SHARON HEALTH CARE PINES
For profit - Corporation
116 Beds
Independent
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
0/100
#630 of 665 in IL
Photo by Timothy Powers
Photo by Timothy Stephen Powers
Photo by John Woodard
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Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Sharon Health Care Pines has received a Trust Grade of F, indicating significant concerns and a poor overall quality of care. Ranking #630 out of 665 facilities in Illinois places it in the bottom half, and it is the lowest-rated facility in Peoria County. The facility is currently improving, as issues decreased from 12 in 2024 to 7 in 2025, but it still faces serious challenges, including a concerning $235,100 in fines, which is higher than 87% of Illinois facilities. Staffing is below average with a rating of 2 out of 5 stars, but turnover is relatively low at 22%, suggesting some stability among staff members. There have been troubling incidents, such as a staff member taunting a resident, resulting in emotional distress, and failures to protect residents from physical abuse, which led to serious injuries requiring hospital treatment. Overall, while there are some positive aspects, families should be cautious due to the significant issues reported.
- Trust Score
- F
- In Illinois
- #630/665
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ✓ Good
- 22% annual turnover. Excellent stability, 26 points below Illinois's 48% average. Staff who stay learn residents' needs.
- Penalties ⚠ Watch
- $235,100 in fines. Higher than 99% of Illinois facilities. Major compliance failures.
- Skilled Nurses ⚠ Watch
- Each resident gets only 22 minutes of Registered Nurse (RN) attention daily — below average for Illinois. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 33 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 6%
Review needed
12 → 7 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 12 issues
2025: 7 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Low Staff Turnover (22%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (22%)
26 points below Illinois average of 48%
Facility shows strength in quality measures, staff retention, fire safety.
The Bad
1-Star Overall Rating
Below Illinois average (2.5)
Significant quality concerns identified by CMS
Federal Fines: $235,100
Well above median ($33,413)
Significant penalties indicating serious issues
The Ugly 33 deficiencies on record
1 life-threatening 4 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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to protect a resident from physical abuse for one of four residents (R2) reviewed for abuse in a sample of 11. Findings include: The Abuse Pre...
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Based on interview and record review, the facility failed to protect a resident from physical abuse for one of four residents (R2) reviewed for abuse in a sample of 11. Findings include: The Abuse Prevention Program Facility Policy, revised 12/18/24, documents that the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This form also documents that abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Instances of abuse of all residents, irrespective of a mental or physical condition, cause physical harm, pain, or mental anguish. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behaviors through corporal punishment. R2's Progress Notes, dated 8/6/25, documents that R2 was involved in a physical altercation with a peer. Peer (R10) pushed resident (R2). (R2) fell to the floor, landing on his left side. R2's Brief Interview for Mental Status, dated 6/3/25 documents a score of 3, indicating that R2 is cognitively impaired. R2's current care plan documents that R2 displays poor planning, poor insight, judgment, and decision-making ability, poor stress and emotion management, and poor impulse control. This form also documents that R2 has reactionary responses to situations. R2 reacts impulsively and without thought. R10's Progress Notes, dated 8/6/25, documents that R10 was involved in a physical altercation with a peer (R2). (R10) pushed (R2), causing him to fall and land on his left side. R10's Brief Interview for Mental Status, dated 6/9/25, documents a score of 15, indicating that R10 is alert and oriented to person, place, and time. R10's current care plan documents that R10 has issues with regulating emotions and outbursts. R10 can become verbally and physically aggressive. R10 will initiate the conflict but will take responsibility for her own behavior. R10's goal is not to harm self or others by the next review date and to seek out staff when agitated. On 8/22/25 at 11:30am, R10 stated that R2 was attempting to cut in front of her in line, so she pushed him away, and he fell. R10 became agitated and started to yell out and curse during the interview. On 8/22/25 at 10:30am, V1, Administrator, verified that V18, Registered Nurse, did not notify him of the incident, so there were no interventions implemented. V1 also verified that an investigation was not started until today when notified of the incident.
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 resident-to-resident physical abuse to the State Agency for one (R2) of four residents reviewed for abuse in a sample of 11. Finding...
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Based on interview and record review, the facility failed to report resident-to-resident physical abuse to the State Agency for one (R2) of four residents reviewed for abuse in a sample of 11. Findings include: The facility's Abuse Prevention Program Facility Policy, dated 8/12/25, documents that employees are required to report any incident allegation or suspicion of potential abuse, neglect, exploitation, mistreatment misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act as administrator in the administrator's absence. This form also documents that when an allegation of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property has occurred, the resident's representative and the Department of Public Health's regional office shall be informed by telephone or fax. R2's Progress Notes, dated 8/6/25, documents that R2 was involved in a physical altercation with a peer. Peer (R10) pushed resident (R2). (R2) fell to the floor, landing on his left side. R10's Progress Notes, dated 8/6/25, documents that R10 was involved in a physical altercation with a peer (R2). (R10) pushed (R2), causing him to fall and land on his left side. On 8/22/25 at 10:30am, V1, Administrator, verified that he was not notified of this incident, so no investigation or reporting was done.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to investigate resident-to-resident physical abuse for one of four residents (R2) reviewed for abuse in a sample of 11. Findings include: The ...
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Based on interview and record review, the facility failed to investigate resident-to-resident physical abuse for one of four residents (R2) reviewed for abuse in a sample of 11. Findings include: The facility's Abuse Prevention Program Facility Policy, dated 8/12/25, documents that upon learning of the report of an allegation of abuse, the administrator or designee shall initiate an incident investigation. R2's Progress Notes, dated 8/6/25, documents that R2 was involved in a physical altercation with a peer. Peer (R10) pushed resident (R2). (R2) fell to the floor, landing on his left side. R10's Progress Notes, dated 8/6/25, documents that R10 was involved in a physical altercation with a peer (R2). (R10) pushed (R2), causing him to fall and land on his left side. On 8/22/25 at 10:30am, V1, Administrator, verified that he was not notified of this incident, so no investigation or reporting was done. V1 stated that any allegation or incident to supposed to be reported to him or V9 as soon as it happens. V1 also stated that an investigation is initiated immediately, even on weekends or after hours.
Jul 2025
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
Based on record review and interview, the facility failed to protect a resident from physical abuse for two of four (R1 and R3) residents reviewed for abuse in a sample of four. This failure resulted ...
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Based on record review and interview, the facility failed to protect a resident from physical abuse for two of four (R1 and R3) residents reviewed for abuse in a sample of four. This failure resulted in R1 sustaining a complex fracture of the left hip requiring surgical intervention. Findings include:The facility's Abuse Prevention Program, reviewed 7/21/25, documents that 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. This form also documents that willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention.R1's electronic medical record documents the following diagnoses: Schizophrenia, Major Depression, Dementia, EPS, HTN, Thrombocytopenia, GERD, Hypercholesterolemia, BPH, Dysfunction of the bladder, chronic kidney disease stage four. R1's current care plan documents that R1 is delusional daily. He also experiences auditory hallucinations to which he responds. Often, he becomes agitated at the voices and will yell and curse.R1's Brief Interview for Mental Status, dated 5/5/24, documents a score of 14, indicating the R1 is alert and oriented to person, place, and time.R1's Progress Notes, dated 7/22/25, document that resident (R1) was involved in an altercation with a peer (R2) while outside on the smoking patio. (R1) was lying on the patio, stating his hip hurt. (R1) was lying on his left side near his wheelchair on the pavement of the smoking patio. (R1) stated that his right hip hurt; however, he was lying on his left side. (R1) stated that he was unable to stand up due to the pain. Orders were received to send (R1) to the emergency room for an evaluation.R1's emergency room Notes, dated 7/22/25, document that R1 presented after a ground-level fall when one of the residents of his nursing home pushed him out of his wheelchair and he fell to the ground on his left side, leading to a complex left hip fracture. The Patient states that he does not want to return to the SNF (skilled nursing facility) because of the other residents. R1's Radiology Report, dated 7/22/25, documents a complex fracture of the left hip including both intertrochanteric and suspected basicervical components. Femoral foreshortening and coxa vera deformity at the left hip. R2's electronic medical record documents the following diagnoses: Encephalopathy, Diverticulosis, Mood Disorder, Paraphilia, Seizures, Heart Disease, Chronic Embolism and Thrombosis, Toxic effect of alcohol abuse, and Obsessive Compulsive Disorder.R2's current care plan documents that R2 has a behavior problem: (R2 has a history of socially inappropriate behaviors. (R2) can be verbally and physically aggressive, intrusive, and property destruction. (R2) displays a delusional thought process as to his limitations and effects on self, others, and surroundings, as well as the safety of self and others.R2's Progress Notes, dated 7/22/25, document that R2 had an incident with a peer (R1) this morning. (R2) stated that the peer (R1) was Saying stuff that pissed me off and that's all I'm going to say.On 7/25/25 at 10:45am, R4 stated that R1 and R2 were bickering back and forth on the patio. R4 stated that all of a sudden, R2 got up and dumped R1 out of the wheelchair onto the concrete.On 7/25/25 at 11:00am, R3 stated that R1 was sitting in his wheelchair with his back to the wall, confused and yelling out. R3 also stated that R2 was sitting with his back to R1, yelling back at R1. R3 stated that R2 got tired of listening to R1, so R2 got up, pushed R1's wheelchair in front of the patio door, and tipped him out of the wheelchair. R3 stated that he got between R1 and R2. R3 stated that he got punched in the face during the altercation. R3 verified that R1 was yelling in pain and could not get up.On 7/25/25 at 1:00pm, V3, Administrative Quality Assurance/Grievance/Abuse Coordinator, stated that the majority of the resident population has a traumatic brain injury, so they are impulsive. V3 stated that this incident was an impulse, not abuse.
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 notify local law enforcement of a resident-to-resident physical altercation resulting in an injury, for one of two residents (R1) reviewed ...
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Based on interview and record review, the facility failed to notify local law enforcement of a resident-to-resident physical altercation resulting in an injury, for one of two residents (R1) reviewed for reporting abuse in a sample of four. The facility's Abuse Prevention Program Facility Procedures, reviewed 7/21/25, documents that the facility shall contact local law enforcement authorities (i.e., non-emergency police number or 911) in the following situations: Physical abuse involving physical injury inflicted on a resident by another resident, except in situations where the behavior is associated with dementia or developmental disability.R1's Progress Notes, dated 7/22/25, document that resident (R1) was involved in an altercation with a peer (R2) while outside on the smoking patio. (R1) was lying on the patio, stating his hip hurt. (R1) was lying on his left side near his wheelchair on the pavement of the smoking patio. (R1) stated that his right hip hurt; however, he was lying on his left side. (R1) stated that he was unable to stand up due to the pain. Orders were received to send (R1) to the emergency room for an evaluation. R1's Radiology Report, dated 7/22/25, documents a complex fracture of the left hip including both intertrochanteric and suspected basicervical components. Femoral foreshortening and coxa vera deformity at the left hip.R2's Progress Notes, dated 7/22/25, documents that R2 had an incident with a peer (R1) this morning. (R2) stated that the peer (R1) was Saying stuff that pissed me off and that's all I'm going to say. On 7/25/25 at 1:00pm, V3, Administrative Quality Assurance/Grievance/Abuse Coordinator stated that the local police were not notified of the incident between R1 and R2.
May 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
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 investigate an incident when residents were exposed to a toxic chemi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to investigate an incident when residents were exposed to a toxic chemical and failed to follow their policy regarding Safety/Supervision related to Incidents/Accidents. The facility failed to perform and document an individual assessment after a resident was known to have been exposed to a toxic chemical for one of three residents (R2) reviewed for quality of care and treatment in the sample of three.
Findings include:
The facility's undated Incidents/Accidents Policy and Procedure documents an accident is an unexpected, unintended event that can cause a resident bodily injury. An Incident is any occurrence that could result in physical harm or great emotional upset to a resident. Each incident or accident must be detailed in the medical record of the involved resident. This includes drug reactions or any happening or experience which may be traumatic or inflict bodily injury to a resident. This policy further documents a nurse will assess the resident's condition and if an injury or suspected injury results, will notify the physician and follow the specific treatment plan. The nurse will document the event in the residents' individual clinical record and an incident/accident report will be written and given to Director of Nursing upon completion.
R2's current Minimum Data Set Assessment documents R2 is cognitively intact.
On 5/20/25 at 9:45 AM, R2 stated (on 4/14/25), R2 was in the dining room eating supper. I remember my eyes began burning and I was coughing, but I didn't know what was going on. R2 stated residents were being evacuated out of the facility because a can of [NAME] went off in the dining room. R2 denied being assessed by a nurse after the incident.
As of 5/20/25, R2's medical record did not contain documentation of the 4/14/25 incident and did not contain documentation that a nursing assessment was completed on R2 after.
On 5/20/25 at 2:51 PM, V10 (Registered Nurse/RN) stated V10 had a small can of [NAME] on a keychain. V10 stated V10 was standing in the dining room and the can of [NAME] accidently went off. V10 further stated there were some residents in the dining room who started coughing, so V11 (RN) called 911. V10 stated the staff took the residents outside for fresh air until the fire truck and ambulance came. V10 stated the police were going to call in a biohazard team to investigate until V10 told the police V10's can of [NAME] accidently went off. V10 confirmed V10 was R2's nurse on 4/14/25 and verified V10 did not complete any resident assessments.
On 5/19/25 at 1:39 PM, V8 (Registered Nurse/RN) stated on 4/14/25, V11 (RN) called V8 and stated, something is going on with the residents, they are coughing and nauseous. V11 began moving the residents outside and called 911. V8 stated the police came to the facility and later determined a can of [NAME] had gone off. V8 stated residents were present in the dining room at the time but could not recall who. V8 verified V8 did not complete an Incident Report or any resident assessments after the 4/14/25 incident.
On 5/20/25 at 9:30 AM, V4 (Licensed Practical Nurse) stated V4 saw an orange substance in the air and staff members started coughing. V4 stated the staff didn't know immediately what happened. V4 stated residents were eating supper in the dining room at the time. V11 (RN) called 911 and the residents in the dining room were evacuated to the outside. V4 verified V4 did not complete an Incident Report or document any resident assessments after the 4/14/25 incident.
