ACCOLADE HEALTHCARE OF SAVOY
For profit - Limited Liability company
213 Beds
ACCOLADE HEALTHCARE
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
0/100
#422 of 665 in IL
Photo by Accolade Healthcare of Savoy
Photo by Sun Brothers
Photo by Sun Brothers
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Last Inspection: December 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Accolade Healthcare of Savoy has a Trust Grade of F, indicating significant concerns about the quality of care provided. The facility ranks #422 out of 665 in Illinois, placing it in the bottom half of nursing homes in the state, and #3 out of 4 in Champaign County, meaning there is only one local option performing worse. While the facility is trending towards improvement with a reduction in issues from 24 in 2024 to 15 in 2025, it still faces serious challenges, including critical incidents of resident-to-resident abuse and inadequate supervision of residents, which raise major red flags. Staffing is rated 2 out of 5 stars, which is below average, and has a turnover rate of 46%, matching the state average, suggesting potential instability among caregivers. Additionally, the facility has incurred $179,055 in fines, which is concerning, and while RN coverage is average, it is essential to note that there have been serious failures in ensuring resident safety and managing behaviors that could lead to harm.
- Trust Score
- F
- In Illinois
- #422/665
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 46% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $179,055 in fines. Lower than most Illinois facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 32 minutes of Registered Nurse (RN) attention daily — about average for Illinois. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 109 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 37%
Review needed
24 → 15 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 24 issues
2025: 15 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Illinois average (2.5)
Significant quality concerns identified by CMS
Staff Turnover: 46%
Near Illinois avg (46%)
Higher turnover may affect care consistency
Federal Fines: $179,055
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: ACCOLADE HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 109 deficiencies on record
2 life-threatening 11 actual harm
Sept 2025
6 deficiencies
2 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to monitor and report changes in condition, including monitoring and re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to monitor and report changes in condition, including monitoring and reporting blood pressures, daily weights, and urination for two of five residents (R1, R2) reviewed for changes in condition in the sample list of nine. These failures resulted in a delay in treatment for R1's changes in condition, R1 was hospitalized with congestive hyponatremia (low sodium), acute kidney injury (AKI), renal failure, urinary tract infection (UTI), and required dialysis. The facility's Physician Notification of Resident Change of Condition policy dated [DATE] documents the Director of Nursing (DON) is responsible for monitoring the 24-hour report to ensure physicians are notified of changes in condition. This policy documents when there is a change in resident condition, the nurse must assess the resident, document the change in the resident's medical record, notify the resident's physician, and place the resident on the 24-hour report to ensure close monitoring of the condition on each shift.1.) R1's hospital Discharge summary dated [DATE] documents R1 was hospitalized for cystitis with hematuria, AKI, Acute on chronic respiratory failure, Pneumonia, Myocardial Infarction, Severe Sepsis, Pulmonary Edema, elevated B-Type Natriuretic Peptide, UTI and Acute Heart Failure. R1's Blood Urea Nitrogen (BUN) was 47 and Creatinine (Cr) was 1.8 on [DATE]. R1's Minimum Data Set, dated [DATE] documents R1 as cognitively intact and required supervision/touch assistance from staff for toileting hygiene and partial/moderate staff assistance for toilet transfers. R1's Care Plan dated [DATE] documents R1 receives diuretic therapy, monitor for side effects and effectiveness, observe/document/report adverse reactions including postural hypotension, report lab results to the physician, especially Sodium and Potassium. R1's [DATE] Medication Administration Record (MAR) documents R1's daily weight (pounds) as 144.9 on [DATE], 145 on [DATE], 148.8 on [DATE], 150.2 on [DATE], 149 on [DATE] and 149.6 on [DATE]; and to notify of three-pound gain in 24 hours or five-pound gain in one week. This MAR documents R1 received the following medications: Amlodipine 10 milligrams (mg) one tablet by mouth (PO) daily 8/13-[DATE] when changed to half a tablet daily. Lasix 20 mg PO daily, Isosorbide Mononitrate Extended Release (ER) 120 mg PO daily, Lisinopril 20 mg PO daily and Metoprolol Succinate ER 50 mg twice daily [DATE]-[DATE]. R1's Physician Orders dated [DATE] document to notify if no urinary output for eight hours, and reporting parameters for systolic blood pressure less than 100.R1's Urinary Continence report dated [DATE]-[DATE] documents R1 as continent/incontinent once on [DATE], [DATE], [DATE], [DATE], and twice on [DATE], [DATE], and [DATE]. This report does not document the number of times R1 urinated or the amount. R1's blood pressure log documents R1's blood pressures as follows:[DATE] at 4:02 PM 90/43 [DATE] at 5:21 PM 90 / 42 [DATE] at 4:24 PM 79 / 29 [DATE] at 2:52 PM 95 / 47 [DATE] at 7:36 AM 89 / 34 [DATE] at 11:04 PM 91 / 35 [DATE] at 11:10 PM [DATE]/2025 at 8:34 PM 91 / 39 [DATE] at 1:25 AM 149 / 49 [DATE] at 7:31 PM 138 / 71R1's Progress Note dated [DATE], recorded by V21 Nurse Practitioner, documents to continue daily weight and will recheck Basic Metabolic Panel (BMP). There is no documentation that a BMP was collected prior to [DATE]. The Coverage On-Call Note dated [DATE] at 10:29 PM documents nurse contacted V20 Nurse Practitioner to report that R1 reports she had not urinated for two days, and R1 had been eating/drinking well with fluids encouraged. This note documents V21 ordered Urinalysis with culture and sensitivity this morning, but the nurse did not think this was completed. This note documents to straight catheterize to obtain urine sample and if greater than 300 cubic centimeter of urine return then leave the catheter inserted. R1's Progress Note dated [DATE], recorded by V21, documents R1 reported having minimal urine output for the last couple of days, R1's BUN was 76 and Cr was 6.2 on [DATE], will send R1 to the emergency room for further evaluation and treatment. R1's Nursing Notes document the following: -[DATE] at 7:36 AM R1 reported scanty urine overnight and was concerned she may be developing UTI. A request for straight catheterization and urinalysis was sent via electronic facsimile to V28 Physician. -[DATE] at 6:47 AM R1's urinalysis/culture and sensitivity order note, will collect on Sunday shift for lab to pick up Monday morning. [DATE] at 7:39 PM due to lab schedule, will collect tomorrow. [DATE] at 12:24 AM due to lab schedule, collect tomorrow.- [DATE] at 1:40 PM R1 urinated twice this shift and had removed the collection hat from the toilet, and the second time urine sample obtained by clean catch, but was contaminated with bowel movement. Urine sample to be collected and picked up on Monday. - [DATE] at 10:05 PM R1 voided in collection hat, but urine was contaminated with bowel movement. R1 also voided in the shower, but was unable to collect sample. R1 was unable to void again at this time. -[DATE] at 5:20 AM R1 had minimal urine in collection hat, missed hat. -[DATE] at 1:13 PM Unable to obtain R1's urine sample. -[DATE] at 10:17 PM R1's urine was collected via straight catheterization and placed in the fridge for lab pick up.-[DATE] at 1:21 PM V21 Nurse Practitioner reported R1 is being sent to the hospital due to critical lab results, acute kidney injury, low output, and increased confusion.R1's Care Plan Conference Note dated [DATE] document R1 and V23, R1's Family, voiced concerns regarding urine output and fluids; and V23 reported this to the floor nurse. R1's medical record does not document that R1's urine output and urine characteristics were routinely monitored every shift between [DATE] and [DATE], that R1's low blood pressures were reported prior to [DATE], or that R1's weight gain was reported to a provider. There is no documentation in R1's nursing notes that a provider was notified of unsuccessful attempts to obtain R1's clean catch urine sample or urinalysis and culture results prior to [DATE]. R1's urine culture dated [DATE] documents Candida Albicans (fungus) 70-99,000 colony forming units per milliliter (cfu/ml).R1's hospital emergency room note dated [DATE] documents R1 reports for the last couple days she has had diarrhea which started yesterday, increased back pain and concern for possible UTI with painful urination and frequency. This note documents R1 as alert and oriented to person, place and time, and R1 had coarse rhonchorous lung sounds. R1's laboratory results showed [NAME] Blood Cell 14.07 (normal 4-11), B-Type Natriuretic Peptide 1785 (normal 0-100), BUN 85 (normal 10-20), Chloride 87 (normal 98-107), Cr 6.51 (normal 0.55-1.02), and Sodium (NA) 115 (normal 136-145). R1's chest x-ray documents patchy bilateral infiltrates, which are stable and noted on prior x-ray, may be related to congestive heart failure. R1's urine culture dated [DATE] documents greater than 100,000 cfu/ml of Nakaseomyces glabrata and Candida Albicans (bacteria.) R1 was admitted to the intensive care unit (ICU) with diagnosis of hyponatremia (low sodium), acute kidney injury, hypoxia (low oxygenation), renal failure, and hypochloremia (low chloride). R1's ICU note dated [DATE] documents R1 received IV fluids, IV antibiotics, and had low urine output. R1 had AKI on CKD likely prerenal from diarrhea and volume contraction and likely the cause of hypovolemia and hyponatremia, R1's baseline Cr is around 2.25 and baseline NA is 133-139. R1's AKI on CKD is likely acute tubular necrosis (kidney damage leading to AKI or renal failure) and R1 has possible Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) (body produces too much ADH causing water retention and hyponatremia). Lasix was held due to signs of hyponatremia and may need continuous renal replacement therapy (dialysis) if diuresis remains inadequate. R1's ICU Note dated [DATE] documents R1 started dialysis and was intubated due to worsening oxygen requirement. R1's Death Summary documents R1 expired on [DATE] at the hospital after almost 10 days of intubation with worsening shortness of breath and continued dialysis through today, family opted for comfort measures. On [DATE] at 3:48 PM, V23 (R1's Family) stated R1 had pneumonia and UTI prior to readmitting to the facility, and the staff should have been monitoring R1's urination and labs. V23 stated R1 had reported back pain and lack of urination to her, which had been reported to unidentified nurses on day four, but R1 went seven days before anything was done. V23 stated by that time, R1 had developed low sodium levels and kidney problems, and was hospitalized . V23 stated R1 was placed on a ventilator and is actively dying.On [DATE] at 11:31 AM, V8 Licensed Practical Nurse (LPN) stated R1 initially admitted to the facility for about 16 hours and was sent to the hospital for a heart attack and sepsis. V8 stated R1 returned from the hospital and was sent out again due to lab work and concerns about kidney function. V8 stated it started out that we needed to get a urine sample on V8's shift and a collection hat was placed in R1's toilet. V8 stated we couldn't get the urine sample because it was contaminated with bowel movement and the second time R1's roommate had removed the hat. V8 stated R1 wanted to use the toilet rather than trying to straight catheterize her, so we let her. V8 stated R1's lab results came back before her urine results. V8 stated lab does not collect on the weekend, we have to have someone drop the sample off at the lab, and we would have straight catheterized R1 if we wouldn't have gotten the sample by Monday for the lab to pick up on Tuesday. On [DATE] at 3:08 PM, V7 Certified Nursing Assistant (CNA) stated V7 took care of R1 one time and R1 complained of back pain, which was reported to the nurse. V7 stated urine output measurements are recorded for catheters, otherwise it is charted once per shift if the resident was incontinent or continent. On [DATE] at 3:21 PM, V6 Registered Nurse stated V6 sent R1 to the hospital as ordered by V21 for critical labs and concern for kidney issues on [DATE]. V6 stated R1 urinated that day and twice on her shift on [DATE] but was unsure of the amount. V6 stated we were checking R1's urine because R1 thought she had a UTI, R1 toileted herself at times and we attempted to get a clean catch specimen in the hat, but it was contaminated with bowel movement. V6 was unsure if V6 notified the provider of unsuccessful attempts to obtain R1's urine sample. V6 stated provider notification would be documented in the nursing notes. On [DATE] at 10:09 AM, V16 Licensed Practical Nurse (LPN) stated staff tried to obtain R1's urine sample, but R1 kept having bowel movements in the collection hat. V16 stated R1's urine was being tested because R1 had complained of scanty urination, per the nursing notes. V16 stated on 8/16 or [DATE] V23 told V16 R1 had not urinated, but then V23 took R1 to the bathroom and R1 urinated, so V23 told V16 not to worry about it. V16 stated V16 encouraged R1 to drink cranberry juice and water, and refilled R1's water pitcher multiple times. V16 stated R1 drank the fluids at mealtimes too. V16 stated V16 was urinating but was unsure of the amount. V16 stated a urine sample can't' be collected too early which would cause lab to deny it on Monday's pick up. V16 confirmed V16 did not attempt to straight catheterize R1 prior to [DATE], when the sample was obtained and sent to lab. V16 stated only clean catch attempts were made since R1 was able to use the bathroom, and straight catheterization is used for residents who are incontinent. V16 confirmed R1 had low blood pressure and thought V16 reported this to the provider, which would be documented in a nursing note. On [DATE] at 11:25 AM, V2 Director of Nursing (DON) stated the providers specify if a straight catheterization or clean catch is needed, and clean catch is attempted if the resident is able to urinate on their own. V25 Assistant DON stated we have a standing order to straight catheterize if we are unable to obtain a clean catch sample within 24-48 hours. V2 stated lab only collects samples on the weekends if it is for STAT (immediate) orders, otherwise lab collects on Monday. V25 stated the nursing staff should call the on-call nurse manager to drop off a specimen on the weekends. V25 confirmed R1's urine culture was completed on [DATE]. V2 reviewed R1's daily weights and confirmed R1's weight gain noted between [DATE] and [DATE] and confirmed provider notification if greater than three pounds in one day or five pounds in a week. V2 stated strict intake, and output is only recorded if the resident has a catheter, otherwise it is documented in a progress note or as needed in the CNA tasks as incontinent/continent not the number of times or amount. V2 stated if it isn't recorded in the tasks, then that doesn't mean that the resident did not urinate. V25 provided R1's provider notes and communication notes and confirmed [DATE] was the only notification of R1's low blood pressures. At 11:58 AM, V2 confirmed there was no documentation that a provider was notified of R1's weight gain. On [DATE] at 8:45 AM, V21 stated R1's low blood pressures were reported to V21 on [DATE] and R1's Amlodipine was decreased to 5 mg and parameters given for blood pressure medications. V21 reviewed R1's recorded blood pressures and stated R1's blood pressures should have been reported sooner and V21 would have made adjustments in R1's medications sooner and added blood pressure parameters for blood pressure medications. V21 stated the facility contacted V20 Nurse Practitioner on [DATE] and confirmed the order to obtain urine via straight catheter and leave in catheter if greater than 300 ml of urine return. V21 stated V20 communicated this to V21. V21 stated V21 evaluated R1 on [DATE] and ordered BMP and CBC, which V21 scheduled for [DATE] since R1 had labs on [DATE]. V21 stated daily weights should be monitored and reported if gain of three pounds in one day or five pounds in a week. V21 reviewed R1's daily weights and confirmed R1's weight gain was not reported. V21 stated if this was reported, V21 would have ordered a one-time additional dose of Lasix based on R1's [DATE] BMP. V21 confirmed the staff should have been monitoring R1's urine output after R1's complaints on [DATE]. V21 stated staff should notify the provider if it has been eight hours without urination and staff should have straight catheterized R1 on [DATE]. V21 stated this delay in treatment could lead to complicated UTI, decreased urine output, and AKI. V21 stated if V21 was made aware of these changes in R1's condition sooner, V21 probably would have sent R1 out to the hospital sooner due to needing fluids and diuresis on top of having congestive heart failure and renal disease. V21 reviewed R1's [DATE] urine culture and stated V21 would have treated this as a UTI since R1 was symptomatic. sent her out to the hospital sooner due to needing fluids on top of having CHF. Reviewed R1's urine culture results from facility [DATE], stated she would have treated it as a UTI since she was symptomatic. V21 stated decreased blood pressure and decreased urine output along with days without reporting could have contributed to R1's [DATE] lab results, and R1 could have been sent out sooner and may not have required dialysis. V21 stated R1 was very sick and had a lot of things going on, so it is hard to say if these failures and delay in treatment caused R1's death, it may have only prolonged things if R1 had received hospital treatment sooner. On [DATE] at 10:27AM, V20 stated V20 verbally gave R1's orders listed on [DATE] to the facility nurse. V20 stated the facility does not have a nurse manager on the weekends to remove the orders from (electronic health record software) so the orders aren't followed up on until Monday. 2.) R2's Progress Note dated [DATE], recorded by V20, documents post hospital evaluation for R2 who was hospitalized 6/13-[DATE] for congestive heart failure exacerbation, sepsis, pneumonia, orthostatic hypotension; and hospitalized 7/16-[DATE] for worsening anemia. upper gastrointestinal bleed from duodenal ulcer, weakness, and shortness of breath. This note documents R1's weight is up 10-15 pounds, suspect fluid overload from hospital hydration and blood administration, if BMP is stable on [DATE] will consider increasing Lasix over several days if weight remains elevated, continue to monitor vitals and weight daily. R2's Progress Note dated [DATE], recorded by V30 Physician, documents the same findings as V20 noted above and to monitor weight and vital signs daily. R2's [DATE] Medication Administration Record (MAR) documents to obtain daily weights and report weight gain of three pounds in 24 hours or five pounds in one week, but there is no documentation this order was resumed after R2 readmitted from the hospital on [DATE]. This MAR documents to obtain vital signs every shift, but the last recorded vitals are on dayshift on [DATE].R2's weight log documents R2's readmission weight as 160.4 on [DATE] and 175.8 on [DATE]. There are no recorded weights after [DATE].R2's blood pressure log does not document R2's blood pressure was obtained after dayshift on [DATE] prior to R2's hospitalization on evening shift on [DATE]. On [DATE] at 10:00 AM, V25 Assistant Director of Nursing (ADON) confirmed R2 did not have daily weights resumed after [DATE] and no vital signs documented after dayshift on [DATE]. V25 stated V25 thought R2 was still in the hospital on [DATE] and therefor discontinued some of his orders. V25 stated we are pushing for the providers to enter their orders into the resident's electronic medical record (EMR) so that it requires the nurse to sign off and activate the orders. V2 and V25 confirmed physician and nurse practitioner progress notes are not consistently uploaded into the resident's EMR, these notes have to be pulled from (electronic health record software), which the floor nurses do not have access to. On [DATE] at 10:27 AM, V20 stated per facility policy, vital signs should be monitored at least twice daily, and staff should have been monitoring R2's vitals and daily weights. V2 stated R2 had a history of edema and shortness of breath with prior hospitalization. V20 stated the protocol for daily weight monitoring is to report a three-pound gain in one day or five-pound gain in one month.
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 use foot pedals during wheelchair transportation for tw...
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 use foot pedals during wheelchair transportation for two of four residents (R3, R4) reviewed for accidents in the sample list of nine residents. This failure resulted in R3's right leg contacting the floor causing ankle fractures. The facility also failed to supervise a cognitively impaired resident (R7) at risk for elopement, which resulted in R7 leaving the facility's property unnoticed. R7 was one of three residents reviewed for elopement in a sample list of nine. 1.) On 8/27/25 at 9:30 AM, R3 was sitting in her wheelchair in her room. R3's right leg was in a splint and elevated on the wheelchair leg rest. R3 stated that V3 Physical Therapy Assistant was pushing R3 in a wheelchair down to the therapy gym, R3's feet were sticking out and the wheelchair did not have foot pedals. R3 stated R3 had difficulty holding her legs up, R3's right foot went underneath of R3 causing R3's ankle to roll or twist and R3 screamed out in pain. R3 stated R3 has two broken ankle bones because of that incident. R3 stated R3 had right knee replacement surgery on 7/23/25, V29 (Podiatrist) applied R3's leg splint yesterday and told R3 that she could either choose to have surgery or go four to six weeks non-weight bearing without surgery. R3 stated R3 has a follow up orthopedic appointment next week to determine if there was any damage to R3's right knee. R3 stated R3 has not had any other falls or incidents that could have caused the injury. R3 stated R3 admitted to the facility for rehab and planned to return home, but now R3's recovery will take longer.
R3's Minimum Data Set, dated [DATE] documents R3 as cognitively intact and has impaired range of motion to one lower extremity. R3's Care Plan active care plan documents R3 admitted to the facility following right knee arthroplasty (knee replacement), R3 has decreased functional ability and fatigue, and requires wheelchair for long distance transportation.
R3's Incident Report dated 8/22/25 at 9:30 AM documents the following: R3 was assisted in wheelchair by staff while R3 was holding leg up with immobilizer in place. As R3 went over the threshold, R3 dropped her leg causing her foot to drop to the ground and R3 complained of pain after therapy. R3 reported that R3 thought she could make it to the therapy gym without wheelchair foot pedals, but by the time R3 made it to the threshold of the gym, R3 was too weak to hold her leg up causing her leg to drop.
R3's right ankle portable x-ray dated 8/22/25 documents acute nondisplaced medial malleolus fracture of right ankle. R3's emergency room right ankle x-ray dated 8/23/25 documents R3 has severe osteopenia (low bone mineral density), R3 had Subtle linear lucencies noted through the medial and lateral malleoli suspicious for acute nondisplaced fractures and soft tissue swelling. R3's emergency room Note dated 8/22/25 at 11:09 PM documents R3 presented for ankle pain after being pushed in a wheelchair to therapy while R3's right knee was in immobilizer and without wheelchair foot pedals. R3 reported R3 was unable to hold her right leg up, her leg dropped and her foot/ankle bent underneath the wheelchair causing significant pain, [NAME], and bruising.
R3's Progress Note dated 8/26/25, recorded by V29 Podiatrist, documents R3 was evaluated for right nondisplaced medial and lateral malleoli fractures. Treatment options were discussed and included fracture fragments are in anatomical alignment, given R3's age and limited ambulatory status related to knee replacement, conservative therapy would be an option, which would consist of four to six weeks of non-weight bearing followed by 4 weeks of weight-bearing in a boot prior to transitioning to ankle brace. Risk associated with this include continued instability of the ankle joint requiring of surgical intervention in the future and with R3's osteopenia, healing may take longer. Surgical intervention option would include fixation of the fractures to the right lower extremity, with weight-bearing pivot status approximately two weeks post-surgery, and full weight-bearing with boot for 4 weeks to transition back into an ankle brace. Associated risks include infection, pain, and need for additional surgery. R3 wanted to think about the treatment options before making a decision at this time.
On 8/27/25 at 10:14 AM, V3 stated V3 was pushing R3 in a wheelchair down to the therapy gym, R3's right leg dropped as they crossed the threshold causing R3's ankle to turn. R3's right leg was in an immobilizer and there were no foot pedals on the wheelchair. V3 stated there were foot pedals in R3's room, but V3 did not apply them prior to transporting R3 to the gym. V3 confirmed the use of foot pedals would have prevented R3's leg from dropping. V3 stated the facility did an in-service and now everyone should have footrests on when being transported in a wheelchair by staff, and if they don't have footrests on, we are to ask the resident to self-propel their wheelchair rather than transporting them.
On 8/27/25 at 2:05 PM, V2 Director or Nursing stated osteopenia is an underlying contributing factor, and V3 pushing R3 in a wheelchair without foot pedals, causing R3 to hold her legs up, caused R3's ankle fractures. V2 stated the facility does not have a policy regarding wheelchair transportation or use of foot pedals. V2 stated V2 expects foot pedals to be used whenever staff are pushing residents in a wheelchair long distances, otherwise the staff should have the resident self-propel their wheelchair.
On 9/3/25 at 8:45 AM, V21 Nurse Practitioner stated on 8/22/25 R3 had ice on her ankle when V21 evaluated R3. R3 told V21 that her foot got caught underneath the wheelchair while staff transported her to therapy. V21 stated R3 did not have any complaints of ankle pain prior and had admitted post right knee replacement. V21 stated an x-ray was ordered and confirmed R3's ankle fractures. V21 stated it depends on the angle R3's foot/ankle got caught on whether this incident caused R3's fractures. V21 stated R3's right leg is weak due to post knee replacement, and staff should have used the footrests, which could have prevented R3's injury.
2.) On 8/27/25 at 9:23 AM, V13 Certified Occupational Therapy Assistant transported R4 in a wheelchair without foot pedals, down the hallway, past the nurses' station and into R4's room which was near the end of the hall. R4's feet were approximately two inches off of the floor.
On 8/27/25 at 9:27 AM V13 stated R4 broke her clavicle from a fall prior to admitting to the facility and R4 is receiving physical and occupational therapy. V13 confirmed there were no foot pedals on R4's wheelchair and there should be. V28 stated V28 is going to have to get R4 foot pedals, and foot pedals should be used when transporting a resident in a wheelchair.
On 8/27/25 at 9:49 AM R4 was lying in bed with a sling to her right arm. R4 stated R4 had fallen prior to admitting to the facility due to low blood sugar and broke her collar bone. R4 stated R4 doesn't have foot pedals on her wheelchair and R4 has to hold her feet up during transportation. There were no foot pedals in R4's room or on R4's wheelchair at this time.
3.) The Facilities Missing residents Policy Revised on 1/23 is to provide facility staff with guidelines for ensuring the health, safety and welfare of all residents, and protocol to be followed when a resident is noted to be missing. Each Unit Charge Nurse, during their respective tour of duty will be aware and responsible for always knowing the location of their residents. Nursing must report and investigate all reports of missing residents. This policy also documents that should an employee discover that a resident is missing from the facility, he/she should: Determine if the resident is out on an authorized leave or pass, Announce a Code “green” three times consecutively. Make a thorough search of the building and premises. If the resident is not located within 15 minutes the charge nurse will report the incident to the shift supervisor who will direct additional staff to search the premises outside of the facility. The residents attending physician will be notified. This policy also documents that upon return of the resident the facility, should announce a code [NAME] is all clear, examine the resident for injuries, contact the attending physician and report what happened, take orders pertaining to the resident condition and follow through as indicated. Contact the resident's legal representative and inform him/her of the incident. Complete and file an incident report, make appropriate notations in the medical record, reflecting all facts induing specific times, time discover, time of notification, local police, administrator.
On 9/2/25 at 11:08AM, R7 was wandering around the memory care unit walking up to the doors and windows and looking outside.
On 9/2/2025 at 12:37PM, V10 Licensed Practical Nurse reenacted how R7 left the building through the door in the memory care unit. V10 stated that she had left to go to break around 8:55AM and when she returned around 9:08AM, V18 (R9's Family) had come into the facility and told V10 that V18 thought a resident was in the church parking lot. V10 stated V10 ran outside, R7 was in the church parking lot and V10 called V2 Director of Nursing to report the situation. V10 did not complete an assessment, notify the Medical Director or the Power Attorney and didn't follow the Facilities Missing Resident Policy regarding R7's elopement from the facility on 8/31/25.
On 9/2/2025 at 1:10PM, V1 Administrator stated he was unaware of the situation that had occurred with R7 as it wasn't reported to V1 and V1 just initiated an investigation into the incident. Video surveillance was viewed with V1 at this time. On 8/31/25 at between 8:55 AM and 9:07 AM R7 left the facility through the southwest alarmed door of the memory care unit walking across the parking lot and grass lot, towards a church located next to the facility. R7 was found by V18 (R9's Family) at the church, which is located approximately a football distance away from the facility door. At 9:10 AM V10 Licensed Practical Nurse was alerted by V18 and was observed going to get R7 in the parking lot of the church. V1 stated that no notification to the medical director, power of attorney, and green code was completed, as V1 is still investigating the failure.
R7's minimum data set documented on 7/1/25 documents R7 is cognitively impaired. There is no documentation in R7's medical record that R7's elopement risk was reassessed after this incident or that new interventions were developed and implemented to address R7's elopement and exit seeking behavior. The last recorded Elopement Risk Assessment in R7's medical record is dated 7/6/25 and documents R7 as low risk. R7's active care plan documents the problem area elopement/risk wandering related to Dementia was not revised after R7's elopement until 9/3/25.
On 9/2/2024 at 2:35pm, V2 Director of Nursing stated she received a call around 9:15am on 8/31/25 from V10 stating R7 had got out of the building and was next door in the church parking lot.
On 9/3/2025 at 9:10AM, V21 (Nurse Practitioner) stated that there was no communication provided to any of the Physician On Call encounters from the facility about R7's elopement. V21 stated R7 has a history of Asthma, has a shuffled gait, and is at high risk for falling. V21 stated if V21 had been notified, she would have put in an intervention for increased monitoring or one to one supervision.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on Interview, Observation and Record Review the facility failed to notify the physician and power of attorney for an incident of elopement for one (R7) of three residents reviewed for elopement ...
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Based on Interview, Observation and Record Review the facility failed to notify the physician and power of attorney for an incident of elopement for one (R7) of three residents reviewed for elopement on a sample list of nine. On 9/2/2025 at 12:37PM, V10 Licensed Practical Nurse (LPN) stated V10 did not complete an assessment, notify R7's physician or family, and didn't follow the Facilities Missing Resident Policy for R7's elopement from the facility on 8/31/25. On 9/2/2025 at 1:10PM, V1 Administrator stated he was unaware of the situation that had occurred with R7 as it wasn't reported to V1 and V1 just initiated an investigation into the incident. Video surveillance was viewed with V1 at this time. On 8/31/25 between 8:55 AM and 9:07 AM, R7 left the facility through the southwest alarmed door of the memory care unit walking across the parking lot and grass lot, towards a church located next to the facility. R7 was found by V18 (R9's Family) at the church, which is located approximately a football distance away from the facility door. At 9:10 AM, V10 Licensed Practical Nurse was alerted by V18 and was observed going to get R7 in the parking lot of the church. V1 stated that no notification to the medical director, power of attorney, and green code was completed, as V1 is still investigating the failure. On 9/2/2025 at 2:35pm, V2 (Director of Nursing), stated V2 received a call around 9:15AM on 8/31/25 from V10 stating that R7 had left of the memory care unit of the facility and was next door in the church parking lot, and V2 informed V10 to chart that R7 was exit seeking. On 9/3/2025 at 9:15AM, V21 Nurse Practitioner stated that there was no communication provided from the facility about R7's elopement. The Facilities Missing residents Policy Revised on 1/23 is to provide facility staff with guidelines for ensuring the health, safety and welfare of all residents, and protocol to be followed when a resident is noted to be missing. This policy also documents that should an employee discover that a resident is missing from the facility, he/she should: Determine if the resident is out on an authorized leave or pass, Announce a Code green three times consecutively. Make a thorough search of the building and premises. If the resident is not located within 15 minutes the charge nurse will report the incident to the shift supervisor who will direct additional staff to search the premises outside of the facility. The residents attending physician will be notified. This policy also documents that upon return of the resident the facility, should announce a code [NAME] is all clear, examine the resident for injuries, contact the attending physician and report what happened, take orders pertaining to the resident condition and follow through as indicated. Contact the resident's legal representative and inform him/her of the incident. Complete and file an incident report, make appropriate notations in the medical record, reflecting all facts induing specific times, time discover, time of notification, local police, administrator.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to transcribe physician's orders for one of four residents (R3) reviewed for accidents in the sample list of nine. On 8/27/25 at 9:30 AM, R3 wa...
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Based on interview and record review the facility failed to transcribe physician's orders for one of four residents (R3) reviewed for accidents in the sample list of nine. On 8/27/25 at 9:30 AM, R3 was sitting in her wheelchair in her room. R3's right leg was in a splint and elevated on the wheelchair leg rest. R3 stated that V3 Physical Therapy Assistant was pushing R3 in a wheelchair down to the therapy gym, R3's feet were sticking out and the wheelchair did not have foot pedals. R3 stated R3 had difficulty holding her legs up, R3's right foot went underneath of R3 causing R3's ankle to roll or twist and R3 screamed out in pain. R3 stated R3 has two broken ankle bones because of that incident. R3's right ankle x-ray dated 8/23/25 documents R3 has severe osteopenia (low bone mineral density), R3 had Subtle linear lucencies noted through the medial and lateral malleoli suspicious for acute nondisplaced fractures and soft tissue swelling. R3's emergency room Note dated 8/22/25 at 11:09 PM documents R3 presented for ankle pain after being pushed in a wheelchair to therapy while R3's right knee was in immobilizer and without wheelchair foot pedals. R3 reported R3 was unable to hold her right leg up, her leg dropped, and her foot/ankle bent underneath the wheelchair causing significant pain, swelling, and bruising. R3's Progress Note dated 8/26/25, recorded by V29 Podiatrist, documents R3 was evaluated for right nondisplaced medial and lateral malleoli fractures, treatment options were discussed, including R3's osteopenia which may delay healing. This note documents an order for Vitamin D3 2000 units daily. R3's August and September 2025 Medication Administration Records document as of 8/6/25 R3 receives Os-Cal Calcium plus D3 500 milligrams (mg) - 5 micrograms (200 units of vitamin D3) one tablet by mouth daily and PreserVision multivitamin with minerals two tablets by mouth twice daily. As of 9/3/25, the order for Vitamin D3 2000 units had not been transcribed or implemented. On 9/3/25 at 10:00 AM, V2 Director of Nursing stated the facility does not receive any communication of new orders or progress notes after R3's orthopedic/podiatry appointments. V2 stated these progress notes have to be obtained from (electronic health records software). V2 confirmed R3's order for Vitamin D3 2000 units ordered on 8/26/25 by V29. V2 stated R3 receives a multivitamin and Os-cal, which provides less than 2000 units of Vitamin D3 daily. V2 stated V2 will implement the order today.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to administer medications as ordered resulting in significant medication errors for one of five residents (R2) reviewed for changes in conditio...
