GOLDWATER PONTIAC NURSING HOME
For profit - Corporation
90 Beds
GOLDWATER CARE
Data: November 2025
Trust Grade
43/100
#365 of 665 in IL
Photo by Goldwater Care Pontiac
Photo by Goldwater Care Pontiac
Photo by Meir Katzenstein
1 / 5 photos
Last Inspection: May 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Goldwater Pontiac Nursing Home has a Trust Grade of D, which indicates below-average performance and some concerning issues. It ranks #365 out of 665 facilities in Illinois, placing it in the bottom half, and #6 out of 6 in Livingston County, meaning only one local option is better. The facility is showing improvement, with issues decreasing from 14 in 2024 to 3 in 2025. However, staffing is a weakness, rated only 1 out of 5 stars, with a turnover rate of 48%, which is average but still indicates instability among staff. There are also specific concerns, such as a resident not receiving necessary behavioral health services for major depression, which left them feeling tearful and anxious, and failures in infection control that could potentially affect all residents. While the facility has no critical issues, these weaknesses should be carefully considered alongside its improving trend.
- Trust Score
- D
- In Illinois
- #365/665
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 48% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $13,635 in fines. Higher than 66% of Illinois facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 21 minutes of Registered Nurse (RN) attention daily — below average for Illinois. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 32 deficiencies on record. Higher than average. Multiple issues found across inspections.
43/100
Bottom 46%
Needs review
14 → 3 violations
★★☆☆☆
2.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 14 issues
2025: 3 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Below Illinois average (2.5)
Below average - review inspection findings carefully
Staff Turnover: 48%
Near Illinois avg (46%)
Higher turnover may affect care consistency
Federal Fines: $13,635
Below median ($33,413)
Minor penalties assessed
Chain: GOLDWATER CARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 32 deficiencies on record
1 actual harm
Aug 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to protect a resident's right to be free from misappropriation of money for one of 10 residents (R86) reviewed for misappropriation of property...
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Based on interview and record review the facility failed to protect a resident's right to be free from misappropriation of money for one of 10 residents (R86) reviewed for misappropriation of property in the sample list of 38. On 8/18/2025 at 10:40 AM, R86 stated R86 thought her money was in her purse, but when she went to get her hair done there were only singles left, and the large bills were gone, which was $80. R86 stated R86 had gotten $40-$50 from V10 Business Office Manager and had some money left over from a prior withdrawal. R86 stated R86 keeps her purse in her room and does not leave her room, so the only time someone could have taken it was during the night when R86 was asleep. R86 stated the facility replaced the $80. On 8/19/25 at 9:30 AM R86 stated R86 is unsure what happened to her missing $80 but is certain R86 did not misplace it. R86 stated R86 always keeps her purse in her closet but now is keeping it with her at all times. R86 stated there was only one time, over six months ago, when an unidentified person was going through R86's closet during the night and asked R86 how many pairs of jeans R86 had. R86's Nursing Note dated 7/28/25 documents R86 as alert and oriented to person, place, and time. The facility's investigative file of R86's allegation of misappropriation of money contained the following information: The Initial Abuse Investigation Report dated 7/1/25 documents on 7/1/25 at 3:00 PM R86's Family, V23, reported to V1 Administrator that $80.00 was missing from R86's room. The facility's Final Abuse Investigation Report dated 7/3/25 documents resident and staff interviews were conducted, and R86's room, laundry, and common areas were searched and were unable to locate the missing funds which would be replaced by the facility. This report documents R86 stated R86 never goes out to activities or the dining room, R86 is always in her room, and was unsure where the missing funds could have gone. R86's Cash Disbursement Forms dated 5/14/25 and 6/10/25 document R86 made a cash withdrawal of $50 on these dates from her resident trust fund account and was signed by both R86 and V10. On 8/19/25 at 12:51 PM, V1 Administrator stated R86 was not sure of the exact day that the money went missing. Stated R86 goes out on Mondays to get her hair done and R86 stated on Monday 6/30/25 R86 realized R86's cash was no longer in her purse. V1 stated R86's $80 was unable to be located.On 8/19/25 at 2:46 PM, V23 stated R86 went to get her hair done on 6/30/25 and didn't have money to pay. V23 confirmed R86 was missing $80. V23 stated R86 keeps money in her purse to pay for her hair appointments, and V23 knows that R86 did not misplace the money. V23 stated V23 believes someone took R86's money during the night while R85 was asleep. On 8/19/2025 at 2:07 PM, V10 confirmed R86 made $50 cash withdrawals on 4/2/25, 5/14/25, and 6/10/25. V10 stated the largest bill she gives out is a $20 bill and typically would give two $20 bills and one $10 bill. On 8/19/25 at 2:30 PM, V6 Licensed Practical Nurse confirmed R86's credibility. V6 also stated R86 is alert and oriented to person, place, time, and situation; has never been dishonest; and has no history of prior accusations or behaviors. The facility's Abuse Prevention and Reporting-Illinois policy dated 10/24/22 documents the facility affirms the resident's right to be free from misappropriation of property, which means the deliberate misplacement, exploitation, or wrongful use of a resident's belongings or money without the resident's consent.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to conduct a thorough investigation of an allegation of misappropriation of funds for one of ten residents (R86) reviewed for mis...
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Based on observation, interview, and record review the facility failed to conduct a thorough investigation of an allegation of misappropriation of funds for one of ten residents (R86) reviewed for misappropriation of property in the sample list of 38. On 8/18/2025 at 10:40 AM R86 stated R86 thought her money was in her purse, but when she went to get her hair done there were only singles left, and the large bills were gone, which was $80. R86 stated R86 had gotten $40-$50 from V10 Business Office Manager and had some money left over from a prior withdrawal. R86 stated R86 keeps her purse in her room and does not leave her room, so the only time someone could have taken it was during the night when R86 was asleep. R86 stated the facility replaced the $80. On 8/19/25 at 9:30 AM R86 stated R86 is unsure what happened to her missing $80 but is certain R86 did not misplace it. R86 stated R86 always keeps her purse in her closet but now is keeping it with her at all times. R86 stated there was only one time, over six months ago, when an unidentified person was going through R86's closet during the night and asked R86 how many pairs of jeans R86 had. On 8/18/25 during general intermittent observations between 9:30 AM and 4:15 PM there were video surveillance cameras located throughout the 300 unit, including on R86' hallway. R86's Nursing Note dated 7/28/25 documents R86 as alert and oriented to person, place, and time. The facility's investigative file of R86's allegation of misappropriation of money contained the following information: The Initial Abuse Investigation Report dated 7/1/25 documents on 7/1/25 at 3:00 PM R86's Family, V23, reported to V1 Administrator that $80.00 was missing from R86's room. The facility's Final Abuse Investigation Report dated 7/3/25 documents resident and staff interviews were conducted, and R86's room, laundry, and common areas were searched and were unable to locate the missing funds which would be replaced by the facility. This report documents R86 stated R86 never goes out to activities or the dining room, R86 is always in her room, and was unsure where the missing funds could have gone. This report documents the floor nurse and nurse aides were interviewed but were not aware funds in R86's room but does not identify that video surveillance was reviewed or which specific staff were interviewed. R86's Cash Disbursement Forms dated 5/14/25 and 6/10/25 document R86 made a cash withdrawal of $50 on these dates from her resident trust fund account and was signed by both R86 and V10.On 8/19/25 at 2:46 PM, V23 stated R86 went to get her hair done on 6/30/25 and didn't have money to pay. V23 confirmed R86 was missing $80. V23 stated R86 keeps money in her purse to pay for her hair appointments, and V23 knows that R86 did not misplace the money. V23 stated V23 believes someone took R86's money during the night while R85 was asleep. On 8/19/25 at 12:51 PM, V1 Administrator stated R86 was not sure of the exact day that the money went missing. V1 stated R86 goes out on Mondays to get her hair done and R86 stated the following Monday (6/30/25) R86 realized R86's cash was no longer in her purse. V1 stated R86's $80 was unable to be located and it is hard to say if R86's money was lost in the facility or while out in the community. On 8/19/25 at 1:53 PM V1 confirmed the entire investigative file for R86's allegation was provided. V1 stated V1 did review video surveillance for night shift and interviewed staff but has no documentation of this. V1 stated since R86 wasn't able to identify a specific date that the money went missing, V1 didn't have a certain date to review video surveillance. V1 stated video surveillance is only kept for 30 days.On 8/19/2025 at 2:07 PM, V10 confirmed R86 made $50 cash withdrawals on 4/2/25, 5/14/25, and 6/10/25. V10 stated the largest bill she gives out is a $20 bill and typically would give two $20 bills and one $10 bill. On 8/19/25 at 2:30 PM, V6 Licensed Practical Nurse confirmed R86's credibility. V6 also stated R86 is alert and oriented to person, place, time, and situation; has never been dishonest; and has no history of prior accusations or behaviors. The facility's Abuse Prevention and Reporting-Illinois policy dated 10/24/22 documents the facility affirms the resident's right to be free from misappropriation of property, which means the deliberate misplacement, exploitation, or wrongful use of a resident's belongings or money without the resident's consent. This policy documents the administrator, or designee will initiate an incident investigation, and will at a minimum attempt to interview the person who reported the incident, anyone likely to have knowledge of the incident, the resident, and any employees with whom the accused has regularly worked with.
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
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain physician orders for the use and care of a CPA...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain physician orders for the use and care of a CPAP (continuous positive airway pressure) for one of two residents (R6) reviewed for respiratory care on the sample list of 38. On 8/18/2025 at 10:08 AM there was a CPAP machine on R6's desk in R6's room. R6 stated R6 is suppose to use it, but has had problems getting parts for it. R6 removed the filter from the machine to show the filter was dirty, covered in gray debris/dust. R6 stated R6 has talked to facility staff about needing parts for the machine. R6's Minimum Data Set, dated [DATE] documents R6 has severe cognitive impairment. R6's active physician orders and active care plan do not document the use or care of R6's CPAP machine as of 8/18/25. On 8/18/2025 at 3:54 PM V6 Licensed Practical Nurse stated R6 sleeps in her recliner and uses the CPAP machine, at least for the last five months that V6 has worked in the facility. V6 stated there should be physician's orders for use and care that would prompt to document on the Treatment Administration Record (TAR). V6 confirmed R6 did not have any physician's orders regarding the use of the CPAP. On 8/19/25 at 4:54 PM V21 Registered Nurse stated V21 works night shift and R6 has used a CPAP for about 5-6 months, R6 applies and cares for the machine herself. On 8/19/2025 at 12:08 PM V2 Director of Nursing stated CPAPs should be rinsed/washed on Mondays, and need filled with distilled water. V2 stated there should be physicians orders for use and documented on the TAR. V2 stated V2 would have to look at the facility's policy regarding changing filters on CPAPs. V2 stated V2 just found out about R6's CPAP yesterday and obtained orders for use/care. V2 stated it probably isn't care planned since we just found out about it yesterday. The facility's undated CPAP Therapy policy documents to verify physician orders, if ordered connect humidifier to CPAP unit, fill humidifier with distilled sterile water, and adjust the ramp to prescribed time if ordered. This policy documents to use a soft cloth and gently wash th3 mask or pillows with a solution of warm water and mild detergent, rings, and allow to air dry; wash/rinse/dry tubing as necessary; clean and inspect all components regularly. This policy documents that disposable filters should be replaced according to manufacturer's instructions, and reusable filters should be rinsed of dust and allowed to air dry. The User Manual dated 2021 for R6's CPAP machine, documents the device should only be used as instructed by a physician, including correct pressure settings, device configurations, and accessories. This user manual documents the device uses a reusable blue pollen filter that can be rinsed and includes an automatic reminder every 30 days to check and replace filters as directed.
Nov 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to timely notify a resident representative and physician of an allegati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to timely notify a resident representative and physician of an allegation of abuse for one (R1) of 38 residents reviewed for abuse in the sample list of 38.
Findings include:
The facility's policy Physician-Family Notification - Change in Condition dated 11/13/18 documents the facility will notify the resident's representative and physician when there is an accident involving the resident that results in injury and has the potential for requiring physician intervention, when there is a significant change in the resident's health, mental, or psychosocial condition, or when there is a need to alter treatment significantly.
On 11/25/24 at 10:03-10:20 AM R1 stated last Wednesday (11/20/24) R1 needed repositioned in bed, V4 and V5 Certified Nursing Assistants were rough and R1 felt R1's back and ribs pop when V4 and V5 jerked R1 over in bed. R1 stated V4 and V5 yelled at R1 too. R1 stated R1 reported this to an unidentified nurse that evening. R1 stated R1 had right side pain since the incident, x-rays were completed around midnight last night, and nothing was broken. V7 (R1's Family Member) stated R1 reported this incident to V7 on the morning of 11/22/24, a few hours later V7 posted this allegation on (social media platform) and then the facility contacted V7 about the incident.
R1's Minimum Data Set, dated [DATE] documents R1 as cognitively intact.
