room. When V6 came back to the nursing station, V6 said that R1 had her dressing up to her waist and R2 had his pant off. R1 was brought to the nursing station and had bowel movement all over.
On 09/30/24 at 4:35PM V6 (Certified Nursing Assistant) said, he was going down the hallway when R3 was talking to V5 (Licensed Practical Nurse), R3 stated that R1 is in the room with R2. V5 asked me to go investigate what was going on. V6 stated that when he went to the room, he saw R2 on top of R1. R1 had her dress up to her waist without her brief and R2 had his jeans at his thigh level without his brief. V6 said he called V5. R1 and R2 were separated.
On 09/30/24 at 12:51PM V10 Family Member was called and stated, I received a phone call on 09/16/24 around 8:00 PM and received a report that R1 and R2 were found without pants. V10 said, R1 was then sent to the hospital for evaluation.
On record review R1 was taken to a local Hospital for Sexual Assault Exam (SANE) and Police report completed. R1 returned to the facility the next day.
On 10/01/24 at 2:26 PM V1 (Administrator) said, the diagnosis of dementia of R1 and her wandering behavior will place her at risk for abuse and requires increased supervision. V1 stated that he was not aware of how long R1 was not supervised before a staff member went to get on R1 out of R2's room.
On 10/01/24 at 2:50PM V2 (Director of Nursing) said that R1 cannot speak for herself, and her Dementia is advanced and cannot give consent for sexual activity. V2 said R1 requires close monitoring because of her wandering behavior and R1 was not supervised when she went to R2's room.
On 09/30/24 V1 provided a Facility Policy titled, Abuse Prevention Program Facility Policy undated. Which reads: This facility affirms the right of our residents to be free from abuse.
Abuse means any physical, or mental injury or sexual assault inflected upon a resident other than by accidental means.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to follow their policy and procedure for Involuntary Discharge by not...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to follow their policy and procedure for Involuntary Discharge by not demonstrating that the safety of individuals in the facility was endangered due to the clinical or behavioral status of a resident who was not permitted to return to the facility after hospital transfer and by not ensuring the required documentation for transfer or discharge was included in the resident's medical record. This failure applies to one (R2) of three residents reviewed for involuntary discharge.
Findings include:
R2 is a [AGE] year-old male with a diagnoses history of Vascular Dementia without Behavioral Disturbance, Depression, Cognitive Communication Deficit, Degenerative Disease of the Nervous System, Seizures, Hepatitis C, Dysphagia, and Gout who was admitted to the facility 10/26/2022.
R2's progress note dated 9/16/2024 at 6:20 PM documents he was transferred to the Hospital per physician orders for a psychological evaluation around 6 pm; progress note at 11:14 PM documents progress note was entered late, Writer was made aware at approx. 3:20pm R2 was involved in an inappropriate occurrence with female peer. R2 is alert and orientated x 2 with confusion and bouts of forgetfulness, benefits from cues and supervision due to poor decision-making skills. Writer spoke with notified nurse practitioner of incident and was given orders to send R2 to the hospital with a petition.
R2's Discharge Minimum Data Set, dated [DATE] documents his return was anticipated.
R2's progress note created by V2 (Director of Nursing) dated 9/17/2024 documents he was admitted to the hospital for psych evaluation. Belongings packed and bed remains on hold for 10 days per policy.
Abuse Investigation Report dated 09/20/2024 documents R2 was observed engaged in sexually inappropriate behavior with R1 after she wandered into his room, and he was sent to a hospital for psychiatric evaluation.
R2's progress note dated 9/21/2024 documents V9 (Family Member) came to pick up R2's clothes and left the facility with one bag of clothes.
R2's progress note created by V3 (Social Services Director) dated 9/23/2024 documents Writer emailed R2's POA paperwork and upcoming medical appointments to VA Clinic addressed to the Admissions Department at another facility. Family also came to pick up the last bag of clothing within R2's room.
On 09/30/2024 at 11:01 AM V7 (Certified Nursing Assistant) stated she heard there was an incident with R2 but she was not working on that day. V7 stated she has worked in the facility for two years and typically works on the 2nd floor and has not known R2 to ever engage in any inappropriate behaviors. V7 stated none of the other residents have ever complained about any inappropriate behaviors from R2.
On 09/30/2024 at 11:20 AM V8 (Housekeeper) stated she has never observed R2 engaged in any inappropriate behaviors and had not had known of any previous incidents involving sexually inappropriate behaviors from R2. V8 stated R2 does not roam and wander around.
R2's current care plan does not include documentation of a history of sexually inappropriate behaviors or any other behaviors that would place him or other residents in danger.
On 09/30/2024 at 11:54 AM V1 (Administrator) stated R2 was sent to another facility just to be on the safe side.
On 09/30/2024 at 12:15 PM V2 (Director of Nursing) sated R2 does not have any discharge records or reports because it was V4's (Psychiatrist) decision to send R2 to another facility. V2 stated no one from the facility talked to R2 to determine if it was his wish to discharge. V2 stated she was not aware that R2 was transferred to another facility until after it was done. V2 stated R2 is confused and forgetful with a diagnosis of dementia. V2 stated R2's family notified the facility that R2 was transferred to another facility and spoke with the V3 (Social Services Director) about his transfer. V2 stated she and V1(Administrator) spoke with R2's family regarding his discharge and they were concerned about the facility he was transferred to. V2 stated R2's family was advised it wasn't the facility's decision, it was the decision of the hospital social worker. V2 stated she and V1 spoke with V9 (Family Member). V2 stated R2 and his family did sign a contract for him to stay at this facility. V2 stated residents are not transferred or discharged to another facility without them or their family member requesting it. V2 stated she can't speak to why this did not apply to R2 because she wasn't a part of the process of having him transferred. V2 and V1 agreed R2 was their responsibility. When asked by the surveyor why no one asked V9 if she wanted R2 to return to the facility, V2 stated V9 never mentioned she wanted R2 to come back to the facility and informed she would handle having him transferred to another facility.
On 09/30/2024 at 12:31 PM V9 (Family Member) stated the facility called her and said R2 couldn't come back here. V9 stated the facility didn't give her any options and did what they did with him and that was it. V9 stated her wish was for R2 to remain at the facility but they made it clear as day they didn't want him to come back to the facility. V9 stated she was told that a woman entered R2's room, and he was found on top of her. V9 stated she was told that clothes were down and then was told they were not down. V9 stated she was told multiple different stories about the incident that occurred between R2 and R1. V9 stated R2 had responded about the incident by saying it wasn't like that but they weren't listening to him. V9 stated R2's belongings were packed and she picked up his things because she felt like she had no other choice.
On 10/01/2024 at 11:54 AM V2 (Director of Nursing) sated the physician never provided any documentation to the facility regarding R2's transfer/discharge to another facility.
On 10/01/2024 at 12:35 PM When asked if R2 had a history of engaging in sexually inappropriate or other unsafe behaviors towards other residents V2 (Director of Nursing) responded not that she was aware of. V2 stated at least approximately 6 months ago R2 was involved in some type of altercation with a male that he shared a room with before. V2 stated she would not say she considered R2 to be a threat to the other residents. V2 stated if residents engage in behaviors that are unsafe for other residents they will be petitioned out to the hospital for a psychological evaluation. V2 stated if this is a continuous issue where they've tried to intervene unsuccessfully then they would initiate an involuntary discharge.
The facility's Involuntary Discharge or Transfer Policy received 09/30/2024 states:
The facility will provide proper procedure of an involuntary transfer or discharge pursuant to the regulations of the Health Care Financing Administration for States and long-term care facilities, 42 CFR 438.12 (federal regulations): and State rules and regulations.
The resident's record must include the (1) reasons for the transfer/discharge (2) needs that cannot be met by the facility, steps taken to meet those needs, and needs that can be met by new facility as documented by resident's physician. Documentation in the notice must (1) demonstrate the condition which warrants the transfer.
The resident's physician must document in the record if the reason for discharge is either the resident's welfare cannot be met; or any physician can document in the resident's record when the safety of other individuals are endangered.
The explanation and discussion of the transfer or discharge with the resident and his representative shall be summarized in the resident record.
The Illinois Department of Public Health (IDPH) prescribed form entitled Notice of Involuntary Transfer or Discharge and Opportunity for Hearing must be completed and given to the resident with a copy placed in the resident record.
The resident's record must include descriptive ongoing documentation to demonstrate the need for transfer/discharge.
R2's most current physician order sheet does not include an order for discharge.
R2's medical records did not include documentation a history of sexually inappropriate or unsafe behaviors from R2 or of the physician's reason's for his discharge.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate supervision for a resident with dementia and a his...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate supervision for a resident with dementia and a history of wandering by not ensuring that the resident was not wandering into resident rooms. This failure affected one (R1) of three residents reviewed for supervision.
Findings include:
R1 is a [AGE] year-old female who was admitted to the facility 07/13/2021 with diagnosis history of Dementia with behavioral disturbance, Psychosis, Vitamin D Deficiency, Gastroesophageal reflux disease, Dysphasia, Bipolar, and history of falling.
R2 is a [AGE] year-old male who was admitted to the facility on [DATE] and discharged [DATE] after an allegation of sexual abuse towards R1. R2 has a diagnoses history of Dementia, Hypertensive, Encephalopathy, Cerebral atrophy, Right Inguinal Hernia, and Anemia.
On 09/30/24 at 11:19 AM R3 said R1 has a habit of wandering in and out of rooms and did so just a couple of days ago. R3 said on 09/16/24 he was in his room when R1 came in and sat down on R2's bed. R3 said R2 touched R1 inappropriately then wrapped his arms around R1's leg. R3 said he then went straight to the nursing station to call the nurse. R3 said R1 had her brief on but she exposed herself and R2 does not wanderer around. R3 said, I never seen him touching anyone inappropriate before.
On 09/30/24 at 11:25 AM V5 (Licensed Practical Nurse) said, when she was by the nursing station charting, R3 came in and let me know that R1 wandered into his room, and she was there with R2's. V5 requested V6 (Certified Nursing Assistant) to go and get R1 out of the room. When V6 came back to the nursing station, V6 said that R1 had her dressing up to her waist and R2 had his pant off.
On 09/30/24 at 4:35PM V6 (Certified Nursing Assistant) said, he was going down the hallway when R3 was talking to V5 (Licensed Practical Nurse). R3 stated that R1 is in the room with R2. V5 asked me to go investigate what was going on. V6 stated that when he went to the room, he saw R2 on top of R1. R1 had her dress up to her waist without her brief and R2 had his jeans at his thigh level without his brief. V6 said he called V5. R1 and R2 were separated.
On 09/30/24 at 11:20AM V8 (Housekeeper)stated that R1 wanderers around the unit, and she did not see R2 being sexual inappropriate or touching anyone in the past.
On 09/30/2024 at 12:31 PM V9 (Family Member) stated if they were being watched I'm trying to figure out how she even got in his room.
On 10/01/2024 at 12:40 V2 (Director of Nursing) stated that R1 wanderers around the unit, and she sits by the nursing station or goes to the dining room.
On 10/01/24 at 2:26 PM V1 (Administrator) said, the diagnosis of dementia of R1 and her wandering behavior will place her at risk for abuse and requires increased supervision. V1 stated that he was not aware of how long R1 was not supervised before a staff member went to get on R1 out of R2's room.
On 10/01/24 at 2:50PM V2 (Director of Nursing) said, that R1 cannot speak for herself and her Dementia is advanced and R1 cannot give consent for sexual activity. V2 said R1 requires close monitoring because of her wandering behavior and R1 was not supervised when she went to R2's room.
On 10/01/2024 at 3:08PM V2 provided Facility Policy Title Wanderers undated, which reads:
Residents identified as wanderers will have a Preventative Program to prevent possible injury and/or elopement.
Supervision and Safety:
3. Staff will use various sources to identify residents' risks factors
4. The type and frequency of supervision is determined by individuals' resident assessment needs.
10. Staff to make visual rounds on residents minimally every two hours and more often, if necessary, based on resident's assessment needs.
May 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent a verbal argument from escalating to a resident to resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent a verbal argument from escalating to a resident to resident physical assault. This affected two of three residents (R1, R2) reviewed for resident to resident abuse in the sample of 8.
The findings include:
R1 and R2 were discharged to the local hospital on 5/22/24 and have not returned to the facility.
R1's electronic face sheet printed on 5/26/24 showed R1 has diagnoses including but not limited to dementia without behaviors, history of transient ischemic attack, depression, and heart disease.
R1's facility assessment dated [DATE] showed R1 has moderate cognitive impairment, delusions, and wandering behaviors.
R1's care plan dated 5/14/24 showed, Risk for increasing confusion related to diagnosis of dementia .
R1's nursing progress notes dated 5/21/24 showed, Resident observed laying on the floor in the hallway. Resident stated, 'She pushed me'. Writer and another staff member assisted resident off the floor and walker her to her room. Full body assessment complete. No bruises or open areas noted to body at this time .Physician notified and order to send to (local hospital) for further evaluation .When she came back from the hospital had aggressive behaviors toward staff and residents used a lot of profanity threatened staff, seeing things that were false. Wandering around the unit made attempt to get on the elevator and when staff intervened she tried to hit them with her fist .Resident returned from hospital with no findings; however, psych physician made aware of aggressive behaviors and ordered to send to (local hospital) for psych evaluation
R1's nursing progress notes from 5/10/24-5/22/24 showed R1 had 14 episodes of behaviors consisting of verbal outbursts, threatening residents, rummaging through other resident's rooms, threatening staff members, delusions, and verbal altercations with another resident. R1's progress notes showed other residents were becoming anxious, unable to sleep, and disturbed by her behaviors.
R2's facility assessment dated [DATE] showed R2 has moderate cognitive impairment and behaviors not directed towards others.
The facility's document titled, Final Abuse Incident Investigation Report Form showed, Date of alleged incident: 5/21/24. Physical abuse UNSUBSTANTIATED. (R1) alert and oriented x 2 with periods of confusion and forgetfulness, able to make her needs known .requires no assistance to ambulate. Her care plan was reviewed with a history of compromised decision making, roaming or pacing, becoming agitated, oppositional, and combative when re-directed by staff, displays conflictual, difficult behavior with other persons related to Dementia .(R2) alert x 1-2, able to verbalize herself with periods of confusion. She requires assistance with activities of daily living. Her care plan was reviewed with a history of pacing/roaming, displays conflictual, difficult behavior with other persons relate to dementia .Upon further investigation the following was found: On Tuesday, May 21, 2024 at approximately 1:15PM, (R2) went into her room and closed the door behind her. (R1) opened her co-peer's door. The two began arguing and calling each other names. (R2) pushed (R1) causing her to fall backwards. Staff immediately separated the two residents .The facility attributes the illness of both residents for their actions sites no findings of willful or intentional physical abuse .
On 5/26/24 at 1:26PM, V6 (Certified Nursing Assistant) stated, (R1) and (R2) have been constantly arguing back and forth for a while now. They used to share a room but they couldn't get along so they separated them. They were still only about one room apart so they saw each other all the time. On 5/21/24, (R1) kept trying to get into (R2's) room and (R2) was pushing the door back on (R1) so she couldn't get in. (R2) then pushed (R1) onto the floor because she was sick of her trying to get into her room. I was the only person who saw the whole thing. I didn't get in between them when they were arguing because I didn't really know what was going to happen. It happened kind of fast.
On 5/26/24 at 3:12PM, V2 (Director of Nursing) stated, I'm not sure what happened between (R1) and (R2). I don't do the abuse investigations. All I was told was (R1) kept trying to get into (R2's) room and then (R1) ended up on the floor. It's hard to say if it was abuse because they both have dementia. I think (R2) was just acting out and it got out of hand.
On 5/26/24 at 3:25PM, V1 (Administrator) stated, I am the abuse coordinator for the facility and I handle all of the abuse investigations. In this particular incident, (R2) went into her room, closed the door, and then (R1) attempted to go into her room behind her. (R2) got upset and pushed (R1) down to the ground. (V6) was the only witness to this incident. This is not considered abuse because it wasn't willful or intentional. They both have symptoms of impulsivity and they can't control themselves. You and I could get into an argument and walk away but they don't understand how to do that. It's not okay that this is occurring but they both have dementia. A willful action would be a resident with dementia saying they are going to push someone and then they do. This was not the case in this situation. Neither resident knew what they were doing so it's not abuse.