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Based on interview and record review the facility failed to administer medications as ordered resulting in significant medication errors for one of five residents (R2) reviewed for changes in condition in the sample list of nine. R2's hospital discharge orders dated 7/22/24 include orders for Metoprolol Succinate (cardiac medication) Extended Release 12.5 milligrams (mg) by mouth (PO) daily, Midodrine (treats low blood pressure)10 mg PO three times daily, and Novolog insulin per blood glucose-based sliding scale three times daily before meals. R2's July 2025 Medication Administration Record documents R2's Metoprolol, Midodrine, and Novolog insulin were stopped on 7/23/25 and R2 did not receive any doses of these medications after the morning dose on 7/23/25 prior to being hospitalized on the evening of 7/24/25. There is no documentation in R2's medical record as to why these medications were stopped or that the physician was notified of the missed doses. On 9/3/25 at 10:00 AM, V25 Assistant Director of Nursing stated on 7/23/25, V25 thought R2 was still in the hospital and did a batch order discontinuing R2's medications. V25 stated later that day V25 resumed R2's orders, but with batch orders not all of the orders pop up if they are too close to the next scheduled dose, so not all of R2's medication orders were resumed. V25 confirmed R2's missed doses of Midodrine, Metoprolol and Novolog insulin between 7/23/25 and 7/24/25. V25 stated these medications would be considered significant with missed doses as medication errors, but there was no negative impact on R2.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to ensure medical records are complete and accurate for four of seven residents (R1, R2, R3, R7) reviewed for changes in condition and elopemen...
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Based on interview and record review the facility failed to ensure medical records are complete and accurate for four of seven residents (R1, R2, R3, R7) reviewed for changes in condition and elopement in the sample list of nine. The facility's Content of the Medical Record policy dated August 2017 documents the Administrator is responsible for ensuring medical records are maintained according to regulations and guidelines. This policy documents medical records should include documentation of resident care, observations, assessments and changes in condition. This policy documents physician and consultant visits should be recorded at the time of each visit.
1.) R1's 8/13/25 and 8/19/25 Provider Progress Notes with print date 9/2/25 were provided by V2 Director of Nursing (DON) on 9/2/25. These visit notes were not uploaded into R1's Electronic Medical Record (EMR).
On 9/3/25 at 10:00 AM, V2 and V25 both confirmed provider progress notes are not consistently uploaded into each resident's EMR, including R1, R2, and R3. V2 stated these notes have to be pulled off of (electronic health record system), which the floor nurses do not have access to, only the nurse managers have access.
2.) R2's 7/11/25, 7/22/25 and 7/23/25 Provider Progress Notes with print date of 9/2/25 were provided by V2 on 9/2/25. These visit notes were not uploaded into R2's EMR.
On 9/2/25 at 2:07 PM, V25 stated the providers enter notes in (electronic health record system) which the floor nurses do not have access to. V25 confirmed R2's Provider Progress Notes were obtained from (electronic health record system) and not included in R2's EMR.
3.) R3's 8/22/25 Provider Progress Note with print date 8/27/25, recorded by V21 Nurse Practitioner, documents at the time of visit R3 was sitting in a wheelchair with ice on her right ankle, and her ankle had mild swelling. This note documents R3 reported that R3's right leg was caught on the doorway causing R3 pain after this incident. V21 ordered an x-ray. This note was provided by V2 on 8/27/25 and was not uploaded into R3's EMR.
R3's Incident Report dated 8/22/25 documents R3 was in a wheelchair propelled by staff. There were no foot pedals on R3's wheelchair. R3 was holding R3's leg up, which was in an immobilizer as R3's wheelchair crossed the threshold R3's leg dropped, and foot contacted the ground. This incident is not documented in R3's EMR.
On 8/27/25 at 2:05 PM, V2 stated incidents are documented on an incident report which links to a nursing note in the resident's medical record. V2 confirmed R3's incident was not documented in R3's EMR.
4.) On 9/2/2025 at 1:10PM, V1 Administrator stated he was unaware of the situation that had occurred with R7 as it wasn't reported to V1 and V1 just initiated an investigation into the incident. Video surveillance was viewed with V1 at this time. On 8/31/25 between 8:55 AM and 9:07 AM, R7 left the facility through the southwest alarmed door of the memory care unit walking across the parking lot and grass lot, towards a church located next to the facility. R7 was found by V18 (R9's Family) at the church, which is located approximately a football distance away from the facility door. At 9:10 AM, V10 Licensed Practical Nurse was alerted by V18 and was observed going to get R7 in the parking lot of the church. V1 stated that no notification to the medical director, power of attorney, and no green code was completed, as V1 is still investigating the failure.
R7's 8/31/25 Nursing Progress notes documents R7 was exit seeking. There is no documentation in R7's medical record that R7 eloped from the facility on 8/31/25 or what steps were taken after R7's elopement and return to the facility.
On 9/2/2025 at 12:37PM, V10 confirmed V10 did not follow the facility's missing resident policy and did not document R7's elopement incident in R7's medical record.
On 9/2/2024 at 2:35pm, V2 (Director of Nursing) stated V2 received a call around 9:15AM on 8/31/25 from V10 stating R7 had left the building and was found next door in the church parking lot. V2 stated V2 told V10 to chart that R7 was exit seeking.
The Facilities Missing residents Policy Revised on 1/23 is to provide facility staff with guidelines for ensuring the health, safety and welfare of all residents, and protocol to be followed when a resident is noted to be missing. Each Unit Charge Nurse, during their respective tour of duty will be aware and responsible for always knowing the location of their residents. Nursing must report and investigate all reports of missing residents. This policy also documents that should an employee discover that a resident is missing from the facility, he/she should: Determine if the resident is out on an authorized leave or pass, Announce a Code “green” three times consecutively. Make a thorough search of the building and premises. If the resident is not located within 15 minutes the charge nurse will report the incident to the shift supervisor who will direct additional staff to search the premises outside of the facility. The residents attending physician will be notified. This policy also documents that upon return of the resident the facility, should announce a code [NAME] is all clear, examine the resident for injuries, contact the attending physician and report what happened, take orders pertaining to the resident condition and follow through as indicated. Contact the resident's legal representative and inform him/her of the incident. Complete and file an incident report, make appropriate notations in the medical record, reflecting all facts induing specific times, time discover, time of notification, local police, administrator.
Aug 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
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to protect a resident's right to privacy. This failure affects one resident (R1) of three reviewed for privacy in the sample of ...
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Based on observation, interview, and record review, the facility failed to protect a resident's right to privacy. This failure affects one resident (R1) of three reviewed for privacy in the sample of six. This past non-compliance occurred from 7/10/2025 to 7/16/2025.Findings include:R1's diagnosis list (8/7/2025) documents diagnoses including Dementia, Hemiplegia (paralysis or severe weakness on one side of the body), Cerebral Infarction (stroke), and Major Depressive Disorder. R1's Resident Assessment (6/4/2025) documents R1 has severe cognitive impairment, is immobile, and is dependent on staff for mobility and performing activities of daily living. The facility incident report (7/16/2025) documents V6 (formerly employed as a Certified Nurse Aide in the facility) had taken an unauthorized video of R1 with V6's cell phone. The report documents the video was no longer stored on V6's phone but a copy existed in V6's digital cloud storage. The report further documents access to V6's cloud storage was shared with V9 (V6's boyfriend) and V8 (mother of V9) subsequently had accessed the video via V9's phone and then reported the presence of the video to V7 (sister facility administrator) who in turn reported the concern to V1 (facility administrator).On 8/6/2025 at 3:45PM, V1 showed the surveyor the video V6 had taken of R1 which was approximately 10-12 seconds in duration, blurry, and depicted R1 fully clothed in bed with bedding covering R1's lower extremities and torso while R1 was speaking to V6. The audio accompanying the video was indecipherable. On 8/7/2025 at 2:24PM, V6 reported taking the above video of R1.The facility employee handbook (undated) documents facility employees should never photograph or record residents due to privacy rights. V6's Employee Acknowledgement form (8/6/2024) documents V6 understood and agreed to abide by the facility policies located in the employee handbook.V6's personally signed Witness Statement (7/16/2025) documents V6 took the video of R1 approximately a year prior to the incident and documents I (V6) know I should never take a video of residents at work. Prior to the survey date of 8/7/2025, the facility had taken the following actions to correct the noncompliance:1. Staff were educated about appropriate cell phone usage while in the facility.2. A supplemental special Resident Council meeting was held to discuss resident privacy rights and to educate residents to report any staff cell phone usage in resident areas. Department managers educated residents unable to attend the meeting.3. The facility Administrator, Director of Nursing, Assistant Director of Nursing, or designee will physically audit staff compliance with cell phone use in the facility four times a day for three weeks, five times a week for two weeks, and three times a week for two weeks.4. The facility Director of Nursing and Assistant Director of Nursing will maintain audit forms for the above audits and will continue to perform audits on an as-needed basis.5. The facility Quality Assurance Performance Improvement (QAPI) committee with review the above audits for patterns and trends and will continue recommendations for process monitoring and improvement.
Jul 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to report a resident fall to the licensed nurse, directly resulting in a lack notification of the residents physician and family...
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Based on observation, interview, and record review, the facility failed to report a resident fall to the licensed nurse, directly resulting in a lack notification of the residents physician and family member. This failure affects one resident (R1) out of one reviewed for notifications on the sample list of six.
This past compliance occurred from 6/20/25 and 7/1/25.
Findings include:
On 7/1/25 at 10:39 AM, V3, Family Member and legal Power of Attorney for R1, stated that the facility had not notified her of R1's most recent fall. V3 stated she had found out about R1's fall during a conversation with a friend (unidentified) who worked at the facility.
R1's comprehensive Electronic Medical Record did not document any actual recent fall event experienced by R1. R1's Nurses Notes dated 6/20/25 documented facility staff held a care plan conference for R1 attended by V3. R1's Nurses Notes dated 6/21/25 document one post fall neurological check conducted by V15, Licensed Practical Nurse. R1's Assessment record documented further neurological checks beginning with the documented one on 6/21/25 and continuing through 6/25/25, with one additional check on 6/27/25 (date of survey entrance).
On 7/1/25 at 2:40 PM, V10, Registered Nurse Manager, stated that V3 had attended the care plan conference on 6/20/25 and questioned why she (V3) had not been notified about R1's fall the day prior to the care plan conference. V10 stated she had questioned the nurse who was on duty (unidentified) at the time of the alleged fall who told V10 that there had been no reported falls from the day referenced (6/19/25). V10 further stated she had checked with the Certified Nursing Assistants (CNA) and did find that V16 CNA had found R1 on the floor and, with assistance form V17 CNA, did pick R1 up from the floor without reporting the fall to the nurse on duty. V10 confirmed there was no documentation in R1's medical record about the actual fall event, only a note in the risk management portion of R1's record (inaccessible to state survey staff). V10 stated she had then reported the incident to the Administrator (V1), and Director of Nursing (V2), who had given a written disciplinary notice to V16, and conducted an investigation into the fall experienced by R1.
On 7/1/25 at 2:50 PM, V16, Certified Nursing Assistant, stated she was delivering meal trays to resident rooms and had gone into R1's room to find R1 on the floor by the bed. V16 stated she could not locate the nurse on duty, assumed the nurse was on lunch break, and did seek assistance to pick R1 up from the floor and back into bed. V16 further stated she was busy during the resident supper time into the evening shift and by the time she saw the nurse, had forgotten about R1's fall.
During the survey period on 6/27/25 and 7/1/25 first and second shifts, there was a minimum of two licensed nurses on duty on the second floor of the facility, as well as a nurse manager.
The facility policy for Accidents and Incidents dated 11/2023 documents accidents and incidents must be reported to the department manager. Employees must report accidents and incidents to their immediate supervisor. The charge nurse must be informed of all accidents and incidents so medical attention can be provided. Employees must summon help by reporting to the nurses station that help is needed, asking someone else to report to the nurses station, or by using the resident call light.
On 7/1/25 at 3:27 PM, V1, Administrator, confirmed there is an expectation for staff to report falls to the licensed nurse. V1 stated there has to be a problem before we can identify and correct the problem. V1 then provided a notebook with a plan of correction implemented by the facility prior to the initiation of this survey.
Surveyor was able to determine that the facility initiated a plan of correction on 6/20/25 with the following corrective actions:
Assembled an Interdisciplinary Team and Quality Assurance plan of action.
The plan of action included identification of the problem, an unreported fall.
Initiated audits of all resident falls to determine of the fall was reported and documented timely.
Implemented an all staff inservice education regarding the facility policies for fall reporting and definitions of a fall.
Established a Quality Assurance monitoring system of the conducted audits.
Initiated an investigation into the fall circumstances for R1.
Assessed R1 for injury, finding none.
Monitored R1 for neurological changes, finding none.
Administered a written disciplinary warning for V16.
The facility continued with their auditing of resident falls from 6/20/25 through 7/1/25 (date of survey exit).
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility staff failed to report a resident fall to the licensed nurse, directly resulting in a lack of a licensed nurse completing a nursing ass...
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Based on observation, interview, and record review, the facility staff failed to report a resident fall to the licensed nurse, directly resulting in a lack of a licensed nurse completing a nursing assessment and a neurological assessment prior to picking the resident up from the floor. This failure affects one resident (R1) out of one reviewed for fall reporting on the sample list of six.
This past compliance occurred from 6/20/25 and 7/1/25.
Findings include:
On 7/1/25 at 2:40 PM, V10, Registered Nurse Manager, stated R1 did experience a fall on 6/19/25. V10 stated she had only found out about the fall because V3, Family Member of R1, had attended a care plan conference on 6/20/25 and made an inquiry as to why she (V3) was not notified of R1's fall the day prior to the care plan conference. V10 stated she had found that V16, Certified Nursing Assistant, had picked R1 up from the floor without notifying the licensed nurse.
On 7/1/25 at 2:50 PM, V16 stated she had gone into R1's room to deliver a meal tray and found R1 on the floor by the bed. V16 stated she could not locate the licensed nurse on duty and, assuming the nurse was on meal break, had sought the assistance of V17, Certified Nursing Assistant, to pick up R1 from the floor and back to the bed.
During the survey period on 6/27/25 and 7/1/25 first and second shifts, there was a minimum of two licensed nurses on duty on the second floor of the facility, as well as a nurse manager.
The facility policy for Accidents and Incidents, dated 11/2023, documents the charge nurse must be notified of all accidents and incidents so medical attention can be provided. Summon assistance from the nurses station or use the call light for assistance. Do not move the victim until he/ she has been examined for injuries. The charge nurse shall examine all accident or incident victims.
On 7/1/25 at 3:27 PM, V1, Administrator, confirmed there is an expectation for staff to report falls to the licensed nurse and to not pick residents up from the floor until a licensed nurse assesses the resident. V1 stated there has to be a problem before we can identify and correct the problem. V1 then provided a notebook with a plan of correction implemented by the facility prior to the initiation of this survey.
Surveyor was able to determine that the facility initiated a plan of correction on 6/20/25 with the following corrective actions:
Assembled an Interdisciplinary Team and Quality Assurance plan of action.
The plan of action included identification of the problem, an unreported fall.
Initiated audits of all resident falls to determine of the fall was reported and documented timely.
Implemented an all staff inservice education regarding the facility policies for fall reporting and definitions of a fall.
Established a Quality Assurance monitoring system of the conducted audits.
Initiated an investigation into the fall circumstances for R1.
Assessed R1 for injury, finding none.
Monitored R1 for neurological changes, finding none.
Administered a written disciplinary warning for V16.
The facility continued with their auditing of resident falls from 6/20/25 through 7/1/25 (date of survey exit).
May 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect a resident right to be free from verbal abuse (R3) by anoth...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect a resident right to be free from verbal abuse (R3) by another resident (R2) and failed to protect a resident right to be from physical abuse (R3) by another resident (R2).
R2's Facility Census documents R2 was admitted to the facility on [DATE] and has the following medical diagnosis; Spastic Quadriplegic Cerebral Palsy, Seizures, Quadriplegia, Obstructive Sleep Apnea, Anxiety Disorder, Hyperlipidemia, Deficiency of Specified B Group Vitamins, Schizophrenia, Esophagitis without Bleeding, GERD, Insomnia, Functional Quadriplegia, HTN, Depression, Retention of Urine and Personal History of Malignant Neoplasm of Testis.
R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview for Mental Status (BIMS) score 6, severe cognitive impairment and is dependent on staff's assistance with Activities of Daily Living.
R2's Care Plan dated 6/21/23 documents R2 potential for abuse and neglect due to current cognition, medical condition and physical function. Interventions/ monitor R2 whereabouts, monitor for changes in behavior, notify Medical Doctor and family for any changes in condition, encourage R2 to verbalize any incidents of abuse and neglect and staff to monitor and intervene with any potential or actual acts of abuse and neglect.
R2's Incident Note dated 4/23/25 at 4:12 pm documents assessment completed due to R2 to R3 altercation, no redness/bruising noted to right side of face/head. R2 denies any pain/discomfort at this time. 15-minute checks continue at this time.
R3's Facility Census documents R3 was admitted to the facility on [DATE] and has the following medical diagnosis; Parkinson's Disease with Dyskinesia, Hemiplegia and Hemiparesis following Cerebral Infraction Affecting Right Dominant Side, Symptoms and Signs Involving Cognitive Functions Following Cerebral Infarction, COPD, Atrial Fibrillation, Shortness of Breath, Long Term Use of Anticoagulants, Chronic Kidney Disease Stage 2, Adult Failure to Thrive, Insomnia, Benign Prostatic Hyperplasia, Anemia, HTN, Paroxysmal Atrial Fibrillation, Rheumatoid Arthritis, Hyperlipidemia, and Chronic Diastolic Heart Failure.
R3's Minimum Data Set (MDS) dated [DATE] documents R3's Brief Interview for Mental Status (BIMS) score 14, cognitively intact and is dependent on staff's assistance with Activities of Daily Living.
R3's Incident Note dated 4/23/25 at 4:15 pm assessment completed, and no redness/bruising/injuries noted to right hand due to R3 to R2 altercation. R3 denies pain/discomfort at this time. 15-minute checks continue at this time.
Facilities Abuse Prevention Policy Program dated February 2025 documents: Purpose: This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. This facility will not knowingly employ individuals who have been convicted of abusing, neglecting, or mistreating individuals. Policy: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment.
V7's Licensed Practical Nurse witness statement dated 4/23/25 at 5:00 pm documents V7 was standing at the nurse cart near the nurse's station, when V7 heard R2 yelling. V7 went to the room and just as V7 entered the door, V7 watched R3 quickly wheel up to R2 chair from behind and smack R2 on the right side of the head, open palm. V5 R3's Daughter/Power of Attorney was sitting with V5's hands folded on the side of R3's bed. As V7 pulled R3's chair back to separate them, V5 told V7 that R2 was saying the N-Word. V7 brought R2 to the TV room, which was vacant. There was no more yelling after that.
On 5/22/25 at 1:15 pm R3 said, R2 was R3's roommate until last month. R3 said, R2 was yelling out last month while V5 R3's Daughter/POA was visiting. R3 said, R2 yelled out the N-word (slur) and R3 wheeled over to R2 and hit R3 in the head with R3's hand.
On 5/22/25 at 1:47 pm V7 Licensed Practical Note said, on 4/23/25 at 2:52 pm V7 was standing at the nurse's medication cart near the nurse's station. V7 said, V7 heard R2 yelling and went to R2 and R3's room. V7 said, as V7 entered into R2's and R3's room, V7 observed R3 quickly wheel up to R2's wheelchair from behind and smack R2 on the right side of the head with an open palm. V7 said, V5 R3's Daughter/Power of Attorney was sitting with her hands folded on the side of R3's bed. V7 said, while V7 was separating R3 and R2, V5 told V7 that R2 was saying the N-word (derogatory).
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 injury of an unknown origin to the state survey agency for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an injury of an unknown origin to the state survey agency for one (R6) of three residents reviewed for injuries in the sample list of 8.
Findings include:
Facilities Accidents and Incidents Policy dated November 2023 documents. Purpose: To provide staff with guidelines for investigating, reporting, and recording Accidents and Incidents. Policy: All accidents/incidents involving a resident, visitor or volunteer will be investigated, and then recorded in Risk Management of Electronic Health Record. Incident reports will be retained in accordance with State statue of limitations and record retention laws. Procedure: 1. Reporting an Accident and Incident: A. Accident and incidents, including injuries of an unknown origin, must be reported to the department supervisor, and an Accident/Incident Report Form must be completed on the shift the accident/incident occurred. 4. Investigate and follow/up Action: A. The charge nurse must conduct an immediate investigation of the accident/incident and implement immediate appropriate interventions to affected parties. H. The Director of Nursing/Designee will report and accident/incident of major injury to IDPH within 24 hours.
R6's Facility Census documents R6 was admitted to the facility on [DATE] and has the following medical diagnosis; Atrial Fibrillation, Severe Protein-Calorie Malnutrition, Major Depressive Disorder, Dementia, Hyperlipidemia, Anemia, Depression, Osteoarthritis, Gastro-Esophageal Reflux Disease, Essential Hypertension and Personal History of Transient Ischemic Attack (TIA), and Infarction without Residual Deficits.
R6's Minimum Data Set (MDS) dated [DATE] documents R6's Brief Interview for Mental Status (BIMS) score 6, severe cognitive impairment and is partial/moderate assistance with Activities of Daily Living.
R6 Nursing Note dated 4/16/25 at 9:00 am documents R6 observed with significant discoloration at Right Upper Extremity (RUE); area of concern has been measured (11 centimeters x 7 centimeters) and reported to clinical management; awaiting response from Power of Attorney and assigned APRN. R6 denies pain, discomfort or acknowledgement on how area may have developed. V14 Licensed Practical Nurse observed R6's arms equal in alignment to arm rests on wheelchair. R6 received protective sleeves and personal sweater per request. The integrity of arm rests seem within normal limits -no ripping or increased concern for skin shearing. Will continue to monitor.
R6's Weekly Skin assessment dated [DATE] documents Right Upper Extremity (RUE) 11.0 centimeters x 7.0 centimeters discoloration. No raised areas or opening skin. Skin intact.
R6's Weekly Skin assessment dated [DATE] documents no skin issues.
On 5/22/25 at 1:20pm V14 stated on 4/16/24 at 9:00 am V14 reported R6's bruise to V1 Administrator and V2 Director of Nursing (DON). V14 stated the bruise was noted to R6's Right Upper Extremity (RUE). V14 stated chart the measurements in R6's chart.
On 5/22/25 at 1:58 pm, V16 Assistant Director of Nursing (ADON) stated they (facility) assumed R6's injury was based on history of bruising, taking an anticoagulant, and what the nurse (V14) noted in the report. V16 stated they did not consider the bruise to R6's right upper extremity to be an injury of unknown origin and did not report it to Illinois Department of Public Health.
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
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 implement Enhanced Barrier Precautions (EBP) for one (...
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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 implement Enhanced Barrier Precautions (EBP) for one (R1) of three residents reviewed for pressure ulcers in the sample list of four.
Findings include:
The facility's Enhanced Barrier Precautions policy dated 10/21/22 documents EBP expands the use of gloves and gowns to be worn during high-contact care activities that provides opportunities for Multidrug Resistant Organisms (MDROs) to be transferred between staff hands or clothing and between residents during these high-contact cares. This policy documents residents with wounds and indwelling medical devices are at high risk of acquisition and colonization of MDROs. This policy documents to wear gown and gloves when assisting residents on EBP with high-contact care activities, including dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, providing device care or wound care.
R1's readmission Skin assessment dated [DATE] documents R1 has a stage three pressure injury to R1's left Achilles area and a stage four pressure injury to R1's left Ischial area.
R1's care plan dated 1/11/2025 documents staff will always maintain Enhanced Barrier Precautions (EBP) during high-contact resident care areas.
R1's order summary report dated 4/17/2025 documents an order for EBP when providing cares involving R1's urinary catheter and wounds.
On 5/7/25 at 1:20 PM, R1's doorway contained an EBP sign that indicated to wear gown and gloves during the high-contact care activities listed which included wound care.
On 5/7/25 at 1:25 PM, V4 Registered Nurse and V5 Licensed Practical Nurse entered R1's room and completed wound care for R1's left ischial wound and R1's left Achilles wound. V4 and V5 did not don gowns to complete the treatments.
On 5/7/25 at 1:40 PM, V5 Licensed Practical Nurse stated the EBP sign and supplies on R1's room door are for use when providing cares to R1's roommate not for R1.
On 5/7/25 at 1:40 PM, V4 Registered Nurse agreed with V5 and stated she never puts on a gown when performing R1's wound treatments because the EBP sign and the supplies are for the other resident in that room.
On 5/7/25 at 1:45 PM, V2 Director of Nursing confirmed that R1 was on EBP for pressure ulcers and that V4 and V5 should have worn a gown and gloves when performing R1's wound treatment.
Apr 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to timely report post fall pain and implement radiology orders timely, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to timely report post fall pain and implement radiology orders timely, resulting in a delay in treatment of a left hip fracture for one (R4) of three residents reviewed for falls in the sample list of eight.
Findings include:
The facility's Acute Condition Changes - Clinical Protocol dated June 2023 documents the nurse should assess, document and report changes in pain level. Nursing staff will contact the physician based on the urgency of the situation and the physician will be paged/called requesting prompt response, approximately one half hour or less, for emergencies. This policy documents the nursing staff and the physician will discuss possible causes including resident history and symptoms, and the physician will order diagnostic testing or directly evaluate the resident if necessary. This policy documents the physician will review the status of the condition change and document the evaluation, including the significance of the acute change, at the next visit.
R4's admission Minimum Data Set, dated [DATE] documents R4 is cognitively intact and R4 had no pain during the review period.
R4's Nursing Note dated 4/1/2025 at 6:05 AM documents at 2:35 AM R4 was heard yelling out and R4 was found on the floor near the doorway of his room. R4 reported R4 was trying to go to the bathroom, got weak and fell to the floor. R4 had a bruise and abrasion to the left knee, bruise to left arm, and denied pain. R4 had upper and lower extremity range of motion. The on-call physician, V27, was notified.
R4's Physical Therapy (PT) Encounter Note dated 4/2/25 at 12:06 PM, recorded by V28 PT Assistant, documents R4 was only able to tolerate sitting on the edge of the bed for two minutes due to increased left lower extremity pain from recent fall. R4 refused to stand or transfer into the wheelchair and tolerated the session poorly secondary to increased left lower extremity pain.
R4's Occupational Therapy (OT) Encounter Note dated 4/1/25 at 2:46 PM, recorded by V13 Certified OT Assistant (COTA), documents R4 complained of hip pain related to a fall this morning and was waiting on an x-ray. V13 spoke with the nurse who reported R4 fell at 2:30 AM and there were no x-ray orders since R4 had not complained of pain. R4 was encouraged to try and sit on the edge of the bed, but refused. R4's therapy participation was limited due to lack of motivation and recent fall. R4's OT Encounter Note dated 4/2/25 at 2:44 PM, recorded by V13, documents R4 continues to complain of hip pain from fall. R4 reported not taking pain medications since no one had asked. V13 spoke with the nurse about pain medications and getting an x-ray since R4 refused to get out of bed until x-ray obtained.
R4's Progress Note dated 4/1/25 at 6:21 PM, recorded by V17 Physician, documents R4 was evaluated for hospital follow up. This note does not document follow up evaluation for R4's fall that morning. There is no documentation that R4's hip pain was reported to a physician prior to 4/2/25. R4's Nursing Note dated 4/2/2025 at 1:15 PM documents R4 complained of left hip pain following recent fall, R4 is requesting an x-ray, and an x-ray was ordered. R4's Nursing Note dated 4/3/2025 at 11:00 AM documents technician performed left hip x-ray.
R4's Progress Note dated 4/3/25, recorded by V16 Nurse Practitioner, documents R4 fell on 4/1/25 and initially was without pain. R4 reported left hip pain rated 8 on a 1-10 scale and R4 had not been participating in therapy due to pain. R4 had limited left lower extremity range of motion. V16 ordered a STAT (immediate/urgent) portable x-ray of left hip and nonweight bearing status of left lower extremity until cleared by x-ray.
R4's left hip x-ray dated 4/3/25 at 11:31 AM documents acute nondisplaced left femoral intertrochanteric fracture. R4's Hospital Procedure Note dated 4/4/25 documents R4 required surgical repair of left hip fracture.
On 4/17/25 at 12:12 PM R4 stated R4 fell while walking to the bathroom by himself, R4 broke his left femur and had to have surgery.
On 4/21/25 at 10:12 AM V19 Licensed Practical Nurse stated R4 fell on night shift around 2:00 AM and the next day R4 complained of left hip pain to V13 COTA during therapy. V19 stated V19 obtained an order for an x-ray and entered it as STAT, but the x-ray company did not come until the next day around 11:00 AM. V19 stated V19 received R4's x-ray results around 12:30 PM, which indicated a fracture, V19 notified V16, and R4 was transferred to the hospital. R4's x-ray order dated 4/2/25 was reviewed with V19 and confirmed entered as STAT.
On 4/21/25 at 10:57 AM V13 COTA stated R4 was in bed during R4's therapy session on 4/1/25 and only limited therapy was provided since R4 complained of hip pain because of his fall. V13 stated V13 reported R4's pain to the nurse, V19, that day.
On 4/21/25 at 12:53 PM V16 Nurse Practitioner stated 4/3/25 was the first day V16 was notified of R4's left hip pain. V16 stated R4 had a fall a few days prior. V16 stated R4 had a lot of pain during V16's assessment so V16 ordered a STAT x-ray. V16 stated STAT should be done within four hours and V16 told the staff that R4 would need to go to the hospital if the x-ray was not obtained within four hours. V16 stated the staff should report post fall pain to the provider so that an x-ray can be ordered. V16 stated V16 would have ordered a STAT x-ray sooner if she was notified. V16 stated a delay in treatment of a hip fracture could cause nerve issues or if delayed a week or more there would be concerns with healing. V16 stated R4 missed therapy sessions due to pain.
On 4/21/25 at 1:46 PM V20 Registered Nurse stated R4 was found on the floor of his room and initially did not have any complaints of pain. V20 stated R4's fall on 4/1/25 was reported to the on-call physician, V27. V20 stated V20 worked a double shift, evenings/nights on 4/2/25 and R4 did not have any complaints of pain. V20 stated it was passed on in shift report that R4 had complained of pain during therapy and an x-ray was ordered. V20 stated V20 did not contact the x-ray company to inquire about an estimated time of arrival.
On 4/21/25 at 2:28 PM V17 Physician stated V17 was not aware of R4's fall when V17 evaluated R4 on 4/1/25. V17 stated V17 would have asked R4 about his pain, which would have been really important. V17 stated protocol should be followed, the provider should be notified of a fall and then notified of pain post fall. V17 stated the therapist should report pain to the nurse and the nurse should notify the physician or Nurse Practitioner. V17 stated when V17 evaluated R4 on 4/1/25, R4 was comfortable, did not appear to be in any pain, and did not voice any complaints. V17 stated V17 cannot say whether V17 would have ordered an x-ray on 4/1/25 if she had been notified of R4's fall and post fall pain, but V17 would have asked R4 to move his legs during R4's exam.
Feb 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide bathing, oral care, and toileting for three (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 provide bathing, oral care, and toileting for three (R1, R2, and R4) of four residents reviewed for dependent activities of daily living from a total sample list of four.
Findings include:
The facility provided Activities of Daily Living Policy dated 7/2024 documents that all residents will have activities of daily living (bathing, oral care, perineal care) provided by nursing staff as needed in accordance with each individual's needs and that it is the responsibility of both the Certified Nursing Assistants and Charge Nurse to ensure that the care is being provided and documented in the electronic health record.
1.) R1's Minimum Data Set, dated [DATE] documents R1 is severely cognitively impaired.
R1's Minimum Data Set, dated [DATE] documents R1 is totally dependent for bathing, dressing, toileting and oral care.
R1's local hospital admission record dated 2/4/25 documents that R1 was admitted to the local hospital with thick hardened oral secretions to the base of tongue and upper palate.
R1's medical record documents a bath on 1/27/25 and another on 2/10/25.
On 2/10/25 at 12:30PM, R1 was laying in bed with eyes closed and mouth open. R1 appears disheveled with the odor of urine noted and teeth have a white film on them along with R1's tongue.
On 2/11/25 at 9:30AM, R1 had an old appearing, wrinkled, undated dressing to her coccyx. Additionally, R1 had bilateral wound dressings of the same kind on her heels covering from the mid foot to mid-calf that appear worn and old.
On 2/11/24 at 9:55AM, V7 C.N.A. stated that before R1 went to the hospital on 2/4/25, she found a wad of brown gunk in R1's mouth and that she reported to V8 Licensed Practical Nurse and was told that R1's gums bleed and that it was probably blood, but V7 was not sure how it was handled after that.
On 2/10/25 at 12:45AM, R1's roommate R2, who is cognitively intact stated that R1 had not been bathed or had her teeth brushed for weeks. R2 stated, (R1) was in a dirty dress for weeks before she went to the hospital, but she can tell them.
On 2/11/25 at 4:30PM, V2 Director of Nursing stated that she did not believe that R1 had received a bath since readmission from the hospital on 2/8/25 because the dressings would have been addressed if they had gotten a bath. Additionally, V2 DON stated that she was told by the hospital that R1's oral care was so poor when she arrived at the Emergency Room, it took a hospital staff member 45 minutes to get R1's mouth properly cleaned. V2 stated that she expected oral care to be provided daily and baths to be given at least weekly.
2.) R2's Minimum Data Set, dated [DATE] documents that R2 is cognitively intact.
R2's Minimum Data Set, dated [DATE] documents that R2 requires partial assistance with oral care.
On 2/10/25 at 1:00PM, R2's teeth were observed to have food in them and appeared spiky and broken.
On 2/10/25 at 1:01PM R2 stated that she would like to brush her teeth, but that she doesn't have a toothbrush or toothpaste.
On 2/10/25 at 1:30PM, V2 Director of Nursing stated that it is her expectation that oral care is provided daily for residents who need assistance.
R2's medical record does not document oral care assistance for R2.
3.) R4's Minimum Data Set, dated [DATE] documents that R4 is dependent for toileting.
