WINNING WHEELS
Non profit - Corporation
88 Beds
Independent
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
0/100
#664 of 665 in IL
Photo by Ally Johnson
Photo by Gary Schwigen
Photo by Ally Johnson
1 / 5 photos
Last Inspection: July 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Winning Wheels nursing home has received a Trust Grade of F, indicating significant concerns about the quality of care provided. It ranks #664 out of 665 facilities in Illinois, placing it in the bottom tier, and #7 out of 7 in Whiteside County, meaning there are no local options rated lower. The facility’s performance trend is stable, with 17 issues reported consistently in recent years, suggesting persistent problems. Staffing is a weakness, rated at only 1 out of 5 stars, with a high turnover of 45%, which is slightly better than the state average of 46%. There are concerning findings, including a critical incident where a resident at high risk for elopement was found wandering outside and became physically aggressive, as well as serious issues where residents were not protected from abuse, leading to feelings of fear among them.
- Trust Score
- F
- In Illinois
- #664/665
- Safety Record
- High Risk
- Inspections
- Holding Steady
- Staff Stability ⚠ Watch
- 45% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $76,343 in fines. Lower than most Illinois facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 23 minutes of Registered Nurse (RN) attention daily — below average for Illinois. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 50 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 1%
Review needed
17 → 17 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 17 issues
2025: 17 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
1-Star Overall Rating
Below Illinois average (2.5)
Significant quality concerns identified by CMS
Staff Turnover: 45%
Near Illinois avg (46%)
Higher turnover may affect care consistency
Federal Fines: $76,343
Well above median ($33,413)
Moderate penalties - review what triggered them
The Ugly 50 deficiencies on record
1 life-threatening 4 actual harm
Jul 2025
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0605
(Tag F0605)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure psychotropic medications were prescribed for a defined duration for 1 of 5 residents (R12) reviewed for unnecessary medications in th...
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Based on interview and record review the facility failed to ensure psychotropic medications were prescribed for a defined duration for 1 of 5 residents (R12) reviewed for unnecessary medications in the sample of 18.The findings include:R12's Order Summary Report dated 7/23/25 shows R12 has an order for a psychotropic medication (Diazepam) to be administered as needed. The start date for the order was 3/10/25. There is no end date. On 7/23/25 at 10:10 AM, V9, MDS Coordinator, said psychotropic medications ordered as needed can only be prescribed for a duration of 14 days, then a new order must be obtained. The facility's Psychotropic Medication Use Policy (undated) shows psychotropic medications are subject to prescribing, monitoring and review requirements; psychotropic medication management includes duration.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete a Preadmission Screening and Resident Review (PASARR) Level...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete a Preadmission Screening and Resident Review (PASARR) Level 2 screen after a resident that was diagnosed with schizoaffective disorder diagnoses which applies to 1 of 18 residents (R7) reviewed for PASARR assessments in a sample of 18.The findings include:R7's Facesheet printed on 7/23/25 showed R7 is a sixty-year-old male originally admitted to the facility on [DATE].R7's Physician Summary notes dated 3/31/2020 showed R7's schizoaffective disorder diagnosis onset is dated 4/17/2019.R7's electronic record showed no PASARR level 2 was completed after R7 received the new diagnosis of schizoaffective disorder.The facility's PASARR Policy dated 2024 showed a resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or related conditions will be referred promptly to the state mental health or intellectual disability authority for a level 2 resident review.On 7/23/25 at 2:00 pm, V1 Administrator stated a resident with a new mental disorder diagnoses needs a level 2 PASARR assessment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a dressing was in place for a resident with a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a dressing was in place for a resident with a stage 4 pressure injury for one of one resident (R71) reviewed for pressure injuries in the sample of 18.The findings include:R71's Order Summary Report dated July 22, 2025 shows he was admitted to the facility on [DATE] with diagnoses including spina bifida, urinary tract infections, wheelchair dependence, pressure injury of left buttock stage four, and malnutrition. Orders for calcium alginate apply to left buttock topically every day shift started July 14, 2025.On July 21, 2025 at 10:18 AM, V8 Certified Nursing Assistant placed R71 into the shower chair and placed him in the shower so he could shower himself. At 10:49 AM, V8 placed R71 back into bed and dried off R71's body and got him dressed. There was a dressing that came off of R71's left buttock. The wound to R71's left buttock had some depth to it and was a little bigger than a quarter size in diameter. V8 put a shirt onto R71 and said she was waiting for the wound doctor to come to replace the dressing. R71 was positioned in bed onto his back with no dressing on his buttocks. At 2:26 PM, V8 said the wound care doctor is in the building but is on a different hallway and has not been to R71's room yet. At 2:35 PM, R71 said no staff have replaced the dressing on his left buttock. R71 said he is still in bed because they are waiting for the wound doctor to replace the dressing. R71 said he prefers to be in his wheelchair and not in the bed.R71's Treatment Administration Record dated July 1, 2025-July 31, 2025 shows R71's dressing to his left buttock was not documented as done on July 18, 2025 and July 21, 2025.R71's Wound Evaluation Management Summary dated July 21, 2025 at 3:35 PM shows that R71 has a stage four pressure injury to his left buttock that measured 4.2 X 3.5 X 3.5 cm. Dressing treatment plan was alginate calcium apply once daily and as needed; if saturated, soiled, or dislodged. Secondary dressing was gauze island with border apply once daily and as needed if saturate, soiled, or dislodged.On July 23, 2025 at 9:27 AM, V2 Director of Nursing (DON) said dressings should be replaced to pressure injuries if they come off.The facility's Prevention of Pressure Injuries policy dated April 2020 shows, Review the resident's care plan and identify the risk factors as weel as the interventions designed to reduce or eliminate those considered modifiable. Use facility-approved protective dressings for at risk individuals.
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 ensure a resident was transferred in a safe manner fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident was transferred in a safe manner for 1 of 18 residents (R73) in the sample of 18 reviewed for safety.The findings include:On 7/21/25 at 11:03 AM, R73 was sitting in a recliner in the TV room. V12, Certified Nursing Assistant (CNA), was pulling R73's left arm to get him out of the recliner. R73's left arm was pulled to the point where his left elbow was above the level of his head. On 7/23/25 at 9:30 AM, V2, Director of Nursing (DON), said a gait belt should be used to help pull a resident out of their chair. A resident's arm should not be pulled because it could cause an injury. R73's admission Record dated 7/23/25 shows he was admitted to the facility on [DATE]. R73's diagnoses include, but are not limited to, traumatic brain injury, quadriplegia, and repeated falls. R73's current care plan provided by the facility shows R73 has limited mobility, decreased strength, history of falls, and decreased sitting and standing balance and requires assistance with ambulation and transfers. The facility's Safe Resident Handling/Transfers Policy (undated) shows all residents require safe handling when transferred to prevent or minimize the risk for injury.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
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 date and time liquid nutrition when it was initiated ...
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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 date and time liquid nutrition when it was initiated for 1 of 4 residents (R34) reviewed for tube feeding in the sample of 18.The findings include:R34's Order Summary dated July 22, 2025 shows R34 was admitted to the facility on [DATE] with diagnoses including intracranial injury with loss of consciousness, dysphagia, pain, contractures, aphasia, and epilepsy. A liquid nutrition order was entered on November 22, 2024 for Isosource 1.5 two times per day.On July 21, 2025 at 9:39 AM, there was a bag of liquid nutrition hanging next to R34's bed. There was no resident's name on the bag nor date nor time. There was liquid nutrition noted in the tubing and the bag of nutrition was half empty. At 1:05 PM, this same unlabeled bag was still hanging next to R34's bed.On July 23, 2025 at 9:27 AM, V2 Director of Nursing said the liquid nutrition should be labeled with the date and time it was hung, the type of liquid nutrition, and the resident's name.The facility's Tube Feeding Policy and Procedure effective November 2012 shows, To provide a means of safely introducing a complete nutritional feeding to the resident, using a formula that is premixed and premeasured in a specifically designed container with a bacterial filter to protect the formula from being exposed to harmful airborne contaminates. Procedure using clean technique, write the date, and initials on the label provided on the tubing of the pump set and enter the residents name, room number, date, start time, rate and initials on the identification information label on the bottle of tube feeding.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer a medication as ordered by the physician for one of 18 r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer a medication as ordered by the physician for one of 18 residents (R3) reviewed for pharmacy services in the sample of 18. The findings include:R3's Order Summary Report shows she was admitted to the facility on [DATE] with diagnoses including myocardial infarction, congestive heart failure, generalized anxiety disorder, major depressive disorder, pain, major depressive disorder, post-traumatic stress disorder, alcohol use, and other bipolar disorder.On July 22, 2025 at 10:39 AM, R3 said it takes the facility a long time to start new medication orders. R3 said the psych doctor ordered an increase in her trazodone but she did not get the medication when it was ordered. I take it to help me sleep.R3's note from the psychiatry nurse practitioner dated July 10, 2025 shows, Plan Med changes: Patient's diagnosis of major depressive disorder is worsening and unstable at this visit. Increase trazodone to 100mg by mouth at bedtime.R3's Order Summary Report shows an order for trazodone 100mg (milligrams) one tablet by mouth at bedtime for mood related to major depressive disorder was entered July 11, 2025 to start on July 11, 2025.R3's Medication Administration Record (MAR) dated July 1, 2025-July 31, 2025, shows she received trazodone 75 mg from July 1, 2025-July 10, 2025 as ordered. The new order for the increase in trazodone to 100mg at bedtime was to start July 11, 2025. R3's MAR shows that R3 did not receive trazodone 100mg until July 13, 2025. R3's Psychotropic Informed Consent form for the increase in trazodone was signed by R3 on July 13, 2025.On July 23, 2025 at 9:27 AM, V2 Director of Nursing (DON) said she did not know why R3 had not received her increase dose of trazodone.The facility's Medication and Treatment Orders policy revised July 2016 shows, Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to ensure a multidose insulin pen was discarded 28 days after being opened for 1 of 18 residents (R3) reviewed for medication stor...
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Based on observation, interview and record review the facility failed to ensure a multidose insulin pen was discarded 28 days after being opened for 1 of 18 residents (R3) reviewed for medication storage in the sample of 18. The findings include:On 7/21/25 at 10:13 AM, R3's Lispro Insulin Pen was in the medication cart. The pen was labeled with an open dated of 6/15/25 and there was no discard date documented. 07/21/2025 10:13 AM, V7 (Licensed Practical Nurse) said that all insulin pens should be marked with the open date when it is opened and a discard date should be documented for 28 days after the date that it was opened. R3's July Medication Administration Record shows that she received Lispro Insulin Pen five times between 7/13/25 and 7/21/25. The facility's Insulin Pen Policy shows, Insulin pens must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency and expiration date Insulin pens should be disposed according to manufacturer's recommendations. The Lispro Manufacturer Guidelines show, Throw away the Insulin Lispro Pen you are using after 28 days, even if it still has insulin left in it.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide dental services for a resident which applies t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide dental services for a resident which applies to 1 of 1 resident (R49) reviewed for dental services in a sample of 18.The findings include:R49's Facility assessment dated [DATE] showed R49 is a thirty-nine-year-old male resident with moderate cognitive impairment. R49 was admitted to the facility on [DATE] with diagnoses which include hemiplegia/hemiparesis and intercranial injury.On 07/21/2025 at 2:00 PM, R49 was sitting in their wheelchair watching television. R49 had several broken teeth on their upper jaw, and dark colored tooth fragments/tooth roots along their lower jaw.R49's electronic medical record showed the last dental consent and appointment notes were dated 10/20/2020.On 7/23/25 at 1:50 PM, V11 Social Services stated we set up in house or out of house services for dental work. R49 does get seen out of the facility for dental services. V11 stated R49 does have broken teeth and gum issues. V11 stated they were not aware R49 has not seen a dentist since 2020.The facility's Dental Policy dated 2025 showed the facility is to assist residents with obtaining routine (covered by the State plan) and emergency dental care.On 7/23/25 at 2:00 PM, V1 Administrator stated they had no other documentation of R49 receiving dental care since 10/20/2020.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to change their gloves and perform hand hygiene in a man...
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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 change their gloves and perform hand hygiene in a manner to prevent cross contamination for one of 18 residents (R34) reviewed for infection control in the sample of 18.The findings include:R34's Order Summary Report dated July 22, 2025 shows she was admitted to the facility on [DATE] with diagnoses including intracranial injury with loss of consciousness, insomnia, dysphagia, atopic dermatitis, and neuromuscular dysfunction of the bladder.R34's Care Plan initiated on April 20, 2020 shows R34 has bowel and bladder incontinence. R34's Care Plan initiated on April 15, 2025 shows R34 is on enhanced barrier precautions and ensure proper hand washing is completed as resident allows.On July 21, 2025 at 9:39 AM, V5 and V6 Certified Nursing Assistants (CNAs) provided incontinence care to R34. V6 CNA removed R34's incontinence brief. There was a large amount of urine in R34's incontinence brief. V6 then touched the mechanical lift sling to place underneath R34, touched the mechanical lift sling controls to elevate R34 and place her into the shower chair. V6 then showered R34. V6 did not change her gloves while doing the above.On July 23, 2025 at 9:27 AM, V2 Director of Nursing (DON) said gloves should be changed prior to touching any clean items when doing incontinence care.The facility's Handwashing/Hand Hygiene policy revised October 2023 shows, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Hand Hygiene is indicated after contact with blood, body fluids, or contaminated surfaces and before moving from work on a soiled body site to a clean body site.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
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 rooms were free from pests which appl...
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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 rooms were free from pests which applies to 2 of 18 residents (R46, R54) reviewed for pest control is a sample of 18.The findings include:The facility's resident roster dated 7/16/25 showed R46 and R54 are roommates on the B-wing of the facility.R46's Facesheet printed on 7/22/25 showed R46 is a [AGE] year-old male with diagnoses which include tracheostomy, traumatic brain injury, and hemiplegia of the left side.On 7/21/25 at 10:30 AM, R46 was lying in bed with no shirt on. R46 had 4-6 flies flying around bed area and landing and walking on R46. R46 was having difficulty waving the flies off himself. R46 nodded when asked if the flies were bothering him. No pest reduction methods were in the room at this time. There were more than a dozen flies in R49's room at this time.R54's Facesheet printed on 7/22/25 showed R54 is a [AGE] year-old male with diagnoses which include intracranial injury with loss of consciousness, quadriplegia, and dysphagia.On 7/21/25 at 2:10 PM, R54 was in his room resting in reclined wheelchair. R54 had several flies landing on his face and crawling across his nose and cheek. R54 would flex his arm, but due to quadriplegia was unable to scare flies away.On 7/22/25 at 10:30 AM, V16 pest control specialist (3rd party) stated they do have treatments for flies, but they cannot utilize them in resident rooms. The main treatment is a chemical spray in open areas. The resident rooms are maintained by the facility. If we are told a certain room or hallway has pests (flies) we can go and give recommendations to reduce the issue. V16 stated they have not had anyone direct them to any specific resident rooms for pest (flies) control concerns.On 7/23/25 at 10:20 AM, V10 Safety Director stated if any of the staff notice a bug issue (ants, flies, etc.) they need to let me know so we can try to reduce the issue and let the pest control group about the problem when they come in. V10 stated he was not notified about R46 and R54's fly problem. There should not be flies crawling on residents. The facility's Pest Control Policy dated 2025 showed the facility is to maintain an effective pest control program that contains common household pests including bed bugs, ice, roaches, ants, mosquitos, flies, mice, and rats.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to follow the pureed diet menu for 4 of 4 residents (R4, R16, R38 and R42) reviewed for menus in the sample of 18. The findings in...
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Based on observation, interview and record review the facility failed to follow the pureed diet menu for 4 of 4 residents (R4, R16, R38 and R42) reviewed for menus in the sample of 18. The findings include:The facility provided Diet Type Report printed on 7/22/25 shows that R4, R16, R38 and R42 are all on a pureed diet.The Diet Spreadsheet for the noon meal on 7/21/25 shows that residents on a pureed diet should receive pureed barbecue on cornbread, pureed green beans and pureed canned fruit.The Recipe for Pureed Barbecue Pork on Cornbread shows ingredients of: BBQ Pork on cornbread with creamed corn and milk.On 7/21/25 at 10:42 AM, V15 (Cook) prepared the pureed food for the noon meal. V15 placed 10 scoops of barbecue pork into the blender bowl and processed it. V15 added warm milk and processed again. V15 then place the pureed barbecue into a container and placed it onto the steam table. V15 did not add cornbread to the barbecue. On 7/21/25 at 11:37 AM, R4, R16, R38 and R42 were served the pureed barbecue without a cornbread serving. V15 then ran out of pureed barbecue and prepared additional barbecue by adding corn bread into the barbecue. On 7/22/25 1:10 PM, V4 (Dietary Manager) said that the menu and recipe should be followed by the staff when making pureed food. V4 said that the pureed barbecue should have had corn bread added to it during the puree process. The facility's Puree Food Preparation Policy shows, Puree Food Preparation Guidelines for serving per individual recipes.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to ensure residents on a pureed diet were served a meal in a form that meet their needs for 4 of 4 residents (R4, R16, R38 and R42...
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Based on observation, interview and record review the facility failed to ensure residents on a pureed diet were served a meal in a form that meet their needs for 4 of 4 residents (R4, R16, R38 and R42) reviewed for pureed diets in the sample of 18. The findings include:The facility provided Diet Type Report printed on 7/22/25 shows that R4, R16, R38 and R42 are all on a pureed diet.The Diet Spreadsheet for the noon meal on 7/21/25 shows that residents on a pureed diet should receive pureed barbecue on cornbread, pureed green beans and pureed canned fruit and an alternative of pureed breaded fish and pureed potatoes. On 7/21/25 at 10:42 AM, V15 (Cook) prepared the pureed food for the noon meal. V15 pureed breaded fish sticks and added warm milk. V15 then placed the pureed fish into a container. When scooped into the container, the fish appeared very thick. V15 then pureed barbecue pork and added warm milk. V15 then placed the barbecue into a container. When scooped into the container, the barbecue appeared thick. On 7/21/25 at 11:37 AM, R4, R16, R38 and R42 were served the pureed meal. On 7/21/25 at 12:15 PM, the pureed fish and barbecue was tasted. The fish and barbecue were thick, dry and not a smooth consistency. On 7/22/25 1:10 PM, V4 (Dietary Manager) said that pureed foods should be pureed to a smooth, pudding like consistency. The facility's Puree Food Preparation Policy shows, Puree foods should be prepared in such a manner to prevent lumps and chunks. The goal is a smooth, soft, homogenous consistency similar to soft mashed potatoes.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a meal was served in a sanitary manner and faile...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a meal was served in a sanitary manner and failed to ensure the temperature of resident refrigerators were monitored. This has the potential to affect all 77 residents residing in the facility. The findings include:
1. On 7/21/25 at 11:30 AM, V15 (Cook) was plating the noon meal from the steam table. V15 had gloves on and was putting the fish sticks and cornbread onto the plates using her hands. At 11:45 AM, V15 coughed onto her right wrist area. At 11:49 AM, V15 sneezed into her left elbow area. At 11:51 AM, V15 wiped her nose with her left wrist area. V15 continued to serve the food with her hands and did not remove her gloves and perform hand hygiene.
On 7/22/25 1:10 PM, V4 (Dietary Manager) said that staff should always be using utensils to serve food to the residents. V4 said that if the staff coughs or sneezes while plating food, they should leave the line and wash their hands and put a new pair of gloves on.
The facility's Handwashing Guidelines for Dietary Employees shows, Dietary employees shall keep their hands and exposed portions of their arms clean .Dietary employees shall clean their hands and exposed portions of their arm immediately before engaging in food preparation including working with exposed food .and also in the following situations: After coughing, sneezing, or blowing your nose .
2. R30’s Facility assessment dated [DATE] showed R30 is a fifty-one-year-old cognitively intact female resident admitted to the facility on [DATE].
On 7/21/25 at 10:15 AM R30’s room refrigerator had no thermometer in it. The refrigerator had 2 yogurt containers, lunchmeat, and sliced cheese. R30 stated she did not remember the last time any of the staff had checked the refrigerator. R30 stated there has not been a thermometer in it in a long time.
3. R2’s Facility assessment dated [DATE] showed R2 is a forty-eight-year-old cognitively intact female resident admitted to the facility on [DATE].
On 7/21/25 at 1:25 PM, R2’s refrigerator had no thermometer in it. The freezer/fridge had an open ice cream container, an opened heart (Valentine’s Day) candy box, yogurt, guacamole, and assorted small candies. R2 stated they did not know if/when anybody has checked the fridge. R2 stated when she gets food leftovers they put it in the refrigerator.
On 7/23/25 at 10:20 AM, V10 Safety Director stated they do room checks, but do not have documentation for the resident room refrigerators. They should all have a thermometer in them to make sure they are working.
The facility’s undated Resident Food Storage and Handling Policy showed the facility ensure proper handling, serving a storage of any food items brought into the facility.
May 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to treat a residents (R1) urinary tract infection (UTI) for nearly 48 hours. This applies to 1 of 3 residents (R1) reviewed for improper nursi...
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Based on interview and record review, the facility failed to treat a residents (R1) urinary tract infection (UTI) for nearly 48 hours. This applies to 1 of 3 residents (R1) reviewed for improper nursing care in the sample of 5.
The findings include:
R1's admission Record (Face Sheet) showed an admission date of 8/23/23 with diagnoses to include partial paralysis following a stroke, ESBL (bacteria in the urinary tract that are resistant to many antibiotics), history of urinary tract infections, morbid obesity, and congestive heart failure.
R1's 3/26/25 Nurse's Note from 5:05 PM showed, Final report received for urine C&S (culture and sensitivity, a urine test showing which bacteria are present in the urine) . The note showed which bacteria and fungi were present and that R1's doctor, nurse practitioner, and the director of nursing were notified.
R1's 3/27/25 Nurse's Note from 11:04 AM showed, (no other progress notes were documented between this note and the previous note listed) Resident in bed sleeping, easily awakened to take scheduled medications. c/o (complains of) urinary frequency, burning, and level 10 generalized pain with fatigue. Temp 97.8. PM [narcotic pain medication] given. Urine noted to be dark and concentrated. U/A (urine analysis) with C&S completed with results to [R1's doctor, nurse practitioner, and director of nursing] notified of results.
R1's 3/27/25 Nurse's Note from 1:14 PM showed, (this is the next consecutive progress note) This nurse called [local area hospital] for [V10 Infectious Disease Doctor] switchboard took message regarding patient needing antibiotic for UTI. Awaiting return call from [infectious disease doctor].