The facility's policy titled, Abuse Prevention Program dated 6/7/13 showed, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents .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 .
Dec 2023
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a dependent resident has clean and trimmed fing...
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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 dependent resident has clean and trimmed fingernails. This deficiency affects one (R49) of three residents in the sample of 23 reviewed for Activity of Daily Living (ADL) care.
Findings include:
On 12/19/23 at 11:20AM, while V30 (Certified Nursing Assistant/CNA) and V33 (CNA) were providing morning care to R49, the resident was observed with long dirty fingernails on both hands. R49 has contractures on his right hand and the fingernails were pressing on his palm. Informed the CNAs of observation made. Both said that they will inform V12 (Licensed Practical Nurse/LPN).
On 12/19/23 at 12:10PM, Informed V12 (LPN) of observation made. V12 said that CNAs and nurses are responsible for cleaning and trimming resident's fingernails as needed. Usually, the restorative aide is the one responsible for it.
On 12/20/23 at 10:30AM, informed V3 (Director of Nursing) of above observation. V3 said that the staff, nurses and CNAs, are responsible to observe the resident's nails each time they are bathing or receiving morning care and to clean and trim them as needed.
R49 is re-admitted on [DATE] with diagnosis listed in part but not limited to Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Vascular Dementia. Care plan indicates ADL self-care performance deficit related to Cerebrovascular accident, hemiparesis, Chronic contractures. Intervention: Provide assistance with all ADLs as required per resident's need dependence: personal hygiene.
Facility's policy on Care of nails indicates:
Purpose: To provide cleanliness. To prevent infection. To promote safety.
Procedure:
1. Observe condition of resident nails during each time of bathing.
4. After bathing, use orange stick and clean debris from around and under fingernails.
5. Trim fingernails in an oval fashion avoiding tissue after bathing or when needed. Be sure nails are soft before trimming.
Facility's policy on Activity of Daily Living indicates:
Purpose: to preserve ADL function, promote independence, and increase self -esteem and dignity.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to identify, assess/monitor, and report the presence of 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 identify, assess/monitor, and report the presence of a stage 2 pressure ulcer, and failed to notify the physician for appropriate treatment. The facility also failed to implement pressure ulcer prevention interventions. This failure affects two (R49 and R80) of three residents in the sample of 23 reviewed for Pressure ulcer Prevention Management.
Findings include:
1.) On 12/19/23 at 1:03PM, observed R80 lying in bed with oxygen via nasal cannula. She is nonresponsive to verbal stimuli. She needs total care with Activity of Daily Living. She is on a low air loss (LAL)mattress. Surveyor asked V15 (Licensed Practical Nurse/LPN) if R80 has skin impairment. V15 said that he is not aware and will ask V5 (Wound Care Nurse/WCN). Observed that R80 wears a disposable adult brief, with cloth pad and flat sheet over the LAL mattress.
On 12/20/23 at 12:57PM, V15 (LPN) said that he spoke with V5 (WCN) and was informed that R80 has no skin impairment, her skin is intact. Surveyor asked V15 to observe R80's sacral area. V15 and V26 (Certified Nursing Assistant/CNA) repositioned R80 to side lying position and removed her disposable brief. Observed a blood stain in the brief, white cream ointment over the sacral area and an open wound bleeding on the left buttocks. V26 said that she is the assigned CNA for R80, but she has not seen her until this time. She has not provided morning care or incontinent care yet. R80 has a disposable brief, cloth pad and flat sheet over the LAL mattress. V26 said that R80 should only have a cloth pad and flat sheet over LAL mattress. She said that night shift is the one who put the disposable brief on R80. V15 (LPN) said that he is not familiar with what the appropriate layers of linen should be underneath R80.
On 12/20/23 at 11:46AM, V15 (WCN) said that she has been working in the facility since August 2023. She said that when the CNA observe any skin impairment or open wound, they should inform the nurse on duty. The nurse will then assess the skin impairment, call the physician for appropriate skin treatment, notify the family, and then inform the Wound Care Nurse.
On 12/20/23 at 2:00PM, V28 (LPN) said that she has been taking care of R80 on 11-7 shift. She took care of R80 on 12/19/23. She does not know if R80 has any skin impairment. She usually said the wound care nurse will do the treatment for residents with skin impairments. Informed V28 that R80 was observed on 12/20/23 with open wound/stage 2 pressure ulcer on left buttocks. V28 said that she is not aware that R80 has a pressure ulcer. The CNA who took care of her did not report to her of R80's stage 2 pressure ulcer/open wound. She does not know who the CNA is who took care of R80 on 12/19/23 11-7. V28 said that the CNA should inform the nurse on duty for any skin impairment that they notice.
On 12/21/23 at 2:30PM, V5 (WCN) presented a copy of R80's wound report dated 12/21/23 that indicates: Stage 2 pressure ulcer on right buttock. Date of onset- 12/20/23. Size- 1.0cm x 1.0cm Facility acquired. Small drainage.
On 12/22/23 at 9:58AM, Informed V5 that R80's new identified stage 2pressure ulcer is on the left buttocks and not the right buttocks as she documented in the wound report. V21 (CAN) and V22 (Registered Nurse/RN) repositioned R80 on her side and observed stage 2 pressure ulcer on left buttocks and observed new open wound/stage 2 on right upper thigh. No skin barrier cream or treatment cream applied to R80's sacral area. Showed observation to V5.
R80 is re-admitted on [DATE] with diagnosis listed in part but not limited to Hemiplegia affecting right dominant side, History of transient ischemic attack and cerebral infraction, Morbid obesity, Encephalopathy. Active physician order sheet indicates: Moisture barrier cream/ointment to buttocks and groin as needed. Care plan indicates: She is at risk for alteration in skin integrity related to impaired communication, incontinence of bladder and bowel, impaired mobility status, impaired nutritional status, and co-morbidities. 8/14/23 Resolved right buttocks. Interventions: Skin will be checked during routine care on daily basis and during weekly /biweekly bath/shower schedule. Any skin integrity issues/concerns will be conveyed to the charge nurse for further evaluation and or treatment changes/new interventions and the physician will be called as needed. Pressure reducing mattress. R80's re-admission skin /Braden scale assessment done on 11/27/23 indicates that she is at high risk for developing skin impairment.
2.) On 12/19/23 at 11:00AM, Observed R49 lying in bed with flexion contractures of the right arm/hand. Observed bilateral heel protector at bedside. V30 (CAN) said that she received R49 without his bilateral heel protectors. She is aware that bilateral heel protectors should be applied while the resident on bed.
On 12/21/23 at 2:30PM, V5 (WCN) said that R49's bilateral heel protector should be applied while he is in bed. Physician order and care plan intervention should be implemented to prevent development of pressure ulcer.
R49 is re-admitted on [DATE] with diagnosis listed in part but not limited to Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Vascular Dementia. Active physician order sheet indicates: Apply the heel protectors while in bed. Care plan indicates: He is at risk for alteration in skin integrity related to incontinence of bladder and bowel, diabetes. 12/2/23 reddened heels. Intervention: Pressure reducing/relieving boots. R49 skin /Braden scale assessment indicates that he is at moderate risk for skin impairment.
Facility's policy on Pressure injury and skin condition assessment indicates:
Purpose: To establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure and other ulcers and assuring interventions are implemented.
Standards:
4. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the initial assessment.
6. Caregivers are responsible for promptly notifying the charge nurse of skin observations.
21. Resident's care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches and goals for care
Facility's policy on Care Plan indicates:
Policy: All residents will have comprehensive assessments and an individualized c=pan of care developed to assist them in achieving and maintaining their optimal status.
Procedure:
9. The interdisciplinary team is responsible for the implementation of resident care management.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to apply a resident's splint/brace as ordered by the phys...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to apply a resident's splint/brace as ordered by the physician and as indicated in the resident's restorative assessment and care plan to prevent further contractures. This deficiency affects two (R49 and R80) of three residents in the sample of 23 reviewed Limited Range of Motion.
Findings include:
1.) On 12/19/23 at 11:00AM, Observed R49 lying in bed with flexion contractures of the right arm/hand. R49 does not have a splint or brace on his right arm/hand contractures. V30 (Certified Nursing Assistant/CNA) said that she has been taking care of R49, but she has not seen him with a splint or brace to his right arm/hand contractures. V30 CNA does not know if R49 has a splint or brace.
On 12/19/23 at 12:10PM, Surveyor informed V12 (Licensed Practical Nurse/LPN) of above observation. V12 said that V32 (Restorative aide) is responsible for applying the splint /braces to residents on the 2nd floor.
On 12/19/23 at 1:30PM, V2 (Assistant Administrator) said that they don't have an assigned Restorative Nurse in the facility. V3 (Director of Nursing/DON) is responsible for the Restorative program.
On 12/20/23 at 11:49AM, V3 (DON) said that she is not responsible for the restorative program. V13 (MDS/Care Plan Consultant) is the one responsible for the restorative program. Surveyor informed V3 of above observation made that R49 is not wearing right hand splint and his right fingernails are pressing on his palm. V3 said that they should follow the physician's orders for splint usage.
On 12/20/23 at 12:59PM, V13 (MDS/Care Plan Consultant) said that she is also the restorative nurse for the facility. Surveyor informed her of the above observation that R49 was observed without a splint on the right arm/hand contractures and his right long fingernails are pressing on his palm. V13 said that they should apply a splint/brace as ordered by physician.
On 12/21/23 at 2:30PM, V30 (CNA) said that she did not apply the splint and did not document it for R49 on 12/19/23 for 7-3 shift. V30 said that V32 (Restorative aide/RA) is the one applying it and documenting it.
On 12/21/23 at 3:05PM, V32 (RA) said that she applied the splint but did not document it, the CNA on the floor should be documenting it. Reviewed R49's restorative log for the splint on 12/19/23 with V32. She said that V30 is the one that documented that she applied it. Surveyor informed V32 that R49 was observed on 12/19/23 without the right elbow splint/brace. R49 has an order for a splint to the right elbow in the morning every 12 hours.
R49 is re-admitted on [DATE] with diagnosis listed in part but not limited to Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Vascular Dementia. Active physician orders sheet (POS) indicates: Splint to right elbow on in AM every 12 hours and remove per schedule. Care plan indicates ADL self-care performance deficit related to Cerebrovascular accident, hemiparesis, Chronic contractures. R49 requires splint to left elbow related to contractures, hemiplegia, limitation in Range of motion (ROM). R49's Restorative assessment dated [DATE] indicates: ROM- Right shoulder has moderate loss/50% of norm, Right elbow has severe loss/less than 50% of norm, Right wrist has fixed/no joint mobility. Recommendation: marked yes for currently using splint/brace.
2.) On 12/19/23 at 1:03PM, Observed R80 lying in bed with oxygen via nasal cannula. She is non-responsive to verbal stimuli. She needs total care with ADLs. She has contractures to both arms, no splint/brace in place. V15 (LPN) said that R80 does not have a splint/brace to her upper extremities.
On 12/20/23 at 11:49AM, Surveyor informed V3 (DON) of above observation made that R80 is not wearing a right-hand splint as indicated in her care plan. V3 said that they should implement the care plan intervention.
On 12/20/23 at 12:59PM, Surveyor informed V13 of above observation that R80 was observed without a right-hand splint as indicated in her care plan and in her restorative assessment. V13 said that R80 has a right-hand splint, but it was not carried over in POS (Physician order sheet) when she was re-admitted on [DATE]. V13 said that R80 should have a right-hand splint as indicated in her restorative assessment and care plan.
R80 is re-admitted on [DATE] with diagnosis listed in part but not limited to Hemiplegia affecting right dominant side, History of transient ischemic attack and cerebral infraction, Morbid obesity, Encephalopathy. Care plan indicates: She requires splint to right hand related to contracture, hemiplegia. R80's Restorative assessment Review dated 11/27/23 indicated: range of motions to all extremities- severe loss, less than 50 & of norm. Muscle strength and functional movement to all extremities- poor. Recommendations for restorative program: Marked yes for resident will benefit from splint/brace to maintain or improve current ROM functioning and currently using right hand Brace.
Facility's policy on Splint/Braces/Devices 11/17 indicates:
1. A physician's order is necessary to apply a splint/brace or restorative device. This order should include the application location and time to be worn.ie, 24 hours day, daytime, or nighttime only, apply at bedtime and remove in morning. As tolerated should also be included in the order.
2. A resident will be evaluated for the use of a splint/brace or device at the time of admission, re-admission, or significant change of functional status.
3. Resident with the following conditions, but not limited to, may be eligible for evaluation:
a. Weak or absent muscle strength
4. An occupational therapist may be consulted to evaluate the resident.
5. Nursing/restorative will document the application of the splint/brace/device on the appropriate facility ADL form
6. The splint/brace/device will be care planned and reviewed minimally quarterly.
Facility's policy on Restorative Nursing Program 9/14 indicates:
Purpose: The facility promotes restorative nursing to attain or maintain the highest practicable physician, mental and psychosocial well-being. Increased independence fosters self-worth and dignity as well as promote a quality-of-life to resident, families, and staff. Restorative Nursing is available seven days a week and is provided for residents with assessed needs according to program criteria. The restorative nursing program is designed to preserve function, promote optimal improvement, increase independence, self-esteem, and dignity, promote safety, and minimize deterioration within the limits of normal aging and recognized disease process.
Components and types of Restorative Nursing Programs: Contractures prevention and management- Passive ROM, Active Assistance ROM, Active ROM, positioning and tone reduction.
Policy:
* Each resident involved in a restorative program will have an individualized program with individualized goals and measurable objectives documented on the plan of care.
Procedure:
To determine a restorative need for a resident during their stay:
*Develop an individualized restorative program based on the assessment information and update the resident care plan.
* If a resident is determined to be appropriate for a restorative program, no physician order's is needed, except for splint and PROM.
Facility's policy on Care Plan indicates:
Policy: All residents will have comprehensive assessments and an individualized plan of care developed to assist them in achieving and maintaining their optimal status.
Procedure:
9. All interdisciplinary Team is responsible for the implementation of resident care management.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to obtain physician order for indwelling catheter, the med...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to obtain physician order for indwelling catheter, the medical indication for usage and the care of the catheter. This deficiency affects one (R80) of three residents in the sample of 23 reviewed for Indwelling catheter management.
Findings include:
On 12/19/23 at 1:03PM, Observed R80 lying in bed with oxygen via nasal cannula. She is non-responsive to verbal stimuli. She needs total care with ADLs (Activities of Daily Living). She has an indwelling catheter draining to dark yellow, orange urine connected to the drainage bag.
On 12/21/23 at 11:20AM, V15 (Licensed Practical Nurse/LPN) said that the resident has an indwelling catheter and should have a physician's order and its clinical indication. Surveyor informed V15 that R80 does not have an order for an indwelling catheter size and type, clinical indication and the care of catheter. V15 said that the admitting nurse should've gotten the order when R80 was re-admitted on [DATE] from the hospital. V15 checked for R80's indwelling catheter size, he said the indwelling catheter size is French 16 with 10cc balloon. R80 has dark yellow orange colored urine connected to urinary drainage bag with sediments in the catheter tubing.
On 12/20/23 at 11:49AM, V3 (Director of Nursing/DON) said that when resident is admitted with indwelling catheter the admitting nurse should get an order from the physician for its size and type, clinical indication and the care of the catheter. Then restorative nurse will do urinary assessment and formulate care plan. Surveyor informed V3 that R80 was re-admitted on [DATE] from hospital with indwelling catheter that there is no physician order for indwelling catheter usage, size and type, clinical indication and care of catheter.
On 12/20/23 at 12:59PM, V13 MDS (Minimum Data Set)/Care Plan Consultant said that she is also the restorative nurse for the facility. Surveyor informed above concerns with R80. V13 said that residents with an indwelling catheter should have an order for indwelling catheter size, type clinical indication and care of the catheter.
R80 is re-admitted on [DATE] with diagnosis listed in part but not limited to Hemiplegia affecting right dominant side, History of transient ischemic attack and cerebral infraction, Morbid obesity, Encephalopathy. Active physician order sheet does not indicate order for indwelling catheter size and type, clinical indication and care of the catheter.
Facility's policy on Indwelling catheterization and removal indicates:
Purpose: to maintain constant urinary drainage.