The facility provided grievance dated 1/29/25 documents that R4 complained to therapy services that he was saturated in urine, through his brief and gown to his upper back and was left in that condition.
The facility response to this grievance dated 1/29/25 was to have staff check to see if R4 is wet, physically.
R4's medical record dated 2/11/25 does not document toileting on the 6:00AM-2:00PM shift.
On 2/11/25 at 2:55PM observed R4 receive pericare with V11 and V12 Certified Nursing Assistant (CNA). R4's brief was saturated with dark urine and R4 had old, sticky, partially dried feces between his buttocks. V12 CNA stated that based on the amount of urine and state of feces, R4 could not have been changed on the previous shift. V11 CNA stated that given the bed pad was saturated and the urine was cold, she agreed that R4 had not been changed for many hours and that the second floor of the building was out of wipes and wash cloths.
On 2/11/24 at 3:00PM, R4 stated that he had not had his brief changed all day.
On 2/11/25 at 3:00PM, V2 Director of Nursing stated that her expectation was for incontinent residents to be checked and changed every two hours as needed and that R4's care today was not acceptable.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to identify, assess, make the appropriate notifications, obtain treatments and interventions for three pressure wounds for one (R1...
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Based on observation, interview and record review the facility failed to identify, assess, make the appropriate notifications, obtain treatments and interventions for three pressure wounds for one (R1) of four residents reviewed for pressure wounds from a total sample list of four residents.
Findings include:
The facility provided Skin and Wound Management Guidelines Policy dated 4/2024 documents that upon admission or readmission a complete skin assessment is to be done and documented. If a wound is present on admission, ensure that there is a treatment order, notify the resident's representative, and initiate care plan interventions.
The facility provided wound report dated 2/10/25 documents that R1's only wound is a wound on her right middle finger that was identified on 1/30/25.
R1's progress notes dated 2/4/25 document that R1 was transferred to the local hospital for a change of condition including decrease consciousness and tachypnea.
R1's hospital admission notes dated 2/4/25 document's R1 has stage one to two changes at the coccyx and a stage one pressure ulcer injury to bilateral heels.
R1's hospital notes dated 2/6/24 document a pressure ulcer present on right medial coccyx (stage two), right medial gluteal pressure injury (stage two), and a right heel pressure injury (deep tissue). All covered with appropriate dressings.
R1's progress notes document return to the facility from the local hospital on 2/8/25.
On 2/11/25 at 9:56AM, V8 Licensed Practical Nurse stated that R1 has no wounds at present.
On 2/11/25 at 9:30AM observed R1's pericare, performed by V6 and V7 Certified Nursing Assistants (CNA). A large old looking, wrinkled, undated wound dressing was covering R1's coccyx. Underneath the dressing were two, stage two openings approximately the size a of dime and nickel on R1's coccyx and right buttock. Both V6 and V7 CNAs stated that they were unaware of R1 having any opening on her coccyx or buttocks, but had not seen her bare skin in those areas since before she went to the hospital.
On 2/11/25 at 9:55AM, V7 C.N.A. stated that she did not know when the wounds occurred or what interventions were being put into place for R1's heels.
On 2/11/25 at 10:20AM, V5 Nurse Manager removed the bilateral dressings from R1's feet/ankles. A quarter sized fuchsia colored deep tissue injury was noted on R1's right heel. V5 stated that it was boggy to the touch and that this dressing must have been left over from the hospital. V5 confirmed that there were two stage two wounds on R1's buttocks, and one deep tissue injury on R1's right heel. Additionally, V5 confirmed that there were no interventions put in place for the right heel, no orders for treatments for any of the wounds, nor was the treatment nurse, physician or family notified.
On 2/11/25 at 6:51PM, V10 Licensed Practical Nurse who readmitted R1 from the hospital on 2/6/25 stated that she did not do a full and complete skin check upon R1's return from the hospital and that she was unaware of any wounds on R1's bottom or heels.
On 2/11/25 at 10:40AM, V9 Wound Nurse stated that she was not made aware of R1 having any wounds on her bottom or feet and that staff are expected to do full and complete skin assessments upon return from the hospital including looking under dressings.
Dec 2024
2 deficiencies
2 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R89's Facility Census dated 12/5/24 documents R89 has the following medical diagnoses: Acute on Chronic Systolic (Congestive)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R89's Facility Census dated 12/5/24 documents R89 has the following medical diagnoses: Acute on Chronic Systolic (Congestive) Heart Failure, Ischemic, Cardiomyopathy, Chronic Systolic (Congestive) Heart Failure and Pleural Effusion.
R89's Care Plan dated 11/17/23 documents R89 has the potential for fluid volume overload relayed to Congestive Heart Failure. Interventions: Weigh each morning before breakfast. Contact provider if gain of more than 3 pounds in 24 hours or 5 pounds in 1 week.
R89's Physician Order Sheet (POS) dated 9/20/24 documents daily weight-Notify Medical Doctor if weight gain of more than 3 pounds in 24 hours or 5 pounds in 1 week, in the morning related to Chronic Systolic (Congestive) Heart Failure.
R89's Minimum Data Set (MDS) dated [DATE] documents R89 had a 5% or more weight loss in the last month or a 10% or more weight loss in last 6 months and a 5% or more weight gain in the last month or a 10% or more weight gain in last 6 months.
R89's Weight Summary documents from 9/20/24 to 10/5/24 R89 missing 53 daily weights.
3. R96's Facilities Census dated 12/5/24 documents R96 has the following medical diagnoses: Dependence on Renal Dialysis, End Stage Renal Disease and Congestive Heart Failure.
R96's Care plan dated 8/17/21 documents R96 is nutritionally at risk due to diagnosis of Diabetes Mellitus and Hypertension related to dialysis. R96 has potential for weight fluctuations due to dialysis. Interventions: R96 will be weighed as facility directed policy and notify dialysis of weight gain.
R96's Physician Order Sheet (POS) dated 11/21/24 documents obtain daily weights, notify Medical Doctor if weight gain of more than 2 pounds per day or 5 pounds in one week, in the morning every Tuesday, Thursday, Saturday and Sunday for Congestive Heart Failure.
R96's Minimum Data Set (MDS) dated [DATE] documents R96 had a 5% or more weight loss in the last month or a 10% or more weight loss in last 6 months and a 5% or more weight gain in the last month or a 10% or more weight gain in last 6 months.
R96's Weight Summary documents from 11/21/24 to 12/5/24 R96 missing 9 weights.
On 12/4/24 at 10:15am R96 stated that the facility doesn't weigh R96 daily, they do it every so often.
On 12/5/24 at 10:30am V1 Administrator stated that the facility is not weighing the residents per physician orders as they should be. V1 said the facility is going to address this issue with staff. V1 acknowledged that R89 and R96's were not getting weighed per physicians orders.
Based on interview and record review, the facility failed to obtain weights per physician orders for two residents (R89, R96) and failed to adequately monitor an at risk resident for weight loss, failed to obtain weekly weights, failed to notify the resident's representative of weight loss, and failed to develop a plan of care to address severe weight loss for one resident (R154). These failures affected three of ten residents (R89, R96, R154) reviewed for nutrition on the sample list of 82. These failures resulted in continued severe weight loss for R154.
Findings Include:
The facility's Weight policy dated March 2023 documents weekly weights will be done with a significant change of condition, food intake declines for more than one week, or with a physician order. Any resident with an unexplained significant weight loss will be ordered a supplement until discussed during weekly RISK meeting. The family or Power of Attorney will be notified of significant weight changes and plan of care which will be documented in the resident's chart. The Director of Nurses (DON) or designee will forward dietary recommendations to the Physician or Nurse Practitioner for approval.
1. R154's Medical Diagnoses list dated December 2024 documents R154 is diagnosed with Dysphagia, Vascular Dementia with Psychotic Disturbance, Major Depressive Disorder, Alzheimer's Disease, and Anxiety Disorder.
R154's Minimum Data Set, dated [DATE] documents R154 is severely cognitively impaired and requires supervision or touching assistance of one staff member for eating. R154 has had a significant weight loss and is not on a physician-prescribed weight loss regimen.
R154's Weight documentation from June 2024 to December 2024 documents R154 had a -22.80% severe weight loss from June (210.5 pounds) to December (162.5 pounds) and a -5.52% severe weight loss from 11/13/24 (172.8 pounds) to 12/6/24 (162.5 pounds). R154's monthly weights are documented as 6/27/24- 210.5 pounds, 7/11/24- 200 pounds, 8/2/24- 193.4 pounds, 9/4/24- 188 pounds, 10/24/24- 188.3 pounds, 11/13/24- 172.8 pounds, 12/6/24- 162.5 pounds.
R154's Physician Order Sheet (POS) dated December 2024 documents that R154 is on a regular diet with pureed texture and honey-thick consistency liquids with a bedtime snack. There is no order for any nutritional supplements or increased weekly weight monitoring for R154. On 12/6/24, after R154's severe weight loss was discussed with V2 Director of Nurses, V13 Regional Registered Nurse, and V7 Registered Dietician, orders were added to R154's POS for weekly weights, blood draw for Albumin, fortified foods with meals -nutritionally fortified cereal at breakfast- and pudding cups three times per day.
R154's Nutrition/Dietary Note dated 11/13/2024 (V7 Registered Dietician) documents a November weight of 172.8 pounds, which is down 8% in two weeks, 10% in three months, and 18% in six months. R154's diet was recently changed to puree/honey-thick liquids, but intakes still need to be better-fair per food logs. Recommendations include high-protein ice cream twice per day for extra calories and protein and weekly weights for four weeks or until weight is stable.
R154's current Care Plan does not address severe weight loss or provide any plan or interventions to address R154's continued weight loss.
On 12/06/24 at 11:11 AM, V19, the Certified Dietary Manager, confirmed that although the order for the high-protein ice cream was not entered into R154's POS, it was on her dietary card and provided for R154 at breakfast and lunch. V19 stated he does not enter the orders; that would be the nursing's job. V19 stated there are standing orders from each resident's physician for any Dietician (V7) recommendations to be followed.
On 12/06/24 at 11:18 AM, V23 Licensed Practical Nurse confirmed she works with R154 regularly. V23 confirmed that staff obtain monthly weights for residents unless there is an order for weekly or daily weights to be done. Certified Nurses Assistant CNAs complete the weights and give their sheets to the nurses. Nurses enter the weights into the electronic medical record. V23 stated she does not verbally notify anyone about weight loss, she believes the electronic medical record system flags residents for weight loss and notifies the dietary department. V23 confirmed there was no order in the electronic medical record system for R154 to be weighed weekly.
On 12/06/24 at 11:19 AM V21 Certified Nurses Assistant confirmed she just obtained R154's December weight today at 162.5 pounds. V21 stated R154 is not on weekly weights. R154 requires assistance with meals and her intakes are variable.
On 12/06/24 at 11:37 AM V13 Regional Registered Nurse confirmed the high protein ice cream and weekly weight recommendation from V7 Registered Dietician should have been entered on R154's chart as an order and weights should have been completed weekly. V13 confirmed further weight loss could have been identified sooner and potential changes could have taken place such as adding further interventions or changing the timing of supplements. V13 stated she believes R154 is having unavoidable weight loss due to her deteriorating medical condition. V13 confirmed unavoidable weight loss has not been determined or documented on until today (12/6/24).
On 12/06/24 at 12:08 PM V13 Regional Registered Nurse confirmed the weekly weights should have been completed and if further weight loss continued then V7 Registered Dietician should have been notified and could have at least attempted to implement further interventions. V13 confirmed a resident's physician and representative should be notified with changes of condition such as severe weight loss.
On 12/06/24 at 12:16 PM V7 Registered Dietician confirmed if she would have been notified of continued weight loss, she could have increased the high protein ice cream or added pudding for R154. V7 confirmed some weight loss is to be expected due to R154's progressive medical diagnoses however this should be addressed in her plan of care. R154's physician and family should all be involved and even if further weight loss continues it wouldn't hurt to exhaust all of the available options (interventions).
On 12/06/24 at 12:58 PM V2 DON and V13 Regional RN confirmed weight loss should have been addressed in R154's Care Plan and it should be documented in R154's record when the physician and/or resident representatives are notified of a change of condition (R154's severe weight loss).
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0698
(Tag F0698)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -
Based on an interview and record review, the facility failed to communicate regularly with the dialysis center to coordinate c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -
Based on an interview and record review, the facility failed to communicate regularly with the dialysis center to coordinate care and failed to monitor a dialysis central venous catheter access site for one resident (R22). This failure resulted in R22's hospitalization with a central venous catheter infection. R22 is one of two residents reviewed for dialysis on the sample list of 82.
Findings include:
The facility Dialysis Protocol (revised 9/23) documents the following: It is the responsibility of nursing to provide care for the dialysis resident. Nursing will also monitor the access site for signs and symptoms of infection or bleeding at the site. Communication with dialysis center will be done by nursing, dietary, and/or social services with a change of status in the patient's care or treatment. Dialysis will also communicate to the facility any abnormal lab work or change of orders. The resident's care plan will reflect their dialysis needs.
The facility Nursing Home Dialysis Transfer Agreement dated 9/13/23 documents the facility will provide for the interchange of information useful or necessary for the care of the designated resident.
R22's Face Sheet (current) documents the following diagnoses: End Stage Renal Disease, Chronic Kidney Disease, Dependence on Renal Dialysis, and Cellulitis of Chest Wall.
R22's Care Plan documents the following: 7/26/23- Check daily at the access site. Monitor/document/report PRN (as needed) any signs and/or symptoms of infection to the access site-redness, swelling, warmth, or drainage.
R22's Physician Orders (current) document the following order: Dialysis: May go to dialysis on Mondays, Wednesdays, Thursdays, and Fridays at [outside] dialysis center.
R22 did not have orders to monitor R22's dialysis site in August, September, and October of 2024. R22 only had orders to monitor R22's dialysis site in November 2024 when R22 returned from the hospital on [DATE]. This order was discontinued on 11/25/24.
R22's EMR documents R22 was out of the facility at the hospital from [DATE] through 11/29/24.
R22 did not have orders to monitor R22's dialysis site from 11/29/24 to 12/5/24.
R22's Electronic Medical Record (EMR) does not document routine pre and post dialysis communication with the dialysis center.
R22's Progress Note dated 11/5/24 at 2:59pm documents R22's dialysis port dressing to left upper chest saturated with brown discharge and reddened edema noted under port site. This same note further documents R22 stated dialysis sent a culture of drainage on Monday [11/4/24] and R22 states that it [dialysis site] looks worse and itches. R22 sent to Emergency department.
R22's 11/5/24 Emergency Department Report documents the following: [R22] presented to the emergency department with the concern of dialysis line (central venous catheter) infection. Patient [R22] states has had increased drainage and itching for the past week. [R22] states the drainage is brown. Physical Exam: Left chest port site with surrounding erythema (abnormal redness of the skin) and mild warm. Mild to purulent (containing pus) drainage noted from the port site. Suspected central line associated bloodstream infection. [R22] treated with Zosyn (antibiotic) and Vancomycin (antibiotic). [R22] admitting diagnoses: Complication associated with dialysis catheter and Cellulitis of the chest wall.
On 12/3/24 at 2:00 pm, R22 stated a communication notebook used to go with R22 to and from dialysis. R22 stated R22 has not seen it in a while. R22 stated R22 was hospitalized with a dialysis port infection in November, and facility staff were not monitoring R22's dialysis site.
On 12/5/24 at 2:46pm, V14 Licensed Practical Nurse stated R22 has a bag R22 takes to dialysis that contains a notebook for communication between the facility and the dialysis center. V14 stated R22 keeps that bag in R22's possession. V14 stated R22 has a central venous catheter (CVC) in R22's left chest for dialysis. V14 stated that the dialysis center handles everything related to CVC. V14 stated R22's CVC is covered with a clear occlusive dressing and nursing staff can see if there is any signs and/or symptoms of infection. V14 stated the monitoring of R22's CVC site is not documented.
On 12/6/24 at 12:53 pm, V24's Nurse Practitioner stated that nurses should assess the CVC site for signs and/or symptoms of infection and document the status of the site and the dressing at least daily. V24 also stated that communication should occur between the facility and the dialysis center to inform the resident of any changes in condition, weights, and/or any other pertinent information.
Oct 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** --
Based on record review and interview, the facility failed to notify a resident's family representative of positive laboratory...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** --
Based on record review and interview, the facility failed to notify a resident's family representative of positive laboratory test results for an infectious disease and failed to notify both the family representative and a physician/nurse practitioner of a significant decline in a resident's level of consciousness, abnormal lung assessment, and a productive cough. This failure affected one of four residents (R4) who were reviewed for changes in condition on the sample list of seven.
Findings include:
R4's Diagnoses Sheet, dated 10/22/24 at 12:13 pm, documents the following: Alzheimer's Disease and Unspecified Dementia Mild, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety.
R4's Minimum Data Set, dated [DATE] documents R4's Brief Interview of Mental Status score as four out of a possible 15, indicating severe cognitive impairment.
R4's Orders - General Note dated 10/18/24 at 1:46 pm (day shift) documents: Late Entry (unidentified time of covid test): Note Text: NP (V18, Nurse Practitioner) is aware of Covid positive results. There is no documentation in R4's medical record that V33, R4's Family Representative/Power of Attorney (POA) was notified of R4's COVID-19 positive diagnosis on 10/18/24.
R4's Infection Note dated 10/18/24 at 9:44 pm (evening shift) (seven hours and 58 minutes after the above late entry note), signed by V11, Licensed Practical Nurse (LPN), documents the following: Note Text: resident (R4) lethargic (declined in level of consciousness), appetite poor, lung sounds diminished lower lobes, productive cough, responds to physical and verbal stimuli, started on COVID Isolation (day shift), afebrile, droplet precautions in place.
There is no documentation that V33, R4's Family Representative/POA, or any facility providers (Nurse Practitioners/ Physicians) were notified of R4's Lethargy, lung sounds diminished the lower lobes, and R4's productive cough.
On 10/22/24 at 11:20 am V2, Director of Nursing (DON) reviewed R4's medical records and acknowledged R4 had changes of condition on 10/18/24 of testing positive for Covid on day shift of 10/18/24. V2 also acknowledged no documentation of R4 presenting with lethargy, diminished lung sounds, and a productive cough on the 10/18/24 evening shift, which was a change in the resident's condition. V2, DON stated a physician or nurse practitioner and family should have been notified of R4's changes in condition.
On 10/23/24 at 2:10 pm V11, LPN stated, I stand by what I wrote. He (R4) was lethargic but did respond to verbal and tactile stimuli. He was alert earlier in my shift. It was a change because he was sick. He had Covid. I figured the lethargy was related to Covid. He was not in respiratory distress. The Nurse Practitioner (unidentified) was aware he had Covid. She was notified prior to my shift. There was no reason to notify her (V18, Nurse Practitioner) or the family (V33, R4's POA) since the previous shift would have already done the notifications (as noted above, there is no documentation of family notification when R4 tested Covid positive).
On 10/23/24 at 3:20 pm V31, Licensed Practical Nurse / Infection Control Preventionist stated R4 tested positive for Covid and was not symptomatic when tested. V31 said she notifies the provider, and the floor nurse is expected to notify the residents family when a resident test positive for Covid.
The facility policy Subject: PHYSICIAN NOTIFICATION OF RESIDENT
CHANGE OF CONDITION dated as revised August 15, 2023, documents the following:
PURPOSE:
To provide guidelines for facility staff to follow to ensure that there is appropriate physician notification of any change in a resident's condition.
POLICY:
The resident's attending physician will be notified of changes that occur in the resident's condition by Licensed Personnel as warranted. Physician notification is to include, but is not limited to the following:
e.
Symptoms of infectious process.
j.
Changes in Level of Consciousness.
The facility policy Subject: RESPONSIBLE PARTY NOTIFICATION OF RESIDENT CHANGE OF CONDITION, dated as revised August 2021, documents the following:
PURPOSE:
To ensure that residents' responsible parties are notified of changes in conditions that occur.
POLICY:
Residents responsible parties will be notified of changes that occur in residents condition as warranted. If a resident is deemed mentally competent, and exercise his/her right to privacy, not wishing for the family to be notified, then the facility must respect this right, and therefore would not be required to notify the family, however, attending physician must still be notified. If the resident chooses not to exercise this right, then the family must be notified of the change in condition.
RESPONSIBILITY:
It is the responsibility of All Licensed Personnel to notify the family or responsible parties of a change in residents' condition.
PROCEDURE:
1. Family Members or responsible party will be notified of a change in residents condition.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on record review and interviews, the facility repeatedly failed to maintain complete and accurate resident medical record, by failing to document the application of a physician ordered back brac...
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Based on record review and interviews, the facility repeatedly failed to maintain complete and accurate resident medical record, by failing to document the application of a physician ordered back brace. This failure affected one of seven residents (R1) reviewed for complete medical records, on the sample list of seven.
Findings include:
R1's current Diagnoses Sheet documents the following diagnoses: Dementia, and Vertebral fractures.
R1's Physician Order Summary Report dated 10/18/24 documents the following: UP with one assist, with gaitbelt and RW (roller walker); TLSO (speciality, back) brace ON when out-of-bed; Increase activity as tolerated. Active (as of) 09/26/2024.
R1's Electronic Medication/Treatment Administration Records dated 9/26/24- 9/30/24 (five days) and 10/1/24 - 10/19/24 (19 days) dose not have nurses initials in the administration box to confirm R1's physican order for the TLSO back brace was in place, when R1 was out of bed.
On 10/23/24 at 8:25 am V2, Director of Nursing reviewed R1's MAR/TAR and stated I have updated the error in (R1's) back (TLSO) brace order. That was entered incorrectly by the admission nurse (V24). The order had no verification that the nurses were following the order. The nurses will be signing off the physician order for (R1's) brace every shift. Since, it was not documented as applied, I cannot prove it was always on when she (R1) was out of bed.
On 10/23/24 at 10:05 am V24, Registered Nurse/Admissions Nurse stated she messed up when entering R1's physician order for the back brace, by failing to make the administration record option, open for the nurses to initial R1's brace was being applied when R1 was out of bed.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility repeatedly failed to implement fall interventions for R1, R2...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility repeatedly failed to implement fall interventions for R1, R2, and R3 and repeatedly failed to complete R2's quarterly fall risk assessments. These failures affected three of the three residents (R1, R2, and R3) reviewed for falls on the sample list of seven.
Findings include:
1.) R1's Census Record dated 10/18/24 documents that R1 was admitted to the facility on [DATE]. The same census record documents the following: Special Instructions: 1 (one) person transfer with gait belt and RW (roller walker). Ensure TLSO (Thoracolumbar sacral orthosis, type of support to promote healing of spinal fractures) brace is on when OOB (out of bed).
R1's current Diagnoses Sheet, with multiple dates, documents the following diagnoses:
Repeated Falls (dated 9/26/24), Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety (dated 02/18/24), Multiple Fractures Of Ribs, Right Side, Subsequent Encounter For Fracture With Routine Healing, Non-Surgical Orthopedic/Musculoskeletal ( dated 9/25/2024), Unspecified Fracture Of First Lumbar Vertebra, Subsequent Encounter For Fracture With Routine Healing, Major Joint Replacement or Spinal Surgery (dated 9/25/2024), Sprain Of Ligaments Of Lumbar Spine, Subsequent Encounter (dated 9/25/24), and Spinal Stenosis, Lumbar Region Without Neurogenic Claudication ( dated 9/25/24).
R1's Physician Order Summary Report dated 10/18/24 documents the following: UP with one assist with gait belt; TLSO brace ON when out-of-bed; Increase activity as tolerated. Active (start date) 09/26/2024.
On 10/18/24 at 4:30 pm V7, R1's Family Member/ Power of Attorney (POA) was seated next to R1, at a dining room table, on the Dementia unit of the facility. R1 was in a wheelchair. R1 was wearing a hard plastic brace that extended over R1's right shoulder down to R1's right hand. R1 did not have on R1's TLSO back brace. V7, POA stated the facility staff have not been putting R1's back brace on every day, and she is supposed to wear the back brace when she is up out of bed. V7 also stated, You can see she doesn't have it today. Staff (unidentified) said they couldn't find it. My mother (R1) fractured several vertebrae in a fall at the assistive living facility (prior to admission to this facility) after she was discharged from here (this facility) last month. She came back here for therapy. She (R1) is not supposed to be up without the back brace.
On 10/18/24 at 4:35 pm, V2, the Director of Nursing (DON), was in the Dementia unit and confirmed that R1 does not have R1's TLSO back brace to support R1's spine. V2 stated, 'The back brace should be on.' V7 (R1's POA) stated to V2, DON, Everyone at the facility should know to keep (R1's) back braces on when she is out of bed. She has a fracture to her vertebrae. She is also supposed to have her arm brace on at all times (in bed and out of bed).
2.) R2's Current Diagnoses Sheet (multiple dates) documents the following diagnoses: Unspecified Dementia, Unspecified Severity With Other Behavioral Disturbance, Delusional Disorders, Personal History of Falling, Ataxia (poor muscle control that causes clumsy movements), Anxiety, Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure With Hypoxia.
R2's Minimum Data Set, dated [DATE], documents that R2 has moderate cognitive impairment and requires partial to moderate assistance when standing from a seated position and for transfers.
R2's Fall assessment dated [DATE], documents R2's score of 95. The same assessment documents: Fall Risk is based upon Fall Risk Factors, and it is more than a Total Score. Determine Fall Risk Factors and Target Interventions to Reduce Risks. Complete (assessment) on admission, quarterly, at change of condition, and after a fall. The same evaluations document R2's score of 95 as High risk, 46 or higher.
R2's medical record does not document a quarterly fall risk assessment for March 2024 or June 2024.
On 10/24/24 at 5:05 pm, V2 the Director of Nursing, stated, (R2's) quarterly fall risk assessments since December 2023 could not be found in his (R2's) medical record. V2 also stated, If it wasn't charted, it was likely not done.
R2's Fall note dated 9/9/24 documents the following: Incident Description:
Nursing Description: The was observed on the fall mat of the Resident's roommate; the Resident denies any pain. Resident Description: The Resident is Unable to give a Description. Was this incident witnessed? N (no).
Immediate Action Taken:
Description: got vitals, asked if was ok, denies any pain, discomfort, was able to get in bed Resident Taken to Hospital? N
Injuries Observed At The Time Of The Incident:
Injury Type: No Injuries were observed at the time of the incident.
Predisposing Physiological Factors:
Incontinent (box checked)
Impaired Memory (box checked)
Weakness/Fainted (box checked.)
Predisposing Situation Factors:
Ambulating Without Assist (box checked)
During Transfer (box checked)
The same 'Fall' noted documents:
IDT (Interdisciplinary Team) reviewed: Resident attempted to stand by self, landing on fall mat in room. Recent GDR (Gradual Dose Reduction) on 09/06/2024 for doxepin (antidepressant medication) was reduced to every other night. Post-fall intervention continues. CP (Care Plan) updated.
R2's Care Plan, dated as revised on 9/9/24, documents the following:
Focus: (R2) can potentially have a fall incident and may have an injury for being in a new
environment, poor safety awareness, history, and recent fall episodes, limited
Mobility and weakness. High Fall risk. Interventions include the following:
·
Continue current interventions,
·
Assist Resident with transfers (name brand, non-skid material) in a wheelchair,
·
Visual Cues (sign) hung in Resident's room to remind the Resident to use call light for assistance.
On 10/22/24 at 4:55 pm V19, Licensed Practical Nurse (LPN) entered R2's room and confirmed R2's wheelchair had no (name brand non-skid material) in the seat, above or below the wheelchair cushion, R2's wheelchair was not locked as it sat at the side of R2's bed, and there was no visual cue signage hung in residents bedroom room or bathroom to remind R2 to use his call light for assistance. R2 was laying in low bed with call light draped over the head of his bed and within reach. R2 stated to V19 LPN that he used to have a piece of paper on the wall in the bathroom to remind him to push the call button when he needed help, and he didn't know what happened to it. R2 also stated he does not remember ever having a reminder sign in his bedroom.
On 10/23/24 at 9:35 am, V2, the Director of Nursing (DON), entered R2's bedroom. R2 was laying in bed. R2's wheelchair was not within reach and sat unlocked, approximately one foot from the footboard of R2's bed. Above and below R2's wheelchair cushion, there was no non-slid material placed (also observed 10/22/24 above). The silky material on the cushion slid easily forward and back on the wheelchair seat. There were still no signs on R2's bathroom or bedroom walls to remind R2 to call for assistance when getting up (as observed on 10/22/24 above). V2, DON confirmed the lack of R2's fall intervention. V2 stated, (R2's) wheelchair needs to be within his (R2's) reach and locked. (R2's) walls will have signs in the bathroom and bedroom, and I will get (non-skid material) in his chair immediately.
3.) R3's Current Diagnoses sheet documents the following: Repeated Falls, Deaf Non-speaking, Acute Respiratory Failure With Hypoxia, and Chronic Respiratory Failure With Hypoxia.
R3's Minimum Data Set (MDS) dated [DATE] documents R3's Brief Interview of Mental Status score as 14 out of a possible 15, indicating no cognitive impairment. The same MDS documents that R3 has had one fall but no injury since the previous assessment.
R3's General Note dated 10/06/2024 at 11:23 am documents the following:
Note Text: Writer was alerted that Resident was on the floor in Resident's bathroom. The writer assessed the Resident. Resident denies pain. Vitals WNL (within normal limits).
The Resident stated she slid to the floor and, was not hurt, and did not hit her head. Nurse assessed patient. CNA (Certified Nursing Assistant) and Nurse used (full body mechanical) lift to transfer
resident from floor back to the chair.
R3's Care Plan revised 10/6/24 document the following: (R3) exhibits self-care deficit and
requires assistance with activities of daily living such as bed mobility, transfers, toileting, eating, dressing/grooming, bathing, and personal care needs due to current medical condition.
On 10/22/25 at 2:00 p.m., R3 could be seen through a wide-opened door in a shared hall bathroom, standing in front of the toilet. R3 unsteadily and slowly transferred herself to a seated position in her wheelchair. Multiple unidentified staff members passed the opened bathroom door without offering R3 assistance.
R3 self-propelled her wheelchair to the hallway. R3 used a communication board as she cannot clearly speak or hear. R3 wrote that she must take herself across the hall to the bathroom because the call light does not come on for staff assistance from her own room. (R3 then points to the light fixture above her bedroom door). R3 then writes on her communication board. I wait and wait, as long as I can hold it. I have to go to the bathroom across the hall. There is more room in that bathroom for me to go by myself. The surveyor attempted to activate R3's bedroom bathroom light. When triggered, R3's bathroom call light did not activate the light above her door. The bathroom was a shared with the room next to R3's room. The light came on above the other bedroom door. There was still no sound activated. V17, the Social Service Director, stopped in the hall outside R3's bedroom door. V17 confirmed the light did not come on above R3's door and did not sound to alert staff of residents' need for assistance. V17 stated V17 would report to the Maintenance department for repair. V17 also stated (R3) takes herself to the bathroom without waiting for staff assistance, and as had several previous falls doing so.
On 10/22/24 at 2:08 pm, V16, Certified Nursing Assistant (CNA), was in the hallway, just down from R3's room. V16, stated V16, CNA knows R3 well. R3 is not safe to transfer herself. R3 is unsteady and is supposed to wait for staff assistance. R3 has had many falls.
On 10/22/24 at 2:20 pm V15, Licensed Practical Nurse stated (R3) is not supposed to be taking herself to the bathroom. V15 stated, 2:00 pm is a shift change. The staff going by the bathroom should have helped (R3) or let next shift staff know (R3) needed to go to the bathroom.
The facility policy Fall Prevention Policy, dated October 2023, documents the following:
Policy:
* To provide guidelines on preventing Resident falls or injuries.
PROCEDURE:
3. Complete the fall assessment initially on admission and then quarterly.
The same policy document:
Individualized Care Plan
l. Identify the Problem or need
2.
State measurable goal
3.
Specify Target Date
4.
List interventions
5.
Provide Resident and family education as appropriate
Action Steps
1.
Provide ongoing risk-reducing interventions
2.
Initiate physician orders as needed
3.
Identify and implement related care link interventions
4.
Provide ongoing evaluation of resident response to interventions.
Oct 2024
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide pain management by not having the correct pain medication av...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide pain management by not having the correct pain medication available for R1 upon admission to the facility. This failure resulted in R1 experiencing severe pain from R1's recent joint replacement surgery when pain medication was not available. R1 is one of three residents reviewed for pain management in a sample of three. This past compliance occurred from 9/26/24 to 9/27/24.
Findings include:
The facility policy titled Management of Pain revise date 7/23 documents Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. We will achieve these goals through: Screen for pain every shift. Encourage residents to self-report pain. Preventing and minimizing anticipated pain when possible and using pain mediation judiciously to balance the resident's desired level of pain relief with the avoidance of unacceptable adverse consequences.
R1's Progress note dated 9/26/24 documents R1 was admitted to the facility on [DATE] at approximately 6:30 PM. The same Progress note dated 9/26/24 at 6:39 PM documents (R1) was admitted to his room, alert and oriented times 4 and able to make needs known. The Physician's Order Sheet (POS) dated September 2024 documents R1 was admitted with the following diagnoses: Aftercare following Joint Replacement Surgery and Chronic Lymphocytic Leukemia of B-Cell type not having achieved remission.
R1's hospital transfer/discharge orders dated 9/26/24 document the medications R1 was prescribed to receive at the nursing home. Per doctor's orders, R1 was to receive the following the following medication
for pain Oxycodone 5 milligram (mg) 1 tablet by mouth every 6 hours as needed for severe pain.