R1's 3/27/25 Nurse's Note from 1:40 PM showed, (this is the next consecutive progress note) [V10] returned phone call to this nurse. [V10] states he has not seen resident recently enough and will not prescribe antibiotics for UTI at this time.
R1's 3/28/25 Nurse's Note from 7:53 PM showed, (This is the next note with information pertaining to R1's UTI and more than 24 hours after the previous note) Res (Resident) requesting to be evaluated in ER (Emergency Room) for urinary symptoms. VS (vital signs) wnl (within normal limits) .Res left facility at [7:50 PM] (over 48 hours after positive UTI test results) .
R1's 3/29/25 Nurse's Note from 1:54 PM showed, .res admitted with UTI .
R1's March 2025 Medication Administration Record (MAR) showed she was taking Doxycycline 20 milligrams twice daily due to personal history of urinary tract infections. This order was started on 8/23/23; R1's admission date. The MAR showed no other antibiotics were started on 3/26/25, 3/27/25, or 3/28/25.
The facility's electronic provider communication system showed a message from V3 R1's Nurse Practitioner on 3/26/25 at 5:52 PM, Unfortunately, if she is symptomatic and we cannot treat in house at this time, she likely needs sent out for treatment. Her UTIs are getting more complicated to treat in house.
On 5/20/25 at 12:33 PM, V3 stated that signs and symptoms of a urinary tract infection are lower abdominal pain, urinary frequency, urinary urgency, burning with urination, and urine odor. V3 stated, based on R1's culture and sensitivity from 3/26/25, she did have a urinary tract infection. V3 stated that prompt treatment of urinary tract infection is important to prevent blood infections and hospitalizations.
On 5/20/25 at 2:11 PM, V3's electronic note from 3/26/25 at 5:52 PM was read back to her. V3 replied, If she was symptomatic and not able to be treated at the facility, they should have sent her out at that time. V3 continued, if the facility did not send her out on 3/26/25, they then should have sent her out following the infectious disease doctor's refusal to treat
On 5/20/25 at 2:36 PM, V2 Director of Nursing (DON), stated that UTI treatment should not be delayed. V2 said a delay in treatment could lead to blood infections and/or hospitalizations. V2 said if the facility is unable to treat a resident's urinary tract infection, they should be sent out for evaluation.
Feb 2025
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure controlled medications were signed off in the electronic narcotic inventory system at the time the controlled medicatio...
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Based on observation, interview and record review, the facility failed to ensure controlled medications were signed off in the electronic narcotic inventory system at the time the controlled medications were administered for 7 of 10 residents (R4-R10) in the sample of 10.
The findings include:
On 2/13/25 between 9:12 AM and 10:20 AM, a medication pass by V4 (Licensed Practical Nurse-LPN) was observed on the B wing of the facility. At 10:20 AM, V4 said she had completed the AM medication pass for the residents she was assigned to, and there were no more residents with AM medications due on the B wing. At 10:47 AM, V4 was informed that this surveyor would like to do a narcotics count with her for the B wing medication cart. V4 said she had to sign off on her narcotics prior to doing the narcotics count. V4 was informed that we would go ahead and do the narcotics count at that time. During the narcotics count, controlled medications for R4-R10 were not signed off in the electronic narcotic inventory system at the time they were administered to R4-R10.
The narcotic count showed the following:
R4's Tramadol (a schedule IV-controlled substance used to treat moderate to severe pain) 50 mg (milligram) tablets. Dosage 1 tablet. The count in the facility's electronic narcotic inventory system showed 28 and 8 tablets. R4's medication cards showed 28 and 7 tablets.
R4's Pregabalin (a schedule V-controlled substance used to treat nerve and muscle pain) 75 mg pills. Dosage 1 pill. The count in the facility's electronic narcotic inventory system showed 77 pills. R4's medication cards showed 76 pills.
R5's Morphine (a schedule II-controlled substance used to treat moderate to severe pain) 15 mg. Dosage 0.5 pill. The count in the facility's electronic narcotic inventory system showed 12.5 pills. R5's medication card had 12 pills.
R5's Klonopin (a schedule IV-controlled substance used to treat seizures, panic disorders, and anxiety) 0.5 mg. Dosage 1 pill. The count in the facility's electronic narcotic inventory system showed 65 pills and R5's medication card had 64 pills.
R6's Tramadol (a schedule IV-controlled substance used to treat moderate to severe pain) 50 mg tablets. Dosage 1 tablet. The count in the facility's electronic narcotic inventory system showed 68 tablets and R6's medication card had 67 tablets.
R7's Lyrica (a schedule V-controlled substance used to treat nerve and muscle pain) 150 mg capsules. Dosage 1 capsule. The count in the facility's electronic narcotic inventory system showed 104 capsules. R7's medication cards showed 103 capsules.
R8's Tramadol Hcl (a schedule IV-controlled substance used to treat moderate to severe pain) 50 mg tablets. Dosage 1 tablet. The count in the facility's electronic narcotic inventory system showed 104 and R8's medication cards had 103 tablets.
R9's Lacosamide (a schedule V-controlled substance used to treat seizures) 150 mg pills. Dosage 1. The count in the facility's electronic narcotic inventory system showed 62 pills and R9's medication cards showed 61 pills.
R10's Lorazepam (a schedule IV-controlled substance used to treat anxiety, sleeping problems, and seizure disorders) 0.5 mg tablets. Dosage 1 tablet. The count in the facility's electronic narcotic inventory system showed 63 tablets and R10's medication card showed 62 tablets.
On 2/13/25 at 11:04 AM, V4 (LPN-Agency nurse) said controlled medications should be signed out in the electronic narcotic inventory system when given, to prevent medication count errors.
On 2/13/25 at 1:00 PM, V2 (Director of Nursing-DON) said the nurses should sign off controlled medications as they are giving them to the residents. V2 said they should have the (electronic narcotic inventory system) up and sign off in conjunction with the residents' MARS (medication administration records) for tracking purposes. V2 said the facility uses the (electronic narcotic inventory system) in place of the medication reconciliation binder. V2 said it is important to do this for safe medication administration, to monitor the counts, to make sure the counts are accurate, and to ensure there is no medication diversion.
R4's Order Summary Report, printed by the facility on 2/13/25, showed an order for Tramadol Hcl 50 mg tablet one time a day for pain in the morning, and an order for Pregabalin 75 mg capsule. One capsule two times a day related to chronic pain syndrome.
R5's Order Summary Report, printed by the facility on 2/13/25, showed an order for Clonazepam (Klonopin) 0.5 mg tablet. Give 1 tablet two times a day related to tremor. The report showed an order for Morphine Sulfate IR 15 mg. Give 0.5 tablet two times a day related to pain.
R6's Order Summary Report, printed by the facility on 2/13/25, showed an order for Tramadol Hcl 50 mg tablet. Give one tablet two times a day related to pain.
R7's Order Summary Report, printed by the facility on 2/13/25, showed an order for Pregabalin (Lyrica) 150 mg capsule. Give 150 mg three times a day for nerve pain.
R8's Order Summary Report, printed by the facility on 2/13/25, showed an order for Tramadol Hcl 50 mg tablet. Give one tablet three times a day for left leg pain.
R9's Order Summary Report, printed by the facility on 2/13/25, showed an order for Lacosamide 150 mg tablet. Give one tablet two times a day for seizures.
R10's Order Summary Report, printed by the facility on 2/13/25, showed an order for Lorazepam 0.5 mg tablet. Give one tablet two times a day related to generalized anxiety disorder.
On 2/13/25, the facility provided the following electronic narcotic inventory system printouts showing:
R4's Tramadol Hcl 50 mg tablet and Pregabalin 75 mg tablet showed they were signed off in the electronic narcotic inventory system on 2/13/25 at 11:17:40 and 11:17:44 AM respectively.
R5's Morphine 15 mg 0.5 tablet showed it was signed off in the electronic narcotic inventory system on 2/13/25 at 11:16:57 AM.
The printout did not include R5's Klonopin information.
R6's Tramadol Hcl 50 mg tablet showed it was signed off in the electronic narcotic inventory system on 2/13/25 at 11:20:35 AM.
R7's Lyrica 150 mg capsule showed it was signed off in the electronic narcotic inventory system on 2/13/25 at 2:41:22 PM.
R8's Tramadol Hcl 50 mg tablet showed it was signed off in the electronic narcotic inventory system on 2/13/25 at 11:36:36 AM.
R9's Lacosamide 150 mg tablet showed it was signed off in the electronic narcotic inventory system on 2/13/25 at 11:22:32 AM.
R10's Lorazepam 0.5 mg tablet showed it was signed off in the electronic narcotic inventory system on 2/13/25 at 11:13:17 AM.
The facility's January 2001 policy and procedure titled Controlled Medications-Ordering and Receipt showed Medications included in the Drug Enforcement Administration classification as controlled substances, and medications classified as controlled substances by state law, are subject to special ordering, receipt, and record keeping requirements in the facility, in accordance with federal and state laws and regulations .The form used to check in a schedule II-controlled substance is also used as the special dose administration record required by federal guidelines. The medication will be entered into the (electronic narcotic inventory system) and will be used as the special dose administration record required by federal guidelines.
Jan 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to utilize a glucose monitoring sensor per physician orders for 1 of 3 residents (R1) reviewed for physician orders in the sample...
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Based on observation, interview, and record review the facility failed to utilize a glucose monitoring sensor per physician orders for 1 of 3 residents (R1) reviewed for physician orders in the sample of 4.
The findings include:
On 1/7/25 at 10:12 AM, R1 was in bed watching TV. R1 said she was upset with V7 (Registered Nurse-RN) because she placed her glucose monitoring sensor wrong and now she had to be poked in the finger to check her blood sugar. R1 said this happened over the weekend. R1 said V7 bent the needle and so it had to be removed. R1 said the nurses told her a new one couldn't be used since the insurance wouldn't pay for it. R1 said insurance only pays for 2 per month and now she has to wait 14 days.
On 1/7/25 at 10:30 AM, V5 (Licensed Practical Nurse-LPN) said she was told in report that V7 tried to insert the glucose sensor and bent the needle so it wasn't working and had to be removed. V5 said they have to wait for 2 weeks since insurance only covers 2 per month. V5 said she was not sure if V2 (Director of Nursing-DON) was notified but she was going to tell her today.
On 1/7/25 at 1:08 PM, V2 said she had just applied a new sensor on R1. V2 said they had the second sensor in the box for the month and just put that one on. V2 said the facility will pay for a new one in 14 days when it is due. V2 said she had not been made aware of the situation.
R1's Physician Orders dated 11/5/24 shows Change (glucose monitoring sensor) every 14 days per manufacturer's instructions. Apply to back of arms only. These same orders shows accucheck in AM and HS (bedtime) two times a day related to type 2 diabetes.
R1's Medication Administration Record for December 2024 shows R1's (glucose monitoring sensor) was to be placed on 12/31/24 (7 days prior) and was charted as HOLD.
The facility's Medication Administration Policy dated 12/2014 shows The facility will provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all medications to meet the needs of each resident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure residents received assistance with activities of daily living for 2 of 4 residents (R1, R2) reviewed for activities of ...
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Based on observation, interview, and record review the facility failed to ensure residents received assistance with activities of daily living for 2 of 4 residents (R1, R2) reviewed for activities of daily living (ADL) in the sample of 4.
The findings include:
1. On 1/7/25 at 10:12 AM, R1 was in bed watching TV. R1 said staff have to assist her up to her reclining chair since her electric wheelchair is broke. R1 said she can not propel herself in the reclining chair and staff don't like to deal with the chair. R1 said she has a pendant call light to use when she is not in her room for staff to come help her get back to her room.
On 1/7/25 at 11:48 AM, R1 was up in her reclining wheelchair in the dining room. R1 did not have her pendant call light on. R1 said she didn't have it on today, and staff usually don't put it on unless she asks for it. R1 said the other day at dinner time, she didn't have her pendant on and staff left her in the dining room. R1 stated they just left me down here! I had to holler out for help! The kitchen staff heard me and went and got someone but is was a long time. R2 said it was V6 (Certified Nursing Assistant-CNA) and V8 (Agency CNA) that left her in the dining room.
On 1/7/25 at 12:15 PM, V6 said she did work that day but was not assigned to R1. V6 said V8 and another Agency CNA were assigned to R1. V6 said R1 is supposed to have her pendant on when she is not in the room. V6 said R1 had complained to her that the staff wouldn't help her and told her they didn't have time for her. V6 said she did not see R1 in the dining room, she was helping residents on her hallway.
On 1/7/25 at 1:08 PM, V2 (Director of Nursing-DON) said R1 has a pendant that she wears, it's a portable call light since she is unable to move herself in the reclining wheelchair. V2 said R1 should have it when she is not in her room.
On 1/7/25 at 12:14 PM, a message was left for V8 (Agency CNA) with no return call.
R1's Facesheet shows R1 has a diagnoses of cerebral palsy, chronic respiratory failure, morbid obesity, stiff-man syndrome, heart failure, type 2 diabetes, muscle wasting and atrophy, and chronic fatigue.
2. On 1/7/25 at 9:50 AM, R2 was up in his wheelchair in his room. R2 had a breath activated call light near his mouth. R2 said he had already had breakfast. R2 said he has a hard time getting his teeth brushed in the morning. R2 said the staff will get him changed and up to his chair and then leave. R2 said his teeth had not been brushed today. R2 said the CNA got him up and then just walked out before he could even say anything. R2 said it wasn't just today, it happens all the time and he is sick of it. R2 said he likes to get his teeth brushed before he goes down to breakfast. R2 said he has told the nurses but was not sure if the message got to V2 (DON). R2 said he is afraid of getting tooth decay if he doesn't get his teeth brushed.
On 1/7/25 at 10:20 AM, V3 (CNA) said R2 is alert and able to voice what he needs 100%. V3 said in the morning, R2 gets a bed bath, dressed, up to his chair, gets his teeth brushed right away before going to breakfast. V3 said there was an emergency and she did not get to brush R2's teeth yet today.
On 1/7/25 at 10:30 AM, V5 (Licensed Practical Nurse-LPN) said R2 has complained to her about not getting his teeth brushed last week and again this morning. V5 said she brushed R2's teeth for him last week.
On 1/7/25 at 1:08 PM, V2 (DON) said staff should honor residents preferences for teeth brushing and try to accommodate as able.
R2's Care Plan shows R2 is dependent on staff due to limited movement- oral hygiene- total assist of 1 twice daily. R2 is unable to perform own oral hygiene due to left hemiparesis- perform mouth care as per ADL personal hygiene.
The facility's undated Daily Personal Care & Privacy Policy shows Every resident shall be given daily personal attention. This personal care shall include, but not be limited to, perineal cleanliness, skin care, nails, hair, and oral hygiene.
Jul 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure orders were in place for a resident with non-pressure skin injuries and failed to ensure a resident's central venous catheter dressin...
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Based on interview and record review the facility failed to ensure orders were in place for a resident with non-pressure skin injuries and failed to ensure a resident's central venous catheter dressing was changed weekly. This applies to 2 of 3 residents reviewed for nursing care in the sample 4.
The findings include:
1. R1's 6/6/24 Progress Note from 5:00 PM, showed he returned from his wound care appointment with a PICC line. (Peripherally Inserted Central Catheter, a type of Intravenous (IV) catheter which extends to the large veins in the chest.)
On 7/23/24 at 1:30 PM, V1 Administrator stated a resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) should include all the resident's orders and treatments.
R1's June 2024 MAR and TAR showed no PICC line dressing order being in place; therefore, no PICC line treatments were documented as being done.
R1's July 2024 TAR showed, Change PICC line dressing Weekly and PRN (as needed) every day shift every 7 days for infection control. The TAR showed this order was started on 7/9/24 (over a month after the PICC was inserted).
R1's 6/27/24 Progress Notes from 12:26 PM, showed the PICC line dressing was changed.
On 7/23/24 at 2:00 PM, V2 Director of Nursing stated she could not find any other documented PICC line dressing changes for R1 before 7/9/24, except for the 6/27/24 dressing change documented in R1's progress notes. V2 said she could not locate any PICC line dressing change orders before 7/9/24.
On 7/9/24 at 11:03 AM, V3 Wound Care Nurse stated the purpose of weekly PICC line dressing changes is to allow close inspection of the insertion site and to prevent infection of the site. V3 said R1's nurse on 6/6/24 should have entered the orders for the PICC line dressing change or request clarification if there were no orders.
The facility's Central Venous Catheter Dressing Change policy/procedure (revision 2008) showed the dressing should be change at least weekly.
2. R2's 6/21/24 Progress Note from 2:27 PM, showed R2 returned to the facility from the hospital, and he was placed into hospice care.
R2's Skin Evaluation note from 6/23/24 at 4:29 AM, showed he had a surgical wound to his right abdomen.
R2's 6/26/24 Skin/Wound Note from 6:59 PM, showed he had a skin tear to the left elbow measuring 3.0 centimeters by 4.0 centimeters with redness surrounding it. The note also showed he had drainage from a biopsy site in his right upper abdomen and it was covered with a dry dressing.
On 7/23/24 at 1:30 PM, V1 Administrator stated a residents Medication Administration Record (MAR), and Treatment Administration Record (TAR) should include all the resident's orders and treatments.
R2's June 2024 MAR and TAR showed no orders for R2's left elbow or abdominal biopsy site.
R2's July 2024 TAR showed the first order to treat R2's abdomen was entered on 7/4/24 and was entered as his left abdomen. This treatment was not documented as being done, was discontinued, then on 7/5/24 an order to treat the right upper abdomen was entered. The order showed, Cleanse RUQ (right upper quadrant) with NS (normal saline) pat dry apply [calcium alginate] and dry dressing EOD (every other day) and PRN (as needed). The TAR showed the first documented treatment was on 7/5/24 (9 days after wounds were identified).
On 7/23/24 at 11:03 AM, V3 Wound Care Nurse stated, at the time the skin tear was identified, the facility did not have standing orders for skin tears. V3 stated when wounds are identified the floor nurses should reach out to her or call the physician for orders. V3 said if orders are not obtained and/or the orders are not entered into the computerized charting, the floor nurses do not know what treatments each resident requires. V3 said the purpose of treating wounds is to promote wound healing and to prevent infection. V3 said R2's RUQ was a biopsy site and progressively worsened with swelling. V3 said there should have been orders in place for R2's RUQ wound and his elbow skin tear once they were identified.
On 7/23/24 at 1:30 PM the facility's wound care policy was requested. The facility provided a Pressure Ulcer Prevention Program policy.
The facility's Pressure Ulcer Prevention Program policy (revision 6/2014) showed the Wound Care Coordinator: Role and Responsibility .Confers with the resident's attending physician regarding treatment recommendations. Documents and transcribes all new physician orders received .
Jun 2024
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide personal care for a resident in a manner to p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide personal care for a resident in a manner to promote dignity for 1 of 1 resident (R49) in the sample of 20.
The findings include:
R49's admission Record, printed by the facility on 6/12/24, showed he had diagnoses including quadriplegia, C5-C7 incomplete, neuromuscular dysfunction of bladder, neurogenic bowel, polyneuropathy (damage to multiple peripheral nerves resulting in problems with sensation, coordination and other body functions) neuralgia (pain caused by damaged or irritated nerve), neuritis (inflammation of one or more nerves that can lead to impaired transmission of neural signals), and edema. R49's facility assessment dated [DATE], showed he was cognitively intact, had an indwelling catheter and was always incontinent of bowel. R49's functional performance care plan, initiated on 4/20/2020, showed he required extensive assist of two staff members for dressing and bed mobility, and total assist of two staff members for toileting, total assist of staff for bilateral lower extremity bathing, and maximal assist of staff for bilateral upper extremity bathing. R49's care plan initiated on 4/20/2020 showed he had impaired physical mobility due to a spinal cord injury. R49's care plan, initiated on 4/20/2020, showed he had an indwelling suprapubic catheter due to neurogenic bladder.
On 6/11/24 at 1:32 PM, V16, V17, and V18 (all CNAs-Certified Nursing Assistants) were in R49's room bathing R49. V17 and V18 were washing R49's hair and V16 was washing R49's suprapubic catheter, penis and groin areas. V16 left the room to get an incontinent brief and to let V3 (Wound Nurse) know that R49 needed the dressings on his sacral area changed. R49's entire body was left exposed while V17 and V18 finished washing R49's hair and removed his heel protectors to pull his pants over his feet. V18 emptied R49's urinary drainage bag and placed the drainage bag through one of R49's pant legs. The pants were only pulled up to R49's shin areas. No sheet or blanket was draped over R49. R49 was turned on his right side. At 1:47 PM, V3 entered the room to do the dressing change for R49. V3 left the room twice to get supplies needed for the wound care. R49 was left exposed until 2:08 PM (36 minutes in total) when staff finished providing care and wound care.
On 6/12/24 at 11:19 AM, V11 (Registered Nurse-RN) said leaving a resident's private areas exposed during care is not acceptable for the resident's privacy and dignity. V11 said anyone can walk into the room.
On 6/12/24 at 2:49 PM, V3 said R49 should have been covered when not providing care to that area of the body. He should not have been left uncovered for half an hour for the resident's dignity.
On 6/13/24 at 1:15 PM, V2 (Director of Nursing-DON) said when the CNAs are not providing care to that area, the resident should be covered to maintain the resident's privacy, and to maintain his dignity.
The facility's policy and procedure titled Promoting Resident's Dignity, with a revision date of March 2017, showed This facility will promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in recognition of their individuality.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) R25's electronic face sheet printed on 6/13/24 showed R25 has diagnoses including but not limited to intracranial injury, epi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) R25's electronic face sheet printed on 6/13/24 showed R25 has diagnoses including but not limited to intracranial injury, epilepsy, hemiplegia, and major depressive disorder.
R25's facility assessment dated [DATE] showed R25 has mild cognitive impairment.
R25's care plan dated 5/1/24 showed, Another peer (R66) was driving down the hallway and said trains coming through out loud causing (R25) to get upset and block (R66) from driving down the hallway. (R66) then smacked (R25) in the face and grabbed his shirt.
R66's electronic face sheet printed on 6/13/24 showed R66 has diagnoses including but not limited to traumatic brain injury, dementia with agitation, and anxiety disorder.
R66's behavior monitoring for the past 30 days showed R66 has had behaviors 20 out of the last 30 days ranging from verbal aggression to physical aggression.
3) R44's electronic face sheet printed on 6/13/24 showed R44 has diagnosis including but not limited to arthrogryposis multiplex, fusion of spine, mood disorder, and developmental disorder.
R44's facility assessment dated [DATE] showed R44 has no cognitive impairment.
R44's care plan dated 5/3/24 showed, Another resident (R66) was driving down the hall cursing out loud causing (R44) to be upset and drove up to (R66) telling him to stop. This caused (R66) to become agitated and kick (R44).