On 5/20/25 at 11:36 AM, V11 (RN) stated on 4/14/25, V11 was in the hallway passing medications. V11 stated a staff member began yelling to not go to the dining room. V11 went to look and see what was happening. V11 started coughing and stated many residents were coughing. V11 yelled to evacuate because V11 had no idea what was happening. V11 called 911 and V1 (Administrator) immediately. V11 stated V11 filled out an Incident Report but believes it was destroyed. V11 stated the incident was not investigated.
On 5/19/25 at 2:01 PM, V2 (Director of Nursing) stated V10 (RN) was given the can of the [NAME] from an unknown nurse. On 4/14/25, V10 accidently dropped the can of [NAME] on the dining room floor, causing it to go off. V2 stated the staff evacuated residents outside. V2 stated the police and fire department came and ultimately gave all clear for everyone to come back inside. V2 stated nursing assessments should have been completed and documented on the residents in the dining room at the time, but they were not.
On 5/20/25 at 9:15 AM, V3 (Quality Assurance) stated V3 was unable to find an Investigation, Witness Statements, or an Incident Report for the can of [NAME] going off in the dining room of the facility on 4/14/25. V3 further stated V3 is unable to find any assessments or documentation completed on the residents who were exposed in dining room. V3 stated V1 (Administrator) is currently out of the country. V3 stated V3 called V1 to find information on the 4/14/25 incident and V1 stated V1 came to the facility at the time of the incident on 4/14/25, but that V1 did not complete an investigation.
As of 5/20/25, the facility was unable to state what residents were in the dining room at the time of the 4/14/25 incident and the facility was unable to provide documentation that an Investigation or Incident Report had been completed.
Apr 2025
1 deficiency
1 IJ (1 facility-wide)
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
Based on interview and record review the facility failed to protect a resident (R1) from mental and verbal abuse and failed to protect residents from further potential abuse. This failure resulted in ...
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Based on interview and record review the facility failed to protect a resident (R1) from mental and verbal abuse and failed to protect residents from further potential abuse. This failure resulted in residents experiencing emotional distress and persistent fear of V3 (Certified Nursing Assistant). This failure has the potential to affect all 102 residents who reside in the facility.
This failure resulted in an Immediate Jeopardy.
The Immediate Jeopardy began on 3/19/25 at approximately 5:00 pm, when V3 (Certified Nursing Assistant/CNA) responded inappropriately to R1. V3 taunted R1 by sticking her tongue out at R1; calling R1's significant other ugly; and asking if R1 was going to fight V3. R1 experienced emotional distress and fear of V3. V3's termination was rescinded and V3 returned to work in the facility, leaving residents fearful.
While the immediacy was removed on 4/24/25, the facility remains out of compliance at Severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring.
Findings include:
The Facility Abuse Prevention Program Facility Policy, reviewed 12/18/24, documents: the Facility affirms the right to our Residents to be free from abuse and neglect; prohibits mistreatment, neglect or abuse of its Residents, and has attempted to establish a Resident sensitive and secure environment; purpose of this policy is to assure that the Facility is doing all this within its control to prevent occurrences of mistreatment, neglect or abuse of our Residents; by orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of mistreatment, neglect and abuse; establishing an environment that promotes Resident sensitivity, security and prevention of mistreatment; identifying occurrences and patterns of potential mistreatment promptly and aggressively and making the necessary changes to prevent future occurrences; committed to protecting our Residents from Abuse by anyone including, but not limited to Facility staff, other Residents and staff from other Agencies, or any other individuals; this Facility will not knowingly employ individuals who have been convicted of abusing, neglecting or mistreating individuals; the following are based on Federal and State Regulations and interpretive guidelines; verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to Residents, within their hearing distance, regardless of their age, ability to comprehend, or disability; example of verbal abuse include, but no limited to, threats of harm or saying things to frighten a Resident; and mistreatment means inappropriate treatment.
The Facility Resident Rights for People in Long-Term Care Facilities, revised 3/2011, documents: Your Facility must provide services to keep your physical and mental health and sense of satisfaction and you must not be abused by anyone, physically, verbally or mentally.
The Facility Diffusing Behaviors Policy, undated, documents: do not raise voice; do not argue, scold or threaten; do not treat patients like they are your children, do not be condescending; do not talk about patients in his/her presence; and do not take it personally and get upset; do remain calm; do intervene early; do not try to reason with someone who is unreasonable; and do take time to listen.
The facility's current Room Roster documents 102 residents currently reside in the facility.
The Facility's local Report to the State Agency, dated 3/25/25, documents an Abuse incident on 3/19/25 between R1 and V3 (CNA). The Final Report documents an event that occurred in the Main Dining Room. R1 and V5 (Registered Nurse/RN) were discussing R1's request for a wheelchair to assist temporarily with mobility issues, when V3 (CNA) interrupted the conversation to comment that (R1) was not having any kind of difficulties with mobility earlier when your new girlfriend was visiting, then R1 told V3 to shut up, and called V3 a bitch. R1 stated, I am not talking to you (V3). V3 proceeded to tell R1 your girlfriend is ugly. R1 got upset and V3 remained argumentative and confrontational, raising both arms into fists, saying What are you going to do about it? Fight me?
The Facility's local Report to the State Agency, dated 3/25/25, documents an interview with R1. R1 stated that while R1 was at the Nurse's Station, R1 was talking to V5 (Registered Nurse) and V3 (CNA) stated to me by the way, your girlfriend is ugly. So R1 stated, no she is not. R1 also stated, I also could have said more to her, but I do not recall. Then R1 stated that (V3) started to stick her tongue out and stated, I am going to take away your visitor pass and V3 was making threatening gestures.
R1's Information Report, dated 3/21/25 at 1:45 pm, documents that V3 (CNA) told R1, Your girlfriend is ugly. R1 stated, Look, she is not ugly, she is beautiful. V3 then stuck her tongue out at (R1) three times.
V1's (Administrator/ADM) Information Report, undated, documents that it was difficult getting V3 to write a statement regarding the incident with R1. V1 documents that V3 was very confrontational and aggressive. The Information Report also documents that V3 was fixated on wanting to know what was being done to (R1) personally and how (R1) was going to be punished for cussing at (V3). V1 attempted to explain to V3 that the Facility does not punish Residents and that the Resident population in the Facility has mental illnesses or brain injuries and consequently may have behaviors. V3 remained argumentative with minimal insight.
V3's (CNA) Information Report, dated 3/19/25, documents that R5 was helping R1 walk, and V3 stated that V3 jokingly said to R5, Why are you holding her arm? She can walk. R1 told V3 to shut up. V3 then stated to R1, I was not even talking to you, why are you even talking to me? R1 told V3 because I can. V3 stated, that is when I said 'girl' by the way, yo (your) girlfriend ugly.
V5's (Registered Nurse/RN) Informational Report, undated, documents that R1 was talking to V5 about obtaining a wheelchair. V5 stated (V3) 'chimed' in and responded to R1. R1 responded to V3 stating you are not my nurse or CNA so shut up. V5 then proceeded to ask R1 to calm down and go back to R1's hall. Then V3 proceeded to call (R1's) girlfriend ugly. R1 then called V3 a b*tch. V3 then responded to R1 fight me, fight me. V5 states that the staff grabbed (R1) and (V3) and proceeded to tell them to let her (R1) go. R1 went down the hallway. V5 stated that V3 was inappropriate and R1 told V5 that R1 felt disrespected and that R1 is afraid of (V3) when (V3) works down (R1's) hallway.
V6's (Registered Nurse/RN) Informational Report, undated, documents that V3's response to R1 was over-the-top and inappropriate. R1 wanted to sit in a wheelchair because R1's foot hurt. V3 stated, you was not hurting earlier. R1 told V3 to shut the f*** up b****, I was not talking to you. V6 states that R1 was tired of being interrupted by (V3). V3 then told R1 well, your girlfriend is ugly. V6 stated that V3 would not stop and kept saying what (are) you gonna do about it? and like (V3) was trying to get (R1) to fight. V6 stated that V3's behavior was inappropriate and unprofessional.
V7's (Registered Nurse/RN) Informational Report, undated, documents that V3 is confrontational, demeaning to the Residents and just talks down to them. V7 also stated that V3 acts like she does not provoke them (Residents) on purpose.
V8's (Licensed Practical Nurse/LPN) Informational Report, undated, documents that V8 reports that V3 is borderline rude and not appropriate with Residents. V8 also reports that V3 is often confrontational with residents and talks down to them.
V10's (Certified Nursing Assistant/CNA) Informational Report, undated, documents that V3 was grossly inappropriate and unprofessional. V10 also states that V3 presents as confrontational and argumentative with Residents.
The Facility Nursing 24 Hour Staffing Reports (dated 4/1/25, 4/2/25, 4/3/25, 4/5/25, 4/6/25, 4/9/25, 4/10/25, 4/14/25, 4/15/25, 4/17/25, 4/19/25 and 4/20/25) document V3 (CNA) working Second Shift on the B Hall, C Hall, E Hall and Kitchen Window.
V3's (CNA) Timecard Report, dated 3/20/25 through 4/22/25, documents that V3 worked a total of 119.65 hours (3/27/25, 3/28/25, 3/31/25, 4/1/25, /4/2/25, 4/3/25, 4/5/25, 4/6/25, 4/8/25, 4/9/25, 4/10/25, 4/14/25, 4/15/25, 4/17/25, 4/19/25 and 4/20/25).
V3's (CNA) Employee Report, dated 3/19/25, documents V3's misconduct. The Employee Report documents that V3 was grossly inappropriate with a Resident offering unprofessional personal observations on a Resident's relationship. The Employee Report also documents that V3 presented as confrontational and argumentative with a Resident and that further issues will result in termination, as behavior will not be tolerated.
V3's (CNA) Employee Report, dated 3/20/25, documents a suspension pending an investigation of possible verbal abuse and inappropriate dialogue with a Resident.
V1's (ADM) letter to V11 (Union President), dated 3/28/25, documents that the Facility found that V3 (CNA) was found to have displayed actions and/or conduct that is not in keeping with the Facility Employee Guidelines and/or State and Federal Regulations. The letter documents that V3 was grossly inappropriate with a Resident (R1) during an unprovoked verbal interaction and that V3's demeanor was confrontational, threatening and unprofessional. Furthermore, the letter also documents that V3's exchange was borderline blatant emotional and verbal abuse. V1 advised V11 that, after much deliberation, V3's termination was modified to a suspension.
On 4/19/25 at 10:30 am, R1 stated, (V3) was not joking with me, at all that day. (V3) says she is joking, but I never feel like she is joking. (V3) is always derogatory, insulting and threatening towards me and knows how to push my buttons. She knows that things bother me and continues to just poke and poke at me. My girlfriend had come down from Chicago to visit me earlier that day and I was walking fine at that time. Then around dinner time, (R5) was helping me walk to talk to V5 (Registered Nurse) at the Nurse's Station, and I was asking for a wheelchair because my legs had started hurting. I was not even talking to (V3) and (V3) just walked up and interrupted my conversation with (V5). I told (V3) to shut up, I was not even talking to (V3), and it was none of (V3's) business. Then (V3) told (V5) not to help me walk and that (V3) thought I did not need a wheelchair or any help because (V3) saw me walking earlier in the day with my girlfriend and (V3) told (V5) that I was walking just fine then. Then I got mad at (V3) and called (V3) a b*tch. (V3) put her fists up at me and asked me if I wanted to fight her and (V3) called my girlfriend ugly. I told (V3) that my girlfriend is not ugly, she is beautiful. Then (V3) stuck her tongue out at me and she did that like three times. (V3) causes so many problems for everyone here, I am scared of her. I walked back to my room to avoid her, but I was scared walking back down the hallway by myself, like (V3) was going to come after me. It is not right for (V3) to work in a place like this. (V3) is still rude to me and I feel like (V3) keeps bullying me and antagonizes me on purpose. (V3) constantly demeans me and harasses me, even when I am minding my own business. I have seen (V3) do this bullying and intimidation to so many people that are here and (V3) even does it to the employees. We all see it and it is very uncomfortable. I am scared to even be around her, it makes me nervous, so a lot of times I just have to go to a different area to be away from her. I think people are scared to say anything, I know that I am scared.
On 4/19/25 at 7:59 am, R2 stated, I have had run-ins with (V3). (V3) has an attitude with me. We all think she is mean and are scared of her. (V3) is aggressive and hateful. I think (V3) does and says things on purpose to hurt people. (V3) is just not a nice person to anyone. (V3) works second shift, and usually works the kitchen window with serving food. When we are in the Dining Room, (V3) says mean things to all the residents.
On 4/19/25 at 8:13 am, R3 stated, Oh, (V3) is not known as a nice person. What's sad is, I think (V3) is a good CNA. (V3) acts like (V3) is kidding with me, but I know that (V3) really is not. I never say anything because I really do not want to deal with it, so I just keep it to myself. I am just glad that (V3) really does not need to help me much, because it makes me nervous and uncomfortable when (V3) is around.
On 4/19/25 at 10:45 am, R4 (Resident Council President) stated, (V3) is known to talk to people very harsh and people complain about it, but not everyone tells on (V3) because they are scared of (V3).
On 4/19/25 at 10:45 am, V5 (Registered Nurse) stated, I was the nurse on duty the night that (R1) and (V3) got into it. (R1) walked up to me at the Nurses' Station in the Dining Room area and (R5) was holding on to (R1's) arm to help because (R1) wanted a wheelchair. (V3) just walked up to the Nurses' Station and interrupted our conversation and told me that (R1) did not even need a wheelchair. (R1) told (V3) to shut up and leave (R1) alone and that it was not any of (V3's) business. (R1) cursed at (V3) and (V3) put up (V3's) fists towards (R1) and asked (R1) to fight. (V3) also stuck out (V3's) tongue a couple times at (R1). (V3) is very rude and evil to people. I have been scared to walk out to my car by myself at night after Second Shift because of her. I am not gonna lie, (V3) is getting by with everything and (V3) tells everyone that (V3) is part of the Union, and they cannot do anything to (V3).