R1 stated per phone interview on 10/09/2024 at 12:05 PM Yes, I was in pain the first couple of days I was at the nursing home. (V5, LPN (Licensed Practical Nurse) ) the nurse on duty that night came in and asked me if I had any pain and I told her not at that time because I received some pain medication at the hospital before I left to go to the nursing home. I told (V5,) I would need the pain medication when I go to bed so I would be able to sleep. At 9:00 PM I asked for my pain medication and (V5 ) told me they did not have my pain medication available and it was ordered from the pharmacy and it should be delivered around 4:30 to 5:00 AM, because this was the time they got their medication. I asked the night nurse (V6, RN (Registered Nurse)) if my pain mediation was available and (V6) stated 'no your pain medication did not come.' I was in bad pain and did not get any pain medication until later that day.
On 10/9/24 at 2:27 PM (V5) stated, Yes I was the nurse working the night (R1) was admitted . All of his medication orders were faxed to the pharmacy by the admitting nurse. I went in to (R1's) room and explained to him we did not have his pain medication here at the facility. V5 stated the medication should have arrived around 5:00 AM. V5 stated R1 reported R1 would need pain medication around 9:00 PM. V5 stated No I did not call the Nurse Practitioner (V7) or V11 (R1's Doctor) to get an order for a substitute medication. V5 stated we did not have Oxycodone in our Emergency Box, we only had Oxycodone with Tylenol.
On 10/9/24 at 2:35 PM per phone interview V7, Nurse Practitioner stated, I went to visit (R1) in his room from 8:00 AM to 10:00 AM on 9/27/24 to see how he was doing. I was shocked because (R1) was in excruciating pain you could see it in his face and his movements. (R1) looked really bad due to his pain. I asked him if he received his pain medication, he stated 'no the facility does not have my type of pain medication.' He stated the medication did not arrive with his other medications according to the night nurse (V6). V7 stated V7 went to the nurse (V3, ADON ) ( Assistant Director of Nursing ) and asked her why R1 did not receive his medication for pain and V3 stated the medication was not received from the pharmacy, and the emergency box only had Percocet available. V7 stated V7 immediately called the pharmacy with an emergency order for R1 to have Percocet two doses which is available in the Emergency Box. V7 stated I then had the nurse remove the medication from the Emergency Box and give it to (R1). Then called the pharmacy and sent the prescription that was needed for R1 to receive his Oxycodone 5 mg. V7 stated R1 should not have been in pain like that. V7 stated no one called V7 or the doctor when R1 was admitted for an order for a different type of pain medication.
On 10/9/24 at 12:11 PM, V8 Pharmacist confirmed V7 called in an emergency order on 9/27/24 at 12:03 PM for R1, and the pharmacy received the prescription for R1's Oxycodone 5mg at on 9/27/24 at 3:49 PM.
On 10/9/24 at 1:32 PM V3, ADON stated Yes V7 wrote new prescriptions for (R1) to receive his pain medication and I faxed to our pharmacy the new prescriptions for (R1) to receive his Oxycodone 5 mg.
On 10/4/24 at 1:40 PM V1, Administrator stated We did not have the medication in the Emergency Box and the nurse did not pick up the phone and call the nurse practitioner or the doctor for an order to get the medication.
The facility's policy titled admission Orders and Process with the revised date of 7/23 documents under Procedure # 1 and 2
1. Physician orders for the resident immediate care will be obtained prior to or upon admission/readmission.
2. The Licensed Nursing staff shall obtain orders for the care of the resident from the resident's physician or his/her designee. If the resident's attending physician or his/her designee cannot be contacted, the DON (Director of Nursing) will be notified and the Medical Director will be contacted for immediate orders for care of the resident.
Prior to the survey date of 10/10/24, the facility took the following actions to correct the noncompliance:
1. On 9/27/24 R1 was interviewed by V3 ADON and R1 was informed an alternative medication had been ordered while the pharmacy was processing his orders and pain medication was administered by V3 on 9/27/24 at 1:32 PM.
2. On 9/27/24 a plan was implemented to audit all newly admitted residents for narcotics orders and compare to the list of available medications in the emergency box. Completed by V3 ADON on 9/27/24.
3. On 9/27/24 all nursing staff were educated on the narcotic process and how to obtain a one time order for a narcotic that is available in the emergency supply. The emergency supply list will be placed in the Nurse Resource Binder for quick reference. The admissions nurse will screen orders for narcotics when received. Completed by ADON on 9/27/24
4. Audits are in place for each new admission to ensure alternative narcotics are available and ordered by the provider until original ordered narcotics arrived from pharmacy. This audit will be completed for each admission by the ADON. The results of these audits will be reviewed by the facility Quality Assurance Performance Improvement (QAPI) committee for patterns, trends, and continued recommendations for process monitoring and improvement. Completed on 9/27/24 and ongoing with each new admission by ADON.
Sept 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
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to properly transfer one of two residents (R1) reviewed for periph...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to properly transfer one of two residents (R1) reviewed for peripherally inserted central catheter (PICC) maintenance on the sample list of three. This past noncompliance occurred from 8/29/24 through 9/7/24.
Findings Include:
The facility's PICC/Central Venous Catheter Dressing Changes policy, dated 9/1/23, states that PICC/Central venous catheter dressings will be changed at specific intervals, or when needed, to prevent catheter-related infections associated with contaminated, loosened, soiled, or wet dressings. Transparent semi-permeable dressings are changed every seven days or as needed.
R1's Minimum Data Set, dated [DATE] documents that R1 is cognitively intact.
R1's Medical Diagnoses Sheet, dated September 2024, documents that R1 is diagnosed with Osteomyelitis.
R1's Physician Order Sheet dated September 2024 documents an order for Daptomycin-Sodium Chloride Intravenous Solution - 1000 milligrams intravenously, every 24 hours, for Osteomyelitis of the right foot, until 9/30/2024.
R1's August Medication Administration Report (MAR) does not document dressing changes for R1's PICC line.
R1's September MAR documents R1's PICC line dressing change order was placed on 9/9/24.
On 9/19/24 at 12:00 PM, R1 stated he had a PICC line upon admission to the facility to get his intravenous (IV) antibiotics. The nursing staff never changed the PICC line dressing. R1 stated the PICC line fell out on 9/7/24, requiring him to get a peripheral IV to continue his antibiotics. On 9/9/24, R1 was able to get another PICC line placed.
On 9/18/24 at 12:16 PM, V3 Assistant Director of Nurses (ADON) stated that R1 was admitted with a PICC line for intravenous antibiotics related to a wound infection. V3 confirmed no PICC line dressing change order was placed on R1's chart and no documented dressing changes were completed. V3 confirmed that R1's PICC line came out on 9/7/24 and was replaced on 9/9/24. On 9/9/24, orders were placed for dressing changes on R1's new PICC line. V3 confirmed that 9/7/24 is when the facility realized R1 had not had PICC line dressing changes in place since his admission on [DATE]. V3 ADON stated the facility completed education and began an audit to ensure PICC line dressing changes were no longer missed.
Prior to the survey date of 9/19/24, the facility had taken the following action to correct the noncompliance:
1. On September 7, 2024, the facility filled out a Resident Grievance/Concern form and began a formal process of investigating and resolving R1's concern regarding the lack of care for his PICC line
2. On September 7, 2024, R1 was provided with V1 Administrator and V3's ADON direct cell phone numbers, and V3 was assigned to check in with R1 daily to monitor daily care/progress/concerns.
3. On September 7, 2024, facility nursing staff received training regarding PICC line care and dressing changes.
4. On September 7, 2024, audits of all PICC lines in the facility began. Audits were completed three times in the last two weeks to ensure orders were placed and being followed for all PICC lines.
Sept 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 mental abuse to the state agency in the 2 hour required timeframe. This failure affects one resident (R1) out of tw...
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Based on interview and record review, the facility failed to report an allegation of mental abuse to the state agency in the 2 hour required timeframe. This failure affects one resident (R1) out of twelve reviewed for abuse on the sample of 35.
Findings include:
On 9/4/24 at 8:55 AM, V1 stated, (V7, Family Member of R1) called me to complain that a staff member had woken (R1) in the middle of the night and (R1) wasn't happy about it. V1 further stated, I will have to go check my 'soft file' to see if the employee was suspended.
On 9/5/24 at 9:02 AM, V1 stated, What happened was I received a phone call from (V7) that a staff member was rude to (R1) during the night (allegation). V1 continued, I was at the facility so I went down to talk with (R1) (investigation). V1 then stated, (R1) told me a CNA (Certified Nursing Assistant) had startled her awake during the night (early 8/22/24). Then I called (V5) and informed her I had a potential allegation and had to suspend her for now. V1 further stated, I had (V4, Assistant Administrator) go and speak with other residents to find out how the night went for them.
On 9/4/24 at 10:25 AM, V1 presented a copy of an initial report to IDPH (Illinois Department of Public Health) of an allegation of abuse documenting this report was sent 9/4/24 at 10:20 AM. V1 stated, I only reported this because you (surveyor) presented this as an allegation of abuse. I did not think (V7's) statements amounted to an allegation, especially after I went and talked to (R1).
On 9/4/24 at 1:11 PM, R1 stated, There was an instance where a CNA (V5) came into my room and took the bed pan out from under me and left without cleaning me. R1 then stated, I had to put my call light back on for the CNA to come back in and place pillows under my leg and when the CNA came in, she was rude to me and asked if I wanted another CNA to take care of me. R1 continued, When the other CNA (V9) came in to take care of me, I let her know the first CNA (V5) had not cleaned me after taking me off of the bed pan, then I heard the first CNA from the hallway yelling at me back into the room 'I did clean you.'
The facility policy Abuse Prevention Program dated 10/20/22 documents the facility affirms the right of our residents to be free from abuse, and prohibit abuse including verbal abuse, and mistreatment. This same policy documents (in bold typing) any allegation of abuse will be reported to the Illinois Department of Public Health immediately but not more than 2 hours of the allegation.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to maintain residents' dignity by failing to answer call lights and respond to requests for assistance in a timely manner. This failure affect...
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Based on interview and record review, the facility failed to maintain residents' dignity by failing to answer call lights and respond to requests for assistance in a timely manner. This failure affects eight residents (R1, R2, R6, R8, R9, R20, R21, and R23) out of 17 reviewed for call light response times on the sample of 35.
Findings include:
On 9/4/24 at 10:25 AM, R6 stated, The call lights can take up to 30 minutes for someone to answer.
On 9/4/24 at 10:45 AM, R8 stated, At times the call lights take longer to answer than I would like. The staff do come clean me up when I get wet or soiled. There are times when someone will answer my call light and say 'I'll be right back,' but they don't come right back.
On 9/4/24 at 11:05 AM, R2 stated, The call lights do take a long time especially during meal times. It does happen sometimes that someone answers the light and says they will come back but then they don't unless I push the light again.
On 9/4/24 at 12:20 PM, R9 stated, The call lights can take up to 45 minutes for someone to come. Once in a great while someone will come real quickly and that is a shock. It happens all the time someone will come in and turn off the light and say they will come back, or say they will go get a CNA (Certified Nursing Assistant), but then no one shows up unless I push my light again. R9 further stated, I use (incontinence undergarments) and I only have one leg so I can't really get on and off the toilet by myself, then they do help me get cleaned up because I don't have much control over my bowels or bladder.
On 9/4/24 at 1:11 PM, R1 stated, I would push my call light and because of my medications I fall asleep before someone would come wake me up and ask what I need. There were times when someone would turn off the call light and leave and not return.
The facility's Resident Council Meeting Minutes dated 8/27/24 documents, Concern raised over call light response times on overnight shift - grievance written.
The facility's Resident Council Meeting Minutes dated 7/30/24 documents, Call light times over night a concern (grievance written).
The facility's Resident Council Meeting Minutes dated 6/25/24 documents, Questions on who can answer call lights: ANYONE can but limited to CNAs/ nurses on specific responses (ie. transfers, medications, oxygen).
On 9/5/24 at 9:40 AM, R20 stated, My main complaint is the call lights taking 45 minutes for someone to answer. That is about the longest that it takes but it is always more than 15 minutes. There may be 4 or 5 CNAs working but there are 4 halls so that is really only one per hall for about 20 residents each hall.
On 9/5/24 at 9:50 AM, R21 (R20's roommate), unsolicited, stated, I agree with everything she (R20) said.
On 9/5/24 at 10:00 AM, R23 stated, The night shift doesn't answer my call light, well they really do but it takes 30 to 35 minutes. I sometimes have accidents (involuntary bowel or bladder releases) and I need an extra cleaning. I think there just isn't enough staff on night shift.
On 9/5/24 at 3:00 PM, V1, Administrator, provided a print-out containing approximately 217 pages, printed on both sides of each page, and handwritten across the top of the first page was 18,694 call lights - 30 days. V1 stated, I had the IT (Information Technology) print these for the last 30 days and arrange them from the longest response time to the shortest, indicating that the printout had some level of user input for selection criteria to generate this report. This form solely documents the date, time, and location any given call light in the facility was activated, and the time the call light was turned off. This document does not refute the statements by R1, R2, R8, and R9 that someone would turn off their call light and not return. At 3:30 PM, V1 stated, At around 20 minutes response time I might consider writing someone up (disciplinary warning). This printout documents over 650 call light response times over 20 minutes, including 9 call lights activated from resident bathrooms, and one from the second floor dining room.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain flooring in resident bathrooms in a clean, safe, and homelik...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain flooring in resident bathrooms in a clean, safe, and homelike manner. This failure affects 15 residents (R7, R8, R12, R22, and R25 through R35) out of 23 reviewed for environmental concerns on the sample of 35.
Findings include:
On 9/4/24 during an environmental tour beginning at 10:25 AM, the bathroom vinyl floor in room [ROOM NUMBER] had ground in dirt and stains which would rub off with a dry piece of bathroom tissue. R7 stated, They just cleaned in here about 45 minutes ago.
The bathroom vinyl floor connecting rooms [ROOM NUMBERS] had age-related ground in dirt and stains. The dirt portions could be rubbed off with a dry piece of bathroom tissue. The stained portion was imbedded in the vinyl.
The bathroom vinyl floor connecting rooms [ROOM NUMBERS] had dark ground in dirt which could be rubbed off with a dry piece of bathroom tissue, rusty colored stains around the toilet imbedded in the vinyl, cracks approximately 14 inches long and half-inch wide at the floor to wall junctions on both sides of the toilet, and the edges of the vinyl at the bathroom threshold was loose and raised, presenting a trip hazard.
On 9/5/24 at 11:00 AM, V18, Maintenance Director, stated, What I would really like to do is get rid of all the vinyl floors in all the bathrooms and put in poured epoxy floors. V18 stated, No you can't clean into those cracks at all.
The bathroom vinyl floor connecting rooms [ROOM NUMBERS] had imbedded rusty colored stains around the toilet. room [ROOM NUMBER] had a missing threshold at the room entry door. V18 stated, There are a lot of those missing.
The bathroom vinyl floor of room [ROOM NUMBER] had rusty colored stains imbedded around the toilet.
On 9/5/24 at 11:35 AM, V1, Administrator, confirmed the floors in the bathrooms are stained and dirty.
The facility's Resident Roster dated 9/4/24 documents R7, R8, R12, R22, and R25 through R35 reside in the aforementioned rooms.
Jul 2024
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 F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
Based on record review and interviews the facility failed to protect two residents from misappropriation of property by facility staff. This failure caused R1 to have 11 transactions totaling $1515.96...
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Based on record review and interviews the facility failed to protect two residents from misappropriation of property by facility staff. This failure caused R1 to have 11 transactions totaling $1515.96 being misappropriated from R1's private bank account. This failure affects two (R1, R2) residents on the sample list of three reviewed for misappropriation of personal property.
Findings include:
The Physicians Order Sheet dated July 2024 documents R1 has the following diagnoses: Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Acquired absence of Right Leg Above the Knee, and Type 2 Diabetes Mellitus with Hyperglycemia. R1 moves about the facility with an electric wheelchair that she is able to operate without difficulty. R1 requires total assistance with all daily activities. R1's Minimum Data Set (MDS) assessment date 05/02/24 Section C Brief Interview Mental Status (BIMS) documents R1 has a score of 15 which is cognitively intact.
Facility investigation documents:
- R1 reported to V1 (Administrator) on June 27, 2024 at 10:52 AM that her personal debit card from her bank was missing. R1 told V1 she was very nervous because R1 did not know how to hand this situation. V1 assured R1 the facility would assist R1 and see this through for her.
-V1 and V15, Activity Director contacted the bank, cancelled R1's debit card, requested bank statements for 3 months, and reviewed recent transactions with R1 and the fraud department. R1 had 11 transactions appeared to be fraudulent. Of the 11 transactions, 8 was used for C*** A**(mobile payment service) and 3 were used on D**** K****(online sports betting). Names associated with the C*** A**(mobile payment service) was V4 and V5. R1 did not know anyone by either of these names. The final 3 were on D**** K****(online sports betting) transactions. No names were associated with the D**** K****(online sports betting). The total of all transactions was $1515.96.
-V6, female not associated with the facility called V1 and stated she had proof of V7, CNA taking pictures of R1's personal items to include Debit Card with R1's name on it, the CVV code on back of the debit card, R1's Social Security card and mailing address of bank statement. Upon receiving the evidence V6 stated she had ,V7 was immediately suspended and the information was turned over to the police department. V8, was the officer who received the information about the on-going investigation. V8 sent V1 an email dated July 11, 24 at 9:09 AM stating I was advised by V6 that V16 will not talk with me because he knows V16 will go back to prison for this. I'm reaching out to his probation officer who is aware of what is going on.
-On July 9, 24 at 8:30 AM a female individual (V6) called and spoke with V1, stating she had information that a facility CNA (Certified Nursing Assistant) has supplied V6's husband with photographs of R1's personal information including debit card, CVV number on back of the debit card, Social Security Card and mailing address of bank statement. V6 provided evidence to what she was speaking of to V1. V7 was suspended immediately. The investigation continued and with the provided evidence by V6 this evidence also showed a picture of R2's personal debit card. V1 immediately contacted the bank and canceled R2's card and also requested bank statements which proved R2's debit card had not been compromised. The bank issued R2 a new debit card.
-V1 upon reviewing all the information V6 had given him realized R2's bank debit card was also compromised. The bank was contacted, they cancelled the debit card provide a new card for R2 and sent the bank statements to the facility. R2's account was not compromised there were no transaction that could not be accounted for. R2 stated all was good.
R1 stated in interview on 7/19/24 at 2:49 PM I was very nervous about this I did not know what to do. The girl who did this was smart she waited until my Social Security check was deposited and did all of those transaction to me. I did not know what was going to happen to me because most of my Social Security check goes for my room and board here at this facility. All of the money was replaced by the bank. I did not know when she could of taken the pictures of my personal stuff. I usually keep everything on me. I have a lock box now to lock all my personal belongings up.
V7, CNA stated on 7/23/24 at 3:07 PM One of the resident's information was stolen and they said I took pictures and gave this to another person. V6 was suppose to be the one who brought pictures in and gave to V1. V6 is crazy and she did this on purpose because I was having an (relationship)with her husband V16. I don't know how she did everything but I was terminated from the facility due to her evilness. V7 stated no one had her phone. V7 confirmed they were allowed to carry their phones while working. I lay my phone down on the nurses station so I can charge it while I work. I did not do this.
The facility's policy titled Abuse Prevention Program dated 10/20/22 documents the following statement under the section titled Policy This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone . The Policy continues to stated under the section titled Establishing a Resident Sensitive Environment documents under Photographing and Recording Residents Staff photographing or recording residents or their private space (even if the resident is not present) for other than medical or facility purposes, as described in a signed Audio, Video and Photographic Release Form, is strictly prohibited.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to protect the residents' right to be free from misappropriation of property by failing to follow the facility's Abuse Prevention Program by st...
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Based on interview and record review the facility failed to protect the residents' right to be free from misappropriation of property by failing to follow the facility's Abuse Prevention Program by staff taking photographs of residents (R1, R2) personal property and sharing the photographs with another person. R1 and R2 are two residents reviewed for abuse in the sample list of three.
Findings Include:
The facility's Abuse Prevention Program dated 10/20/2022 documents the facility affirms the right of it's residents to be free from misappropriation of property. Misappropriation of property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belonging or money without the resident's consent. The facility's policy titled further documents under the section titled Policy This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone . The Policy continues to state under the section titled Establishing a Resident Sensitive Environment documents under Photographing and Recording Residents Staff photographing or recording residents or their private space (even if the resident is not present) for other than medical or facility purposes, as described in a signed Audio, Video and Photographic Release Form, is strictly prohibited.
R1's Minimum Data Set (MDS) assessment date 05/02/24 Section C Brief Interview Mental Status (BIMS) documents R1 has a score of 15 which is cognitively intact.
Facility investigation documents:
- R1 reported to V1 (Administrator) on June 27, 2024 at 10:52 AM that her personal debit card from her bank was missing. R1 told V1 she was very nervous because R1 did not know how to hand this situation. V1 assured R1 the facility would assist R1 and see this through for her. V1 and V15, Activity Director contacted the bank, cancelled R1's debit card, requested bank statements for 3 months, and reviewed recent transactions with fraud department. R1 had 11 transactions appeared to be fraudulent
-V6, female not associated with the facility called V1 and stated she had proof of V7, CNA taking pictures of R1's personal items to include Debit Card with R1's name on it, the CVV code on back of the debit card, R1's Social Security card and mailing address of bank statement. Upon receiving the evidence V6 stated she had ,V7 was immediately suspended and the information was turned over to the police department. V8, was the officer who received the information about the on-going investigation. V8 sent V1 an email dated July 11, 24 at 9:09 AM stating I was advised by V6 that V16 will not talk with me because he knows V16 will go back to prison for this. I'm reaching out to his probation officer who is aware of what is going on.
-On July 9, 24 at 8:30 AM a female individual (V6) called and spoke with V1, stating she had information that a facility CNA (Certified Nursing Assistant) has supplied V6's husband with photographs of R1's personal information including debit card, CVV number on back of the debit card, Social Security Card and mailing address of bank statement. V6 provided evidence to what she was speaking of to V1. V7 was suspended immediately. The investigation continued and with the provided evidence by V6 this evidence also showed a picture of R2's personal debit card. V1 immediately contacted the bank and canceled R2's card and also requested bank statements which proved R2's debit card had not been compromised. The bank issued R2 a new debit card.R1 had a total of 11 transactions from the debit card V7 took a picture of which totaled to the amount of $1515.96. R2 debit card had not been compromised so R2 had no money removed from her bank account.
-V1 upon reviewing all the information V6 had given him realized R2's bank debit card was also compromised. The bank was contacted, they cancelled the debit card provide a new card for R2 and sent the bank statements to the facility. R2's account was not compromised there were no transaction that could not be accounted for. R2 stated all was good.
R1 stated in interview on 7/19/24 at 2:49 PM I was very nervous about this I did not know what to do. The girl who did this was smart she waited until my Social Security check was deposited and did all of those transaction to me. I did not know what was going to happen to me because most of my Social Security check goes for my room and board here at this facility. All of the money was replaced by the bank. I did not know when she could of taken the pictures of my personal stuff. I usually keep everything on me. I have a lock box now to lock all my personal.
V7, CNA stated on 7/23/24 at 3:07 PM One of the resident's information was stolen and they said I took pictures and gave this to another person. V6 was suppose to be the one who brought pictures in and gave to V1. V6 is crazy and she did this on purpose because I was having an (relationship) with her husband V16. I don't know how she did everything but I was terminated from the facility due to her evilness. V7 stated no one had her phone. V7 confirmed they were allowed to carry their phones while working. I lay my phone down on the nurses station so I can charge it while I work. I did not do this.
May 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 fall interventions were in place, safely positi...
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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 fall interventions were in place, safely position a resident on a low air loss mattress, keep necessary items within reach for a resident, and store a rolling chair away from resident areas. The facility also failed to complete post fall assessments, transfer a resident post fall according to facility policy, and thoroughly investigate falls. These failures affect three of three residents (R1, R4, R5) reviewed for falls on the sample list of seven.
Findings include:
1. R1's undated Medical Diagnosis List documents R1's medical diagnoses as Chronic Obstructive Pulmonary Disease (COPD), Diabetes Mellitus, Neurological Neglect Syndrome, Paralytic Syndrome following Cerebral Infarction affecting Left Non-Dominant side, Nontraumatic Intracerebral Hemorrhage, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left non-dominant side, Seizures, Kidney Failure, Protein Calorie Malnutrition, Dysphagia, Cognitive communication Deficit and Vascular Dementia.
R1's Minimum Data Set (MDS) dated [DATE] documents R1 as severely cognitively impaired. This same MDS documents R1 as requiring maximum assistance for bed mobility and dependent on staff for assist with eating, toileting, transfers, personal hygiene, dressing and bathing.
R1's Physician Order Sheet (POS) dated March 2024 documents a physician order for a Low Air Loss (LAL) mattress dated 1/9/24.
R1's Care plan includes interventions dated 7/14/23 that document R1 requires extensive assistance of two staff for turning and positioning at least every two hours.
R1's Fall Scale assessment dated [DATE] documents R1 as being at risk for falls. No further Fall Risk Assessments were documented.
R1's Nurse Progress Note dated 2/1/24 at 11:33 PM documents Observed (R1) face down on the floor with Right Arm pinned under his body. Staff lifted resident back into bed. Upon assessment, (R1's) eyes were pinpoint and nonreactive to light. Resident began complaining of pain every place nurse touched. (R1) sent to emergency room for evaluation. (R1) returned from hospital at 8:10 PM. (R1's) tests /x-ray negative for breaks.
R1's Computerized Tomography (CT) of the brain without contrast for head trauma moderate/severe unwitnessed fall results dated 2/1/24 document Impression Mild frontal scalp soft tissue swelling without associate Calvarial injury.
R1's fall investigation dated 2/1/24 documents R1 had an unwitnessed fall on 2/1/24 at 2:00 PM. This same investigation documents R1 was found lying face down on the floor by his bed with Right Arm under his body. R1's Right side of face was on the floor. This same investigation documents an Interdisciplinary Team (IDT) note on 2/2/24 which documents (R1) slumps/leans and has poor trunk control. (R1) is unable to move the left side of his body due to Cerebral Vascular Accident (CVA). (R1) was positioned in high fowlers and began to lean on air mattress and slid out of bed.
On 5/19/24 at 11:15 AM V17 Certified Nurse Aide (CNA) stated V17 was in R4's room at 1:45 PM to provide incontinence care before shift change at 2:00 PM. V17 CNA stated When I left (R1) he had just been changed (incontinence care) and I put his bed in the low position. I had left (R1's) head of bed up 60 degrees or so and the foot of the bed was flat. I had (R1) nice and propped up. V17 stated R1 had been positioned on his Left side on the 'door' side of the bed but 'kind of in the middle.' V17 stated R1's head and knees were more towards the middle of the bed and R1's hips/buttocks were closer to the door side of the bed. V17 stated (R1) was always so stiff. (R1) would not move in bed. (R1) had a previous stroke and couldn't move so wherever we (staff) put him in bed is where he would stay. V17 CNA stated I walked into R1's room and he was face down on the floor. Somehow (R1) had fallen out of bed and landed right on his face. V17 stated R1 could have been positioned better if there had been two people to assist with positioning. V17 stated I didn't do anything wrong on purpose but (R1) still fell out of bed. Those air mattresses sometimes make people fall out of bed. They (resident) have to lay on them just right or they (LAL mattress) will pop people right out of that bed. V17 stated after R1 was assisted back to bed, (V10) Registered Nurse (RN) did a physical assessment on R1.
On 5/18/24 at 3:15 PM V10 Registered Nurse (RN) stated V10 was R1's nurse the day he fell out of bed. V10 RN stated (R1's) fall on 2/1/24 was unwitnessed so (R1) had to have been left unattended. The staff should have either stayed with (R1) or lowered the head of his bed down before leaving his room. V10 stated there was nothing for R1 to have hit his head on except for the floor. V10 stated V10 sent R1 to the emergency room.
On 5/18/24 at 2:25 PM V3 Director of Nurses (DON) stated V3 did not work for this facility when R1 fell on 2/1/24. V3 stated after reviewing R1's unwitnessed fall investigation report V3 could confirm R1 was positioned by staff in a high fowler's position when R1 utilized a low air loss mattress. V3 stated R1 should not have been left unattended in that position on an air mattress. V3 DON stated Most likely (R1's) air mattress had a shift in air and bumped (R1) right out of bed.
2. R4's undated Medical Diagnosis List includes Chronic Osteomyelitis, Diabetes Mellitus (DM) Type II, Chronic Systolic Congestive Heart Failure (CHF), Ischemic Cardiomyopathy, Pleural Effusion, Sacral Stage IV Pressure Ulcer, Alzheimer's Disease, Anemia, and Vitamin D Deficiency.
R4's Minimum Data Set (MDS) dated [DATE] documents R4 as moderately cognitively impaired. This same MDS documents R4 as requiring maximum assistance of two people for bed mobility, dressing and transfers and R4 is dependent on staff assistance for all other areas assessed.
R4's Care plan intervention dated 11/16/23 documents R4 requires two staff and a total body mechanical lift for transfers.
R4's Clinical Mobility assessment dated [DATE] documents R4 has extremely impaired mobility.
R4's Fall Risk assessment dated [DATE] documents R4 as a high fall risk.
R4's Nurse Progress Note dated 3/22/24 at 3:34 AM documents (R4) was heard yelling for help. (R4) was found sitting on bottom on floor with floor mat pushed aside. (R4) assisted to bed with (V16 CNA) and gait belt. (R4) stated 'I was asleep then I fell. I was on the ground'. This same progress note documents R4 was assessed with no injuries and Floor mat was positioned alongside of bed so that mat is unable to be pushed away.
On 5/18/24 at 10:20 AM R4 was lying in bed in R4's room. R4's fall was mat was doubled over standing up on end at the end of R4's bed. There was no fall mat in place on the floor in front of R4's bed.
On 5/19/24 at 10:43 AM R4 was lying in bed with covers over her. call light was laying on the floor at the end of R4's bed out of R4's reach. R4's fall was mat folded up standing on end at the end of R4's bed.
On 5/18/24 at 10:21 AM R4 stated I remember the night I fell. I was trying to reach for my drink, but the table was just too far away. I was lying in bed and trying to reach but my arms aren't that long. The call light was laying across the table so I couldn't put the light on either. So, I yelled out and a couple of nurses (V19, V21) Registered Nurse (RN) came in to check on me because I was yelling out. I told them (V19, V21) that my leg and butt hurt. I don't remember who but two of the (staff) lifted me up and put me back in bed. I normally have to have that big swing machine (total body mechanical lift) but they didn't use that. R4 stated after V19 RN and V21 RN both left the room, then V20 RN came into R4's room to do a physical assessment.
On 5/19/24 at 5:15 AM V20 Registered Nurse (RN) stated V20 was assisting another resident when R4 fell on 3/22/24. V20 stated (V19, V21) both RN's assisted R4 after she fell. V20 stated the first time V20 saw R4 was after R4 was already back in her bed. V20 stated R4 normally has a lot of pain and does remember R4 complaining of generalized pain on her buttocks after R4's fall. V20 stated she was not certain who might have assisted R4 back into bed after her fall. V20 RN stated I remember getting the pen light out and taking her blood pressure one time. I honestly don't remember doing the Neurological Assessments after that first time. Normally we (facility) would not move a resident who has fallen and complaining of pain until the nurse saw and assessed them but (V19, V21) are both RN's. They (V19, V21) were both in the room with (R4) before I was. I am sure one of them (V19, V21) would have assessed (R4) before moving her.
On 5/19/24 at 9:30 AM V21 Registered Nurse (RN) stated V21 heard R4 yelling out from R4's room. V21 stated when V21 entered R4's room, R4 was sitting on the floor on her buttocks with her left leg outstretched and R4 was sitting on her Right Leg her Right leg bent at the knee with R4's right foot on the outer side of R4's right thigh. V21 stated R4 complained of pain in 'her leg or buttocks.' V21 stated R4 was alert and responding. V21 RN stated R4 reported that R4 was trying to reach something on her table, but the table was too far away. V21 RN stated R4's fall mat was pushed to the side and R4 was sitting directly on the floor. V21 stated V21 did not complete a physical or neurological assessment. V21 stated V19 RN entered R4's room shortly after V21. V21 RN stated V21 left the room with V19 remaining in R4's room.
On 5/19/24 at 11:35 AM V19 Registered Nurse (RN) stated V19 RN and V16 Certified Nurse Aide (CNA) assisted R4 up after R4's fall. V19 RN stated V19 and V16 did not use a lift (total body mechanical lift) machine to assist R4 up. V19 stated V19 entered R4's room right after V21 RN. V19 stated V19 did not complete any type of physical assessment or neurological assessment prior to moving R4. V19 stated (R4) was moving ok and talking so I thought she would be ok. I didn't get out my pen light or anything but (R4) was talking to me. I don't know if (R4) was having any pain. No one said anything to me if she was. In hindsight, I should have made sure to use the lift to get (R4) up. The neurological exam should have been done by (R4's) nurse (V20) RN. I wasn't (R4's) nurse, (V20) was.
3. R5's undated Medical Diagnosis List includes Alzheimer's Disease, Cerebral Infarction, Apraxia following other Cerebrovascular Disease, Muscle Weakness, Hallucinations, Essential Hypertension, and Insomnia.
R5's Minimum Data Set (MDS) dated [DATE] documents R5 as severely cognitively impaired. This same MDS documents R5 requires maximum assistance for toileting, bathing, dressing, Supervision or touching assistance for transfers and moderate assistance of one staff for bending/stooping from a standing position to pick up a small object from the floor.
R5's Care plan intervention dated 4/12/24 instructs staff to cue, orient and supervise as needed.
R5's Fall Risk assessment dated [DATE] documents R5 as a moderate fall risk.
R5's Nurse Progress Note dated 4/17/24 at 7:32 PM documents (R5) was attempting to sit in a computer chair with wheels, fell onto bottom. No injury noted. Cause: Rolling chair moved when (R5) was trying to get into it. Immediate intervention: helped (R5) into a stable chair.