R1's Concern/Compliment Form dated 11/20/24 documents R1 stated V4 and V5 were being mean, had bad attitudes, and moved R1 in a rough fashion. This form documents staff were re-educated on customer service and to remember to be nice, smile, and be patient. There is no documentation in R1's medical record that this allegation was reported to V20 Medical Director/V21 (R1's Physician) and V7 prior to 11/22/24.
The facility's initial report to the Illinois Department of Public Health dated 11/22/24 documents on 11/22/24 at 7:08 PM V7 posted on (social media platform) an allegation of abuse of R1 by V4 and V5 and the post was sent to V1 Administrator. This report documents R1's family and physician were notified. V1's typed notes dated 11/20/24 documents that afternoon R6, resident council president, reported to V1 that R1 said V4 and V5 were rude to R1, expected R1 to do things for herself, and were rough when they repositioned R1 in bed. This note documents V1, V10 Social Services Director, and R6 spoke to R1 who voiced the same concerns as reported to R6. V1's typed notes dated 11/22/24 document R1 told V1 that during the incident R1 felt a pop in her ribs, V1 offered to have x-rays done, V1 asked V12 Licensed Practical Nurse to assess R1 for injury, and V1 notified V7 to schedule a meeting to discuss R1's concerns.
R1's Nursing Note dated 9:59 PM documents R1 was assessed and had no injury and no complaints of pain, V7 was notified, and a message was left for V21 to return call. R1's Nursing Note dated 11/22/24 at 10:01 PM documents V20 was notified of R1's abuse allegation and obtained new order for x-ray of right ribs.
On 11/25/24 at 2:02 PM-2:20 PM V1 Administrator stated around 2:00 PM on 11/20/24 R6 said R1 reported V4 and V5 were rude to R1, expected R1 to do things for herself, and they were rough with R1. V1 stated V1 spoke with R1 and R1 reported the same things that R6 told V1. V1 stated V1 was out of the facility on 11/21/24, V1 followed up with R1 on 11/22/24, and at that time R1 reported that during the alleged incident R1 felt a pop in her ribs and was unable to shampoo R1's hair on 11/22/24, so V1 asked a nurse to assess R1. V1 stated on the evening of 11/22/24 V1 received a copy of V7's social media post alleging abuse of R1, and that is when V1 reported the incident and the nurse notified the physician that night.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to timely notify the administrator, state survey agency, and local law ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to timely notify the administrator, state survey agency, and local law enforcement of an allegation of abuse for one (R1) of 38 residents reviewed for abuse in the sample list of 38.
Findings include:
The facility's Abuse Prevention, Identification, and Reporting Program Policy and Procedure dated 9/10/19 documents employees are required to immediately report any potential/actual abuse or mistreatment that they observe, hear about, or suspect to the facility's Administrator. This policy documents the Illinois Department of Public Health will be notified within several hours of the reported allegation, not to exceed 24 hours, and other external agencies will be notified such as local/state law enforcement as indicated based on the nature of the allegation, physical injuries, and as required per state/federal regulations.
On 11/25/24 at 10:03-10:20 AM R1 stated last Wednesday (11/20/24) R1 needed repositioned in bed, V4 and V5 Certified Nursing Assistants were rough and R1 felt R1's back and ribs pop when V4 and V5 jerked R1 over in bed. R1 stated V4 and V5 yelled at R1 too. R1 stated R1 reported this to an unidentified nurse that evening. R1 stated R1 had right side pain since the incident, x-rays were completed around midnight last night, and nothing was broken. V7 (R1's Family Member) stated R1 reported this incident to V7 on the morning of 11/22/24, a few hours later V7 posted this allegation on (social media platform), and then the facility contacted V7 about the incident.
On 11/25/24 at 12:01-12:17 PM R6 stated on 11/20/24 around 12:30 PM V19 Housekeeper said R1 wanted to speak with R6. R6 stated R1 told R6 that V4 and V5 were being very rough and abusive to R1. R6 stated R6 asked what R1 meant, and R1 said V4/V5 told R1 to turn and pulled on R1 while attempting to reposition R1 as R1 was holding onto the bed rail. R6 stated R1 said V4/V5 moved R1's legs back and R1 felt R1's back crack. R6 stated R6 reported this to V1 within 15 minutes, they went to speak to R1 together, and R6 said V4/V5 brutally hurt R1, they cussed R1 out, they were aggressive and mean to R1 as they jerked R1 around and yelled at R1. R6 stated R1's story changed and R1 denied the staff cussed at R1 when asked by V1.
R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. R6's MDS dated [DATE] documents R6 as cognitively intact.
R1's Concern/Compliment Form dated 11/20/24 documents R1 stated V4 and V5 were being mean, had bad attitudes, and moved R1 in a rough fashion. This form documents staff were re-educated on customer service and to remember to be nice, smile, and be patient.
The facility's initial report to the Illinois Department of Public Health dated 11/22/24 documents on 11/22/24 at 7:08 PM V7 posted on (social media platform) an allegation of abuse of R1 by V4 and V5 and the post was sent to V1 Administrator. V1's electronic mail dated 11/22/24 at 9:47 PM documents V1 submitted the initial report of R1's abuse allegation to the state survey agency. There is no documentation that this allegation was reported to local law enforcement. V1's typed notes dated 11/20/24 documents that afternoon R6, resident council president, reported to V1 that R1 said V4 and V5 were rude to R1, expected R1 to do things for herself, and were rough when they repositioned R1 in bed. This note documents V1, V10 Social Services Director, and R6 spoke to R1 who voiced the same concerns as reported to R6. V1 and V2 Director of Nursing spoke with V4 and V5 who stated that R1 refused to let go of the bed rail when they attempted to reposition R1, R1 was upset and started screaming at them, and R1 kicked them out of R1's room.
On 11/25/24 at 11:14 AM V4 stated around 6:00 AM on 11/20/24 R1's call light was on and R1 requested to be repositioned in bed. V4 stated V4 attempted to use a cloth incontinence pad to reposition R1, but the pad pulled out from under R1, so V4 went to ask V5 for assistance. V4 stated V4 and V5 were on each side of R1's bed and attempted to turn R1, but R1 would not let go of the bed rail. V4 stated R1 was afraid of falling, but we explained to R1 that we wouldn't let her fall, and we were able to get the cloth pad underneath of R1. V4 stated R1 needed to be scooted up in bed and V4 and V5 used the cloth pad to pull R1 up in bed. V4 stated R1 got upset with V4 and V5, you could just tell it in R1's voice that R1 was not happy with us. V4 stated R1 is sensitive and has a history of back problems. V4 stated later that day the nurse told us that R1 no longer wanted V4 or V5 in R1's room and V4 and V5 went immediately to talk to V2. V4 stated that afternoon V1 spoke with V4 and V5 about the incident.
On 11/25/24 at 11:25 AM V5 described R1's incident on 11/20/24 as described by V4. V5 stated R1 was not very happy with V4 and V5, and R1 said to V4/V5 that they were purposefully hurting R1, broke R1's back and ribs, and that R1's ribs popped. V5 stated V4/V5 stopped what they were doing, asked R1 how they could help, and exited the room to notify V11 Licensed Practical Nurse (LPN) of the situation. V5 confirmed V5 would consider R1's statements to be an abuse allegation. V5 stated that is why V5 reported to V11. V5 stated V5 has received abuse training and confirmed abuse allegations should be reported to V1. V5 stated V11 said to use two staff for R1's cares. V5 stated at 10:30 AM V11 said R1 no longer wanted V4 and V5 to provide R1's cares, and around 3:00 PM that day V1 and V2 discussed the incident and V5 was told this wouldn't be considered abuse, that it would be considered a grievance.
On 11/25/24 at 11:42 AM V11 LPN stated R1 was upset on the morning of 11/20/24, but V11 was unsure of the specifics other than R1 stated R1 didn't like it here. V11 asked V4 and V5 to talk to R1 and they said they were using two staff for R1's cares and were going to talk to V2. V11 stated later that day another resident (R6) went into R1's room to speak with R1. V11 stated V4 and V5 did not report to V11 anything involving R1 that day.
On 11/25/24 at 12:43 PM V13 Certified Nursing Assistant stated on 11/20/24 at 6:00 PM R1 told V13 R1 had a problem with the dayshift Certified Nursing Assistants that day, R1 said R1's right side hurt because the staff had pulled on R1, and R1 was still hurting the next day.
On 11/25/24 at 2:02 PM-2:20 PM V1 Administrator stated around 2:00 PM on 11/20/24 R6 said R1 reported V4 and V5 were rude to R1, expected R1 to do things for herself, and they were rough with R1. V1 stated V1 spoke with R1 and R1 reported the same things that R6 told V1. V1 stated R1 denied being fearful of V4/V5 or that they intentionally hurt R1. V1 stated V1 interviewed V4 and V5 that day, who said that R1 would not let go of the siderail while they attempted to reposition R1. V1 stated V1 was out of the facility on 11/21/24, V1 followed up with R1 on 11/22/24, and at that time R1 wanted to know why V4 and V5 weren't terminated. V1 stated at that time R1 reported that during the alleged incident R1 felt a pop in her ribs and was unable to shampoo R1's hair on 11/22/24, so V1 asked a nurse to assess R1. V1 stated on 11/22/24 at 7:08 PM V1 received a copy of V7's social media post alleging abuse of R1, and that is when V1 reported the incident to the state survey agency at 9:47 PM. V1 stated V1 did not notify the local law enforcement, V1 should have, and V1 will do that today. V1 stated V1 did not report R1's concerns on 11/20/24 because V1 felt at that time there was no abuse allegation and that it was more of a customer service issue since V1 investigated and R1 said that it wasn't intentionally done to hurt R1 and R1 was not fearful. V1 was asked what would be the expectation of staff if during cares R1 voiced to staff that the staff were intentionally hurting R1, R1 broke R1's back and ribs, and R1's rib popped. V1 confirmed this would be considered an abuse allegation. V1 stated V4 and V5 should have stopped providing R1's care and reported R1's allegation to V1. V1 was unaware that R1 made these statements during R1's care. V1 confirmed if R1's statements were reported to V1 on 11/20/24, V1 would have initiated the steps that were taken on 11/22/24.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to prevent further abuse from occurring by allowing employees (V4 and V...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to prevent further abuse from occurring by allowing employees (V4 and V5 Certified Nursing Assistants) unrestricted access to residents following an abuse allegation. This failure has the potential to affect 36 residents (R1, R3, R4, R5, R7-R38) of 38 residents reviewed for abuse in the sample list of 38.
Findings include:
The facility's Abuse Prevention, Identification, and Reporting Program Policy and Procedure dated 9/10/19 documents employees will be immediately removed from work following an allegation of abuse/mistreatment and will not be allowed to return until the investigation results have been reviewed by the administrator.
On 11/25/24 at 10:03-10:20 AM R1 stated last Wednesday (11/20/24) R1 needed repositioned in bed, V4 and V5 were rough and R1 felt R1's back and ribs pop when V4 and V5 jerked R1 over in bed. R1 stated V4 and V5 yelled at R1 too. R1 stated R1 reported this to an unidentified nurse that evening. R1 stated R1 had right side pain since the incident, x-rays were completed around midnight last night, and nothing was broken.
On 11/25/24 at 12:01-12:17 PM R6 stated R6 stated on 11/20/24 around 12:30 PM V19 Housekeeper said R1 wanted to speak with R6. R6 stated R1 told R6 that V4 and V5 were being very rough and abusive to R1. R6 stated R6 asked what R1 meant, and R1 said V4/V5 told R1 to turn and pulled on R1 while attempting to reposition R1 as R1 was holding onto the bed rail. R6 stated R1 said V4/V5 moved R1's legs back and R1 felt R1's back crack. R6 stated R6 reported this to V1 within 15 minutes and they went to speak to R1 together, and R1 said V4/V5 brutally hurt R1, they cussed R1 out, they were aggressive and mean to R1 as they jerked R1 around and yelled at R1. R6 stated R1's story changed and R1 denied the staff cussed at R1 when asked by V1.
R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. R6's MDS dated [DATE] documents R6 as cognitively intact.
R1's Concern/Compliment Form dated 11/20/24 documents R1 stated V4 and V5 were being mean, had bad attitudes, and moved R1 in a rough fashion. This form documents staff were re-educated on customer service and to remember to be nice, smile, and be patient.
The facility's initial report to the Illinois Department of Public Health dated 11/22/24 documents on 11/22/24 at 7:08 PM V7 (R1's Family Member) posted on (social media platform) an allegation of abuse of R1 by V4 and V5 and the post was sent to V1 Administrator. This report documents V4 and V5 were suspended from work pending investigation results. V1's typed notes dated 11/20/24 documents that afternoon R6, resident council president, reported to V1 that R1 said V4 and V5 were rude to R1, expected R1 to do things for herself, and were rough when they repositioned R1 in bed. This note documents V1, V10 Social Services Director, and R6 spoke to R1 who voiced the same concerns as reported to R6. V1 and V2 Director of Nursing spoke with V4 and V5 who stated that R1 refused to let go of the bed rail when they attempted to reposition R1, R1 was upset and started screaming at them, and R1 kicked them out of R1's room.