On 4/22/25 at 8:17 am, V9 (Ombudsman) stated, I am aware of verbal situations with (V3/CNA). (V3) is a Second Shift CNA and let me tell you, (V3) is something else. I have heard from Residents that (V3) is very rude and they have even voiced concerns to me. It does also happen during the mealtimes too, when other Residents are around. (V3) has a nasty attitude, not only with Residents but also to staff, and the Residents are witnessing that. I do know that (V3) got suspended for talking to a Resident (R1) in an abusive manner. Even though these residents here in this Facility have a lot of psychological diagnoses and brain injuries, some are still very well with it. The way that (V3) talks to the residents, is still a form of abuse and (V3) should not be talking to them in that manner, and we know that is not right.
On 4/19/25 at 1:01 pm, V3 (CNA) stated, (R5) was helping (R1) and was holding (R1's) hand; they were up at the Nurses' Station. I heard (R1) ask (V5/RN) for a wheelchair because (R1) said that (R1's) legs were weak, and I said 'that is funny you were just walking fine earlier today when your girlfriend was here. I did not think that she needed a wheelchair and said, you do not even need a wheelchair. (R1) then said to me 'b*tch shut up.' (R1) was cursing at me and telling me to shut up. So, I told (R1) that (R1's) girlfriend was ugly and just stuck my tongue out at (R1) to mess with (R1), because we are all like family and we all just joke around. I was kidding with (R1) that we were gonna fight. I do not even help or talk to half of them Residents anyway because I am on the other side of the building. I just stay in the break room and mind my own business. The only time I see the other residents is when I am in the Dining Room working the serving window. I think they have me mistaken with someone else, I never am rude to them. I ended up getting fired but then I grieved that and ended up getting suspended instead for that incident with (R1) about the wheelchair and had to do some additional training.
On 4/22/25 at 11:58 am, V11 (Certified Nursing Assistant Union President) stated, I am aware of the incident with a Resident in the Facility (R1) and (V3). (V3) was discharged and then employment was re-instated. I cannot really get into it much because there is a Union Grievance, and it is going to Arbitration. We do expect our Union employees to follow the Federal and State Regulations for Nursing Homes for Abuse. I do not condone Verbal or Mental Abuse.
On 4/22/25 at 9:10 am, V4 (Abuse Coordinator/Assistant Administrator/Quality Assurance) stated, I am the Abuse Coordinator. We became aware of (V3's) interaction with (R1) and completed a full investigation. (V3) is part of a Union, and we terminated (V3) over the incident, but then the Union became involved, so we had to just suspend (V3) and bring (V3) back to work, under the guidance of our attorney and the Union. We became aware of (V3's) demeanor and behaviors with the Residents and staff, but we had no choice but to bring (V3) back. We have put safety measures in place to monitor (V3's) behaviors because (V3) is very intimidating and insulting.
On 4/19/25 at 8:52 am, V1 (Administrator) stated, I reported and investigated the allegation between (R1) and (V3). I actually terminated (V3) over it but (V3) is a Union employee and the Union made me reinstate (V3) after a five-day suspension. We had to backpay (V3) also. They contributed it to cultural interpretation according to the Union. Basically, staff reported to me that (V3) interrupted a conversation between (R1) and (V5) and was antagonizing (R1), told (R1) that (R1's) girlfriend is ugly and raised (V3's) fists at (R1) and wanting to fight, apparently (V3) states it was a joke. I told (V3) we do not joke like that. I had multiple staff and Residents that witness (V3's) aggressiveness and inappropriate language with the Residents. There are staff that are actually scared of (V3) too. After this incident, we started reviewing the camera footage and have a monitor on (V3's) shift. When I was investigating the incident, (V3) was more upset that (R1) cursed at (V3) than anything and wanted me to reprimand (R1). I tried to explain to (V3) that our Residents have mental issues, and we need to learn to de-escalate and not provoke behaviors, and to be patient with them.
On 4/24/25 at 1:00 pm, V4 (Abuse Coordinator/Assistant Administrator/Quality Assurance) stated, (V1/ADM) is in firing (V3) right now and I can hear (V3) yelling through the door.
V1 (Administrator/ADM) was notified of the Immediate Jeopardy on 4/24/25 at 8:50 am.
On 4/23/25, the surveyor confirmed through interview, observation, and record review, the facility took the following actions to remove the Immediate Jeopardy:
1. V3 completed Abuse training and Behavior De-escalation training on 4/9/25 and was monitored continuously on Second Shift.
2. V3 was immediately terminated on 4/24/25 by V1 (ADM) and V2 (Director of Nursing/DON).
3. On 4/22/25, V1 (ADM), V2 (DON) and V4 (Abuse Coordinator) completed an entire whole house audit to evaluate Facility Residents at risk for potential abuse and no evidence was noted.
4. On 4/22/25, an all-Staff in-service by V1 (ADM) and V4 (Abuse Coordinator) was conducted on Resident Abuse and Reporting. A tracking sheet was expected to be completed by close of business on 4/23/25.
5. A sign was placed by the Facility timeclock to ensure employees complete the Abuse training prior to work on floor and direct care with Residents.
6. A checklist was developed to ensure one-hundred percent compliance with the mandatory training for employees/staff that are on vacation and as needed basis (PRN).
7. A current employee list was audited and over seen on 4/22/25, by V1 (ADM), V2 (DON) and V3 (Abuse Coordinator) to evaluate potential staff requiring one-on-one review and said employees to have additional training on Abuse and Mandatory Behavioral De-escalation courses.
8. An Abuse training module through the Facility computer program was initiated in April 2025 with trainings on Abuse prevention, sensitivity and respect to be scheduled and implemented for part of the progressive disciplinary process.
9. V1 (ADM), V4 (Abuse Coordinator) and Department Heads to monitor for compliance.
Completion Date: 4/24/25.
Dec 2024
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
Based on observation, interview, and record review, the facility failed to ensure a resident (R2) was free from physical abuse by another resident (R1) for two of four residents reviewed for abuse in ...
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Based on observation, interview, and record review, the facility failed to ensure a resident (R2) was free from physical abuse by another resident (R1) for two of four residents reviewed for abuse in a sample of four. This failure resulted in R2 receiving sutures at the hospital for a facial laceration.
Findings include:
The facility's undated Abuse Prevention Program Facility Policy documents Policy: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, 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 policy continues to state, This facility is committed to protecting our residents from abuse by anyone including, but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. This policy also states Definitions: The following definitions are based on federal and state laws, regulations and interpretive guidelines. Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.
R1's current Face sheet documents diagnoses including, but not limited to Psychotic disorder, Mood disorder, Unspecified Dementia, Anxiety, and Traumatic Brain Injury/TBI.
R1's Minimum Data Set/MDS Assessment, dated 11/11/24, documents R1 has fluctuations of inattention and disorganized thinking and is severely cognitively impaired.
R1's Care plan includes but is not limited to (R1) can become verbally and physically aggressive due to TBI (Traumatic Brain Injury) diagnosis. (R1) is delusional and feels he can care for himself. (R1) displays poor planning, poor insight judgment and decision-making ability, poor stress and emotion management, poor impulse control, and poor coping skills.
R1's Progress note, dated 11-15-24, documents Resident was in altercation with peer (R2). This RN (Registered Nurse) did not witness altercation. Per report, resident swung right hand striking (R2) in the face.
On 12/6/24, at 11:55am, R2 sat in the TV (television) area with a suture line noted to his left cheek. R2 did not recall being hit or having any altercation with another resident (R1).
R2's current Face sheet documents diagnoses including, but not limited to Unspecified Dementia, Anxiety, and Schizoaffective disorder, depressive type.
R2's Minimum Data Set/MDS Assessment, dated 9/30/24, documents R2 has fluctuations of inattention and disorganized thinking and is moderately cognitively impaired.
R2's Care plan includes but is not limited to (R2) displays (episodes) of verbal aggression, physical aggression, and agitation related to being over stimulation and to misinterpretation of others and situations. He displays poor decision making and poor impulse control.
R2's Progress note, dated 11-15-24 by V5 Registered Nurse/RN, documents Resident was involved in an altercation. Resident was in the TV area, him and another peer (R1). First, they started arguing. As another nurse and I went to intervene to separate them, the other resident (R1) stood up and swung before we could stop him (R1). Resident (R2) has a wound on the left side of the cheek. This nurse applied pressure to wound to stop bleeding and area was cleaned. The patient (R2) was sent to (named hospital) for further evaluation.
R2's progress note, dated 11-15-24, documents Resident returned from (named hospital) around (6:35pm). Laceration repair L (left) side of face; stitches to be removed in 7-10 days.
The facility's abuse reportables include an altercation between R1 and R2; witness included V4 Certified Nurse Assistant/CNA and V5 Registered Nurse/RN. The Final Report, dated 11-20-24, by V3 Abuse Coordinator, documents the following: Residents (R2 and R1) sitting in TV dining room area 11-15-24 at approximately 2:45pm watching television. Video (camera) was watched. (R2) made a lunge like movement from his chair toward (R1). (R1) stood up from his chair and struck (R2). (R2) sent to hospital with a laceration on the left side of face. (R1) had superficial scratch on right hand.
On 12/6/24, at 11:46am, V4 CNA stated the following: (On 11/15/24) I was behind the desk, and I saw (R2) yell at the TV. Then (R1) yelled. (R1) stood up so I tried to calm (R1) down. (R1) started hitting (R2) so I moved (R1) away from (R2). R2's face was bleeding. V4 continued to state (R1) was intentional and knew who his target was.
On 12/6/24, at 11:51am, V5 RN stated the following: (On 11/15/24) I remember those two (R1 and R2) were sitting beside each other .Yelling was going on by (R2). (R1) gets very agitated with loud noises, banging and yelling. (R1) doesn't like it close to him and gets agitated. (R1) yelled and then stopped. I walked away from nurses' station then it started again. Now (R1) was standing up, when (R1) stood up staff tried to intervene, but (R1) had hit (R2) before we reached them. (R1) hit (R2) on the left side of (R2's) face and it was bleeding. At this time V5 confirmed (R1's) strike was on purpose and stated, 'Oh, he hit him.'
On 12/10/24, at 11:53am, V3 Abuse Coordinator stated that V3 reviewed the video camera to see what had happened. V3 stated on 11/15/24, R1 and R2 were in the TV area talking and next thing (R1) got up and hit (R2) in the face. V3 stated R1 and R2 are very impulsive and reactive. There is no pre-meditation. They have no impulse control. Never know when those things are going to happen. V3 confirmed it was not an accident.
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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a resident was free from physical abuse for one (R6) of seven residents reviewed for abuse in the sample of seven.
Findings Include...
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Based on interview and record review, the facility failed to ensure a resident was free from physical abuse for one (R6) of seven residents reviewed for abuse in the sample of seven.
Findings Include:
The Facility's undated Abuse Policy documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property and exploitation as defined below, this includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this proclaims is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This facility is committed to protection out residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to individual, family members or legal guardians, friends or any to her individuals.
The Abuse Policy documents the definition of physical abuse include hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.
The facility's Abuse Investigation dated 9/1/24 documents (R2 and R6) with TBI (Traumatic Brain Injury) diagnosis in their late twenties got in a verbal altercation in the main dining room which escalated to a physical incident with name calling, slapping, scratching, and hair pulling.
An Incident Report dated 9/1/24 documents R6 was in a brief physical altercation resulting in scratch to forehead. No first aid was required per the Incident Report.
On 11/08/24 at 12:00 PM, V3 (Quality Assurance) stated that multiple staff members were in the dining room when R2 smacked R6. The staff members reported that R6 spoke to R2, but none of the staff could hear what R6 said. R2 then smacked R6 before staff could intervene.
R2's documented interview dated 9/5/24 documents, I didn't mean to; it never should have happened. It started with (R6) talking nonsense, calling me retarded and a b*tch. I let the anger take over and smacked (R6) to make her shut up.
Throughout the survey R2 would not speak with surveyor.
Oct 2024
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to treat one resident (R91) with dignity and respect of 24 residents reviewed for dignity and respect in a total sample of 34.
Fi...
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Based on observation, interview and record review the facility failed to treat one resident (R91) with dignity and respect of 24 residents reviewed for dignity and respect in a total sample of 34.
Findings Include:
The Facility's undated Resident Dignity policy documents (This Facility) promotes care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or individuality. Dignity means that in their interactions with residents, staff carry out activities which assist the resident to maintain and enhance his/her self esteem and self worth. For example: promoting residents independence and dignity in the dining room, respecting resident's social status, speaking respectfully, listening carefully, treating residents with respect and focusing on residents as individuals when they talk to them and addressing residents as individuals when providing care and services. A person's dignity is vitally important to each individual's mental and emotional wellbeing. When your dignity is violated, you begin to question your self worth and may begin to feel that there is no reason to go on. Violation of an individual's dignity may result in an increase in negative behavior, embarrassment, anger, frustration, depression and uncooperativeness, among other things.
On 9/18/24 at 11:30 AM, R91 walked up to V10 (Medical Records) and held out his tray and calmly stated I was just in the hospital, and they changed my diet order back to general. V10 stated Uh, you ain't gotta do all that and took the tray from R91 handed it to another staff member and told them to throw it away and said to R91 You need to go talk to your nurse, when she fixes it, you can get a tray then V10 turned her back to R91 and began talking to other staff and distributing trays to other residents.
On 9/18/24 at 11:35 AM R91 was sitting at his table in the dining room very upset and angry. R91 stated Why am I the bad guy for trying to make sure I eat what is ordered for me? I don't like the mechanical soft. We were having pork chops, so I did not want mine all chopped up. I was not being rude in any sort of way. The staff here and especially (V10/Medical Records) are very dismissive and act like if you have a question or concern about anything to do with your care that you are acting up. I am not acting up; I just want my general diet.
On 9/19/24 at 10:30 AM V10 (Medical Records) confirmed that she told R91 he aint got to do all that. V10 stated that she felt that R91 was being aggressive and obsessive about what he eats. (R91) has a lot of behaviors a lot of the time. V10 was unable to specify how R91 was being aggressive during the interaction regarding his meal tray on 9/18/24. V10 confirmed that she had been trained on de-escalation techniques and stated Well, maybe (R91) wasn't being aggressive right then, but he does get aggressive at times. V10 also confirmed that R91 was correct that after his recent hospitalization he had been changed from a mechanical soft diet to a general diet.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to assist one resident (R93) to find an alternate nursing home placement of 20 residents reviewed for discharge planning in a total sample of 3...