On 5/18/24 at 2:15 PM V12 Licensed Practical Nurse (LPN) stated R5 normally wanders about the Dementia Unit independently all day long. V12 stated R5 fell on 4/17/24 after trying to sit in a chair 'that was not stable.' V12 LPN stated R5 needs a lot of supervision due to her poor safety awareness. V12 stated there was a dining room table sitting outside of the nurse's station. V12 stated the table and chairs were positioned 10-15 feet away from the nurse's station. V12 LPN stated (V11) Certified Nurse Aide (CNA) had been sitting at one of those chairs. (V11) stood and walked away and left the wheeled chair out in the open for anyone to sit at. (R5) walked over and tried to sit on one of those wheeled chairs and ended up falling. (R5) did not get hurt thank goodness but those types of chairs do not belong back on our Dementia Unit.
On 5/18/24 at 10:29 AM V5 CNA stated residents on a dementia unit have to have 'all the clutter' removed for their protection. V5 stated R5 walks around 'all the time.' V5 stated R5 is always on the go. V5 stated (R5) needs redirected a lot. (R5) keeps us busy.
On 5/18/24 at 2:25 PM V3 Director of Nurses (DON) stated if the resident is complaining of any type of pain, the nurse should assess the resident prior to moving that person. V3 stated staff should do a thorough physical assessment and neurological assessment if needed for all residents who have fallen prior to any staff moving that resident. V3 stated the staff should be using the lift (total body mechanical lift) to assist residents off of the floor after a fall. V3 DON stated staff should have completed neurological assessments on R4. V3 DON stated the facility is not able to provide documentation of the neurological assessment being completed on R4's unwitnessed fall. V3 DON stated it is the policy of this facility to complete full neurological assessments after any resident has an unwitnessed fall. V3 DON stated the facility management team/Interdisciplinary Team (IDT) puts in a lot of effort to review falls and fall interventions. The staff should be making sure the interventions are in place to help prevent falls. V3 Director of Nurses (DON) stated V3 recently started at the facility and was not present when R1 and R4 fell. V3 DON stated after reviewing the falls for R1, R4 and R5 it was hard to determine what exactly happened. There were no staff interviews other than what was on the risk management report itself, but more people were involved in (R1 and R4) falls. I had to go back and find out what happened because the original investigations were not thorough. V3 DON stated (R5's) fall is straight forward. (R5) went to sit down on a wheeled chair and slipped and fell. The chair should not have been there to begin with.
The facility policy titled 'Fall Prevention Program' revised 10/2023 documents the facility will complete the fall assessment initially on admission, and then quarterly, initiate risk reducing interventions, provide ongoing risk reducing interventions, and provide ongoing evaluation of resident response to interventions.
The undated facility policy titled 'Safe Resident Transfer Program' documents the resident transfers will be designated into one of the following categories: Independent=no verbal or physical assistance, one person transfer=one person transfers with gait belt (assistance from the caregiver and ability to statically stand for four seconds), two person transfer =should only be used when the resident is not medically appropriate Sit to Stand or Total Lift, sit to stand=requires two caregivers, Full Mechanical Lift=total lift transfer with two caregivers, sliding board-1-2 caregivers as care planned and use of sliding board with gait belt. When a resident has fallen to the floor, a nurse will assess the resident. If the resident is deemed medically appropriate to transfer from the floor, a total body mechanical lift will be used.
May 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a resident right to dignified care and treatment. This failur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a resident right to dignified care and treatment. This failure affects one of three residents (R3) reviewed for dignity/abuse on the sample list of three.
Findings include:
R3's Minimum Data Set (MDS) dated [DATE] documents R3 has a brief interview of Mental Status score of 13 out of a possible 15, indicating no cognitive impairment. The same MDS documents R3 is incontinent of bowel and bladder, frequently.
R3's Diagnoses Sheet dated 3/11/24 documents the following: Anxiety Disorder Unspecified, Other Fatigue, Irritable Bowel Syndrome with Diarrhea, and Benign Neoplasm of Unspecified Part of Small Intestine.
R3's Care Plan dated 4/9/24 documents (R3) has Bowel & bladder incontinence, R3 will remain free from skin breakdown due to incontinence and brief use through the review date, and (R3) has a need for assistance during transfers.
On 5/7/24 at 12:30 pm V10, Auxiliary Assistant was interviewed regarding abuse. V10 stated the following: Anything abuse, I heard myself or seen, I overheard (R3) say something to a nurse. I think it was (V7, Licensed Practical Nurse) the Nurse. She is an LPN. I don't know if it was true or not. I think I heard (R3) said something like a (racial description) CNA (later identified as V13, Certified Nursing Assistant) asked her (R3) why she was wearing a diaper and ask (R3) why she needed to go to the bathroom with a diaper on.
On 5/7/24 at 4:20 pm R3 stated There was a situation this past weekend, Friday (5/3/24) overnight (described the CNA and identified the CNA by first name). I want to make sure you know it is not the other (CNA with the same first name). She is very nice to me. Friday overnight (later identified as V13, Certified Nursing Assistant) with the (specific description) is always coming in here (R3's room) rolling her eyes, when I ask for things. That night (V13, CNA) said, 'Why are you wearing a diaper and why do I still have to take you to the bathroom.' R3 then stated I told the morning nurse that next day. I felt humiliated. I asked who the CNA's supervisor was and the day nurse (unidentified) said 'I guess I am.' I don't remember her name (remains unidentified), but she has long dark hair. (V13, CNA) was in here again last night and she was fine. Friday night she made me feel like I was two inches tall. I didn't feel abused. I did feel (V13, CNA) was very disrespectful.
The facility Grievance/Complaint Form signed by V1, Administrator/Abuse Prevention Coordinator dated 5/7/24 documents R3 reported that a CNA (unidentified) said You don't need to go to the bathroom, you have a diaper on.
On 5/7/24 at 4:35 pm V1, Administrator stated he talked to R3 and received the same information. R3 told V1 that she did not feel her interactions with V13, CNA were abuse, just very poor customer service. V1 confirmed the incident between V13, CNA and R3 was a dignity issue.
On 5/8/24 at 8:40 am V1, Administrator re-iterated the situation with R3 was a dignity issue. V1 stated V13, Certified Nursing Assistant was suspended until she completes education on customer service.
The facility Subject: Policy Resident Privacy and Dignity dated as revised 10/15/23 documents the following:
PURPOSE:
To provide all residents with a home like environment that promotes dignity and respect to the residents of the facility.
POLICY:
To ensure that all residents are provided with dignity and privacy.
RESPONSIBILITY:
It is the responsibility of all staff to ensure that all residents have privacy and dignity.
PROCEDURE:
1. All residents will be addressed and spoken to with dignity and respect at all times. All residents will be addressed by their preferred name during conversation.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to protect a residents' right to be free from verbal/ment...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to protect a residents' right to be free from verbal/mental abuse by another resident. This failure affects two of three residents (R1 and R2) reviewed for abuse on the sample list of three.
Findings include:
R2's Diagnoses Sheet dated 5/1/24 documents the following: Unspecified Dementia, Unspecified Severity Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety.
R2's Brief Interview of Mental Status (BIMS) on admission 5/1/24 score is documented as 4 out of a possible 15, indicating severe cognitive impairment.
R2 admission Note dated 5/01/24 at 3:07 pm documents R2 ambulates with a walker.
R1's Diagnoses Sheet dated 5/5/22 documents the following: Hemiplegia and Hemiparesis Following a Cerebra Infarction Affecting Left Non-Dominant Side, Chronic Obstructive Pulmonary Disease Unspecified, Major Depressive Disorder Recurrent, and Unspecified and Anxiety. R1's diagnoses sheet does not document a diagnoses of Dementia or related cognitive impairment diagnoses.
R1's Minimum Data Set, dated [DATE] documents R1 has a BIMS score of eight out of a possible 15, indicating moderate cognitive impairment. The same MDS documents R1 has limited range of motion to one upper and one lower extremity and uses a wheelchair for mobility.
R1's Care Plan dated 3/28/24 documents the following: (R1) is at risk for abuse and neglect, per assessment tool. (R1) will not experience any abuse/neglect.
The facility initial report to the State Agency dated 5/6/24 at 11:40 am documents Suspected Abuse and Argument /Incident between R2 and R1.
The facility alleged abuse investigation included the following Resident/Staff Statement dated 5/6/24 at 10:15 am, signed by V23, Assistant Administrator Resident (R1) states roommate (R2) began going through her (R1's) side of the closet and accusing her (R1) of stealing her belongings. (R1) states she can't get up to stop her, so (R1) told her (R2) to stop. States roommate (R2) started yelling slurs and got in her (R1) face but never hit her or anything. Stated roommate had two men in her room with her (R2) but they did not do anything.
R2's Incident Note dated 05/05/2024 at 2:21 pm, by V4, Licensed Practical Nurse (LPN) documents that V3, Housekeeper reported a resident to resident altercation between R1 and R2 that occurred in their resident room. The note documents (R1) threw her water jug at R2 to stop R2 from pulling R1's hair. The note documents R2 was removed from the room and redirected to the television lounge. The note documents Resident (R2) keeps accusing her bedridden roommate (R1) of stealing her (R2's) clothes and other things but she (R2) was reassured multiple times that those belongings aren't hers. Right before shift change the resident (R2) peeked outside her room and waved for myself (V4, LPN) and the oncoming nurse (V5, LPN) to come to her. When we got there, she (R2) continued to complain about the same thing. Accusing her roommate (R1) of stealing her (R2) things. Her roommate (R1) then reported to us that (R2) called her (R1) a racial slur. (R2) didn't deny it, in fact she apologized to myself and the other nurse for the racial slur that was said. Again, she (R2) was removed from the room, we told her to remain in the tv lounge until we figured out what to do next. The administrator was also contacted about the situation, currently waiting on a response.
On 5/7/24 at 8:10 am V4, LPN confirmed the details of the 5/5/24 Incident Note.
On 5/8/24 at 11:53 AM V3, Housekeeper stated (R1) was worried about (R2) getting into her clothes. They both argued with each other. This was Sunday (5/5/24), a fight of words, going back and forth. (R2) was getting really agitated. (R1) did keep arguing with (R2). She kept saying the clothes in the closet were her (R1) own. They were arguing and (R2) was on (R1's) side of the room. (R1) cannot get out of bed. She is always in bed. (R1) was afraid as any resident would be that (R2) was going to hit her. I did not see her hit her and did not see (R2) pull (R1's) hair. We, the nurse (V4) and I, explained to (R2) that (R1's) things were her own and showed (R2) her side of the closet and her own things. (V4) then told (R2) to stay on her side of the room. (R2) laid down on her bed. A little while later (R2) was back over on (R1's) side of the room and yelling at (R1) who was in bed. (R2) was saying (R1) needed to give (R2) back her clothes. (V4) went back in (R1 and R2's room) with another nurse (V5, LPN)). I went on with my work. V3 stated I did hear racial slurs. I did hear one of them call the other a hillbilly. I did hear (R2) call (R1) a (racial slur). There was no physical connection (contact). It was all words.
5/7/24 at 2:34 pm V5, LPN said V4, LPN provided information of the alleged abuse to V5 at shift change on 5/5/24. V5 stated, V4 and V5 heard R2 call R1 an ugly (racial slur). V5 stated (R1) confirmed what we heard. She (R1) told me and (V4) at the same time.
On 5/7/24 at 3:55 pm. R1 was lying in bed, the left side of R1's body appeared flaccid. R1 stated My roommate (R2) is downstairs now. She thought I took her clothes. I kept telling her I did not take her clothes. I don't need her clothes. I have been here a long time. Staff all treat me really good. The woman's name, I don't remember, but she was my roommate (R2). That woman (R2) just kept fussing. She came all the way over here by this table (taps on bedside table) and shook it. R1 stated She (R2) did not hit me or pull my hair. I thought she was going to though. I thought she was wanting to fight me. She was loud and abusive. She was very mean. A real nice nurse (unidentified) came in and got her away from me. Then, that woman (R2) came back in my room, and stood by my bed yelling, again. She was really close to my table and shaking it again. That is when I threw my water pitcher towards her. I can't walk. My legs don't work. I am unable to move away from her. I did not know what to do. Two nurses came back and got her out of here. They were in the hall and heard her (R2) yelling and call me (R1) a (racial slur). They (unidentified nurses) got her out of here, again. Then, awhile later her, her brother (later identified as V16, R2's Family Member) and his friend (unidentified) came in here (R1 and R2's room). Her brother saw she was cursing at me again and saying I took her clothes. It was not true. She (R2) even took clothes out of my (R1) bag in the closet. Staff took them back. She was insisting my blanket was hers one day. It is not. My nephew (unidentified) got this blanket for me. With her brother and friend in here, she called me a (racial slur) again. I was very upset. I was afraid that day, all day. Not knowing what she would do next. She came over to my bed twice. Every day she would say I took her stuff. That day she got close enough and had her hand right here on my table. She was way too close for comfort. I can't walk. I did not know what to do. She really scared me. I thought she was going to hit me.
On 5/8/24 at 4:00 pm V1 Administrator/Abuse Prevention Coordinator and V12, Regional Nurse Consultant were present during the interview. V1 acknowledged the incident between R1 and R2 occurred 5/5/24, and stated the investigation is ongoing. V12, Regional Nurse Consultant stated V12 had talked to R1. (R1) says she feels safe here and staff treat her well. (R1) was scared, immediately during the confrontation. (R1) is fine now and said she was happy and not afraid of anyone in the facility.
On 5/8/24 at 4:15 pm R1 was lying in bed. R1, recognized this surveyor and stated she knew I was from the State. When asked if she remembered what R1 and the surveyor talked about the day before (5/7/24 at 3:55 pm) R1 stated Of course I do R1 then repeated the same details R1 had shared regarding R1 being verbal/mentally abused by R2 on 5/5/24.
The facility Abuse Prevention Program dated 10/20/22 documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: conducting pre-employment screening of employees and pre-admission screening of residents; orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse neglect, exploitation, and misappropriation of property; establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment
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 record review and interview the facility failed to ensure an allegation of physical and verbal abuse by R2 towards R1, was reported to the Administrator/Abuse Prevention Coordinator. This fai...
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Based on record review and interview the facility failed to ensure an allegation of physical and verbal abuse by R2 towards R1, was reported to the Administrator/Abuse Prevention Coordinator. This failure resulted in R1 and R2 continuing to reside in the same bedroom, potentially subjecting R1 to further abuse by R2. R1 and R2 are two of three residents reviewed for abuse on the sample list of three.
Findings include:
R2's Incident Note dated 05/05/2024 at 2:21 pm, by V4, Licensed Practical Nurse (LPN) documents the following: After lunch the Resident (R2) became physically violent with her roommate (R1). The housekeeper (V3) reported that the resident (R2) was pulling her roommates (R1's) hair before her roommate (R1) threw her water jug at her (R2) to stop her from pulling her (R1's) hair. Resident (R2) was removed from her room and redirected to the tv (television) lounge. POA (V22, Power of Attorney/Family Member) was notified about the incident, and her (R2's) other (Family Member, V16) came to help calm her (R2) down. Resident (R2) keeps accusing her bedridden roommate (R1) of stealing her (R2's) clothes and other things but she was reassured multiple times that those belongings aren't hers. Right before shift change the resident (R2) peeked outside her room and waved for myself (V4, LPN) and the oncoming nurse (V5, LPN) to come to her, when we got there she (R2) continued to complain about the same thing. Accusing her roommate (R1) of stealing her (R2) things. Her roommate (R1) then reported to us that (R2) called her (R1) a racial slur. (R2) didn't deny it, in fact she apologized to myself and the other nurse for the racial slur that was said. Again, she (R2) was removed from the room, we told her to remain in the tv lounge until we figured out what to do next. The administrator was also contacted about the situation, currently waiting on a response.
On 5/7/24 at 8:10 am V4, LPN stated she notified V1, Administrator, by text 5/5/24 at 2:02 pm that R2 was being combative.
On 5/7/24 at 1:38 pm V2, Director of Nursing said the first V2 news of an allegation of physical and verbal abuse, related to R1 and R2 was on 5/6/24. V2 stated, V8, Registered Nurse (RN) Manager found a note in R2's medical record. V2 stated she interviewed V4, who told V2 she sent a text to V1, Administrator on 5/5/24. V4 then read the text to V2 which documented R2 was combative, but the text did not identify R2 was combative with R1. V2 stated V1, Administrator had directed V4 to move R2 to another room.
On 5/7/24 at 2:07 pm V8, RN stated I was the on-call manager on the weekend. We do a rotation. I did not hear anything other than staff call ins, falls and residents being sent out to the hospital. I did not hear anything regarding (R2) and the other resident (R1). I should have, as the nurse manager on call. I would have followed our policy and immediately called (V1, Administrator/Abuse Prevention Coordinator). I found the note yesterday.
On 5/7/24 at 2:34 pm V5, LPN said V4, LPN provided information of the alleged physical abuse to V5 at shift change. V5 stated V4 and V5 heard R2 call R1 an ugly (racial slur). V5 stated V4 told V5 that V4 reported both verbal and physical abuse to V1, Administrator/Abuse Prevention Coordinator, so V5 did not report.
On 5/8/24 at 11:53 V3, Housekeeper stated (on 5/5/24) I did hear racial slurs. I did hear one of them call the other a hillbilly. I did hear (R2) call (R1) a (racial slur). There was no physical connection (contact). It was all words. V3 stated V3 did not report the incident to the administrator.
The facility Notification of Termination of Employment dated 5/6/24 documents V4, Licensed Practical Nurse ceased employment with the facility due to Failure to follow protocol related to abuse prevention and reporting.
On 5/8/24 at 1:45 pm V1, Administrator/Abuse Prevention Coordinator and V12, Regional Nurse Consultant stated V4 was terminated because she did not report the abuse allegation to the on call Manager (V8, Registered Nurse) or V1 as V4, LPN should have. V1 and V12 stated a vague text to V1, referred to a combative resident. It did not mention the allegation of verbal or physical abuse between the two residents (R1 and R2).
The facility policy Abuse Prevention Program dated 10/20/2022 documents the following: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents.
The same policy documents: Internal Reporting Requirements and Identification of Allegations. Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. In the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence. Employees, without fear of retaliation, may also independently report to the state survey agency any allegation of abuse, neglect, exploitation, mistreatment or misappropriation of resident property, and to local law enforcement or the state survey agency if they have a suspicion that a crime was committed. All residents, visitors, volunteers, family members or others are encouraged to report their concerns or suspected incidents of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property to the administrator or an immediate supervisor who must then immediately report it to the administrator or the designated individual in the administrator's absence. Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated.
May 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure two staff were assisting during a mechanical lift transfer fo...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure two staff were assisting during a mechanical lift transfer for one of four residents (R2) reviewed for falls on the sample list of four. This past noncompliance occurred from 4/20/24 to 4/25/24.
Findings include:
The Physician's Order Sheet (POS) dated April 2024 documents the following diagnoses for R2: Chronic Obstructive Pulmonary Disease, Unspecified Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure and Morbid Obesity.
The Minimum Data Set (MDS) dated [DATE] documents R2 is independent in decision making skills, uses an electric wheelchair for transportation needs, and activities of daily living are completed by staff due to R2's medical diagnoses.
R2's care plan dated 3/8/24 documents R2 requires two staff assistance for all transfers. Mechanical lift transfer requires two staff to be present.
Facility incident report dated April 20, 2024, documents on April 20, 2024, at approximately 2:00 pm, V12, Certified Nurse Assistant (CNA) attempted to transfer R2 from the wheelchair to the bed using a mechanical lift without the assistance of a second staff member. The report states that during the transfer R2 fell out of the mechanical sling and fell to the floor hitting her buttocks and head on the mechanical transfer base frame. The report states V14, Registered Nurse (RN) was notified and R2 was sent to the Emergency Department. The report documents R2 returned to the facility with no injuries.
On 4/30/24 at 11:30 am R2 stated she was being transferred from her electric wheelchair to the bed. R2 stated at first there were two people assisting with the transfer, then one CNA received a phone call stating it was an emergency and left the room. R2 stated V12 decided he would do the transfer by himself and R2 fell out of the mechanical sling and hit the floor on her buttocks and head.
The facility's policy on Transfers dated 8/2017 documents under Procedures #3 A minimum of two staff members is recommended when transferring with a mechanical lift.
V1, Administrator confirmed on 4/26/24 at 10:00 am, One staff member transferred R2 using the mechanical lift and R2 slipped out of the sling and fell. V1 stated two staff members are needed for a mechanical lift transfer.
Prior to the survey date, the facility took the following actions to correct the noncompliance.
1. All residents that are transferred via mechanical lift have the potential to be affected. All mechanical lift slings were inspected for signs of disrepair. Nursing and laundry staff were educated on mechanical lift sling inspection. All nursing staff were educated on safe use of mechanical lifts requiring two nursing staff for the entire transfer. Action completed 4/22/24.
2. Nursing and laundry staff will be educated upon hire and at least annually on the mechanical lift sling inspection protocols - inspected during laundering and nursing staff to inspect prior to each use. Action completed on 4/22/24 and ongoing.
3. Mechanical lift slings will be inspected by the administrator or designee weekly for four weeks and then bi-weekly for four weeks to ensure slings are in good repair. Action completed on 4/20/24 and ongoing.
4. The facility performed an audit checking the staff using the mechanical lift on 4/25/24. Lift transfers will be monitored/audited on an ongoing basis.
5. The results of these audits will be reviewed by the facility Quality Assurance Performance Improvement (QAPI) committee for patterns, trends, and continued recommendations for process monitoring and improvement.
Compliance Achieved 4/25/24.
Mar 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed notify the physician of a resident refusal of catheterization for one (R1) of three residents reviewed for physician notification on the sample...
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Based on interview and record review the facility failed notify the physician of a resident refusal of catheterization for one (R1) of three residents reviewed for physician notification on the sample list of three.
Findings include:
R1's progress notes dated 2/26/24 document that R1 was complaining of burning with urination.
R1's progress notes dated 2/26/24, document V6 Nurse Practitioner ordered a urinalysis with a culture and sensitivity to be obtained on R1.
R1's progress notes dated 2/26/24 through 2/29/24 document that R1 refused to have a catheterization performed for the urinalysis, with culture and sensitivity.
R1's medical record does not document that the physician was notified that R1's urinalysis with culture and sensitivity was not collected from 2/26/24 through 2/29/24.
R1's progress notes document that R1 was discharged to a local hospital on 2/29/24.
R1's hospital discharge record dated 3/9/24 documents that a catheterization was performed on R1 upon hospital admission that resulted in a positive urinalysis that grew Klebsiella Pneumoniae (ESBL) and was then treated with intravenous antibiotics (Ertapenem) one gram for five days.
On 3/11/24 at 3:10PM, V3 Regional Clinical Nurse/Interim Director of Nursing said that if the nursing staff were unable to obtain an ordered specimen, that they should then notify the provider.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to administer narcotic medications safely to one (R1) of three residents reviewed for narcotic administration on the sample list of three.
Find...
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Based on interview and record review the facility failed to administer narcotic medications safely to one (R1) of three residents reviewed for narcotic administration on the sample list of three.
Findings include:
The Physician Order dated 2/19/24 documents to give R1 one Oxycodone-APAP 5-325 milligram tablet three times a day for pain.
The controlled drug receipt/record/disposition form dated 2/20/24 documents on 2/29/24 at 10:00AM, one Oxycodone/APAP 5-325 milligram tablet (narcotic) was given to R1 by V4 LPN/Licensed Practical Nurse.
The controlled drug receipt/record/disposition form dated 2/20/24 documents on 2/29/24 at 1:00PM, one Oxycodone/APAP 5-325 milligram tablet (narcotic) was given to R1 by V4 LPN.
On 3/11/24 at 9:30AM, V7 Certified Nursing Assistant (CNA) stated that on the morning of 2/29/23, V7 CNA had gone into R1's room to answer a call light for one of R1's roommates and saw R1 lying in bed without wearing her oxygen and without wearing any clothing. V7 CNA stated that he asked R1 what was going on and R1 was lethargic and slow to respond, not like R1's usual self. V7 CNA stated that R1 slept through being changed, which was very unusual for R1. V7 CNA stated that he notified V4 Licensed Practical Nurse of R1's behavior.
On 3/11/24 at 8:53AM, V4 Licensed Practical Nurse (LPN) stated that on the morning of 2/29/23, V4 LPN found R1 with low oxygen saturation levels lying flat in bed. I put oxygen on her and put her head of bed up and kept a close eye on her. I gave her pain medication to her at approximately 10:00AM that morning. She was sleepy, but still complained of pain. I checked her saturation levels throughout the day and gave her another pain pill at about 1:00PM. She continued to get more drowsy and so we called the doctor and got an order for the Naloxone (narcotic reversal agent). It seemed to help some and then we sent her to the emergency room.
On 3/11/24 at 2:50PM, V6 Nurse Practitioner stated, The Oxycodone doses should not have been given (to R1) so close. It was ordered three times a day and that means every eight hours, no sooner.
The facility provided medication error form documents that R1's Oxycodone-APAP 5-325 milligram doses were given too closely together and that the resident has a history of lethargy, respiratory symptoms, and hyperglycemia. Additional documentation includes that a reversal agent was administered after the narcotics and R1 became more alert and was then hospitalized .
The facility Administration of Medications Policy dated 8/2023 documents that residents shall receive their medications on a timely basis.
The National Institute of Health Oxycodone-APAP 5-325 milligram daily medication information sheet documents that Oxycodone-APAP 5-325 milligrams can cause respiratory depression and must be monitored closely.
Feb 2024
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 F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to revise and update a resident's (R1) Plan of Care to include Gastrostomy Residual Volume checks before each enteral feeding. R1 is one of th...
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Based on interview and record review, the facility failed to revise and update a resident's (R1) Plan of Care to include Gastrostomy Residual Volume checks before each enteral feeding. R1 is one of three residents reviewed for Care Plans in the sample of three.
Findings include:
R1's Diagnosis Sheet (current) includes the following diagnoses: Dysphagia Status Post Cerebral Vascular Accident, Chronic Cholecystitis, Gastrostomy Status and Left Sided Hemiparesis.
R1's Care Plan (current) documents G Tube (Gastrostomy Tube) placement R/T (Related To) Dysphagia and initiated on 6/4/23. Intervention tasks are documented as Check G Tube placement as ordered. Flush G Tube as ordered. Check for Patency of G Tube, Monitor area around Stoma for S/S (Sign and Symptoms) of Infection. There is no intervention for Gastrostomy Residual Volume (GRV) checks and parameters for holding the tube feeding prior to administration when residuals exceed a certain amount.
R1's Physician Order Sheet (POS) dated 2/8/24 documents an order for R1's G Tube to be checked for residuals prior to feeding and if 100 milliliters or greater to hold tube feeding and notify the physician. There are no previous orders for GRV checks and or parameters on previous POS's (December 2023, January 2024 and part of February as described above).
On 2/9/24 at 1:40 pm, V3 Corporate Nurse confirmed that R1's Care Plan did not document that GRV's are to be checked before R1's tube feedings and the Care Plan should have been revised and updated.
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
Tube Feeding
(Tag F0693)
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 have physician orders in place regarding Gastrostomy Residual Volum...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have physician orders in place regarding Gastrostomy Residual Volumes (GRV) check with result parameters prior to starting tube feedings for three (R1, R2, R3) of three residents reviewed for tube feedings in the sample of three.
Findings include:
1. R1's Diagnosis Sheet (current) includes Gastrostomy Status.
R1's Physician Order Sheets (POS) dated December 2023, January and February 2024 do not document any orders prior to 2/8/24 for the facility to check GRV's before starting tube feedings. These same POS's document R1 with continuous tube feedings.
R1's Progress Notes document the following:
On 1/30/24 at 1:03 pm - The patient had an emesis this shift, the same color as (R1's) feeding while receiving a bed bath this a.m./morning. This Nurse (V4 Licensed Practical Nurse) and CNA (V5 Certified Nursing Assistant) were rolling the patient from side to side and the patient vomited. The patient had been flushed prior to that morning.
On 2/1/24 at 7:11 am The patient is experiencing hallucinations and is yelling out very loudly this a.m. The patient has right facial drooping, with slurred speech. Lungs are assessed and are clear, hand grips are equal. The patient is tachycardic. Pupil size is at 3. Bowel sounds present. V/S (vital signs) are as follows Bp (blood pressure) -132/84, P (pulse) 120, R (respirations) -16, T (temperature) -97.4 SPO2 (oxygen saturation) -93%. Np (Nurse Practitioner) contacted this shift at 07:15 and is aware of the patient's symptoms and recommends the patient be sent to the ER (Emergency Room) for further evaluation.
R1's Hospital Records dated 2/1/24 include the following admitting diagnoses: Severe Sepsis (temperature 104.8) and Aspiration Pneumonia.
2. R2's Diagnosis Sheet (current) includes Gastrostomy Status.
R2's Progress Note dated 1/9/24 at 6:39 pm documents resident experiencing respiratory.
distress, loud labored breathing, accessory muscles, adventitious lung sounds, pulmonary edema. On 1/9/24 At 6:56 pm R2's Progress Notes document R2 being sent to the hospital and admitted .
The facility Infection Control Log dated 1/9/2024 documents R2 with Aspiration Pneumonia.
R2's Physician Order Sheets (POS) dated December and January document continuous tube feedings but do not contain any orders until 1/16/24 for GRV's with parameters prior to tube feedings. On R2's January POS dated 1/16/24 (readmission from hospital) a new order for nursing to check gastrostomy residual amounts before tube feedings and if 100 milliliters or greater to hold tube feeding and call physician.
3. R3's Diagnosis Sheet (current) includes the diagnosis of Gastrostomy Status.
R3's Physician Order Sheet (POS) dated December 2023, January and February 2024 does not document an order for Gastrostomy Residual Volume (GRV) checks with parameters until 2/9/24. The new order on 2/9/24 documents for nursing to check GRV's before feeding and if 100 milliliters or greater to hold tube feeding.
On 2/9/24 at 1:30 pm V6, Licensed Practical Nurse stated V6 had no knowledge of what the GRV parameters would be to hold a tube feeding. V6 stated That's a good question.
On 2/9/24 at 1:40 pm V3 Corporate Registered Nurse stated that checking GVR's is a Standard of Nursing Practice and should be done before any tube feedings are started. V3 could not say why this was not on the resident's POS (Physician Order Sheet) or MAR (Medication Administration Record) for R1, R2, or R3.
The Facility Policy titled Enteral Feeding dated (revised) August 2023 documents the following directives to staff:
Purpose:
To provide guidelines to Licensed nursing staff for providing liquid nourishment, through a tube, into the stomach also known as Gavage, Gastric Tube Feeding, [NAME] Tube Feeding, Nasogastric tube feeding, Gastrostomy Tube Feeding, and Jejunostomy tube feeding. The tubes Provide a method of administering nutrients directly into the stomach/GI (gastrointestinal) tract and is indicated for those residents who cannot consume adequate nutrients [NAME] (sic) via the oral cavity. Tube feedings are ordered by the physician and administered either intermittently or continuously.
Policy:
Residents with Asiatic, Gastrostomy, or Jejunostomy shall receive hydration, nutrition and medication via the tube as ordered.
Responsibility:
It is the responsibility of Charge Nurse to monitor and care for feeding tubes as ordered.
It is the responsibility of the DON (Director of Nursing)/Designee to provide education and training to ensure knowledge of procedure.
Procedure:
8. Checking Residual of Stomach Content:
A. Check physician's order to check gastric residual.
B. Insert feeding syringe into feeding tube and aspirate stomach contents gently.
C. The amount of residual may determine the amount of current feeding.
D. Fifty cc's (cubic centimeter) or less is usually returned to the stomach, disregard and feeding administered.
E. Fifty to one hundred cc's is usually returned to the stomach, subtracted from the amount of feeding to be administered.
F. Two hundred cc's and over is usually returned to the stomach and the tube feeding held. Notify the physician as ordered.
Jan 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to thoroughly investigate an injury of unknown origin for one of four residents (R6) reviewed for injuries in the sample list of 33.
Findings ...
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Based on interview and record review the facility failed to thoroughly investigate an injury of unknown origin for one of four residents (R6) reviewed for injuries in the sample list of 33.
Findings include:
The facility's Illinois Department of Public Health reporting form dated 1/23/24 documents on 1/23/24 at 8:44 PM the facility received a phone call from the hospital reporting bruising to R6's genital area that appears to be of unknown origin, and an investigation was initiated. This report documents this incident as suspected abuse/neglect. The facility's undated investigation of R6's bruising documents R6 was sent to the hospital on the afternoon of 1/23/24 and the emergency room nurse noted bruising to R6's penis and testicles. This investigation documents V8 Licensed Practical Nurse (LPN) provided a statement that attempts were made to obtain urinalysis due to increased lethargy on 1/22/24, and R6 became combative/agitated during the procedure. R6 struggled against the nurse's hold during attempt of catheter insertion and R6 receives Plavix (blood thinning medication). This report documents a conclusion that R6's penile bruising was the result of factors of pressure to the surface area, Plavix use, and liver cancer diagnosis. V8's Written Statement dated 1/24/24 documents V8 was unsuccessful in obtaining R6's urine sample with a urinal and V7 LPN attempted to straight catheterize R6. V8's statement documents V7 reported that R6 became combative, and the catheterization was unsuccessful. V8's statement documents V8 told the oncoming Nurse V9 LPN that R6 still needed a urine sample for urinalysis. The electronic mail dated 1/30/24 at 1:25 PM documents V1 Administrator submitted the final report of the investigation to this allegation to the state survey agency.
The facility's Daily Nursing Assignment Log dated 1/22/24 documents V10 Certified Nursing Assistant (CNA) was assigned to R6's hallway on 2nd shift and V11 CNA on 3rd shift. R7's and R6's undated census document R6 and R7 shared rooms from 1/16/24 until 1/23/24. R7's Nursing Notes ranging from 1/19/24-1/30/24 document R7 is alert and oriented to person, place, time, and situation. There is no documentation that V10, V11, V9, V7 or R7 were interviewed as part of the investigation of R6's abuse allegation.