Procedure:
1. Obtain physician order for insertion/removal of indwelling catheter. The order must include size, type, and reason for catheter.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to follow the Registered Dietician's recommendations and failed to notify the Physician for approval of the recommendations for 1 ...
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Based on observation, interview and record review the facility failed to follow the Registered Dietician's recommendations and failed to notify the Physician for approval of the recommendations for 1 of 4 residents (R53) reviewed for nutrition in a sample of 23.
Findings include:
On 12/20/2023 at 1:00pm R53 was asked why he was losing weight, R53 said I cannot chew well, my teeth are bad. The resident exposed his teeth to the writer, which are decayed and missing in places.
On 12/21/2023 at 10:00am V5(Wound care Nurse) was asked why did R53 not have a weight on 12/14/2023. V5 said I thought I carried that out, there should be a weight for 12/14/2023.
On 12/21/2023 at 10:15am V3 (Director of Nursing) said my wound care nurse carries out the dietitian recommendations. There should be a weight for 12/14/2023. I do not know why it's not there.
On 12/20/2023 an electronic dietary note dated 12/4/2023 from the Dietician indicated a recommendation of to refer to speech therapy for an evaluation, add super cereal and double portions entrée at breakfast and dinner with whole milk at all meals, ready care and lunch and dinner, weekly weights for 2 weeks. An electronic weight sheet indicates a weight on 12/7/2023 of 121.0 pounds and no weight for 12/14/2023. On 12/21/2023 a weight of 120.6 pounds. A prescriber order sheet on 12/5/2023 for weekly weights x2 weeks one time a day every Thursday for weight for 2 weeks.
On 12/22/2023 at 10:20am Facility Policy: Facility was unable to provide a policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to follow their facility menu for 1 of 4 residents (R75) reviewed for menus in a sample of 23.
Findings include:
On 12/20/2023 at...
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Based on observation, interview and record review the facility failed to follow their facility menu for 1 of 4 residents (R75) reviewed for menus in a sample of 23.
Findings include:
On 12/20/2023 at 12:40pm R75 was observed with a hot dog on her meal tray and was asked did she prefer a hot dog. R75 said no I was looking forward to having roast beef.
On 12/20/2023 at 12:50pm V7(Dietary Supervisor) said we did not have enough roast beef after we took it out the oven, so we asked the residents would they like the substitute and they all agreed yes.
On 12/20/2023 at 12:52pm V11(Cook) said I did not realize that it was not enough food until I saw the roast come out the oven, then I started cooking hotdogs after we asked who preferred hot dogs instead of roast beef.
An order summary sheet indicates that R75 is on a regular diet.
Facility Policy: Facility unable to provide a policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure coordination of care and communication between the facility and the hospice provider for 1 of 3 residents (R97) reviewed for hospice ...
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Based on interview and record review the facility failed to ensure coordination of care and communication between the facility and the hospice provider for 1 of 3 residents (R97) reviewed for hospice care in a sample of 23.
Findings include:
On 12/21/2023 at 11:30am V12 (Licensed Practical Nurse) was asked how they know what care is provided for R97, a hospice resident. V12 said the staff use the progress notes and she cannot find the notes and it should be in the hospice book for reference.
On 12/21/2023 at 1:00pm V3 (Director of Nursing) said the hospice progress notes should be in R97's hospice binder. She not sure why the notes are not there, the progress notes are how we communicate between hospice and the facility.
An order summary report dated 12/22/2023 indicates that R97 was placed on hospice on 9/23/2023 and hospice order continued 10/10/2023.
Facility Policy: Hospice Services Policy
Purpose:
To ensure that appropriate services are available to the residents and families and to outline the responsibilities of Hospice Service providers as well as facility staff.
Responsibility:
Administrator, Attending Physicians, Director of Nursing, Social Services Director, Nursing Personnel, Spiritual Advisor and Contract Hospice Service Providers.
Policy:
It is the policy of the facility to honor the advance directives and care alternatives residents may desire when terminally ill and to afford residents with care that allows for dignity and comfort during the end stage of their lives.
The facility will provide hospice services either directly or through arrangements with a qualified service provider.
6. All hospice service staff will write a progress note for each resident visit indicating treatment provided and pertinent information related to the resident's condition which is available in the medical record for all interdisciplinary staff to access.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
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 wear appropriate Personal Protective Equipment (N95 mas...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to wear appropriate Personal Protective Equipment (N95 mask, face shield, gown, and gloves) when entering a COVID isolation room, failed to change gloves and perform hand hygiene after providing incontinence care for a resident on COVID isolation precautions. This deficiency affects 3 residents (R49, R16 and R95) in the sample of 23 reviewed for Infection Control Management.
Findings include:
On 12/19/23 at 10:48AM, V30 (Certified Nursing Assistant/CAN) said that she is going to provide morning care to R49. She said that R49 and the other 2 residents (R16 and R95) are on isolation precautions for COVID-19. R49 is located at the corner of the room by the window. V30 prepared all clean linens, gown, disposable brief, and towels/wash clothes and placed it on top of the soiled linen cart she used from other residents. She donned appropriate PPE, and she got inside the isolation room and brought the soiled linen cart with her. The linen cart was full of soiled linens from other residents where V30 had provided care. Surveyor informed V30 of the observation regarding the soiled linen cart brought inside the isolation room. V30 said that she should not bring the soiled linen cart inside the isolation room. V30 said that the isolation room has its own red isolation bag for the soiled linen. V30 said that she will get someone to help her to provide morning care for R49.
On 12/19/23 at 11:05AM, observed that V33 CNA went inside the isolation room without appropriate PPE. V33 was only wearing a surgical mask and gloves. Surveyor called the attention of V33 and informed him that R49 is on COVID isolation. V33 went out of the room without removing his gloves and mask, and without performing hand hygiene. V33 donned face shield and gown, using the same mask and gloves, then he went back inside the isolation room. Surveyor called again his attention and asked him what kind of mask he should be using in COVID isolation rooms. V33 said that he should be wearing an N95 mask. V33 went out of the room, without removing his PPE and performing hand hygiene. V33 donned a N95 mask over the same surgical mask and used the same face shield, gown, and gloves. V33 went inside the isolation room. V33 was gathering the washcloths that he would be using to provide incontinence care, he dropped one of the washcloths and placed it together with clean ones.
On 12/19/23 at 11:22AM, Both CNAs (V30 and V33) provided morning care with R49. V33 CNA removed R49's soiled disposable brief with urine. V33 cleaned sacral and peri-area with wet washcloth then he applied a clean disposable brief without changing his gloves and performing hand hygiene. V33 CNA used the same gloves throughout the procedure.
On 12/19/23 at 11:30AM, Surveyor informed V33 of the observation made. V33 said that he should not use the washcloth that fell on the floor, and he should change his gloves after providing incontinence care, wash his hands and wear a new pair of gloves.
On 12/20/23 at 12:20PM, Surveyor informed V6 (Infection Control Coordinator) of above observation made. V6 said that the soiled linen cart should not be brought inside the COVID isolation room. The isolation room has its own red bags inside the room for soiled linen/clothes and garbage. The staff should be wearing appropriate PPE- face shield, N95 mask, gown and gloves when entering COVID isolation rooms. The staff should remove all PPE and perform hand hygiene. The washcloth that fell on the floor should not be used because it's already contaminated. The staff should change gloves after providing incontinence care- cleaning rectal/peri care area and perform hand hygiene before donning a new pair of gloves.
On 12/20/23 at 12:41PM, Observed V30 (CNA) wearing appropriate PPE inside the COVID isolation room, brought disposable lunch plates to R49 and assisted him to set up his lunch plate. After assisting, she removed her gloves and donned a new pair of gloves without performing hand hygiene. Then she continued to bring disposable lunch plates handed by V34 (CNA) by the door. After providing lunch plates to three residents inside the room. Surveyor informed V30 of observation made. V30 said that she should perform hand hygiene after removing gloves and before donning a new pair of gloves.
On 12/20/23 at 2:30PM, Surveyor informed V6 (Infection Control Coordinator) of above observation. V6 said that hand hygiene should be performed after removing gloves and before donning a new pair of gloves.
R49 is re-admitted on [DATE] with a diagnosis listed in part but not limited to COVID 19 infection. He was placed on Droplet and contact isolation precaution on 12/12/23. Care plan indicates: He is on contact/droplet isolation precautions for COVID 19. Intervention: Follow infection control standards of care published for isolation type. [NAME] PPE gloves, gown, mask, when providing direct care yielding contact with patient and entering patient room.
R16 is re-admitted on [DATE] with diagnosis listed on part but not limited to COVID 19 infection. He was placed on Droplet and contact isolation precaution on 12/12/23. Care plan indicates: He is on contact/droplet isolation precautions for COVID 19. Intervention: Follow infection control standards of care published for isolation type. [NAME] PPE gloves, gown, mask, when providing direct care yielding contact with patient and entering patient room.
R95 is re-admitted on [DATE] with diagnosis listed in part but not limited to COVID 19 infection. He was placed on Droplet and contact isolation precaution on 12/12/23. Care plan indicates: He is on contact/droplet isolation precautions for COVID 19. Intervention: Follow infection control standards of care published for isolation type. [NAME] PPE gloves, gown, mask, when providing direct care yielding contact with patient and entering patient room.
Facility's policy on CORONAVIRUS (COVID-19) indicates:
Policy: This policy is to educate, prevent the spread, identify, and treat the Coronavirus.
General Prevention:
*When community transmission is HIGH or if the facility is in outbreak, all residents, including new admissions, should be evaluated at least weekly for signs and symptoms of COVID-19.
Respiratory germs protection spread within your facility:
*Staff to wear appropriate PPE (gown, gloves, N95 respirator, eye protector) daily during care of COVID (+), PUI (Person Under Investigation) and county rate high when giving treatments.
Core principles of COVID-19 infection prevention:
* PPE worn appropriately
* Facemasks/KN95/N95 usage- N95 required to enter COVID (+) room and to give aerosol treatment
In-house Plan:
*Wear N95, eye protection, gown, gloves for care of resident with confirmed COVID -19
Facility's policy on hand hygiene indicates:
Purpose: Hand Hygiene is the most effective way of preventing the transmission of healthcare associated infection to residents, staff, and visitors.
1. Hand hygiene shall be performed:
*After contact with a resident or resident's environment
Nov 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
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 interview and record review, the facility failed to protect a resident identified to be at risk for abuse from a reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect a resident identified to be at risk for abuse from a resident-to-resident sexual abuse. This affected one of three residents (R1) reviewed for resident-to-resident sexual abuse. This failure resulted in resulted in R1 feeling sad, scared, and powerless.
Findings include:
On 11-14-23 at 9:55 AM, R1 said she went with R2 to his room to get a pop. R1 said R2 did not touch R1 and moments later said R2 touched R1's genitals with his hands. R1 said R2 touched between my legs under my clothes. R1 said they were in R2's bed. R2 asked R1 to sit on his bed and R1 said R2 is big, and she didn't have a choice. R1 said R2 put 2 hands under the skirt and R2's 2 fingers penetrated R1's vagina. R1 said she did not fight R2 and did not tell R2 to stop. R1 said R2 put R1 in her wheelchair and pushed R1 out of his room. R1 said she told R1 told V4 (Certified Nursing Assistant/CNA) who told V3 (Licensed Practical Nurse/LPN). R1 said V3 called the local police. R1 said she did not talk to the police. R1 said R2 is no longer at the facility however said she still feels scared at the facility. R1 said she feels safer since R2 is not here anymore. R1 said she is satisfied with the facility handling this situation. R1 said R2 has not touched R1 before. R1 said R2 did not try to be romantic with R1. R1 said R2 was able to lift her up and place her on his bed and this happened in the afternoon. On 11-16-23 at 8:54 AM, R1 said R2 pushed R1's wheelchair to his room R2 did not say what they would do in his room. R1 said R2 told R1 to get on the bed, R2 assisted (lifted) R1 on the bed, R2 flipped R1 over on the bed, R2 pulled R1's skirt and panties down, and R2 slapped his penis on R1's vagina. R1 said R2 did not penetrate me with his penis. R1 said she did not consent to any of this. R1 said she did not put up a fight because he was a big guy. R1 said this lasted 3 minutes. R1 said after, R2 put panties back on and skirt on. R2 threw me in the chair and wheeled me out. R1 said she did not tell anyone because she did not like the nurse. There are no previous altercations or encounters with R2 prior to this. R1 denies any previous abuse concerns prior to this incident.
On 11-14-23 at 9:30 AM, V2 (Director of Nursing/DON) said on 11-12-23 around 8:00 AM, R1 informed V3 informed R1 made sexual assault allegation against (R2). V2 said she was on her way to facility and said the staff kept R1 and R2 separated. On the phone, R1 told V2 that R2 pushed R1's wheelchair into his room around 2:00 PM on Saturday (11-11-23). R1 said R2 told R1 to get on R2's bed. R1 needed assistance to transfer on to his bed. R1 said she transferred herself onto R2's bed. While on his bed, R2 vaginally penetrated R1 with his penis. V2 asked R1 if she yelled or screamed for help and R1 said no. V2 asked R1 why she didn't scream for help and R1 said R2 was big. R1 said she was scared of R2. R1 told V2 that she went back to her chair and she left out of R2's room. When V2 arrived at facility, R1 was interviewed by 2 other staff ( V12 Assistant Administrator and V5 Social Services). V2 talked with V12 (Assistant Administrator) and V5 (Social Services). V2 said local police were called by Assistant Administrator and they arrived at the same time ambulance was bringing R1 to hospital. MD was notified and gave order to send R1 for hospital evaluation and rape kit. Emergency contact was called however no response and message left. Facility called R2's psych MD and family. MD gave order for R2's psych evaluation. V2 said R2 can show behaviors of flirtation and making inappropriate sexual comments towards staff residents. V2 said R2 may attempt to touch an arm but has not seen R2 grab or sexually touch a resident or staff. V2 said she would not condone R2 taking a female to his room knowing R2's sexual behaviors and mental illness for a safety measure. V2 said R2 requires standard rounding because he is out and about. V2 said when she is around and sees R2's door closed, she would make it a point to knock on the door to check on his due to his behaviors.
On 11-14-23 at 11:08 AM, V3 (LPN) said on 11-12-23 around 7:15 AM, R1 told V3 R2 raped her (R1). V3 immediately asked if R1 was OK and did a visual inspection. V3 said R1 did not complain of any pain or discomfort. V3 appeared to be OK at that time. V3 said R1 did not show any signs of abuse. V3 said she did not check R1's genitals. V3 asked when this happened and R1 said it happened yesterday at 2:00 PM (11-11-23). R1 said R2 raped her and did not give any detail. V3 said R1 did not mention any penetration or finger activity. V3 immediately notified social worker, V2 (DON), (Administrator was on vacation), V11 (MD), and no family was listed. V3 said V5 (Social Worker) called police. V3 said local police met R1 at the hospital. V3 said R2 was sent out for hospital evaluation and has not returned.
On 11-14-23 at 11:51 AM, V4 (CNA) R1 is alert, oriented, and able to make her needs known. V4 said R1 would be able to report abuse if it happened to her. V4 said R2 is alert, oriented, and able to make his needs known. V4 said she is not aware of R2 being capable of sexual abuse towards others. V4 said she has not seen R2 have any sexual behaviors towards other residents. V4 said she arrived to work on Sunday (11-12-23) at around 7:15 AM, R1 saw V4 at the elevator and took V4's hand and lead V4 around the corner. R1 told V4 R2 raped R1. R1 did not give details however V4 immediately reported to V3 (LPN). V3 arrived and R1 told V3 the same allegation. V3 reported it to necessary administration. V4 said R1 was tearful, emotional, and scared.
On 11-14-223 at 12:18 PM, V5 (Social Service Director/SSD) said R1 is alert, oriented, and able to make her needs known. V5 said R1 is capable of reporting abuse if it happened to R1. V5 said R2 is alert, oriented, and able to make his needs known. V5 said R2 is known for inappropriate jokes which can be very personal or sexual at times. V5 said staff will report inappropriate touch from R2. V5 said R2 can be difficult to redirect and R2 has poor respect of other people's boundaries and can be impulsive. V5 said she would separate R2 from female peers due to his joking and sexually inappropriate behaviors. V5 said if she would see a female with R2 going to his room, she would suggest they meet in a common area of the floor. This way staff can monitor and ensure resident safety. On 11-16-23 at 9:30 AM, V5 said R1 is vulnerable for abuse because of confusion related to CVA, Hemiplegia, Psychiatric History, and Depression.