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Based on record review and interview the facility failed to assist one resident (R93) to find an alternate nursing home placement of 20 residents reviewed for discharge planning in a total sample of 34.
Findings Include:
The Facility's admission Packet includes the following Discharge Planning information The Social Service Department is the department dedicated within the facility to assist with discharge planning. The resident or family should contact Social Service as soon as the option of leaving the facility is being considered. It is the philosophy of this facility to help residents make transition to alternative living arrangements as smooth as possible. To achieve this, the Social Service Department works to maintain current information about services available to assist with independent living and other communal settings, which may be less restrictive, than an intermediate or skilled nursing facility discharge planning assistance has no additional charge.
On 9/17/24 at 9:30 AM R93 stated I hate it here; I want to go back to (A different long term care facility). I have been telling anyone who will listen that I want to go back.
On 9/18/24 at 11:00 AM V1 (Administrator) stated (R93) moved here from (a different long term care facility). He seemed fine at first, but we have seen a different side of (R93) since he has come, he is very demanding, very aggressive. He has told me he would love to go back to (a different long term care facility). I don't think they want to deal with him either.
On 9/18/24 at 11:30 AM V7 (a different long term care facility Administrator in Training) stated I have not gotten any requests to rescreen or reassess (R93) for readmission. I have double checked with everyone. Please let (V1/Administrator) know he just needs to email us a referral packet and we will review it.
On 9/19/24 at 1:30 PM V1 (Administrator) confirmed there was no documentation of any attempts to have R93 screened by the long term care facility of his choice.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a Preadmission Screening and Resident Review/PASARR including...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a Preadmission Screening and Resident Review/PASARR including an initial Omnibus Budget Reconciliation Act/OBRA were revised for 2 of 2 residents (R8, R67) who were diagnosed with a psychiatric condition after admission in the sample of 34.
Findings include:
1) R8's Interagency Certification of Screening Results document R8 was admitted to the facility on [DATE]. R8's OBRA-1 Initial Screen does not document a psychiatric diagnosis.
R8's electronic medical record documents a diagnosis of Schizoaffective Disorder, Bipolar Type on 12/12/2018.
On 09/19/24 at 11:03 AM V4/Quality Assurance stated she cannot provide an updated screening of a Level I PASARR to determine the need for a Level II PASARR after R8 was diagnosed with a psychiatric condition.
2) R67's Interagency Certification of Screening Results document R67 was admitted to the facility on [DATE]. R67's OBRA-1 Initial Screen does not document a psychiatric diagnosis.
R67's electronic medical record documents a diagnosis of Other Schizoaffective Disorders and includes a comment, Added per psych (psychiatric) visit on 09/28/23.
On 09/1/24 at 11:03 AM V4 stated she cannot provide an updated screening of a Level 1 PASARR to determine the need for a Level II PASARR after R8 was diagnosed with a psychiatric condition.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0678
(Tag F0678)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to update one resident's chart (R99) for a code status change from Full...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to update one resident's chart (R99) for a code status change from Full Code to Modified DNR (Do Not Resuscitate). This failure resulted in R99 receiving full CPR including chest compressions after being found unresponsive.
Findings Include:
R99's POLST (Physician Order Life Sustaining Treatment) dated [DATE] documents Modified DNAR (Do Not Attempt Resuscitation) to include: non-invasive airway and breathing, IV (Intravenous medications) and transfer to the hospital. Do Not perform chest compressions.
R99's care plan dated [DATE] documents (R99) wishes to be full code. R99's care plan was updated on [DATE] (one day after her death) to (R99) has DNR (Do Not resuscitate) order.
R99's Nurse' Notes written by V13 (Licensed Practical Nurse) document that on [DATE] at 3:15 AM At about 2:30 am resident was found unresponsive after several room checks through the night. I retrieved an ambu-bag and used it until EMS (Emergency Medical Services) arrived as she was still warm and blood pooling and mottling had not started yet. EMS arrived and worked until about 3:20 and called her death at 3:21 (AM).
On [DATE] at 9:15 AM V13 (Licensed Practical Nurse) stated that when EMS (Emergency Medical Services) arrived at the facility on [DATE] that she (V13) was distracted by R99's roommate and left the room and she did not speak to EMS. V13 reported that code status is usually on the banner in the electronic medical record and a paper is kept in a book in the common area. V13 stated that she did know that R99 was a DNR upon EMS arrival.
On [DATE] at 1:51 PM V20 (Certified Nurse Aid) stated I called 911 and I told the dispatcher that (R99) was a full code because I did not know it had changed while she was in the hospital. I checked the book and there was no DNR paper in there.
The Ambulance documentation sheet dated [DATE] documents (Gel Airway) inserted to patient, chest compressions started upon arrival to the facility. The ambulance documentation documents breathing, chest compression and medications were given to R99 during EMS care. R99 was then pronounced dead via phone call with emergency room Physician due to futile efforts.
On [DATE] at 10:30 AM V19 (R99 Health Care Power of Attorney) stated The coroner told me that (R99) received CPR with chest compressions, and she (R99) specifically did not want that and had changed it in [DATE] when she was in the hospital.
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, record review and interview, the facility failed to ensure therapy services were provided as ordered for 1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure therapy services were provided as ordered for 1 of 2 (R96) residents reviewed for limited range of motion in the sample of 34.
Findings include:
On 09/17/24 at 3:15 PM R96 was observed sitting in a community room watching videos on his phone using his right hand. R96 appeared to have left upper extremity weakness and lack of coordination.
R96's Physician Order Sheet dated September 19, 2024; documents he was admitted to the facility on [DATE]. R96 had an order dated 08/15/24 for a referral to outpatient ST/speech therapy, PT/physical therapy and OT/occupational therapy.
On 09/17/24 at 3:15 PM R96 stated he is not receiving therapy. R96 stated, I've been here for 6 weeks, and they are finally getting me a paper for therapy today. My mom and I had to set it up ourselves.
On 09/18/24 1:30 PM V11/R96's Power of Attorney stated she has spoken with staff regarding getting R96 screened for physical, occupational and speech therapy and he has not received services yet. V11 stated she contacted the outside physical therapy department who stated they had not received a referral for services. V11 stated the lack of therapy affects R96 because he would like to be evaluated in hopes of increasing his diet to general from mechanical soft so he can enjoy more of the foods he likes.
On 09/18/24 at 1:30 PM V9/Restorative Nurse confirmed R96 had an order for ST, OT and PT. V9 stated R96's evaluation appointment was missed on 09/17/24. R96 is scheduled to go for OT evaluation today and PT on 09/24/24. V9 confirmed R96 has had a delay in treatment. V9 confirmed R96 is not on a formal restorative program to prevent further decrease in range of motion while R96 awaits therapy evaluations.
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 registered dietician recommendations to prevent weight loss for one (R75) of three residents reviewed for nutrition in ...
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Based on observation, interview, and record review the facility failed to follow registered dietician recommendations to prevent weight loss for one (R75) of three residents reviewed for nutrition in the sample of 34.
Findings include:
The facility's Weight policy and procedure, dated 1/12/22, documents Within a week after weights have been received and reviewed by the Nursing Department and Dietary Manager, the Weight Committee will meet to discuss and recommend the need for any possible dietary interventions or diet order changes. If the Dietician is present in the facility, the Committee will consult with her. If not, they will simply notify the physician for the possibility of new orders. Order changes will be recorded in the clinical record as well as any needed care plan intervention changes. At any time when the Dietician is in the facility, any recommendations she makes will be referred to the physician for approval.
The facility Significant Weight Changes weekly weight meeting form, dated 9/2024, documents R75 weight as 159.2 lbs (pounds) down 5.4 % (percent) in one month and down 10.3 % in three months.
The current weight logs for R75, documents R75's weight decline as follows: 9/15/24 at 159.2 lbs, 7/26/24 at 164 lbs, 6/14/24 at 178 lbs, 5/29/24 at 173.1 lbs, 4/23/24 at 173 lbs, 3/25/24 at 175.8 lbs, 2/26/24 at 176 lbs, 1/5/24 at 185 lbs, 12/4/23 at 188 lbs, and 11/11/23 at 190 lbs. This log documents a continual weight decline for R75.
The Dietary Progress Note for R75, dated 9/15/24, documents R75 has had a significant weight loss of 5.4% in one month and 10.3% in six months with current weight of 159.2 lbs.
The RD (Registered Dietician) Note for R75, dated 7/26/24, documents R75 with weight loss of 6.7% in one month and 11.4% in six months. Recommendations: Change sandwich and milk at HS (bedtime) to pudding and thickened health shake. Honey thick health shake with breakfast and lunch. Refer RD PRN (as needed).
The RD Note for R75, dated 5/29/24, documents R75 with no May 2024 weight, 4/23/24 as 173 lbs, 2/26/24 at 176 lbs, and 11/11/23 as 190 lbs.
The RD Note for R75, dated 12/27/23, documents R75 weight 12/4/23 at 188 lbs, 11/11/23 at 190 lbs, 9/26/23 at 180 lbs, and 6/23/23 at 243 lbs. with recommendation to continue to offer meals and snacks per preferences.
The Dietary Progress Note for R75, dated 11/24/23, documents R75 has had significant weight loss of 23.2% in six months with weight at 189.6 lbs.
The Dietary Profile for R75, dated 12/6/23, documents R75 weight on 12/4/23 at 188 lbs, 11/11/23 at 190 lbs, 9/26/23 at 180 lbs, and 6/23/24 at 243 lbs. Weight loss of 55 lbs/22.8%.
The Dietary Profile for R75, dated 5/29/24, documents no new weight for R75 for 5/2024, 4/23/24 at 173 lbs, 2/26/24 at 176 lbs, 11/11/23 at 190 lbs. No recent weight to compare.
The current Physician Orders for R75, document the following dated orders: 8/27/24 LCS (low concentrated sweet)/NAS (no added salt) diet, mechanical soft texture with honey thick consistency liquids; 5/23/24 Weigh every month. The are no diet supplements or dietary recommendations in R75's Physician Orders.
On 9/17/24 through 9/19/24 R75 sat in the dining room for breakfast and lunch and fed himself without assist.
On 9/17/24 at 2:01 pm, R75 stated he has lost some weight, a lot of weight. On 9/19/24 at 3:30 pm, R75 stated he doesn't get milkshakes, or he would drink them.
On 9/19/24 at 9:17 AM V12 RN stated R75 has been eating pretty good lately but doesn't like the mechanical soft diet or the thickened liquids. R75 is very particular with what he eats. V12 RN stated she is unaware of R75 receiving any special supplements.
On 9/19/24 at 9:25 am, V13 LPN stated sometimes R75 will ask for a snack at night, but not often and does not think R75 gets additional supplements.
09/18/24 03:34 PM, V2 DON stated the facility has weight meetings weekly and they discuss resident weight losses and try to put in new interventions as needed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the Facility failed to prevent and monitor residents for Physical Abuse and Verbal Abuse for four (R1, R23, R59, and R66) of 32 Residents reviewed for...
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Based on observation, interview and record review the Facility failed to prevent and monitor residents for Physical Abuse and Verbal Abuse for four (R1, R23, R59, and R66) of 32 Residents reviewed for Abuse in a sample of 34.
Findings include:
Facility Abuse Prevention Program Policy, reviewed 11/10/23, documents: the Facility affirms the right of our Residents to be free from Abuse; has attempted to establish a Resident sensitive and Resident secure environment; the purpose of the policy is to assure that the Facility is doing all that is within its control to prevent occurrences of Abuse; the Facility is committed to protecting our Residents from Abuse by anyone including, but not limited to, Facility Staff and other Residents; the following definitions are based on Federal and State laws, regulations and interpretive guidelines; Abuse is a willful infliction of injury; any instance of Abuse of Residents irrespective of any mental or physical condition, cause harm, pain or mental anguish; including verbal abuse and physical abuse facilitated or enabled through the use of technology; Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention; physical abuse is hitting, slapping, pinching, kicking and controlling behavior through corporal punishment; and verbal abuse is the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to Residents, or within hearing distance, regardless of age, ability to comprehend, or disability; and examples of verbal abuse include but are not limited to, threats of harm, saying things to frighten a Resident.
Facility Smoking Policy and Procedure Policy, undated, documents: it is the safety of all Residents, smoking will be allowed in designated areas only; Residents will be oriented to, and will be monitored for adherence to the rules, regulations and smoking guidelines; smoking rules and regulations are read to each Resident upon admission with an agreement signed stating an understanding and agreement to comply with the terms; Residents will be monitored by for awareness and adherence of the smoking rules and guidelines; supervised smoking in designated areas will only be allowed while monitored by staff and cigarettes will be passed at the following times (7:00 am -7:30 am, 9:00 am-9:30 am, 11:00 am-11:30 am, 1:00 pm-1:30 pm, 3:00 pm-3:30 pm, 5:00 pm-5:30 pm, 7:00 pm-7:30 pm and 9:00 pm-9:30 pm); and Residents who carry their own cigarettes may not give cigarettes, lighters or lights to any other Resident, may smoke in designated areas and must maintain appropriate behavior in smoking areas.
1. R23's Physician Order Sheet/POS, dated 9/19/24, documents diagnoses including Intracranial Injury without loss of consciousness, Extrapyramidal and Movement Disorder, Psychosis, Borderline Personality Disorder, Epilepsy with Seizures, Frontotemporal Neurocognitive Disorder, Major Depressive Disorder, Anxiety Disorder, Schizoaffective Disorder and Borderline Intellectual Functioning.
R23's POS, dated 9/18/24, also documents physician orders for: behavioral psychological/psychiatric services, mental health services and medication management; and psychotropic medications for Schizoaffective Disorder (Divalproex, Invega and Olanzapine).
R23's current Care Plan documents: a criminal background history of aggravated stalking, damage to property, domestic battery and violation of order of protection; diagnoses including a Traumatic Brain Injury and is a moderate risk offender; requires supervised smoking program and will follow smoking policy and rules; has behavior problem related to limitations, poor impulse control, poor decision making, poor coping skills and poor management; displays verbal and physical aggression, intrusive, swears, threatens, inappropriate comments, provokes peers, property damage and non-compliant with facility policies.