On 1/30/24 at 7:36 PM V7 LPN stated V7 stated V7 was not aware of any bruising to R6's genitals, R6 is on blood thinners so bruises easily. V7 stated V8 LPN received an order to straight catheterize R6, V7 was busy, so V8 told V7 that V8 would catheterize R6. V7 stated V7 attempted to catheterize R6 one time and R6 yelled at V7 to stop. V7 stated V7 immediately stopped and reported to V8. V7 stated there were no other staff present with V7 during R6's catheterization attempt. V7 stated no facility staff had interviewed V7 about this incident or R6's bruising. V7 stated V7 was not aware that something had happened to R6.
On 1/31/24 at 10:46 AM V8 LPN stated we were told R6's genital bruising was found when R6 went to the hospital. V8 stated a day or prior we had to obtain a urine sample and V7 LPN attempted to catheterize R6 to obtain the sample, R6 became combative, and the catheterization was unsuccessful. V8 stated that is what V7 told V8, and V8 had not attempted to catheterize R6.
On 1/31/24 at 8:58 AM V1 stated all of the interviews and investigation have been provided for R6's injury of known origin, other than V1 needs to add the physician's statement. At 12:22 PM V1 stated interviewing resident's roommates is the easiest way to determine if there is an abuse allegation. V1 stated V1 interviewed R7 regarding R6's allegation but must have forgot to document that. Staff are interviewed if they have cared for the resident or may have possible information. V8 was the nurse who attempted R6's catheterization, and R6 was agitated during the catheterization. V1 stated the only incident we could identify to be the logical cause of the bruising was R6's straight catheterization attempt. V1 stated V1 did not interview V7. V1 did not realize that V7, and not V8, was the nurse who attempted R6's catheterization.
The facility's Abuse Prevention Program dated 10/20/22 documents: An injury should be classified as an injury of unknown source when All of the following conditions are met: The source of the injury was not observed by any person and; The source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury (e.g. (for example) the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time, or the incidence of injuries over time. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable.
The facility's Reporting/Investigating Resident Abuse policy dated as revised May 2022 documents abuse investigations should include, when appropriate, interviews with the person who reported the incident, the resident, any witnesses, staff members who have contact with the resident during the time frame of the alleged incident, the resident's roommate/family/visitors, and the alleged person responsible.
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 F0659
(Tag F0659)
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 medications in accordance with physician's orders for two...
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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 medications in accordance with physician's orders for two of five residents (R5 and R9) reviewed for medications in the sample list of 33.
Findings include:
The Medication Error Form dated 1/13/24 at 5:00 PM documents V12 Registered Nurse (RN) administered the wrong medications to R5. The medications given were Metformin (diabetic medication) 500 milligrams (mg), Duloxetine (antidepressant) 60 mg, Omeprazole (treats heartburn, ulcers, reflux) 40 mg, Pregabalin (controlled medication for pain) 200 mg, and Topiramate (seizure medication) 100 mg. This form documents V12 prepopped medications and inadvertently administered the wrong medications to R5. This form documents V12 was educated not to prepop medications and a photograph was placed in R5's medical record that day.
R5's Order Summary dated 1/13/24 documents R5 admitted to the facility on [DATE] and R5's orders did not include the medications listed as given in the Medication Error Form. R9's Order Summary dated 1/13/24 documents R9's orders include Metformin 500 mg three times daily, Duloxetine 60 mg twice daily, Omeprazole 40 mg twice daily, Pregabalin 200 mg three times daily, and Topiramate 100 mg twice daily.
On 1/31/24 at 11:52 AM V12 RN stated, in regards to R5's medication error, V12 was working the 1st floor North medication cart. V12 stated due to Respiratory Syncytial Virus (RSV) isolation V12 pulled medications out for two residents and V12 had prepopped the medications for that hallway. V12 stated R5's roommate had questions about her medications and when V12 returned to the medication cart V12 realized R5 was given another resident's medications. V12 stated R5 was given Omeprazole, blood sugar medication, Lyrica, and Topiramate. V12 stated the nurse practitioner was notified and we monitored R5's vital signs, blood sugars, and level of consciousness. V12 stated it is not standard practice to prepop medications and it was V12's first time caring for R5 that day. V12 stated we are suppose to verify the resident by name and picture, which V12 did not do that day.
On 1/31/24 at 12:07 PM V2 Director of Nursing stated V12 had prepop the medications due to the RSV and R9's medications were given to R5. V2 stated R9 was not R5's roommate, but resided on the same hallway.
The facility's Administration of Medications policy dated as revised August 2023 documents medications must be administered in accordance with the physician's written orders and may not be prepared in advance. This policy documents medications should not be administered until positive resident identification has been made.
The facility's Medication Errors policy dated August 2017 documents medication errors are any variation from the physician's orders and/or facility policy and a Medication Error Form will be completed.
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 implement its policies to accurately record and account for controlled medications for 28 of 28 residents (R1, R2, R3, R9-R33)...
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Based on observation, interview, and record review the facility failed to implement its policies to accurately record and account for controlled medications for 28 of 28 residents (R1, R2, R3, R9-R33) reviewed for controlled medications in the sample list of 33.
Findings include:
1.) On 1/30/24 at 8:59 AM the medication cart and controlled medication binder for 1st floor [NAME] Hall was reviewed with V4 Licensed Practical Nurse (LPN). The last recorded entry on the controlled substance shift to shift count is 2:00 PM-10:00 PM, indicating the form is not up to date/current to account for shift count between nights and dayshift. This entry only includes one nurse signature and not two as indicated. V4 stated controlled medication counts are to be done with two nurses at change of shift, both nurses sign the count sheet, and the number of cards and bottles are also counted. V4 stated the count was done this morning, but the form doesn't document the nurse signatures for this count. At this time V4 documented on the controlled count form an untimed entry date of 1/30 and V4's initials. V4 stated there are 11 cards and three bottles of controlled medications for this cart since an unidentified hospice resident passed so their medications were destroyed. V4 documented on the form 11 cards and three bottles as the count at start of shift. V4 confirmed this form does not document the destroyed medications. Random controlled medication audits of this cart were conducted. The cart contained 18 tablets of R10's Pregabalin 150 milligrams (mg), 15 tablets of R28's Norco 5/325 mg, and 20 tablets of R30's Norco 5/325 mg. The [NAME] Hall controlled medication shift count forms dated as ranging from 1/13/24-1/30/24 document 25 blank entries with no nurse initials. These forms document under the column count at start/end of shift, 25 blank entries for the number of medication cards/bottles. These forms do not consistently document recorded entries for each shift every day. There are eight missing shifts that are not accounted for.
On 1/30/24 at 9:09 AM the medication cart and controlled medication binder for the 1st floor North Hall was reviewed with V5 LPN. Random controlled medication audit of this cart was conducted. The cart contained 22 tablets of R33's Norco 5/325 mg, 28 tablets of R33's Tylenol with Codeine 3000-600 mg, 21 tablets of R25's Norco 7.5/325 mg, a bottle of R26's Clobazam 2.5 mg/milliliter. The North Hall controlled medication shift count forms dated ranging from 12/30/23-1/30/24 document 22 blank entries with no nurse initials and 24 blank entries for the number of medication bottles/cards. There are 34 missing shifts that are not accounted for.
On 1/30/24 at 9:13 AM the medication cart and controlled medication binder for the 1st floor East Hall was reviewed with V3 LPN. Random controlled medication audit of this cart was conducted. The cart contained four tablets of R19's Norco 5/325 mg, four tablets of R3's Norco 5/325 mg, and 28 tablets of R2's Norco 5/325 mg. The East Hall controlled medication shift count forms dated as ranging from 1/12/24-1/30/24 document 12 blank entries for nurse initials and 16 blank entries for the number of medication bottles/cards. There are 11 missing shifts that aren't accounted for.
On 1/30/24 at 9:30 AM the medication cart and controlled medication binder for the 1st floor South Hall was reviewed with V4 LPN. Random controlled medication audit of this cart was conducted. The cart contained 11 tablets of R12's Oxycodone 5 mg, 13 tablets of R14's Pregabalin 100 mg, 15 tablets of R14's Tramadol 50 mg, three tablets R16's Tramadol 50 mg and 16 tablets of R17's Pregabalin 100 mg. The South Hall controlled medication shift count forms dated as ranging from 1/28/24-1/30/24 document three blank/missing entries for nurse initials and medication card/bottle counts.
On 1/30/24 at 3:15 PM V1 Administrator stated a few years ago there was an issue with a controlled medication card missing so that is why the nurses document the number of controlled medication bottles/cards on the shift-to-shift counts.
On 1/31/24 at 10:56 AM V13 Corporate Nurse stated some nurses work 12 hour shifts and some work eight-hour shifts. V13 reviewed the 1st floor-controlled medication shift count forms and acknowledged the blank nurse signatures.
The Controlled Drug Receipt/Record/Disposition Forms for R1, R2, R3, and R9-R33 document these residents' controlled medications and accounting of these medications. The resident roster dated 1/30/24 document R1, R2, R3, and R10-R33 reside on the 1st floor of the facility.
2.) R1's Controlled Drug Receipt/Record/Disposition Form with dispense date 10/30/23 documents an accounting of Norco 5/325 mg that includes entries for 11/9/23 at 5:30 AM, 11/10/23 at 4:45 AM, 11/13/23 at 8:30 AM, 11/14/23 at 8:17 AM, 11/23/23 at 4:30 AM, 11/25/23 at 8:45 AM, 11/29/23 at 7:47 AM, 12/23/23 at 8:18 AM, and 12/24/23 at 7:10 AM. R1's November and December 2023 Medication Administration Records (MARs) does not document Norco was administered on the dates/times listed from R1's Controlled Drug Receipt/Record/Disposition Form.
On 1/30/24 at 9:22 AM R1 stated R1 used to take Norco as needed.
3.) R2's Controlled Drug Receipt/Record/Disposition Form with dispense date 12/15/23 documents an accounting of Norco 5/325 mg that includes entries for 12/23/23 (no documented time), 12/28/23 at 7:00 PM, and 1/11/24 at 8:00 PM. R2's Norco 5/325 mg Controlled Drug Receipt/Record/Disposition Form with dispense date 1/26/24 documents an entry for 1/28/24 at 9:15 PM. R2's December 2023 and January 2024 MARs do not document Norco was administered on the dates/times listed from R2's Controlled Drug Receipt/Record/Disposition Forms.
On 1/30/24 at 12:34 PM R2 stated R2 lets the nurse know when R2 wants Norco, and it is taken as needed.
4.) R3's Norco 5/325 mg Controlled Drug Receipt/Record/Disposition Form with dispense date 9/1/23 documents entries for 1/20/24 at 1:00 AM and 1/28/24 at 5:30 PM. R3's January 2024 MAR does not document any Norco administrations.
On 1/30/24 at 3:39 PM V18 Registered Nurse recalled administering R3's Norco in January. V18 stated sometimes V18 gets in a hurry and forgets to record the PRN (as needed) administration on the MAR.
On 1/30/24 at 3:00 PM V2 Director of Nursing confirmed the nurses should document on the MAR when as needed narcotics are administered. V2 stated when the medication is given the nurse should sign the count sheet, and if for some reason the medication was not given after being popped from the card it has to be wasted and signed by two nurses to verify.
The facility's Administration of Medications policy dated as revised August 2023 documents medication administration must be documented immediately following administration, and the date/time/dose will be recorded on the MAR.
The facility's Narcotic Count policy revised 9/5/22 documents a physical inventory of narcotics will be completed at each change of shift by the licensed nurses in order to identify discrepancies, reconciliation, accountability, proper storage/disposal, and proper record keeping. This policy documents the inventory check will be completed by the nurse going off duty and the nurse coming on duty, and both nurses must physically count and verify accuracy of the narcotic supply for each resident. This policy documents the Shift Change Accountability Record Sheet for Controlled Substances will be used to document the shift counts and each nurse must sign and date at the beginning and end of each shift that this count was verified and correct.
Nov 2023
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to provide Advance Beneficiary Notices (ABN) to three of three residents (R264, R146, and R6) reviewed for Beneficiary Protection Notifications...
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Based on interview and record review the facility failed to provide Advance Beneficiary Notices (ABN) to three of three residents (R264, R146, and R6) reviewed for Beneficiary Protection Notifications on the sample list of 77.
Findings include:
1. R264's Beneficiary Protection Notification Review form provided by V1 Administrator, documents R264's Medicare start date as 10/17/23. This form documents R264's last covered Medicare day as 11/2/23. This form documents the facility/provider initiated R264's discharge from Medicare Part A Services when benefit days were not exhausted. This form documents a Skilled Nursing Facility Advanced Beneficiary Notice (ABN) was not provided. The explanation handwritten on the form documents, (the facility) was not aware that business office manager was to complete ABN upon takeover.)
On 11/15/23 at 8:30 AM, V1 Administrator stated an Advanced Beneficiary Notice should have been provided to R264. V1 stated an ABN was not completed for R264.
2. R146's Beneficiary Protection Notification Review form provided by V1 Administrator, documents R146's Medicare start date as 9/22/23. This form documents R146's last covered Medicare day as 10/23/23. This form documents the facility/provider initiated R146's discharge from Medicare Part A Services when benefit days were not exhausted. This form documents a Skilled Nursing Facility Advanced Beneficiary Notice (ABN) was not provided. The explanation handwritten on the form documents, (the facility) was not aware that business office manager was to complete ABN upon takeover.)
On 11/15/23 at 8:30 AM, V1 Administrator stated an Advanced Beneficiary Notice should have been provided to R146. V1 stated an ABN was not completed for R146.
3. R6's Beneficiary Protection Notification Review form provided by V1 Administrator, documents R6's Medicare start date as 9/28/23. This form documents R6's last covered Medicare day as 10/27/23. This form documents the facility/provider initiated R6's discharge from Medicare Part A Services when benefit days were not exhausted. This form documents a Skilled Nursing Facility Advanced Beneficiary Notice (ABN) was not provided. The explanation handwritten on the form documents, (the facility) was not aware that business office manager was to complete ABN upon takeover.)
On 11/15/23 at 8:30 AM, V1 Administrator stated an Advanced Beneficiary Notice should have been provided to R6. V1 stated an ABN was not completed for R6.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide nail care to one of 31 residents (R56) reviewed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide nail care to one of 31 residents (R56) reviewed for Activities of Daily Living in the sample list of 77.
Findings include:
The facility's Activities of Daily Living policy with a revised date of June 2023 documents, All residents will have activities of daily living provided by nursing staff as needed in accordance with each individual's needs. Responsibility: It is the responsibility of the C.N.A. (Certified Nursing Assistant) to provide activities of daily living to residents as required for everyone. It is the responsibility of the Charge Nurse to ensure that activities of daily living have been provided to all residents on each unit. Procedure: 12. Provide nail care.
The facility's Nail Care (Finger & {and} Toes) policy with a revised date of February 2020 documents, Nail care will be provided for all residents in order to provide cleanliness, prevent spread of infection, for comfort, and to prevent skin problems. Residents' nails will be kept neat and clean.
R56's Order Recap Report dated 11/15/23 documents diagnoses including Contracture of Muscle Multiple Sites, Muscle Wasting and Atrophy Multiple Sites, Diabetes Mellitus due to Underlying Condition with Foot Ulcer and Cerebral Palsy.
R56's Minimum Data Set (MDS) dated [DATE] documents R56 is cognitively intact and has impairment in range of motion on one side of R56's upper and lower extremities. This MDS documents R56 requires substantial/maximal assistance for bathing and personal hygiene.
R56's Care Plan documents R56 has Cerebral Palsy affecting Right side weakness and contractures. This Care Plan dated 5/18/23 documents R56 has the potential for skin alteration and staff will assist with Activities of Daily Living (ADLs) tasks such as person hygiene. This Care Plan dated 5/18/23 documents R56 exhibits self-care deficit and requires assistance with ADLs such as grooming/bathing and personal care needs. This Care Plan documents and interventions dated 5/18/23 to keep nails clean, trim nails as needed and staff will provide extensive assistance to R56.
On 11/13/23 at 10:58 AM, R56's fingernails on both hands were approximately more than 1/8-inch past R56's fingers and there was dark brown substance underneath the fingernails. R56 stated that R56 has not had R56's nails trimmed. R56 stated that R56 knows that the CNAs (Certified Nursing Assistants) can't trim them since R56 has Diabetes but R56 does not know who is supposed to trim them. R56 stated that the nurses have not offered to trim R56's nails.
On 11/15/23 at 1:05 PM, R56 was in R56's room in R56's wheelchair. R56's fingernails on both hands are still long and have a dark brown substance underneath them. R56's right thumb nail is jagged and had visible sharp edges on it. R56's right hand and right arm are contracted and the fingernails on R56's right hand press into the palm of R56's hand. R56 stated that R56 checks the palm all the time to make sure it is not getting sore from the fingernails.
On 11/15/23 at 12:45 PM, V2 Director of Nursing stated that it would be the responsibility of the CNAs to trim and clean resident's nails. V2 stated that for Diabetic residents they have the Podiatrist trim the toenails but V2 stated V2 was not sure whose responsibility it is to trim Diabetic resident's fingernails.
On 11/15/23 at 1:08 PM, V20 Licensed Practical Nurse stated that V20 just started at the facility and is not sure whose responsibility it is to trim diabetic resident's nails, but a resident asked V20 to trim their nails this morning and V20 stated that V20 did so.
On 11/15/23 at 1:09 PM, V21 Licensed Practical Nurse stated that the nurses are supposed to be the ones to trim the Diabetic resident's nails. V21 stated that if the resident doesn't request it to be done the CNAs should notify the nurse when they do the resident's showers if the nails need to be trimmed.
On 11/15/23 at 1:19 PM, V2 stated that the Podiatrist does all of the Diabetic resident's toenails and the nurses are supposed to do the Diabetic resident's fingernails.
On 11/15/23 at 3:30 PM, V7 Regional Nurse Consultant stated that they have attended to R56's fingernails and they have been cut and filed and cleaned.
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 interview and record review the facility failed to have fall prevention interventions in place on admission for one of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have fall prevention interventions in place on admission for one of two residents (R215) reviewed for falls in the sample list of 77.
Findings include:
The facility's Accident/Incident log provided by the facility on 11/13/23 documents R215 sustained falls on 10/2/23 and 10/25/23.
R215's Minimum Data Set (MDS) dated [DATE] documents R215 was admitted to the facility on [DATE] from the hospital and documents R215 has severe cognitive impairment and has impaired range of motion on both upper extremities and one side of the lower extremities. This MDS documents R215 is dependent with walking.
R215's Fall Risk assessment dated [DATE] documents R215 is at high risk for falls.
R215's Care Plan dated 10/12/23 documents R215 requires two assist with transfers and documents on 10/2/23 that R215 is at high risk for falls.
R215's unsigned and undated baseline care plan for the admission date of 9/27/23 documents R215 had a history of falls but does not document any interventions that were put into place to prevent falls.
R215's Fall Investigation dated 10/2/23 documents R215 was found on the floor of R215's room and R215 was in R215's wheelchair ten minutes prior. R215 had no injuries and mats were placed next to the bed as an intervention after this fall. There is no documentation that any fall prevention interventions were in place prior to this fall.
R215's Fall Investigation dated 10/25/23 documents R215 was observed laying on the foot pedals of the wheelchair with the wheelchair tipped forward. This investigation documents that the cushion slipped forward out of the wheelchair. There were no injuries and a nonskid device was placed in the wheelchair to prevent the cushion from sliding out of the wheelchair.
On 11/15/23 at 11:54 AM, V2 Director of Nursing stated that V2 does not see any fall prevention interventions documented in R215's record prior to the fall on 10/2/23.
On 11/15/23 at 12:53 PM, V19 Minimum Data Set/Care Plan Coordinator stated that V19's first day was on 10/2/23 and that is why R215's Care Plan is dated 10/2/23. V19 stated that when V19 started that V19 went through all of the high fall risk residents because V19 stated V19 knew the facility had not had a Care Plan Coordinator for quite some time. V19 confirmed that there were no documented fall prevention intervention in place for R215 prior to the 10/2/23 fall.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to perform hand hygiene before or after administering medications and obtaining a blood glucose level for five (R52, R119, R64, R4...
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Based on observation, interview and record review the facility failed to perform hand hygiene before or after administering medications and obtaining a blood glucose level for five (R52, R119, R64, R415 and R156) of five residents reviewed for medication administration on the sample list of 77.
Findings include:
The facility provided Hand Washing Policy dated March/2021 documents that all staff will properly wash hands after direct contact with any contaminated substance, after direct resident care, and as instructed. The use of gloves does not replace handwashing/hand hygiene.
On 11/13/23 at 3:23PM, V17 Licensed Practical Nurse (LPN) provided medication to R52 without washing or sanitizing V17's hands before or after administering medications.
On 11/13/23 at 3:31PM, V17 LPN provided medication to R119 without washing or sanitizing V17's hands before or after administering medications.
On 11/13/23 at 3:39PM, V17 LPN provided medication to R64 without washing or sanitizing V17's hands before or after administering medications and V17 LPN obtained R64's blood sugar without washing or sanitizing V17's hands before or after checking R64's blood sugar.
On 11/13/23 at 3:57PM, V17 LPN provided medication to R156 without washing or sanitizing V17's hands before or after administering medications.
On 11/14/23 a 8:23AM, V16 LPN provided medications to R415 without washing or sanitizing V17's hands before or after administering medications.
On 11/15/23 at 11: 50 AM, V3 Infection Control Nurse said that she would expect staff to wash their hands before and after medication administration and before and after blood sugars are obtained.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.) R63's Medication Administration Record dated 10/1/23 to 10/31/23 documents an order dated 10/04/23 for Hydroxyzine (antihist...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.) R63's Medication Administration Record dated 10/1/23 to 10/31/23 documents an order dated 10/04/23 for Hydroxyzine (antihistamine) 25 milligrams one tablet twice a day for Anxiety.
R63's medical record does not include an assessment for the use of Hydroxyzine.
On 11/15/23 at 10:30 AM, V2 Director of Nursing stated that the facility did not obtain initial assessments for psychotropic medications.
3. R80's undated diagnosis sheet documents diagnoses of Bipolar Disorder with Psychotic Features and Unspecified Dementia.
R80's November 2023 physician orders document an order for Quetiapine (antipsychotic) 50 milligrams for behaviors.
R80's medical record documents a quarterly assessment for antipsychotic medications on 7/6/23. A quarterly assessment for the antipsychotic medication was not found in the medical record for the month of October.
On 11/14/23 at 3:00 PM, V7 stated the facility is behind on getting psychotropic assessments completed.
Based on interview and record review the facility failed to assess the need for psychotropic medication upon admission and quarterly for four of five (R73, R63, R134, R80) residents reviewed for psychotropic medications on the sample list of 77.
Findings include:
The facility's Psychotropic Medications Policy with a revision date of February/2021 documents under procedures that, 4. Psychotropic medications will have a nursing Psychotropic Medication Assessment completed on admission or with changes to any psychotropic medications ordered for the resident. This policy also documents, 8. Each resident taking antipsychotic/psychoactive medications shall have their medications reviewed and documented by a physician 2 times a year, monthly by the Pharmacy Consultant and quarterly or as needed by the Interdisciplinary Team.
1. R73's Medication Administration Record (MAR) dated November of 2023 documents an order dated 7/24/23 for Clonazepam (antianxiety) one milligram by mouth once a day, an order dated 9/6/23 for Abilify (antipsychotic) two milligrams once a day, and an order dated 7/24/23 for Mirtazapine (antidepressant) 45 milligrams at bedtime.
R73's Psychotropic Medication Observation dated 7/6/23 documents R73 is receiving a antipsychotic medication. This assessment does not document an assessment for the use of an antianxiety (Clonazepam) medication or an antidepressant (Mirtazapine) medication.
R73's medical record does not include a quarterly assessment for October 2023.
On 11/14/23 at 3:00 PM, V7 Regional Nurse Consultant stated R73's psychotropic assessment was due in October and has not been completed. V7 stated the facility is behind on getting psychotropic assessments completed.
2. R134's MAR dated November 2023 documents an order dated 10/20/23 for Mirtazapine (antidepressant) 22.5 milligrams at bedtime.
R134's Psychotropic assessment dated [DATE] documents an assessment for R134's antidepressant (Mirtazapine) medication. R134's medical record does not include a psychotropic assessment for October of 2023.
On 11/14/23 at 3:00 PM, V7 Regional Nurse Consultant stated that R134's psychotropic assessment was due in October and the facility is behind on getting it done.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to dispose of undated insulin for seven (R104, R51, R68, R1, R134, R119, R64) of seven residents reviewed for medication storage f...
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Based on observation, interview and record review the facility failed to dispose of undated insulin for seven (R104, R51, R68, R1, R134, R119, R64) of seven residents reviewed for medication storage from a total sample list of 77 residents.
Findings include:
The Long-Term Care Facility Application for Medicare and Medicaid dated 11/13/23 documents 158 residents reside in the facility.
The facility provided insulin drug manufacturer instructions document that multidose Lantus, Novolog and Humalog Insulin vials and pens must be disposed 28 days after opened.
The facility provided insulin drug manufacturer instructions document that multidose Levemir Insulin vials and pens must be disposed 42 days after opened.
On 11/14/23 at 8:42AM, V8 Licensed Practical Nurse (LPN) confirmed that R104's Novolog Insulin vial, R51's Levemir Insulin vial, and R68's Lantus Insulin vial were open without opened on dates. Additionally, V8 LPN confirmed that stock Glargine Insulin vial, was without an opened-on date.
On 11/14/23 at 9:00AM, V9 LPN confirmed that R1's Lantus Insulin and R134's Lantus Insulin pen were open without opened on dates. Additionally, V9 LPN confirmed that stock Levemir, Lantus and Humalog pens were open without opened on dates.
On 11/14/23 at 10:05AM, V10 LPN confirmed that R119's Novolog Insulin and R64's Aspart Insulin were open without opened on dates. Additionally, V10 LPN confirmed that stock Humulin 70/30 Insulin and Glargine Insulin were open without opened on dates.
On 11/15/23 at 9:30AM, V2 Director of Nursing said that all Insulins should be dated upon opening.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to complete performance reviews to identify training needs and provide training for CNAs (Certified Nursing Assistants). This failure has the p...
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Based on interview and record review the facility failed to complete performance reviews to identify training needs and provide training for CNAs (Certified Nursing Assistants). This failure has the potential to affect all 158 residents who reside in the facility.
Findings Include:
The Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) documents 158 residents reside at the facility.
The Facility's Assessment tool dated December/2022 through November/2023 states Required in-service training for nurse aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours every year. Include dementia management training and resident abuse training. Address areas of weakness as determined in nurse aide's performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff. For nurse's aides providing services to individuals with cognitive impairment, also address the care of the cognitively impaired.
On 11/14/23 at 11:00AM V1, Administrator stated The facility hasn't done annual performance reviews to determine the learning needs of Certified Nurse's Aides (CNA's). Since we have not done the annual reviews, we don't have documentation of resulting training.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected most or all residents
Based on interview, and record review the facility failed to ensure all Certified Nurse's Aide's (CNA) received twelve hours of annual training including required subjects. This failure has the potent...
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Based on interview, and record review the facility failed to ensure all Certified Nurse's Aide's (CNA) received twelve hours of annual training including required subjects. This failure has the potential to affect all 158 residents residing in the facility.
Findings Include:
The Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) documents 158 residents reside at the facility.
The Facility's Assessment tool dated December/2022 through November/2023 states Required in-service training for nurse aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours every year. Include dementia management training and resident abuse training. Address areas of weakness as determined in nurse aide's performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff. For nurse's aides providing services to individuals with cognitive impairment, also address the care of the cognitively impaired.
On 11/14/23 at 11:00AM V1, Administrator stated The facility does not have documentation of the required 12 hours of annual training for Certified Nurse's Aides (CNA's).
Sept 2023
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
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 observation, interview and record review the facility failed to prevent the worsening of a resident's facility acquired...
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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 the worsening of a resident's facility acquired pressure ulcers. The facility failed to implement pressure ulcer care plan interventions and prevent cross contamination during pressure ulcer wound care for a resident (R3). These failures affect one (R3) residents of three residents reviewed for pressure ulcers in a sample list of nine residents. These failures resulted in R3's Stage III pressure ulcer worsening and development of two additional necrotic pressure ulcers.
Findings include:
R3's undated Face Sheet documents R3 was admitted on [DATE] with medical diagnoses of Chronic Systolic Congestive Heart Failure, Moderate Protein-Calorie Malnutrition, Gastroesophageal Reflux Disease without Esophagitis, Atherosclerotic Heart Disease, Peripheral Vascular Disease, Chronic Obstructive Pulmonary Disease, (COPD), Atrial Fibrillation and Anemia.
R3 Minimum Data Set (MDS) dated [DATE] documents R3 as modified independent for daily decision making. This same MDS documents R3 as requiring extensive assistance of two people for bed mobility, transfers, toileting, extensive assistance of one person for dressing and personal hygiene.
R3's Care Plan documents R3 is not able to make his own decisions. This same care plan documents an intervention dated 5/31/23 instructs staff to assist in turning and positioning R3 at least every two hours. This same care plan documents a pressure ulcer prevention intervention dated 7/3/23 for R3 to wear bilateral boots to offload pressure.
R3's Wound Physician Progress Notes document the following:
9/12/23 documents R3's facility acquired Left Lateral Foot Stage 4 Pressure Ulcer as measuring 10.2 centimeters (cm) long by 2.5 cm wide by 0.3 cm deep. This same progress note documents an initial onset for this same wound of 5/26/23. 9/12/23 documents R3's facility acquired Right Lateral Ankle Stage 4 Pressure Ulcer as measuring 2.1 cm long by 2.3 cm wide by 0.1 cm deep. This same progress note documents an initial onset date for this same pressure ulcer of 7/3/23.
9/12/23 documents R3's facility acquired Right Lateral Lower Leg Stage 3 Pressure Ulcer as measuring 1.7 cm long by 0.6 cm wide by 0.1 cm deep. This same progress note documents an initial onset date for this same pressure ulcer of 7/3/23.
9/12/23 documents R3's facility acquired Left Anterior Ankle Unstageable Pressure Ulcer as measuring 0.9 cm long by 3.1 cm wide by unable to determine depth due to necrosis. This same progress note documents an initial onset date for this same pressure ulcer of 9/12/23. This same progress note documents this same pressure ulcer as being caused by a medical device with an initial onset date of 9/12/23.
9/12/23 documents R3's facility acquired Left Heel Unstageable Pressure Ulcer as measuring 3.8 cm long by 3.4 cm wide by unable to determine depth due to necrotic tissue. This same progress note documents this same pressure ulcer initial onset date of 9/12/23.
R3's Facility Wound Assessment Details Report documents the following:
9/21/23 documents R3's facility acquired Left Lateral Foot Stage 4 Pressure Ulcer as measuring 9.0 cm long by 1.5 cm wide by unable to determine depth due to necrotic tissue.
9/21/23 documents R3's facility acquired Right Lateral Ankle Stage 4 Pressure Ulcer as measuring 6.3 cm long by 2.5 cm wide by 0.2 cm deep.
9/21/23 documents R3's facility acquired Right Lateral Lower Leg Stage 3 Pressure Ulcer as measuring 5.2 centimeters (cm) long by 2.0 cm wide by 0.25 cm deep.
9/21/23 documents R3's facility acquired Left Anterior Ankle Unstageable Pressure Ulcer as measuring 0.7 cm long by 3.5 cm wide by unable to determine depth due to necrotic tissue.
9/21/23 documents R3's facility acquired Left Heel Unstageable Pressure Ulcer as measuring 3.8 cm long by 2.4 cm twice by unable to determine depth due to necrotic tissue.
On 9/21/23 continual observations were made from 8:51 AM-11:50 AM of R3 laying on R3's back in bed with legs crossed, knees out to each side and feet drawn up between thighs. R3's head of bed was elevated at 45 degrees. R3 was not wearing heel protectors. R3's bed did not have any pillows. R3's bilateral feet were pressing directly into R3's inner thighs and calves. No observations were made during this timeframe of staff assisting R3 with repositioning or offloading R3's facility acquired pressure ulcers.
On 9/21/23 at 11:55 AM V8 Licensed Practical Nurse (LPN) and V9 Registered Nurse (RN)/Wound Nurse completed R3's dressing changes for R3's facility acquired pressure ulcers including Left Lateral Foot Stage 4 Pressure Ulcer, Right Lateral Ankle Stage 4 Pressure Ulcer, Right Lateral Lower Leg Stage 3 Pressure Ulcer, Left Anterior Ankle-Deep Tissue Pressure Injury (DTPI), Left Heel Unstageable Pressure Ulcer. R3's prior dressings to Right and Left lower legs/feet were not dated nor initialed. These same outer dressings were grossly contaminated with a dirt brown color and debris from unknown source. V9 RN removed all of the dressings at one time, then cleansed each wound and re-dressed each wound without changing gloves or using hand sanitizer. V9 RN did not perform R3's pressure ulcer wound care in order from less severe wound to most severe wound. V9 RN started wound care with R3's Right Lateral Lower Leg, then proceeded to R3's Right Lateral Ankle, then Left Lateral Foot, Left Anterior Ankle and lastly Left Heel pressure ulcer. V9 RN utilized the same paper measuring tape by pressing the paper measuring tape into every wound. R3's facility acquired Left Lateral Foot Stage 4 pressure ulcer observed to have red periwound and moderate amount of yellow/grey drainage. R3's facility acquired Right Lateral Ankle Stage 4 Pressure Ulcer area of cluster wounds as open and red with moderate amount of pink/clear drainage. R3's facility acquired Right Lateral Lower Leg Stage 3 pressure ulcer observed to be open, dark red tissue with moderate amount of yellow/pink drainage. Observed this same wound's prior undated dressing was firmly adhered to open wound. V9 Registered Nurse attempt to soak the prior dressing off for eight minutes. R3's facility acquired Left Anterior Ankle Unstageable Pressure Ulcer observed as firm brown necrotic tissue covering most of surface of pressure ulcer with minimal clear drainage. R3's facility acquired Left Heel Unstageable Pressure Ulcer observed as having a dry black surface with slightly reddened periwound and no visible drainage.