R1's Minimum Data Set/MDS (ARD 9-11-23) documents: BIMS = 11. Active Diagnoses (not limited to): Cerebrovascular Accident.
R1's Progress Note dated 11-12-23 documents: Upon checking rooms this a.m., resident came out to nurses' station and stated to writer and CNA that she had been raped by R2. Resident stated that (R2) pushed her wheelchair into his room and told her to get on the bed and she did. She stated, He pulled my dress up and raped me. When writer asked where roommate was, she stated, he was in his bed. Writer asked why you didn't scream. She stated, I was scared, he is a big guy, and I was afraid of him. T 98 P 84 R 18 B/P 162/111. Rapid Covid 19 complete. Results are negative. Dr. [NAME] called and notified. Order sends to ER (Emergency Room). EMS (Emergency Medical System) called and ETA (Estimated Time of Arrival) within 30 minutes. At 9:00 a.m. EMS arrived EMTs (Emergency Medical Technicians) x2 with stretcher to pick up resident. DON notified and present. Assistant Administrator notified. Social Service notified.
R1's Social Service Note dated 11-12-23 documents: Writer was made aware that resident made an alleged statement against peer, writer informed SSD. DON (Director of Nursing) and Assistant Administrator were made aware. Resident was sent out for observation. Writer gathered witness statement and room change was made because resident felt unsafe. Staff will continue to monitor resident needs upon return from hospital.
R1's Comprehensive Assessment Care Plan documents: R1 is susceptible for abuse/neglect.
R2's Social Service Note dated 11-12-23 documents: Writer provided resident with a wellness check due to resident being named in an alleged incident. Writer took residents' statement, during which time resident appeared nervous due to labile (shaking) affect. Also, during intake of statement resident held a blank stare. Due to the nature of the incident resident was sent out for observation (around noon) and writer will provide an update upon residents' return.
R2's Care Plan documents: Focus: Comprehensive assessment reveals history of suspected abuse and/or neglect or factors that may increase his/her susceptibility to abuse/neglect. Intervention: Assure the resident that he is in a safe & secure environment with caring professional. Explain that psychosocial adjustment is often facilitated by developing a trusting relationship with another person (i.e., social worker, nurse, CNA, peer) and by verbalizing thoughts, needs & feelings.
R2's Care Plan documents: Focus: (R2) exhibits sexually inappropriate behavioral symptoms related to Severe Mental Illness. Intervention: Intervene & redirect when any inappropriate behavior is observed. Communicate assertively that the resident must exercise control over impulses &behavior (Social skills training). Remind the resident to refrain from hostile and inappropriate touching.
Initial State Reportable dated 11-12-23 documents: Circumstances of alleged incident: It was reported to the nurse by the resident that she was allegedly sexually assaulted by another resident. The victim evaluated and sent out for further evaluation. The alleged perpetrator sent out as well. The police were called, and a report was filed. MD made aware. Family made aware and administration made aware.
R1's Hospital Record dated 11-1-223 documents: HPI: (R1) female with medical history as noted who presents with call for sexual assault. R1 is a resident at a nearby nursing home. She states that another resident brought her into his bedroom against her will. States he slapped his penis on her unclothed vagina. Denies penetration, did not see bodily fluids. This interaction was brief lasting couple seconds to minutes. She was able to leave shortly after. She denies sustaining any other injury during this event. She is low concern for STDs. Of note, the patient does have history of hypertension and had a stroke last year which is why she is now living in a nursing home. She denies any pain. Denies any skin changes. Denies any trauma or injury. Police called by NH (nursing home) and present in dept (department). Pt does not want to discuss with police does not want a SA (sexual assault) kit. Medical Decision Making: Initial Assessment and Plan: female with medical history as noted above who presents with report of sexual assault. No penetration. No apparent involvement of bodily fluid. There was skin to skin contact between this man's penis and the skin over her vagina. She denies any vaginal discharge, bleeding, lesions. This occurred within the past 24 hours. Patient initially refusing to make a police report. Has gone back and forth. Multiple discussions with (R1), SANE (Sexual Assault Nurse Examiner). Sexual assault kit catered to exposures and desires of the patient. Please see SANE full documentation. Reviewed this work-up with the patient and she does not feel comfortable with this plan. We also called the nursing home to confirm that this individual is no longer living there he has been sent to another institution nursing supervisor aware and she will be living on a different floor from here on out according to the nursing supervisor. All questions answered patient does feel safe to go back to the institution. No further needs at this time will discharge in stable condition.
May 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to develop and implement an abuse care plan for one of eight residents (R3) reviewed for comprehensive care plan.
Findings include:
R3 has dia...
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Based on interview and record review, the facility failed to develop and implement an abuse care plan for one of eight residents (R3) reviewed for comprehensive care plan.
Findings include:
R3 has diagnoses of: Schizoaffective Disorder Depressive Type, Bipolar Disorder Unspecified, Anxiety Disorder Unspecified, Violent Behavior. The symptoms include manic periods of high energy, anxiety, impulsivity, aggression, mood swings and anger
R3's BIMS (Brief Interview for Mental Status) score was 2. A score of 0 to 7 means severe impairment.
R3's (Target Date: 05/26/2023) Care Plan was reviewed; no abuse care plan documented
On 5/20/2023 at 11:25pm, Surveyor asked V2 (Director of Nursing/DON) if all residents are assessed for abuse, and if at risk, would the resident be care planned for abuse? V2 stated, Yes, if a resident is assessed for abuse and the resident is at risk, the resident would be care planned for abuse by social services. Surveyor asked V2 if R3 was at risk for abuse due to wandering behaviors. V2 stated, Yes, I would say so. Surveyor requested R3's abuse care plan.
On 5/20/2023 at 11:47am, V3 (Social Services Director) stated, she remembered R3 and the incident that occurred on 4/3/2023 involving R3. V3 (Social Services Director) stated, yes, I remember R3. Surveyor asked V3 if R3 was at risk for abuse. V3 stated that because of her SMI diagnosis of severe mental illness R3 qualified for the screening of self-harm assessment, which shows R3 was at risk for abuse. R3 gets this during admission, quarterly assessment, and comprehensive annual assessment. One was completed for R3 on 4/3/2023 after the incident and the quarterly one before the incident. I believe this would have been her first incident, and then she (R3) was sent a week after to the hospital. R3 was not care planned for abuse. V3 stated, she (R3) should not have been care planned for abuse. V3 stated, based on the quarterly assessment completed on 2/3/23 and the assessment completed on 4/3/2023 after the incident R3 was assessed at low risk for abuse. V3 stated, I am responsible for putting a care plan in place for abuse. Surveyor asked V3 if R3 was care planned for abuse. V3 stated, No. Surveyor asked V3 based on R3's screening assessments for indicators of Aggressive and/or Harmful Behaviors should R3 have been care planned for abuse. V3 stated, Yes.
Review of R3's Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors (SS) 02/03/2023 documents D. Abuse/Neglect Factors a score of 3 indicating Moderate.
Review of R3's Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors (SS) 04/03/2023 documents D. Abuse/Neglect Factors a score of 3 indicating Moderate.
Review of Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors Question 6 in part: History of presence of dysfunctional behavior (e.g., aggressive) including roaming/wandering into peer's rooms/personal space? This question was answered: 2. which indicated No for the assessment completed on 02/03/2023 and 04/03/2023, but R3 has documented history of behaviors and roaming.
During the course of this survey, the facility did not submit an abuse care plan for R3.
Facility's Care Plan Policy documents in part: A. POLICY: All residents will have comprehensive assessments and an individualized plan of care developed to assist them in achieving and maintaining their optimal status. 5. Care plans are reviewed and discussed individually. a. Concerns, problems, needs, and/or strengths are listed based on resident's individual needs. Physicians' orders and personal care and nursing needs are also listed based upon comprehensive assessments. c. All concerns, problems, needs and/or strengths have a corresponding goal. The format for a goal is who, what, how, and when. Goals are resident oriented, specific problem-oriented goals relative to medical and nursing diagnosis, realistic, measurable, and directed towards increased functional levels. e. Notation is made on the care plan when a goal is resolved and changed. f. Notation is made on the care plan when a goal is changed. The goals may be changed for many reasons. A Few examples are resolved, unrealistic, deterioration in condition. b. When a change occurs in a resident's condition the Care Plan Coordinator is notified by a member of the Interdisciplinary Team. The care plan is then reviewed and updated. c. The Care Plan Coordinator reads report books and makes rounds daily and updates care plans as needed. 10. All interdisciplinary Team departments are responsible for charting that reflects the care plan concerns, problems, needs and/or strengths, approaches, progress, or lack of progress with possible reasons for and any new problems. 17. Care plans must be person-centered inclusive of skilled therapy needs.
Facility's Abuse Policy documents in part: IV Establishing a Resident Sensitive Environment. This facility desires to prevent abuse, neglect, or misappropriation of property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach involving the following: Resident assessment: as part of the resident social history evaluation and MDS assessments, staff will identify resident with increased vulnerability for abuse, neglect, mistreatment, or who have needs 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 or mistreatment for these residents. Staff will continue to monitor the goals and approaches on a regular basis.
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 F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to revise the comprehensive care plan for one of eight residents (R3) reviewed for behaviors.
Findings include:
Facility's final reportable to...
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Based on interview and record review, the facility failed to revise the comprehensive care plan for one of eight residents (R3) reviewed for behaviors.
Findings include:
Facility's final reportable to state agency regarding R2 and R3 documents in part: Incident occurred on 4/3/23 at 1:30 pm. Upon further investigation the following found: On April 3, 2023, at approximately 1:30pm, R3 entered her co-peer's room attempting to take her snacks. The co-peer, R2 called R3 a Bi_ _h. R3 responded by hitting the resident on both side of her cheeks with two open hands and then left the room. The resident was assessed for injuries with no redness, bruising, or swelling noted. Staff monitored R3 to prevent any further interactions between the two residents.
R3 has diagnoses of Schizoaffective Disorder Depressive Type, Bipolar Disorder Unspecified, Anxiety Disorder Unspecified, Violent Behavior. The symptoms include manic periods of high energy, anxiety, impulsivity, aggression, mood swings and anger
R3's BIMS (Brief Interview for Mental Status) score was 2. A score of 0 to 7 means severe impairment.
On 5/20/2023 at 11:23am, surveyor asked V2 (Director of Nursing/DON) if R3's care plan was updated after the 4/3/2023 incident when R3 wandered into R2's room and slapped R2? V2 stated, I am not sure if R3's care plan was revised, but I would expect the care plan to be revised? V2 stated, Yes, it should have been (referring to care plan). V2 stated, social services would update behavior care plan.
On 5/20/2023 at approximately 11:50pm, V3 (Social Services Director) stated that if a resident wanders into another resident's room, then staff should be there to redirect the resident to make sure the resident is in a safe environment. Surveyor asked V3 based on the incident R3 had when wandering into another residents (R2) room and slapping R2, should R3's behavior care plan be revised? V3 looked away and did not answer the question. Surveyor asked V3 who is responsible for revising residents care plan for behavior(s). V3 stated, I am responsible for putting a care plan in place for behaviors, revising the care plan, and completing screening for behaviors and aggression and completing any comprehensives. Surveyor asked V3 if R3's care plan was revised after the 4/3/2023 incident when R3 slapped R2. V3 stated, No.
On 5/20/2023 at approximately 11:50pm, V3 stated, if a resident wanders into another resident's room, then staff should be there to redirect the resident to make sure the resident is in a safe environment.
V3 stated, I am responsible for putting a care plan in place for behaviors. I (V3) am responsible for behavior care plan revisions and completing screening for behaviors and aggression and any comprehensives. Surveyor asked V3 if R3's care plan was revised after the 4/3/2023 incident. V3 stated, No.
R3's (4/3/2023 11:56 am) Social Service Note: R3 was observed pacing hallway and attempting to enter other several peer's rooms without permission. Staff provided redirection along with small self-activities, but no gain. R3 appears to be showing signs of restlessness, agitation and increase confusion. Writer attempted to educate on the importance of respecting other boundaries and space but R3 current symptoms is preventing her to understand basic cognitive tasks. She continued to pace the milieu area. Staff will continue to monitor, support, and encourage appropriate behavior.
R3's (4/3/2023 at 2:17 pm) nursing Progress documents: Resident walked down to XX main and went in R2's room and slapped her and tried to take her chips. Nurse Practitioner (NP) notified. Full assessment did on R3, and no bruises or injuries noted at this time. T 98 P 71 R 18 B/P 118/80, Director of Nursing notified. Administrator notified.
R3's (4/3/2023 at 5:09 pm) social service note documents: Writer was informed that R3 exhibited aggressive behavior by hitting a peer. Writer met with R3 to process her feelings regarding this behavior, she appeared confused stating she did not do anything. I just wanted a bag of chips. Social service will continue to monitor, reassure her safety, and document any behaviors.
R3's (02/17/2023) care plan includes in part: psychotropic medication to help manage and alleviate: Agitation and aggressive behavior. Date Initiated: 10/26/202 Last Revised on: 02/15/2023
R3's (2/17/2023) care plan includes in part demonstrates movement behavior that may be interpreted as wandering, pacing, or roaming r/t the diagnosis of dementia and problems understanding the immediate environment. Symptoms are manifested by: Pacing, roaming, or wandering in and out of peers' rooms. Date Initiated: 04/27/2022 Last Revision on: 02/17/2023.
Facility's Care Plan Policy documents in part: A. POLICY: All residents will have comprehensive assessments and an individualized plan of care developed to assist them in achieving and maintaining their optimal status. 5. Care plans are reviewed and discussed individually. a. Concerns, problems, needs, and/or strengths are listed based on resident's individual needs. Physicians' orders and personal care and nursing needs are also listed based upon comprehensive assessments. c. All concerns, problems, needs and/or strengths have a corresponding goal. The format for a goal is who, what, how, and when. Goals are resident oriented, specific problem-oriented goals relative to medical and nursing diagnosis, realistic, measurable, and directed towards increased functional levels. e. Notation is made on the care plan when a goal is resolved and changed. f. Notation is made on the care plan when a goal is changed. The goals may be changed for many reasons. A Few examples are resolved, unrealistic, deterioration in condition. b. When a change occurs in a resident's condition the Care Plan Coordinator is notified by a member of the Interdisciplinary Team. The care plan is then reviewed and updated. c. The Care Plan Coordinator reads report books and makes rounds daily and updates care plans as needed. 10. All interdisciplinary Team departments are responsible for charting that reflects the care plan concerns, problems, needs and/or strengths, approaches, progress, or lack of progress with possible reasons for and any new problems. 17. Care plans must be person-centered inclusive of skilled therapy needs.
Facility's Wanders Policy documents in part: A. POLICY: Residents identified as wanderers will have a Preventative Program to prevent possible injury and/or elopement. B. PROCEDURE: 1. Identification of potential wanderers will be made by either: c) Observation d) Incident e) History 2. Upon identification of a wanderer, the following steps should be taken b) An initial assessment will include an evaluation of the resident for wandering and the degree of wandering (e.g., room to room, floor to floor, or outside) as a narrative nursing note. d) Within 72-hrs of admission, the potential for wandering will be identified on the resident's plan of care with individual goals and approaches. The plan of care should be based on 1. Cognitively impaired 2. Behavioral problems k) Behavior with interventions will be documented in resident's clinical record. Physician and/or Family Member will be notified if warranted
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
On 5/19/2023 at 2:58pm, V8 (Licensed Practical Nurse/LPN) stated, I remember the incident that occurred between R3 and R2. I (V8) was the nurse for R3. I (V8) was working on ZZ pavilion. The aides cam...
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On 5/19/2023 at 2:58pm, V8 (Licensed Practical Nurse/LPN) stated, I remember the incident that occurred between R3 and R2. I (V8) was the nurse for R3. I (V8) was working on ZZ pavilion. The aides came down from XX main and told me R3 had slapped R2 and took her (R2's) chips. When I (V8) confronted R3 and asked R3 if she slapped R2, R3 said no. R3 was always going into R2's room. R3 always does that, they (R2 and R3) were friends at a different facility so R3 was familiar with R2. R2 was talking to the aides (people that came to the incident) and R2 said R3 did hit her (R2). R2 said, R3 slapped her (R2) in the face. V8 stated, I (V8) did not see any mark on R2's face. V8 stated, I (V8) don't remember what aide it was, but I (V8) remember seeing R3 walking really fast, and the aide said R3 just hit R2. R2's room is on the other side (referring to Main). V8 stated, I (V8) was trying to get R3 on the side she (R3) was supposed to be on. I (V8) know R3 wanted R2's chips and that is why R3 hit R2. I (V8) was the nurse for R3, but R3 had walked on the other side to where R2's room was. R3 would always walk out of her (R3's) room and would always go to R2's room when you are not looking, R3 would always walk into R2's room. We did not always see R3 leave R3's room.