R23's Care Plan documents interventions for local behavioral psychological/psychiatric services, mental health services, hourly checks, staff to remind to wait turn in smoking lines, while on smoking patio will inform staff if having issues with peers, anticipate needs and response to environmental triggers, assist with developing appropriate methods of coping and interacting through education, intervene as necessary to protect the rights and safety of others, minimize potential for disruptive behaviors and monitor behavior episodes and attempt to determine underlying cause.
R59's current Care Plan documents that R59 has diagnoses including Benign Neoplasm of Cerebral Meninges Traumatic Brain Injury, Anxiety Disorder and Depression. The Care Plan also documents that R59 requires supervision while smoking, will follow designated smoking times and will follow the Facility smoking policy.
R23's Smoking Assessment, dated 7/16/24, documents that R23 requires managed/supervised smoking materials and is on a supervised smoking program.
R59's Smoking Assessment, dated 8/29/24, documents that R59 may be independent to handle own smoking materials.
R23's local State Agency Reported Incidents/Report Incident, dated 3/15/24, documents a verbal altercation which escalated to physical acting out between R23 and R59, while on the smoking patio. R23 sustained a minor abrasion around left eye and R59 sustained a left wrist laceration and bruised hand.
The Report Incident, dated 3/15/24, documents that Certified Nursing Assistant/CNA) went outside, both Residents were on the ground. I heard a male peer yell 'they are on smoking patio fighting' and a male CNA and Nurse ran out on the A/B patio.
R23's Nursing Progress Note, dated 3/15/24 at 9:39 pm, documents R23 was in a physical altercation.
R23's local State Agency Reported Incidents/Report Incident, dated 9/7/24, documents that R23 is the perpetrator and approached a female peer (R59) on the patio (A/B Hall smoking patio) and requested a light (for R23's cigarette). R59 told R23 no. R59 stood up walking behind and to the side of R23, words were exchanged and R23 slapped R59 on the side of R59's body. Per the video, R23 stood up, and did turn and went in opposite direction. R59 stayed in the same vicinity pointing at R23 and continued to verbally engage. R23 then returned to R23's wheelchair and pushed the wheelchair in to R59. Staff accompanied R23 off of the patio area. R59 complained of right side pain and right knee pain from the wheelchair, however, refused treatment. The Police were contacted and R23 was arrested and taken to the county jail. R23 returned the following day (9/8/24).
The Report Incident, dated 9/7/24, documents R59's interview and R59 stated that R23 asked for a lighter and when R59 said no, R23 began yelling, cursing and demanding to use R59's lighter. When R59 got up from the bench, R23 struck R59. R59 stated that R59 tried to leave the area, however, R23 continued to yell and curse. R59 also stated that R23 pushed R23's wheelchair into to R59. R59 stated that they kept yelling at each other until staff came and separated them.
The Report Incident, dated 9/7/24, documents R23's interview and R23 stated that R23 asked R59 for a lighter for R23's cigarette. R23 states that R59 started yelling, cursing and using racial slurs. R23 stated that R23 did yell at R59 and denied hitting R59. R23 stated that R59 continued coming at R23, calling R23 names and putting R59's finger in R23's face, calling him nigger until staff came and separated them.
The Report Incident, dated 9/7/24, documents interviews with V15 (Certified Nursing Assistant/CNA) and V16 (Registered Nurse/RN). V15's interview documents that, I was told that (R23) was outside hitting another Resident (R59), so I went outside to calm the situation down and they was going back and forth with each other. V15 also states that R23 hit R59 with R23s wheelchair. V16's interview documents that, I just saw the aftermath of the incident and that V16 did a preliminary assessment on R59 and R59 refused first aid or pain medication.
R23's Nursing Progress Note dated 9/7/24 at 1:19 pm, documents: R23 was in a physical altercation with a peer, on the A/B patio. When R23 requested to use a female peer's lighter (R59) and when told no, R23 pushed R23's wheelchair at R59 and made physical contact with R59; the local Police Department was notified and R23 was arrested and taken to county jail.
R23's Nursing Progress Note dated 9/8/24 at 11:56 am, documents that R23 returned from the county jail and returned in an aggressive mood and was redirected.
On 9/19/24 at 11:45 am, V15 (CNA) stated, I was passing the last lunch tray on that day, and a Resident came to the door and said that (R23) was hitting (R59), so I looked outside the dining room window and went outside to help, because no other staff members were out there. (R23) was pushing (R23's) empty wheelchair into (R59) and someone told me that they saw (R23) hit (R59) twice in the ribs and once in the face, but I did not see that. (R23) was not supposed to be out on the smoking patio anyway, because (R23) needs supervised while (R23) is out there.
On 9/19/24 at 2:37 pm, V16 (RN) stated, I was the nurse on duty that day (9/7/24). (R23) does have a history of aggression towards staff and other Residents. I did not witness the altercation between (R23) and (R59). All I know is that (V15/CNA) went running out to the smoking patio because (R23) was yelling and pushing a wheelchair at (R59), and there was no other staff out there at the time. (R23) had a red mark on (R23's) leg but there were no other physical injuries that I could see. (R23) wanted us to call the Police and they came and arrested (R23) and took (R23) to jail. Most of those Residents out on the smoking patio need supervision.
On 9/19/24 at 12:30 pm, V14 (Medical Director) stated, (R23) is a tough one with (R23's) behavior. (R23) has poor social skills and needs supervision. The Facility did notify me that (R23) pushed a wheelchair, got into a verbal altercation with (R59) and was taken to jail. The best we can do for (R23) is monitor and avoid (R23) from hurting himself or other people.
On 9/19/24, at 1:15 pm, V2 (Director of Nursing) stated, On 9/7/24, (R23) and (R59) got into an altercation on the smoking patio and (R23) was arrested and went to jail. R23 has a history of behaviors and also had another altercation (with R59) about six months ago. R23 is not allowed on that A/B Hall smoking patio and (R23) should be supervised because (R23) has multiple behaviors as a result of R23's Traumatic Brain Injury. We now have (R23) smoking on the front patio.
2. The facility Initial Report to the State Agency, dated 9/17/24, documents an allegation of abuse was initiated on 9/17/24 between R1 and R66. Residents (R1 and R66) in a verbal altercation which escalated to a physical confrontation.
The Progress Notes for R1, dated 9/17/24 at 6:45 pm, documents R1 and R66 were eating in the dining room. R66 was telling R1 Stop staring at me! (R66) began striking (R1) with his fist and started a physical altercation. Staff immediately intervened and separated the residents. No apparent injuries. (R1) requesting to go to hospital. V14 (R1's) Primary Care Physician was notified and R1 was sent to the local hospital for an evaluation.
The Progress Note for R1, dated 9/18/24 at 3:43 am, documents R1 returned from the local hospital with no injuries and no new orders. Will continue to monitor.
On 9/17/24 at 8:50 am and on 9/18/24 8:28 am and 1:00 pm, and on 9/19/24 at 10:30 am, R1 was witnessed feeding himself in the dining room, waiting for breakfast, ambulating in the hallway and lying in his bed with no behaviors noted. On 9/18/24 and 9/19/24 R66 was visible sitting in various areas of the dining area, hallways, and near the nurses' station.
On 9/19/24 at 2:33 pm, V16 RN (Registered Nurse) stated she was the nurse working on 9/17/24 when the altercation occurred between R1 and R66. During dinner R1 and R66 were sitting next to each in the dining room, talking back and forth. R66 began yelling at R1 to stop looking at (R66) and as (V16 RN) was approaching R1 and R66, R66 began hitting R1 and the two residents were immediately separated. V16 RN stated R66 is impulsive and has to be monitored. The police were called, R66 talked to them, and did calm down. R1 didn't have any visible injuries but was sent out to the hospital for evaluation and returned without any injuries. No, we didn't do anything new after the incident. There is not much we can do once it starts.
On 9/19/24 at 11:05 am, V1 Administrator stated he has started an investigation for the incident that occurred the evening of 9/17/24 and all he knows is that the allegation was witnessed by staff and the event occurred for only about 15 seconds. It started with verbal and supposedly quickly escalated to physical and was intervened immediately. V1 stated he has five days to complete the investigation and did send the initial report to the State Agency and has not yet completed the investigation. V1 stated after he completes the investigation he will update the State Agency as to the findings.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected most or all residents
Based on record review and interview the facility failed to respond to repeated resident council concerns. This has the potential to affect all 96 residents who reside in the facility.
Findings Inclu...
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Based on record review and interview the facility failed to respond to repeated resident council concerns. This has the potential to affect all 96 residents who reside in the facility.
Findings Include:
The Facility's admission Packet contained information on Resident Council that documented At least once a month, the residents of this facility participate in Resident Council meetings to discuss the diverse matters of nursing home life. The officers of the resident council communicate any matters of concern to the facility's management. The staff at our facility and the Resident Council will work cooperatively to effectively address resident concerns and advice. Participation in the Resident Council is not mandatory, and any issues raised by the residents, whether at the Resident Council meeting or otherwise will be addressed.
The Facility's undated Procedure for Resident Grievances or Complaints policy documents, Residents, guardians, responsible parties and/or legal representatives are encouraged to make known their problems or complaints. Open discussion or written communication is the only way problems can be aired and resolved. There is no problem too small for consideration; the entire staff is concerned with the residents' well-being. All members of the facility staff will make prompt efforts to resolve grievances- including those with respect to the behavior of other residents. Anyone presenting a grievance is free to do so without fear of discrimination or reprisal. If for any reason the problem is not resolved within a reasonable period of time or to your satisfaction, bring the issue to the Administrator.
The Resident Council Meeting Minutes for January, February, March, April, May, June, and August 2024 all document Residents are requesting larger portions. Relayed to dietary supervisor.
On 9/18/24 at 10:15 AM, R70, R65 and R44 all stated the serving sizes of meals are too small and they are not always able to get second helpings.
On 9/18/24 at 8:30 AM R93 stated We always get very small servings and if we ask for seconds, they will close the window right in your face and not give them.
The Resident Council Meeting Minutes for February, March, April, July, and August 2024 all document Residents are requesting for administration to be present with residents more often. Relayed to supervisor.
During Resident Council Meeting on 9/18/24 at 10:00 AM R44, R53, R65, R70, R78, R79 and R85 all stated that V1 (Administrator) is very hard to get to talk to. All residents present state that they would like all Administration to be more available and willing to help the residents.
On 9/18/24 at 11:45 AM V5 (Activity Director) stated There are multiple complaints that we get every month during resident council. The day after I have council with the residents, I type up the minutes and pass them out to the department managers so they can review. Some department managers respond very quickly or ask if they can come talk to the residents to clarify things. Some department managers never respond to any of their complaints. The complaint about the serving sizes is one that is constant. They always say they want more food. I have told (V7/Dietary Manager) and she has not responded to them or me.
The facility's Long Term Care Facility Application for Medicare and Medicaid, dated 9/17/24 and signed by V1 (Administrator) documents 96 residents currently reside in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to implement Enhanced Barrier Precautions throughout the facility to protect vulnerable residents and prevent the spread of multi...
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Based on observation, interview and record review, the facility failed to implement Enhanced Barrier Precautions throughout the facility to protect vulnerable residents and prevent the spread of multi-drug resistant organisms (MDROs). This failure has the potential to affect all 96 residents residing in the facility.
Findings include:
The facility's (undated) Enhanced Barrier Precautions (EBP) policy documents It is the policy to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organism (MDROs). Enhanced barrier precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes. EBPs involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk for MDRO acquisition (residents with wounds or indwelling medical devices). High-contact resident activities include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care: any skin opening requiring a dressing. Enhanced barrier precautions are recommended for residents with indwelling medical devices or wounds, who do not otherwise meet criteria for Contact Precautions, even if they have no history of MDRO colonization. This is because devices and wounds are risk factors that place these residents at higher risk for carrying or acquiring a MDRO and many residents colonized with a MDRO are asymptomatic or not presently known to be colonized. This same policy documents Gowns and gloves will be available immediately near or outside of the resident's room. Face protection may also be available if performing activity with high risk of splash or spray.
On 9/17/24 at 9:30 AM the facility's resident hallways were toured in entirety and no residents were observed to be in isolation or to have signs on their doors to indicate any EBPs.
On 9/19/24 at 9:00 AM, V2 (Director of Nursing/Infection Preventionist) confirmed the facility currently does not have any residents in isolation. V2 stated We (the facility) do not have any urinary catheters or central lines. We have two residents with open wounds and dressings that are changed. (R1) has venous ulcers that are open currently and require dressing changes to his lower legs. (R75) has open wounds on his right foot and left foot. Both of those areas are open and also require daily dressing changes. We do not have any residents in isolation right now. I was just given some information about EBP from corporate recently. We have not implemented EBP on any existing or new residents in the facility. We just use standard precautions.
The facility's Long Term Care Facility Application for Medicare and Medicaid, dated 9/17/24 and signed by V1 (Administrator) documents 96 residents currently reside in the facility.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0577
(Tag F0577)
Minor procedural issue · This affected most or all residents
Based on interview, observation and record review, the facility failed to ensure the (state agency) survey inspection book contained three years of previous survey results for complaint and certificat...
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Based on interview, observation and record review, the facility failed to ensure the (state agency) survey inspection book contained three years of previous survey results for complaint and certification inspections and ensure the survey book was readily accessible to residents and families without asking for assistance to view. This failure has the potential to affect all 96 residents residing in the facility.
Findings include:
On 9/18/24 at 10:15 AM, during the resident group meeting, residents who have previously attended resident council meetings R44, R53, R65, R70, R78, R79, and R85 all confirmed they did not know where in the facility to access the facility's previous annual and complaint investigation results and did not know that (State Agency) survey results are something accessible for them to review.
On 9/18/24 at 11:00 AM, the facility's main hall bulletin board contained a posting that documents (State Agency) survey results are available for inspection in our survey room. Please let us know and we can provide this to you if the survey room is locked.
On 9/18/24 at 11:35 AM, the facility's Survey Results book was located behind the reception/security front desk. This book was reviewed and contained one annual Licensure and Certification survey dated 6/2023. This book did not contain any complaint survey results or annual Certification surveys prior to 2023.