V4's Time Card Report documents V4 worked on 11/20/24 from 5:57 AM until 9:59 PM, on 11/21/24 from 6:00 AM until 6:06 PM, and on 11/22/24 from 1:56 AM until 6:06 PM. V5's Time Card Report documents V5 worked on 11/20/24 from 5:57 AM until 6:13 PM. The facility's Daily Schedules dated 11/20/24, 11/21/24, and 11/22/24 document V4 and V5 worked on the Memphis (300) unit. The facility's Daily Census dated 11/24/24 document R1, R3, R4, R5, and R7-R38 reside on the 300 unit.
On 11/25/24 at 11:14 AM V4 stated the Memphis unit is V4's primary unit. V4 stated around 6:00 AM on 11/20/24 R1's call light was on and R1 requested to be repositioned in bed. V4 and V5 assisted R1 with repositioning, but R1 wouldn't let go of the bed rail. V4 stated R1 needed to be scooted up in bed and V4 and V5 used a cloth pad to pull R1 up in bed. V4 stated R1 got upset with V4 and V5, you could just tell it in R1's voice that R1 was not happy with us. V4 stated V4 continued working and later that day the nurse told us that R1 no longer wanted V4 or V5 in R1's room, V4 and V5 went immediately to talk to V2 and that afternoon V1 spoke with V4 and V5 about the incident.
On 11/25/24 at 11:25 AM V5 described R1's incident on 11/20/24 as described by V4. V5 stated R1 was not very happy with V4 and V5, and R1 said to V4/V5 that they were purposefully hurting R1, broke R1's back and ribs, and that R1's ribs popped. V5 stated V4/V5 stopped what they were doing, asked R1 how they could help, and exited the room to notify V11 Licensed Practical Nurse (LPN) of the situation. V5 confirmed V5 would consider R1's statements to be an abuse allegation. V5 stated that is why V5 reported to V11. V5 stated at 10:30 AM V11 said R1 no longer wanted V4 and V5 to provide R1's cares, and around 3:00 PM that day V1 and V2 discussed the incident and said this wouldn't be considered abuse that it would be considered a grievance. V5 stated V5 worked until 6:00 PM on 11/20/24 and received a call from V1 on 11/22/24 notifying of an abuse allegation and V5's suspension.
On 11/25/24 at 2:02 PM-2:20 PM V1 Administrator stated around 2:00 PM on 11/20/24 R6 said R1 reported V4 and V5 were rude to R1, expected R1 to do things for herself, and they were rough with R1. V1 stated V1 spoke with R1 and R1 reported the same things that R6 told V1. V1 stated R1 denied being fearful of V4/V5 or that they intentionally hurt R1. V1 stated V1 interviewed V4 and V5 that day, who said that R1 would not let go of the siderail while they attempted to reposition R1. V1 stated on 11/22/24 at 7:08 PM V1 received a copy of V7's social media post alleging abuse of R1, and that is when V1 reported the incident to the state survey agency at 9:47 PM. V1 stated on 11/22/24 R1 told V1 that during the alleged incident R1 felt a pop in her ribs and was unable to shampoo R1's hair. V1 confirmed V4 and V5 were not suspended until the evening of 11/22/24. V1 stated V1 felt R1's concerns on 11/20/24 was not an abuse allegation and that it was more of a customer service issue since V1 investigated and R1 said that it wasn't intentionally done to hurt R1 and R1 was not fearful. V1 was asked what would be the expectation of staff if during cares R1 voiced to staff that the staff were intentionally hurting R1, R1 broke R1's back and ribs, and R1's rib popped. V1 confirmed this would be considered an abuse allegation. V1 stated V4 and V5 should have stopped providing R1's care and reported R1's allegation to V1. V1 was not aware of R1's statements made during R1's cares and confirmed if R1's statements were reported to V1 on 11/20/24 V1 would have initiated the steps implemented on 11/22/24.
May 2024
11 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0740
(Tag F0740)
A resident was harmed · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide behavioral health services to maintain the highest practicable mental well-being for a resident diagnosed with major d...
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Based on observation, interview and record review, the facility failed to provide behavioral health services to maintain the highest practicable mental well-being for a resident diagnosed with major depression. This failure affects one of two residents (R53) reviewed for behavioral health services on the sample list of 30. This failure resulted in R53 being tearful, visibly shaking, and expressing despair.
Findings Include:
R53's ongoing diagnosis listing documents the following diagnoses: Vascular Dementia without Behaviors, Anxiety Disorder and Major Depression.
R53's May 2024 Physician Order Sheets documents an order for Lorazepam {Benzodiazepine} topical gel 1 mg (milligram) per ml (milliliter) to the inner wrist or other hairless area prn (as needed) every every 4-6 hours for anxiety or agitation but does not have any medication orders for R53's diagnosis of major depression.
On 5/14/24 at 11:21 AM, R53 was sitting up in a wheelchair in the doorway of R53's room. R53 became tearful and began to shake when talking about having to come to the long term care facility. R53 stated R53's family told R53 that R53 was not taking care of R53's self or dog, so they initially put R53 into an assisted living facility and now R53 is in long term care. R53, while still crying, explained R53's family sold everything that R53 owned stating, I have nothing now. R53 stated, they tell me (R53) I'm adjusting but I don't feel I am adjusting, I just want to run away and keep running and running with no place to go.
R53's Care Plan dated 3/25/24 documents R53 has a psychosocial well-being problem related to R53's medical diagnosis of Anxiety Disorder and Major Depressive Disorder with interventions that include: allow R53 time to answer questions and to verbalize feelings perceptions, and fears as needed; Assist/encourage R53 to set realistic goals; Encourage participation from R53; Increase communication between R53/family/caregivers about care and living environment; and explain all procedures and Treatments, Medications, Results of labs/tests, Condition, All changes, Rules, and options. This Care Plan also documents R53 is on hospice and will work cooperatively with the hospice team to ensure R53's spiritual, emotional, intellectual, physical and social needs are met.
R53's medical record does not contain any documentation that R53 is obtaining any behavioral health services to assist R53 in coping with R53's depression.
On 5/15/24 at 10:30 am, V10 SSD (Social Service Director) stated any resident who takes any type of psychotropic medication is referred to behavioral health services upon admission, or when started on medication however R53 was not do to being on hospice and hospice wanting to manage their own medication. At this time, V10 explained that when R53 was admitted to the facility, R53 was unresponsive and non-verbal however R53 has improved so much, R53 is being taken off of hospice. V10 was not aware of R53 being severely emotionally about being at the facility and R53's recent events.
On 5/15/24 at 11:00 am, V10 stated V10 completed a PHQ (Patient Health Questionnaire) - 9 on R53 and stated R53 scored a 12, which indicates possible depression. V10 stated that V10 called V32 (R53's POA (Power of Attorney)) after completing the assessment to see if it was okay for R53 to be seen by behavioral health services and V32 gave permission and actually stated that R53 had been taking an antidepressant for depression prior to being placed on hospice.
The facility's Hospice Service Agreement dated 11/3/23 documents the facility will furnish to the individual who is both a resident of Facility and a patient of Hospice, all of those services which Facility normally would have provided in the absence of Hospice Program, as provided for the Facility's policies, procedures, and protocols as required by State and Federal Law and agreements with the resident and the resident's family.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
3. 05/13/24 11:55 AM R66 Urinary drainage bag observed hanging on the right side of the bed at the foot of the bed, visible from doorway/hallway. No dignity/cover bag observed.
05/13/24 1:15PM R66 Rec...
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3. 05/13/24 11:55 AM R66 Urinary drainage bag observed hanging on the right side of the bed at the foot of the bed, visible from doorway/hallway. No dignity/cover bag observed.
05/13/24 1:15PM R66 Record review indicate a diagnosis of Neuromuscular Dysfunction Of Bladder indicating the need of an indwelling urinary catheter to drain the bladder.
05/14/24 09:00 AM R66 Urinary drainage bag hanging on the foot of the bed at the right side, uncovered/not placed in dignity bag at this time visible from the doorway/hallway.
05/14/24 09:05 AM R66 states staff just hang the bag from the bed and leave. R66 states he has had the indwelling urinary catheter for a long time due to not being able to empty his bladder on his own. R66 states a doctor told R66 has sign and symptoms of Multiple Sclerosis and will always have the need for a catheter going forward.
05/16/2024 09:18 AM V2 and V3 both state that all nursing staff should be putting all urinary collection/drainage bags inside a dignity bag unless being drained to protect resident dignity and privacy.
Based on observation, interview and record review the facility failed to ensure that residents are treated with respect and dignity. This failure affects three (R76, R43, & R66) of twenty four residents reviewed for dignity on the sample list of 30.
Findings include:
The facility's Dignity policy dated 11/28/12 documents, The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. This policy also documents that maintaining a resident's dignity should include refraining from practices demeaning to residents.
1. On 5/14/24 at 10:42 AM, R76 stated that V25 Certified Nurse's Assistant asked her if she had pooped right in the hallway in front of everyone. R76 stated she felt embarrassed by V25 asking her this out in the hallway. R76 stated she told V26 Licensed Practical Nurse about it.
On 5/15/24 at 11:38 AM, V26 stated that R76 did report to her that V25 asked her if R76 pooped in the hallway. V26 stated it is not appropriate to ask that in the hallway and that she should have asked her in the room.
2. R43's MDS (Minimum Data Set) dated 2/28/24 documents R43 has severe cognitive impairment.
On 5/13/24 at 12:35 PM, R43 was sitting in the lounge area eating lunch, by R43's self, away from all other residents who were in the dining area. At this time, V3 ADON (Assistant Director of Nursing) / Licensed Practical Nurse stated V3 is unsure why R43 is in the lounge area by R43's self other than the fact that R43 likes to tool around and take food off of other resident trays.
R43's Care Plan dated 4/23/24 does not document that R43 takes food from other residents and is to sit by R43's self.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
Based on observations, record reviews, resident and staff interviews, the facility failed to complete a self-administration of medication assessment for one of one resident (R29), reviewed for self-ad...
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Based on observations, record reviews, resident and staff interviews, the facility failed to complete a self-administration of medication assessment for one of one resident (R29), reviewed for self-administration of medication.
Findings Include:
05/15/24 09:15 AM R29 was observed with a medication cup on the bedside table with several unidentified medications still inside. R29 was observed with eyes closed resting in a recliner at this time.
05/15/24 09:20 AM R29 room door under constant observation from 09:15 AM until V12 (Registered Nurse) returned to nurses station at 09:20 AM. V12 then accompanied this surveyor to R29's room. V12 looked at the medication cup located on bedside table and picked it up from the bedside table concealing it in her left hand. V12 then aroused R29 by shaking R29's right hand/speaking loudly over the television and asked R29 why R29 did not take his medication. V12 was asked if V12 left the medication cup containing the medications at the bedside, V12 stated V12 left a calcium tablet at the bedside but did not leave this medication cup with medications in it.
05/15/24 09:25 AM V2 (Director of Nursing) stated nurses are not supposed to leave medications at the bedside, the nurse is supposed to watch the residents take the medications.
05/15/24 09:30 AM Clinical Physician Orders record review does not contain a physician order for medication self-administration.
05/15/24 09:40 AM R29 Standard Assessments record review does not contain an assessment for medication self-administration.
05/15/24 09:45 AM R29 Care Plan review indicate to Administer medications as ordered and to monitor/document for side effects and effectiveness by the License Practical Nurse (LPN), or Registered Nurse (RN).
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 staff failed to report allegations of abuse to the Abuse Coordinator for one of three residents (R44) reviewed for abuse on the sample list of 30.
F...
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Based on interview and record review, the facility staff failed to report allegations of abuse to the Abuse Coordinator for one of three residents (R44) reviewed for abuse on the sample list of 30.
Findings Include:
R44's MDS (Minimum Data Set) dated 3/14/24 documents R44 has severe cognitive impairments.
R44's Nursing Progress Notes document the following:
5/11/24 at 3:34 am by V27 RN (Registered Nurse) - R44 expresses frustration toward staff members, refusing care, and accusing CNAs (Certified Nursing Assistant's) of punching R44 in the gut. Upon inspection, R44 had no bruising or redness to indicate a punch to the gut.
4/27/24 by V28 LPN (Licensed Practical Nurse) - R44 was sitting out in the living room on the wing. There was another resident (unidentified) talking to a stuffed animal. R44 started yelling at that resident, Shut up .you need to comb your hair .When staff told resident that we don't talk like that, R44 said F*** you b****. When staff educated R44 that if R44 was going to talk like that, R44 could go to R44's room because that isn't nice to talk to people that way, R44 then stated to the other resident, stop yelling or I'll hit you in the head. Staff kept R44 away from other residents as R44 walked R44's self back to her room. R44 was raising R44's middle finger and saying f*** you to the staff.