Facility's Abuse Policy documents in part:
This facility affirms the right of our residents to be free of abuse.
Facility's WANDERERS POLICY documents in part: Residents identified as wanderers will have a Preventative Program to prevent possible injury and/or elopement.
3. If the facility determines admission acceptance or continued stay, the following occurs:
a) Department supervisors are notified of the admission of potential elopers during the admission meeting. A determination is made for a floor and room assignment that will provide increased observation capabilities by staff. Department supervisors are expected to notify members of their department regarding the potential wanderer.
Facility Assessment Tool dated 10/5/2022 documents in part that the facility provides person-centered/directed care. This includes identifying hazards and risks for residents.
Based on interview and record review the facility failed to supervise a known wanderer resident R3 in a sample of 8 residents reviewed for supervision. This failure resulted in R3 wandering to R3's room and slapping one resident (R2) on both cheeks.
Findings include:
Facility's final reportable to state agency regarding R2 and R3 documents in part: Incident occurred on 4/3/23 at 1:30 pm. Upon further investigation the following found:
On April 3, 2023, at approximately 1:30pm, R3 entered her co-peer ' s room attempting to take her snacks. The co-peer, R2 called R3 a Bi_ _h. R3 responded by hitting the resident on both side of her cheeks with two open hands and then left the room. The resident was assessed for injuries with no redness, bruising, or swelling noted. Staff monitored R3 to prevent any further interactions between the two residents. R2 has diagnoses of Major Depressive Disorder Recurrent Episode, Paranoid Schizophrenia, Violent Behavior, Generalized Anxiety Disorder. The symptoms include aggression, agitation, compulsive behavior, and anger as evident in the resident calling her co-peer a Bi _ _h when she tried to take her snacks.
R3 has diagnoses of Schizoaffective Disorder Depressive Type, Bipolar Disorder Unspecified, Anxiety Disorder Unspecified, Violent Behavior. The symptoms include manic periods of high energy, anxiety, impulsivity, aggression, mood swings and anger as evident in the resident hitting her co-peer when she was called a Bi _ _ h. (Both R2 and R3 no longer reside at the facility)
R2's BIMS (Brief Interview for Mental Status) score was 9, R3's score was 2, R8's score was 13. A score of 13 to 15 means the resident is cognitively intact, 8 to 12 means moderately impaired and 0 to 7 is severe impairment.
On 5/20/23 at 9:07 am, V11 (Certified Nursing Assistant/CNA) stated that she was familiar with R3. V11 stated, R3 walked and was a wanderer and sometimes was a little argumentative. V11 stated, R3 wandered to residents' rooms and needed to be redirected to stay in her hallway. V11 stated, the unit R3 stayed on was Pavilion, and the unit is for memory care residents. V11 said, we would keep the door closed that separates Pavilion and Main unit so R3 would not wander to the other unit on the same floor.
On 5/20/23 at 9:12 am, V4 (Licensed Practical Nurse/LPN) stated, residents have the right to refuse medications, but she would talk to the resident 3 separate times to provide education and if the resident still refused, she would document, call the doctor, and make the family aware. V4 stated that R3 was confused, demented, unstable, needed lots of redirection, and needed to be monitored all the time because R3 wandered to residents' rooms and the nurse's station. V4 stated, R3 walked fast, like she was running and would push people out of her way with her head so staff would keep the hallway free and clear of any items. V4 stated, R3 would go into other residents' rooms and would lay in their beds and staff would have to bring her back. V4 stated, R2 stayed on the Main unit, which is same floor as R3 stayed on, she was seeking attention, was also independent.
On 5/20/23 at 10:04 am, V9 (Certified Nursing Assistant/CNA) stated on 4/3/23 she was by R2's room at the kiosk (where aides chart, in the hallway) and V9 was facing the computer and not R2's room. V9 stated, she heard R2 scream and commotion, so she went there. V9 stated, as she heard the commotion and scream, she turned around and saw R3 come out of R2's room. R8 (R2's roommate) and R2 stated, a resident (R3) came in and slapped R2. V9 stated, she reported this to V1 (Administrator) immediately. V9 stated, she did see R3 coming out of R2's room.
On 5/20/23 at 10:12 am, V1 (Administrator) stated, R3 went down to R2 room, and she attempted to take her snacks and when she tried to take her snacks, R2 called her a b and R3 contacted her cheeks and left the room. V1 stated, R2 was observed after the incident and there was no bruising or redness with R2's face. V1 stated, both R2 and R8 stated the same thing as to the event that occurred. V1 stated, he made sure to keep R2 and R3 separated and made sure R3 stayed on the pavilion side, and both residents have behaviors as anxiety and violent behavior as far as their diagnosis, abuse was ruled out based on the behaviors of the residents. V1 stated, R3 had good and bad days, most days she was nervous and hard to communicate with. V1 stated that R3 moved around a lot and that was part of the nervousness she had. V1 stated, pavilion is a skilled unit and some dementia unit, staff keep an eye on the residents as they are close to the nursing station.
On 5/20/23 at 10:23 am, V3 (Social Service Director) stated, R3 was alert times 1-2 with confusion, would pace hallway and was known for wandering, she would wander to residents' rooms. V3 stated, staff redirected her back to her unit or her room. V3 stated, the purpose to monitor R3 was for not to wander to other residents' rooms as it could cause harm to self and other residents. V3 stated, staff knew R3's behaviors.
On 5/21/23 at 3:00 pm, R2 said she remembers residing at the facility. R2 stated, R3 used to always come in her room, and she was not invited by R2 and would always try to take her stuff, especially chips. R2 stated, one day R2 and R8 (roommate) were in their room's doorway and R3 came in and slapped R2 with both hands. R2 stated, it felt dull in pain and it's not like she wasn't slapped before. R2 stated, she immediately informed V3 (Social Service Director) what R3 did to her.
R3's (4/3/2023 11:56 am)
Social Service Note: R3 was observed pacing hallway and attempting to enter other several peer's rooms without permission. Staff provided redirection along with small self-activities but no gain. R3 appears to be showing signs of restlessness, agitation and increase confusion. Writer attempted to educate on the importance of respecting other boundaries and space but R3 current symptoms is preventing her to understand basic cognitive tasks. She continued to pace the milieu area. Staff will continue to monitor, support, and encourage appropriate behavior.
R3's (4/3/2023 at 2:17 pm) nursing Progress documents: Resident walked down to XX main and went in R2's room and slapped her and tried to take her chips. Nurse Practitioner notified. Full assessment did on R3, and no bruises or injuries noted at this time. T 98 P 71 R 18 B/P 118/80, Director of Nursing notified. Administrator notified.
R3's (4/3/2023 at 5:09 pm) social service note documents: Writer was informed that R3 exhibited aggressive behavior by hitting a peer. Writer met with R3 to process her feelings regarding this behavior, she appeared confused stating she did not do anything. I just wanted a bag of chips. Social service will continue to monitor, reassure her safety, and document any behaviors.
R3 (Date Initiated: 04/27/2022) care plan documents in part: R3 demonstrates movement behavior that may be interpreted as wandering, pacing, or roaming r/t the diagnosis of dementia and problems understanding the immediate environment. Symptoms are manifested by: Pacing, roaming, or wandering in and out of peers' rooms., Engaging in theme behavior, believes he/she is in another time & place with specific responsibilities (i.e., must get in car to go to work, church). Intervention: Implement preventative intervention strategies: Make rounds/room checks per facility protocol to minimize chance of unauthorized leave.
Apr 2023
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
Based on observation, interview, and record review, the facility failed to follow its abuse prevention policy to prevent an incident of staff to resident sexual assault. This affected 1 of 3 residents...
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Based on observation, interview, and record review, the facility failed to follow its abuse prevention policy to prevent an incident of staff to resident sexual assault. This affected 1 of 3 residents (R1) reviewed for sexual abuse. This failure resulted in V3 being found in bed on top of R1. Using the reasonable person concept, R1 would be scared and traumatized.
Findings include:
On 4/5/23 at 3:35pm, R1 was observed to be alert, confused, oriented to name only. This surveyor's conversation with R1 was nonsensical.
On 4/6/23 at 1:30pm, R1 was more alert. R1 was able to answer simple questions appropriately. R1 did not recall any staff coming into her room at night on 3/26/23.
On 4/5/23 at 2:08pm, V6 (Certified Nursing Assistant/CNA) stated that V6 was working 3/26/23 from 10:30pm-6:30am on R1's nursing unit. V6 stated that V6 rounded on all her assigned residents; R1 was asleep in R1's bed. V6 stated that V3 (Registered Nurse/RN) was working on another nursing unit during the evening shift, 3:00pm-11:30pm, on 3/26/23. V6 stated that V8 (Licensed Practical Nurse/LPN) had gone down to the first floor nursing unit. V6 stated that at 10:50pm, V6 observed V3 (RN) walking down hall towards V6, V3 checked to see if V8 (LPN) was at the nurses' station, and then proceeded to enter R1's room. V6 stated that it took a while, about 15 minutes, for V8 to return to the nursing unit. V6 stated that when V8 exited the elevator, located on this nursing unit, V8 sensed something was wrong with V6. V6 stated that V6 informed V8 that V3 was in R1's room. V6 stated that V8 looked in R1's room briefly then shut R1's door leaving V3 in room with R1. V6 stated that V8 informed V6 that V3 said he was giving R1 a pop. V6 stated that V3 only had a book in his hand when he came onto R1's nursing unit. V6 denied V3 had any pop with him. V6 stated that V8 took the elevator to the first floor nursing unit and came back onto unit with V7 (LPN/Nurse Supervisor). V6 stated that V7 and V8 were both standing at the nurses' station. V6 stated that V7 instructed V6 to go into R1's acting like she was making resident rounds. V6 stated that V6 pushed R1's door open and witnessed V3's feet were off the floor. V6 stated that V3's whole body was on top of R1's body, and V3 was holding R1's arm. V6 stated that V3 didn't look back to see who came in R1's room; V3 jumped out of R1's bed. V6 stated that V6 informed V7 and V8 what she witnessed. V3 exited R1's room at 11:30pm, made small talk with V7 and V8 and then left the nursing unit. V6 stated that V3, V7, and V8's conversation did not involve what happened or any allegation of abuse. V6 stated that R1 was still asleep. V6 stated that V7 stated he was contacting V2 (Director of Nursing/DON) as he picked up his personal cellular phone. V6 stated that V6 did not call V1 (Administrator/Abuse Coordinator) to report the allegation of abuse, because V6 did not have V1's phone number and V7 was notifying V2.
On 4/5/23 at 3:30pm, V7 (Nurse Supervisor) stated that V7 was working on first floor nursing unit for the 3:00pm-11:00pm and 11:00pm-7:30am shifts on 3/26/23. V7 stated that V7 was also the nurse supervisor on both shifts that day. V7 stated that between 11:00pm and 11:30pm, V8 (LPN) informed him that V3 (RN) was on V8's nursing unit. V7 stated that V8 did not say anything else. V7 stated that V6 (CNA) informed him V3 was in R1's room. V7 stated that V7 did not see V3 in R1's room; only saw V3 coming out of R1's room. V7 stated that V3 will walk into residents' rooms when not providing care for them during his shift. V7 stated that V7 spoke with V3 after V3 exited R1's room. V7 stated that V7 asked V3 How is everything, is everything okay? V7 stated that V3 informed him that R1 is calm now. V7 denied asking V3 who called V3 to inform him that R1 needed to be calmed down or what behaviors was R1 exhibiting that R1 needed to be calmed down. V7 denied asking V3 the length of time V3 was in R1's room or reason door was closed. V7 stated that R1 will stand in R1's doorway with bags waiting for a bus. V7 stated that V7 has only witnessed this on one occasion. V7 denied checking on R1 afterwards. V7 denied notifying V1 (Administrator) or V2 (DON) of an allegation of abuse on 3/26/23. Surveyor asked V7 why V7 was not concerned that V3 left the residents on his nursing unit unattended to go to R1's room late in the evening with R1's door closed and calming down a resident that was asleep. V7 replied, V3 is a nice guy and V3 was just being V3.
On 4/6/23 at 9:30am, V1 (Administrator) stated that V8 (LPN) was interviewed after the alleged incident on 3/26/23 involving R1 and V3 (RN). V1 stated that V8 informed V1 that V6 (CNA) informed V8 that V3 was in R1's room. V8 went into R1's room to check on R1, saw V3 by R1's bedside, and then V8 walked out of R1's room and closed the door. V1 stated that V1 reviewed the video tapes from 3/26/23. V1 stated that he saw V3 enter R1's room about 11:25pm. V1 stated that R1's door was partially closed. V1 stated that he saw V8 enter R1's room briefly and when V8 exited she closed the door. V1 stated that V3 left R1's room shortly afterwards. V1 stated that V3 spoke briefly to V7 and V8 and then left facility. V1 stated that he could not tell what they were saying on the video. This surveyor requested to view the video tapes from 3/26/23. V1 stated that he would have to speak with the corporate office regarding request.
This surveyor was not able to view the video recording during this survey.
On 4/6/23 at 9:17am, V8 (LPN) stated that V8 was informed by V6 (CNA) that during V6's rounds, V6 saw V3 (RN) going into R1's room. V8 stated that V8 was not present on the nursing unit at the time V3 came onto nursing unit and went into R1's room. V8 stated that the event occurred around 11:20pm on 3/26/23. V8 stated that V8 was downstairs and was getting off the elevator. V8 stated that V8 went to R1's room and stood in doorway. V8 stated that V8 observed R1 and V3 speaking to each other. V8 stated that V3 was standing by R1's bathroom door and R1's bed is next to bathroom. V8 denied closing R1's door while V3 was still in R1's room. V8 denied asking V3 reason for being in R1's room as V3 was assigned to another nursing unit. V8 stated that V7 (Nurse Supervisor) came onto R1's nursing unit and V8 informed V7 that V3 was in R1's room. V8 stated that R1 does not need to be calmed down. V8 stated that R1 is a wanderer and needs to be re-directed. V8 stated that V8 did not think anything of this event. V8 stated that V3 was always visiting with residents on other nursing units during V3's work hours. V8 denied previously observing V3 enter any resident's room or visiting residents that late in the evening. V8 was unable to articulate reason V8 was not concerned with V3 visiting R1 in R1's room at 11:20pm when R1 had been asleep.
V6's (CNA) written statement, dated 3/28/23, was reviewed. V6's statement correlates with V6's interview on 4/5/23.
V7's (Nurse Supervisor) written statement, dated 3/27/23, was reviewed. V7 noted at approximately 11:00pm, V7 went to R1's nursing unit. V7 was made aware V3 was in R1's room. V7 had conversation with V8. V7 then instructed V6 (CNA) to round on R1. V7 saw V3 exiting R1's room and asked V3 if everything was okay. V3 replied Yes. V7 and V3 talked for a couple of minutes and then V3 left to go back on his assigned nursing unit.
V8's (LPN) written statement, dated 3/27/23, was reviewed. Inconsistencies were noted in V8's written statement, interview, and video tapes. Video tape and staff interviews note V8 closed R1's door. There were also inconsistencies with V8's timeline of events.
V3's (RN) written statement, dated 3/29/23, was reviewed. V3's statement included One of the ideas of being a nurse is, in my opinion, to console residents. With R1, I have given her hugs and tried to make R1 feel loved. V3 also wrote, R1 is a woman with dementia, and I've learned to help keep R1 in the moment R1 is in. So I believe I only went to R1's room to console R1.
Attempts to interview V3 were unsuccessful during this survey.