On 9/21/23 at 1:25 PM V9 Registered Nurse (RN) stated R3 should always have his heel protectors on for pressure prevention. V9 stated I have just started in this position and have only worked at this facility for a couple of weeks. I only see one heel protector in (R3's) room. It is sitting on (R3's) bedside dresser completely out of his reach. I don't know why (R3) doesn't have those on. (R3) really needs them. (R3) crosses his legs (with legs crossed, knees out to each side and feet drawn up between thighs) which forces his feet to press on his thighs and calves. (R3) has multiple significant pressure ulcers on his lower legs and both feet. A few of the wounds did get larger but they all look better each time I see them. V9 RN stated not performing hand hygiene and the cross contamination of open wounds could lead to an infection in R3's pressure ulcer wounds.
On 9/22/23 at 1:30 PM V27 Wound Physician stated I started at this facility approximately 10 weeks ago. I have been seeing (R3's) wounds since that time. (R3) has seven or eight total pressure ulcers in addition to a couple of Vascular ulcers. (R3's) wounds have been improving since I have taken over, but I am surprised (R3) has lived this long due to the condition of his wounds. Prior to me seeing (R3's) wounds they (wounds) had been deteriorating and with no one in charge of the wound program it was a recipe for disaster. I wouldn't say (R3's) pressure ulcers were unavoidable due to (R3) has shown healing properties in these wounds since I took over. I would be more inclined to say that the previous staff were not caring for (R3) as they should have been. There have been times I have seen (R3's) heel protectors not on and there have been times they have been on. I believe the Left Anterior Ankle-Deep Tissue Pressure Injury (DTPI) was caused the by staff applying the heel protector incorrectly which caused the strap to rub against the top of his Left Ankle. (R3's) bilateral hips and knees are very contracted. I believe (R3's) knees are measuring at 135 degrees flexion contraction. (R3) always needs those heel protectors on at all times. There is no excuse for (R3) going long periods without them. I can see that they might come off during showers or something like that but that would be the only reason. If they are soiled, then get them laundered and while (R3) is waiting apply another pair. This isn't critical thinking here. It is just basic care that was not being provided. The dressings should always be dated otherwise no one would know how long that previous dressing had been on. If (R3's) dressing to Right Lateral Lower Leg took that much work to soak it off of the pressure ulcer, then it has been on much longer than what I had ordered.
The facility policy titled 'Wound Ulcer Treatment' revised 8/2023 documents put on gloves, loosen tape, and remove dressing. Dispose of dressing and gloves. Wash hands. Put on clean gloves. Date and initial tape before applying. Apply individual dressings and ointments as directed.
The facility policy titled 'Wound Treatments dated 4/2023 documents mobility guidelines to turn resident every two hours and provide appropriate pressure reducing devices. When treating a resident with multiple pressure injuries, treat the most contaminated ulcer last.
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
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 ensure the dignity of residents. This failure affects 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 ensure the dignity of residents. This failure affects two (R3, R4) out of three residents reviewed for Activities of Daily Living in a sample list of nine residents.
Findings include:
1.) R3's Electronic Medical Record (EMR) documents medical diagnoses of Chronic Systolic Congestive Heart Failure, Moderate Protein-Calorie Malnutrition, Gastroesophageal Reflux Disease without Esophagitis, Atherosclerotic Heart Disease, Peripheral Vascular Disease, Chronic Obstructive Pulmonary Disease, (COPD), Atrial Fibrillation and Anemia.
R3's Minimum Data Set (MDS) dated [DATE] documents R3 as modified independent for daily decision making.
R3's Care plan includes interventions dated 5/31/23 of Aspiration Precautions, cue R3 to take small bites or small sips one at a time, encourage to eat slowly, ensure R3 is sitting upright during meals and assist with eating and meal set up encourage to attempt to feed self-assisting as needed.
On 9/20/23 at 12:21 PM R3 laying on R3's back in bed with legs crossed, knees out to each side and feet drawn up between thighs. R3's head of bed was elevated at 45 degrees. Observed R3's meal of breaded chicken cutlet, spaghetti, spinach, cake, and drinks. V15 CNA assisted R3 with eating lunch meal for two to three minutes. V15 CNA exited R3's room when R3 was not finished with lunch and did not return.
On 9/20/23 at 12:50 PM R3 laying on back in bed with head of bed up 45 degrees using bare hands to eat spaghetti, spinach, and cake on plate. Observed R3's hands to be soiled with moderate amount of food debris. R3's fingernails had a thick layer of a dark thick substance underneath nails. R3 was attempting to feed self with hands. R3 drank from a cup and then immediately coughed several times with no staff supervision.
On 9/20/23 at 1:05 PM V11 CNA removed R3's lunch tray without asking R3 if he was finished eating. V11 did not attempt to assist R3 in eating lunch.
On 9/21/23 at 8:51 AM R3 laying on R3's back in bed with legs crossed, knees out to each side and feet drawn up between thighs. R3 did not have any flat sheet nor covers on R3's bed. R3 was wearing only an incontinence brief. R3's bed did not have any pillows. R3's door was wide open. Observed residents passing by R3's room in hallway.
On 9/21/23 at 8:53 AM V19 Certified Nurse Aide (CNA) walked by R3's room. V19 stated I took (R3's) blankets off at about 8:45 AM. (R3) is fine. At the same time, V26 Licensed Practical Nurse (LPN) instructed to provide R3 with covers to provide warmth and dignity. V19 CNA let out a sigh, rolled her eyes at V26 LPN and walked away. At 8:56 AM V19 CNA provided R3 a sheet and bath blanket.
2.) R4's Electronic Medical Record (EMR) documents medical diagnoses of Anemia, Ectropian of the Eye, Extropia, Arthritis, Hypokalemia and Macular Keratitis.
R4's Minimum Data Set (MDS) dated [DATE] documents R4 as moderately cognitively impaired.
R4's Care plan intervention dated 6/29/21 documents R4 is to be in proper position for eating and staff is to provide meal support per (R4's) needs.
The facility undated list of residents who need assistance with eating meals includes R4.
On 9/20/23 at 12:18 PM R4 was laying in bed with head of bed raised approximately 30 degrees. R4 was using hands to try to find foods on lunch tray. R4 spilled glass of juice over spaghetti and cake. R4 picked up breaded chicken cutlet with hands and biting off large pieces. R4 was observed to have many missing teeth and several natural teeth.
On 9/20/23 at 12:19 PM V13 Certified Nurse Aide (CNA) entered R4's room, look at R4 and then walked past R4 to assist R4's roommate.
On 9/20/23 at 12:53 PM R4 was laying on back with head of bed raised 30 degrees. R4 was using hands to feel around in spinach and spaghetti to pick up foods. R4 was holding breaded chicken cutlet. Observed R4's remaining cake and spaghetti to be saturated with spilled juice.
On 9/20/23 at 12:59 PM R4 was laying on back with head of bed raised 30 degrees. R4 was using hands to feel around in spinach and spaghetti to pick up foods. Observed R4's remaining cake and spaghetti debris to be saturated with spilled juice.
On 9/20/23 at 1:15 PM V13 Certified Nurse Aide (CNA) assisting R4 with hand hygiene and remove R4's tray from her room. V13 CNA did not attempt to assist R4 with eating.
On 9/20/23 at 12:20 PM V13 Certified Nurse Aide (CNA) stated I am assigned to west hall on the second floor. I am (R4's) CNA. (R4) does not require any assistance eating. There isn't anyone on this hall that requires assistance with eating. (R4) regularly makes a mess with her meals and requires staff to assist in cleaning up after meals.
On 9/21/23 at 9:25 AM V22 Certified Nurse Aide (CNA) stated there are no residents on the west hall of second floor that require feeding assistant. V22 stated R4 lives on this hall and does not require any assistance eating. V22 stated the staff pass the meal trays to the residents eating in their rooms first and then go to another hall to help those residents who need assistance.
On 9/21/23 at 9:55 AM V25 Certified Nurse Aide (CNA) stated R4 does not require any assistance eating. V25 stated the staff pass the meal trays on R4's hall and then go to another hall to help other residents eat.
On 9/21/23 at 10:35 AM V25 Licensed Practical Nurse (LPN)/Second Floor Nurse Manager stated R3 and R4 both need assistance with feeding. V25 stated (R4) should not have to dig around in her food like that. I didn't know (R4) needed that extra assistance; we (staff) haven't been helping her. We (staff) just serve (R4) her meal tray and let her eat on her own. (R4) does have poor vision so I can see why she might need extra help. (R3) can start eating on his own but he tires easily and doesn't see very well. (R3, R4) both need the help, and we (facility) didn't help them.
The Illinois Long-Term Care Residents' Rights for People in Long Term Care Facilities revised 11/2018 documents the facility must treat the resident with dignity and respect and must care for you in a manner that promotes quality of life.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident (R2) who had previously been placed on continual m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident (R2) who had previously been placed on continual monitoring was monitored resulting in R2's fall. This failure affects one (R2) resident out of three residents reviewed for accidents in a sample list of nine residents.
Findings include:
R2's Medical Diagnosis List documents active diagnoses of Alzheimer's Disorder, Anxiety, Polyneuropathy and Dementia with other Behavioral Disturbances.
R2's Minimum Data Set (MDS) dated [DATE] documents R2 as moderately impaired in decision making.
R2's Electronic Medical Record (EMR) does not document R2's fall on 8/29/23. This same medical record does not document R2's skin assessment, neurological assessment, or Post Fall Evaluation for R2's fall on 8/29/23.
R2's Care Plan documents an intervention revised 8/24/23 for R2 to use one person assist for all transfers. This same care plan instructs staff to monitor whereabouts of R2.
R2's Physician Order Sheet (POS) dated September 2023 documents a physician order for R2 to be monitored on a one-to-one basis starting 8/1/23 with no end date listed.
R2's fall investigation dated 8/29/23 at 11:06 PM documents (V17) Licensed Practical Nurse (LPN) heard a thud and turned and saw (R2) on the floor. This same fall investigation documents R2's fall on 8/29/23 had no witnesses and R2 had no injuries.
On 9/22/23 at 9:45 AM V1 Administrator stated There was a (V16) Certified Nurse Aide (CNA) assigned to (R2) and was sitting with (R2) at the time of the fall on 8/29/23. We (facility) are working on educating the staff on the importance of documenting all events. (R2) did fall the evening of 8/29/23. The staff (V16 CNA, V17 LPN) did not see the fall but did see (R2) laying on the floor in her room. Due to the way (V16) was sitting (V16) did not see (R2) get up or fall. (R2) had no injuries from this fall.
On 9/22/23 at 3:00 PM V16 Certified Nurse Aide (CNA) stated V16 was assigned to be R2's one to one staff member the evening of 8/29/23 when R2 fell. V16 CNA stated (R2) was laying in bed the last time I saw her. I was sitting in a chair in the hallway next to (R2's) room. I could see in (R2's) room if I turned my head to look. I did not see (R2) get up or fall. I looked up and saw (R2) wasn't in her bed, so I went to investigate and saw (R2) laying on the floor. I should have been watching (R2) better. I didn't realize what a one to one really meant until after (V1) Administrator educated me the next day in his office. I felt so bad then. I know now that I have to watch that resident ALL the time instead of just keeping an eye on them. I should have been sitting in (R2's) room next to her bed or at least closer where I would have known when she was getting up.
Sept 2023
5 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
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify a resident's Family Member and provide a written Notice of Tr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify a resident's Family Member and provide a written Notice of Transfer and Discharge from the facility, when being discharged to the hospital. This failure affects one of three residents (R1) reviewed for discharge from the facility. This past non-compliance occurred from 8/15/23 to 9/1/23.
Findings include:
R1's Minimum Data Set, dated [DATE] documents R1 has severe cognitive impairment.
On 9/5/23 at 4:00 pm, V6, (R1's Power of Attorney/Family Member) stated the facility failed to notify V6 by phone and in writing, that R1 was transferred to the hospital on 8/15/23. V6 stated V6 found out R1 was transferred to the hospital, when V6 received a phone call, from a staff member, at a local hospital.
R1's Health Status Note dated 08/15/2023 at 01:42 am, signed by V39, Agency Registered Nurse, documents the following: Note Text: Resident is warm to touch. Lethargic and none verbal. Responds to hard sternal rub with slight eye opening. Sweating. VS (vital signs): 146/90 (blood pressure measurement), 139 (pulse measurement), 20 (respiration measurement), 99% (percent of blood oxygen) on 2L/M (two litters per minute) via NC (nasal cannula). temp (body temperature) at 100.5 (degrees Fahrenheit), [NAME] (Tylenol) PRN (as need) given with noted temp to 98.8 (decrease in elevated body temperature). Blood sugar of 403 (measurement of blood glucose) while on call doctor (unidentified) notified with order to send to ER (emergency room) for further treatment and evaluation. recheck blood sugar prior to ambulance arrival, blood sugar increased to 503. Covid test (-) (negative). On call nurse (unidentified) notified. Report given to ER (private hospital) nurse (unidentified). Transported at 0155 (01:55 am) via (private hospital) ambulance. There was no documentation that V6, R1's Power of Attorney/ Family Member was notified.
On 9/6/23 at 3:00 pm V1 Administrator stated the facility received a grievance by phone message left on an answering machine on 8/30/23. V1 responded to the message on 8/31/23. V1 reviewed the grievance with this surveyor. The facility Resident / Family Concern/Grievance Form dated 8/30/23 identified V6's concern as V6 had not been notified when R1 left the facility to go the hospital. V1 stated the facility had the wrong phone number to contact V6. V1 stated the facility had an agency nurse (V39, Registered Nurse) who did not document contacting V6 when R1 went to the hospital 8/15/23. V1 stated the agency nurse would not have gotten a hold of V6 because the phone number was wrong on R1's chart. V1 also acknowledged the facility failed to provide a bed hold notification in writing to V6 when R1 went out to the hospital.
Based on record review and interview the facility has a Quality Assessment and Assurance committee system in place to identify quality issues, provide timely response to address the cause, implement corrective action, implementing monitoring mechanism to ensure continued correction and revision approaches as necessary to eliminate the potential risk of occurrence to other residents and to ensure continued compliance. The facility QAA meets monthly and quarterly. The facility education documentation and staff interviews confirm the facility followed their action plan of correction as noted below.
Prior to the survey date of 9/8/23, the facility took the following actions to correct the noncompliance:
1. This deficiency was corrected on 9/1/23. This facility action plan, Performance Improvement Project in response to the statement of deficiency, demonstrates the facilities good faith effort and desire to improve the quality of care and services rendered to the residents. This plan of correction constitutes a written allegation of compliance with Federal Medicaid and Medicare requirement: F623.
The facility Performance Improvement Project (PIP) Internal Use-Quality Assurance purposes only form documents the following:
System: Facility Initiated Transfer and Discharge.
Date Identified: 8/31/23.
Department Responsible: Administrator.
Scope of Priority for Improvement: Priority 4 (four).
Goal/ Objective: Meet requirements of F623- Notice Requirements Before Transfer/Discharge, 483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident the facility must-
(i)
Notify the resident and the resident's representative (s) of the transfer or discharge and the reason for the move in writing and in a language and manner they understand.
(ii)
Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section, and
(iii)
Include in the notice the items described in paragraph (c)(5) of this section. 483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) must include the following: (i) The reason for the transfer or discharge. (ii) The effective date of the transfer or discharge. (iii) The location to which the resident is transferred or discharged . (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and
Analyze the data. Requires gathering and analyzing data to determine if a process is producing the desired results. Is this facility following policies, procedures and meeting internal and organizational benchmarks.
Issue Identified,
The facility failed to meet requirements of F623 per conversation with (V6) POA (Power of Attorney) of (R1).
Number of residents affected, all (sic).
Number of residents that have the potential to be affected, all.
Find opportunities for improvement. Requires identifying the process that needs to be corrected or redesigned and determine possible causes of the identified issues in these processes. Utilize 'ROOT CAUSE ANALYSIS';
Facility recently acquired under new management and if former P&P (policy and procedure) in place, facility was not following to meet the requirements of regulation as notices cannot be located nor determined by staff transfer/discharge notices were being given to resident and/or POA. Facility did not have proper leadership guidance to follow requirements appropriately.
Execute actions.
Requires developing action plan. Assigning responsibility, providing education, and executing actual improvements. Implementation of changes or corrective action to the system must be made resulting in improvement or reduction of risk for the event to reoccur. This is often the most challenging step in the QAPI process. Choose interventions that are closely tied to the root cause. These interventions should lead to an overall change in the system or process. Remember the goal is to make changes that will lead to lasting improvement. The interventions or corrective actions should target the elimination of the root cause, offer long term solutions, and have a greater positive effect on the system or process. Interventions must be achievable, objective, and measurable.
Action #1, Re-educate IDT (Interdisciplinary team) on F623 Requirements. Person responsible (V27), Regional LNHA (Licensed Nursing Home Administrator)/SS (Social Service) Consultant.
Action #2, Determine staff member/department responsible for initiating P&P- Unit Managers (V2, DON, V2, ADON, V9 Nurse Manager, V15, Nurse Manager) in unison with SSD (Social Service Director, V11 and V28 Regional SSD).
Action #3, 1:1 (one to one) education with responsible staff member. Agency staff member (V39, Registered Nurse) has not responded to phone calls and has been DNR (determined - do not return) facility.
Action #4, Review documentation of transfers out to ensure documentation shows appropriate notifications.
Action #5, Monthly Audits x 3 months 10/1/23, 11/1/23, 12/1/23.
Action # 6 End of year audit around 1/1/24.
Reevaluate performance. Requires monitoring improvement and validating that the improvement is effective and may involve making additional changes to achieve the desired outcome.
Reevaluation date: 9/15/23.
Reevaluation date: 10/07/23.
Reevaluation date: 11/07/23.
Reevaluation date: 12/07/23.
Reevaluation date: 01/07/24.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure pressure ulcer risk assessments, wound assessme...
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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 pressure ulcer risk assessments, wound assessments, and wound physician progress notes were part of the electronic medical record for one of five residents (R3) reviewed for pressure ulcers in the sample list of 88.
Findings include:
R3's Care Plan documents R3 admitted to the facility on [DATE]. The only Braden Assessment documented in R3's electronic medical record is dated 5/3/23 and documents a score of 12, indicating R3 is at high risk for developing pressure ulcers.
R3's August 2023 Treatment Administration Record (TAR) documents on 7/27/23 an order for a bordered foam gauze dressing to the right buttock was implemented as a preventative. On 8/13/23 an order was initiated to cleanse the right buttock and coccyx, apply medicated honey, and cover with a foam dressing daily.
R3's Nursing Notes document on 8/13/23 R3 had three new open pressure wounds. Two to the right buttock that measured 1.5 centimeters (cm) by 2 cm and the other measured 3 cm by 2.5 cm. The coccyx wound measured 5.5 cm by 0.5 cm. This note documents the wounds were open, pink, and without drainage. There is no documentation of the stage of these pressure ulcers. There are no documented wound assessments or Wound Physician (V23) Progress Notes in R3's medical record after 8/13/23.
On 9/27/23 at 12:15 PM R3 was lying in bed on R3's back. V20 Registered Nurse (RN) and V3 Assistant Director of Nursing entered R3's room to assess R3's wound. R3 was turned onto R3's right side and there were pink scarred areas to R3's left and right buttocks, and coccyx. There were no open wounds. V3 stated V3 has been assessing R3's wound weekly and the assessments are documented in an electronic application which is not part of R3's electronic medical record. V3 stated R3's buttock wound was open but is now healed. The wound was almost healed last week during V3's last assessment. V23 Wound Physician evaluates R3's wounds weekly. At 1:14 PM V3 stated Braden assessments are used to determine pressure ulcer risk and are to be completed upon admission, then weekly for 3 weeks, and then at least quarterly after that. V3 reviewed R3's electronic medical record and confirmed R3 only has one documented Braden completed in May 2023.
On 9/7/23 at 2:12 PM V13 Licensed Practical Nurse stated on 8/13/23 R3 had three newly opened areas, one to R3's coccyx and two to the right buttock. These were old, healed wounds that had reopened. V13 stated V13 documented R3's wound assessments and the wounds were approximately 2 millimeters deep and were either Stage 2 or Stage 3 Pressure Ulcers.
On 9/7/23 at 1:40 PM V1 Administrator stated wound assessment and V23's Progress Notes should be integrated into the resident's electronic medical record.
On 9/7/23 at 3:36 PM V7 Regional Clinical Consultant provided R3's Braden Assessments (8/22/23 and 9/6/23) and Wound assessment dated [DATE]. R3's Braden Assessments document a score of 10, indicating high risk. R3's Wound Assessment documents a coccyx wound as a facility acquired stage 2 pressure ulcer that healed on 9/7/23. This assessment does not identify the stage or evaluation of the right buttock pressure ulcers. V7 stated these are documented in the wound program that has not yet been integrated into R3's medical record.
The facility failed to provide documentation of R3's Progress Notes by V23 Wound Physician.
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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to complete pressure ulcer risk assessments for (R3), mon...
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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 complete pressure ulcer risk assessments for (R3), monitor and assess pressure ulcers for (R3), document skin assessments as ordered for (R3) and implement pressure relieving interventions for (R1 and R3). R1 and R3 are two of three residents reviewed for pressure ulcers in the sample list of 88.
Findings include:
1.) R3's Diagnoses List dated 9/7/23 documents R3's diagnoses include Cerebral Infarction, Diabetes Mellitus Type 2, Protein-Calorie Malnutrition, and gastrostomy tube status. R3's Minimum Data Set, dated [DATE] documents R3 has cognitive impairment, requires extensive assistance of at least two staff, is always incontinent of bowel and bladder, and R3 is at risk for pressure ulcers.
The only Braden Assessment documented in R3's electronic medical record is dated 5/3/23 and documents a score of 12, indicating R3 is at high risk for developing pressure ulcers.
R3's Physician Order dated 8/13/23 documents to use an air mattress.
R3's August 2023 Treatment Administration Record (TAR) documents on 7/27/23 an order for a bordered foam gauze dressing to the right buttock was implemented as a preventative. On 8/13/23 an order was initiated to cleanse the right buttock and coccyx, apply medicated honey, and cover with a foam dressing daily. This order is documented on R3's September 2023 TAR as administered daily through 9/6/23. These TARs document to complete skin checks daily and indicate I for intact and A for altered. This order is signed out every shift but does not document whether R3's skin was intact or altered.
R3's Nursing Notes document R3 was on isolation due to COVID-19 positive from 8/9/23 until 8/21/23. On 8/13/23 R3 had three new open pressure wounds. Two to the right buttock that measured 1.5 centimeters (cm) by 2 cm and the other measured 3 cm by 2.5 cm. The coccyx wound measured 5.5 cm by 0.5 cm. This note documents the wounds were open, pink, and without drainage. There is no documentation of the stage of these pressure ulcers. There are no documented wound assessments in R3's medical record after 8/13/23.
R3's Care Plan dated 5/2/23 documents R3 has impaired physical mobility and includes interventions to assess skin for blanching/redness, implement a turning and repositioning schedule, and use of pressure relieving devices on appropriate surfaces. R3's Care Plan dated 8/14/23 documents R3 has a wound to the right buttocks and includes interventions to measure the wound, evaluate the wound characteristics, and assess for decline or improvement. There are no new pressure relieving interventions updated on R3's plan of care after 5/2/23, and it does not include the use of an air mattress. This care plan documents R3 was admitted to the facility on [DATE].
R3's shower sheets document an open area to R3's right inner buttock on 8/17/23 and abnormal coloring to R3's buttocks on 8/24/23 and 9/1/23.
On 9/6/23 at 11:00 AM R3 was lying in bed on R3's back with the head of the bed elevated. On 9/7/23 at 8:07 AM, 9:45 AM, 10:38 AM, 11:05 AM, and 11:28 AM R3 was lying in bed on R3's back with the head of the bed elevated. R3's bed contained an air mattress.
On 9/7/23 at 11:41 AM V18 and V19 Certified Nursing Assistants entered R3's room. R3 was lying on R3's back with the head of the bed elevated, and there were no pillows or devices used to offload pressure from R3's back and buttocks. V18 and V19 provided incontinence care and positioned R3 back onto her back. V19 stated usually pillows are used to position R3 onto R3's side. V18 confirmed no pillows or devices had been used to position R3 off R3's back and buttocks that morning.
On 9/7/23 at 12:15 PM R3 was lying in bed on R3's back. V20 Registered Nurse (RN) and V3 Assistant Director of Nursing entered R3's room to assess R3's wound. R3 was turned onto R3's right side and there were pink scarred areas to R3's left and right buttocks, and coccyx. There were no open wounds. V3 stated V3 has been assessing R3's wound weekly and the assessments are documented in an electronic application which is not part of R3's electronic medical record. V3 stated R3's buttock wound was open but is now healed. The wound was almost healed last week during V3's last assessment. V3 stated the air mattress should be documented on the care plan. V20 stated the CNAs should be turning and repositioning R3 preferably every 2 hours and they should use pillows or wedges to offload pressure from R3's buttocks and back. V20 confirmed a lack of repositioning and offloading can contribute to developing buttock pressure ulcers. V20 states R3's air mattress also helps with offloading pressure.
On 9/7/23 at 11:33 AM V21 RN stated R3's wound was slightly open when V21 last saw the wound about a month ago. V21 stated the wound seems to be pressure related since R3 is always in bed. There was a wound there previously that healed, and the air mattress was discontinued at that time. R3's skin is assessed weekly and during showers. V21 stated every resident on this unit has an order for daily skin checks, but that does not mean we do a full body skin check. V21 stated we just monitor if they have bruises or skin tears.
On 9/7/23 at 12:34 PM V3 stated the daily skin checks were put in by a former nurse consultant due to prior issues with wounds. V3 stated V3 expects the nurses to complete full body skin checks daily as ordered and confirmed the MAR does not identify if R3's skin is intact or abnormal per the order. At 1:14 PM V3 stated Braden assessments are used to determine pressure ulcer risk. V3 stated Braden assessments are to be completed upon admission, then weekly for 3 weeks, and then at least quarterly after that. V3 reviewed R3's electronic medical record and confirmed R3 only has one documented Braden completed in May 2023.
On 9/7/23 at 2:12 PM V13 Licensed Practical Nurse stated on 8/13/23 R3 had three newly opened areas, one to R3's coccyx and two to the right buttock. These were old, healed wounds that had reopened. V13 stated V13 documented R3's wound assessments and the wounds were approximately 2 millimeters deep and were either Stage 2 or Stage 3 Pressure Ulcers. V13 stated R3 was not on an air mattress at that time and V13 obtained an order for one that day. V13 stated R3's pressure relieving interventions include repositioning side to side every 2 hours and use of pillows behind R3's back. V13 was asked what caused or contributed to the development of these wounds. V13 stated R3 is immobile, is always in bed, and has moisture related to incontinence.
On 9/7/23 at 3:36 PM V7 Regional Clinical Consultant provided R3's Braden Assessments (8/22/23 and 9/6/23) and Wound assessment dated [DATE]. R3's Braden Assessments document a score of 10, indicating high risk. R3's Wound Assessment documents a coccyx wound as a facility acquired stage 2 pressure ulcer that healed on 9/7/23. This assessment does not identify the stage or evaluation of the right buttock pressure ulcers. V7 stated these are documented in the wound program that has not yet been integrated into R3's medical record. V7 confirmed there were no other wound assessments besides 8/13/23 and 9/7/23.
The facility's undated Pressure Injury Prevention Guidelines & Suggested Interventions documents residents at high risk for pressure ulcers suggests repositioning the resident at least every 2 hours and an air mattress may be required for residents who are completely immobile.
The facility's Preventative Skin Care policy dated April 2023 documents to reposition residents based on their assessment and to use pillows or positioning devices to offload pressure areas.
The facility's Pressure Ulcer, Lower Extremity Ulcer Treatment and Documentation policy dated April 2023 documents pressure ulcers will have weekly evaluations including assessing wound characteristics, measurements, and stage. Wounds will be documented upon identification.
2.) R1's Order Summary Report dated 9/6/23 documents the following diagnoses: Alzheimer Disease and Functional Quadriplegia.
R1's Pressure Ulcer Risk Assessment note dated 8/22/23 signed by R40, Licensed Practical Nurse documents the following: Braden Evaluation:
Sensory Perception: Very Limited. Moisture: Very moist. Activity: Bedfast.
Resident is Completely Immobile: does not make even slight changes in body or extremities position without assistance. Nutrition: Adequate. Friction and Shear; Problem.
R1's Care Plan dated 8/14/23 includes the following: Wound Management Wound right buttock: Reposition as tolerated to alleviate pressure.
R1's (private company) Skilled Nursing Facility Acute Note dated 9/1/23 signed by V5, Nurse Practitioner documents R1 has a Stage III pressure ulcer on R1's right buttocks.
R1's Minimum Data Set, dated [DATE] documents R1 has severe cognitive impairment and is totally dependent on two staff for bed mobility.
On 9/7/23 at 8:00 am R1 was laying on her back in bed.
On 9/7/23 at 8:55 am R1 continued to lay on her back in bed.
On 9/7/23 at 9:50 am R1 continued to lay on her back in bed.
On 9/7/23 at 10:05 am, R1 laid on R1's back in bed. V16, Certified Nursing Assistant (CNA) and V17, CNA provided R1's incontinence care, intermittently positioning resident with great effort to maintain R1's position for care. R1 did not assist. As R1 was rolled to her left side for posterior perineal care, R1 was soiled with feces. V17 cleansed R1's buttocks. R1 had a dime size open area on each end of a figure-eight shaped pressure ulcer on R1's right buttocks. V17, CNA stated R1 had been laying on R1's back since 6:00 am (for four hours) when V17 came to work. V17 stated an unidentified CNA called off work and V17 was not able to reposition R1 without assistance.
On 9/7/23 at 10:22 am V5, Nurse Practitioner stated the following: Repositioning for dependent residents should occur every two hours. (R1) should be repositioned more frequently because she is unable to adjust on her own, has the skin breakdown (Stage III) on her buttocks and is incontinent.
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
Tube Feeding
(Tag F0693)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed repeatedly to ensure gastrostomy tube (G-tube) feeding vo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed repeatedly to ensure gastrostomy tube (G-tube) feeding volumes were administered as ordered for (R2 and R3), failed to record the amount of feeding administered for (R2 and R3), and failed to verify gastrostomy tube placement prior to administering feeding and medications for (R1). These failures affect three of three residents (R1, R2, and R3) reviewed for gastrostomy tubes on the sample list of 88.
Findings include:
1.) R3's Physician Order dated 7/3/23 documents an order for Glucerna 1.2 at 65 cc (cubic centimeters) on at 4:00 PM and off at 12:00 PM. This order does not document the total volume to be infused.
R3's Nutrition Note dated 08/31/2023 recorded by V24 Dietitian documents R3 receives nothing by mouth and receives full tube feedings via gastrostomy tube. R3's tube feeding regimen is Glucerna 1.2 at 65 ml/hour for 20 hours to provide 1300 ml of feeding, 1560 kilocalories, 78 grams of protein, which is 100 % of the recommended dietary intake.
R3's August and September 2023 Medication Administration Records (MAR) document R3's tube feeding is scheduled at 16 hour increments and only prompts to administer in the evening every other day. The administered times vary and do not consistently document R3's feeding is turned on at 4:00 PM and off at 12:00 PM every day. There is no documentation that R3's tube feeding pump is cleared and the total volume infused daily.
On 9/7/23 at 10:38 AM R3 was lying in bed with Glucerna 1.2 infusing at 65 cc/hour via a pump. The pump indicated 1151 cc had been delivered. On 9/7/23 at 12:15 PM R3's tube feeding was disconnected. On 9/7/23 at 1:03 PM V21 Registered Nurse entered R3's room and turned on R3's tube feeding pump. The pump indicated 1247 cc had been administered, indicating R3 did not receive 1300 cc as noted by V24 Dietitian on 8/31/23.
On 9/7/23 at 12:46 PM V21 reviewed R3's enteral feed order and stated the order was entered for every 16 hours. V21 confirmed the order was entered incorrectly. V21 stated R3's tube feeding is to be turned on at 4:00 PM and off at 12:00 PM each day. V21 confirmed the amount infused is not documented. V21 stated the nurse who initiates the feeding at 4:00 PM is the one who clears the pump for the total volume infused.
On 9/7/23 at 1:38 PM V2 Director of Nursing stated tube feeding volumes would be documented on the MAR. V2 stated we can set R3's pump to turn off once a certain amount is infused to ensure the correct amount is administered.
2.) R2 Physician Order Sheet (POS) dated 9/6/23 documents the following:
NPO (Nothing by mouth) related to Dysphagia (swallow deficit) following a Cerebral Infarction. Gastrostomy Status (G-Tube), active as of 7/31/23. The same POS documents the following nutrition order: Enteral feeding, Jevity 1.5 cal with fiber. Use as directed, 75 ml (milliliters/hr (hour) for 18 hrs, on at 6pm, off at 6am
Total volume of 1350 ml '(only running at 12 hrs)', two times a day. The twelve hours of feeding volume equals 900 ml. The dose does not equal the total volume of g-tube feeding required to meet the 1350 ml that the physician ordered.
R2's Medication Administration Record (MAR) dated August 1-31, 2023, documents R2 only received the accurate Jevity 1.5 ml, physician ordered volume of 1350 ml on August 7, 2023.