On 6/12/24 at 12:15PM, V22 (Licensed Practical Nurse) stated, We don't know why (R44) went down the hallway to yell at (R66). (R44) was swearing at (R66) because (R66) was having a fit and swearing. We separated them immediately after (R66) kicked (R44). I don't work with (R66) very much so I don't know what his cognitive status is but he is aware of his needs so I would say yes it was intentional and it would be resident to resident abuse. It's hard with this popoulation though because they do have behaviors of hitting other people but I don't know that I would always consider it abuse. I guess I need more clarification on what resident to resident abuse actually is.
Based on interview and record review the facility failed to ensure a resident's right to be free from abuse for 2 of 3 residents (R38, R44) reviewed for abuse in the sample of 20 and 1 resident (R25) outside the sample.
The findings include:
1. On 6/11/24 at 10:11 AM, R38 was in her room in a wheelchair. She was alert and oriented X3. Her speech was clear and she had good eye contact.
On 06/11/24 at 10:11 AM, R38 said on the Saturday of Memorial Day weekend (5/25/24), she and her old roommate (R42) were in their room. R38 said R42 kept interrupting her and she asked her not to. R38 said R42 became defensive and lifted a fist toward her. R38 said R42 then pulled the room separating curtain and hit her with an open hand and hit her in the back of her head. I started yelling and she (R42) left the room. If she was not in here in the facility, she'd be in jail. She assaulted me. I went down the hall and told V11 Registered Nurse (RN) what happened. She (R42) is very aggressive. She blackened another resident's eye after throwing a shoe at her and hit another resident too. I'm concerned residents more vulnerable than me are at risk. I don't have a traumatic brain injury. I know what's going on and can remember. They're saying I provoked her which is gaslighting. I'm the one who got hit.
On 06/11/24 at 11:08 AM, V11 RN said on 5/25/24, R38 came down the hall in her wheelchair yelling. R42 was ahead of R38 walking down the same hall. R38 told her R42 open handedly smacked her in the back of the head. V11 said R42 was short tempered and R38 wants to control the behavior of other residents. V11 said she called V1 Administrator and notified her of the incident after she was told about it.
06/11/24 02:32 PM, V1 said R38's resident to resident incident on 5/25/24 was not abuse because there was no willful intent.
On 06/12/24 at 09:44 AM, R38 said, when R42 assaulted her she was surprised, scared, and outraged. It was abuse. She hit me.
On 6/12/24 at 01:59 PM, V1 said she was the abuse coordinator. The report says resident to resident altercations and that's how they are investigated and sent in. Abuse investigations and altercations are sent in the same way. None of the reportable incidents were deemed resident to resident abuse. I go back and watch video footage, most areas of the building have cameras. I have determined through video footage that it is not willful intent and a lot of times it is just residents passing by each other swinging their arm out. There haven't been injuries or intent to cause harm. Sometimes there is a red mark, but it disappears. A lot of our residents have cognitive disabilities, so I don't think they are trying to inflict harm on someone. If they are really intending to hurt someone, or harm someone, then that would be considered abuse. This is a difficult population to handle, sometimes we have therapy evaluate them in their electric wheelchairs because that can be an issue with residents getting tangled and getting angry with each other. I think a lot of it is just frustration. We try to give them outlets to discuss things, but it doesn't always work.
R38's face sheet showed a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of myocardial infarction, heart failure, Diabetes, obesity, major depressive disorder, generalized anxiety disorder, and hypertension.
R38's 4/30/24 facility assessment showed she was cognitively intact and had no behaviors. This assessment showed she required supervision or touch assistance to toilet, transfer from bed to a chair, and walk 10 feet. R38 used a walker and required partial/moderate assistance to pick up an object from the floor.
R38's 5/25/24 at 1:32 PM nurse note authored by V11 showed R38 was in her room. Peer was speaking with patient and interrupted her sentence. R38 asked peer not to interrupt. Peer did not like that, verbal altercation arose, and peer closed curtain to separate herself. R38 stated Slam the curtain, that will show me. Peer reapproached pt and open hand struck other resident on right side back side of head. Peer then left room and R38 came out to hall to report to staff.
R38's 5/25/2024 at 10:53 PM nurse note showed resident is still upset about the peer to peer.
R38's 5/25/24 care plan showed she was hit in the back of her head by her roommate.
R38's 5/25/24 incident report showed R38 was hit in the back of the head by her roommate.
The facility's 5/26/24 first and final report to the State agency showed R42 hit R38 on the back side of her head after a verbal altercation and becoming upset.
A 2/25/24 State agency report showed R42 allegedly threw a shoe at another resident and that resident was holding her left eye.
The facility's 3/17 Abuse Program Policy showed abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This presumes that instances of abuse of residents even those in a coma, cause physical harm, pain, or mental anguish. Physical abuse includes hitting, slapping, pinching, and kicking. Resident to resident abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish by one resident toward another.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
2) The facility's document titled, Illinois Department Of Public Health Facility Report dated 5/3/24 showed, (R25) was sitting in hallway where wing meets hallway, a resident from another hallway star...
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2) The facility's document titled, Illinois Department Of Public Health Facility Report dated 5/3/24 showed, (R25) was sitting in hallway where wing meets hallway, a resident from another hallway started to come down the wing. (R25) grabbed his arm to try to redirect him the other way and let go, the other resident (R66) continued past him and made open contact with (R25's) cheek. (R25) grabbed (R66's) shirt sleeve. Residents were immediately separated and redirected first and final report.
No investigation was performed for a possible resident to resident abuse altercation.
3) The facility's document titled, Illinois Department of Public Health Facility Report dated 5/4/24 showed, (R66) was driving power wheelchair down the hallway and repeatedly saying profanity, this was not directed towards anyone. (R44) went up to resident in regards to the words he was saying out loud. (R66) kicked the other resident in the left leg .First and final report.
No investigation was performed for a possible resident to resident abuse altercation.
Based on interview and record review, the facility failed to investigate an allegation of abuse for 2 of 3 residents (R38, R44) reviewed for abuse in the sample of 20 and 1 resident (R25) outside the sample.
The findings include:
1. On 6/11/24 at 10:11 AM, R38 was in her room in a wheelchair. She was alert and oriented X3. Her speech was clear and she had good eye contact.
On 06/11/24 at 10:11 AM, R38 said the Saturday of Memorial weekend (5/25/24) her roommate (R42) hit her in the back of the head. R38 said she reported it to V11 Registered Nurse (RN) right afterward and nobody talked to her about it until the following Tuesday (5/28/24). No one from management came in that whole weekend. R38 said on 5/28/24 around 11:00 AM, V1 Administrator asked how her weekend was. I told her it was fine before the incident. R38 said V1 did not seek her out for any additional questioning but she sought her out later and eventually talked with her about the incident. I told her what happened and that R42 keeps coming and touching me.
R38's 4/30/24 facility assessment showed she was cognitively intact and had no behaviors. This assessment showed she required supervision or touch assistance to toilet, transfer from bed to a chair, and walk 10 feet. R38 used a walker and required partial/moderate assistance to pick up an object from the floor.
R38's 5/25/24 at 1:32 PM nurse note authored by V11 showed R38 was in her room. Peer was speaking with patient and interrupted her sentence. R38 asked peer not to interrupt. Peer did not like that, verbal altercation arose, and peer closed curtain to separate herself. R38 stated Slam the curtain, that will show me. Peer reapproached pt and open hand struck R38 on the right back side of head. Peer then left room and R38 came out to hall to report to staff.
R38's 5/25/2024 at 10:53 PM nurse note showed resident is still upset about the peer to peer.
R38's 5/25/24 care plan showed she was hit in the back of her head by her roommate.
R38's 5/25/24 incident report showed R38 was hit in the back of the head by her roommate.
The facility's incident investigation was requested, and a one-page timeline was received. The facility provided timeline of events showed on 5/25/24, V1 was notified of an incident where R42 struck R38 with an open hand on the right back side of her head.
The facility's 5/26/24 first and final report to the State agency showed R42 hit R38 on the back side of her head after a verbal altercation and becoming upset. This report showed it was a resident-to-resident altercation not suspected abuse.
The facility provided timeline of events showed V1 did not speak to R38 or R42 until 5/28/24 (3 days after the event occured).
The facility's 3/17 Abuse Program Policy showed its purpose was to ensure ongoing safety of residents, to ensure that a thorough investigation is completed in alleged incidents An investigation into the alleged incident-during the shift it occurred, is initiated as follows: interview the resident or other resident witnesses (i.e., roommate if appropriate). This interview is to be dated, documented and signed by the supervisor. Use the Resident Interview Form. Interview staff on that unit. Interview staff witnesses or other available witnesses. Witnesses are to document their knowledge of the incident in a written narrative, signed and dated. Use the Employee/Witness Investigation Statement. Obtain narrative statements from employees, residents and other witnesses and include the date, time, identification of employee, implicated, and the account of the incident as witnessed by the individual being interviewed. Narrative statements should be taken after the incident is reported. Staff on the unit at the time of the incident occurred must be interviewed-written statements are to be obtained. The resident involved is interviewed at least three times (by the supervisor on duty at the time the initial report is made, by the Director of Nursing and by the Social Worker or Administrator). Each is to complete the Resident Investigation Report. The purpose of three separate interviews is to determine if the story is consistent. Do not automatically discount a resident with dementia or other cognitive impairment. The Social Worker is to interview other potential victims within 24-48 hours of the alleged incident. Having statements taken- do not allow employees to leave the facility until their statements are obtained. Take statements from everyone that was working on that unit even if they say they do not have information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to obtain a Level 2 PASRR (Pre-admission Screening and Resident Review) for 2 of 5 residents (R61,R67) reviewed for PASRR screening in the sam...
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Based on interview and record review, the facility failed to obtain a Level 2 PASRR (Pre-admission Screening and Resident Review) for 2 of 5 residents (R61,R67) reviewed for PASRR screening in the sample of 20.
The findings include:
1) R61's electronic face sheet printed on 6/13/24 showed R61 has diagnoses including but not limited to schizophrenia and depression.
R61's document titled, Notice of PASRR Level 1 Screen Outcome dated 9/26/22 showed R61 does not require a Level II PASRR and has no mental health diagnosis.
2) R67's electronic face sheet printed on 6/13/24 showed R67 has diagnoses including but not limited to schizophrenia and bipolar disorder.
R67's document titled, Notice of PASRR Level 1 Screen Outcome dated 1/25/24 showed R67 does not require a Level II PASRR and has no mental health diagnosis.
On 6/13/24 at 12:04PM, V1 (Administrator) stated, PASRR's are done prior to admission, if there are changes while they are here then we would do a new one. R61 and R67 have not had a Level 2 done. The system says they don't need one. I know it's our responsibility to get them if there is a mental health diagnosis but I'm not sure why we didn't have one done. They should be done to ensure the residents get the appropriate services for their mental health diagnosis.
The facility was unable to provide a policy regarding PASRR's.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide feeding assistance to 1 of 1 residents (R37) reviewed for a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide feeding assistance to 1 of 1 residents (R37) reviewed for activities of daily living (ADL's) in the sample of 20.
The findings include:
R37's electronic face sheet printed on 6/13/24 showed R37 has diagnoses including but not limited to cerebral palsy, dysphagia, major depressive disorder, diaphragmatic hernia, and gastroesophageal reflux disease.
R37's facility assessment dated [DATE] showed R37 has no cognitive impairment, dependent on staff for eating, and has a mechanically altered diet.
On 6/12/24 at 10:45AM, during the resident council meeting R37 stated, There was a night last week where I didn't get fed dinner. I need assistance with all of my meals because I can't move my arms to reach my mouth. I eat dinner in bed because I have a lot of pain so I only eat breakfast and lunch in the dining room most of the time. The staff brought a tray to my room and then left it there and never came back to help me eat.
The facility's form titled, Facility Grievance Form-Written Decision Form dated 6/5/24 showed, (R37) reported to (counselor) that he did not get a dinner tray last night. He states this is not the only time this has happened .steps taken to investigate: Spoke with (R37) regarding tray pass and he stated staff brought the tray in then passed remainder of trays without returning to room-reminded resident to use the call light.
R37's care plan dated 5/18/23 showed, Resident receives a pureed diet. At risk for aspiration in weight loss. Resident prefers to eat some meals in his bed due to pain. Assist resident with all intake, provide pureed diet.
R37's care plan dated 6/26/23 showed, Resident receives a pureed diet, due to poor dental status. At risk for weight loss and pressure injury. Assist resident with meal intake.
R37's meal intake record for 6/4/24 showed no meal intake for R37 at the evening meal.
On 6/12/24 at 11:22AM, V16 (Certified Nursing Assistant) stated, We should be ensuring that we are documenting meal intakes at all meals for all residents except the tube feeders. If someone refuses a meal we offer an alternative and if they still refuse we would let the nurse know. (R37) doesn't refuse meals. When we deliver trays we should ensure we are circling back to feed the residents after delivering trays so nobody gets missed.
On 6/13/24 at 12:37PM, V2 (Director of Nursing) stated, There is no reason why any resident would not get assistance with a meal. When staff are delivering trays they should be performing meal set up and assistance right when the tray is served. There is never any excuse as to why a resident would miss a meal due to staff not feeding them.
The facility's policy titled, Feeding and Tray Delivery Procedures: dated 3/17 showed, The following feeding and tray procedures must be followed to ensure prompt and palatable meal service: Tray Procedure For All Meals: B. If a resident refuses to get up or go to the dining room for a meal, please ask Why? Try to encourage them to participate in meal time in the dining room. If they refuse, offer them the first choice on the menu .Once their tray has arrived on the wing, serve it promptly and provided assistance if needed .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to identify a resident's skin concern, assess the area, a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to identify a resident's skin concern, assess the area, and start a treatment for 1 of 1 resident (R49) reviewed for skin concerns in the sample of 20.
The findings include:
R49's admission Record, printed by the facility on 6/12/24, showed he had diagnoses including quadriplegia, C5-C7 incomplete, neuromuscular dysfunction of bladder, neurogenic bowel, polyneuropathy (damage to multiple peripheral nerves resulting in problems with sensation, coordination and other body functions) neuralgia (pain caused by damaged or irritated nerves), neuritis (inflammation of one or more nerves that can lead to impaired transmission of neural signals), and edema. R49's facility assessment dated [DATE], showed he was cognitively intact, had an indwelling cather, was always incontinent of bowel and was at risk of developing pressure ulcers/injuries. R49's functional performance care plan, initiated on 4/20/2020, showed he required extensive assist of two staff members for dressing and bed mobility, total assist of two staff members for toileting, total assist of staff for bilateral lower extremity bathing, and maximal assist of staff for bilateral upper extremity bathing. R49's care plan initiated on 4/20/2020 showed he had impaired physical mobility due to a spinal cord injury.
On 6/11/24 at 1:32 PM, V16-V18 CNAs (Certified Nursing Assistants) were providing personal care for R49. After bathing and washing R49's hair, he was turned onto his right side. This surveyor saw an area on R49's right buttocks that was dark in color and asked V17 what that was. V17 said she did not know what it was and took a wash cloth and wiped over the area several times. At 1:47 PM, V3 (Wound Nurse) entered R49's room. V17 asked V3 about the area on R49's right buttocks. V3 said she did not know about it, it must be a new area. V3 said she would have to measure the area and start a treatment for it. V3 went out of the room to get treatment supplies and a tape to measure the area. After assessing the area, V3 said it was a scab measuring 3.0 cm (centimeters) by 2.5 centimeters.
The facility's Wounds report, from 6/3/24-6/10/24, showed R49 had venous wounds to his right lower extremity and his left lower extremity. The report did not list any other wounds for R49.
R49's Wound Evaluation and Management Summary dated 6/10/24 showed venous wounds to his left and right calf. No other wounds were identified in the Wound evaluation.
R49's Order Summary Report, printed by the facility on 6/12/24, showed an active order dated 5/26/23 for daily skin checks for R49. The order showed a progress note must be completed after each skin check. Must include any new skin issues with measurements and treatment orders if applied. R49's Order Summary Report also showed a new order dated 6/11/24 (the day this surveyor inquired about the area) to cleanse scab to buttock every other day and apply xeroform with dry dressing as needed. Change dressing as needed if soiled.
On 6/12/24 at 2:49 PM, V3 said she would have at least expected the wound on R49's right buttocks to be identified the day before (6/10/24) because he has daily skin checks.
On 6/13/24 at 9:07 AM, V24 (Nurse Practitioner) said she would expect staff to identify a skin issue prior to it developing into a 3.0 cm by 2.5 cm scab.
R49's care plan showed: Wound Management Shearing to upper right gluteal measures 3.0 cm x 2.5 cm with no measurable depth due to dry non-viable fibrous tissue (scab) dated 6/11/2024.
On 6/13/24 at 9:29 AM, V3 said she categorized the scab on R49's right buttocks as shearing. V3 said shearing is not pressure, V3 said shearing occurs when the skin is moving and the pressure of the weight of the body coming down on the skin, as it is moving, causes shearing of the skin tissue. V3 was asked about the 6/10/24 wound physician's notes only listing the venous wounds to R49's bilateral lower extremities. V3 said the wound doctor had been in the previous day (6/10/24) but did not look at R49's buttocks because there was no wounds on his buttocks. V3 said R49 only had a dressing to protect the skin on his sacral area due to previous skin issues.
R49's daily Skin Assessments from 6/7/24-6/10/24 showed only the bilateral venous wounds on R49's posterior lower extremities.
On 6/13/24 at 1:22 PM, V2 (Director of Nursing-DON) said she would expect staff to identify an area of skin concern prior to a 3.0 x 2.5 cm scab, especially since most of our residents have decreased sensation.
R49's COMS-Skin Only Evaluation dated 6/11/24, showed a scab on his buttocks measuring 3.0 x 2.5.
R49's 6/11/24 Skin-Non-Pressure note entered by V11 (Registered Nurse-RN) 2:26 PM, showed Sheering on buttock causing scab measuring 3 x 2.5 cm. No depth. Xeroform and dry dressing applied. Order to change every other day until healed.
The facility's policy and procedure titled Pericare, with a revision date of March 2017, showed Report to the nurse on duty significant assessments, such as redness, swelling, or discharge, excoriation, and/or open area.
The facility's undated Skin Care Protocol showed 1. Nurse aides and Certified nurse aides are to notify the nurse of any changes of the skin while performing daily cares. This includes completing a bath/shower assessment on all residents when bathing and showering them. The nurse is then to notify the Director of Nursing (DON). 2. The nurse will start a newly acquired skin care sheet. The sheet is turned into the DON for assessment and staging of the area. 3. The nurse will then notify the MD and obtain orders for appropriate treatment. The protocol showed 13. Weekly skin checks to be done by a licensed nurse and documented on the appropriate forms.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent a medical device related pressure injury and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent a medical device related pressure injury and failed to identify an area of pressure prior to becoming a Stage 3 for 2 of 4 residents (R32, R23) reviewed for pressure in the sample of 20.
The findings include:
R32's face sheet showed a [AGE] year-old male with diagnosis of spina bifida, obstructive sleep apnea, chronic kidney disease stage 3, neuromuscular dysfunction of the bladder, klebsiella pneumoniae infection, presence of a cerebrospinal fluid drainage device, dependence on a wheelchair and history of urinary tract infections.
On 06/11/24 at 09:30 AM, R32 was on his back in bed. R32 had an indwelling urinary catheter. There was a catheter securing device to his right anterior thigh. R32's catheter tubing was not in the device but over his left thigh and attached to a urinary drainage bag. R32's penile shaft was disfigured by a split in the shaft beginning at the distal (entry) end downward. The skin on both sides of the split was healed.
On 06/12/24 at 12:06 PM, V3 wound nurse said R32 was admitted with one pressure wound to the ischium. R32 now has a pressure injury to his penis from his catheter. The penis wound is a medical device related pressure injury. We use a stat lock now. A stat lock holds the catheter in place so it can't be pulled and keeps pressure off the skin. It's important to use the device to prevent further damage and to promote healing. V3 said the slit is healed now.
On 6/13/24 at 8:00 AM, V3 said R32's penis is permanently disfigured now. Without surgery, it will always have that slit there.
R32's 4/26/24 skin evaluation showed an open area to the tip of the penis measuring 3.0 centimeters (cm) X 1.0 cm X 0.5 cm. R32's catheter tends to lay on the area when brief is in place.
R32's care plan showed he required extensive assist of two person to physically assist for toilet use and bed mobility. R32 was dependent for toileting hygiene and rolling in bed.
R32's penis wound care plan showed to change stat lock to other direction to prevent further skin complications.
The facility's 9/2014 Urinary Catheter Care Policy showed to prevent the catheter from being pulled out, secure the catheter tubing to the thigh without tension on the tubing. Nursing assistants must do catheter and perineal care with am and pm care, and after each of the resident's bowel movements. With all catheter care, check the skin around the catheter entry site for signs of irritation, redness, tenderness, swelling or discharge.
The facility's 6/2014 Pressure Ulcer Prevention Program Policy showed the facility will ensure that a resident that enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable. A pressure ulcer is defined as a localized injury to skin and/or underlying tissue, usually over a bony prominence, as a result of pressure in combination with shear.
2. R23's admission record shows he was admitted to the facility on [DATE] with multiple diagnoses including diffuse traumatic brain injury with loss of consciousness of unspecified duration, and hemiplegia. The facility's annual assessment of 4/18/24 documents R23 to have moderate cognitive impairment. The same assessment shows he is dependant on staff for bathing, showers, and transfers. He is unable to roll left and right or sit to stand. The bladder and bowel assessment shows he is always incontinent of his bowels.
R23's skin evaluation of 4/11/24 shows V3 identified a pressure ulcer wound on the sacrum. The note shows R23 had a 1.5 cm x 2.0 cm x 0.2 cm stage 3 pressure injury to scar tissue on an old wound site. The 4/15/24 wound physician noted the stage 3 wound to be 2.5 cm x 2.5 cm x 0.2 cm.
On 6/13/24 at 8:05 AM, V3 said R23's sacral wound was identified by staff, and evaluated on 4/11/24. It was unstageable because it had necrotic tissue, and could not see the wound bed. Staff found it on the weekend and let me know, then did the evaluation, but do not know the cause of the injury. His skin checks are nightly because he is up most of the day, V3 said she would have hoped the wound happened that day, and they found it that day.
On 6/12/24, at 2:00 PM, V3 positioned R23 on his right side. When the sheet was pulled back, he was found to have stool on his buttocks. Without cleaning up the bowel movement, V3 removed the dressing from the sacral area, and cleaned the wound, and applied a new dressing. V3 called for an aide to clean R23's buttocks. When the CNA arrives, he wipes the stool from R23's buttocks area, around the clean dressing V3 just applied. After the buttocks were cleaned, V3 then removed the remaining dressings and cleaned the wounds and applied clean dressings.