On 9/18/24 at 11:40 AM, V4 (Quality Assurance) verified the State Agency Survey inspection book contains only the last annual survey, dated 6/2023. V4 stated The inspection book does not have any complaint surveys and does not contain any surveys for the previous three years with the exception of 2023 annual Licensure and Certification. The book is kept in the family room or behind the security front desk. If residents want to see the book they can ask, and we will give it to them. The family room is usually open, but we do lock it at night because things will go missing, so it isn't unlocked all of the time.
The facility's Long Term Care Facility Application for Medicare and Medicaid, dated 9/17/24 and signed by V1 (Administrator) documents 96 residents currently reside in the facility.
Jun 2023
4 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Laboratory Services
(Tag F0770)
A resident was harmed · This affected 1 resident
Based on observation, interview, and record review, the facility failed to obtain a physician ordered Dilantin level for one of two residents (R47) reviewed for hospitalizations in the sample of 30. T...
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Based on observation, interview, and record review, the facility failed to obtain a physician ordered Dilantin level for one of two residents (R47) reviewed for hospitalizations in the sample of 30. This failure resulted in R47 being hospitalized with a critically high Dilantin level.
Findings include:
On 06/20/23 at 10:41 AM, R47 was alert self-propelling himself in the hallway. R47 stated, A few weeks ago, I had to go to the hospital because they messed something up with my medicine.
R47's Care plan, dated 6/21/23, documents, (R47) has a seizure disorder. (R47) has a (vagal nerve) Interventions: Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness. Obtain and monitor lab/diagnostic work as ordered. Report results to physician and follow up as indicated.
R47's Nurses' notes, dated 4/15/23 at 10:23 a.m., document, This nurse was notified that (R47) was out on the patio having a seizure. (R47) was having a seizure for 4 minutes. No falls or no injuries. (R47) stayed in a catatonic state for 15 minutes. Doctor was notified and his orders are as follows add Dilantin 250 mg (milligrams) TID (three times a day), and also get a Dilantin level in two weeks. New orders updated in MAR (Medication Administration Record). Facility protocol put in place for seizure activity. Management notified of new orders.
R47's Physician's orders, dated 6/22/23, document that on 4/15/23 Dilantin 250 mg by mouth three times a day was ordered to be received for convulsions.
R47's Physician progress note, dated 5/10/23, documents, Feels weaker since starting Dilantin. Plan: Start Vimpat 100 mg BID (twice a day). Discontinue Dilantin.
R47's Nurses's notes, dated 5/11/23 at 9:23 p.m., document, (R47) reported to this nurse that he has been feeling 'foggy' lately and that he feels like that he 'fades out' at times but only for a few seconds. Other residents stated that (R47) goes limp and that it lasts for only seconds. (R47) also stated that he has moments of slurred speech. This information was reported to Doctor and his recommendation was to send resident to local emergency room for evaluation/treatment. (R47) recently was put on Dilantin to which he stated made him feel worse and the Dilantin was then discontinued and replaced with Vimpat.
R47's Laboratory form, dated 5/11/23, documents that R47's Dilantin level was not drawn until 5/10/23 and was at a critically high level at 38 mcg (microgram)/ml (milliliter). Normal therapuetic range for an adult is (10-20 mcg/ml).
R47's Nurses's notes, dated 5/11/23 at 11:25 p.m., documents, Reported to this nurse from previous nurse (R47) at local hospital. This nurse called local hospital and obtained Information on (R47). (R47) being admitted to local hospital, admitting diagnosis: Seizures and Seizure medications.
R47's Hospital After Visit Summary, dated 5/13/23, documents that on 5/11/23 a Dilantin level was drawn upon admission with critically high results of 38.
On 6/22/23 at 11:20 a.m., V2 (Director of Nursing) confirmed that R47's Dilantin level was not obtained two weeks after the Dilantin was initially started as ordered by the physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a resident was free from verbal abuse for one of one resident (R81) reviewed for abuse in the sample of 30.
Findings include:
The fa...
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Based on interview and record review, the facility failed to ensure a resident was free from verbal abuse for one of one resident (R81) reviewed for abuse in the sample of 30.
Findings include:
The facility's Abuse Prevention Program Facility Policy, dated 12/1/22, documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, 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. This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. The policy also documents, Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of their age, ability to comprehend, or disability.
R81's Care plan, dated 4/12/23, documents (R81) is verbally/physically aggressive. (R81) displays a delusional/hallucinations thought process as related to acceptance of limitations, refusal of medications and care expectations, not accepting of Diagnosis/unaware of effects on others and self. (R81) makes false accusations and manipulative towards residents and staff. (R81) has homicidal thoughts and states he hears voices. (R81) feels he is a staff member and demands/bossy towards peers. (R81) becomes impatient with staff and goes from staff to staff to get his perceived needs met. He becomes upset with staff when they are unable to change their schedule to assist him with doing community errands or other nonemergent needs. (R81) at times will become agitated and curse at staff if they do not take care of what he needs immediately. The care plan also documents the following interventions: Communication: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated; When (R81) becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.
A facility Final Abuse Investigation Report, no date available, documents, Verbal altercation between (V6/CNA-Certified Nursing Assistant) and (R81) occurred in the main dining of the facility. (V6 told R81) that he was spoiled and entitled, and (R81) called her a b****. (V6) got triggered and was cussing, yelling, and oppressively gesturing. (R81 and V6) continued to yell and cuss. (V6) was grossly inappropriate with public ranting with profanity. Documentation indicates V6 was immediately escorted from the facility and terminated for gross misconduct and disruptive behavior.
V8 (Security) Informational Report, dated 6/8/23, documents, Turned around and (R81) and (V6) were yelling at each other, then (V9 Housekeeper) got between them, because they were about to fight.
V5 (Social Services Director) Informational Report, dated 6/6/23, documents, I was sitting in Social Service office and heard a commotion from the dining room. When I entered the dining room I heard (R81) and (V6) yelling at each other. (V6) then charged at (R81) in an aggressive manner to the extent that a male staff member had to intervene.
R81's Informational Report, dated 6/8/23, documents, Asked (V7 CNA) if I could get a tray because I was participating in my online class. (V6) states, 'You act like you are spoiled and get special treatment.' I told her, 'Most of ya'll women in here don't do your job anyway.' She said, 'You don't know me or my family, and I will f*** you up.' Then she began lunging towards me trying to hit me and staff held her back.
R22's Informational Report, dated 6/8/23, documents, I heard (V6) and (R81) exchanging words. I heard her call him an a******.
R56's Informational Report, dated 6/8/23, documents, I heard (R81) and (V6) exchanging words and then she lunged at (R81) swinging her arms.
V9's Informational Report, dated 6/8/23, documents, Heard (V7) tell (R81) to hold on and she would get his tray. (V6) told (R81) he was entitled. (R81) spoke back. (V6) lunged at (R81). I was between them. She scratched me trying to get to (R81). She continued to yell at (R81) and threaten him and saying, 'I don't give a f*** about this job.'
V10's Informational Report, dated 6/8/23, documents, (V6) was heard and seen arguing back and forth with (R81). Curse words were used by both (R81) and (V6). (V6) then tried to attack (R81) but was held back by other staff member.
V6's Employee Report, dated 6/8/23 documents that V6 was terminated for disorderly behavior fighting on the job yelling profanity.
On 06/22/23 at 09:11 AM, V9 stated, (R81) was talking with another CNA about getting his lunch early, and (V6) said something to get (R81) and he started yelling. This is just (R81). He has problems and we have to be able to deal with that. (V6) started yelling back at him. I saw her take a step towards (R81) and that's when I stepped in before she was able to get to him. I was holding her back and she scratched me trying to get to (R81). She kept yelling and threatening (R81). I would say what she did was verbal abuse towards (R81).
On 06/22/23 at 09:42 AM, R81 stated, That morning I was asking for my breakfast tray, and all of a sudden (V6) starts going off on me telling me I think I'm special and deserve special treatment. I responded back telling her about how she walks around the facility and doesn't do her job. She flipped out like a crazy a**. She started cussing and threatening to kick my a**. She kept saying, 'Do you know who I am mother f*****? I'll beat your a**. I'll kill you.' (V9) stepped in and was trying to hold her back. She kept trying to get around him to get to me. She was crazy and wouldn't stop. This lady is supposed to be taking care of me, and now she is verbally abusing me and threatening my life.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview, the facility failed to ensure all medication was stored and labeled in accordance with facility policy and procedure, for three of 15 residents (R26,...
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Based on observation, record review and interview, the facility failed to ensure all medication was stored and labeled in accordance with facility policy and procedure, for three of 15 residents (R26, R32, R49) observed for medication pass, in a sample of 30.
Findings include:
The facility policy, titled Medication Administration Treatment Management Evaluation (no date), documents that the facility utilizes a plastic cassette packaging system that is prepared by the pharmacy and adheres to the FDA (Food and Drug Administration) guidelines. This packaging system includes a label on each cassette that contains the following information: Doctor's name, Resident's name, original date of prescription, prescription number, brand name of medication, room number, direction of medication, facility code, and time of administration. The policy advises, (Medication) Containers with no labels are destroyed by the pharmacist and/or nurse as stated in the Destruction of Medication Protocol. The policy later documents, If a medication is prepared and the resident is not available at the time to take the medication, it may be placed in the top of the med (medication) cart with a med (medication) ticket for each medication, including the resident's name, medication, dose and time of administration.
On 6/20/23 at 11:33 am, the task of observing V4 (Licensed Practical Nurse) for the Medication Pass was initiated. From 11:33 am to 11:58 am, V4 performed glucose monitoring and administered insulin to residents on her hall. At 12:00 pm, V4 stated, I prepped all of my pills this morning for my lunch med (medication) pass. I wouldn't have done that if I had known you were going to watch me. At that time, V4 removed a small cup with a pink pill in it from the drawer of the medication cart. The cup was sitting in a small plastic basket that had the name of R49 on it and no other information. V4 stated the pink pill was Carafate 1 gm. V4 then removed another cup containing four pills from the medication cart drawer, which was in a small plastic basket with the name of R32 on it and no other information. V4 stated the unlabeled cup contained Ativan 1 mg (Scheduled IV controlled substance), Clozapine 100 mg, Clozapine 200 mg and Dilantin 100 mg. V4 then removed another small medicine cup from the drawer, which was in a small plastic basket with R26's name and no other information. The medicine cup contained crushed pink powder, which V4 stated was Carafate 1 gm and Clonazepam 0.5 mg (Scheduled IV controlled substance).
On 6/22/23 at 9:01 am, V2 (Director of Nursing) stated Licensed Nursing Staff should not be prepping their resident's medication in advance, as it is against facility policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview, the facility failed to ensure a glucose monitor was disinfected between use for two of four residents (R80, R84) reviewed during the medication pass ...
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Based on observation, record review and interview, the facility failed to ensure a glucose monitor was disinfected between use for two of four residents (R80, R84) reviewed during the medication pass with blood glucose monitoring, in a sample of 30.
Findings include:
The facility policy, titled Infection Control - Glucometers Use and Cleaning (no date), documents According to recommendations published by the Centers for Disease Control: 'Glucometers should be assigned to individual patients. If a glucometer that has been used for one patient must be used for another patient, the device must be cleaned and disinfected. The policy further documents, All glucometers shall be disinfected using a chlorine-based wipe prior to and following each use; the glucometer shall be wiped completely with a new, saturated, chlorine cloth and set aside until dry. The drying time for each sanitized glucometer is generally 2 minutes, unless otherwise specified by the manufacturer of the disinfectant.
On 6/20/23 at 11:33 am, while observing the Medication Pass, V4 (Licensed Practical Nurse) used the glucometer from her medication cart to obtain a blood sugar reading from R9. After checking R9's blood sugar, V4 placed the glucometer directly on the medication cart and did not disinfect it. The glucometer remained sitting on top of the medication cart. V4 continued with the medication pass. At 11:39 am, V4 used the glucometer that had been sitting on the medicaiton cart and obtained a blood glucose reading from R80, without disinfecting the glucometer. V4 continued with the medication pass and entered the medication room at 11:44 am to retrieve bleach disinfectant wipes. At that time, V4 wiped down the glucometer with the bleach disinfectant wipe and set it on a paper towel on top of the medication cart to dry. V4 then stated, We are supposed to clean the glucometers between each resident use. They need to be disinfected. At 11:54 am, V4 used the glucometer to obtain a blood sugar reading from R14. When V4 was finished, she placed the glucometer directly on the top of the medication cart and did not disinfect it with a bleach wipe. V4's medication pass was continuously observed, and the glucometer remained directly on the medication cart. At 12:00 pm, without disinfecting the glucometer, V4 obtained a blood sugar reading from R84.
R9 and R14's Electronic Medical Records were reviewed and contained no documented evidence that would indicate they have an infection or communicable disease. R80 and R84's Electronic Medical Records were reviewed for documented evidence that would suggest they are immunocompromised, with none found.
On 6/22/23 at 9:01 am, V2 (Director of Nursing) stated glucometers are shared amongst residents in the facility and staff are required to disinfect them with bleach wipes after each use.
Sept 2022
10 deficiencies
1 Harm
SERIOUS
(G)
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, record review and interview the facility failed to prevent an occurrence of resident-to-resident physical abuse from occurring for 2 residents (R106 and R204) reviewed for abuse ...
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Based on observation, record review and interview the facility failed to prevent an occurrence of resident-to-resident physical abuse from occurring for 2 residents (R106 and R204) reviewed for abuse in the sample of 11. This failure resulted in R204 aggressively pushing R106 resulting in an acute right rib fracture.
Findings Include:
The facility policy, Abuse Prevention Program Facility Procedures, dated (revised) 9/15/22 documents, The facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation of resident property by establishing a resident sensitive and resident secure environment.
1. R204's current Medical Diagnosis Sheet, documents the following diagnosis: Intracranial Injury, Bipolar Disorder, Anti-social Personality Disorder.
R204's MDS (Minimum Data Sheet) Assessment, dated 9/27/2022, documents, under E.) Behavior-B.) Potential Indicator of Psychosis. Yes-Delusions (Misconceptions or beliefs that are firmly held, contrary to reality.)