Review of R1's medical record, dated 3/27/23 at 4:29pm, documents V13 (Director of Clinical Services) noted: V13 was informed earlier by human resources of an allegation that a staff member, V3, had been seen lying in bed with R1 last night. Stated both R1 and V3 were fully dressed and that R1 was asleep. Administrator immediately made aware. Went to R1's room where she was observed walking independently in room, confused as per her baseline, oriented to name only as per her baseline. Talking incoherently when questions asked. R1 did allow body check without difficulty and no obvious evidence of trauma, redness, drainage, signs of pain or discomfort or injury noted with focus on vaginal area.
Review of R1's BIMS (Brief Interview for Mental Status) score, dated 3/28/23, documents R1's score is 4 out of 15, indicating severely impaired cognition.
Review of V3's timecard, dated 3/26/23, documents V3 did not clock out until 11:45pm.
The facility's investigation into an allegation of sexual abuse involving V3 (RN) and R1 was reviewed. Summary of findings documented V3 left his assigned nursing unit and entered R1's room. Several minutes later, V8 (LPN) looks in R1's room and sees V3 standing by R1's bed. Several minutes later, V6 looked into R1's room and alleges seeing V3 in R1's bed on top of R1. When asked why V3 went in R1's room, V3 replied, To tell R1 good night. V3 stated V3 was in the room for 1-2 minutes and that R1 was asleep. When asked why did V3 stay in the room if R1 was asleep, V3 replied, I don't know.
Facility Abuse Prevention policy, undated, documents this facility affirms the right of our residents to be free from abuse. Abuse means any sexual assault inflicted upon a resident other than by accidental means. All instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish.
According to the Association for the treatment and Prevention of Sexual Abuse, sexual abuse is defined as any sexual or sexually motivated behavior that is done to someone without that person's consent. This includes a continuum of intrusive behaviors ranging from hands-off offending, such as voyeurism and verbal comments, up to and including sexual penetration with or without violence. The key is that there is no consent.
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 report an allegation of staff to resident sexual abuse to the State Surveying and Licensing Agency immediately but no more than two hours a...
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Based on interview and record review, the facility failed to report an allegation of staff to resident sexual abuse to the State Surveying and Licensing Agency immediately but no more than two hours after being made aware of the abuse allegation. This failure affected one (R1) out of three residents reviewed for abuse in a sample of 5.
Findings include:
On 4/5/23 at 2:08pm, V6 (Certified Nursing Assistant/CNA) stated that V6 was working 3/26/23 from 10:30pm-6:30am on R1's nursing unit. V6 stated that V6 rounded on all her assigned residents; R1 was asleep in R1's bed. V6 stated that at 11:30pm, V6 was instructed to go into R1's acting like she was making resident rounds. V6 stated that V6 pushed R1's door open and witnessed V3's (Registered Nurse/RN) feet were off the floor. V6 stated that V3's whole body was on top of R1's body, and V3 was holding R1's arm. V6 stated that V3 didn't look back to see who came in R1's room; V3 jumped out of R1's bed. V6 stated that V6 informed V7 (Licensed Practical Nurse/LPN/Nurse Supervisor) and V8 (LPN) what she witnessed. V3 exited R1's room at 11:30pm, made small talk with V7 and V8 and then left the nursing unit. V6 stated that V3, V7, and V8's conversation did not involve what happened or any allegation of abuse. V6 stated that R1 was still asleep. V6 stated that V7 stated he was contacting V2 (Director of Nursing/DON) as he picked up his personal cellular phone. V6 stated that V6 did not call V1 (Administrator/Abuse Coordinator) to report the allegation of abuse, because V6 did not have V1's phone number and V7 was notifying V2.
On 4/5/23 at 3:30pm, V7 (Nurse Supervisor) stated that V7 was working on first floor nursing unit for the 3:00pm-11:00pm and 11:00pm-7:30am shifts on 3/26/23. V7 stated that V7 was also the nurse supervisor on both shifts that day. V7 stated that between 11:00pm and 11:30pm, V8 (LPN) informed him that V3 was on V8's nursing unit. V7 stated that V6 (CNA) informed him that V3 was in R1's room. V7 stated that V7 did not see V3 in R1's room; V7 only saw V3 coming out of R1's room. V7 stated that V7 asked V3 How is everything, is everything okay? V7 stated that V3 informed him that R1 is calm now. V7 denied notifying V1 (Administrator) or V2 (DON) of an allegation of abuse on 3/26/23.
On 4/5/23 at 12:35pm, V1 (Administrator) stated that V7 (LPN) was the nurse supervisor on evening of 3/26/23. V1 stated that V1 was made aware the following day when V4 (Maintenance Director) asked V1 if V1 had heard about the incident the previous night. V1 stated that V1 was then informed by V5 (Human Resources Director). Neither V4 nor V5 could provide a time incident occurred. V1 stated that V6 (CNA) works 11:00pm to 7:00am shift and informed V1 the incident happened between 11:00pm and 11:30pm. V1 stated that V1 initiated an abuse investigation. V1 stated that V1 is aware that allegations of abuse must be reported within two hours after allegation made. V1 stated that V1 wanted to get the full story before reporting the abuse allegation to the State Surveying and Licensing Agency. V1 stated that V1 waited until two staff members came in at 3:00pm for their shift to interview them.
On 4/5/23 at 1:25pm, V4 (Maintenance Director) stated that at 3:00 or 4:00am, V4 was made aware of incident on 3/26/23. V4 stated his family member, V6 (CNA), called him and informed him of the event because V6 was very upset. V4 stated that V6 informed V4 that V6 reported the incident to V8 (LPN) and V2 (DON) was notified. V4 stated that V4 spoke with V1 (Administrator) around 8:30am or 9:00am. V4 stated that he does not think V1 was aware of the incident prior to V4's call.
On 4/5/23 at 1:40pm, V5 (Human Resources Director) stated that V5 was made aware of the incident after this facility's daily 10:00am meeting. V5 stated that V5 informed V1 immediately.
On 4/5/23 at 2:30pm, V2 (DON) stated that V2 was notified of the incident the next day, 3/27/23, at home about 10:00am. V2 denied being informed the night before of the incident by V7 (Nurse Supervisor).
On 4/6/23 at 9:17am, V8 (LPN) stated that V7 (Nurse Supervisor) came onto R1's nursing unit and V8 informed V7 that V3 was in R1's room. V8 stated that V8 did not think anything of this event. V8 stated that V3 was always visiting with residents on other nursing units during V3's work hours. V8 denied previously observing V3 enter any resident's room or visiting residents that late in the evening. V8 was unable to articulate reason V8 was not concerned with V3 visiting R1 in R1's room at 11:20pm when R1 had been asleep.
The facility's investigation into an allegation of sexual abuse involving V3 (RN) and R1 was reviewed. The facility notified the State Surveying and Licensing Agency of an allegation of staff to resident sexual abuse on 3/27/23 at 5:30pm.
Facility Abuse Prevention policy, undated, documents employees are required to report any allegation of potential abuse to the administrator immediately or to an immediate supervisor who must then immediately report it to the administrator or designee. The administrator or designee will initiate an investigation into the allegation as soon as possible. An initial report to the State licensing agency shall be made immediately after the resident has been assessed and the alleged perpetrator has been removed.
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 conduct a thorough abuse investigation into an allegation of staff to resident sexual abuse involving one (R1) out of three residents revie...
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Based on interview and record review, the facility failed to conduct a thorough abuse investigation into an allegation of staff to resident sexual abuse involving one (R1) out of three residents reviewed for abuse in a sample of 5.
Findings include:
On 4/5/23 at 2:08pm, V6 (Certified Nursing Assistant/CNA) stated that V6 was working 3/26/23 from 10:30pm-6:30am on R1's nursing unit. V6 stated that V6 rounded on all her assigned residents; R1 was asleep in R1's bed. V6 stated that V3 (Registered Nurse/RN) was working on another nursing unit during the evening shift, 3:00pm-11:30pm, on 3/26/23. V6 stated that V8 (Licensed Practical Nurse/LPN) had gone down to the first floor nursing unit. V6 stated that at 10:50pm, V6 observed V3 (RN) walking down hall towards V6, V3 checked to see if V8 (LPN) was at the nurses' station, and then proceeded to enter R1's room. V6 stated that it took a while, about 15 minutes, for V8 to return to the nursing unit. V6 stated that when V8 exited the elevator, located on this nursing unit, V8 sensed something was wrong with V6. V6 stated that V6 informed V8 that V3 was in R1's room. V6 stated that V8 looked in R1's room briefly then shut R1's door leaving V3 in room with R1. V6 stated that V8 informed V6 that V3 said he was giving R1 a pop. V6 stated that V3 only had a book in his hand when he came onto R1's nursing unit. V6 denied V3 had any pop with him. V6 stated that V8 took the elevator to the first floor nursing unit and came back onto unit with V7 (LPN/Nurse Supervisor). V6 stated that V7 and V8 were both standing at the nurses' station. V6 stated that V7 instructed V6 to go into R1's acting like she was making resident rounds. V6 stated that V6 pushed R1's door open and witnessed V3's feet were off the floor. V6 stated that V3's whole body was on top of R1's body, and V3 was holding R1's arm. V6 stated that V3 didn't look back to see who came in R1's room; V3 jumped out of R1's bed. V6 stated that V6 informed V7 and V8 what she witnessed. V3 exited R1's room at 11:30pm, made small talk with V7 and V8 and then left the nursing unit. V6 stated that V3, V7, and V8's conversation did not involve what happened or any allegation of abuse. V6 stated that R1 was still asleep. V6 stated that V7 stated he was contacting V2 (Director of Nursing/DON) as he picked up his personal cellular phone. V6 stated that V6 did not call V1 (Administrator/Abuse Coordinator) to report the allegation of abuse, because V6 did not have V1's phone number and V7 was notifying V2.
On 4/5/23 at 3:30pm, V7 (Nurse Supervisor) stated that V7 was working on first floor nursing unit for the 3:00pm-11:00pm and 11:00pm-7:30am shifts on 3/26/23. V7 stated that V7 was also the nurse supervisor on both shifts that day. V7 stated that between 11:00pm and 11:30pm, V8 (LPN) informed him that V3 (RN) was on V8's nursing unit. V7 stated that V8 did not say anything else. V7 stated that V6 (CNA) informed him V3 was in R1's room. V7 stated that V7 did not see V3 in R1's room; only saw V3 coming out of R1's room. V7 stated that V3 will walk into residents' rooms when not providing care for them during his shift. V7 stated that V7 spoke with V3 after V3 exited R1's room. V7 stated that V7 asked V3 How is everything, is everything okay? V7 stated that V3 informed him that R1 is calm now. V7 denied asking V3 who called V3 to inform him that R1 needed to be calmed down or what behaviors was R1 exhibiting that R1 needed to be calmed down. V7 denied asking V3 the length of time V3 was in R1's room or reason door was closed. V7 stated that R1 will stand in R1's doorway with bags waiting for a bus. V7 stated that V7 has only witnessed this on one occasion. V7 denied checking on R1 afterwards. V7 denied notifying V1 (Administrator) or V2 (DON) of an allegation of abuse on 3/26/23. Surveyor asked V7 why V7 was not concerned that V3 left the residents on his nursing unit unattended to go to R1's room late in the evening with R1's door closed and calming down a resident that was asleep. V7 replied, V3 is a nice guy and V3 was just being V3.
On 4/6/23 at 9:30am, V1 (Administrator) stated that V8 (LPN) was interviewed after the alleged incident on 3/26/23 involving R1 and V3 (RN). V1 stated that V8 informed V1 that V6 (CNA) informed V8 that V3 was in R1's room. V8 went into R1's room to check on R1, saw V3 by R1's bedside, and then V8 walked out of R1's room and closed the door. V1 stated that V1 reviewed the video tapes from 3/26/23. V1 stated that he saw V3 enter R1's room about 11:25pm. V1 stated that R1's door was partially closed. V1 stated that he saw V8 enter R1's room briefly and when V8 exited she closed the door. V1 stated that V3 left R1's room shortly afterwards. V1 stated that V3 spoke briefly to V7 and V8 and then left facility. V1 stated that he could not tell what they were saying on the video. This surveyor requested to view the video tapes from 3/26/23. V1 stated that he would have to speak with the corporate office regarding request.
This surveyor was not able to view the video recordings from 3/26/23 during this survey.
On 4/6/23 at 9:17am, V8 (LPN) stated that V8 was informed by V6 (CNA) that during V6's rounds, V6 saw V3 (RN) going into R1's room. V8 stated that V8 was not present on the nursing unit at the time V3 came onto nursing unit and went into R1's room. V8 stated that the event occurred around 11:20pm on 3/26/23. V8 stated that V8 was downstairs and was getting off the elevator. V8 stated that V8 went to R1's room and stood in doorway. V8 stated that V8 observed R1 and V3 speaking to each other. V8 stated that V3 was standing by R1's bathroom door and R1's bed is next to bathroom. V8 denied closing R1's door while V3 was still in R1's room. V8 denied asking V3 reason for being in R1's room as V3 was assigned to another nursing unit. V8 stated that V7 (Nurse Supervisor) came onto R1's nursing unit and V8 informed V7 that V3 was in R1's room. V8 stated that R1 does not need to be calmed down. V8 stated that R1 is a wanderer and needs to be re-directed. V8 stated that V8 did not think anything of this event. V8 stated that V3 was always visiting with residents on other nursing units during V3's work hours. V8 denied previously observing V3 enter any resident's room or visiting residents that late in the evening. V8 was unable to articulate reason V8 was not concerned with V3 visiting R1 in R1's room at 11:20pm when R1 had been asleep.
V6's (CNA) written statement, dated 3/28/23, was reviewed. V6's statement correlates with V6's interview on 4/5/23.
V7's (Nurse Supervisor) written statement, dated 3/27/23, was reviewed. V7 noted at approximately 11:00pm, V7 went to R1's nursing unit. V7 was made aware V3 was in R1's room. V7 had conversation with V8. V7 then instructed V6 (CNA) to round on R1. V7 saw V3 exiting R1's room and asked V3 if everything was okay. V3 replied Yes. V7 and V3 talked for a couple of minutes and then V3 left to go back on his assigned nursing unit.
V8's (LPN) written statement, dated 3/27/23, was reviewed. Inconsistencies were noted in V8's written statement, interview, and video tapes. Video tape and staff interviews note V8 closed R1's door. There were also inconsistencies with V8's timeline of events.
V3's (RN) written statement, dated 3/29/23, was reviewed. V3's statement included One of the ideas of being a nurse is, in my opinion, to console residents. With R1, I have given her hugs and tried to make R1 feel loved. V3 also wrote, R1 is a woman with dementia, and I've learned to help keep R1 in the moment R1 is in. So I believe I only went to R1's room to console R1.
Attempts to interview V3 were unsuccessful during this survey.
Review of R1's medical record, dated 3/27/23 at 4:29pm, documents V13 (Director of Clinical Services) noted: V13 was informed earlier by human resources of an allegation that a staff member, V3, had been seen lying in bed with R1 last night. Stated both R1 and V3 were fully dressed and that R1 was asleep. Administrator immediately made aware. Went to R1's room where she was observed walking independently in room, confused as per her baseline, oriented to name only as per her baseline. Talking incoherently when questions asked. R1 did allow body check without difficulty and no obvious evidence of trauma, redness, drainage, signs of pain or discomfort or injury noted with focus on vaginal area.
Review of R1's BIMS (Brief Interview for Mental Status) score, dated 3/28/23, documents R1's score is 4 out of 15, indicating severely impaired cognition.
Review of V3's timecard, dated 3/26/23, documents V3 did not clock out until 11:45pm.
The facility's investigation into an allegation of sexual abuse involving V3 (RN) and R1 was reviewed. Summary of findings documented V3 left his assigned nursing unit and entered R1's room. Several minutes later, V8 (LPN) looks in R1's room and sees V3 standing by R1's bed. Several minutes later, V6 looked into R1's room and alleges seeing V3 in R1's bed on top of R1. When asked why V3 went in R1's room, V3 replied, To tell R1 good night. V3 stated V3 was in the room for 1-2 minutes and that R1 was asleep. When asked why did V3 stay in the room if R1 was asleep, V3 replied, I don't know.
Facility Abuse Prevention policy, undated, documents this facility will orient and train employees on how to recognize and report occurrences of abuse, immediately protect residents involved in reports of possible abuse, implement systems to investigate all reports and allegations of mistreatment promptly and aggressively, and make the necessary changes to prevent future occurrences, and file accurate and timely investigative reports.