On 5/13/24 at 1:27 PM, V1 Administrator stated V1 has not had any allegations of abuse reported to V1.
On 5/15/24 at 1:08 PM, V1 stated V1 was not aware of the above allegations as nobody reported them to V1. V1 explained staff have all been inserviced many times therefore should be aware of what needs reported and explained, this should have been reported.
On 5/15/24 at 2:09 PM, V28 stated on 4/27/24 R44 was lashing out, yelling and threatening to hit another resident (unidentified) . V28 stated, sometimes R44 just gets up in a bad mood and lashes out and takes it out on others but then at other times, R44 is as sweet as pie. V28 stated V28 has been instructed on what constitutes as abuse and what needs reported and explained V28 thinks that R44 was just angry. V28 stated R44 went back to R44's room when instructed to do so, if (R44) kept doing it {yelling and threatening}, I (V28) would have reported it.
On 5/16/24 at 4:22 PM, V2 DON (Director of Nursing) with V1 present stated that V2 counseled V27 that R44's allegations that R44 was hit in the stomach should have been reported to V1 immediately.
The facility's Abuse Prevention and Reporting Policy dated 4/14/22 documents abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse includes verbal, sexual, physical and mental abuse. 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. 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 them immediately report it to the administrator.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) 05/13/2024 09:50 AM V1 states there are no residents currently receiving dialysis in the facility.
05/15/24 09:20 AM V12 (Re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) 05/13/2024 09:50 AM V1 states there are no residents currently receiving dialysis in the facility.
05/15/24 09:20 AM V12 (Registered Nurse) stated R29 has a left forearm fistula (Dialysis access port) but R29 has never had dialysis. R29 states R29 has not had dialysis and does not want dialysis at this time.
05/15/24 09:25 AM V2 (Director of Nursing) and V3 (Assistant Director of Nursing) review Minimum Data Set (MDS) for R29. R29 MDS Section O dated Tue [DATE] at 09:19:21 AM is marked (documented) Yes, R29 as having dialysis while a resident. V2 and V3 agree that R29 has never had dialysis while a resident in this facility and the MDS was completed incorrectly. V2 states R29 had the left arm fistula placed in January 2024 but has not had dialysis performed. V2 states the left arm fistula has never been accessed.
Based on interview and record review, the facility failed to accurately code the Minimum Data Set for three of 24 residents (R29, R43, R53) reviewed for Assessments on the sample list of 30.
Findings Include:
1) R43's MDS (Minimum Data Set) dated 2/28/24 documents R43 has limited ROM (Range of Motion) to both bilateral upper and lower extremities. R43's Care Plan dated 4/23/24 does not document any limited ROM.
On 5/13/24 at 1:57 PM, V3 ADON (Assistant Director of Nursing) / LPN (Licensed Practical Nurse) stated R43 does not have any limited ROM.
On 5/14/24 at 3:05 PM, V5 LPN stated R43 has full ROM to all extremities but does have some weakness in the legs.
On 5/15/24 at 10:45 AM, V29 MDS Coordinator stated R43's MDS was completed prior to V29 starting at the facility so V29 is not sure why it is coded the way it is but verified that it is coded incorrectly as R43 does not have any limited ROM.
2) R53's May 2024 Physician Orders documents an order dated 3/25/24 to admit into hospice care for comfort measures only. R53's Care Plan dated 3/25/24 documents R53 is on hospice. R53's MDS (Minimum Data Set) dated 3/29/24 does not document that R53 is receiving hospice care.
On 5/14/24 at 11:18 AM, R53 confirmed R53 was placed on Hospice after having a small stroke but has improved so will be coming off of hospice.
On 5/15/24 at 11:23 AM, V29 MDS Coordinator confirmed R53's MDS is coded incorrectly due to not having hospice care marked and stated it should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to assist with shaving and nail care for two (R12, R69) of twenty four residents reviewed for activities of daily living on the s...
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Based on observation, interview, and record review the facility failed to assist with shaving and nail care for two (R12, R69) of twenty four residents reviewed for activities of daily living on the sample list of 30.
Findings include:
1. R12's care plan dated 12/18/23 documents that R12 has a self care performance deficit. This documents that R12 needs supervision with touch assistance for personal hygiene. This care plan also documents an intervention for staff to check nail length and to clean nails as needed.
On 5/14/24 at 10:30 AM, R12 was sitting in the hallway in a wheel chair. R12's face was partially shaved. R12's neck and cheeks had an over growth and sides of face. R12 stated that he shaved himself and that he did the best he could. R12's fingernails were jagged and had an accumulation of a black substance underneath them.
On 5/15/24 at 11:36 AM, R12 was sitting in the hallway. The sides of his face and neck continued to have an overgrowth of facial hair. R12 stated he did the best he could to shave his face. R12 stated he likes to be clean shaven but needs help and can't do it by himself. R12 fingernails remained jagged and continued to have an accumulation of a black substance underneath them.
On 5/16/24 at 2:00 PM, V1 Administrator stated that R12 does require assistance with shaving and the staff should help him.
2. R69's care plan dated 4/19/23 documents R12 has a self care performance deficit related to weakness. This care plan documents R12 requires extensive assistance of one staff member for assistance with personal hygiene.
On 5/13/24 at 12:20 PM, R69 was sitting at the dining room table. R69 had one quarter inch growth of facial hair. When asked if growing a beard, rubbed face and stated no, just waiting for someone to cut it or me, anybody will do, what are you doing now, can you do it?
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R13's care plan dated 5/23/24 documents a risk for pressure ulcer development due to weight, mobility, bowel incontinence, a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R13's care plan dated 5/23/24 documents a risk for pressure ulcer development due to weight, mobility, bowel incontinence, and fragile skin.
R13's Minimum Data Set, dated [DATE] documents R13 is cognitively intact.
R13's care plan dated 5/2/24 documents that R13 is dependent on two staff, requiring the mechanical lift, for toileting needs including catheter care and incontinence care.
R13's care plan dated 5/6/24 documents to report any changes in skin status.
R13's bowel and bladder record dated 5/11/24, 5/14/24 and 5/15/24 documents bowel movements on these dates.
On 5/14/24, R13's medical record does not document any current wounds or wound treatment.
On 5/14/24 at 10:41 AM, R13 said that she has wounds that come and go on her buttocks and legs and that she feels like there is one there now and has been for several days.
On 5/15/24 at 12:00 PM, V2 Director Of Nursing assisted R13 to roll onto left her left side to complete pericare. An open stage two pressure ulcer the size of a quarter was on R13's right buttock.
On 5/15/24 at 12:30 PM, V17 Certified Nursing Assistant (CNA) stated that she provided pericare/catheter care to R13 this morning and that R13 had an open wound, but that they wiped barrier cream over it and didn't tell anyone.
On 5/15/24 at 1:56 PM, V2 said that based on how the wound looks, she would guess that it had been open for a few days and that the CNA's should have reported it.
Based on observation, interview and record review, the facility failed to ensure a pressure ulcer wound treatments was completed as ordered, implement pressure relieving interventions and prevent potential cross contamination of the wound for two of five residents (R13, R51) reviewed for pressure ulcers on the sample list of 30.
Findings Include:
The facility's Pressure Ulcer Prevention Policy dated 1/15/18 documents specialty mattresses such as a low air loss, alternating pressure, etc mattress may be used as determined clinically appropriate. Specialty mattresses are typically used for resident who have multiple stage 2 wounds or one or more stage 3 or stage 4 wounds, and use a pressure reducing pad in chairs of all types to protect bony prominence's for residents.
1) On 5/13/24 at 11:29 AM, V3 LPN (Licensed Practical Nurse)/ADON (Assistant Director of Nursing) stated that R51 has a chronic stage four Pressure Ulcer to the Sacrum.
On 5/13/24 at 11:36 AM, R51 was sitting up in a wheelchair with a gel pressure cushion seat at the dining room table. R51 had a mechanical lift sling under R51 and between R51's buttocks and the gel pressure cushion.
On 5/14/24 at 8:25 AM, R51 was sitting up in a wheelchair with a gel pressure cushion seat but also had a mechanical lift sling between R51's buttocks and the gel pressure cushion. At this time, R51's bed had a regular mattress on it.
R51's Wound assessment dated [DATE] documents R51 has a stage four pressure ulcer to the sacrum measuring 0.3 cm (centimeters) by 0.5 cm by 0.9 cm.
R51's May 2024 Physician Orders document the following order to the Coccyx wound - cleanse with wound cleanser pack with indoor gel to wound bed place small piece of calcium alginate with silver over the top of the wound bed then cover with a thick absorbent pad and secure in place daily. If iodoform gel is not available, may use honey.
R51's Care Plan dated 5/8/24 documents R51 has a pressure ulcer to the sacrum with interventions that include: educate family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during
ambulating/mobility, good nutrition and frequent repositioning, follow facility policies/protocols for the prevention/treatment of skin breakdown, monitor nutritional status and serve diet as ordered, monitor intake and record, monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, signs of infection, assist with repositioning approximately every two hours, pressure relieving/reducing mattress on bed and pad in chair, encourage/assist to use the bathroom every
two hours and PRN in an attempt to reduce incontinent episodes, complete treatment as ordered.
On 5/14/24 at 10:19 AM, V2 DON (Director of Nursing) and V8 CNA (Certified Nursing Assistant) donned gowns and entered R51's room to provide wound care. At this time, V2 DON stated R51 is on EBP (Enhanced Barrier Precautions) due to having a pressure wound. Both V2 and V8 washed hands and donned gloves. R51 was lying in bed on a regular mattress. V8 rolled R51 to left side and V2 removed R51's wound dressing to the sacrum which consisted of a small piece of thick absorbent dressing that had a small amount of yellow drainage on it. No calcium alginate was on the wound as ordered. The wound to the sacrum presented as a stage four pressure ulcer. V2 measured the wound and reported the measurements as 0.6 cm by 0.4 cm by 1.1 cm. After cleansing the wound appropriately, V2 applied the iodoform gel to the wound base, then pulled a pair of scissors out of V2's uniform pocket to cut the silver calcium alginate and thick absorbent pad, before placing them over the wound. V2 confirmed V2 used scissors from V2's pocket and did not clean them prior to using them and stated, V2 had already cleansed the scissors with bleach wipes prior to placing them in (V2's) pocket. At this time, V2 also confirmed the dressing that V2 removed from R51 did not contain the ordered silver calcium alginate. V2 also confirmed that R51 was on a regular mattress and should be on an alternating pressure air mattress and explained that is V2's fault because V2 thought R51 was already on one.
On 5/14/24 at 1:34 PM, R51 was sitting up in the wheelchair with the mechanical lift sling under R51 and between R51's buttocks and pressure relieving cushion.
On 5/14/24 at 1:53 PM, V5 LPN stated R51 has had the same wound the entire time and even though it is sometimes documented as the coccyx and other times as sacrum, it is the same wound.
On 5/15/24 at 4:20 PM, V2 confirmed that sitting on a transfer sling could interfere with pressure relieving interventions when up in the wheelchair.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure that as needed psychotropic medications were limited to 14 days or less for one of five residents (R53) reviewed for psychotropic me...
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Based on interview and record review, the facility failed to ensure that as needed psychotropic medications were limited to 14 days or less for one of five residents (R53) reviewed for psychotropic medications on the sample list of 30.
Findings Include:
R53's May 2024 Physician Orders document an order dated 4/5/24 for Lorazepam {benzodiazepine} topical gel 1 mg (milligram) per ml (milliliter) - apply 1 ml to the inner wrist or other hairless area every 4-6 hours PRN (as needed) for anxiety or agitation.
The facility's Psychotropic Medication-Gradual Dosage Reduction Policy dated 2/1/18 documents PRN hypnotic, antianxiety or antidepressant medications shall not be used beyond 14 days unless the prescribing practitioner indicates the clinical rationale for extended use and the expected duration for PRN use of the medication.
On 5/15/24 at 10:25 am, V2 DON (Director of Nursing) stated PRN psychotropic medications, including Lorazepam, should be limited to 14 days or less.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to administer medications according to Physician Orders and follow Manufacturer's Recommendations for medication administration f...
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Based on observation, interview and record review, the facility failed to administer medications according to Physician Orders and follow Manufacturer's Recommendations for medication administration for two of six residents (R36, R71) reviewed for medication administration on the sample list of 30 . The facility had two errors out of 34 opportunities for a medication error rate of 5.88%.
Findings Include:
1. On 5/14/24 at 3:23 pm, V30 RN (Registered Nurse) entered R36's room to check R36's blood glucose level, which was 156. At this time, V30 stated V30 was only checking R36's blood glucose level and would be giving R36 the ordered insulin, which will be 5 units per the sliding scale orders and other ordered medications at 4:00 pm.