R204's Care Plan dated, 10/4/2022. Documents, R204 has a behavior problem, displays a delusional thought process as to limitations of diagnosis, effects on self-others, environment and surroundings. R204 has been seen being threatening and verbally aggressive with staff and peers.
R204's Progress Notes, dated 11/11/2022 at 10:39 AM, R204 has displayed aggressive behavior, R204 threw two full pitchers of water on V12/ CNA (Certified Nursing Assistant). R204 got into an altercation with a peer where R204 was the aggressor. R204 was redirected and has been put on a 1 to 1 with a CNA or staff member for 24 hours.
On 11/10/2022 at 11:20 AM R204 was observed standing in front of the nurse's station, R204, appeared to be irritated and anxious with staff. R204 had a water pitcher in each hand and threw them at V12/ CNA (Certified Nursing Assistant) that was behind the nurse's station. R204 was heard yelling very loudly at R106. V5/Social Service Assistant was able to intervene and remove R204 from the occurrence. R204 was taken into a nearby office to calm down. After just a few minutes R204 was seen walking out of the office in front of V5/ Social Service Assistant towards R106. R204 was observed to violently hit R106 in the back causing R106 to fall on R106's knees, landing in a fetal position. R204 was removed from the scene and taken to R204's room.
On 11/10/2022 at 12:10 PM V12 stated, I am not sure what was going on with R204, but R204 threw 2 full water pitchers at me for no reason. Got the front of my uniform all wet. R204 can be very impulsive, it doesn't take much for R204 to get agitated and combative. R204 can be hard to redirect from an altercation.
On 11/10/2022 at 12:20 PM V14/RN (Registered Nurse) stated, R106 was pushed very hard, R106 was complaining of right sided rib pain and was having some shortness of breath. He also had a large abrasion down R106's right side. The impact from R106 being pushed was very hard, it could have really hurt R106. I don't know what started the altercation, but it occurred fast for anyone to try and stop it.
R106's Hospital ED (Emergency Department) Notes, dated 11/10/22 document, (R106) presented to the ER (Emergency Room) complaining of right sided chest pain after being pushed down prior to arrival. (R106) states he was pushed down by another member of the facility he lives at. (R106) presenting with right rib pain after being pushed. Tenderness overlying area of bruising to the right chest wall. Chest x-ray shows what might be a fracture to lateral fifth rib. Clinical Impression: Closed fracture of one rib right side.
On 11/11/22 at 8:45 AM R106 was lying in bed on his left side. R106 had no incentive spirometer in his room. R106 stated, I got pushed down yesterday. I did not appreciate it. That resident (R204) is mean. I am hurting whenever I move. My ribs hurt. I haven't gotten anything for pain, and no one has had me do deep breathing.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0559
(Tag F0559)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to allow 2 residents (R71 and R72) to share a room upon their request o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to allow 2 residents (R71 and R72) to share a room upon their request of 19 residents reviewed for choices in a total sample of 34.
Findings Include:
R71's Medical Record documents R71 was admitted on [DATE] with diagnosis COPD (Chronic Obstructive Pulmonary Disease), Type II Diabetes Mellitus, Schizoaffective Disorder and Unspecified Mood Disorder. R71's admission MDS (Minimum Data Set) records a BIMS (Brief Interview for Mental Status) score of 15/15 indicating R71 is cognitively intact.
On 8/31/22 at 12:13 P.M. R71 stated Me and my boyfriend weren't allowed to live in the same room until we told on this place.
R72's Medical Record documents R72 was admitted on [DATE] with diagnosis of Bipolar Disorder, Type II Diabetes Mellitus and COPD (Chronic Obstructive Pulmonary Disease). R72's admission MDS (Minimum Data Set) records a BIMS (Brief Interview for Mental Status) score of 12/15 indicating R72 some cognitive impairment for R72.
On 8/31/22 at 12:22 P.M. R72 stated facility wouldn't let him live with his girlfriend upon admission. I just thought it was really dumb because we had been living together for years and (the facility) wouldn't even consider it, so we (R71 and R72) called V6 (Ombudsman) to see if she could do anything about it.
On 8/30/22 at 4:00 PM V6 (Ombudsman) stated she was contacted by R71 and R72 with concerns because they were not being allowed to live together in the facility because they were not married. V6 stated she educated V1 (Administrator) regarding the current regulations in place to address unmarried couples cohabitating.
On 8/30/22 at 11:30 A.M. V1 (Administrator) confirmed R71 and R72 were told upon admission that they were not allowed to live together because they were not married. V1 stated after being educated regarding the federal regulation that addresses cohabitation of unmarried couples that he did move the couple together on 8/23/22.
R71's Medical Record contained a consent to cohabitate with significant other and consent to use a bathroom shared by other residents possibly of the opposite sex dated 8/23/2022.
R72's Medical Record contained a consent to cohabitate with significant other and consent to use a bathroom shared by other residents possibly of the opposite sex dated 8/23/2022.
CONCERN
(D)
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 record review and interview the facility failed to notify the doctor about a significant weight gain for one resident (R89) of 19 residents reviewed for weights in a total sample of 34.
Find...
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Based on record review and interview the facility failed to notify the doctor about a significant weight gain for one resident (R89) of 19 residents reviewed for weights in a total sample of 34.
Findings Include:
The Facility's Weight Policy dated 1/12/2022 documents The purpose of this Policy is to monitor the resident's weights and track weight changes as they occur. The Policy documents If there is a significant weight change noted, the resident will be reweighed. If the significant weight gain persists, the doctor and responsible party will be notified. This notification will be documented.
The Facility's Weight Policy defines Significant weight change as follows: 1. If being weighed weekly, 2% in one week. 2. 5% or more in one month. 3. 7 1/2% or more in 3 months 4. 10% or more in 6 months.
The Weight Policy documents Within a week after weights have been received and reviewed by the Nursing Department and Dietary Manager, the Weight Committee will meet to discuss and recommend the need for any possible dietary interventions or diet order changes. If the Dietician is present in the facility, the Committee will consult with her. If not, they will simply notify the physician for the possibility of new orders.
R89's Medical Record documents the following weights: 7/20/22 232.8 pounds, 8/6/22 294.4 pounds, 8/8/22 293.0 pounds, 8/17/22 292.1 pounds and 8/22/22 293.0 pounds
R89's Progress Notes document that he was seen on 8/23/22 by V11 (Registered Dietician). V1 documented Resident experienced an undesirable weight gain this month. Unsure etiology of large weight gain in short time period. BMI (Body Mass Index): 42.0, obesity class III.
R89's Medical Record did not have any documentation of R89's Doctor being notified of his significant weight gain.
8/31/22 at 11:30 AM V4 (Dietary Manager) stated I give all the weights to the nursing department to notify doctors and to handle it.
8/31/22 at 12:00 P.M. V2 DON (Director of Nursing) stated I haven't seen the August weights. V2 stated that R89 should have been reweighed and was not. V2 confirmed that R89's doctor had not been notified of the 26.46% weight gain in one week.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
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 medical symptoms, failed to obtain a physician...
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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 medical symptoms, failed to obtain a physician order, failed to assess - including length of application time and frequency of release for the use of a wheelchair lap seatbelt for one resident (R29) of two residents reviewed for wheelchair lap belts in the sample of 34.
Findings include:
Current Physician's Orders indicate R29 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that include Traumatic Brain Injury, Schizoaffective Disorder, Abnormality of Gait/Mobility and Extrapyramidal Movement Disorder.
Current Comprehensive Assessment indicates R29 is moderately cognitively impaired.
On 8/30/22 at 1:15pm and 8/31/22 at 9:15am and 2:20pm R29 was sitting in a wheelchair with an airline-style lap seatbelt. R29 did not respond verbally or with eye contact when greeted and was noted to have small non-purposeful movements of upper and lower extremities.
On 8/31/22 at 9:15am V10, CNA (Certified Nurse Assistant) stated that R29 can sometimes release the seatbelt himself but can't use the call light or feed himself. At that time, V10 instructed R29 to release the seatbelt, telling R29 to push the button and physically motioning toward the seatbelt. R29 made no purposeful movement to attempt to remove the seatbelt. R29's hands/fingers were stiff and appeared unable to manipulate the button-release or even move the belt itself. R29 did not seem able to acknowledge V10's instruction or staff's presence in the room. R29 did not look up toward V10 or move his head in a manner to look at the seatbelt. V9, CNA entered the room and stated that R29 is unable to remove the seatbelt and has not been able to for a month or two.
V10 stated that R29 had a different wheelchair before this one and it also had a seatbelt.
On 8/31/22 at 2:25pm V9 assisted R29 to the bathroom, R29 was not able to follow instruction for standing and grabbing onto the grab bar - V9 had to physically place R29's hands on the grab bar. V9 again stated that R29 has changed and cannot release the seat belt any longer.
Fall Follow-Up dated 2/25/22 8pm indicates R29 had a fall in the dining room Lost balance while ambulating - released his seatbelt and got up from wheelchair.
Physician List of residents to be seen dated 2/9/22 indicates Orders: (R29) may wear self-release seatbelt if he allows.
No orders were found or presented for a self-release seat belt for R29.
Progress Note dated 4/2/22 indicates R29 was readmitted to the facility from the hospital after a 33 day hospital stay for an infection.
Progress Note dated 4/9/22 indicates R29 Now in a wheelchair.
Progress Note dated 6/21/22 indicates R29 In a wheelchair now.
No progress notes were found or presented that addressed the use of a lap seatbelt for R29.
On 08/31/22 at 11:12am V2, DON (Director of Nursing) stated We consider (R29's) seatbelt an assisted device - we don't do assessments for assisted devices. (R29) can release the seatbelt. We can't have restraints here. They have to be able to self-release.
On 9/01/22 at 12:40pm V8, Restorative Nurse stated that she has been the Restorative Nurse for two months and stated (R29) already had a seat belt when I took over. From what I understand he was put in a wheelchair with the lap belt because of all the falls. It was a safety/compliance issue. I don't know anything about assessments for a seatbelt.
On 9/1/22 both V2 and V12, MDS (Minimum Data Set) Coordinator stated that they recognize that R29 has declined and will ask the MD for a Hospice Evaluation order.
R29's medical record did not include a physicians order, consent, medical symptoms, assessment, length of time lap belt would be applied/released, or any on-going re-evaluation for use of a lap seatbelt. No documentation was found or presented that identified when the lap seatbelt was initiated.
R29's Care Plan did not include the lap seatbelt until 8/31/22.
On 9/1/22 a request was made for the facility's restraint policy. A policy entitled Physical Function Policy was presented by V2, DON who stated This is the only policy we have that mentions restraints.
Facility Policy/Physical Function Policy dated 3/2000 documents:
Physical Restraints are not used for purposes of discipline or convenience, but only as required to treat the resident's medical symptoms.
No other information in the policy addressed restraints.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to implement its abuse policy of immediately reporting abuse, separating, and placing a resident on one-to-one supervision and investigating a...
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Based on interview and record review, the facility failed to implement its abuse policy of immediately reporting abuse, separating, and placing a resident on one-to-one supervision and investigating an allegation of resident-to-resident physical abuse for two of seven residents (R101 and R104) reviewed for abuse in the sample of 11.
FINDINGS INCLUDE:
The facility policy, Abuse Prevention Program Facility Procedures, dated (revised) 9/15/22 directs staff, Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator. Residents involved in a physical altercation will be separated and placed on one- to-one supervision for 12 hours. Upon learning of the report, the administrator or a designee shall initiate an incident investigation.
On 11/11/22 at 10:06 A.M., V4/Quality Assurance Nurse, Abuse Coordinator stated, I am unaware of any resident to resident physical abuse between (R101) and (R104). No one told me about the incident of (11/4/22). I didn't report the incident to (V1/Administrator) and I didn't report the incident to the (state agency).
On 11/11/22 at 10:12 A.M., V5/Social Services Assistant stated, I was in my office on (11/4/22) around 12:30 or so and I saw (R101) trying to move his wheelchair between tables. (R101) and (R104) started calling each other names, then I saw (R101) slap (R104) across the face. (R107) got up and pushed (R101's) wheelchair away from (R104). I went and talked to (R104). (R104) didn't have a visible mark on her face, but she was mad. I didn't report the incident to (V1 Administrator). (R101) was not put on one-to-one supervision after the incident.
CONCERN
(D)
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 ensure one allegation of abuse was immediately reported to the Administrator for two of seven residents (R101 and R104) reviewed for abuse ...
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Based on interview and record review, the facility failed to ensure one allegation of abuse was immediately reported to the Administrator for two of seven residents (R101 and R104) reviewed for abuse in the sample of 11.
FINDINGS INCLUDE:
On 11/4/22 at 12:26 P.M., V5/Social Services Assistant documented in R104's electronic medical record, There was an altercation between (R104) and (R101). (R101 and R104) called each other names. (R101) slapped (R104). There were no visible injuries. Another resident stepped in to protect (R104).
On 11/11/22 at 10:12 A.M., V5/Social Services Assistant stated, I was in my office on (11/4/22) around 12:30 or so and I saw (R101) trying to move his wheelchair between tables. (R101) and (R104) started calling each other names, then I saw (R101) slap (R104) across the face. (R107) got up and pushed (R101's) wheelchair away from (R104). I went and talked to (R104). (R104) didn't have a visible mark on her face, but she was mad. I didn't report the incident to (V1Administrator).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to thoroughly investigate a claim of abuse for one resident (R72) of 19...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to thoroughly investigate a claim of abuse for one resident (R72) of 19 residents reviewed for abuse in a total sample of 34.
Findings Include:
The Facility's undated Abuse Prevention Program Resident Protection Investigation Procedure defines Verbal Abuse as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Mental Abuse is defined as Included but not limited to, humiliation harassment, threats of punishment or deprivation.
The Facility's undated Abuse Prevention Program Resident Protection Investigation Procedure documents all incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. Any incident or allegation, involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation.
The Facility's undated Abuse Prevention Program Resident Protection Investigation Procedure documents The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interview able. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents. Resident to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed to determine whether anyone has witnessed any prior abuse, neglect, exploitation, mistreatment or misappropriation of property by the accused individual.