On 6/13/24 at 8:05 AM, V3 said the stool was not near the wound, but she still should have cleaned the bowel movement before applying clean dressings to the sacral wound.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's splint was applied to prevent fur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's splint was applied to prevent further limited range of motion for 2 of 4 residents (R19, R30) reviewed for limited range of motion in the sample of 20.
The findings include:
1) R19's electronic face sheet printed on 6/13/24 showed R19 has diagnoses including but not limited to hemiplegia affecting left non-dominant side, traumatic brain injury, edema, mild cognitive impairment, and localized swelling of left limb.
R19's facility assessment dated [DATE] showed R19 has severe cognitive impairment, no rejection of cares, upper and lower extremity impairment, and requires splint or brace assistance 7 days a week.
R19's care plan dated 4/14/20 showed, Decrease in functional range of motion in my BLE (bilateral lower extremity) and LUE (left upper extremity). Apply L (left) WHO (wrist, hand, finger orthosis) for 8 hours daily for contraction management.
R19's physician's orders dated 9/21/23 showed, left WHO on for up to 4 hours as tolerated.
On 6/11/24 at 1:32PM, R19 was laying in his bed with no splint to his left hand. On 6/13/24 at 9:45AM, R19 was up in his wheelchair with no splint to his left hand. V16 (Certified Nursing Assistant) was in the room and stated R19 does wear a splint to his left hand but she is unable to find it.
2) R30's electronic face sheet printed on 6/13/24 showed R30 has diagnoses including but not limited to aneurysm, morbid obesity, flaccid hemiplegia, edema, major depressive disorder, and anxiety disorder.
R30's facility assessment dated [DATE] showed R30 has no cognitive impairment, has no rejection of care behaviors, and requires splint or brace assistance 7 days a week.
R30's care plan dated 4/8/20 showed, I have risks of contractures due to hemiplegia and cerebrovascular accident. Will be able to wear left WHO when up in wheelchair and off at bedtime .
R30's physician's orders showed, 2/25/22 left WHO on in morning-6 hours wear time. 9/21/23 left WHO on for up to 4 hours.
On 6/11/24 at 9:32AM, R30 was up in his wheelchair with no splint applied to his left hand. R30 stated staff put his splint on sometimes, but not all the time. R30 stated he would wear the splint if it was applied. On 6/13/24 at 10:33AM, R30 was up in his wheelchair with not splint to his left hand and stated staff had not applied his splint today nor had they offered to apply it.
On 6/13/24 at 9:45AM, V23 (Restorative Director) stated, (R30's) hand brace is applied by restorative staff, foot braces are done by floor staff due to residents needing them applied prior to transfers. His hand brace is supposed to be put on daily for 4 hours. I'm not sure why it wasn't put on Tuesday. Two of my staff members got pulled to the floor earlier today but one of them is back so that's probably why it's not on. (R19) has a hand brace and that is supposed to be on during the day as well. He plays with his brace a lot so sometimes we have to find it. Tuesday it was put on and then he took it off. The aides should be checking to make sure it is on and they are able to reapply braces and splints as needed if we are not there to do it. Today (R19's) brace hasn't been put on because of staffing. It's important that both of these residents wear their braces and splints to prevent further debilitation of their joints.
The facility's policy titled, Restorative Nursing Program/Services dated 8/08 showed, It is the policy of this facility to provide restorative nursing which promotes the residents ability to adapt and adjust to living as independently and safely as possible. Restorative nursing focuses on achieving and maintaining optimal physical, mental and psychological functioning of the resident. 1. Restorative nursing services are provided by restorative nursing assistants, certified nursing assistants, or other trained in restorative techniques .6. Specific components of the restorative nursing program include .prosthetic care, splint of brace assistance .
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 safely transfer a hospice resident using a gait belt f...
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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 safely transfer a hospice resident using a gait belt for 1 of 1 resident (R76) reviewed for transfers in the sample of 20.
The findings include:
R76's admission Record, printed by the facility on 6/12/24, showed she had diagnoses including cerebral infarction (stroke), chronic obstructive pulmonary disease, polyneuropathy (damage to multiple peripheral nerves resulting in problems with sensation, coordination and other body functions), hypertension, osteoarthritis of bilateral knees, dyspnea (shortness of breath), restlessness and agitation, pain and edema. R76's facility assessment dated [DATE] showed she had short-term memory problems and modified independence in cognitive skills for daily decision making. The assessment showed R76 required substantial/maximal assistance with transfers from chair-to-bed, and bed-to-chair.
On 6/11/24 at 12:42 PM, V19 CNA (Certified Nursing Assistant) entered R76's room to transfer her into bed after the lunch meal. V19 wrapped her arms around R76, under her arms and told R76 to put her arms around V19's neck. V19 picked R76 up out of her wheelchair, pivoted her around and sat her on the bed. Other than putting her arms around V19's neck, R76 was not assisting with the transfer and her feet were not flat on the floor. No gait belt was used during R76's transfer from her wheelchair to her bed.
On 6/12/24 at 11:16 AM, V11 (Registered Nurse-RN) was asked what R76's transfer needs were. V11 said she would check the CNAs group list. V11 walked over to V25 (CNA) and asked where the list was showing resident transfer needs. V25 showed V11 the list and both V11 and V25 said R76 is a stand-pivot-transfer using two staff members. V11 and V25 said there should be a gait belt used for the transfer. V11 said it is important to have two staff for the transfer and to use a gait belt, to prevent a change of plane. V11 said that is what the facility uses to describe falls.
R76's care plan initiated on 12/28/23 showed she is at risk for falls due to decreased mobility, pain, decreased strength, and a new diagnosis of CVA (stroke) with some confusion. R76's ADL (activities of daily living) care plan, initiated on 12/28/23 showed she had an ADL self-care performance deficit related to activity intolerance, confusion, fatigue, impaired balance, limited mobility and pain. The care plan showed resident is on hospice services post CVA. The ADL care plan showed R76 requires max assist of 1 staff for a stand-pivot transfer to move between surfaces.
On 6/13/24 at 1:19 PM, V2 (Director of Nursing-DON) said she does not know if R76's transfer needs were changed, however, a gait belt should be used with all assisted resident transfers.
The facility's policy and procedure titled Safe Patient Lifting Policy, with a revision date of March 2017, showed The Safe Patient Lifting Policy exists to ensure a safe working environment for resident handlers .Initial screening will be performed on residents to assess transfer and ambulating status. Resident transfer status will be reviewed via care-plan time frame and on an as needed basis .Gait Belt usage is mandatory for resident handling with the exception of bed mobility and medical contraindications. the gait belt will be considered a part of the certified nursing assistant's uniform. An ambulating belt may be used as an appropriate substitute
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to keep a urinary drainage bag below the level of the bla...
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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 keep a urinary drainage bag below the level of the bladder and failed to prevent a urinary drainage bag from contact with the floor for 1 of 2 residents (R28) reviewed for catheters in the sample of 20.
The findings include:
R28s face sheet showed a [AGE] year-old male with diagnosis of intracranial injury, protein-calorie malnutrition, retention of urine, chronic peripheral venous insufficiency, neuromuscular dysfunction of the bladder, convulsions, dementia, history of urinary tract infections, acquired absence of a kidney, and carrier or suspected carrier or methicillin resistant staphylococcus aureus.
On 06/11/24 at 02:18 PM, R28 was in his bed. R28's catheter drainage bag and tubing were in contact with the floor and not in a dignity bag.
On 06/12/24 at 08:33 AM, V7 Certified Nursing Assistant (CNA) assisted R28 to reposition to his left side while in bed. R28 was supine. V7 removed R28's urinary drainage bag from the bed frame, lifted it over his body and laid it on the bed. The urine in the drainage tubing was cloudy yellow with white sediment.
On 6/12/24 at 12:06 PM, V3 wound nurse/Infection Preventionist was asked if a urinary drainage bag should be on the floor. V3 said I would think not, bugs do crawl. They should be inside a dignity bag. It could cause infection to go up drainage tubing and cause a urinary tract infection (UTI). A urinary drainage bag should never be above the level of the bladder. If it was, it can backflow (of urine) into the bladder, cause pain and infection. R28 gets frequent UTI's and has other issues that put him at a higher risk for infection.
The facility's 9/2014 Urinary Catheter Care Policy showed to keep the bag below the level of the resident's bladder at all times.
R28's catheter care plan showed to ensure the catheter bag is always lower than the bladder.
R28's 3/25/24 nurse's note showed he was unresponsive and sweaty. R28 was sent to a local emergency room. R28 returned to the facility with a diagnosis of a urinary tract infection.
R28's 3/25/24 urine culture showed a urinary tract infection with greater than 100,000 colonies per milliliter of methicillin resistant staphylococcus aureus.
CONCERN
(E)
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** 4. R67's electronic face sheet printed on 6/13/24 showed R67 has diagnoses including but not limited to cerebral infarction, hem...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R67's electronic face sheet printed on 6/13/24 showed R67 has diagnoses including but not limited to cerebral infarction, hemiplegia and hemiparesis, schizophrenia, depression, aphasia, and hypertension.
R67's physician's orders dated 6/12/24 showed, Enhanced barrier precautions due to history of multi-drug resistant organism with indwelling devices.
R67's facility assessment dated [DATE] showed R67 has mild cognitive impairment and has an indwelling catheter.
On 6/11/24 at 9:25AM, R67's door showed a sign stating Enhanced barrier precautions V17 (Certified Nursing Assistant) emptied R67's urinary catheter bag with only gloves on. V17 stated that R67 is on enhance barrier precautions and when staff are providing catheter care, emptying catheter drainage bag, and providing wound care they should be wearing a gown and gloves at all times.
On 6/13/24 at 12:37PM, V2 (Director of Nursing) stated, I'm not sure why there wasn't an order in (R67's) chart for her enhanced barrier precaution isolation. She has been on that since at least March 2024. Staff should be wearing a gown and gloves in her room whenever they are providing care due to her resistant organisms in her urine and wound.
Based on observation, interview, and record review, the facility failed to ensure staff wore the correct personal protective equipment when providing care to a resident on enhanced barrier precautions and failed to identify residents on enhanced barrier precautions for 4 of 4 residents (R32, R23, R31, R67) reviewed for infection control in the sample of 20.
The findings include:
1. R32's face sheet showed a [AGE] year-old male with diagnosis of spina bifida, obstructive sleep apnea, chronic kidney disease stage 3, neuromuscular dysfunction of the bladder, klebsiella pneumoniae infection, presence of a cerebrospinal fluid drainage device, dependence on a wheelchair and history of urinary tract infections.
On 6/11/24 at 3:20 PM, V9 Certified Nursing Assistant (CNA) and V10 CNA were in R32's room changing his incontinent brief and linens. R32 was involuntary of stool. Neither V9 nor V10 had isolation gowns or masks on. V9 emptied R32's urinary drainage bag into a urinal. V9 then transported the urine from the bedside to the bathroom with only gloves on. R32's room door had an enhanced barrier precaution (EBP) sign posted which directed staff to wear gloves and a gown when changing linens, providing hygiene, changing briefs and care of a urinary catheter. There was personal protective equipment (PPE) available immediately outside R32's room.
On 06/12/24 at 12:06 PM, V3 wound nurse/Infection Preventionist (IP) said R32 is on Enhanced Barrier Precautions (EBP) because he has a multi drug resistant organism (MDRO) in the urine. He has had it and been on isolation for a few years. Staff should wear gowns and gloves when providing care to him. If appropriate personal protective equipment (PPE) is not worn, the infection can be spread. PPE needs to be worn to stop the spread and not give him anything else. Staff should have worn gowns when providing care, emptying his catheter and transporting the urine.
R32's care plan showed he had a urinary tract infection, bacteremia, extended-spectrum beta-lactamase (ESBL) in the blood and urine history. This care plan showed to utilize enhanced barrier precautions due to a history of multiple multi drug resistant organisms (MDRO)s in the blood and urine. Ensure proper personal protective equipment (PPE) is worn when entering room.
R32's physician orders showed a 6/11/24 or for enhanced barrier precautions (EBP) due to MDRO in urine with indwelling device.
R32's 3/13/24 hospital history and physical (H&P) showed admission for severe sepsis/septic shock, presumed ESBL/gram positive cocci urinary tract infection (UTI) and methicillin resistant staphylococcus aureus (MRSA) positive nasal swab and a temperature of 104.4. This H&P showed admission to the intensive care unit (ICU).
The enhanced barrier precautions signage showed staff must wear gloves and a gown for the following activities: dressing, bathing, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: urinary catheter, feeding tube, tracheostomy; wound care: any skin opening requiring a dressing.
The facility's 2023 Enhanced Barrier Precautions Policy showed it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug resistant organisms (MDRO). Enhanced barrier precautions refer to the use of gown and gloves for use during high contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high contact resident care activities that require the use of gown and gloves. An order for enhanced barrier precautions will be obtained for residents with any of the following: wounds and/ or indwelling medical devices (e.g., central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. Initiate enhanced barrier precautions for infection or colonization with any resistant organisms targeted by the CDC and epidemiologically important MDRO when contact precautions do not apply. Make gowns and gloves available immediately outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray. Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. The Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education. High contact resident care activities include: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes and wound care: any skin opening requiring a dressing. Enhanced barrier precautions should be followed outside the resident's room when performing transfers and assisting during bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility, or any high contact activity. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until the wound heals or indwelling medical device is removed.
2. R23's order summary sheet for June 2024 shows an order for enhanced barrier precautions related to history of MDRO (Multiple Drug Resistant Organism) with indwelling devices every day and night shift for infection control management. The order was not started until 6/12/24.
On 6/12/24 at 2:00 PM, V3 entered R23's room to complete his dressing change. He had no sign on the door to indicate enhanced barrier precautions, and V3 did not don a gown before performing the dressing change. R23 was observed to have open wounds on his buttocks, an indwelling catheter, and a feeding tube.
On 6/13/24 at 8:05 AM, V3 said R23 should be on enhanced barrier precautions due to having a MDRO in his blood and multiple indwelling devices such as his tracheotomy, feeding tube and catheter. He should have signage up on his door and PPE available for staff. She stated when performing his dressing change, she should have been wearing a gown.
3. R31's order summary sheet for June 2024 documents an order for EBP (Enhanced Barrier Precautions) for history of MDRO with indwelling devices every day and night for infection control management. The orders show R31 to have a feeding tube, and a suprapubic indwelling catheter.
R31's door was observed on throughout the survey from 6/11/24 to 6/13/24, and at no time was a sign posted on his door to indicate to staff the needed PPE to enter and provide care.
On 6/13/24 at 11:10 AM, V2 said R31 has a history of MDRO and he should be on EBP status. He should have a sign on his door for staff to wear PPE.
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 prepare and serve food in a clean, sanitary manner. This failure has the potential to affect all of the residents in the facil...
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Based on observation, interview and record review, the facility failed to prepare and serve food in a clean, sanitary manner. This failure has the potential to affect all of the residents in the facility.
The findings include:
The CMS 671 form dated 6/11/24 showed 82 residents resided in the facility. The Diet Type Report, printed by the facility on 6/12/24 showed 5 of the 82 residents (R31, R35, R40, R60, and R184) did not take food by mouth.
On 6/11/24 at 9:10 AM, the oil in the deep fryer was black. Dark food crumbs were visible around the edges of the fryer, at the top of the oil level.
On 6/11/24 at 11:00 AM, V14 (Dietary Cook) was getting ready to serve the lunch meal. V14 was asked to take the temperature of the foods prior to serving. V14 picked up the digital thermometer from the prep table behind her and inserted the thermometer into the orange chicken, and then into the turkey without sanitizing the digital thermometer. At 11:14 AM, V15 ((another Dietary Cook) uncovered two pans that the temperature had not been checked yet. V15 said the items were the pureed and mechanical soft egg rolls. V15 was asked to check the temperatures of these two items. V15 reached back and picked up the digital thermometer and ran the fingers section of her gloved hand down the thermometer gauge two times, then put the thermometer into the mechanical soft, and then the pureed egg rolls. V15 had been handling meal tickets, lid handles and kitchen utensils with the gloves prior to wiping the thermometer gauge with her gloved hand. V15 did not sanitize the digital thermometer before putting it into the mechanical and pureed egg rolls.
On 6/11/24 between 9:10 AM-9:20 AM, the kitchen floor appeared dirty. The floor was sticky and there was food debris in multiple areas (under the prep tables and serving tables, on the floor by the grill and over by where the food carts were stored) in the kitchen. Several raised areas of debris were observed under the left 3-compartment sink area.
On 6/12/24 at 11:29 AM, V15 (Cook) said country fried steak was what was served for the lunch meal that day (6/12/24). V15 said it was cooked in the deep fryer. The oil in the deep fryer was still black and more crumbs could be seen at the top of the oil level. The debris/substance that was observed under the 3-compartment sink area was still there and there were mopheads under the ice machine. Food debris was also seen on the floor, by the food cart storage area.
On 6/12/24 at 11:55 AM, V4 (Dietary Manager-DM) said it is important to alcohol the digital thermometer off before and after use to prevent cross-contamination. At 11:58 AM, V4 said the deep fryer is cleaned as needed depending on how often it is used. V4 said the deep fryer was used today for the country fried steak, yesterday for the egg roll, Monday for the french fries, Sunday for the tater tots, Friday for tater tots and fish poor boy sandwiches, the previous Wednesday for fish, The previous Tuesday for chicken strips and country fried steak. V4 said the oil should be changed when it needs it, adding, Obviously it needs it. V4 said the oil and the deep fryer area does not look appetizing. At 12:02 PM, V4 was asked where the facility stores the unopened oil for the deep fryer. V4 showed this surveyor the unused container. The color of the oil resembled a light-colored apple juice. At 12:14 PM, V4 (DM) provided the facility's policy for cleaning the fryers. the policy showed fryers will be cleaned on a regular basis. V4 was asked how often that would be. V4 said she would say weekly. V4 was shown the weekly cleaning schedule. V4 said the deep fryer cleaning was not marked off as done since May 21, 2024. V4 said it is not being done weekly. V4 said the dietary staff have been using the deep fryer every day for almost a week.
On 6/13/24 at 11:40 AM, the kitchen floor was still tacky/sticky, with debris/substance still under the 3-compartment sink area. food debris was on the floor by the food cart storage area. Mop heads were on the floor, under the ice machine. V20 (Cook, diet aide and CNA-Certified Nursing Assistant) said the dietary aides should be cleaning and mopping the floor every shift. V20 said It only gets done once a week if I complain enough. V20 agreed the floors were tacky and looked dirty. V20 said the kitchen does not look clean and sanitary. V20 said she thinks she is the only one that cleans the deep fryer. V20 said she works in the kitchen on Mondays, Thursdays, and every other weekend. At 11:47 AM, V4 (Dietary Manager) entered the kitchen. This surveyor pointed to the debris along the wall and the substances under the 3-compartment sink area. V4 said the dietary aides mop the floor every shift. V4 said the substances under the 3-compartment sink area were from the drain not draining fast enough, and debris builds up there. V4 provided a copy of the kitchen staff's daily cleaning schedule. Multiple days did not have information/initials entered to show the cleaning was done as scheduled. V4 agreed that the floor did not look clean. V4 said, obviously the aides are not cleaning well enough or it would not look like that.
The facility's undated policy and procedure titled Cleaning Instructions: Fryers showed Fryers will be cleaned on a regular basis and cared for in such a way to maintain optimum production.
The facility's 2017 policy and procedure titled General Sanitation of Kitchen showed Food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule .1. Cleaning and sanitation tasks for the kitchen will be outlined in a written cleaning schedule. 2. Tasks will be assigned to be the responsibility of specific positions. 3. Frequency of cleaning for each task will be defined .6. On the cleaning schedule employees will initial and date tasks when completed.
May 2024
4 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to supervise a resident with exit-seeking behaviors to prevent her from...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to supervise a resident with exit-seeking behaviors to prevent her from eloping from the building unsupervised. This failure resulted in R1 eloping from the facility and being able to reach a heavily traveled highway. This applies to one of three residents (R1) reviewed for the safety in the sample of 8.
The Immediate Jeopardy began on 4/24/24 when R1 was able to elope from the facility. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 4/30/24 at 12:50 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 5/1/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.
The findings include:
The facility face sheet for R1 shows diagnoses to include hypoxic ischemic encephalopathy (type of brain damage caused by a lack of oxygen to the brain), major depression disorder with psychotic features, anxiety, dementia and cardiomyopathy. The brief interview for mental status (BIMS) dated 2/19/24 shows R1 be cognitively intact. R1's facility assessment shows her to be able to walk independently. The elopement risk assessment dated [DATE] shows R1 to be at high risk for elopement.
The facility incident report dated 4/24/24 shows R1 was seen by maintenance staff in the back parking lot, wandering. R1 became physically aggressive with the staff by picking up a block of wood and threatening to hit staff. R1 had cut off her code alert bracelet from her ankle.
On 4/26/24 at 8:20 AM, V1 Administrator said R1 left the building on 4/24/24 out the front door, she had cut off her wander guard alert bracelet. R1 was seen on video going over the fence and walking away.
On 4/26/24 at 10:00 AM, V3 Certified Nursing Assistant (CNA) said she was outside at the back of the building around 12:30 PM - 1:00 PM on her break, when she saw R1 walking alone in the back parking lot. V3 said she called to the staff inside the building with her cell phone, alerting them that R1 was outside alone. V3 attempted to redirect R1 from leaving the property but R1 would not listen to her.
On 4/26/24 at 11:10 AM, V4 Maintenance said he was outside having his break and saw R1 walking alone outside. V4 said he approached R1, trying to get her to stop walking. V4 said R1 was in the back parking lot.
On 4/26/24 at 11:43 AM, V2 Director of Nursing said by the time she got to the back parking lot, there were several staff trying to redirect R1. V2 said she was told R1 had picked up a stick from the ground and attempted to hit the staff. V2 said she phoned 911 for help with the situation. V2 said R1 had removed her code alert bracelet and she was not sure how this happened.
On 4/26/24 at 10:45 AM, V5 Occupational Therapy Assistant said she was at the entrance to the facility when she heard R1 was outside. V5 said she ran to the back of the building and saw R1 with two CNA's trying to redirect R1 back into the building. V5 said R1 was walking to the road and picked up a piece of wood she found and attempted to hit the staff. R1 was yelling and swearing at the staff. V5 said a car drove by on the road and V5 flagged them down asking them to stop and put on their flashers to alert other people passing by to slow down. When R1 saw the flashers, she turned and walked away from the road back towards the facility.