R36's May 2024 Physician Order Sheet documents orders to check R36's blood glucose levels TID (three times a day) and is set up for 6:00 am, 12:00 pm and 4:00 pm. These orders also document to administer Lispro Insulin Subcutaneous Solution Pen Injector
100 U (Units) per ml (milliliter) per sliding scale:
if 0 - 130 = 0 u; 131 - 200 = 5 u; 201 - 250 = 10 u; 251 - 300 = 15 u; 301 - 350 = 20 u; 351 - 400 = 30 u; 401 - 450 = 40 u; 451 - 500 = 50 u;
501 - 550 = 60 u; 551 - 600 = 70 u subcutaneous three times a day which is scheduled for 8:00 am, 12:00 pm and 5:00 pm.
On 5/14/24 at 4:15 pm, V30 prepared and administered all of R36's medications ordered for 5:00 pm which included the 5 units of sliding scale Lispro Insulin {Fast Acting Insulin}. The label documents to administer per sliding scale coverage with meals. At this time, R36 was lying in bed, without food and V30 did not offer any food to R36.
On 5/14/24 at 4:45 pm, 30 minutes after administration of Lispro, R36 still did not have any food served to R36.
The Instructions for Use for Lispro dated 2023 documents that Lispro is a fast acting insulin that should be administered 5-15 minutes prior to a meal.
2. On 5/14/24 at 3:35 pm, V30 RN entered R71's room to check R71's blood glucose level, which was 154. V30 stated R71 will receive 2 units of insulin and will return around 4:00 pm to administer it.
R71's May 2024 Physician Orders document to administer Novolog R Solution 100 U (units) per ml (milliliter) per sliding scale of:
if 150 - 200 = 2 u; 201 - 300 = 4 u; 301 - 999 = 6 u subcutaneously with meals for diabetes.
On 5/14/24 at 4:05 PM, R71 was lying in bed without food. V30 prepared and administered R71's ordered 2 units of Novolog insulin and did not offer R71 anything to eat.
On 5/14/24 at 4:45 pm, 40 minutes after receiving insulin, R71 still did not have supper.
On 5/14/24 at 4:45 pm, V31 Dietary Manager confirmed R36 and R71 have not been served dinner yet as the first hall cart to the opposite wing was just being served and explained the other wings will be served after that, then the main dining room will be served.
The facility's undated Medication Administration General Guidelines document medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Medications are administered in accordance with written orders of the prescriber.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents are free of significant medication er...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents are free of significant medication errors, by administering a residents intravenous antibiotic medications without consulting the physician due to critical lab values. This failure affects one (R71) resident out of a sample of 30.
Findings include:
The facility's Infusion Therapy Procedures policy dated 12/2014 documents: Anti-Infective Therapy lists policy to provide for safe and effective administration of anti-infective therapy. Procedures include the patient will be assessed by the nurse and physician prior to medication administration to ensure that the patient is clinically stable and has no previous history with adverse medication including lab work monitoring.
R71's physician order summary documents order for Ceftriaxone 2 grams intravenously every 24 hours at 2:00 PM and Vancomycin 1500 milligrams intravenously every 24 hours for a foot infection. This physician order summary documents a lab orders dated 5/8/24 to obtain a vancomycin trough level every week prior to infusion of antibiotic.
R71's laboratory results dated [DATE] documents a vancomycin trough level of 43. This report documents that this is a critical high level.
On 5/15/24 at 7:35 AM, V9 Registered Nurse administered Vancomycin 1500 milligrams intravenously to R71.
On 5/15/24 at 9:45 AM, V9 stated R71 had a vancomycin trough this morning and the lab called with critical results. V9 states she called the physician's office and left a message but did not speak with anyone. V9 states she did administer today's dose because there was no order to hold the Vancomycin if the lab trough was high. At this time, the bag of Vancomycin attached to R71's intravenous site was empty.
On 5/15/24 at 10:45 AM, V13 Pharmacist states that R71 should not have received the dose today based on trough level, could develop Red Man Syndrome(redness to face, neck, torso), and could impair kidney function. V13 states she sent an order dated 5/15/24 at 10:43 AM to hold vancomycin and draw a trough level daily until R71's trough level was below 20.
R71's Creatinine with Glomerular Filtration Rate (kidney function test) results data dated 5/16/24 documents R71 has a glomerular filtration rate of 46 which is flagged as low and a blood creatinine level of 1.22 milligrams per deciliter. R71's physician orders dated 5/16/24 documents order to push fluids due to a diagnosis of acute kidney injury.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to operationalize their Infection Prevention and Control Program by fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to operationalize their Infection Prevention and Control Program by failing to track infections and conduct infection surveillance. These failures affects one resident (R13) and has the potential to affect all 80 residents residing at the facility.
Findings Include:
1. The facility Infection Surveillance, Tracking and QA (Quality Assurance) Reporting Policy dated 2/14/18 documents the facility will identify, monitor, track and report infections and monitor adherence to infection control practices. Infection surveillance for compliance may include but is not limited to: review of laboratory/microbiology reports and results, observing for trends and monitoring to ensure appropriate precautions were initiated as appropriate. Infection Tracking includes but is not limited to: completing Infection Tracking Log for all residents with an infection and/or treated with antibiotics, track physician antibiotic prescribing practices as appropriate, monitor for trends by unit/location, clusters of same infection types/organisms, outbreaks, and employee illnesses.
On 5/15/24 at 1:00 PM, V24 (Infection Preventist) provided the Infection Control/resident list documentation that does not include trending and infection surveillance, outbreak investigation and surveillance also remain incomplete with missing data entries for type/location of infection, infectious organism, and if isolation was required or not.
The facility resident list report dated 5/14/24 lists 80 residents residing at the facility.
2.) R13's physician orders dated 5/13/24 document that R13 is to be in strict contact and droplet isolation for Norovirus. R13's progross notes dated 5/14/24 at 1:14 AM documents strict isolation for Norovirus.
On 5/13/24 at 12:30 PM, only a sign for enhanced barrier precautions was on R13's door. On 5/14/24 at 9:30 AM, only a sign for enhanced barrier precautions was on R13's door.
R13's Minimum Data Set, dated [DATE] document R13 as cognitively intact.
On 5/14/24 at 9:32 AM, R13 stated, I'm not on any isolation that I'm aware of. I went out to my restaurant yesterday to make the pies. The girls don't wear any gowns when they come in here. Last night I wasn't feeling good and I threw up.
On 5/15/24 at 9:30 AM, R13's door signage included a sign for contact isolation and to see the nurse before entering. On 5/15/24 at 11:50 AM, V3 Assistant Director of Nursing said that R13 should have been on contact isolation as of 5/13/24.
On 5/15/24 at 11:30 AM, V24 Infection Preventionist stated that she was doing education with staff regarding how they should handle isolation in the future.
Sept 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure employees with symptoms of COVID-19 were tested...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure employees with symptoms of COVID-19 were tested for COVID-19 and excluded from resident contact while symptomatic. This failure had the potential to affect eight (R6, R7, R8, R9, R10, R11, R12, and R13) of thirteen residents reviewed for COVID-19 on the sample list of 13.
Findings include:
On 9/25/23 at 8:45 AM, a sign posted on the facility's front door stated that the facility was experiencing a COVID-19 outbreak.
On 9/25/23 at 10:09 AM, V3 Infection Preventionist stated the facility's COVID-19 outbreak began on 9/16/23. V3 stated V6 Certified Nurse's Assistant (CNA) and V10 CNA both tested positive on 9/17/23.
On 9/25/23 at 10:57 AM, V6 CNA stated she tested positive for COVID-19 on 9/16/23. V6 stated she was working on the floor and started feeling dizzy and getting a migraine. V6 stated it was about 10 AM when she started feeling this way. V6 stated she continued working until 6:00 PM which was the end of her shift. V6 stated when she got home she decided to test and it was positive. V6 stated the facility tested her the next day to confirm the positive test and it was also positive.
On 9/25/23 at 1:09 PM, V10 CNA stated she tested positive for COVID-19 on 9/17/23. V10 stated she worked on Saturday (9/16/23) and felt like she had a head cold. V10 stated she had a runny nose, cough, and was sneezing. V10 stated on Sunday (9/17/23) she felt like she had a head cold times ten. V10 stated she was tested on [DATE] before work and was positive for COVID-19.
On 9/27/23 at 12:00 PM, V1 Administrator stated V6 and V10 worked on the Memphis hallway when symptomatic with COVID-19. V1 stated the staff are expected to report all symptoms of illness. V1 stated V6 and V10 should have reported their symptoms to someone so that they could be tested.
The facility's CNA group assignments documents R6 and R10 worked on the Memphis hallway on 9/16/23 from 6:00 AM to 6:00 PM.
The facility's census sheet dated 9/25/23 provided by V16 Owner/Administrator documents R6, R7, R8, R9, R10, R11, R12, and R13 reside on the Memphis hallway.
The facility's undated COVID Positive Resident list provided by V3 documents 42 residents have tested positive for COVID-19. This log documents R6 tested positive on 9/16/23, R8 on 9/21/23, R9 on 9/21/23, R10 on 9/20/23, R11 on 9/18/23, R12 on 9/23/23, and R13 on 9/17/23.
The facility's COVID Testing policy with a revision dated 5/12/23 documents that staff with signs and symptoms of COVID-19 must be tested and are expected to be restricted from the facility. This policy also documents anyone even with mild symptoms of COVID-19 regardless of their vaccination status should receive a viral test for COVID-19 as soon as possible.
Jul 2023
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain an air mattress is safe operable condition, en...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain an air mattress is safe operable condition, ensure bed brakes were locked, and follow the facility Fall Prevention Program guidelines, which resulted in R57 falling from bed. The facility also failed to ensure a safe environment according to the plan of care, free from trip hazards for one resident (R17) at risk for falls. These four failures affect two of eight residents (R57 and R17) reviewed for falls/accident hazards on the sample list 28.
Findings include:
1.) R57's Minimum Data Set (MDS) dated [DATE] documents the following: R57's Brief Interview of Mental (BIMS) status score of 13, out of a possible 15, which indicates R57 has no cognitive impairment. The same MDS documents R57 requires extensive, physical staff assistance of one person for bed mobility.
R57's Care Plan dated as initiated 11/08/2022, and updated 07/19/23, documents the following:
(R57) is at risk for falls r/t (related to) Weakness, impaired balance r/t LAKA (left above knee amputation), Hx (history) of falls prior to admission. Fell 4/5/23. R57's same Care Plan updated post-fall 4/5/23 documents the following: When repositioning her, make sure she is positioned in the center of the bed. Date Initiated: 04/05/2023 (the same day as the fall from the air mattress, on her bed).
R57's Incident Note dated 4/5/23 documents the following:
Called to room by cna (CNA, unidentified) (,) upon entering room found resident on the floor between the bed and wall (,) by the wall (,) laying on her (R57) right side (,) partially wrapped in blankets, alert (and) oriented, denies hitting (sic) states she (R57) rolled out of bed. (Bed) was in locked position but had moved as resident (R57) fell. mattress (Air- mattress) was only partially inflated, floor dry.
R57's Fall- IDT (Interdisciplinary team) Note dated 4/6/23, signed by V7,
Assistant Director of Nursing (ADON) documents the following:
Root cause; Rolled out of bed.
Intervention and care plan updated: When repositioning her (R57) make sure she (R57) is in center of her bed. Maintenance to check brakes on bed and mattress (air-mattress) for proper functioning.
On 7/27/23 at 1:32 pm, R57's was seated in her wheelchair. R57 had a left above knee amputation. R57 had an air mattress on her bed. R57 stated the following: When I (R57) fell out of bed, two CNA's (unidentified Certified Nursing Assistants) came in and changed (provided perineal care) me (R57). I told them (unidentified CNA's) at that time, my mattress was loosing air. They positioned me, facing the wall after changing me, and left the room. It was about a half hour later the mattress had lost more air. I rolled out of bed and hit the floor. The bed brakes were not working properly. I wasn't hurt, just achy for a day or two. The rest of the night I had to sleep in my recliner. Maintenance came in and looked at the brakes. Later that day, I got this new air mattress (points to her bed).
On 7/27/23 at 1:40 pm V7, ADON stated The CNA's should have reported to the nurse (unidentified) immediately (per R57 interview, during incontinence care 30 minutes before R57's fall 4/5/23) that her (R57's) air mattress was deflating. We did get her a new mattress that same day.
On 7/27/23 at 2:20 pm V15, Assistant Maintenance worker stated V15 did checked the brakes after R57 fall 4/5/23, but knew nothing about the mattress. V15 also stated There was nothing wrong with (R57's) brakes. The CNA (unidentified) just forgot to lock them (bed brakes).
2.) R17's admission Record face sheet dated 7/28/23 documents the following diagnoses: Chronic Obstructive Pulmonary Disease Unspecified, Chronic Respiratory Failure With Hypoxia, Chronic Respiratory Failure With Hypercapnia, Heart Failure Unspecified, Low Back Pain Unspecified, Neuralgia (nerve pain), Neuritis (nerve inflammation) Unspecified and Anxiety.