Feb 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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to ensure a resident received necessary care and services by not transporting her at the scheduled time for a Neurology appointmen...
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Based on observation, interview and record review the facility failed to ensure a resident received necessary care and services by not transporting her at the scheduled time for a Neurology appointment following a craniotomy.
This applies to 1 of 3 residents (R1) reviewed for care and services in a sample of 10.
The findings include:
On 2/17/23 at 10:00 AM R1 was positioned in bed on her right side. R1 was alert and pleasant, very soft spoken. Able to answer simple questions appropriately but mostly with one word answers. Offers no complaints. States she is hungry and when asked if she had breakfast she stated No.
On 2/17/23 at 10:05 AM V3 (Certified Nursing Assistant/CNA) stated that R1 had had breakfast and she ate everything on her plate. V3 also stated that R1 does not get up. V3 stated R1 goes out a lot and she assumes she goes to a lot of doctor's appointments.
On 2/17/ 23 at 12:00PM V12 (Licensed Practical Nurse/LPN) stated, When there is an appointment it goes on the dashboard and then the scheduler knows to make the arrangements for transportation. The one appointment (1/31/23) (R1) had was supposed to be at 1:15 PM but the person that put it in just typed 115 and it looked like 11:15AM so the transport was set for 10:15AM. The ambulance came and picked (R1) up and her daughter was supposed to go with her. I tried calling (R1's) daughter twice around 10:00 AM but she didn't answer. The ambulance took her to the appointment and the hospital said she was too early so they sent her back here. Her daughter came here and was so mad and was yelling at me and telling me that we canceled the appointment. She would not listen to me. When she finally realized that we had sent her (R1) over to the hospital and saw that I called her at 10:00 AM, she calmed down and I was able to explain to her what happened. The hospital then rescheduled her appointment, and I don't remember when it is for but it is a long way out.
On 2/17/23 at 12:15 PM V5 (Scheduler) stated, (Private Ambulance Company) has been here probably 4-5 times to transport her. She went out once for surgery then she had a radiology (neurology) appointment and the time got mixed up or something. At 1:00PM V5 stated, (R1) has an (neurology) appointment scheduled for 3/21/23 (almost 2 months after the initially scheduled, missed appointment) - I have not made transportation arrangements for that yet.
On 2/17/23 at 1:30 PM V2 (Director of Nursing) stated, She (R1) missed the appointment on 1/31 for the neurologist - that was our fault.
On 2/17/23 V5 provided a printed list of R1's appointments that she had been transported to. This list shows, 1/31/23 Post-op appointment at (Local Hospital) 10:15AM pick-up for 11:15AM appointment.
R1's Progress Notes dated 1/5/23 state, Received resident from (Local) hospital around 10:30 AM via stretcher accompanied by two paramedics of (Local) ambulance in stable condition. Resident's hospital discharge diagnosis is status post right cerebellar tumor removal surgery .
R1's Electronic Medical Record does not show any progress/nurse's notes documenting R1's condition after 2/2/23. There is also no documentation of R1's missed appointment on 1/31/23.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain a resident's mobility and ability to sit up in...
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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 a resident's mobility and ability to sit up in a wheelchair by not assisting her to get out of bed.
This applies to 1 of 3 residents (R1) reviewed for mobility in a sample of 10.
The findings include:
On 2/17/23 at 10:00 AM R1 was positioned in bed on her right side. R1 was alert and pleasant, very soft spoken. Able to answer simple questions appropriately but mostly with one word answers. Offers no complaints. Asked R1 if she ever gets out of bed and R1 softly stated, No.
On 2/17/23 at 10:05 AM V3 (Certified Nursing Assistant/CNA) stated, (R1) does not get up; (R1) is not on the get-up list. R1 has a wheelchair but she needs a geri chair.
On 2/17/23 at 10:30 AM V4 (Restorative Nurse/Licensed Practical Nurse/LPN) stated, Every person in the building gets restorative - they are all on 2 programs from admission. Most programs go 3-4 days a week and some are 6 or 7. V4 was asked why R1 does not get out of bed. V4 stated she would find out. At 11:00 AM V4 stated, The get up list is for the night shift to get people up - everybody should be getting up every day.
On 2/17/23 at 12:00PM V12 (LPN) stated, We tried putting her in the wheelchair before, but she couldn't sit up and we felt she might slide out of the chair so she really doesn't get out of bed.
On 2/17/23 at 1:00PM V11 (Physical Therapy/Director of Therapy) stated, (R1) is able to get out of bed with a hoyer transfer and sit in a wheelchair. She could sit in the wheelchair when we discharged her. I was not aware that she was not able to do it anymore.
R1's Physician's Order Sheet dated 2/17/23 shows that R1 was admitted to the facility on [DATE] with diagnoses including Displaced Intertrochanter Fracture of the Left Femur, Malignant neoplasm of the Breast and Specified Disorders of the Brain.
R1's Physical Therapy Discharge summary dated [DATE] states, Patient will improve ability to safely and efficiently transfer to and from a bed to a chair or wheelchair with partial/moderate assistance in the presence of high sensory demand situations, with ability to right self to achieve/maintain balance . This assessment shows that on 1/6/23 and 1/24/23 R1 was dependent on staff for this task and on 2/2/23 (upon discharge from therapy) R1 required substantial/maximal assistance. This same form states, Discharge Recommendations: Establish restorative program and implement staff education to maintain CLOF (Current Level of Function), PT (Physical Therapy) recommend patient be referred back if change in status.
This assessment also states, Range of Motion Program Established/Trained: Restorative to assist patient as she performs BLE (Bilateral Lower Extremity) strengthening exercises. Prognosis to maintain CLOF - Excellent with participation in RNP (Restorative Nursing Program) .
R1's Restorative Nursing assessment dated [DATE] shows that R1 is on two restorative programs, AROM and or AAROM (Active Range of Motion/Active Assisted Range of Motion) and Bed Mobility. This assessment also shows that R1 uses a wheelchair for mobility.
R1's Minimum Data Set assessment dated [DATE] shows that R1 requires extensive assist of 2 staff for transfers and uses a wheelchair for mobility.
Jan 2023
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to ensure the urinary catheter bag was covered for 1 of 7 resident (R38) reviewed for dignity in a sample of 26.
Findings include:...
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Based on observation, interview and record review the facility failed to ensure the urinary catheter bag was covered for 1 of 7 resident (R38) reviewed for dignity in a sample of 26.
Findings include:
On 1/10/2023 at 10:30am R38 was observed in bed with his urinary catheter bag exposed to roommates.
On 1/10/2023 at 10:33am V14 (Licensed Practical Nurse/LPN) said the urinary catheter bag should always be covered.
On 1/12/2023 at 2:00pm V2 (Director of Nursing/DON) said all urinary catheter bags should be covered for dignity.
An Order Summary Report dated on 1/11/2023 indicated that R38 has a diagnosis of Benign prostatic hyperplasia with lower urinary tract symptoms, presence of urogenital implant, neuromuscular dysfunction of bladder, unspecified. An active order dated 8/30/2022 for an indwelling suprapubic.
Facility Dignity policy (1/15) documents: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality.
Responsibility: All Staff. 11. Urinary catheter bags shall be covered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide privacy during an injection administration for one (R57) of one resident observed for privacy in a sample of 26.
Findi...
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Based on observation, interview and record review, the facility failed to provide privacy during an injection administration for one (R57) of one resident observed for privacy in a sample of 26.
Findings include:
On 01/10/2023 at 1:18PM, V11 (Licensed Practical Nurse/LPN) was observed administering a subcutaneous injection to R57 without pulling the privacy curtains or closing the door prior to administration. R57 was in the room with her roommate R11 during this time.
On 01/10/2023 at 1:29PM, V11 (LPN) stated that he should have pulled the privacy curtain prior to giving the subcutaneous injection to R57.
On 01/11/2023 at 11:15AM, V2 (Director of Nursing) stated that nurses are expected to provide privacy by ensuring curtains are pulled or doors are closed prior to giving any injections to a resident.
R57's Order Summary Report indicated admission date of 11/02/2021. R57's diagnoses include but are not limited to heart failure, dementia, essential hypertension, and acute embolism and thrombosis of deep veins of right upper extremity.
Facility Medication Administration: Injection - Subcutaneous policy documents: Level of Responsibility: Registered Nurse (RN)/LPN; Date: 2/14; Procedure: 6. Provide privacy
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide recommended communication board to one (R36) o...
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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 recommended communication board to one (R36) of one resident reviewed for communication in a sample of 26.
Findings include:
Review of R36's face sheet documents a [AGE] year old male admitted to the facility on [DATE] with diagnoses that include Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, acquired absence of right leg above the knee, Dysphagia, Aphasia following cerebral infarction, Retinal detachment, Right eye, and Major Depressive disorder.
On 01/10/23 at 11:37 AM surveyor observed resident who does not talk or have a communication board or a way to communicate. Surveyor observed that the resident shakes head yes and no in response to questions.
On 1/11/2023 at 12:24 PM V9 (Certified Nursing Assistant/CNA) and V8 (Nurse) at nurses' station. V9 stated, It is difficult to communicate with R36. He is independent with eating and dressing but needs help showering. V9 stated it is hard to figure out what R36 is trying to say. V9 stated R36 does not talk. V9 stated, You have to go in deep to figure out what he is saying. V9 stated it is hard for R36 to communicate but he uses hand gestures. V8 (Nurse) stated R36 is independent with activity, answers yes or no questions and roommate helps with communication.
Review of R36's care plan documents a care plan created on 1/10/2023 for alteration in ability to communicate.
On 01/11/23 at 12:30 PM R36 was observed in his room sitting in a wheelchair. Surveyor asked R36 if it is hard to communicate with staff. R36 nodded his head yes. Surveyor asked if he has ever been offered a communication board or any other tool to communicate. R36 shook his head from side to side indicating no. Surveyor asked R36 if he would like a communication board or another way to communicate with staff. R36 got bright eyed, made loud noise similar to yes and shook his head up and down in the affirmative.
On 1/11/23 at 12:35 PM V9 stated she has never seen R36 with a communication tool.
On 1/11/23 at 12:45 PM V10 (Restorative Aide) stated R36 does not say words. V10 stated R36 gets mad and frustrated because they don't know what he wants. V10 stated she has never seen R36 with a communication tool. V10 stated speech therapy has communication boards.
On 1/12/2023 at 10:40 AM V5 (Social Services) stated R36 communicates with gestures and pointing, and R36 should have a communication board to point at. V5 stated that social services or therapy gives residents the communication board. V5 stated that the previous social worker should have given R36 a communication board. V5 stated she started in April of 2022 and has never seen R36 with a communication board.
On 01/12/23 at 12:20 PM V13 (Director of Rehab/Physical Therapy) stated that R36 was getting speech therapy around October or September of 2021. V13 stated therapy recommended a communication board for R36, and R36 had one and it got lost twice. The therapist would draw pictures for R36 and gave him a board. V13 stated they tried to get him to do speech therapy again, but R36 would scream no at them, probably because he was frustrated, and he couldn't communicate.
Facility's Residents Rights policy documents the following: 1. Federal and state laws guarantee certain basic right to all residents of this facility. These rights include the resident's right to: b. The right to have written and verbal information provided in a manner tailored to the resident's language and ability to understand. C. for the resident that has vision, hearing, speech or cognitive impairments the facility will communicate in a manner that meets the resident's needs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record reviewed, the facility failed to obtain wound care orders and develop and implement a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record reviewed, the facility failed to obtain wound care orders and develop and implement a wound care plan for 1 resident (R256) of 2 residents reviewed for wound care in a sample of 26. This failure resulted in R256 missing wound care treatments. Facility also failed to assess and treat 1 resident's (R39) foot wounds based on physician's orders.
Findings include:
1. R256's face sheet documents a [AGE] year old female admitted on [DATE] with diagnoses that include Malignant neoplasm of unspecified site of left female breast and type 2 Diabetes Mellitus.
On 1/10/23 at 12:00 PM R256 stated her wound dressings are not being changed regularly. R256 stated she is concerned her wounds will get infected. Surveyor observed wound to left breast without a dressing and 2 round open wounds with yellow necrotic tissue the size of a quarter. V3 (Nurse) stated that R256 is on hospice and the wound care nurse came today to change her wound dressings.
On 1/10/2023 at 3:01 PM Surveyor went to the room with V3 and R256 stated that no one has changed her dressing for days. R256 stated the nurse doesn't change the dressing like she should. R256 stated the nurse changes her dressing once a week. Surveyor asked permission for nurse and surveyor to see wound again. V3 stated this is the first time she is seeing the resident's wound. After the nurse saw that there was no dressing on the wounds, V3 (Nurse) stated she is not sure if R256's wound care was done. Resident skin was observed red and inflamed below incision. Two open areas about the size of a quarter were observed with what looks like yellow slough on it. There was one other smaller opening on the mid-chest without slough.
On 1/11/2023 at 12:42 PM R256 stated no one put a dressing on her wound today either and showed surveyor her wound that was still not covered and in the same condition.
Record review documents that R256 did not have any orders for wound care, and the Treatment Administration Record (TAR) was blank.
On 1/12/2023 MDS (Minimum Data Set) Coordinator submitted a TAR for R256 with treatments filled in.
On 01/13/23 at 10:30 AM Surveyor reviewed TAR. The created date was 1/10/2023 and the ordered date was 12/29/2022.
On 01/13/23 10:35 AM V2 (Director of Nursing/DON) stated that the created date in the physician orders is the date that the orders were put in. The medical record was reviewed with DON. DON stated she doesn't know why the ordered date and created date in the system are different.
On 1/13/23 at 9:40 AM V2 stated wound care nurse comes in on Mondays.
On 01/12/23 11:37 AM V16 (Hospice Nurse Manager) stated hospice saw resident last on 1/10/23. V16 stated R256 refused dressing change because she was eating, and DON said wound care nurse would come in at 3:00pm to change dressing. Wound care orders dated 12/23/2022 document that staff is to use saline, vaseline gauze, and a barrier dressing every 3 days and as needed. V16 stated that R256's wound note dated 1/4/23 describes left under arm, open malignant wound with light yellow slough. R256 has 2 Malignant wounds of 1 cmx 2 cm x 2 cm wounds on breast with light yellow slough. V17 (Hospice Director) stated they will step up visits and reassess wound care orders.
On 1/12/23 at 2:55 PM V2 (DON) stated she expects nurses to get orders for wound care on admission and put it in the computer and follow the orders. Nurses should be following doctor's orders. Nurses at the facility should be following hospice orders.
2. On 1/10/23 at 11:32 AM R39 was observed undressed sitting on the side of the bed with the right foot wrapped in a dirty ace wrap with yellow/brown drainage on top, on the right side of foot and the heel of the resident.
On 1/11/23 at 12:19 PM R39 was observed sitting in the doorway of his room with brown stains on his gown and the same dirty ace wrap on the right foot with dried yellow/brown drainage on top, heel, and right side of foot.
On 1/11/23 at 4:30 PM R39's TAR documented his dressing had been changed by V8.
On 1/11/23 at 4:40 PM surveyor observed R39 at nursing station in a wheelchair. Right foot ace was still dirty in all the same places: top, heel and right side of dressing. R39's big toe was now sticking out of dressing and some of the ace wrap had come apart and kerlix wrap was showing around the toes. R39's 3rd digit had some dried blood. R39's left foot had a non-skid sock on it and had bright red blood saturated around where the 2nd and 3rd toes would be. V8 stated he is the nurse for R39. Surveyor asked V8 who is the person that signed off on R39's dressing change today. V8 stated he did not know who signed off on the dressing change. V8 stated he did not sign off on the TAR that the dressing was done. V8 stated that he saw another nurse going around with the wound cart today, and maybe she signed off on it. V8 stated he is responsible for changing R39's dressing today. V8 stated he was passing meds and after he would change dressing. Surveyor asked if DON or supervisor could be called so that R39's wound can be viewed.
On 1/11/23 at 4:58 PM V2 (DON) arrived and was asked to see R39's wound. V2 wheeled R39 to room and proceeded to change dressing while R39 was in the chair. Surveyor asked what should be done to dressings that are visibly soiled. V2 stated if dressings are soiled or dirty the nurse is supposed to change the dressing. Surveyor asked what V2 thought of how the dressing looked and V2 stated, it looks horrible. V2 removed dressing over the heel and the wound looked dry and was crusty in layers on top with drainage next to the skin. R39 has an amputated 2nd toe with stiches intact. R39's Right ankle was observed to be very dry with skin flaking off. R39's left sock was removed. Blood was on sock and on 2nd toe with small round abrasions and bloody.