On 4/26/24 at 10:30 AM, V1 said the video of R1 going over the fence showed she had fallen on the other side. The video showed R1 used the building to help lift herself over the fence. V1 said it was about two minutes between the time stamp on the video and when the first CNA called the building to alert us R1 was outside alone. V1 said when she got outside, R1 was walking up the hill towards the road, yelling at the staff. R1 picked up a stick off the ground and attempted to hit the staff. V1 said a car drove by and put on their flashers and this made R1 turn around from the road and go back to the parking lot. V1 said 911 was called and arrived to help with the situation. V1 said R1 cut off her wander guard somehow.
On 4/30/24 at 9:10 AM, V7 RN said she was working with R1 on the day she eloped out the front door on 4/24/24. That morning R1 met her at the back door, R1 was knocking on the kitchen door. R1 was hallucinating and saying she needed to leave to get to the hospital because her kids were sick. V7 said R1 has been hallucinating for a while now. R1thinks her family has been killed or are sick and she needs to help them. V7 said she walked with R1 back to her room, and R1 was sitting on the bed talking to the smoke detector she thought were talking to her. R1 said in a whisper, I gotta run out the door, and then put her shoes on. V7 said she told R1 she was fine and she needed to rest. V7 said R1 laid down on the bed and went to sleep. V7 said R1 has not been sleeping other than a few hours at a time for the last 4-5 days prior to being sent out.
A facility alerts listing report dated 4/21/24 shows R1 was trying to climb the fence surrounding the facility. (Three days prior to when R1 eloped at the same fence)
On 4/30/24 at 9:38 AM, V1 said on 4/21/24, R1 did make it to the fence and was shaking the fence. She was hallucinating and thought she had to get to the hospital to see her kids.
On 4/30/24 at 10:20 AM, V8 CNA said she was in another resident's room on 4/21/24 when she saw R1 outside the facility at the front gate. R1 had one leg up on the fence. V8 said she ran outside right away and it was then that she saw the restorative Aide was with R1 trying to talk her down and to come back in the building.
On 4/30/24 at 10:30 AM, V9 Restorative CNA said she saw R1 walk out the front doors on 4/21/24. The alarm sounded that someone with a wander guard had gone outside the doors. R1 walked down to the fence and had both feet on the bottom rung of the fence. V9 said she was able to redirect R1 from the fence and bring her back inside.
On 5/2/24 at 2:10 PM, V23 Physician Assistant said, When R1 is hallucinating and having exit seeking behaviors she would expect to staff to have very close observation on the resident to keep her safe from harming herself or eloping.
Nursing progress notes dated 4/11/24 to 4/24/24 shows:
On 4/11/24 at 5:36 AM, R1 saying her mother and son are dead and her daughter is dying, and she needs to get out of the facility. R1 walked to the front doors.
On 4/17/24 at 8:20 AM, R1 saying her mother was dead and she had to get out of the building. She walked to the front lobby and sat down. R1 was saying her mother was dead, she had been raped here, her son had been raped, didn't understand why she could not leave the building.
On 4/17/24 2:34 PM was eating lunch in her room and the intercom told her she was getting out of here soon. Hearing voices and wants to leave.
On 4/20/24 8:15 PM upset and wandering in the halls saying she needed to get out of here, wants to leave.
On 4/21/24 at 2:30 PM R1 trying to climb the fence/gate, trying to open locks. Said her children were dead and today is the funeral.
On 4/22/24 5:48 AM, attempted to open the dining room doors saying she had to get out of here. The kitchen staff reported that she attempted to go out the doors again.
4/23/24at 3:24 PM staff unable to redirect as she was saying she needed to get out of the building.
On 4/23/24 11:51 PM, yelling and walking fast, saying she needed to get out of here. Walked to the lobby, threw a wet floor sign, punching the glass, picked up a lamp and slammed onto the table. Police were notified.
On 4/24/24 6:05 AM, R1 met nurse at the back door asking staff to open the kitchen door her children were dead, and she needs to get to the hospital.
On 4/24/24 9:33 AM, R1 went to the dining room as the intercom told her it was time for breakfast, kitchen staff sent her back to her room and given a snack. Sitting on bed, looking at the smoke detector and overheard whispering she had to run out the back door. R1 then put on her shoes and asked the nurse to leave her alone in her room and to turn off the lights.
On 4/24/24 at 12:50PM, R1 found by staff in the back parking lot. R1 became physically aggressive with the staff, attempting to hit staff with a piece of wood. Resident said she was leaving. 911 was called.
R1's care plan dated 4/15/2020 shows the resident is at risk for elopement risk/wanderer due to tendency to wander into other resident rooms and take items as her own. She has poor cognition and unaware of situations at hand and is risk for elopement due to cognitive deficits. Resident exhibits exit seeking behaviors, thinking she has somewhere to go or that someone is coming to get her.
R1's care plan dated 3/25/24 shows R1 is/has potential to be verbally aggressive with yelling out and cursing due to auditory hallucinations .
The facility policy with a revision date of 3/17 for safety and supervision shows 7. resident supervision is a core component of the systems approach to safety. 8. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the enviroment or if there is a change in the residents condition.
The Immediate Jeopardy that began on 4/24/24 was removed and the deficient practice corrected on 5/1/24 when the facility took the following actions to remove the Immediacy and correct the noncompliance.
Immediate action to ensure residents' elopement interventions are effective and appropriate to prevent elopement incidents:
1.
Social Services will review all care plans of residents at high risk for elopement by 5/7/24.
2.
IDT will ensure elopement interventions are implemented following findings of high-risk residents and report to MDS Coordinator starting 4/30/2024. MDS Coordinator will complete audits weekly starting 4/30/2024 x 2 weeks then monthly x 2 months then quarterly x one year (concluding November 2025). Audits will be reported to QAPI monthly starting 5/1/2024 and then quarterly until 11/25/2025.
3.
Any residents that are actively exit seeking, will be placed on line of sight supervision while in courtyard, Code alert checks will be increased to q 4 hours and Code alert will be double banded starting 5/1/2024.
4.
BeSpoke Hotline will be utilized with new onset of hallucinations.
5.
Medical Director will be contacted for support and/or any orders to assist in new onset of hallucinations.
6.
Upon R1 return she will be placed on line of sight supervision while in courtyard, Code alert check q 4 hours, and Code alert bracelet will be double banded.
Procedures to identify residents at risk for elopement:
7.
Upon admission, admitting nurse will complete Elopement Risk Assessments. Social Services or designee will now complete monthly reassessments for high risk residents starting 5/1/2024 and continue Elopement Risk Assessments on all other residents quarterly.
Procedures to increase visual monitoring of courtyard:
8.
Maintenance staff to place cameras in front courtyard by 5/1/2024 . A monitor will be placed in the front office to have visuals of courtyard by 5/3/2024.
9.
Maintenance will immediately complete daily checks x 2 weeks starting 5/1/2024 then weekly starting 5/16/2024 on all door alarms/maglocks, and Code Alert wandering systems.
10.
Front outside door to courtyard will be locked at night by nursing staff or designee and unlocked in the morning by maintenance staff or designee starting 4/30/2024.
Procedures in place to prevent elopement for residents with prior elopements:
11.
Administrator will audit Social Services immediate care plan review to ensure that Elopement Reassessments are complete on high risk elopement residents by 5/7/2024.
12.
Administrator will audit Social Service or designee monthly Elopement Risk Assessments on high risk residents once a month x 6 months starting 5/2024 and ending 10/2024 and results will be reported to QAPI x6 months ending 10/2024.
13.
When resident is determined to be at high risk for elopement and has attempted a prior elopement at this facility, resident will be placed on line of sight supervision while in courtyard by nursing administration and/or Administrator.
14.
Safety Coordinator or designee will place a Code Alert bracelet on residents that are not high risk with exit seeking behaviors followed by 15 minute checks for a minimum of 72 hours until IDT evaluates.
15.
Following an elopement, all exit door codes will be changed by Safety Director or designee.
16.
All new hires complete Elopement Training upon hire by Safety Director and all current staff currently complete Elopement Training annually via Company) Training. However due to incident, all staff will now be required to complete immediate and quarterly training on Preventing and Responding to Elopement x one year via (Company) Training. Immediate training will be completed by 5/7/24.
17.
Safety Coordinator or designee will make all staff aware of high-risk residents for elopement on PCC communications on 5/1/2024. Safety Coordinator or designee will now place a note at time clock for staff notifying them of any changes to Residents at High Risk for Elopement and to check PCC communications.
18.
IT will do weekly maintenance on cameras to ensure they are working properly starting 5/1/2024.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident (R4) was free from sexual abuse (by ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident (R4) was free from sexual abuse (by R5) for 1 of 8 residents reviewed for abuse in the sample of 8.
The findings include:
The facility incident report sent to the Illinois Department of Public Health showed on 4/27/24 that R5 touched R4's breast while both were sitting outside on the front patio.
R4's computerized face sheet printed on 4/30/24 showed diagnosis including but not limited to paraplegia and malignant neoplasm of spinal cord. R4's facility assessment dated [DATE] showed no cognitive impairment and no memory problems. R4's assessment showed the use of a manual wheelchair and the ability to operate it independently.
R5's computerized face sheet printed on 4/30/24 showed diagnoses including but not limited to multiple sclerosis, paraplegia, and cognitive communication deficit. R5's facility assessment dated [DATE] showed moderate cognitive impairment and no upper extremity impairment. R5's assessment showed the use of a motorized wheelchair. R5's care plan showed a focus area start dated 4/15/20 related to the potential to make sexually inappropriate comments to females.
On 4/30/24 at 11:18 AM, R4 was seated in a wheelchair at an activity table. R4 was alert and oriented. R4 stated she was talking with R5 over the weekend (4/27) on the front patio. R4 said it was a pleasant conversation about religion and past medical issues. R4 said R5 reached out with his right arm and tapped her left shoulder in an encouraging manner. R5 then grabbed her left breast and caressed it. R4 said she immediately wheeled herself backward and told R5, Don't you ever do that again! R5 replied, Never? R4 answered, Yes, never! Don't touch me ever again. R4 said R5 said okay and just sat there without any type of apology. R4 stated she wheeled herself away from the area and out of arms reach. R4 said her family arrived for a visit approximately five minutes later. R4 and her daughter went into the facility and reported the incident to V12 (LPN). R4 stated there were no other staff or residents in the immediate area to witness the incident. R4 said she had past conversations with R5 and was dumfounded that he would do anything like that.
On 4/30/24 at 11:42 AM, R5 was seated in a wheelchair on the back patio. R5 was alert and able to carry on a conversation. R5 refused to answer any questions related to R4 and the breast grabbing incident. R5 repeatedly said he did not remember anything. R5 said a staff member talked to him about keeping his hands to his self but refused to give any details why. R5 demanded this surveyor stop asking any more question about the incident but was willing to hold a coherent conversation related to other topics.
On 5/1/24 at 9:40 AM, R5 was seated in a wheelchair at the front receptionist desk. R5 easily recalled speaking together the day before. R5 was able to reach out and touch this surveyor's lanyard and clip board with his hands. Again, R5 refused to answer any questions related to the weekend incident with R4.
On 4/30/24 at 1:31 PM, V12 (Licensed Practical Nurse) stated she was notified by R4 and her daughter that R5 had grabbed her breast (on 4/27). R4 said it was outside on the front patio and just a few minutes ago. V12 said she contacted V1 (Administrator) right away and told her what was reported. V12 said R4 was not upset and went back outside to visit with family. V12 said R5 is slightly confused a times and will tap her arm frequently during medication administration. V12 said R5 has made sexual comments in the past to her, but never grabbed at her. V12 said R5 can not move his motorized wheelchair by himself and has no way to get close to other residents.
On 5/1/24 at 9:27 AM, V16 (CNA-Certified Nurse Aide) stated she wheeled R5 outside to the front patio the day of the incident. V16 said R5 can not reach the wheelchair controls at the back of the wheelchair and always needs help from staff to move it. V16 said R5 is alert and knows what is going on around him. V16 said she left R5 outside and away from any other residents. V16 said she heard about the incident the next day from R4. R4 was embarrassed telling her about it but otherwise her normal self.
On 5/1/24 at 9:57 AM, V15 (CNA) stated R5's cognition can vary but he can express his needs and recall things. V17 said R5 has made sexually inappropriate comments to her in the past and can get grabby during care but is easily redirected.
On 4/30/24 at 2:11 PM, V1 (Administrator) stated she was notified on 4/27/24 by V12 (LPN) that R5 had touched R4 in a sexual manner. V1 said she spoke to R4 and was told R5 grabbed R4's breast during a normal conversation. V1 said R4 demonstrated to her how it happened and that R4 was able to wheel backward to stop it. R4 said she yelled at R5 to never touch her again. V1 said the definition of sexual abuse is any unwanted touching between two individuals.
On 5/1/24 at 9:53 AM, V2 (Director of Nurses) stated R4 is alert and oriented. R5 has intermittent confusion but is alert and can express his needs. V2 said the definition of sexual abuse is any unwanted physical touching.
The facility's Abuse Program policy last revision dated 3/17 states under the purpose section: To ensure on-going safety of resident. The definition section states: 3. Sexual abuse includes, but not limited to, sexual harassment, sexual coercion, or sexual assault. 10. Resident to resident abuse is the willful inflection of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish by one resident towards another.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to report an allegation of abuse. This applies to one of three residents (R1) reviewed for abuse in the sample of 8.
The findings include:
The ...
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Based on interview and record review the facility failed to report an allegation of abuse. This applies to one of three residents (R1) reviewed for abuse in the sample of 8.
The findings include:
The facility face sheet for R1 shows diagnoses to include hypoxic ischemic encephalopathy (type of brain damage caused by a lack of oxygen to the brain), major depression disorder with psychotic features, anxiety, dementia and cardiomyopathy. The brief interview for mental status (BIMS) dated 2/19/24 shows R1 cognitively intact. R1's facility assessment shows her to be able to walk independently.
On 4/26/24 at 11:43 AM, V2 Director of Nursing said R1 was taken to the hospital on 4/24/24 after she eloped from the facility and became aggressive with the staff. V2 said the facility was notified from the hospital R1 was sent to, that R1 was being sent to another hospital for inpatient care. V2 said she assumed it was for psychiatric care. V2 said the next morning they were contacted by a forensic nurse at that hospital saying R1 was claiming to have been sexually abused. V2 said records were faxed to them and the records showed the abuse happened at the hospital so she did not think an abuse investigation needed to be completed or reported.
On 4/26/24 at 10:30 AM, V1 Administrator said the facility was notifed on 4/25/24 that R1 was alleging she had been sexually abused. V1 said the records from the hospital R1 was at showed the abuse happened at the hospital so an abuse investigation was not completed or reported. V1 said R1 makes sexual abuse allegations often as she is hallucinating about past abuse. V1 said this was a behavior of R1. V1 said she has two hours to report abuse and to start an investigation, it's important to protect the residents.
On 4/25/24 at 1:54 PM, V6 Forensic Nurse at hospital said she spoke with the facility staff at 4:50 AM on 4/25/24 and reported to them that R1 was refusing a rape kit, but did make allegations that another resident has sexually abused her in her room. V6 said R1 named R2 as the man who raped her.
The hospital report that V6 faxed to the facility shows R1 refused the rape kit but did accuse R2 of raping her. The note shows R1 at first stated she woke up to him raping her, but that it didn't happen at the facility but at the hospital. The note goes on to show R1 saying it was R2 that raped her. The note also shows she said it was the resident that she sits with at meals at the facility.
The facility policy with a revision date of 3/17 for abuse investigation/reporting/response shows 9. Allegations of abuse or neglect regardless of source or subjectivity belief concerning the truthfulness of the allegation shall be reported to the administator and the appropirate agencies.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to investigate an allegation of abuse. This applies to one of three residents (R1) reviewed for abuse in the sample of 8.
The findings include:...
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Based on interview and record review the facility failed to investigate an allegation of abuse. This applies to one of three residents (R1) reviewed for abuse in the sample of 8.
The findings include:
The facility face sheet for R1 shows diagnoses to include hypoxic ischemic encephalopathy (type of brain damage caused by a lack of oxygen to the brain), major depression disorder with psychotic features, anxiety, dementia and cardiomyopathy. The brief interview for mental status (BIMS) dated 2/19/24 shows R1 cognitively intact. R1's facility assessment shows her to be able to walk independently.
On 4/26/24 at 11:43 AM, V2 Director of Nursing said R1 was taken to the hospital on 4/24/24 after she eloped from the facility and became aggressive with the staff. V2 said the facility was notified from the hospital R1 was sent to, that R1 was being sent to another hospital for inpatient care. V2 said she assumed it was for psychiatric care. V2 said the next morning they were contacted by a forensic nurse at this hospital saying R1 was claiming to have been sexually abused. V2 said records were faxed to them and the records showed the abuse happened at the hospital so she did not think an abuse investigation needed to be completed.
On 4/26/24 at 10:30 AM, V1 Administrator said the facility was notifed on 4/25/24 that R1 was alleging she had been sexually abused. V1 said the records from the hospital R1 was at showed the abuse happened at the hospital so an abuse investigation was not completed or reported. V1 said R1 makes sexual abuse allegations often as she is hallucinating about past abuse. V1 said this was a behavior of R1. V1 said she has two hours to report abuse and to start an investigation, it's important to protect the residents.
On 4/25/24 at 1:54 PM, V6 Forensic Nurse at hospital said she spoke with the facility staff at 4:50 AM on 4/25/24 and reported to them that R1 was refusing a rape kit, but did make allegations that another resident has sexually abused her in her room. V6 said R1 named R2 as the man who raped her.
The hospital report that V6 faxed to the facility shows R1 refused the rape kit but did accuse R2 of raping her. The note shows R1 at first stated she woke up to him raping her, but that it didn't happen at the facility but at the hospital. The note goes on to show R1 saying it was R2 that raped her. The note also shows she said it was the resident that she sits with at meals at the facility.
The facility policy with a revision date of 3/17 for abuse investigation/reporting/response shows the purpose of the policy is to ensure that a through investigation is completed .
Aug 2023
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
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 the confidentiality of a resident's electronic ...
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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 the confidentiality of a resident's electronic medical record was protected for 1 of 1 residents (R13) reviewed for privacy and confidentiality in the sample of 22.
The findings include:
R13's admission Record, printed by the facility on 8/17/23, showed he had diagnoses including unspecified head injury, major depressive disorder, that is severe with psychotic symptoms, and anxiety disorder. R13's facility assessment dated [DATE] showed he was cognitively intact and required extensive assist of staff for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. R13's Order Summary Report, printed by the facility on 8/17/23, showed R13 has orders for medications for major depression and anxiety disorder.
On 8/16/23 at 9:55 AM, the medication cart for the A hall, was sitting in the main hall that leads from the A hall to the dining room, activity room, and the other end of the building that the B and C halls were located. The computer on the medication cart was not locked out and R13's electronic medication administration record was open. R13's medical record was easily seen as you walked by the cart. Between 9:55 AM and 10:00 AM, at least 10 people walked past the medication cart. At 10:00 AM, this surveyor knocked on the door to the medication room. V13 (Registered Nurse-RN) was sitting over to the right side of the medication room, with her back towards the door. V13 identified herself as the nurse for the A hall. V13 said the resident's electronic charting should absolutely not be visible so others could see it.
On 08/17/23 at 10:26 AM, V2 (Director of Nursing-DON) said the nurses are to hit the lock button on the computer or close the computer if they walk away from the medication cart, and the cart is not in view. V2 said this should be done to protect the residents' private information.
The facility's undated policy titled Acceptable Use showed 4.2 Security and Proprietary Information .4.2.3 All PCs, laptops and workstations should be secured with a password-protected screensaver with the automatic activation feature set at 10 minutes or less, or by logging-off (control-alt-delete for Win2K users) when the host will be unattended .4.2.5 Because information contained on portable computers is especially vulnerable, special care should be exercised. Protect laptops in accordance with the laptop Security Tips.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure interventions were in place for a resident with...
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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 interventions were in place for a resident with skin shearing for one of one resident (R30) reviewed for non-pressure wounds in the sample of 22.
The findings include:
R30's face sheet printed on 8/17/23 showed diagnoses including but not limited to multiple sclerosis, morbid obesity, and paraplegia. R30's facility assessment dated [DATE] showed moderate cognitive impairment and extensive staff assistance needed for bed mobility.
On 8/15/23 at 9:45 AM, R30 was lying in a bariatric size bed and stated he had sores on his buttocks. R30 said they have been for quite a while. A sign was posted on the wall above the bed which stated: Raise knees to avoid sliding down in bed. R30's knees were not raised, and he was low in the bed with his toes touching the foot board. At 11:03 AM, V12 (CNA-Certified Nurse Aide) said R30 will stay in bed today until the wound doctor comes to do the weekly rounds. V12 said R30 has open areas but was unsure exactly where on the body. At 12:29 PM, R30 was still in bed with his knees flat and the head of the bed was raised. R30 was low in the bed with his feet almost touching the foot board. R30 grabbed the upper side rails and attempted to hoist himself further up in the bed. R30 was lying on a blue, cotton pad over a thin white, cotton sheet.
R30's August 2023 physician order report showed an order start dated 6/16/23 for: repositioning sheet to be used when in bed.
R30's weight under the vitals tab dated 8/14/23 showed 297 pounds.
R30's Wound Evaluation dated 8/15/23 showed a right buttock non-pressure wound measuring 2.8 x 2.8 x 0.1 centimeters present for greater than 191 days. The same evaluation date showed a left buttock non-pressure wound measuring 7.4 x 8.9 x 0.2 centimeters for greater than 191 days. The evaluation showed both wounds were trauma related causes. R30's August 2023 weekly wound tracking log showed both buttocks wounds were caused by shear and facility acquired.
On 8/16/23 at 9:11 AM, R30 was in bed and again his knees were not raised. At 9:50 AM, staff attempted to get R30 out of bed and he refused. R30's knees were still low, and he was flat on his back. At 11:15 AM, V12 and V15 (CNAs) transferred R30 from the bed to the wheelchair using a mechanical lift. R30 was still lying on a blue cotton pad that was over a thin sheet. There was no repositioning sheet under the resident.
On 8/16/23 at 1:27 PM, V14 (Wound Care Nurse) stated R30 has shearing on his buttocks due to how he repositions himself in bed. The repositioning sheet is a long piece of material to help him move up in bed. R30's knees should be kept bent to keep him up towards the top of the bed. He will use the headboard to pull himself up. When he moves himself in the bed it causes shearing to his skin. V14 said he has open areas on his buttocks right now from the shearing because he pulls himself up in the bed. V14 and the surveyor observed R30's bed and physician orders together. V14 said there is not a reposition sheet on his bed and yes, there is an order for it to be there.