On 7/25/23 at 3:35 pm, R17 sat on the side of R17's bed. R17 had an oxygen nasal cannula actively administering four liters of oxygen via a concentrator. The oxygen concentrator was positioned just inside R17's bathroom. R17's oxygen tubing had an extension approximately 25 feet in length. R17's oxygen tubing lay on the floor, and extended approximately 18 feet from R17 oxygen concentrator in the bathroom, to R17's bed. The tubing had twisted areas that coiled at the side of R17's bed, under and around R17's feet, as R17 sat on the side of the bed. R17 stated This (oxygen tubing) has always been a problem. My room is small and the tubing is long. I like to get all around the room with it (oxygen). They would have to change the tank (E-tank portable oxygen, wheeled caddy) several times a day, if I had to use that (E-tank) to keep the tubing (oxygen) off the floor. The tank (E-tank) does not have all the extra tubing. R17 ambulated to the bathroom from his bed. R17 stated I (R17) was given this bag (attached to the oxygen concentrator in the bathroom which contained excess concentrator electrical cord) but it is too small for all this tubing. R17 ambulates back to R17's bed, stepping repeatedly over the coiled and twisted oxygen tubing. R17 picks up some of the tubing and attempts to untwist the tubing. R17 then states It would be real nice if maintenance could figure out something to fix this tubing. I haven't fallen yet, but I don't want to either.
On 7/27/23 at 3:40 pm V9, Registered Nurse (RN) acknowledged R17 extensive oxygen tubing was strung across R17's floor and into R17's bathroom where R17's oxygen concentrator sat. V9 stated The oxygen tubing is a trip hazard and is not sanitary.
R17's Minimum Data Set, dated [DATE] documents R17 has a Brief Interview of Mental Status score of 15 out of a possible 15, which indicates R17 has no cognitive impairment and requires supervision during ambulation.
R17's Care Plan dated as initiated 1/14/18 and revised 7/26/23 documents the following:
(R17) is at risk for falls r/t (related to) possible side effects of psychotropic medications and
ambulates independently pulling portable O2 (oxygen).
R17's same Care Plan documents an intervention as follows: He (R17) needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light.
The facility policy Fall Prevention Program dated as revised 11/21/17 documents the following: Purpose:
To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Guidelines include: Fall/safety interventions may include but are not limited to: Bullet number four *The bed locks will be checked to assure they are in the locked position at all times. and bullet number 15 * Malfunctioning equipment will be immediately reported to maintenance for repair or removed from service, i.e. bed locks, side rails, and grab bars.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to obtain a physician's order for oxygen administration and failed to store oxygen tubing in a sanitary manner for one of two res...
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Based on observation, interview, and record review the facility failed to obtain a physician's order for oxygen administration and failed to store oxygen tubing in a sanitary manner for one of two residents (R63) reviewed for oxygen in the sample list of 28.
Findings Include:
The Oxygen and Respiratory Equipment policy dated 1/7/19 documents oxygen nasal cannula tubing should be stored in a clear plastic bag when not in use.
R63's Medical Diagnoses List dated July 2023 documents R63 is diagnosed with Chronic Obstructive Pulmonary Disease, Acute Respiratory Failure, and Congestive Heart Failure.
R63's Physician Order Sheet (POS) dated July 2023 documents R63 is prescribed oxygen at two liters via nasal cannula for mild Dyspnea or oxygen saturation less than 88 percent. This order was not added until 7/28/23.
On 7/25/23 at 2:04 PM R63's oxygen tubing was left hanging across the bedside dresser drawer with the cannula touching the floor.
On 7/27/23 at 11:15 AM R63's oxygen tubing was left hanging across the bedside dresser drawer with the cannula touching the floor.
On 7/27/23 at 11:27 AM V17 Registered Nurse (RN) stated R63 only wears her oxygen at night and confirmed the tubing should be stored in a clear plastic bag when not in use.
On 7/27/23 at 4:00 PM V2 Director of Nurses (DON) confirmed residents should have a physician order for oxygen and should also store oxygen tubing in a bag and not leave the tubing, hanging on furniture when not in use.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to obtain a physician order for dialysis treatment and failed repeatedly to monitor the dialysis catheter site and dressings for two of two res...
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Based on interview and record review the facility failed to obtain a physician order for dialysis treatment and failed repeatedly to monitor the dialysis catheter site and dressings for two of two residents (R29, and R58) reviewed for Dialysis on the sample list of 28.
Findings Include:
The Dialysis Monitoring and Observation policy dated 2/13/18 documents if the resident has a catheter for dialysis the nurse should assess the catheter site for any signs of drainage and assess the condition of the catheter dressing every shift.
1. R29's Medical Diagnoses list dated July 2023 documents R29 is diagnosed with End Stage Renal Disease.
R29's July 2023 Physician Order Sheet (POS) does not include an order for Hemodialysis or an order for staff to monitor the dialysis catheter site/dressing.
On 7/25/23 at 2:16 PM, R29 stated she goes out of the facility for Hemodialysis, three times per week, outside of the facility, and the dialysis staff change her catheter site dressing and flush her dialysis catheter. R29 stated the facility nursing staff do not ever ask to observe her dialysis catheter.
2. R58's Medical Diagnoses list dated July 2023 documents R58 is diagnosed with Chronic Kidney Disease.
R58's July 2023 Physician Order Sheet (POS) does not include an order for Hemodialysis or an order for staff to monitor the dialysis catheter site/dressing.
On 7/27/23 at 2:16 PM, R58 stated he goes out of the facility for Hemodialysis, three times per week outside of the facility and the dialysis staff change his catheter site dressing and flush his dialysis catheter. R58 stated the facility nursing staff do not ever ask to observe his dialysis catheter.
On 7/27/23 at 11:20 AM, V17, Registered Nurse (RN) stated R29 and R58 both go out of the facility for Hemodialysis three times per week. V17 stated there should be a physician's order for dialysis and confirmed the facility nurses do not assess R29 or R58's dialysis catheter sites. V17 stated only the dialysis facility does anything with the catheter sites, and she was not even certain what kind of dialysis access V29 or V58 have.
On 7/27/23 at 12:21 PM, V16, Dialysis Clinic Manger stated both R29 and R58 have right upper chest central venous catheters for dialysis use. V16 stated the catheters are flushed and dressings changed at the dialysis center however, the facility nursing staff should be monitoring the catheter site and ensuring the dressing stays dry and intact. V16 stated the facility should also be monitoring for signs and symptoms of infection.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide the necessary behavioral health care services for one of one residents (R48) reviewed for behavioral health on the sample list of 2...
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Based on interview and record review, the facility failed to provide the necessary behavioral health care services for one of one residents (R48) reviewed for behavioral health on the sample list of 28.
Findings include:
On 7/26/23 at 10:05 AM, V12 (R48's family member) stated R48 gets physical with the staff, actually hitting a staff member last week, and has depression due to loosing R48's spouse last year. V12 also stated that back in the day, V12 believes R48 had a diagnosis of Bipolar but it was not really discussed. V12 explained that V12 was called in today by the staff due to R48 refusing care.
R48's ongoing Diagnosis Listing documents diagnoses of : Unspecified Dementia without behavioral disturbances, psychotic disturbance, or mood disturbance, and anxiety.
R48's MDS (Minimum Data Set) dated 7/5/23 documents R48 exhibits physical behaviors 1-3 times a week, verbal behaviors 4-6 times a week, rejects care and wanders 1-3 times a week and receives antipsychotic and antidepressant medications daily and antianxiety medications 6 out of the last 7 days.
R48's July 2023 Physician Orders document R48 receives the following medications: Lorazepam {Antianxiety} 0.5 mg (milligrams) BID (twice a day), Seroquel {Antipsychotic}50 mg BID, and Sertraline {Antidepressant} 50 mg BID.
R48's Care Plan dated 4/10/23 documents R48 is administered Psychotropic Medications for anxiety with repetitive movements and repetitive anxious complaints, and depression with crying and tearfulness.
R48's behavior tracking from April - July 2023 documents multiple occurrences of yelling/screaming, kicking/hitting, abusive language, threatening behaviors, rejection of care, and repeated movements.
On 7/27/27 at 10:09 AM, V5, SSD (Social Service Director) stated the facility uses a behavioral health provider that comes to the facility weekly. V5 explained R48 has not been seen by behaviors health yet due to when R48 was admitted to the facility, it was for a short term rehabilitation stay, but R48 is now considered a long term placement as of 4/23/23, and should have been put on the list to be seen by behavioral health at that time. V5 stated R48 was missed/overlooked because of a change in the facility admission Coordinators around that time. V5 stated that V5 was just told this morning, by V2 DON (Director of Nursing) to make a referral to behavioral health for R48.
On 7/27/23 at 11:13 AM, V13, Nurse Consultant stated when a resident has behaviors, the facility is to have them seen by behaviors health services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to assess for psychotropic medications to ensure appropriate indications for the use of psychotropic medications, and obtain consent repeatedl...
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Based on interview and record review, the facility failed to assess for psychotropic medications to ensure appropriate indications for the use of psychotropic medications, and obtain consent repeatedly for 33 days, for psychotropic medications for one of two residents (R48) reviewed for psychotropic medications on the sample list of 28.
Findings Include:
R48's ongoing Diagnosis Listing documents the following diagnoses: Unspecified Dementia without behavioral, psychotic, mood disturbances or anxiety, and anxiety.
R48's July 2023 Physician Order Sheet documents the following medication orders:
Lorazepam {Antianxiety} 0.5 MG (milligrams) - Give 1 tablet by mouth, BID (two times a day) for anxiety.
Seroquel {Antipsychotic} 50 MG - Give 50 mg, by mouth BID for Unspecified Dementia, Unspecified Severity, without Behavioral Disturbances, Psychotic Disturbances, Mood Disturbance, and Anxiety.
Sertraline {Antidepressant} 50 MG - Give 50 mg, by mouth BID for depression
R48's Discontinued Medication List dated July 2023 documents the following:
Seroquel 50 MG - give 50 mg by mouth in the evening from 4/6/23 - 7/14/23.
Sertraline 50 mg - Give 50 mg by mouth at bedtime from 4/4/23 - 4/12/23
R48's medical record did not contain a consent for the use of Sertraline, or have a consent signed for use of the Seroquel 50 mg every evening, until 5/9/23, 33 days after it was initiated.
R48's medical record also did not contain psychotropic medication assessments.
On 7/27/23 at 8:32 AM, V2, DON (Director of Nursing) confirmed R48 has not had any psychotropic medication assessments completed explaining, There should have been one done upon admission due to (R48) admitting with medications, quarterly and with the changes of medications. V2 also stated consents should have been gotten prior to giving the medications but they weren't obtained. V2 also stated the diagnosis for R48's Seroquel is not an appropriate diagnosis for the use of an antipsychotic medication.
The facility Psychotropic Medication-Gradual Dose Reduction Policy dated 2/1/18, documents residents will not be given psychotropic drug therapy unless it is necessary to treat a specific or suspected condition as per current standards of practice, and are prescribed at the lowest therapeutic dose to treat such conditions. This policy also documents, psychotropic medication shall not be administered without the informed consent of the resident or the authorized resident representative.
On 7/27/23 at 11:13 AM, V13 Nurse Consultant, and V1 Administrator in Training, both stated the only Psychotropic Medication Policy the facility has is in relation to GDR's (Gradual Dose Reductions).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer immunizations according to resident wishes for two of fi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer immunizations according to resident wishes for two of five residents (R7 and R63) reviewed for immunizations on the sample list of 28.
Findings include:
The facility Influenza and Pneumococcal Immunizations Policy dated 4/21/22 documents the facility will minimize the risk of residents acquiring, transmitting, or experiencing complications from influenza and Pneumococcal pneumonia. Each resident is offered a Pneumococcal immunization per CDC (Centers of Disease Control and Prevention) recommendations. The resident medical record includes documentation that indicates, at a minimum that the resident either received or did not receive the Pneumococcal immunization due to medical contraindications or refusal.
R63's medical record documents R63 was born in 1930 and admitted to the facility on [DATE]. R63's Immunization consent dated 5/25/23 documents that R63 would like to receive the Pneumococcal Immunization. R63's ongoing Immunization History does not document that R63 has ever received the Pneumococcal Immunization.
R7's medical record documents R7 was born in 1936 and admitted to the facility on [DATE]. R7's Immunization consent dated 5/11/23 documents R7 wound like to receive the Pneumococcal Immunization. R7's ongoing Immunization History does not document that R7 has ever received the Pneumococcal Immunization.
On 7/27/23 at 8:32 AM, V2 DON (Director of Nursing) stated V2 does not know why R63 and R7 didn't receive the requested immunization explaining V3 IP (Infection Preventionist) was handling vaccinations.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to prevent the potential for cross-contamination and food-borne illness, by failing to maintain sanitary food processing equipme...
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Based on observation, interview, and record review, the facility failed to prevent the potential for cross-contamination and food-borne illness, by failing to maintain sanitary food processing equipment, free of grease-like substance, metal fragments, rust and exposed metal. These failures have the potential to affect all 78 residents residing in the facility.