On 1/12/2023 at 2:55 PM V2 stated she expects nurses at the facility to be following doctor's orders.
R39's skin care plan documents: Skin will be checked during routine care on a daily basis and during the weekly/Biweekly bath or shower schedule.
The facility's Pressure injury and Skin condition assessment policy (undated) documents the following: 22. Physician ordered treatments shall be initialed by the staff on the treatment Administration Record AFTER each administration.
The facility's Pressure injury and Skin condition assessment policy undated documents the following: 12. A separate Wound Assessment form for each identified injury/ulcer area will be completed and will include: site, size, stage of pressure ulcer, odor, drainage, description and date and initials of individual performing assessment.
21. The Resident's care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches and goals for care.
22. Physician ordered treatments shall be initialed by the staff on the treatment Administration Record AFTER each administration.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to ensure that fall prevention interventions were in place for 1 of 7 residents (R18) reviewed for falls in a sample of 26.
Findin...
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Based on observation, interview and record review the facility failed to ensure that fall prevention interventions were in place for 1 of 7 residents (R18) reviewed for falls in a sample of 26.
Findings include:
On 1/10/2023 at 10:55am R18's room door was observed closed, the fall mat was observed folded and pushed away from the side of the bed, and the bed was in a high position.
On 1/10/2023 at 11:00am V15 (Certified Nursing Assistant/CNA) observed with the surveyor the bed in a high position and the fall mat folded away from the bed. V15 stated R18 is a fall risk. V15 lowered the bed's position, put the fall mat next to the bed and opened the door after leaving.
On 1/10/2023 at 11:05am V14 (Licensed Practical Nurse/LPN) stated R18 is a fall risk and fall interventions should always be in place.
On 1/12/2023 at 2:30pm V2 (Director of Nursing/DON) stated R18 is a fall risk and should always have all fall interventions in place.
An Order Summary Report dated 1/11/2023 indicates R18 has diagnoses including contracted left ankle, syncope and collapse, scoliosis unspecified, and age-related osteoporosis without current pathological fracture. R18 has an active order dated 8/9/2019 for low bed with mat at bedside. Care plan intervention dated 10/12/2020 for includes bed in natural/low position when not providing care. A need to be evaluated for and supplied a floor mat next to bed dated 5/10/2018.
Facility Fall intervention Program policy documents: It is the policy of this facility to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. The program will include measures which determines the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Responsibility: Director of Nurses, Licensed Nurses, Therapists, and all facility staff. Program Contents: 1. Methods to identify risk factors; 2. Methods to identify residents at risk; 5. Changes in interventions that were unsuccessful; a. fall prevention surveillance activities; b. Safety interventions will be implemented for each resident identified at risk using a standard protocol; 3. The bed will be maintained in a position appropriate for resident transfers; 7. Residents will be observed approximately every two hours to ensure the resident is safely positioned in the bed or a chair and provide care as assigned in accordance with the plan of care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate pain management for one (R100) out of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate pain management for one (R100) out of six residents reviewed for pain management in a sample of 26.
Findings include:
On 1/10/2023 at 10:45 AM, R100 was observed by the surveyor. R100 stated, I am in a lot pain. R100 stated that his pain was in his legs and rated the pain at 9 on a pain scale between 0 - 10 with 0 = no pain, and 10 = highest pain.
On 1/10/2023 at 10:50 AM, V3 (Registered Nurse/RN) stated, I just gave R100 acetaminophen 500 mg 2 tablets.
On 1/12/2023 at 10:35 AM, surveyor observed R100 with V12 (Minimum Data Set Coordinator/Restorative RN). R100 stated, I am in a lot a pain. R100 stated his pain was in his legs and rated the pain at 10.
On 1/12/2023 at 10:36 AM, V3 (RN) stated that R100's pain should be controlled.
On 1/12/2023 at 10:40 AM, V19 (RN) stated, I just medicated R100 with acetaminophen 500 mg 2 tablets.
On 1/12/2023 at 2:50 PM, V2 (Director of Nursing) stated that the resident's pain should be controlled. V2 stated that nurses should notify the doctors if a resident's pain is not controlled with the current pain regimen.
Review of R100's medication administration sheet for Thursday 1/12/2023 documents a '9.'
On 1/13/2023 at 10:35 AM, V2 stated that '9' on the medication administration record means other, and it means that the medication was not given.
R100 is a [AGE] year old with diagnoses not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.
Review of R100's order sheet documents acetaminophen tablet 500 mg, give 2 tablets by mouth 3 times a day; Duloxetine oral for anxiety nerve pain; Gabapentin oral tablet 600 mg, give 1 tab by mouth 3 times a day; Lidocaine external ointment 5%: apply to left medial ankle topically four times a day for pain.
Facility Residents' Rights policy documents: Employees shall offer all residents privacy and treat all residents with respect, kindness, and dignity. To provide an environment of care that supports a positive self-image. Policy Interpretation and Implementation: Z. To transportation to and from physician, dental appointments and other activities related to care. An attendant will provide if needed. aa. The right to have pain managed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure that the refrigerator temperature is monitored and maintained for one (R76) of one resident observed for food storage i...
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Based on observation, interview and record review, the facility failed to ensure that the refrigerator temperature is monitored and maintained for one (R76) of one resident observed for food storage in a sample of 26.
Findings include:
On 01/10/2023 at 10:34AM, R76's refrigerator was observed without any thermometer and temperature log.
On 01/11/2023 at 11:10AM, R76's refrigerator was again observed without any thermometer and temperature log.
On 01/11/2023 at 11:18AM, R76's refrigerator was observed with V2 (Director of Nursing) and confirmed that the fridge has no thermometer and temperature log. V2 stated that there should be a thermometer and temperature log, and certified nursing assistants and nurses should check the temperature daily.
R76's Order Summary Report dated 01/11/2023 indicated admission date of 10/28/2022 and diagnoses including but not limited to adult failure to thrive, anemia, essential (primary) hypertension and severe protein-calorie malnutrition.
Facility Food Storage - Outside Sources policy (Date: 1/19) documents . Foods or beverages brought in from the outside will be monitored by nursing staff for spoilage, contamination and safety. Procedure: 6. All refrigerators in use in the facility have an internal thermometer to monitor temperature. All refrigerators have their internal temps recorded daily. Any refrigerators found to have an internal temperature that is outside of the accepted safe parameters of temperature will be immediately addressed by maintenance and will be taken out of service if the internal temperature cannot be corrected within a reasonable time frame to maintain food safety. Any affected food/beverages will be discarded.
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** On 1/10/2023 at 04:15 PM, surveyor observed R45 with V7 (Certified Nursing Assistant/CNA) sitting in his wheelchair in his room....
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 1/10/2023 at 04:15 PM, surveyor observed R45 with V7 (Certified Nursing Assistant/CNA) sitting in his wheelchair in his room. R45 was observed with long dirty nails. R45 said that he wants his nails trimmed.
On 1/10/2023 at 04:18 PM, V7 (CNA) said that R45's nails should be trimmed.
On 1/12/2023 at 10:35 AM, surveyor observed R45 with V12 (Minimum Data Set/Restorative Registered Nurse/RN) in his room. R45 still had long dirty nails, and R45 said that he wants his nails to be trimmed.
On 1/12/2023 at 10:37 AM, V12 said that the restorative CNA is supposed to trim the resident's nails.
On 1/12/2023 at 10:39 AM, V10 (Restorative CNA) said that R45 should have his nails trimmed.
On 1/12/2023 at 02:50 PM, V2 (Director of Nursing) said that the CNA should trim the residents' nails and if the residents' refuse, CNA should notify the nurse or DON.
R45 is a [AGE] year old admitted with diagnoses not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side.
Review of R45's care plan initiated on 10/28/2018 documents: I have a Self Care Deficit and requires assistance with ADLs to maintain the highest possible level of functioning AEB (As Evidenced By) the following limitations and potential contributing factors: H/O CVA with Hemiplegia or Hemiparesis, Requires Limited to Substantial/Maximal Assist with most ADLs.
Based on observation, interview, and record review the facility failed to provide nail care to four residents (R20, R45, R60, and R71) of 14 reviewed for nail care in the sample of 26.
Findings include:
On 1/10/23 at 10:45 AM R20 and R71 were observed in their room. Their fingernails were grown past the ends of their fingers and had black dirt under their nails. R20 said, We asked them to cut our nails, but they never did.
On 1/10/23 at 11:55 AM R60 was observed to have long fingernails that were grown past the ends of his fingers. R60 said that he would like to have his nails cut.
On 1/11/23 R20's, R71 and R60's fingernails were unchanged.
The Care Plans for R20, R60, and R71indicate I am at risk for a Self Care Deficit and require assistance with ADLs (Activities of Daily Living) to maintain the highest level of functioning.
Facility Activities of Daily Living documents: Interventions: Grooming-Maintaining personal hygiene, including planning the task and gathering supplies, combing and/or styling hair, face, and hands, brushing teeth, shaving, or applying makeup, oral hygiene, self-manicure (safety awareness with nail care), and/or application of deodorant or powder.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
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 apply splint to residents with limited range of motion...
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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 apply splint to residents with limited range of motion for five (R28, R45, R49, R60, R75) of five residents reviewed for range of motion in a sample of 26.
Findings include:
1. On 01/10/2023 at 10:28AM, R75 was observed with left hand contracture without any splints or brace in place.
On 01/10/2023 at 10:28AM, R75 stated that she applies the splint herself on Mondays, Wednesdays, and Fridays for a couple of hours.
On 01/12/2023 at 10:00AM, V12 (Minimum Data Set/Restorative Registered Nurse) said that R75's splint should be applied daily for the duration of the day as ordered by the physician.
On 01/12/2023 at 2:50PM, V2 (Director of Nursing) stated that if a resident has an order for splint or brace, it should be applied as ordered.
R75's Order Summary Report dated 01/11/2023 indicated admission date of 12/10/2020, diagnoses including but not limited to cerebral infarction and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and an order for splint to left hand, on in AM (morning) and to be removed at HS (bedtime) two times a day related to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side with an order date of 03/25/2021.
Facility Restorative Nursing Policy & Procedure (Date: 9/14) documents: Program Description and Rationale Includes, but is not limited to .splint or brace assistance .
Procedure: To determine a restorative need or a resident during their stay: - If a resident is determined to be appropriate for a restorative program, no physician's order is needed, except for splints .
Facility Splints/Braces/Devices policy (Date: 11/17) documents: A physician's order is necessary to apply a splint/brace .The order should include the application location and time to be worn .
5. On 1/10/2023 at 04:15 PM, surveyor observed R45 with V7 (CNA) sitting in his wheelchair in his room. R45 was observed with a right hand contracture with no splint applied.
On 1/10/2023 at 04:18 PM, V7 stated R45 should have split applied to his right hand.
On 1/11/2023 at 09:35 AM, V10 (Restorative CNA) on 2nd floor stated that she was off on 1/10/2023, and that the Restorative CNA was supposed to apply the splint on her assigned residents when V10 is off.
On 1/11/2023 at 01:20 PM, V6 (Restorative CNA) on the 1st floor said that she did not apply the splint because she arrived at work at 8:30 AM and left the facility about 11:15 AM on an escort with a resident.
On 01/12/2023 at 02:50 PM, V2 (Director of Nursing) stated splints should be applied on the residents as ordered.
R45 is a [AGE] year old admitted with diagnoses not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side.
Review of R45's order initiated on 12/07/22022 documents: Lt (Left) Resting Hand Splint 2 hours a day in AM; Rt (Right) Upper Extremity Splint 2 hours a day in AM.
Review of R45's care plan initiated 6/08/2021 documents: R45 requires splint to RT (right) hand related to: Contracture, Hemiplegia, and Limitation in ROM.
4. On 1/10/2023 at 10:45am R49 was observed in bed with right hand and elbow contracted.
On 1/10/2023 at 10:47am V14 (Licensed Practical Nurse/LPN) stated R49 should have a splint on now during the day.
On 1/12/2022 at 2:00pm V2 (Director of Nursing/DON) stated, I expect all splints to be applied as ordered.
On 1/13/2023 R49's Order Summary Report dated 1/11/2023 documented diagnoses of Hemiplegia and Hemiparesis following cerebral infarction affecting the right dominant side. Active order dated 11/29/2022 documents a splint to right elbow, on in am, every 12 hours and remove per schedule. R49 has a care plan dated 11/11/2020 for splint/brace restorative program.
2. On 1/10/23 at 10:55 AM R28 was observed in her room. R28 did not have a splint or hand roll in her left hand. R28 has diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. The Physician Order Sheet indicates Lt (left) resting hand splint 2 hours a day in AM (morning). The Care Plan indicates that R28 needs assistance with hand splint.
3. On 1/10/23 at 11:55 AM R60 was observed in his room. R60 did not have a splint on his right arm. R60 said that he hasn't had a splint in a long time. R60 stated he doesn't remember when he had it last. R60 has diagnoses of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side. The Physician Order Sheet indicates splint to right hand on in the am (morning) after ADL (Activities of Daily Living) care provided and to be removed at HS (hour of sleep).
On 1/11/23 12:50-1:00 PM R28 was not wearing a splint or hand roll; R60 was not wearing a splint.
On 1/11/23 at 1:05 PM V21 (Certified Nursing Assistant/CNA) stated, I do not put the splints on. Restorative puts the splints on.
On 1/11/23 at 1:25 PM V6 (Restorative Aide) stated, I came in at 8:05 AM. I passed trays and cleaned a couple of people. Then I was sent out as an escort to an appointment. Normally we put splints on Monday, Wednesday, and Friday and as needed.
On 1/12/23 at 10:01 AM V12 (Registered Nurse, Minimum Data Set Coordinator) stated, The restorative aides apply the splint. If they are not here, I should be putting it on. I'm sorry I didn't know the aide went out on an appointment.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation and interview, the facility failed to post nurse staffing that includes facility name, date, census, and the total number and actual hours worked per shift for licensed and unlice...
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Based on observation and interview, the facility failed to post nurse staffing that includes facility name, date, census, and the total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care in an accessible area for visitors and residents to review. This failure effects all residents in the facility.
Findings Include:
On 1/10/2023 at 09:30 am, surveyor observed that the nurse staffing was not posted and easily accessible to the residents.
On 1/10/2023 at 1:11 PM, V2 (Director of Nursing) said that nurse staffing is only in the binder by the front nurses station and not posted anywhere else.
On/13/2023 at 03:30 PM, V1 (Administrator) said, So we are required to post it now.
Facility was unable to provide a policy on posting nurse staffing in an accessible area for both visitors and residents.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 39% turnover. Below Illinois's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 5 harm violation(s), $125,361 in fines, Payment denial on record. Review inspection reports carefully.
- • 57 deficiencies on record, including 5 serious (caused harm) violations. Ask about corrective actions taken.
- • $125,361 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Oak Park Oasis's CMS Rating?
CMS assigns OAK PARK OASIS an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Illinois, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Oak Park Oasis Staffed?
CMS rates OAK PARK OASIS's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 39%, compared to the Illinois average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Oak Park Oasis?
State health inspectors documented 57 deficiencies at OAK PARK OASIS during 2023 to 2025. These included: 5 that caused actual resident harm, 51 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Oak Park Oasis?
OAK PARK OASIS is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by ICARE CONSULTING SERVICES, a chain that manages multiple nursing homes. With 204 certified beds and approximately 116 residents (about 57% occupancy), it is a large facility located in OAK PARK, Illinois.
How Does Oak Park Oasis Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, OAK PARK OASIS's overall rating (2 stars) is below the state average of 2.5, staff turnover (39%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Oak Park Oasis?
Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the substantiated abuse finding on record and the below-average staffing rating.
Is Oak Park Oasis Safe?
Based on CMS inspection data, OAK PARK OASIS has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Illinois. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Oak Park Oasis Stick Around?
OAK PARK OASIS has a staff turnover rate of 39%, which is about average for Illinois nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Oak Park Oasis Ever Fined?
OAK PARK OASIS has been fined $125,361 across 4 penalty actions. This is 3.7x the Illinois average of $34,332. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Oak Park Oasis on Any Federal Watch List?
OAK PARK OASIS is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.