On 8/16/23 at 2:09 PM, V14 and V12 approached this surveyor and had a long, dark navy blue repositioning sheet. V14 said it was found in the laundry. We didn't realize it wasn't on his bed yesterday or today. We did not realize it was missing until you mentioned it. He has this weird way of repositioning himself in bed. He is a very heavy guy and holds onto things to pull himself up in bed. The sheet is needed to reduce the friction on his skin.
On 8/17/23 at 9:35 AM, V14 and V12 performed wound treatments to R30's buttocks. Both the left and right buttocks had open, reddened, and oozing areas. V14 said the open areas come and go over time, depending on how he scoots himself up in bed.
On 8/17/23 at 12:06 PM, V2 (Director of Nurses) stated the repositioning sheet is similar to a glide sheet. It has specialized fabric to help R30's skin glide over the fabric. It stops the stagnant pulling on his buttock skin. It needs to be on his bed at all times. He has shearing to his buttock from the friction of his bottom being pulled along the linens. His knees are to be bent to help keep him up in bed. The higher he is in bed the less likely he will be pulling himself up alone. V2 said there is the potential for his skin to continue to breakdown or slow the healing process if those interventions are not in place.
R30's care plan showed a focus area start dated 4/15/20 related to impaired skin integrity. Interventions included: encourage the use of lifting devices while in bed, position resident to reduce causes of friction or shear, utilize wedges and repositioning sheet for repositioning task when in bed.
The facility's undated Skin and Wound Care Program policy states under the abrasions section: treat per physician's orders and observed environment for need of protective equipment .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident's call light system was in working o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident's call light system was in working order for 1 of 1 resident (R68) reviewed for call lights in the sample of 22.
The findings include:
R68's admission Record, printed by the facility on 8/17/23, showed she had diagnoses including cerebral palsy, epilepsy, gastrostomy (g-tube), major depressive disorder, and dysphagia (difficulty swallowing). R68's facility assessment dated [DATE] showed she is dependent on staff for transfers, bed mobility, dressing, eating, toileting, personal hygiene, and bathing. The assessment showed R68 has a limitation in range of motion to her bilateral upper and lower extremities. The assessment also showed R68 is always incontinent of bowel and bladder.
On 8/15/23 at 10:23 AM, R68 was sitting in her wheelchair. A speech tablet was attached to R68's wheelchair, allowing R68 to communicate using the speech tablet. R68 said almost every night she has to wait about 2 hours for her call light to be answered.
On 8/15/23 at 10:40 AM, this surveyor pushed the call light pad in R68's room. At 10:50 AM, no staff had come by to answer the light. V12 (Certified Nursing Assistant-CNA) was walking in the common area between the B and C halls. This surveyor asked V12 if the electronic signage (that was positioned at each end of the hall) showed that R68's call light was activated. V12 said the signage did not show that R68's call light had been activated. V12 said let me try it again. V12 pushed R68's padded call light button. V12 said the signage still did not show that the call light was activate.
On 8/17/23 at 9:14 AM, V17 (Maintenance Supervisor) said the residents' call lights are checked to see if they are in working order on a monthly basis. V17 said the maintenance department would only know a call light is not working, if it is not working during their monthly checks, or if it is reported to them by staff.
The facility's Nurse Call Inspection forms from June 2023-August 2023 showed the maintenance department's last monthly review was completed on 8/1/23.
The facility's policy and procedure titled Resident Call Light, with a revision date of 12/31/15, showed It is the policy of this facility to provide a communication call-light system that allows the resident to communicate a need from their room, bathroom, and bathing area. The policy showed 1. All of the resident rooms, bathrooms and shower areas are equipped with a call light system. 2. The facility uses a pager system to notify staff of call lights being used by residents. 3. There is also a visual display screen that indicates which call light is activated. 4. The facility also recognizes the individual needs of residents and provides alternatives like the soft-touch call light pads to those who need them .13. If call light is defective, report immediately to maintenance.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R41's face sheet printed on 8/16/23 showed diagnoses including but not limited to cerebral palsy, heart disease, spinal steno...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R41's face sheet printed on 8/16/23 showed diagnoses including but not limited to cerebral palsy, heart disease, spinal stenosis, and neuromuscular bladder. R41's facility assessment dated [DATE] showed no cognitive impairment and total dependence on staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The same assessment showed R41 is always incontinent of urine.
R41's care plan showed a focus area start dated 6/7/21 related to a condom type catheter and the need to wear it when in bed. R41's August 2023 physician orders did not show any indication for the use of or care instructions for the condom catheter.
On 8/15/23 at 10:11 AM, R41 was seated in a motorized wheelchair in his room. R41 stated he was all wet with urine and needed his pants changed. V16 and V11 (CNAs-Certified Nurse Aides) transferred R41 using a mechanical lift. V16 hooked the catheter drainage bag on a metal bar of the lift near R41's head. It remained there throughout the transfer. R41 was transferred onto the bed and V16 laid the drainage bag on the bed at R41's feet. R41's pants, underwear, and shirt were wet with urine. R41 was using a condom type catheter that had come off at some point during the morning. The catheter tubing was not attached to R41's thigh in anyway. V16 wore gloves while wiping R41's groin area with a wet washcloth. V16 wiped the area in an up and down manner several times then used a circular motion. V16 used the same cloth to dry the area. R41's penis was not cleansed. R41 was rolled to his side and V16 used a washcloth to clean his wet back and buttock. V16 used a quick, lightly swiping random motion. V16 used the same cloth to dry R41. V16 opened a new condom catheter set and hung the tubing on the nightstand drawer while the urine-soaked shirt and pants were changed. The tubing end was indirect contact with the drawer, then bed linens, and V16's urine contaminated gloves. V11 applied the condom catheter to the penis and connected the tubing. V11 did not alcohol off the connection sites prior to attaching the two. No leg secure device was applied to the thigh. R41 stated the condom catheter falls off frequently and he is covered with urine a lot of the time. V11 and V16 continued to wear the same gloves while transferring R41 back to his wheelchair. R41's pants, transfer sling, wheelchair belt and tray table, wheelchair joystick controller, and the mechanical lift were touched while the contaminated gloves were still on. V11 and V16 wheeled the mechanical lift out into the hallway and parked it under a sign that stated: Lifts must be cleaned between each use. If not on isolation use alcohol and a paper towel. Clean all touched surfaces.
On 8/17/23 at 11:32 AM, V2 (Director of Nurses) stated physician orders are needed for catheters including the type, how to care for it, and why it is needed. Physician orders are important for maintenance and infection prevention. Physician orders direct the plan of care. V2 reviewed R41's chart and stated there were not orders for the catheter. V2 said R41 should have a device to secure the tubing to the thigh to prevent it from being tugged on. V2 said drainage bags need to always remain below the level of the bladder. It allows the urine to drain correctly and less potential to irritate the groin area. V2 said it is a basic standard of care to alcohol off the drainage tubing and tip prior to connection. It is for infection prevention and reduces the risk of bacteria entering the penis. V2 said pericare should be done in a manner to ensure the washing is done from closest to the body outward. CNAs should be wiping away from the body. Soiled gloves need to be changed before touching other items. The lifts need to be cleaned between residents to stop the spread of potential germs that maybe on it.
The facility's undated Condom Catheter Application policy states: Condom catheters will be applied as per physician's order . The policy states under the special considerations section: Residents and caregivers need instructions regarding the safe application of the condom, the mechanism for attaching the device to a drainage system and principles of skin care associated with its use.
The facility's Pericare policy revision dated 3/17 states under the procedures for males section: wash and dry the upper inner thighs, wash and dry the penis .wash and dry the scrotum, .reglove .clean between the buttocks .dry areas well.
The facility's undated Standard Precautions policy states under the when to wear gloves section: Change gloves between tasks and procedures on the same resident after contact with material that may contain microorganisms. The policy states under the equipment section: Make sure reusable equipment is not used for the care of another resident until it has been cleaned appropriately.
4. R79's admission Record, printed by the facility on 8/17/23, showed she had diagnoses including traumatic subdural hemorrhage without loss of consciousness, hereditary motor and sensory neuropathy, intervertebral disc degeneration, neuromuscular dysfunction of bladder, and retention of urine. R79's Order Summary Report, printed by the facility on 8/17/23, showed an order for a (indwelling urinary catheter). R79's facility assessment dated [DATE], showed she was cognitively intact and required extensive assist of 2 staff members for bed mobility, transfers, dressing, and toileting. The assessment also showed R79 had an indwelling catheter. R79's care plan, with a revision date of 5/1/23 showed R79 had an indwelling catheter related to neurogenic bladder (urinary bladder problems due to disease or injury of the central nervous system (i.e. brain injury). R79's progress notes showed R79 had a history of chronic UTIs (urinary tract infections) prior to admission. The notes dated 5/5/23 showed R79 was diagnosed on that day with a UTI and an antibiotic was started.
On 8/16/23 at 3:27 PM, R79 said she has had UTI's. R79 said since she was admitted to the facility she has had to be sent out to the hospital for a UTI.
On 8/17/23 at 9:49 AM, V10 and V11 (Certified Nursing Assistants-CNAs) were providing personal care for R79. V10 wiped R79's left pubic region, then right down the middle of R79's vaginal area, using the same section of washcloth, V10 continued in a downward motion until she came to where R79's indwelling catheter was inserted. V10 folded the washcloth, then did the same technique; wiping R79's right pubic area, then her middle vaginal area in one swipe, until she came to the insertion site of R79's indwelling catheter. V10 grabbed another wash cloth and repeated the exact same technique to rinse R79 during personal cares. V10 did not clean R79's groin areas or where the catheter tubing entered R79's body during personal cares.
On 8/17/23 at 9:54 AM, V11 (CNA) said you should use a different wash cloth or fold the cloth so you do not use the same section of cloth to wipe the pubic area, then the vaginal area; to prevent cross-contamination and prevent introducing bacteria into the opening of the body.
On 8/17/23 at 9:56 AM, V10 said she should have used a different section of the cloth to prevent bacteria from getting into the opening of the body.
On 8/17/23 at 10:23 AM, V2 (Director of Nursing-DON) said catheter care should be done from the urethra outwards. V2 said when providing incontinence care, the CNAs should use a clean washcloth for each area, or use a different section of the washcloth between a resident's vaginal area and pubic area; To prevent infection. On 8/17/23 at 10:39 AM, V2 (Director of Nursing-DON) said R79 has chronic urinary infections with complications and super bugs. V2 said part of R79's current state is due to a UTI with sepsis prior to admission.
Based on observation, interview and record review the facility failed to ensure a urinary catheter remained below the level of the bladder, failed to ensure the drainage tubing was covered, failed to have a physicians order for a Texas catheter, and failed to provide incontinence care in a manner to prevent cross contamination for a resident with a catheter for 4 of 7 residents (R17, R31, R41, R79) reviewed for urinary catheters in the sample of 22.
The findings include:
1. R31's quarterly assessment of 7/3/23 shows he has an indwelling urinary catheter. The 3/11/21 catheter care plan was updated on 7/28/23 to show R31 had a UTI (urinary tract infection).
R31's Order summary report of 8/17/23 documents he had orders for Cefepime HCI Injection Solution Reconstituted 1 GM (gram) to be given intramuscularly two times a day for urine culture. And Nitrofurantoin Macrocrystal capsule, one capsule every 6 hours for urine culture.
On 8/15/23 at 09:20 AM, R31 was observed lying in bed, his with his urinary drainage bag hanging on the bed rail. The drainage tubing was not secured or covered and was towards the floor.
On 8/15/23 at 09:44 AM, V9 LPN (Licensed Practical Nurse) said R31 just came off isolation for a UTI. She said he is still on 2 antibiotics. She said the drainage tubing should be secured up in the pocket and not out being exposed to more germs. She said there would be potential for more infection.
On 08/17/23 at 11:09 AM, V2 DON (Director of Nursing) said R31 was just released from isolation related to a urine infection. His catheter should be secured and not exposed to the elements for general infection control.
The facility's 2/2019 policy for urinary catheter care documents 3. Emptying the Catheter Bag: e. close the slide valve, clean end with alcohol, and put the drain spout into its sleeve at the bottom of the bag.
2. R17's quarterly assessment of 8/1/23 shows he has an indwelling catheter. The Order summary sheet of 8/17/23 documents a current order for Ceporfloxacin 500 mg tablets twice daily for positive urine culture.
On 8/17/23 at 9:32 AM, V7 CNA (certified nursing assistant) was providing care for R17 when she laid the catheter drainage bag on the bed, then rolled him over causing the drainage bag to land on the floor. V7 picked up the drainage bag and raised it above the bladder to move it over R17's knee and placed the bag back onto the bed.
On 8/17/23 at 9:40 AM, V7 said she did not recall moving the catheter bag over R17's bladder, but did say the drainage bag should not be on the floor.
On 8/17/23 at 11:13 AM, V2 said the drainage bag should not be above the level of the bladder, because it reintroduces urine into the bladder and can cause an infection, R17 is currently on isolation for a UTI. She said the drainage bag on the floor, is not appropriate, the bag should be on the bed and suspended for gravity drainage.
The facility's 2/2019 policy for urinary catheter care documents 2. Catheter Tubing and Bag: c. Keep the bag below the level of the resident's bladder at all times.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation. interview and record review, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner, and failed to cover prepared food. This applies to all resid...
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Based on observation. interview and record review, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner, and failed to cover prepared food. This applies to all residents who reside in the facility that consume food prepared in the facility's kitchen.
The findings include:
The facility Census and Condition of Residents from #672 dated 8/16/23 documents there are 80 resident residing in the facility. The facility provided list of Tube Feed Only (undated) shows 6 residents do not eat food prepared in the facility kitchen.
On 8/15/23 at 9:52 AM, the kitchen hoods were greasy with dust adhered to the grease, giving the surface a fuzzy appearance. The hoods are over the cooking areas. The walk in refrigerator had a tray of fruit cups uncovered. The shelves in walk in refrigerator had a black substance speckled over the horizontal and vertical surface that was not in the plastic design of the shelves, but on the surface. This substance could be scraped off. The shelves were in close proximity to the uncovered fruit cups. The same substance was still there on 8/17/23 at 9:02 AM.
On 08/17/23 at 9:02 AM, V6 (Dietary Manager) said, The hood is cleaned by a company, and is not on her cleaning schedule. V6 said, the staff who didn't cover the fruit cups is new, and is still learning. V6 said the fruit cups should have been covered for sanitary reasons. V6 was not sure what the black substance on the shelving unit was.
The 8/2023 Daily Cleaning Schedule does not include the hood or the shelves in the walk in refrigerator. The 8/2023 Weekly Cleaning Schedule has a line item to clean Walk in Coolers and Freezers (Clean and remove expired food). This document shows this task was done on 8/15/23 (the day the mystery substance was discovered) and on 8/16/23, but the substance was still there on 8/17/23. The 8/2023 Weekly Cleaning Schedule does not include cleaning the hood.
The 2017 Food Storage Policy and Procedure shows it is the policy of the facility to store foods in a manner to keep it safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants .and in a manner designed to prevent cross contamination. The Procedure shows for refrigerated food storage: f. All foods should be covered.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
Based on observation. interview and record review, the facility failed to control the fly infestation throughout the facility. This applies to all residents who reside in the facility.
The findings in...
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Based on observation. interview and record review, the facility failed to control the fly infestation throughout the facility. This applies to all residents who reside in the facility.
The findings include:
The facility Census and Condition of Residents from #672 dated 8/16/23 documents there are 80 resident residing in the facility.
On 08/16/23 at 12:23 PM, R62 was in his room in bed with a fly swatter in his hand. 3 flies were buzzing around him. R62 said, the flies are terrible. R62 said he tries to swat them but more show up. R62's 7/11/23 MDS (Minimum Data Set) shows he has a BIMS (Brief Interview for Mental Status) of 14 showing he is cognitively intact.
On 8/17/23 at 10:04 AM, V14 (Wound Care Nurse) was performing wound care on R26. While gathering supplies a fly lands on V14's gloved hand and she blows it off. There were flies on the R26's sheet, arms. and circling the supplies on the overhead table. V14 said, that the flies are a problem because the doors are opening and closing all the time. V14 said, there is a solution but the facility won't do it. V14 said the facility should install giant overhead fans at the entries to keep the flies out. R26's Face Sheet shows his diagnoses include TBI (Traumatic Brain Injury), hemiplegia, tracheostomy, and major depression. R26's MDS shows requires extensive assistance with all of his ADL's (Activities of Daily Living) and his functional ability is impaired.
On 8/15/23 at 10:15 AM, R41 had flies on his face and arms. R41 does not have the ability to wave the flies off his face. R41 said, the flies are a problem this season. R41's Face Sheet shows his diagnoses includes Cerebral Palsy. R41's MDS shows his BIMS is 15 and he has impaired upper extremities on the right and left side. V16 CNA (Certified Nursing Assistants) was providing care to R41 and said, the flies have not been good around here.
On 8/15/23 at 12:30 PM, R18, R48, and R33 were in the same room, with multiple flies flying around. R18 said it sucks. We don't like. R18 said, she uses her fly swatter to threaten them and get them away.
On 8/15/23 at 12:30 PM, R15 was asleep in bed with a fly on his sheet by his face and his bare feet had flies on them.
On 8/15/23 at 11:39 AM, R39 was in the TV area in her wheel chair with her feeding tube running and her mouth open. R39 had 3-4 flies circling on her contracted hands, and cheeks. R39's Face Sheet shows her diagnoses includes Cerebral Palsy. Her 7/3/23 MDS shows her BIMS is 00 and she is totally dependent on staff for all her ADL's.
On 8/15/23 at 3:16 PM, R79 had 3 flies landing on her face. R39 had a bandage on her head and said she just had surgery. R79's Face Sheet shows her diagnoses includes, Traumatic subdural hemorrhage, and hereditary motor and sensory neuropathy. R79's MDS shows her BIMS to be 13, and requires extensive assistance with her ADL's. R79 has impaired range of motion on her right and left extremities.
The 8/8/23 Resident Council Minutes shows the resident expressed concern about how bad the flies were and if anything can be done.
The Pest Control Policy (revised 3/2017) shows, the facility has a contract with a local licensed pest control service who agree to spray the facility at regular intervals and as needed. Review of the frequency of pest control visits are once a month.
Frequent routine examinations are made of persons, served rooms and other areas of the facility to ensure that the pest control service is effective.
Aug 2023
3 deficiencies
2 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident was free from abuse for 1 of 3 resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident was free from abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 3. This failure resulted in R2 feeling unsafe and in fear of R3.
The findings include:
R2's face sheet printed on 8/1/23 showed he was admitted to the facility on [DATE] with diagnosis including but not limited to injury at the C4 level of cervical spinal cord and paraplegia. The facility assessment dated [DATE] showed no cognitive impairment. The same assessment showed R2 needs extensive staff assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene.
On 8/1/23 at 9:15 AM, R2 was lying in bed with a lap top device and cellular phone on the table over him. R2 was fully alert and oriented. R2 said there are a lot of wandering residents, but one that is especially bad (R3). He is in the room right next door to me and comes in here yelling and cussing. He has brain issues and once I even saw him eating his own feces. That is how bad he is. He hits other residents and even the staff. I saw him grab a nurse's necklace and yank it so hard she was bruised. I hear him yelling F#*k you all the time. He yells to be put to bed, then 2 minutes later, is screaming and crawling around on the floor. The aides have to watch him continually or he wanders into my room. I can push my call light with my head, but it takes them time to get here, especially later in the day. I am so afraid of him. Just last night after about 3 AM, I heard something in my room. I could see him crawling on the floor near my bathroom door. He was growling and coming towards my bed. I immediately called my mom on my cell phone (using voice activation). I was terrified! I can't use my arms or legs well. If he grabbed me, there is nothing I can do to protect myself. I keep praying this man stays away from me. He comes in here 3-4 times weekly. I am completely afraid for my safety and the safety of others. I understand this guy has brain problems, but I shouldn't have to live like this.
On 8/1/23 at 9:41 AM, R3 (does reside in room next door to R2) was lying in bed on a low mattress and fall mats were on the floor. R3 did not respond to his name or react to this surveyor's presence. At 9:45 AM, R3 was heard moaning loudly and observed crawling on the floor of his room and about to exit into the hallway. V4 and V5 (Certified Nurse Aides) entered the room and assisted R3 into a wheelchair. V4 said he gets out of bed and crawls on the floor a lot. He can walk alone too, although he is not supposed to. At 9:55 AM, V6 (R3's case worker) said R3 has cognitive loss and lots of behaviors. He has a history of acting out aggressively at times and will hit others. Right now, I am unaware of any changes in the behaviors.
On 8/1/23 at 10:00 AM, this surveyor entered R3's room and attempted to hold a brief conversation. R3 mumbled in reply and then suddenly began yelling and screaming. R3 yelled F*#k you b*&th* repeatedly. This surveyor exited the room while R3 easily wheeled himself out of the room and down the hall, while continuing to scream profanities. R3 did not stop until a staff member approached and took him back into his room.
On 8/1/23 at 11:20 AM, V10 (R2's family member) stated R2 called her this morning around 3:30 AM. V10 said he was absolutely terrified. R2 was whispering into the phone saying a man was crawling on the floor in his room. He was whispering because he was afraid to arouse the man and cause him to be attacked. V10 said she could see fear and terror (via face time) on R2's face. He said the man was coming right toward his bed. V10 said she heard a staff member taking the man out of the room. V10 said R2 explained it was the man that lives next door (R3). V10 said R2 has told her he has seen R3 being physical to other residents and staff members. V10 said R3 repeatedly wanders into other rooms. V10 said he wandered into the room the last time she was visiting. V10 said, How is it safe for an aggressive resident to wander into rooms in the middle of the night?! V10 stated, (R2) was afraid last night when he called me.
R3's face sheet printed on 8/1/23 showed diagnoses including but not limited to concussion with loss of consciousness, postencephalitic Parkinsonism, traumatic brain injury, dementia with agitation, bipolar disorder, insomnia, restlessness and agitation. R3's facility assessment dated [DATE] showed R3 was unable to complete the cognitive assessment. The same assessment showed R3 has physical behaviors toward others, verbal behaviors toward others, and other behavior symptoms directed toward self. The assessment showed R3's symptoms put others at significant risk for physical injury and significantly intrude on the privacy of others.
The last three months of facility incident reports were reviewed and showed a resident-to-resident incident on 6/8/23. R3 was arguing with another resident and propelled toward him. R3 struck the resident in the left shoulder. An incident report dated 7/5/23 showed R3 propelled by another resident and kicked her in the left shin. (Both reports showed no resident injury and that the Illinois Department of Public Health was notified.)