Findings include:
1. ) On 7/27/23 at 10:00 am V8, Dietary Manager (DM), V8, DM acknowledged the commercial table-top mounted can opener was rusty, corroded with a brown grease-like buildup in the gears and had metal fragments adhering to the grease- like substance. The same can opener had chipped silver paint off of the tip of the can opener blade, which exposed bare metal. V8, DM stated The can opener is not sanitary and will need to be replaced.
2.) On 7/27/23 at 10:15 am, V8, DM also acknowledged the facility commercial table-top, eight quart mixer had exposed metal and a build-up of brown grease-like substance, and yellow food-like particle on the underside plate overhanging the mixer bowl. The same underside plate had embedded grease and food-like particle around the perimeter of the underside plate. V8, DM stated I (V8, DM) can see the mixer has obviously not been cleaned very well after they ( kitchen staff) use it. There is a potential for cross-contamination.
The facility policy Cleaning Rotation dated 2020 documents the following: Equipment and utensils will be cleansed and sanitized according to the following guidelines, or manufacturer's instruction. The same facility policy documents the procedure for cleaning and sanitization is to be completed after each use of the can opener and mixer.
The facility Resident Census and Condition of Residents Form dated 7/25/23 documents 78 residents reside at 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 interview and record review, the facility failed to operationalize their Infection Prevention and Control Program by failing to track infections, conduct infection surveillance, and review th...
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Based on interview and record review, the facility failed to operationalize their Infection Prevention and Control Program by failing to track infections, conduct infection surveillance, and review their policy annually. This failure has the potential to affect all 78 residents residing at the facility.
Findings Include:
The facility policy Infection Prevention and Control Program dated 11/28/17 and last reviewed on 1/7/19 documents the facility is to comply with a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement. This facility has established an Infection Control Program which addressed all phases of the organization's operation to reduce or prevent the risks of nosocomial infections in residents and health care workers. The designated Infection Control employee and Quality Assurance Committee is responsible for monitoring the effectiveness of the program and continually improving outcomes. All infection control policies and procedures will be reviewed annually by the Quality Assurance Committee and revised as needed. Department Heads are responsible for assuring personnel are made aware of all revisions to respective policies and procedures. The program provides for the recording of each suspected infection and surveillance activities as they relate to individual resident infections. A log is maintained of suspected and actual infections on a day to day basis. Antibiotic use will be logged and tracked to ensure prescribing practices and outcomes are monitored for trends.
The facility Infection Surveillance, Tracking and QA (Quality Assurance) Reporting Policy dated 2/14/18 documents the facility will identify, monitor, track and report infections and monitor adherence to infection control practices. Infection surveillance for compliance may include but is not limited to: review of laboratory/microbiology reports and results, observing for trends and monitoring to ensure appropriate precautions were initiated as appropriate. Infection Tracking includes but is not limited to: completing Infection Tracking Log for all residents with an infection and/or treated with antibiotics, track physician antibiotic prescribing practices as appropriate, monitor for trends by unit/location, clusters of same infection types/organisms, outbreaks, and employee illnesses.
The facility's computerized Infection Control Log from August 2022 - July 2023 is incomplete with multiple missing data entries each month for the etiology of infection (if it was house acquired or if the resident admitted with the infection), type/location of infection, infectious organism, if isolation was required or not, and date the infection was resolved.
On 7/26/23 at 12:58 PM, V2 DON (Director of Nursing) stated the facility does not have any infection tracking, trending or infection surveillance but there should be. V2 also confirmed the Infection Control Log is not accurate and has missing pertinent information that is required.
On 07/26/23 at 1:56 PM, V1 Administrator in Training confirmed the provided policy is the most recent and current Infection Prevention and Control Program Policy. V1 confirmed the policy was last reviewed on 01/7/19 and stated the company has a team that reviews policies whenever there is a concern with the policy and explained there has been additions to the Program with COVID-19 {Highly contagious infection} but that is all in a policy of its own.
On 7/26/23 at 4:38 PM, V1 stated, V13, Nurse Consultant has different Infection Control Logs, that include tracking, trending and surveillance of infections that was completed by V13, but they are with V13 in Chicago, not at the facility.
On 7/27/23 at 8:13 AM, V1 provided the Infection Control documentation that does include trending and infection surveillance however, remains incomplete with missing data entries for ordered antibiotics, type/location of infection, infectious organism, and if isolation was required or not.
The facility Anti-Infection Drug Utilization Report dated 7/26/23 documents Erythromycin {Antibiotic} 5 mg (milligrams)/gm (gram) ointment was ordered on 6/3/23 for R17, Amoxicillin 500 mg was ordered on 6/19/23 for R24, and Amoxicillin with Clavulanic Acid 875-125 mg was ordered on 6/2/23 for R75 and none of these are documented on the June 2023 Infection Control Log.
On 7/27/23 at 9:44 AM, V2 DON (Director of Nursing) confirmed V2 is the acting IP (Infection Preventionist) due to V3, IP being off work on medical leave. V2 stated even though (V13, Nurse Consultant) has been doing the antibiotic tracking log, summary and trending of infections, I (V2, DON) have never seen those reports. V2 also stated V2 has not reviewed the Infection Control information or surveillance information or did anything with the information. V2 also confirmed that the June 2023 Infection Control Log is not accurate as it has missing information, therefore the trending and infection surveillance is not accurate either.
The facility Resident Census and Condition of Residents Form dated 7/25/23 documents 78 residents reside at the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to have an Infection Preventionist. This failure has the potential to affect all 78 residents residing at the facility.
Findings include:
On...
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Based on interview and record review, the facility failed to have an Infection Preventionist. This failure has the potential to affect all 78 residents residing at the facility.
Findings include:
On 7/26/23 at 9:38 AM, V1 Administrator in Training stated V3 is the facility IP (Infection Preventionist) however V3 has been off work for a couple of months and is on FMLA (Family Medical Leave Act) but is working some remotely on reporting of infections.
On 7/26/23 at 2:41 PM, V1 stated V1 is not able to find V3's IP certificate of training but since V3 is off of work, V2 DON (Director of Nursing) is covering as IP and provided V2's certificate of training, dated 5/21/22.
On 7/26/23 at 2:44 PM, V2 confirmed V2 is working as the facility IP and has been completing the Antibiotic Stewardship information but nothing else. V2 stated V2 generally works 8-10 hours a day and only spends an hour or two a day on Infection Control.
The facility Resident Census and Condition of Residents Form dated 7/25/23 documents 78 residents reside at the facility.
Nov 2022
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to notify a resident representative of condition changes for one of three residents (R1) reviewed for family notifications on the sample list ...
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Based on interview and record review, the facility failed to notify a resident representative of condition changes for one of three residents (R1) reviewed for family notifications on the sample list of four.
Findings Include:
The facility Physician-Family Notification - Change in Condition Policy dated 10/1/22 documents the facility will inform the resident; consult with the resident's physician or authorized designee such as Nurse Practitioner; and if known, notify the resident's legal representative or an interested family member when there is a change in the resident's physical, mental or psychosocial status, when there is a need to alter the residents treatment significantly. Significantly means a need to stop a form of treatment because of adverse consequences or commence a new form of treatment to deal with a problem (ex: the use of any medical procedure, or therapy that has not been used on the resident before).
On 11/28/22 at 12:58 pm, V8 (R1's family) stated the facility does not call V8 with updates when R1's medications change or R1 gets new orders.
R1's August 2022 Physician Order's document an order for a Modified Barium swallow Study.
R1's Nursing Progress Notes document the following:
8/23/22 - Z22 Physician was contacted and a Modified Barium Swallow Study was requested per V14 ST (Speech Therapy) recommendations.
8/30/22 - Video swallow scheduled for 9/15/22 at 0745.
9/15/22 - R1 leaving for swallow study per wheelchair and facility van
R1's Progress Notes do not document that V8 was notified of the Swallow Study being ordered.
On 11/29/22 at 10:20 am, V13 Care Plan Coordinator stated family members are to be made aware of changes in condition and treatment and it needs to be documented in the Progress Notes.
On 11/29/22 at 10:54 am, V14 ST stated V14 recommended R1 have a swallow study done due to R1's swallowing issues. V14 explained V14 can only assess so much, and V14 needed to know what was going on on the inside. V14 stated after the test was completed, V14 went over those results and the new recommendations with R1 and V8.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to investigate a fall for one of three residents (R2) reviewed for falls on the sample list of four.
Findings Include:
The faci...
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Based on observation, interview and record review, the facility failed to investigate a fall for one of three residents (R2) reviewed for falls on the sample list of four.
Findings Include:
The facility Fall Policy dated 4/19/22 documents accidents/incidents will be discussed in a multidisciplinary meeting to evaluate the incident, determine interventions and prevention strategies for future care.
On 11/28/22 at 11:52 am, R2 was sitting in the lounge area in a wheelchair with a pressure alarm in place. At this time, V6 (R2's family) stated R2 has had several falls due to R2's advanced dementia, R2 doesn't remember that R2 isn't to be up by R2's self, so will try and then fall. That is why the facility uses the pressure alarm for R2 explaining as soon as it sounds, staff comes running.
R2's Care Plan dated 11/18/22 documents R2 is at risk for falls due to impaired cognition/safety awareness and impaired gait/balance. This Care Plan documents an intervention of a pressure pad bed and chair alarm implemented on 10/16/22 following a fall.
R2's 10/26/22 Post Fall Huddle and Witness Statement by V23 CNA (Certified Nursing Assistant) documents at 10:30 pm, R2 was observed lying on R2's back in the bathroom by the toilet. R2 had slipper socks on at the time of fall and had been toileted at bedtime. R2 had bed alarm in place but it didn't go off. V11 RN (Registered Nurse) documented V11 went to check on R2 and found R2 on the floor next to toilet, R2 stated R2 was going to the bathroom. Bed alarm was not sounding. This Post Fall Huddle documents what corrective measures were taken? Staff to make sure (R2's) alarm is in place on rounds.
On 11/29/22 at 10:20 am, V13 Care Plan Coordinator stated falls are investigated by the team or myself and new interventions are discussed and implemented as a team.V13 confirmed R2's bed/chair pressure alarm was implemented after R2's 10/16/22 fall. V13 reviewed R2's Post Fall Huddle Report and Witness Statements for the 10/26/22 fall and stated, the alarm was in place but not sounding so it could have been positioned in the wrong place or was it malfunctioning? That would need to be investigated because I (V13) don't know the answer to that. V13 then stated V13 understands that the reason for the alarm not sounding should have been investigated, and wasn't.
Aug 2022
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to lock bed wheels and provide adequate staff assistance t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to lock bed wheels and provide adequate staff assistance to prevent a fall for R57. The facility also failed to maintain a safe environment, free of tripping hazards in R44 bedroom and bathroom. R44 and R57 are two of six residents reviewed for falls on the sample list of 36.
Findings include:
1. R57's Physician Order Summary Report Sheet (POS) dated 08/10/22 documents the following diagnoses: History of Falls, Morbid Obesity Severe, Type II Diabetes with Diabetic Polyneuropathy, Chronic Kidney Disease, Weakness, Anxiety, Low Back Pain and Bilateral Primary Osteoarthritis of Knees.
R57's Minimum Data Set (MDS) dated [DATE] (before the fall documented below, 1/30/22) documents the following: R57's Brief Interview of Mental Status score of 15 out of a possible score of 15, which indicates no cognitive impairment. The same MDS documents R57 required extensive physical assistance of two staff for bed mobility and has functional limitations in range of motion of bilateral upper and lower extremities.
On 08/09/22 at 11:02 am R57 stated (V9), CNA (Certified Nursing Assistant) was by herself and told me to roll over while she provided my care. I fell between the bed and the wall. (V9, CNA) called (V8, Registered Nurse). I wasn't hurt but it wouldn't have happened had there been two people. It was several months ago (1/30/22). The bed locks were not on, and I (R57) only had (V9, CNA) turning me. I almost always have had two people.
R57's Health Status (Nurse) Note dated 01/30/22 at 3:51 am, documents the following:
Patient was in the process of being changed by CNA (Certified Nursing Assistant) when the patient (R57) started to roll farther over the side of the bed and couldn't stop. Patient (R57) rolled towards wall and failed to stop rolling, rolling off the side of the bed and pushed the bed out from the wall. Patient (R57) received no injury to the head and reports no pain throughout body related to fall. Patient VS (Vital Signs) were T (temperature) 98.0, SpO2 (oxygen saturation) 96%, P (pulse) 84 bpm (beats per minute), R (respirations) 18 rpm (respirations per minute), and BP (blood pressure) 141/86 mmHg (millimeter of mercury), Patient had bed rails up and one side of the bed brakes on the bed. Patient rolled onto back and (full mechanical lift) lifted into bed using the care lift. Patient neuros (neurological assessment) remain stable with GCS (Glasgow Coma Scale) of 15 (15 reflects normal). Patient exhibits no signs of confusion or injury. Patient requested we wait till 8:00AM to call an inform family member. Will continue to monitor.