The Facility's undated Abuse Prevention Program Resident Protection Investigation Procedure documents All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. Reports should be documented, and a record kept of the documentation.
R71's Medical Record documents R71 was admitted to the facility on [DATE] with a diagnosis of COPD (Chronic Obstructive Pulmonary Disease), Type II Diabetes Mellitus, Schizoaffective Disorder and Unspecified Mood Disorder.
R71's admission MDS (Minimum Data Set) dated 5/3/22 documents a BIMS (Brief Interview for Mental Status) score of 15/15, which indicates R71 is cognitively intact.
R72's Medical Record documents R72's Medical Record documents R72 was admitted to the facility on [DATE] with a diagnosis of Bipolar Disorder, Type II Diabetes Mellitus and COPD (Chronic Obstructive Pulmonary Disease). R72's admission MDS (Minimum Data Set) dated 5/3/22 documents a BIMS (Brief Interview for Mental Status) score of 12/15, which indicates R71 has some cognitive impairment.
On 8/31/22 at 12:22 PM, R72 states he was made to get out of his girlfriend's bed while he was naked and get dressed in front of a nurse and leave the room. I was humiliated. R72 stated that he and R71 have been consensual sexual partners for quite a while. I would consider what she did to be abusive, I was willing to get up and leave I just wanted her to give me privacy, but she wouldn't because she was pissed.
On 8/31/22 at 12:23 P.M. R71 stated (V5/LPN) barged in on us while we were having sex and made (R72) get out of the bed while he was naked. He kept asking her to pull the curtain or to turn around and she said she wasn't moving or turning around until (R71) was dressed and out of the room. R71 stated that she and R71 had been consensual sexual partners for years.
On 8/31/22 at 11:00 A.M. V5 (LPN) denied ever having any concerns with R71 and R72 having sex. Stated I have had to ask him to leave her room in the middle of the night but that was for (R33/R71's roommate) privacy. V5 denied ever encountering R72 while he was naked.
On 8/31/22 at 1:00 P.M. V1 (Administrator) stated that V3 (Social Services Director) is the Abuse Coordinator for the facility. V1 stated that he filled out the abuse investigation for state just to help her out. V1 stated he was only told by the Ombudsman (V6) that (R72) felt sexually harassed. V1 was unable to verbalize specific allegations made by R72. You could ask V7 (Human Resources/CNA) she was working when this all happened.
On 8/31/22 at 3:00 P.M. V7 (Human Resources/CNA) stated I was working the floor the day this all happened. It happened about 2 months ago. It was about 230-300 PM; I was getting ready to leave because I had worked the floor as a CNA that day. I saw (V5/LPN) hustling up the C hallway with (R71) following her yelling at her and cussing her. V5 was crying and upset and told me It's not fair that they (R71 and R72) were just having sex in that room with (R33) in the other bed sleeping. It's just not fair to (R33). V7 stated that V5 LPN told her that she had walked in on R71 and R72 having sex and that she had told R72 that he had to get up and get dressed immediately because there was another woman in the room other than R71. V7 stated she has never had concerns with R71 and R72 being sexually inappropriate. V7 states, They always close the door and pull the privacy curtain around them when I have worked down there. V7 stated that R33 had never complained to her regarding R71 and R72.
On 9/1/22 at 10:00 A.M. R33 Stated that she liked R71 and R72. R33 stated that R72 used to spend the night sometimes in her and R33's room. R33 denied any concerns with R72 being in the room. Stated they didn't ever bug me. They pulled the thing (curtain) when they went to bed.
On 8/30/22 at 3:30 P.M. V6 (Ombudsman) stated she had serious concerns regarding the investigation into (R71 and R72's) abuse allegation regarding V5 (LPN). I spoke with (V1/Administrator) and told him exactly what (R71 and R72) told me about the nurse actually interrupting a sexual act and insisting (R72) leave her room although (R71) was consenting. I feel like it was blown off.
Preliminary and Final Abuse Investigation Report dated 8/19/22 documents Resident reports to Ombudsman that he felt sexually harassed by the third shift nurse (V5/ LPN). Resident reported that incident happened 2-3 months ago. During the process of investigation, medical record review and interview of witnesses, the following facts were determined: Resident interviews: Nurse had gone in resident room who was in bed with his girlfriend and reminded of facility rules to no overnight at midnights and he was disturbing her roommate. Based on known facts, the following conclusion have been determined about the original allegation: allegation unfounded. No evidence of abuse. Resident reported that employee is old and very religious but would never be sexually inappropriate.
On 8/31/22 V3 (SSD) and V1 (Administrator) stated that the preliminary/final abuse investigation provided is the only documentation related to the investigation. V1 confirmed there were no resident or staff statements or a list of who was interviewed available.
On 8/31/22 at 2:30 P.M. V3 (SSD) confirmed that the written abuse investigation did not include the allegations that R71 and R72 verbalized against V5/ LPN.
On 8/31/22 at 2:30 P.M. V3 (Social Services Director) stated (V1/Administrator) handled most of this investigation. I interviewed (R71) and (R72) about their allegation after the Ombudsman told (V1/Administrator). Both residents stated that (V5/LPN) entered (R71)'s room and found (R71) and (R72) having sex. Both residents reported that (V5 LPN) pulled privacy curtain back and pulled cover off the residents and stated that (R72) had to get out of the bed immediately and get dressed and leave the room. V3 stated that R72 was very embarrassed. V3 stated that R71 told her, I had no problem with her wanting me out of the room because of (R33/roommate) but I told her I did not want to get up naked with her in the room and she said, too bad, I am not leaving until you are dressed. V3 stated, (R72)'s main concern for being upset seemed to be that (V5 LPN) would not provide privacy for him to get dressed, he seemed very embarrassed. V3 stated that she was not aware of any complaints made to anyone regarding inappropriate sexual contact between R71 and R72. V3 stated R33 (V71's roommate) has never complained to V3's knowledge regarding R71 and R72 having a relationship and/or spending time together in R71 and R33's room. V3 stated that R71 and R72 were a known couple upon admission and have reported to be together for at least 2 years. These two cohabitated prior to coming to this facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to develop a weight loss care plan for one (R72) of 20 residents reviewed for care plan development in the sample of 34.
Finding...
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Based on observation, interview, and record review the facility failed to develop a weight loss care plan for one (R72) of 20 residents reviewed for care plan development in the sample of 34.
Findings include:
The facility's undated Interdisciplinary Care Plan Policy, documents The development, implementation, and maintenance of a patient's plan of care is an interdisciplinary process. All disciplines involved in the care of a patient collaborate to develop the patient's plan of care.
R72's 8/15/22 Quarterly MDS (Minimum Data Set) assessment documents R72 has had a significant weight loss, not on prescribed weight-loss regimen.
On 8/31/22 at 9:01 AM, R72 stated she has lost 70 pounds since admitting to the facility.
R72's current Care Plan does not include any documentation regarding R72's significant weight loss.
R72's weight log, documents the following weights for R72: 10/6/21 at 303.6, 11/3/21 at 303.2, 12/18/21 at 293.0, 1/5/22 at 289.2, 2/2/22 at 278.4, 3.1.22 at 274.0, 4/9/22 at 263.4, 5/12/22 at 260.4, 6/10/22 at 255.4, 7/3/22 at 252.6 and 8/6/22 at 246.0. On 10/06/2021, the resident weighed 303.6 lbs. On 04/09/2022, the resident weighed 263.4 pounds which is a -13.24 % Loss in six months. On 11/03/2021, the resident weighed 303.2 lbs. On 02/02/2022, the resident weighed 278.4 pounds which is a -8.18 % Loss in three months. On 11/03/2021, the resident weighed 303.2 lbs. On 05/12/2022, the resident weighed 260.4 pounds which is a -14.12 % Loss in six months. On 02/02/2022, the resident weighed 278.4 lbs. On 08/06/2022, the resident weighed 246.0 pounds which is a -11.64 % Loss in six months.
On 9/02/22 at 8:29 AM, V12 LPN (Licensed Practical Nurse) MDS/CPC (Care Plan Coordinator) stated R4 has had a significant weight loss but is also wanting to lose weight. V12 verified R4's current care plan does not include a weight loss care plan and stated she would make sure R4 has one.
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 revise the plan of care for two (R4 and R69) of twenty residents reviewed for care planning in the sample of 34.
Findings inc...
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Based on observation, interview, and record review the facility failed to revise the plan of care for two (R4 and R69) of twenty residents reviewed for care planning in the sample of 34.
Findings include:
The facility's undated Interdisciplinary Care Plan Policy, documents The patient goals and plan of action are updated by the individual who identified the problem, or by other healthcare team members according to their expertise and credentials. The patient's progress will be monitored as necessary, and the plan of care will be revised as indicated.
1. On 8/31/22 at 9:02 AM, R4 opened her mouth to reveal her left front tooth missing and stated she went to the dentist on 8/16/22 and had the tooth pulled.
The 8/15/22 Quarterly MDS (Minimum Data Set) assessment documents R4 has obvious or likely cavity or broken natural teeth.
The Progress Notes for R4 document resident was seen by the local dentist for exam, x-rays, and tooth extraction on 8/16/22.
R4's current Care Plan documents (R4) has own teeth and some are in poor repair. The goal documents Will have no oral pain. This Care Plan does not include R4's 8/16/22 extraction.
On 9/02/22 at 8:28 AM, V12 LPN (Licensed Practical Nurse) MDS/CPC (Care Plan Coordinator) stated R4's tooth extraction on 8/16/22 should have been put on R4's Dental care plan and wasn't and (V12) will make sure R4's care plan is updated.
2. On 8/30/22 at 2:00 PM, R69 was sitting outside on the patio smoking cigarettes independently. R69 walked into the facility from the patio area.
On 8/30/22 at 2:03 PM, R69 stated she can smoke independently and carry her own smoking materials and does not need supervised.
R69's current Care Plan documents an initial Smoking Care Plan was initiated on 9/30/21 and documents R69 to be supervised while smoking.
The Smoking Assessment for R69, dated 7/22/22, documents May independently be able to handle own smoking materials.
On 9/02/22 at 8:31 AM, V12 LPN (Licensed Practical Nurse) MDS/CPC stated R69 is an independent smoker and (R69's) Care Plan should have been revised and she will make sure it gets updated.
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 provide a foot brace for one resident (R52) of three re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a foot brace for one resident (R52) of three residents reviewed for mobility in the sample of 34.
Findings include:
Facility Policy (Procedure)/Ankle Foot Orthosis (AFO) Instructions:
Carefully check the foot and leg for pressure areas after each wear period. Remove the orthosis and sock; note any redness or irritation, particularly over bony prominences.
On 8/30/22 at 10:15am R52 was in a wheelchair and stated he is supposed to have AFO (Ankle Foot Orthosis) brace on his left foot at night To stretch my Achilles. R52 stated the brace is Kept locked up and they don't give it to him.
On 9/1/22 at 11am R52 stated he was not given his AFO brace the previous night and stated, They never give it to me.
Current Comprehensive Assessment indicates R52 is cognitively intact.
Current Care Plan (dated initiated 4/28/21) indicates R52 has impaired mobility on left side of body and wears an AFO on left side. Intervention dated 4/28/21 indicates Apply AFO for ambulation, observe for pain/tolerance of wearing AFO.
Restorative assessment dated [DATE] 8:08am does not include any assessment regarding R52's AFO brace.
Current Physician's Order indicates Adjust, Repair or Replace Prosthetic Brace as needed ordered on 5/27/22.
No physician's order to apply R52's AFO brace was included in the physician's orders.
On 9/1/22 at 10:15am V2 stated that applying and removing R52's AFO brace is not on the MAR (Medication Administration Record) or TAR (Treatment Administration Record) because restorative takes care of it. V2 acknowledged there was no physician order for application of R52's AFO brace or documentation of application/removal.
On 9/1/22 at 10:30am V8, Restorative Nurse stated that R52's AFO brace was changed from wearing it in the day to wearing it at night. At that time, V8 was asked where R52's brace was kept. V8 stated it is kept in the Restorative Office, but she did not have a key to the office because she accidentally locked it inside the office. Several other staff members were asked if they had a key without success. Maintenance staff was then notified and able to gain access to the room approximately 20 minutes later where R52's AFO brace was found.
No documentation was found or presented to indicate staff were offering/applying R52's AFO brace or checking for skin irritation from use of the brace.
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 changes have you made since the serious inspection findings?"
- "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
- • 22% annual turnover. Excellent stability, 26 points below Illinois's 48% average. Staff who stay learn residents' needs.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 1 life-threatening violation(s), 4 harm violation(s), $235,100 in fines. Review inspection reports carefully.
- • 33 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $235,100 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 Sharon Health Care Pines's CMS Rating?
CMS assigns SHARON HEALTH CARE PINES an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Illinois, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Sharon Health Care Pines Staffed?
CMS rates SHARON HEALTH CARE PINES's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 22%, compared to the Illinois average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Sharon Health Care Pines?
State health inspectors documented 33 deficiencies at SHARON HEALTH CARE PINES during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 4 that caused actual resident harm, 27 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Sharon Health Care Pines?
SHARON HEALTH CARE PINES is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 116 certified beds and approximately 103 residents (about 89% occupancy), it is a mid-sized facility located in PEORIA, Illinois.
How Does Sharon Health Care Pines Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, SHARON HEALTH CARE PINES's overall rating (1 stars) is below the state average of 2.5, staff turnover (22%) is significantly lower than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Sharon Health Care Pines?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the below-average staffing rating.
Is Sharon Health Care Pines Safe?
Based on CMS inspection data, SHARON HEALTH CARE PINES has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Illinois. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Sharon Health Care Pines Stick Around?
Staff at SHARON HEALTH CARE PINES tend to stick around. With a turnover rate of 22%, the facility is 24 percentage points below the Illinois average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 25%, meaning experienced RNs are available to handle complex medical needs.
Was Sharon Health Care Pines Ever Fined?
SHARON HEALTH CARE PINES has been fined $235,100 across 2 penalty actions. This is 6.6x the Illinois average of $35,430. 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 Sharon Health Care Pines on Any Federal Watch List?
SHARON HEALTH CARE PINES 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.