On 8/1/23 at 11:37 AM, V7 (Social Service) stated R3 is physically and verbally aggressive to staff and other residents. He growls, yells out, and swears. He is being treated by the psychiatric staff and I think there have been changes to his medications. We try to do a lot of one-on-one activities with him and would do counseling too but he can't comprehend that.
On 8/1/23 at 11:55 AM, V9 (Registered Nurse) said R3 is aggressive at times. We all have to pitch in to keep an eye on him. He has had a lot of medication changes in the past. He gets clonazepam (anti-anxiety) twice a day. It is typically effective unless he was up a lot the night before. He does get up a lot during the night. He is hit or miss on how he will act each day. One minute he is fine, and the next minute he is acting out.
On 8/1/23 at 12:05 PM, V8 (Licensed Practical Nurse) stated R3 does have lots of behaviors and gets agitated easily. He does see psychiatric services and they are here on a weekly basis. I know there have been lots of medication changes in the last three months or so. We give him snacks and do one on one supervision until he is calmed down. He does crawl on the floor and wander into other resident rooms. We redirect him and it varies on how well that works.
On 8/1/23 at 12:15 PM, V4 and V5 (Certified Nurse Aides) said R3 gets overstimulated easily and that causes him to escalate quickly. He yells and swears. He does get out of bed by himself and crawls around on the floor. He is able to self-propel his wheelchair around. He goes in and out of other resident rooms. We try to keep a banner across other resident doors, so he doesn't go in there. (R2's door banner was wrapped up and tucked under the wall handrail during the entire survey.) We redirect him with TV, movies, or discuss something to get him off focus. It is generally effective. If he still won't calm down, we tell the nurse.
On 8/1/23 at 1:24 PM, R2 was interviewed again and stated every once in a while they put the banner over my doorway, but it depends on who is working. (R3) is terrifying. He scares the crap out of me when he gets close to me. I hardly leave my room because I know when I come back he will be in here. I try to redirect him the best I can. I call my mom on face time when he is agitated because I don't know if staff will get to me in time. I am only [AGE] years old and I hate admitting that I am scared.
On 8/1/23 at 12:52 PM, V2 (Director of Nurses) stated R3 is seen by psychiatric services every two weeks. There have been several medication adjustments and some his mother would not allow. We have been trying to get R3 into a facility near Chicago, but they do not have the space yet.
On 8/1/23 at 1:20 PM, V1 (Administrator/Abuse Coordinator) stated he would consider hitting or kicking others as abuse. V1 said he would agree with abuse as defined in the facility's policy. V1 said R3 does have a history of hitting or kicking others and does wander in and out of R2's room. V1 said he believed R2 and R3's were friends and did not realize it was an issue until now. V1 stated there is a video camera in the hall right outside R2 and R3's room. He would review it and get back to the surveyor. At 2:00 PM, V1 said the camera did show R3 crawling on the hallway floor around 3 or 4 AM but he could not see exactly if R3 entered R2's room. V1 said staff are afraid of R3 too and that is why we have been trying different avenues for him.
The facility Abuse Program policy last revision dated 3/17 states: PURPOSE: To ensure on-going safety of resident. DEFINITIONS: 10. RESIDENT TO RESIDENT ABUSE is the willful inflection or injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish by one resident towards another.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident was free from abuse for 1 of 3 resid...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident was free from abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 3. This failure resulted in R2 feeling unsafe and in fear of R3.
The findings include:
R2's face sheet printed on 8/1/23 showed he was admitted to the facility on [DATE] with diagnosis including but not limited to injury at the C4 level of cervical spinal cord and paraplegia. The facility assessment dated [DATE] showed no cognitive impairment. The same assessment showed R2 needs extensive staff assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene.
On 8/1/23 at 9:15 AM, R2 was lying in bed with a lap top device and cellular phone on the table over him. R2 was fully alert and oriented. R2 said there are a lot of wandering residents, but one that is especially bad (R3). He is in the room right next door to me and comes in here yelling and cussing. He has brain issues and once I even saw him eating his own feces. That is how bad he is. He hits other residents and even the staff. I saw him grab a nurse's necklace and yank it so hard she was bruised. I hear him yelling F#*k you all the time. He yells to be put to bed, then 2 minutes later, is screaming and crawling around on the floor. The aides have to watch him continually or he wanders into my room. I can push my call light with my head, but it takes them time to get here, especially later in the day. I am so afraid of him. Just last night after about 3 AM, I heard something in my room. I could see him crawling on the floor near my bathroom door. He was growling and coming towards my bed. I immediately called my mom on my cell phone (using voice activation). I was terrified! I can't use my arms or legs well. If he grabbed me, there is nothing I can do to protect myself. I keep praying this man stays away from me. He comes in here 3-4 times weekly. I am completely afraid for my safety and the safety of others. I understand this guy has brain problems, but I shouldn't have to live like this.
On 8/1/23 at 9:41 AM, R3 (does reside in room next door to R2) was lying in bed on a low mattress and fall mats were on the floor. R3 did not respond to his name or react to this surveyor's presence. At 9:45 AM, R3 was heard moaning loudly and observed crawling on the floor of his room and about to exit into the hallway. V4 and V5 (Certified Nurse Aides) entered the room and assisted R3 into a wheelchair. V4 said he gets out of bed and crawls on the floor a lot. He can walk alone too, although he is not supposed to. At 9:55 AM, V6 (R3's case worker) said R3 has cognitive loss and lots of behaviors. He has a history of acting out aggressively at times and will hit others. Right now, I am unaware of any changes in the behaviors.
On 8/1/23 at 10:00 AM, this surveyor entered R3's room and attempted to hold a brief conversation. R3 mumbled in reply and then suddenly began yelling and screaming. R3 yelled F*#k you b*&th* repeatedly. This surveyor exited the room while R3 easily wheeled himself out of the room and down the hall, while continuing to scream profanities. R3 did not stop until a staff member approached and took him back into his room.
On 8/1/23 at 11:20 AM, V10 (R2's family member) stated R2 called her this morning around 3:30 AM. V10 said he was absolutely terrified. R2 was whispering into the phone saying a man was crawling on the floor in his room. He was whispering because he was afraid to arouse the man and cause him to be attacked. V10 said she could see fear and terror (via face time) on R2's face. He said the man was coming right toward his bed. V10 said she heard a staff member taking the man out of the room. V10 said R2 explained it was the man that lives next door (R3). V10 said R2 has told her he has seen R3 being physical to other residents and staff members. V10 said R3 repeatedly wanders into other rooms. V10 said he wandered into the room the last time she was visiting. V10 said, How is it safe for an aggressive resident to wander into rooms in the middle of the night?! V10 stated, (R2) was afraid last night when he called me.
R3's face sheet printed on 8/1/23 showed diagnoses including but not limited to concussion with loss of consciousness, postencephalitic Parkinsonism, traumatic brain injury, dementia with agitation, bipolar disorder, insomnia, restlessness and agitation. R3's facility assessment dated [DATE] showed R3 was unable to complete the cognitive assessment. The same assessment showed R3 has physical behaviors toward others, verbal behaviors toward others, and other behavior symptoms directed toward self. The assessment showed R3's symptoms put others at significant risk for physical injury and significantly intrude on the privacy of others.
The last three months of facility incident reports were reviewed and showed a resident-to-resident incident on 6/8/23. R3 was arguing with another resident and propelled toward him. R3 struck the resident in the left shoulder. An incident report dated 7/5/23 showed R3 propelled by another resident and kicked her in the left shin. (Both reports showed no resident injury and that the Illinois Department of Public Health was notified.)
On 8/1/23 at 11:37 AM, V7 (Social Service) stated R3 is physically and verbally aggressive to staff and other residents. He growls, yells out, and swears. He is being treated by the psychiatric staff and I think there have been changes to his medications. We try to do a lot of one-on-one activities with him and would do counseling too but he can't comprehend that.
On 8/1/23 at 11:55 AM, V9 (Registered Nurse) said R3 is aggressive at times. We all have to pitch in to keep an eye on him. He has had a lot of medication changes in the past. He gets clonazepam (anti-anxiety) twice a day. It is typically effective unless he was up a lot the night before. He does get up a lot during the night. He is hit or miss on how he will act each day. One minute he is fine, and the next minute he is acting out.
On 8/1/23 at 12:05 PM, V8 (Licensed Practical Nurse) stated R3 does have lots of behaviors and gets agitated easily. He does see psychiatric services and they are here on a weekly basis. I know there have been lots of medication changes in the last three months or so. We give him snacks and do one on one supervision until he is calmed down. He does crawl on the floor and wander into other resident rooms. We redirect him and it varies on how well that works.
On 8/1/23 at 12:15 PM, V4 and V5 (Certified Nurse Aides) said R3 gets overstimulated easily and that causes him to escalate quickly. He yells and swears. He does get out of bed by himself and crawls around on the floor. He is able to self-propel his wheelchair around. He goes in and out of other resident rooms. We try to keep a banner across other resident doors, so he doesn't go in there. (R2's door banner was wrapped up and tucked under the wall handrail during the entire survey.) We redirect him with TV, movies, or discuss something to get him off focus. It is generally effective. If he still won't calm down, we tell the nurse.
On 8/1/23 at 1:24 PM, R2 was interviewed again and stated every once in a while they put the banner over my doorway, but it depends on who is working. (R3) is terrifying. He scares the crap out of me when he gets close to me. I hardly leave my room because I know when I come back he will be in here. I try to redirect him the best I can. I call my mom on face time when he is agitated because I don't know if staff will get to me in time. I am only [AGE] years old and I hate admitting that I am scared.
On 8/1/23 at 12:52 PM, V2 (Director of Nurses) stated R3 is seen by psychiatric services every two weeks. There have been several medication adjustments and some his mother would not allow. We have been trying to get R3 into a facility near Chicago, but they do not have the space yet.
On 8/1/23 at 1:20 PM, V1 (Administrator/Abuse Coordinator) stated he would consider hitting or kicking others as abuse. V1 said he would agree with abuse as defined in the facility's policy. V1 said R3 does have a history of hitting or kicking others and does wander in and out of R2's room. V1 said he believed R2 and R3's were friends and did not realize it was an issue until now. V1 stated there is a video camera in the hall right outside R2 and R3's room. He would review it and get back to the surveyor. At 2:00 PM, V1 said the camera did show R3 crawling on the hallway floor around 3 or 4 AM but he could not see exactly if R3 entered R2's room. V1 said staff are afraid of R3 too and that is why we have been trying different avenues for him.
The facility Abuse Program policy last revision dated 3/17 states: PURPOSE: To ensure on-going safety of resident. DEFINITIONS: 10. RESIDENT TO RESIDENT ABUSE is the willful inflection or injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish by one resident towards another.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent a medication error for 1 of 3 residents (R1) ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent a medication error for 1 of 3 residents (R1) reviewed for medication administration in the sample of 5.
The findings include:
R1's electronic face sheet printed on 8/1/23 showed R1 has diagnoses including but not limited to intracranial injury without loss of consciousness, diabetes type 2, hemiplegia, epilepsy, history of traumatic brain injury, hypertension, and dementia with behaviors.
R1's facility assessment dated [DATE] showed R1 has moderate cognitive impairment.
R1's nursing care plan dated 7/14/23 showed, (R1) was given the wrong medications which caused pressure in his chest per resident .send to emergency room for evaluation and treatment.
The facility's incident report investigation dated 8/1/23 showed, On 7/14/23 at 1950 (7:50 PM), this resident (R1) was administered 1 Norco 5/325mg, nystatin swish and swallow, and trazodone 200mg during evening medication administration. This resident has no known drug allergies. Nurse Practitioner notified of occurrence Nursing monitored resident and noted at 2020 (8:20 PM) that he had complaints of chest pressure. Resident sent to the emergency room for evaluation and treatment. Returned with no new orders. emergency room provide stated, Patient has no abnormal vital signs or ill effects .With that and the patient not having anything abnormal taken, nor any large amount, I feel the patient is appropriate to be sent back to his facility for continued monitoring with the caution that he will probably be more sleepy tonight or in the morning based on the medication .
On 8/1/23 at 12:52PM, V2 (Director of Nursing) stated, (V13-Licensed Practical Nurse) was on orientation with (V14-Registered Nurse). They had prepared another resident's medications together and when (V13) went to take them to the resident, she was stopped in the hallway by another resident and got sidetracked. (V13) then went into (R1's) room thinking that was the medication she prepared and administered them to him. She gave (R1) a different resident's medication that consisted of Nystatin swish and swallow, Trazadone 200mg, and Norco 5/325mg. I'm not sure how it happened but ideally the nurse's should have been preparing and administering the medications together since (V13) doesn't know all of the resident's yet. I'm not sure what identifier she used to identify (R1) but he will tell you his name so I don't think she asked him. Shortly after the medications were administered to (R1) he complained of chest pain so we sent him to the emergency room and he returned with no new orders. It was a mistake that shouldn't have happened but unfortunately we can only learn from it at this point. As a nurse, we all know that you have to identify the resident's BEFORE you give them the medication, whether you are familiar with them or not.
On 8/1/23, V13 (Licensed Practical Nurse) and V14 (Registered Nurse) were attempted to be contacted without success.
The facility's policy titled, Medication Administration dated 7/2013 showed, Purpose: To provide a safe method of delivering medication to residents .12. Confirm the identity of the resident. a. A photograph of the resident is in the medication administration record on the page before the resident's medication orders. b. Ask the resident to tell you his/her name .c. Check the room number and bed number. d. Check the resident's arm band .
Jul 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 ensure the safety of a resident dependent upon staff f...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the safety of a resident dependent upon staff for transfers for 1 of 3 residents (R1) reviewed for safety in the sample of 3.
The findings include:
R1's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include diffuse traumatic brain injury with loss of consciousness of unspecified duration, mild intermittent asthma, hemiplegia, dysphagia, major depressive disorder, neuromuscular dysfunction of bladder, Schizoaffective disorder, hypertension, and adjustment disorder with mixed anxiety and depressed mood. R1's facility assessment dated [DATE] showed he has moderate cognitive impairment and requires extensive assistance of 2 staff members and a mechanical lift for transfers.
R1's Restorative Nursing Screen dated 6/19/23 showed he has impairment to range of motion to his bilateral lower extremities. The same assessment showed, Sit to stand: the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed . Not applicable . and that R1 is unable to bear weight.
R1's Incident note dated 6/29/23 showed, Patient was found in room around 1:00 AM with multiple skin tears on right side of the body including face, arms, both knees, and right shoulder .
R1's 6/29/23 Skin Evaluation completed at 1:55 AM showed, . Resident has current skin issues . Bruising . right arm Skin tear . right hand . Skin tear . left hand, bruising . left shoulder . Skin Tear . Left side of the head . Skin Tear . Right knee . Skin Tear left knee .
R1's acute care hospital paperwork dated 6/29/23 at 2:13 AM showed, . The patient presents with altered mental status and patient sent from nursing home for evaluation of left supraorbital contusion and bruise over left shoulder and left elbow. No history of what happened. Per EMS no one at the nursing home knows what happened,,,
R1's 6/29/23 nursing note showed, Patient returned to [the facility] from [acute care hospital]. Performed CT spine and head and xray left arm and shoulder. No findings. Discoloration and small cut to left orbital, and discoloration and abrasion to left shoulder .
R1's 6/30/23 Nurse Practitioner note showed, . Reason: Follow up from incident/ER (emergency room) follow up, was found on ground sent by EMS (emergency medical services) for evaluation . he was seen and evaluated today after an ER follow up after being found on the floor .
R1's 7/2/23 nursing note showed, . Bruising remains to left eye. Dark purple in color .
On 7/5/23 at 11:15 AM, R1 was lying in his bed with his communication book on his lap. R1 had dark purple and yellow bruising to his left eye.
On 7/5/23 at 12:40 PM, V8 LPN (Licensed Practical Nurse) said, That night there were 3 agency CNAs (Certified Nursing Assistants) working. When the next shift came on they did rounds. [R1] wasn't responding and had a bruise and cut on his eye. I got ahold of the administration and the Director of Nursing . The Administrator came in. [R1] had cuts on his leg too and he was holding his head. He does not walk or anything like that. He is bed bound. He can't stand up and I've never seen him try and get out of bed or his chair.
On 7/5/23 at 12:25 PM, V6 CNA said, It was about 9:30 when I got back from my last break. I had never put him to bed before because he is usually already in bed or there has been designated staff to put him into bed. I had gotten to know him so I asked if he was ready for bed. He requested a man to put him to bed so me and [V7 CNA] both left out of the room to find a male staff member. I returned to his room and proceeded to clean him up because he had just eaten. I took his seatbelt off so I could take his shirt off. I went back to the sink to get a towel and it seemed like he was trying to jump into bed. I went to grab him and I tripped over the wheelchair and fell back into the bed. I eased him and myself both to the floor. We were both in a jam between the bed and the wheelchair. I couldn't tell what he hit himself on because everything happened so fast. I did not do a full check on him. I just went off him telling me he was okay. I did not report the incident to the nurse .
On 7/5/23 at 12:43 PM, V7 CNA said, Me and [V6] were trying to get his shirt off and found out afterwards he preferred male staff. Once he let us know he wanted a male staff, we went out of the room to find one. I walked over to another hall to get [V9]. When I got back [V6] was on the floor with [R1] on top of her. I asked her what happened and she said [R1] tried to self transfer . I thought [V6] was reporting it to the nurse so I never reported it We got him up off the floor without using the [mechanical lift] .
On 7/5/23 at 1:35 PM, V9 CNA said, All I remember is [V7] came and got me because [R1] wanted a male staff member to change him. I got there and they were on the floor between the bed and the wheelchair. [V6] said [R1] tried to self transfer, she caught him, and they both fell. All 3 of us (V6, V7, and V9) just lifted [R1] off the floor and into the bed.
On 7/5/23 at 2:15 PM, V3 ADON (Assistant Director of Nursing) said, The best we could find from the investigation is that his injuries were caused from an improper transfer. One CNA [V6] was alone in the room with him and when he told her he could transfer, she tried to do it. When she tried to do the transfer he fell on top of her. That is the story we were told. We know it also looked like she was trying to do a stand pivot transfer with him because the foot pedals were off the wheelchair and they wouldn't be if they were planning to do a hoyer transfer. [R1] would not be able to stand up because he has no strength in his legs. He would topple immediately. When he was found with the injuries they all denied that anything had happened but when we showed them the videos from that night they started to tell us what happened.
On 7/5/23 at 3:55 PM, V1 said, I got a call from [V8 LPN] at about 12:54 AM stating that one of the CNAs had gone into the resident's room to do some cares and noticed some scratches, bruising, and the contusion to his left eye brow. I started looking at cameras and determined [V6, V7, and V9 CNAs] had gone into [R1's] room . [V7 and V9] came in for their next shift and we spoke with them immediately in the conference room and asked them what happened. My investigation determined, [V6] was washing [R1] up to get him ready for bed and he was having some difficulty because he has difficulty with women taking care of him so he was having some issues. V6 had V7 come in to help. [R1] continued having behaviors and [V7] went down to the other hall to get [V9] because he is a male CNA. V6 stayed in the room while V7 went to go find [V9]. When V7 and V9 went back to the room they said that R1 was on top of V6 and they all helped him get into the bed. When I reviewed the video the hoyer lift was outside of the room the entire time. I asked them why they didn't use a lift even though there was one right there. They said when they looked at him he didn't have anything other than scratches on his knees. They said it all happened so fast. When I spoke with [V6] she said when [V7] left to go get [V9] [R1] 'jumped' out of the wheelchair toward the bed and when he did that she did what she was trained to do. [V6] said in the process, their feet became entangled and he fell onto her. [V6] said in the meantime she had taken his seat belt off and was washing him up. Both transfers were improper. She should have had the hoyer in there for the initial transfer and then should have used the hoyer to get him off the floor.
The facility's policy revised 3/17 titled Safe Patient Lifting Policy showed, Purpose: The safe patient lifting policy exists to ensure a safe working environment for resident handlers . Initial screening will be performed on residents to assess transfer and ambulating status . Resident transfer status will be properly communicated with care plan card, coding system or in patient list located at the nursing station. Should a resident fall to the floor, the resident will be first assessed by a nurse. If the resident is deemed medically appropriate to transfer from the floor, a full size mechanical lift will be used . Caregivers are not permitted to upgrade a resident's transferring status prior to transfer assessment being conducted by the program champion .
May 2023
4 deficiencies
2 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to recognize and treat a resident with an infected Stage 4 pressure in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to recognize and treat a resident with an infected Stage 4 pressure injury for 1 of 3 residents (R1) in the sample of 7. This failure resulted in R1 being hospitalized for a systemic infection due to an infected Stage 4 pressure injury requiring surgical debridement.
The findings include:
R1's face sheet showed a [AGE] year-old female with diagnosis of nontraumatic intracranial hemorrhage, hemiplegia and hemiparesis affecting left non-dominant side, Type 2 diabetes, anxiety disorder, epilepsy, dysphagia, left shoulder contracture, major depressive disorder, and hypertension.
On 5/23/23 at 9:14 AM, V4 wound nurse, said R1's wound declined from 5/12-5/15/23. On 5/15/23 there was thick green purulent drainage, the surrounding tissue had changed. There was no indication of an infection. Signs of infection would include a fever, increased pain, increased sleepiness. If a wound is infected, it won't heal. It could progress to sepsis and death. V4 said R1 didn't have any recent wound infections.
At 9:50 AM, V11 Licensed Practical Nurse (LPN) said on 5/17/23, V12 Certified Nursing Assistant (CNA) reported to her and V15 night nurse that R1 was not acting right. V11 said she V15 and V12 went to R1's room and found her up in her chair lethargic, didn't know who I was, and was unable to speak. V11 said she and V15 did a full body assessment and R1 was transferred into the bed without incident. R1 was cold and V11 could not obtain a blood pressure or oxygen saturation. V11 said she had to use a stethoscope over her chest to obtain a pulse. V11 said R1 was clammy, pale and was having 15-30 seconds of apnea. 911 was called and R1 was sent to the hospital.
At 9:58 AM, V12 said she is a restorative aid and on 5/17/23 was going to bring R1 to the restorative dining room for breakfast when she found her slumped over to her right side while in the chair in her room. V12 said R1 was out of it, having periods of apnea, and not recognize staff so she reported this to V11.
At 11:42 AM, V1 Administrator said R1 did not see the facility's wound care provider in April 2023 due to her payor source.