R57's Post Fall Analysis Worksheet dated 01/30/22 documents the following:
Circumstances at the time of the fall: Staff performing cares on resident. Resident rolled towards the wall and failed to stop rolling. Rolling (rolled) off the side of the bed and pushed the bed away from the wall. The same Post Fall Analysis Worksheet documents Interventions Implemented: Bed locked-staff assist of 2 (two) for bed mobility.
On 8/10/22 at 2:25 pm V6, Assistant Director of Nursing (ADON) stated V6, ADON completes all fall investigation in the facility. V6, ADON reviewed R57's fall investigation dated 1/30/22 and stated I (V6, ADON) remember (V9, Certified Nursing Assistant) was providing (R57's) care by herself (V9, CNA) when (R57) rolled out of bed. It shouldn't have happened. The bed was not locked properly, and (V9, CNA) should have had help positioning (R57) in bed during care. I (V6, ADON) educated staff and updated the care plan to reinforce these interventions.
2. R44's Physician Order Summary Report Sheet (POS) dated 08/10/22 documents the following diagnoses: Chronic Respiratory Failure with Hypoxia, Chronic Respiratory Failure with Hypercapnia, Anxiety Disorder, and Heart Failure Unspecified. The same POS documents the following: Oxygen at 4 (four) liters continuous (per nasal cannula) every day and night shift, related to Chronic Obstructive Pulmonary Disease.
R44's Minimum Data Set (MDS) dated [DATE] documents the following: R44 has a Brief Interview of Mental status score of 15 out of a possible 15, indicating no cognitive impairment. The same MDS documents R44 ambulates with staff supervision and has had one fall with minor injury since the last quarterly MDS was completed.
R44's (Formal) Fall Risk) assessment dated [DATE] documents R44 has a fall risk score of 60 (sixty). The same fall risk assessment documents a fall risk score of 45 or higher equals a resident is at high risk for falls.
R44's Care Plan dated revised 07/14/22 documents the following: Ambulation/Restorative: Supervise for technique and safety, especially while handling his oxygen tank and assist him as needed. R44's same Care Plan documents: He (R44) needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light.
On 08/09/22 at 11:25 am, R44 was standing in R44's bedroom/bathroom entry hall. R44 was attaching a oxygen nasal cannula with six foot long oxygen tube to a portable, metal oxygen cylinder tank. The portable metal oxygen cylinder tank was cradled in a double tank wheeled oxygen caddy. In the same entry way to R44's had a second oxygen nasal cannula and tubing. The second nasal cannula had 20 (twenty) feet of oxygen tubing. The second nasal cannula hung on the resident bedroom doorknob with the oxygen tubing hanging down to the floor. The remainder of the 20-foot oxygen tubing was scattered haphazardly across the entry hall floor, and into the bathroom floor. The oxygen tubing was scattered in a cluster just inside the bathroom doorway. The end of the oxygen tubing was attached to an electric oxygen concentrator that sat against the wall in the bathroom. R44 stated I (R44) have never been given a bag to coil the extra oxygen tubing in, but that would be nice. It is a pain in the butt to navigate around this tube (oxygen) on the floor.
On 8/10/22 at 9:55 am R44's was ambulating out of R44's bathroom and into R44's bedroom entry hall. R44 had R44's oxygen nasal cannula in R44's nares with the 20-foot oxygen tubing dangling to the floor. The remainder of the 20 feet of oxygen tubing laid on the floor haphazardly and directly in R44's path. The opposite end of the oxygen tubing was attached to the oxygen concentrator in R44's bathroom. R44 had a shuffling gait as R44 kicked the oxygen tubing repeatedly to get a clear path out of R44's bathroom and into the entry hallway of R44's room. V7, Registered Nurse (RN) was waiting outside R44's bathroom door as R44 came out of R44's bathroom. V7, RN acknowledged R44 had 20 feet of tubing scattered about the floor. V7, RN started coiling R44's excessive oxygen tubing around V7, RN's hand and stated This is definitely a trip hazard. I guess a infection control issue too. I will get him a bag to put this in.
The facility Fall Policy dated 04/19/22 documents the following:
Policy:
Fall and Accident intervention and prevention.
Purpose:
The resident's environment will remain free from accidents and hazards as possible; and each resident will receive adequate supervision and assistance devices to prevent accidents.
The guidelines for accident prevention are:
1. Identifying hazard(s) and risk(s).
2. Evaluation and analyzing hazard(s) and risk(s)
3. Implementing interventions to reduce hazard(s) and risk(s)
4. Monitoring for effectiveness and modifying interventions when necessary.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R51's undated Face Sheet documents medical diagnoses of Dementia With Behavioral Disturbance, Palliative Care, Restlessness a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R51's undated Face Sheet documents medical diagnoses of Dementia With Behavioral Disturbance, Palliative Care, Restlessness and Agitation, Major Depressive Disorder and Adjustment Disorder.
R51's Physician Order Sheet (POS) dated August 1-31, 2022 documents a physician order starting 7/23/22 for Lorazepam 0.5 milligrams (mg) every three hours as needed for Restlessness and Agitation.
R51's Medication Administration Record (MAR) dated August 1-31, 2022 documents R51 was administered Lorazepam 0.5 mg on 8/5/22 at 4:02 PM.
R25's undated Face Sheet documents medical diagnoses of Dementia Without Behavioral Disturbances, Anxiety Disorder and Depression.
R25's Physician Order Sheet (POS) dated August 1-31, 2022 documents a physician order starting 7/19/22 for Mirtazipine 7.5 mg daily for Depression.
R25's MAR dated August 1-31, 2022 documents R25 was administered Mirtazipine 7.5 mg daily on 8/1/22-8/9/22.
On 08/10/22 at 01:40 PM V6 Assistant Director of Nursing (ADON) stated anytime a resident is prescribed a new Psychotropic medication or when the dosage of any Psychotropic medication is increased there should be a consent signed by the resident or resident representative. V6 ADON stated (R51) was prescribed Ativan and no consent has been obtained. (R51) has received this medication and (R51) is not alert and oriented. I am going to obtain a consent this afternoon with (R51) Power of Attorney (POA). V6 ADON stated R25 was prescribed Mirtazipine and also has no consent. V6 stated We (staff) have looked all over for the Psychotropic consents and are not able to find them. The consents should have been completed and were not.
Surveyor: [NAME], [NAME]
3. R57's Physician Order Summary Report sheet (POS) dated 08/10/22 documents the following psychotropic medications: Duloxetine Hydrochloride capsule delayed release sprinkle 60 milligrams (mg), Give one capsule by mouth in the morning
related to Major Depressive Disorder, Single Episode Unspecified, Start date 06/17/2021.
The same POS documents: Alprazolam (Xanax) tablet 0.25 MG, give 1 tablet by mouth
at bedtime related to Anxiety Disorder, Unspecified, start 07/20/2022.
There is no documentation in R57's medical record of consent for R57's Duloxetine Hydrochloride and Alprazolam.
On 8/11/22 at 2:30 pm V6, Assistant Director of Nursing stated We do not have consents for (R57's) psychotropics.
The facility Policy for Psychoactive Medications undated documents the following: Informed Consent: Psychoactive medication shall not be prescribed or administered without the informed consent of the resident, the resident representative, the resident's guardian or other authorized representative. All psychoactive medications dose increases must have an informed consent. Additional informed consents are not required for a reduction in dosage leave or deletion of a specific medication. Side effects shall be described on the informed consent.
Based on interview and record review the facility failed to document appropriate rationale for extended use of as needed (PRN) psychotropic medication, failed to evaluate the need for continued use of PRN psychotropic medication, and failed to obtain and document consent for psychotropic medication. These failures affect four (R25, R51, R55, R57) of six residents residents reviewed for unnecessary medications on the sample list of 36.
Findings include:
1. R55's Face Sheet (undated) documents the following diagnoses: Dementia without Behavioral Disturbance, Psychosis, and Anxiety Disorder.
R55's Order Summary Report dated 8/10/22 documents the following anti-psychotic medication order: Seroquel, give 25mg (milligrams) one tablet by mouth as needed (PRN) for behaviors two times a day PRN. The start date for the medication is 5/14/22 and no end date is documented.
There is no documentation in R55's electronic medical record of the physician's rationale for exceeding 14 days for the PRN Seroquel and no evaluation for continued PRN use.
R55's Medication Administration Record (MAR) dated May 2022 documents R55 was administered two PRN doses of Seroquel after the initial 14 days. R55's June 2022 MAR documents R55 was administered 13 PRN doses of Seroquel and July 2022 MAR documents R55 was administered five PRN doses of Seroquel.
On 8/10/22 at 3:25pm, V6 Assistant Director of Nursing (ADON) confirmed R55's Seroquel order has no end date or documentation for extended use over 14 days.
The facility's Antipsychotic Medication Use Policy (2016) documents: The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. This Policy further documents PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, and interview the facility failed to prevent the potential for cross-contamination and foodborne illness by failing to dispose of expired refrigerated food, failed to date and la...
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Based on observation, and interview the facility failed to prevent the potential for cross-contamination and foodborne illness by failing to dispose of expired refrigerated food, failed to date and label open refrigerated food, failing to maintain a can opener and mixer in a sanitary operable condition. These failures have the potential to affect all 65 residents residing in the facility.
Findings include:
1. On 08/09/22 at 9:32 am, during the initial tour of the facility kitchen where residents meals are prepared, V4, Dietary Manager (DM), acknowledged the facility refrigerator had the following: A five pound, half full container of pasta salad with no open date; a five pound, half full container of cottage cheese with crusted edges at the top of the cottage cheese and no open date; a five pound, half full container of cucumbers and onions with no open date and a 24 ounce three-quarter full container of horseradish sauce that expired on 4/26/22.
On 08 /09/22 at 9:40 am V4, Dietary Manager stated Those need thrown away. I (V4, DM) am not sure why they (food items above) weren't dated. I don't know why the horseradish wasn't thrown out when it expired.
2. On 8/9/229/22 at 9:50 am V4, DM acknowledged the facility tabletop can opener mount was corroded with black dried food- like particles. The same can opener had gears with built-up brown and black grease like substance and fragments of metal shavings. The same can opener had a silver veneer scraped off that exposed one half inch base metal rusted blade tip.
V4, DM stated I did not realize the can opener was in this condition. It will be taken care of today.
3. On 8/11/22 at 10:00 AM full kitchen tour with V12, Assistant Dietary Manager acknowledged the facility had four 24 inches by 18-inch plastic cutting boards that were heavily stained and had food-like brown particles wedged into deep cracks throughout the cutting boards. V12, Assistant Dietary Manager / [NAME] stated Those cutting boards need to be replaced. I don't know how long they have been here, but they need to be replaced. They are in pretty bad shape.
4. On 8/11/22 at 11:18 am V4, DM acknowledged the facility had a large, two-foot-tall commercial sized table-top mixer. The table-top mixer underside attachment component had a build-up of rust and flaking silver paint veneer that exposed bare metal. The mixer underside attachment component also had brown and beige crusty food-like debris, just above the mixer bowl. V4, DM stated We probably shouldn't use this. I did not realize it (commercial sized mixer) had rust, and chipped paint.
The Resident Census and Conditions of Residents report dated 08/09/22 documents 65 residents reside in the facility.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • 32 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $13,635 in fines. Above average for Illinois. Some compliance problems on record.
- • Grade D (43/100). Below average facility with significant concerns.
Bottom line: Trust Score of 43/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Goldwater Pontiac's CMS Rating?
CMS assigns GOLDWATER PONTIAC NURSING HOME an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Illinois, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Goldwater Pontiac Staffed?
CMS rates GOLDWATER PONTIAC NURSING HOME's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 48%, compared to the Illinois average of 46%. RN turnover specifically is 56%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Goldwater Pontiac?
State health inspectors documented 32 deficiencies at GOLDWATER PONTIAC NURSING HOME during 2022 to 2025. These included: 1 that caused actual resident harm and 31 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Goldwater Pontiac?
GOLDWATER PONTIAC NURSING HOME is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by GOLDWATER CARE, a chain that manages multiple nursing homes. With 90 certified beds and approximately 87 residents (about 97% occupancy), it is a smaller facility located in PONTIAC, Illinois.
How Does Goldwater Pontiac Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, GOLDWATER PONTIAC NURSING HOME's overall rating (2 stars) is below the state average of 2.5, staff turnover (48%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Goldwater Pontiac?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Goldwater Pontiac Safe?
Based on CMS inspection data, GOLDWATER PONTIAC NURSING HOME has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Illinois. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Goldwater Pontiac Stick Around?
GOLDWATER PONTIAC NURSING HOME has a staff turnover rate of 48%, which is about average for Illinois nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Goldwater Pontiac Ever Fined?
GOLDWATER PONTIAC NURSING HOME has been fined $13,635 across 1 penalty action. This is below the Illinois average of $33,215. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Goldwater Pontiac on Any Federal Watch List?
GOLDWATER PONTIAC NURSING HOME 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.