On 5/24/23 at 1:24 PM, V9 (Surgeon) said on 5/19/23 she assessed R1 in the hospital. R1 had a Stage 4 pressure ulcer to the right trochanter which measured about 4 centimeters (cm) X 4 cm. V9 said the wound had purulent drainage, was foul smelling, necrotic, and the subcutaneous tissue and muscle were involved. It was infected. It was pouring out pus. The foul odor and drainage were indicative of an infection. The worst tunnel was 2 cm to the bone. Not seeing a wound care provider for 2 months could absolutely cause a decline in the wound and infection. V9 said she sees patients with wounds every 1-2 weeks. It's unacceptable that R1 was not sent to a wound clinic if the provider could no longer see her at the facility. V9 said she took R1 to surgery on 5/19/23 to clean the wound out.
On 5/25/23 at 8:59 AM, V4 wound nurse said R1 did not see the facility wound care provider after the 3/7/23 appointment until 5/9/23.
R1's 5/23/23 and 5/24/23 hospital infectious disease notes showed R1 had sepsis due to her (infected) decubitus ulcer. This note showed an infected decubitus ulcer in the right buttock.
R1's 3/7/23 wound provider note showed a Stage 3 right buttock pressure wound measured 2 cm X 2 cm X 0.6 cm. There was light serous exudate, 75% thick adherent devitalized necrotic tissue and no change in wound progress. A follow up evaluation by the wound care specialist in 8-14 days with further intervention as indicated was recommended.
There were no further wound provider notes from the 3/7/23 visit until 5/9/23.
R1's 5/9/23 wound provider note showed the Stage 3 right buttock pressure wound measured 1.5 cm X 2.8 cm X 0.5 cm. There was moderate serous drainage, 80% thick adherent devitalized necrotic tissue and the wound had deteriorated.
R1's 5/16/23 wound provider note showed a now Stage 4 right buttock pressure wound measured 1.5 cm X 2.6 cm X 1 cm. There was an odor and undermining at 7 o'clock. There was heavy serous exudate, 100% thick adherent devitalized necrotic tissue and the wound had again deteriorated.
R1's 5/15/23 note authored by the facility nurse practitioner showed R1 continues to complain of pain in her buttocks due to wound.
R1's 5/17/23 note, authored by V11 LPN, showed R1 was unresponsive, unable to obtain a blood pressure, pulse was erratic, and could not obtain an oxygen saturation. This note showed R1 was transported to a local hospital at 6:55 AM.
R1's 5/19/23 hospital consultation note authored by V9 (Surgeon) showed she was consulted to determine if the pressure ulcer required debridement. This note showed a 4 cm X 4 cm wound over the right trochanter that was foul smelling and purulent. This note showed necrotic tissue was present and there was concern the wound was the source of her infection as other sources (knee and urine) had been ruled out.
R1's 5/19/23 operative report showed a large amount necrotic subcutaneous and muscle in the wound. There was a tunnel at the 12 o'clock position that went to the bone. A bone biopsy was obtained. The post debridement measurements were 2 cm width X 3 cm height X 1 cm depth. There was a tunnel at 12 o'clock, a 1 cm tunnel at 3 o'clock, and a 1 cm tunnel at 6 o'clock.
R1's 4/13/23 assessment showed R1 was cognitively intact.
R1's 4/14/23 facility assessment showed total dependence on two plus persons physical assistance to transfer, extensive assistance of two plus persons physical assistance for bed mobility, dressing, and toilet use, extensive assistance of one plus person physical assistance for personal hygiene and bathing, and limited assistance of one-person physical assistance for eating.
R1's pressure care plan had not been updated since 3/21/23.
The facility's 6/2014 Pressure Ulcer Prevention Program showed the facility will promote the healing of pressure ulcers that are present (including prevention of infection to the extent possible). The Wound Care Coordinator confers with the facility wound consultation firm, when appropriate, and implement recommendations. The MDS (Minimum Data Set) Coordinator updates the resident care plan whenever a change occurs in the status of the wound or when the treatment plan is altered.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to supervise a resident with difficulty swallowing at mealtime and fai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to supervise a resident with difficulty swallowing at mealtime and failed to ensure a cognitively impaired resident with knee pain and a history of self-transfers was supervised to prevent self-transfer for 2 of 3 residents (R1, R2) reviewed for safety and supervision in the sample of 7. This failure resulted in R1 choking and requiring resuscitation and R2 falling (right leg was fractured) and hitting his head.
The findings include:
1. R1's face sheet showed a [AGE] year-old female with diagnosis of dysphagia, nontraumatic intracranial hemorrhage, hemiplegia and hemiparesis affecting left non-dominant side, Type 2 diabetes, anxiety disorder, epilepsy, left shoulder contracture, major depressive disorder, and hypertension.
On [DATE] at 8:48 AM, V27 Restorative Aide said at lunch on [DATE] she was the only staff person assisting residents in the restorative dining area. Usually there are two staff, but she could do it by herself. There were 7-8 residents present. V27 said there were two tables in the restorative dining area. She was seated at a table with four residents who required feeding. R1 was seated at the other table with her back towards V27. R7 was also at R1's table with his spouse (V21) and another resident. V27 said she was alerted by V21, R7's spouse, that R1 couldn't breathe and was choking. V27 said R1 had not been eating well, needed to be supervised, and needed assistance to eat. V27 said she's not sure what R1 choked on.
At 10:32 AM, V21, R7's spouse said they're short staffed sometimes and on [DATE], there was only one staff person in the restorative dining area during lunch. The girl that was helping was at the other table. R1, me and R7 were at the other table. I'm here almost every day for lunch. R1's back was toward the girl (staff) and R1 was facing me and R7. R1 has trouble eating. V21 said she looked at R1 and she (R1) couldn't talk. Her face was white, lips were blue, eyes were open wide, startled and she mouthed to me that she couldn't breathe. I yelled at the girl in the dining area, V27, that R1 couldn't breathe.
R1's [DATE] nurses note showed R1 was found choking in the restorative dining area. There was no evidence of air exchange. R1's lips and mucous membranes were cyanotic. The Heimlich maneuver was done three times without success. R1 became pulseless and not breathing. Cardiopulmonary resuscitation (CPR) was started. R1 became conscious. R1was sent to the emergency room for further assessment due to choking with loss of consciousness, respirations and pulse.
R1's [DATE] facility assessment showed (R1) required supervision and one-person physical assistance for eating.
R1's [DATE] care plan intervention showed to monitor for signs and symptoms of choking and to serve meals in the restorative dining room for supervision and assistance.
R1's [DATE] speech therapy note showed patient required supervision at mealtime prior to onset of therapy, staff will be trained on safe swallowing strategies to provide prompts to patient during mealtimes and consistent cueing was required for mastication and oral clearance. This note showed patient had a recent choking incident that required the abdominal thrust and CPR, as patient coded.
2. R2's face sheet showed a [AGE] year-old male with diagnosis of diffuse traumatic brain injury, monoplegia affecting the left upper non-dominant side, epilepsy, schizoaffective disorder, anxiety disorder, and major depressive disorder.
On [DATE] at 2:55 PM, V30 R2's orthopedic physician assistant-certified said he was viewing the x-ray and there was no bone cancer, so the fracture was not pathological. V30 said the bone spur was on the opposite side of the knee as the fracture and had nothing to do with the injury. The bony abnormality had nothing to do with the fracture. It was an otherwise normal x-ray. The fracture was from a fall. He must have fallen at the nursing home.
On [DATE] at 8:16 AM, V25 R2's mother said R2 has no history of issues with his right leg. V25 said R2 called her and complained of right knee pain on [DATE]. V25 said she called the facility to tell them about it and they were aware.
R2's [DATE] fall risk assessment showed 1-2 falls in the past 3 months, R2 was chairbound, required use of assistive devices for gait/balance, had intermittent confusion and was at risk for falls.
R2's [DATE] at 10:10 AM provider note showed R2 complained of right knee pain, unknown injury and acetaminophen was not effective. An x-ray was ordered.
R2's [DATE] therapy note showed R2 had acute right knee pain and refused to ambulate in the restorative gym.
R2's [DATE] at 10:32 AM order showed to do a right knee x-ray due to pain.
R2's [DATE] right knee x-ray report showed the results were reported at 10:13 AM and there was a depressed fracture of the medial margin of the tibial plateau presumably acute.
R2's [DATE] 9:25 PM fall incident showed blood on the floor and a large hematoma to the left temple and resident was sent to the hospital. This report showed R2 was confused, had a gait imbalance and impaired memory, there was poor lighting and the incident occurred during a (self) transfer. (Fall occurred less than 12 hours after receiving x-ray report showing a fracture)
R2's 4//21/23 progress note authored by V30 orthopedic physician assistant showed R2 complained of right knee pain on [DATE] and fell [DATE]. This note showed a fracture to the medial aspect of the right tibial plateau and a large osteophyte (bone spur) to the lateral distal femur.
R2's [DATE] incident note showed the knee injury (fracture) occurred prior to the fall (on the evening of [DATE]).
R2's current care plan showed R2 had a history of falls. R2 fell on [DATE] with minor injury; on [DATE] R2 fell with a minor injury after a self transfer. R2 had a fall after a self transfer on [DATE] with injury. R2's care plan also showed short term memory deficits and is unable to recall any education given. R2's care plans do not show interventions to prevent self-transfers.
R2's [DATE] at 8:40 AM nurse note showed R2 was found on the floor in his room after a self-transfer.
The facility's Fall Prevention Program policy with a revision date of 3/17 showed, the facility will identify residents at risk for falls, develop care plans for residents at risk for falls, develop and implement interventions to prevent falls and investigate to determine root causes of falls and implement interventions to prevent reoccurence of falls.
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 observation, interview and record review, the facility failed to report an injury of unknown origin for 1 of 3 resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to report an injury of unknown origin for 1 of 3 residents (R1) reviewed for injuries in the sample of 7.
The findings include:
R1's face sheet showed a [AGE] year-old female with diagnosis of nontraumatic intracranial hemorrhage, hemiplegia and hemiparesis affecting left non-dominant side, Type 2 diabetes, anxiety disorder, epilepsy, dysphagia, left shoulder contracture, major depressive disorder, and hypertension.
On 5/23/23 at 2:00 PM, R1 was in her bed at a local hospital. There was a dressing to the left knee and an immobilizer to her left leg.
On 5/23/23 at 9:06 AM, V1 Administrator said he had provided this surveyor with all state agency reported incidents for the past 3 months. (These reports do not include the one for R1's fractures.)
At 10:50 AM, V2 Director of Nursing (DON) and V3 Assistant Director of Nursing (ADON) said they reviewed R1's clinical information sent by the hospital on 5/19/23.
At 10:58 AM, V5 Assistant Administrator said she looked at R1's clinical information sent by the hospital on 5/19/23. V5 said nothing else was done since she was still in the hospital.
At 11:15 AM, V1 said he was surprised about the x-ray report when he reviewed R1's hospital clinical information. I believe the x-ray report showed a femur fracture. We did not know how or where it happened. V1 said he did not report it to the Illinois Department of Public Health (IDPH). V1 said he became aware of R1's fractured left femur and fibula the morning of 5/19/23.
R1's medical record showed the scanned clinical documents from a local hospital faxed to the facility on 5/19/23 at 9:14 AM. Included with the documents was a 5/18/23 at 12:43 PM orthopedic consultation showing R1 had a left impacted fracture of the distal femur and minimally displaced fracture or the proximal fibula. R1's 5/17/23 infectious disease consultation showed left knee swelling started a few days ago. R1's 5/18/23 orthopedic consultation showed R1 was paralyzed on the left side and does not move her left leg, a large left knee effusion and an impacted fracture of the left distal femur and minimally displaced fracture of the left proximal fibula.
The facility's 3/17 Abuse Program Policy showed it's purpose was to ensure on-going safety of residents, to ensure that a thorough investigation is completed in the alleged incident, and to ensure that proper notification of appropriate regulatory agencies and regional staff occurs. Any complaint of, observation of or suspicion of resident abuse, mistreatment or neglect is to be thoroughly investigated, documented and reported. An injury of unknown origin is an injury to a resident that was not observed or the source of the injury cannot be explained. The injury is one that is suspicious in nature due to the extent or the location of the injury. This would include injuries occurring one at a time, or similar injuries involving the same resident over time, or concurrent reports of suspicious events or extraordinary circumstance. The Administrator, Director of Nursing or the designee assumes responsibility for notification of the incident and preliminary investigation findings to the following; notification to the Department of Public Health (IDPH) and other regulatory agencies per individual state reporting requirements. Written reports to the IDPH Department and other regulatory agencies summarizing the incident, investigation results and facility actions taken to protect resident(s) and prevent a similar occurrence. This report is to be completed per the guidelines of individual state reporting requirements.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to investigate injuries of unknown origins for 2 of 3 res...
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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 investigate injuries of unknown origins for 2 of 3 residents (R1, R2) reviewed for injuries in the sample of 7.
The findings include:
1. R1's face sheet showed a [AGE] year-old female with diagnosis of nontraumatic intracranial hemorrhage, hemiplegia and hemiparesis affecting left non-dominant side, dysphagia, epilepsy, Type 2 diabetes, anxiety disorder, left shoulder contracture, major depressive disorder, and hypertension.
On 5/23/23 at 2:00 PM, R1 was laying in her hospital bed. There was a gauze wrap around her left knee and an immobilizer to her left leg.
On 5/23/23 at 11:15 AM, V1 Administrator said he's known about R1's leg fractures since Friday (5/19/23).
On 5/24/23 at 11:42 AM, V1 said he was the facility abuse coordinator. V1 said an injury of unknown origin is an injury that occurs to a resident and we're unsure of the mechanism of injury. V1 said R1's injury wasn't investigated because he didn't find out about it until she was in the hospital.
R1's 5/18/23 left knee x-ray report showed a comminuted fracture/impacted fracture of the distal femur and a mildly impacted fracture of the proximal fibula.
R1's care plan showed she moves herself in an electric wheelchair for locomotion and uses a sit to stand or total mechanical lift for transfers. R1's care plan showed she required extensive assistance of 2 staff to turn and reposition in bed.
The facility's 3/17 Abuse Program Policy showed it's purpose was to ensure on-going safety of residents, to ensure that a thorough investigation is completed in the alleged incident, and to ensure that proper notification of appropriate regulatory agencies and regional staff occurs. Any complaint of, observation of or suspicioun of resident abuse, mistreatment or neglect is to be thoroughly investigated, documented and reported. An injury of unknown origin is an injury to a resident that was not observed or the source of the injury cannot be explained. The injury is one that is suspicious in nature due to the extent or the location of the injury. This would include injuries occurring one at a time, or similar injuries involving the same resident over time, or concurrent reports of suspicious events or extraordinary circumstance. An investigation shall continue as needed, to be concluded within 48-72 hours, if possible.
2. On 5/23/23 at 9:48 AM, R2 was self-propelling himself in the wheelchair using his right leg to push.
R2's face sheet showed a [AGE] year-old male with diagnosis of diffuse traumatic brain injury, monoplegia affecting the left non-dominant side, epilepsy, schizoaffective disorder, anxiety disorder, and major depressive disorder.
On 5/23/23, this surveyor requested R2's injury of unknown origin investigation. One was never received.
On 5/24/23 at 11:42 AM, V1 said I thought all the information was in the reportable sent to the office. V1 said No, I can't find anything. Injuries of unknown origin should be investigated to find out the root cause, find out what happened and try to prevent it from happening to others. At 12:21 PM, V1 said R2's injury was not investigated because I thought we answered what we needed to in the 5-day report.
On 5/25/23 at 2:55 PM, V30 R2's orthopedic physician assistant-certified said he was viewing the x-ray and there was no bone cancer, so the fracture was not pathological, and the bone spur was on the opposite side of the knee of the fracture. The bony abnormality had nothing to do with the fracture. It was an otherwise normal x-ray. The fracture was from a fall.
On 5/25/23 at 8:16 AM, V25 R2's mother said R2 has no history of issues with his right leg.
R2's 4/18/23 right knee x-ray report showed a depressed fracture of the medial margin of the tibial plateau presumably acute. This report showed the result was reported on 4/18/23 at 10:13 AM.
R2's 4/26/23 facility assessment showed he required extensive assistance of two plus persons to move in bed, transfer, and for toilet use.
R2's care plan showed he will return to a stand pivot with one assist after healing of the tibial fracture but currently required a total mechanical lift with two-person assistance. R2's care plan also showed he had impaired cognitive function or impaired thought processes related to his head injury. This care plan showed he will often forget the day of the week, conversations, and repeat himself.
Mar 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their abuse policy by not reporting an allegation of abus...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their abuse policy by not reporting an allegation of abuse for one of five residents (R2) reviewed for abuse in the sample of five.
The findings include:
R2's Minimum Data Set, dated [DATE] shows R2 is cognitively intact.
R2's Care Plan revised on 7/22/21 shows R2 has a diagnosis of cerebral palsy, cannot self propel wheelchair, and communicates solely with a dynavox (communication device), and may be at risk for abuse and neglect from peers. Social Services 1:1's as needed to discuss any concerns, or sources of frustration. Staff to inform family of any incidents that may arise, and need addressed with family/responsible party.
On 3/2/23 at 11:00 AM, R2 said V4 CNA (Certified Nursing Assistant) yells at R2. R2 said, [V4] yells at me. I don't want her to work with me. I want her fired. R2 said that she told her case worker V3 (Social Services).
On 3/2/23 at 11:54 AM, V4 said, I have never yelled at [R2] before. It may seem like it because I have a stern voice. R2 has told me that I was being mean to her. I reported it to my nurse. I don't remember who the nurse was. I finished my shift as usual and have worked with [R2] since.
On 3/2/23 at 11:25 AM, V3 Social Services said she spoke to R2. V3 said that R2 feels that R2 and V4 Aren't seeing eye to eye. V3 said, About two weeks ago, [R2] reported to me that [V4] is mean and when I asked [R2] more about it, [V4] will tell her when it's time to go to bed, not ask her when she is ready to go to bed. [R2] said that V4 cusses. V3 said the day that the allegation came up, R2 had her communication device on repeat and it was saying, [V4] is mean. V3 said she talked to R2 that day and hasn't followed up with R2 since. V3 said she has seen V4 at the facility since the allegation, and she has kind of watched [V4] from afar. V3 said she did not report the allegation to anyone else at the facility. V3 said she reported the incident to R2's mother and V3 said that R2's mother said, It's going to stop right?
On 3/2/23 at 11:37 AM, V1 Administrator said V3 should have brought the allegation to his attention. V1 said he would have started an investigation. V4 would have been suspended until the investigation was complete.
The facility's Abuse Program: Investigation/Reporting/Response revised 3/17 shows,Any complaint of, observation of, or suspicion of resident abuse, mistreatment or neglect is to be thoroughly investigated, documented and reported in a uniform manner as detailed below. Reporting: Employees are required to notify the Administrator and the Director of Nurses and staff that is on duty of any complaints of, observation of, or suspicion of resident abuse, mistreatment or neglect.
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 report an allegation of abuse for one of five residents (R2) review...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of abuse for one of five residents (R2) reviewed for abuse in the sample of five.
The findings include:
On 3/2/23 at 9:51 AM, V1 Administrator said he does not have any abuse investigations that were done in the last three months. V1 said he is the abuse coordinator. V1 said if abuse is reported to staff, then staff is to immediately notify V1.
R2's Minimum Data Set, dated [DATE] shows R2 is cognitively intact.
R2's Care Plan revised on 7/22/21 shows R2 has a diagnosis of cerebral palsy, cannot self propel wheelchair, and communicates solely with a dynavox (communication device), and may be at risk for abuse and neglect from peers. Social Services 1:1's as needed to discuss any concerns, or sources of frustration. Staff to inform family of any incidents that may arise, and need addressed with family/responsible party.
On 3/2/23 at 11:00 AM, R2 said V4 CNA (Certified Nursing Assistant) yells at R2. R2 said, [V4] yells at me. I don't want her to work with me. I want her fired. R2 said that she told her case worker V3 (Social Services).
On 3/2/23 at 11:54 AM, V4 said, I have never yelled at [R2] before. It may seem like it because I have a stern voice. R2 has told me that I was being mean to her. I reported it to my nurse. I don't remember who the nurse was. I finished my shift as usual and have worked with [R2] since.
On 3/2/23 at 11:25 AM, V3 Social Services said she spoke to R2. V3 said that R2 feels that R2 and V4 Aren't seeing eye to eye. V3 said the day that the allegation came up, R2 had her communication device on repeat and it was saying, [V4] is mean. V3 said, About two weeks ago, [R2] reported to me that [V4] is mean and when I asked [R2] more about it, [V4] will tell her it's time to go to bed, not ask her when she is ready to go to bed. [R2] said that V4 cusses. V3 said she talked to R2 that day and hasn't followed up with R2 since. V3 said she has seen V4 at the facility since the allegation, and she has kind of watched [V4] from afar. V3 said she did not report the allegation to anyone else at the facility. V3 said she reported the incident to R2's mother and R2's mother said, It's going to stop right?
On 3/2/23 at 11:37 AM, V1 Administrator said V3 should have brought the allegation to his attention. V1 said he would have started an investigation. V4 would have been suspended until the investigation was complete.
The facility's Abuse Program: Investigation/Reporting/Response revised 3/17 shows,Any complaint of, observation of, or suspicion of resident abuse, mistreatment or neglect is to be thoroughly investigated, documented and reported in a uniform manner as detailed below. Reporting: Employees are required to notify the Administrator and the Director of Nurses and staff that is on duty of any complaints of, observation of, or suspicion of resident abuse, mistreatment or neglect.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "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
- • Multiple safety concerns identified: 1 life-threatening violation(s), 4 harm violation(s), $76,343 in fines, Payment denial on record. Review inspection reports carefully.
- • 50 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $76,343 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: Trust Score of 0/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Winning Wheels's CMS Rating?
CMS assigns WINNING WHEELS an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Illinois, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Winning Wheels Staffed?
CMS rates WINNING WHEELS's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 45%, compared to the Illinois average of 46%. This relatively stable workforce can support continuity of care. RN turnover specifically is 62%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Winning Wheels?
State health inspectors documented 50 deficiencies at WINNING WHEELS during 2023 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 4 that caused actual resident harm, and 45 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Winning Wheels?
WINNING WHEELS is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 88 certified beds and approximately 74 residents (about 84% occupancy), it is a smaller facility located in PROPHETSTOWN, Illinois.
How Does Winning Wheels Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, WINNING WHEELS's overall rating (1 stars) is below the state average of 2.5, staff turnover (45%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Winning Wheels?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Winning Wheels Safe?
Based on CMS inspection data, WINNING WHEELS has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Illinois. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Winning Wheels Stick Around?
WINNING WHEELS has a staff turnover rate of 45%, 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 Winning Wheels Ever Fined?
WINNING WHEELS has been fined $76,343 across 2 penalty actions. This is above the Illinois average of $33,842. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Winning Wheels on Any Federal Watch List?
WINNING WHEELS 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.