R2's same MAR on August 1- 6 and August 8-31, 2023, documents incorrect volumes, by varying milliliters, throughout the month.
R2's MAR dated September 1-30, 2023, documents R2 was in the hospital (unrelated to g-tube) until 9/3/23. The same MAR documents R2's G-tube feeding was administered 9/3/23 at 6:00 pm continuous until signed off at 6:00 am the next day. Repeated administration occurred on 9/4/23, 9/5/23 and 9/6/23. There are no feeding formula volumes documented on R2's September MAR.
On 9/6/23 at 4:35 PM R2 was laying in bed with his head elevated. V14, Licensed Practical Nurse (LPN) assessed R2's G-tube for placement in preparation of administering R2's medications via g-tube. R2's gastrostomy feeding pump/pole was at the side of R2's bed. A bottle of Jevity 1.5 feeding formula hung on the pole and was dated 9/5/23 at 4:20 am. V14, LPN confirmed R2's Jevity order requires R2 be administered 1350 ml of feeding, at 75 ml hour. V14 confirmed R2's feeding pump setting is to deliver 75 ml an hour. V14 confirmed R2 should be receiving 75 ml an hour for 18 hours to equal the amount of 1350 ml. V14 stated The feeding order (R2's G-tube) is wrong and should have been clarified with the doctor or nurse practitioner.
On 9/7/23 at 2:15 pm V7, Regional Clinical Consultant reviewed R2's Gastrostomy Feeding order and administration record on R2's electronic medical record. V7 acknowledged R2's feeding formula order is incorrect. The Jevity 1.5 cal formula quantity of 1350 milliliters require (R2) to receive 18 hours of Jevity 1.5 feeding formula administration, at a rate of at 75 ml an hour.
3.) R1's Physician Order Sheet (POS) dated 9/6/23 documents the following: NPO (nothing by mouth) G-Tube (Gastrostomy Tube) dependent. May cocktail crushable medication and liquids as appropriate four times a day for Enteral (Gastrostomy) feed. Enteral Feed Order every shift flush G-Tube with 30 ml of water before and after medications q (every) shift Enteral Feeding: Glytrol 1.0 Bolus (to gravity) 150 ml per G-Tube, every 4 (four) hours. Flush G-tube 200 ml free water.
On 9/6/23 at 3:45 pm V13, Licensed Practical Nurse (LPN) entered R1's room to administer R1's medication and gastrostomy tube feeding. V13, checked R1's g-tube placement by residual. There was no stomach content aspirated to indicate R1's g-tube was in R1's stomach. V13, then proceeded, without auscultation (listening for air, in the stomach, with a stethoscope) to administer the following: 30 ml water before medication, Famotidine 20 mg tablet, Levetiracetam solution 100 mg/ml 15 ml, Lacosamide 10 mg/ml solution 12.5 mls, 30 ml water after the medication, and then Glytrol 1.0, 150 ml feeding formula bolus and two hundred milliliters (ml) of water to flush R1's g-tube.
R1's Care Plan dated 8/14/23 documents the following: Check for tube (G-tube) placement and gastric contents/residual volume per facility protocol.
On 9/6/23 at 4:25 pm V13, LPN stated I should have verified placement by listening, when I had no residual (stomach content) back (aspirated). Otherwise, it is not actually known if (R1's) g-tube is in (R1's) stomach.
The facility policy Enteral Tube Feeding dated revised August 2023, documents the following: Purpose: To provide guidelines to Licensed nursing staff for providing liquid nourishment, through a tube, into the stomach also known as Gavage, Gastric Tube Feeding, [NAME] tube feedings, Nasogastric tube feeding, Gastrostomy tube feedings, and Jejunostomy tube feeding. The 'tubes' Provide a method of administering nutrients directly into the stomach/GI tract and is indicated for those residents who cannot consume adequate nutrients [NAME] (sic) via the oral cavity. Tube feedings are ordered by the physicians and administered either intermittently or continuously. Policy: Residents with Nasogastric Gastrostomy, or Jejunostomy shall receive hydration, nutrition and medication via the tube as ordered. The same policy documents: Procedure:
Number 1. Check order (physician), assemble equipment, proceed to resident room. Procedure: Number 7. Check position of tubing by: B. Aspirating (extract using a syringe) stomach contents '(replace what is removed)'. C. If placement of the enteral tube cannot be determined by aspirating stomach contents then placement will be determined by placing a stethoscope over the stomach and instilling (by syringe) a small amount of air into the enteral tube and listening for air to enter the stomach.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to maintain resident bedroom, bathroom and shower room call lights in operable condition on the second floor of the facility. This...
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Based on observation, interview and record review the facility failed to maintain resident bedroom, bathroom and shower room call lights in operable condition on the second floor of the facility. This failure affects 84 of 84 residents (R1-R3, and R8-R88) reviewed for call lights on the sample list of 88.
The findings include:
On 9/7/23 at 4:35 pm R43 was standing next to R43's bed. A hand-held call bell sat on R43's bedside table. R43 stated I am (expletive). It has been way to long waiting for the call lights to get fixed. The CNA's (Certified Nursing Assistants) only hear the bells if they are right outside the door, in the hall. We need something that goes off at the nurse's station. I flag people at the nurse's station when the CNAs don't get to me using the bell.
On 9/7/23 at 4:38 pm R44 was laying in bed with a hand-held call bell on the bedside table. R44 stated I have to agree with (R43) it takes too long for staff to respond, unless they are just outside the door.
On 9/7/23 at 4:41 pm R10, R51, R52, and R53 all had handheld bells on the side tables of their shared room. R10, R51, R52, and R53's room is located the furthest from the nurse's station. R10, R51, R52, and R53 each stated the staff come into their room every couple of hours to check on the residents, because they don't hear the handheld bells when the residents shake them.
On 9/7/23 at 4:50 pm V1, Administrator provided and reviewed with this surveyor the following: Performance Improvement Project (PIPs) form that documents the following:
System: Call lights. Date Identified: 8/24/23. Goal/Objective: To ensure that the facility be adequately equip to allow residents to call for staff assistance throught (sic) a communication system (sic) which relays the call directly to a staff member or to a centralized staff work area. Issue identified: The facility has self-identified that the call light system is not correctly functioning on the 2nd floor. The same form documents (during this survey), on 9/7/23 at 3:30 pm a quote to purchase a new call light system was approved by facility management. V1 Administrator stated it could be four to six weeks to install the new call light system and all residents have been given a handheld bell to call.
On 9/8/23 at 9:40 am V33, Maintenance Director stated the following: It has been a couple weeks the call light system is down (8/24/23). A nurse (unidentified) called me about 6:15 or 6:30 pm. It was the end of August. Not sure of the actual date. I came in immediately. I checked out the voltmeter on the circuit board, looked at the schematics and saw some burnt parts of the mechanical board. I called (V1, Administrator) immediately. (V1) came in by 8:00 pm and distributed the (handheld) bells to all residents on the second floor. Extra staff were brought in to roam the halls. First floor call lights were working fine. By 9:00 pm that night, (Private) company was notified. They came out and assessed the situation. The next couple days they were trying to get replacement parts. The call light system was the original from the 70's (1970's). The parts were not available. (V1) then started getting estimates to fix the call light system completely.
Jun 2023
13 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
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · 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 supervise a resident (R1) with a known history of wand...
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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 supervise a resident (R1) with a known history of wandering, evaluate or assess residents' capacity or ability to consent to sexual activity, and identify resident to resident sexual activity as nonconsensual sexual abuse for three of five residents (R1, R2, R3) reviewed for abuse in the sample list of ten. This failure resulted in R1 sexually abusing R3, and R3 sexually abusing R1.
The Immediate Jeopardy began on 6/13/23 when R1 wandered into R3's room resulting in R1 sexually abusing R3, and R3 sexually abusing R1. V1 Administrator was notified of the Immediate Jeopardy on 6/21/23 at 2:44 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 6/21/23, but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.
Findings include:
The facility's Initial Report dated 6/13/23 documents the facility reported physical contact between confused residents (R1, R2, R3). The section for sexual abuse allegation is not marked. This report documents R1 was seen in R2's room standing beside the bed touching R2's genitals, and it was unclear if this contact was direct or over top of the sheet. R1 was removed from R2's room and later that same day R1 was found in R3's room with R1's shirt pulled up and R3's mouth on R1's breast. R1 was removed from R3's room and was placed on one-to-one supervision. Immediate actions include contacting R1's family about a room change. The time the incidents occurred is unidentified. These incidents were reported to V1 Administrator on 6/13/23 at 6:32 PM.
V7 Certified Nursing Assistant (CNA) statement documents: (V7) was walking down the hall and saw (R1) in (R2's) room with what appeared to be physical contact happening. Resident (R1) had their back to the door blocking a clear view. (V7) asked resident (R1) what they were doing and (R1) stated (R1) was washing (R2's) penis. (V7) approached the residents (R1, and R2) as (V7) could see (R1's) hand appeared to be by (R2's) privates, but by the time (V7) arrived at the bed (R1's) hand was moved. At that point (V7) escorted (R1) out of the room and back to (R1's) room to keep separated from other residents.
V9 CNA written statement dated 6/20/23 documents: V9 walked past R3's room and saw R3 sitting in the recliner. R1 was leaning over R3, R1's dress was low, and R3's mouth was on R1's breast.
R1's Minimum Data Set (MDS) dated [DATE] documents R1 is usually understood and sometimes understands, wanders daily, and has severe impairment with daily decision making. R1 transfers and walks with setup assistance and supervision from staff. This MDS and R1's Brief Interview for Mental Status (BIMS) dated 6/15/23 documents R1 has short- and long-term memory loss. R1's Care Plan dated 9/6/21 documents R1 wanders aimlessly and without regards to needs or safety. R1's Care Plan revised 1/26/23 documents R1 is at risk for abuse/neglect related to diagnoses of dementia with behavioral disturbances and anxiety.
R2's BIMS dated 6/2/23 documents a score of 6, indicating severe cognitive impairment. R3's BIMS dated 5/10/23 documents a score of 13, indicating R3 is cognitively intact.
R1's Census documents R1 changed rooms on 6/14/23 at 3:44 PM (almost 24 hours after R1's/R2's and R1's/R3's incidents).
On 6/15/23 at 9:28 AM and at 11:55 AM R1 was in bed in R1's room. There were no staff present in R1's room or stationed outside of R1's doorway. On 6/20/23 at 9:08 AM there were no staff present in R1's room. R1 walked out of R1's room down the hall towards the nurses' station. V37 CNA told R1 to go back to R1's room, and R1 walked back into R1's room independently.
On 6/15/23 at 10:08 AM R3 stated: The other night R1 came into R3's room. R3 was sitting in the recliner. R1 pulled down the top of R1's gown and exposed R1's breasts. R3 touched R1's breast with R3's hand. R1 told R3 to stop, and R3 complied. R1 is confused and did not ask R3 to touch R1. R3 knows R3 probably should not have touched R1, but R3 did. There was a staff person who witnessed the incident from the doorway. The staff did not intervene, but R1 left R3's room.
On 6/15/23 at 10:00 AM V9 CNA stated V9 passed by R3's room at approximately 4:30 PM- 4:45 PM on 6/13/23 and witnessed R1 bent forward towards R3 who was sitting in the recliner. R1 pulled R1's gown down exposing R1's breasts and R3's mouth was on R1's breast. V9 stated both residents were not upset by the incident and were actively engaged. V9 told R1 to get out of R3's room and R1 went into the hallway. V9 did not report the incident to anyone. V9 did not consider the incident to be abuse since R1 and R3 were both actively engaged in the sexual activity.
On 6/15/23 at 9:34 AM V8 Registered Nurse stated: R2 yells out at times, is confused, and alert/oriented to person only.
V8 stated R3 is alert/oriented to person, place, time, and situation.
V8 stated R1 is confused and wanders into everyone's rooms. On 6/13/23 between 5:00 PM and 6:00 PM V7 CNA reported to V8 that R1 touched R2's genitals. V9 witnessed R1 enter R3's room. V9 went to R3's room and R1 exposed R1's breast and R3 was sucking on R1's breast. After the incident with R1/R2 we brought R1 to the nurse's station to keep a close eye on R1, but R1 just gets up and goes. After R1's/R3's incident R1 was placed on one-to-one supervision, but not continuous supervision. V8 stated staff checked on R1 frequently and observed R1 in the hallway.
On 6/15/23 at 2:46 PM V7 CNA stated on 6/13/23 at approximately 4:30 PM V7 CNA witnessed R1 in R2's room standing over R2's bed. R1 told V7 that R1 was washing R2's penis. V7 did not witness R1 touch R2. V7 redirected R1 back to R1's room which was across the hall from R2's room and left R1 unattended. V7 stated prior to the incident the staff had to redirect R1 from R2's room multiple times. V7 stated there were no staff assigned to provide continuous supervision of R1 on 6/13/23, following the incident with R2. V7 was unsure what interventions were implemented to prevent sexual activity involving R1.
On 6/15/23 at 11:55 AM V32 Licensed Practical Nurse stated R1 did not change rooms until after 2:00 PM on 6/14/23.
On 6/15/23 at 10:48 AM V2 Regional Nurse stated V2 received a call from V1 Administrator on the evening of 6/13/23 informing V2 of the incidents involving R1, R2, and R3. V2 stated V2 instructed to implement one to one supervision after R1's/R3's incident. One to one means if R1 is sleeping staff are to sit outside R1's room and if R1 is outside R1's room then a staff person is assigned to be with R1. The staff had initially asked V2 about 15-minute checks for R1 and V2 told the staff that is not enough, because that would allow for periods of time for R1 to be unsupervised. At 3:45 PM V2 stated residents who exhibit a desire for intimate relationships with a BIMS score of 10 or greater have the ability/capacity to consent to sexual activity. V2 stated this type of behavior is not ok in these incidents (R1/R2 and R1/R3). V2 confirmed R1 does not have the ability/capacity to consent to sexual activity. V2 stated R1's one to one continuous supervision is still ongoing at this time.
On 6/15/23 at 11:21 AM V1 stated V8 called V1 at approximately 6:30 PM to report R1's/R2's and R1's/R3's incidents. V1 did not report the incidents to the local police since R2 and R3 are able to consent to sexual activity. Resident's ability to consent to sexual activity is based on the BIMS score and is situational. V1 stated that there is no set BIMS score to identify when a resident is not able to consent. V1 confirmed the facility does not use any other assessment tool to determine residents' ability/capacity to consent to sexual activity. V1 was asked about R1's cognition and ability to consent to sexual activity. V1 stated That is a good point. V1 stated R1 implied consent because R1 initiated the sexual activity. V1 instructed staff that night to place R1 on one-to-one supervision and move R1's room. V1 stated V1 would have expected staff to notify V1 immediately after the incident with R1/R2 and implement one to one supervision at that time. On 6/20/23 at 11:02 AM V1 stated the facility does not have a policy for how they determine residents' ability to consent to sexual activity.
On 6/20/23 at 8:58 AM V16 CNA stated following the incidents involving R1, R1 had a room change and we try to keep R1 in R1's room or involved in activities. V16 stated there are no staff assigned to do one to one supervision of R1. On 6/20/23 at 9:08 AM V37 CNA confirmed there were no staff assigned to provide one to one continuous supervision of R1.
The facility's Abuse, Neglect, and Exploitation policy dated 2/28/2023 documents: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship; B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; C. Assuring an assessment of the resources needed to provide care and services to all residents is included in the facility assessment; D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator.
The Immediate Jeopardy that began on 6/13/23 was removed on 6/21/23 when the facility took the following actions to remove the immediacy:
1. R1's, R2's, and R3's abuse risk assessments were completed on 6/21/23 and care plans were updated on 6/21/23.
2. The facility made an in-house behavioral health appointment on 6/19/23 for R1 with an appointment date of 6/28/23. Appointment verified by V15 Social Service Aide on 6/26/23.
3. The facility initiated continuous one to one monitoring of R1 on 6/20/23 per V40 Scheduler. Verified through review of Daily staffing sheets and interviews with V40 Scheduler and V2 Regional Clinical Nurse/Interim DON on 6/26/23.
4. The facility initiated continuous one to one monitoring of R3 on 6/21/23 per V40 Scheduler. Verified through review of Daily staffing sheets and interviews with V40 Scheduler and V2 Regional Clinical Nurse/Interim DON on 6/26/23.
5. R1's and R3's care plans were revised on 6/17/23 to include sexual behaviors and interventions to address these behaviors.
6. Abuse policies were reviewed and updated on 6/21/23 per V1 Administrator. V1 Administrator stated V2 reviewed the Abuse policies on 6/15/23 but it was not officially revised until 6/21/23.
7. All staff Abuse Inservice was completed 6/14/23. V2 Regional Clinical Nurse stated the in-service was initiated with all staff on 6/14/23 and is ongoing for any PRN staff that are yet to work. V2 stated all staff that are working have been in serviced and the in servicing is ongoing. We have a plan in place to continue to train staff through organized phone calls and in-service sheets at nurse's desks. No staff are allowed to work without having had been through the in-service.
8. The facility Inservice dated 6/21/23 documents staff were in serviced on 'documentation of behaviors'. V2 Regional Clinical Nurse stated this training was completed on 6/21/23.
9. Resident care plans were reviewed and updated on 6/20/23 and 6/21/23. V2 Regional Clinical Nurse and V40 Social Service Aide both verified that care plans have been updated. Care plan review has shown that all residents reviewed had care plans updated on 6/21/23.
10. The facility has assessed residents for a risk of sexual abuse. V2 Regional Clinical Nurse stated 100% of in-house residents were reviewed and assessed on 6/20/23 and 6/21/23 for being able to consent. Resident care plans were updated with interventions to help in managing behaviors.
11. The facility initiated a policy titled 'Policy on intimate resident behavior, privacy and relationships' dated 6/21/23 per V1 Administrator.
12. The facility implemented an assessment titled 'Screening assessment to determine the presentation of trauma factors including abuse and/or neglect' dated 6/21/23. V2 Regional Clinical Nurse stated the facility implemented a process for screening and assessing all residents for being at risk of sexual abuse.
13. The facility completed audits of resident clinical records who have been identified as having sexual behaviors on 6/20/23 and 6/21/23. V2 Regional Clinical nurse confirmed all audits have been completed on 6/20 and 6/21/23.
14. The facility audited a minimum of five staff members each week starting 6/21/23. Audits were dated 6/23/23 and 6/26/23 with at least five staff members listed on each audit. V2 Regional Clinical Nurse confirmed staff audits have been started and will be ongoing.
15. The facility reviewed all new allegations of abuse to ensure compliance is met. V2 Regional Clinical Nurse stated the facility has had one incident involving two residents on 6/22/23. V2 stated the Abuse policy was followed and the incident has been reviewed by the IDT (Interdisciplinary Team). V2 stated all future incidents will be reviewed ongoing.
16. V1 Administrator stated the facility will continue to follow up with ongoing review of all issues including abuse allegations and survey findings. V1 stated the facility will continue to train incoming staff as new hires on abuse and also V40 Scheduler will let any PRN (as necessary), or agency staff know to complete the abuse training when arriving and prior to caring for residents. V1 stated QAPI (Quality Assurance Performance Improvement) meetings are held monthly, and IDT meets daily and both teams review abuse audits of residents and staff.
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
Based on observation, interview and record review, the facility failed to update resident plans of care for pressure ulcers, failed to document measurements/assessments of pressure ulcers, and failed ...
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Based on observation, interview and record review, the facility failed to update resident plans of care for pressure ulcers, failed to document measurements/assessments of pressure ulcers, and failed to document treatments to pressure ulcers were completed as ordered. The facility also failed to implement physician orders for a pressure ulcer wound treatment and notify the facility's wound nurse and/or wound physician of the development of a new pressure ulcer. These failures affect three of three residents (R4, R6 and R7) reviewed for pressure ulcers on the sample list of 10. The facility also failed to ensure identified pressure ulcer prevention interventions were implemented, causing R6's right buttocks wound to worsen.
Findings include:
1. R6's Care Plans dated 2/9/23 document the following: staff will refer to my Physician as needed for skin impairment and issues; R6 has skin impairments including a Stage 3 pressure ulcer to the sacrum and right upper buttock. These Care Plans document interventions including the following: Assess/record/monitor wound healing measure length, width, and depth where possible, assess and document status of wound perimeter, wound bed and healing progress. These Care Plans document to report improvements and declines to the physician, monitor/document/report as needed, any changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size (length X width X depth), stage. These care plans also document R6 requires pressure relieving/reducing device low loss air mattress on R6's bed with a date of 9/29/22.
R6's Order Summary Report dated 6/22/23 documents the following: An order dated 2/8/23 documents R6 is to have a Low Air Loss (LAL) mattress and to check function and setting every shift. This Order Summary Report documents an order dated 5/16/23 to clean R6's Stage 2 pressure ulcer to the coccyx with wound cleaner and pat dry. This order documents to apply medical honey gel to the wound and cover with a bordered foam dressing. This report does not document orders for R6's pressure ulcer to the right buttock. There are no orders for a treatment for a Stage 3 pressure ulcer to the sacrum.
R6's Wound Physician notes dated 4/25/23 document R6 had a right buttock skin tear that healed. There are no additional wounds documented for R6. These notes document R6 is at risk for reopening previous skin alterations due to: incontinence, limited mobility, poor intake and anemia and that R6 was being discharged from wound care.
R6's Wound Physician notes dated 5/23/23 document R6 had an initial assessment for a Stage 4 right buttock pressure ulcer with full thickness/exposed underlying structure. These notes document R6's right buttock pressure ulcer measurements as 2.8cm (centimeters) length, 1.7cm width, 0.2cm depth with minimal exudate. These notes document orders including preventative wound recommendations including LAL air mattress.
R6's Wound Physician notes dated 6/6/23 document R6's Stage 4 right buttock pressure ulcer with healing status of healing and measurements of 3.1cm length, 1.7cm width, 0.2cm depth with minimal exudate. These notes document Additional Notes/Orders including Wound Improving and LAL mattress.
R6's Wound Physician notes dated 6/13/23 document R6 was not seen by the wound physician because R6 was not in R6's room. There is no additional documentation in R6's medical records as to where R6 was at that time.
R6's Wound Physician notes dated 6/20/23 document R6's right buttock Stage 4 pressure ulcer healing status as declined with measurements of 3.4cm. Length x 4.1cm. Width x 0.1 cm. Depth. These notes document Related to wound status, R6 unable to adhere to offloading and that R6 had a prior stage 4 pressure ulcer to that area in the past. There is no documentation R6 had a pressure ulcer to R6's coccyx at this time. These notes document R6's TREATMENT ORDER: Every three times per weekday(s): Medical Honey Gel - Cleanse wound with normal saline or sterile water - Apply (medical honey gel) to Wound Bed - Cover with Dry Clean Dressing with Preventative Wound Recommendations: LAL Air mattress. This note does not document R6's open pressure ulcer to R6's coccyx.
R6's Order Summary Report dated June 22, 2023, document an order dated 5/16/23 to clean R6's Stage 2 pressure ulcer to the coccyx with wound cleaner and pat dry. This order documents to apply medical honey gel to the wound and cover with a bordered foam dressing. This report does not document treatment orders for R6's pressure ulcer to the right buttock.
On 6/21/23 at 2:05 PM, V32, Licensed Practical Nurse (LPN) completed R6's treatment to R6's right buttock pressure wound with V33, LPN assisting. Upon turning R6 to position R6 on R6's right side, R6's right buttock pressure ulcer was irregular in shape, with an open reddened wound bed. There was no dressing noted to R6's right buttock or coccyx pressure wounds. V32 stated staff cleaned R6 up when they assisted R6 to bed and the dressing was removed at that time. V32 cleaned V32's right buttock and coccyx pressure wounds with wound cleaner. V32 applied medical honey gel to the square bordered foam dressing and used a cotton tipped applicator to move the medical honey gel around on the foam dressing. V32 placed the dressing with the medical honey gel over the top of the right buttock wound. The adhesive portion of the dressing was positioned over the coccyx pressure wound, but not adhered to or covering the coccyx pressure ulcer. The coccyx pressure ulcer did not have any medical honey gel treatment or dressing completed as per R6's Physician's Orders. R6 was noted to be on a regular mattress with no alternating air capabilities. V32 confirmed R6's open pressure ulcer to the coccyx area at this time. There were no sacrum pressure ulcers observed at this time, but evidence of scarring over sacral area from previous sacrum pressure ulcers to which V32 confirmed.
On 6/22/23 at 1:40 PM, V29, Wound Nurse stated V29 is the wound nurse for the facility. V29 stated V29 has only been able to come one day a week to round with V30, Wound Physician because V29 is attending school. V29 stated it is probably V29's fault for not making sure R6 was on an air mattress. V29 stated R6 was on an air mattress and had a room change and that R6's mattress must not have moved with R6. V29 stated R6's wounds had healed, but R6 was always on an air mattress. V29 stated V29 and V30 just saw R6 Tuesday 6/20/23, and R6's right buttock pressure ulcer is declining and not having R6 on an air loss mattress will contribute to/cause the decline. V29 stated they should be following the orders for the coccyx pressure ulcer, but V29 was unsure of when the coccyx pressure ulcer had re-opened as it was opened in the past. V29 stated the floor nurse should have entered the new orders for R6's pressure ulcer to the right buttock as ordered. V29 stated V29 would look at the orders and get them updated in R6's medical records so the treatment would be done to the buttock pressure ulcer and the coccyx pressure ulcer. V29 stated the gel is to be placed on/in wound bed and not on the dressing to ensure the entire wound bed has the medical honey gel applied. V29 also stated the facility documents resident treatments were completed on the Treatment Administration Records (TAR). V29 stated the treatments should be implemented as ordered and transcribed to the electronic medical records. V29 stated treatments are to be documented when they are completed on the TAR.
2. R7's Order Summary Report dated June 21, 2023, documents R7's Physician's Orders including to apply skin prep to bilateral heels every shift.
R7's Care Plans document R7 is at risk for skin breakdown and that staff will refer to R7's physician for skin impairment and issues. These care plans do not document R7's left or right heel pressure ulcers.
There is no documentation of an assessment by V30, Wound Physician or measurements by the facility for R7's right heel pressure ulcer.
On 6/21/23 at 1:29 PM, V31, Licensed Practical Nurse cleaned R7's heels with wound cleanser and applied skin prep to R7's bilateral heels. V31 stated V31 is unsure of measurements of these wounds or who does them and that V29, Wound Nurse and V30, Wound Physician see R7 weekly and document. V31 stated R7 has had bilateral heel pressure ulcers for a while. V31 completed the treatment to R7's MASD (Moisture Associated Skin Damage) of the sacral area. At this time, R7 was noted to have a darkened circular non-blanchable pressure ulcer to the sacrum of which V31 stated was just smaller than a dime in size and that area had not been there previously.
R7's June Treatment Administration Record (TAR) dated June 2023 does not document R7's skin prep to R7's bilateral heels was completed as ordered during the evening shift on 6/1/23, 6/6/23, 6/10/23, 6/20/23.
There is no documentation in R7's medical record that V29 or V30 were notified of R7's new pressure ulcer to the sacrum.
On 6/22/23 at 1:40 PM, V29, Wound Nurse stated staff should notify V29 and/or V30 for any new skin impairments/pressure ulcer development and document in the nurse's notes. V29 stated V29 was unaware of the dime sized circular pressure ulcer for R7.
3. R4's hospital Discharge Transfer Orders dated 5/12/23 document R4's Wound care orders including Pressure Injury - Coccyx/Ischial Instructions including to apply self-adherent bordered foam dressings to the coccyx and all bony prominences. These orders document to peel back and assess skin every shift and change dressings weekly and as needed for soiling, saturation, or slippage to prevent skin breakdown.
R4's Order Summary Report dated June 15, 2023, does not document R4's orders for R4's pressure ulcer treatment to R4's coccyx as ordered on 5/12/23.
R4's medical records do not document monitoring/treatment of R4's coccyx pressure ulcer.
On 6/22/23 at 1:40 PM, V29, Wound Nurse stated the facility documents resident treatments were completed on the Treatment Administration Records (TAR). V29 stated the treatments should be implemented as ordered and transcribed to the electronic medical records. V29 stated treatments are to be documented when they are completed on the TAR. V29 stated V29 did not evaluate or know of R4's coccyx pressure wound.
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 F0552
(Tag F0552)
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 obtain informed consent from the resident's representative prior to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to obtain informed consent from the resident's representative prior to administering a psychotropic medication for one (R1) of five residents reviewed for abuse in the sample list of ten.
Findings include:
R1's Minimum Data Set (MDS) dated [DATE] documents R1 is usually understood and sometimes understands, wanders daily, and has severe impairment with daily decision making. This MDS and R1's Brief Interview for Mental Status (BIMS) dated 6/15/23 documents R1 has short- and long-term memory loss.
R1's Progress Note dated 6/14/23 and recorded by V38 Nurse Practitioner documents: R1was evaluated for inappropriate sexual behavior. R1 was unable to recall the behavior and the behavior is likely related to R1's dementia. V38 ordered Buspirone 5 milligrams twice daily to attempt to decrease R1's libido. R1's Progress Note dated 6/15/23 recorded by V38 documents R1's Power of Attorney (V14) refused to implement Buspirone and requested behavioral reinforcement and increased monitoring.
R1's June 2023 Medication Administration Record (MAR) documents R1 received Buspirone on 6/15/23 at 9:00 AM. There is no documentation in R1's medical record that V14 consented to R1's Buspirone order.
On 6/20/23 at 10:35 AM V2 Regional Nurse stated R1's Buspirone order was discontinued because V14 did not want R1 taking the medication. V2 stated the nurses should have obtained consent prior to Buspirone administration. V2 stated consents are documented under the miscellaneous tab in the resident's electronic medical record.
The facility's Antipsychotic/Psychotropic Medication Use policy dated as revised January 2022 documents to obtain consent from the resident or resident's representative prior to implementing psychotropic medications.
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 F0559
(Tag F0559)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to provide advance and written notification of a room change and reason for the room change for one resident (R3). R1 and R3 are ...
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Based on observation, interview, and record review the facility failed to provide advance and written notification of a room change and reason for the room change for one resident (R3). R1 and R3 are two of five residents reviewed for abuse in the sample list of ten.
Findings include:
On 6/15/23 at 10:08 AM R3's room was located on the 2nd floor of the facility. R3 stated the other night R1 came into R3's room. R3 was sitting in the recliner. R1 pulled down the top of R1's gown and exposed R1's breasts. R3 touched R1's breast with R3's hand. R1 told R3 to stop, and R3 complied. R1 is confused and did not ask R3 to touch R1. R3 knows R3 probably should not have touched R1, but R3 did.
On 6/21/23 at 11:15 AM R3 was in R3's room located on the 1st floor of the facility. R3 stated the staff moved R3's room yesterday and told R3 that R3 was moving rooms that day (6/20/23). R3 stated R3 did not know why R3 had to change rooms.
R3's Brief Interview for Mental Status dated 6/15/23 documents a score of 14, indicating R3 is cognitively intact. R3's Census documents R3 changed rooms on 6/20/23.
R3's Nursing Note dated 6/20/23 at 12:29 PM recorded by V33 Licensed Practical Nurse documents R3's room was changed, R3 was notified and R3 is R3's own Power of Attorney. There is no documentation in R3's medical record that R3 requested the room change or the reason for the room change. There is no documentation that R3 was notified of the room change prior to 6/20/23 or that R3 was provided written notification including the reason for the room change.
R1's Census documents R1 changed rooms on 6/14/23 at 3:44 PM, no longer residing on the same hall as R3.
On 6/21/23 at 11:20 AM V33 stated R3 moved rooms on 6/20/23. V33 was unsure why R3 moved rooms but was given written instructions to transfer R3 to a room on the 1st floor. V33 believes the room change was due to the incident involving R1 and R3, to prevent R1 from approaching R3 again. R3 asked V33 if R3 had to move and V33 instructed R3 to speak with administration.
On 6/21/23 at 11:43 AM V1 Administrator stated when residents have a room change, they are verbally informed and no written notice is given. V1 stated R3 moved rooms because staff reported R3 was upset on 6/13/23 regarding R1's/R3's incident and R3 requested the room change.
The facility's undated Room to Room Transfer policy documents Unless medically necessary or for the safety and well-being of the resident(s), a resident will be provided with an advance notice of the room transfer. Such notice will include the reason(s) why the move is recommended.
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 allegations of sexual abuse to law enforcement for three of f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report allegations of sexual abuse to law enforcement for three of five residents (R1, R2, R3) reviewed for abuse in the sample list of ten.
Findings include:
The facility's Initial Report dated 6/13/23 documents the following: The facility reported physical contact between confused residents (R1, R2, R3). R1 was seen in R2's room standing beside the bed touching R2's genitals, and it was unclear if this contact was direct or over top of the sheet. R1 was removed from R2's room and later that same day R1 was found in R3's room with R1's shirt pulled up and R3's mouth on R1's breast. The time the incidents occurred is unidentified. These incidents were reported to V1 Administrator on 6/13/23 at 6:32 PM. Law enforcement was not notified.
V7 Certified Nursing Assistant (CNA) statement documents: (V7) was walking down the hall and saw (R1) in (R2's) room with what appeared to be physical contact happening. Resident (R1) had their back to the door blocking a clear view. (V7) asked resident (R1) what they were doing and (R1) stated (R1) was washing (R2's) penis. (V7) approached the residents (R1, and R2) as (V7) could see (R1's) hand appeared to be by (R2's) privates, but by the time (V7) arrived at the bed (R1's) hand was moved. At that point (V7) escorted (R1) out of the room and back to (R1's) room to keep separated from other residents.
V9 CNA written statement dated 6/20/23 documents: V9 walked past R3's room and saw R3 sitting in the recliner. R1 was leaning over R3, R1's dress was low, and R3's mouth was on R1's breast.
R1's Minimum Data Set (MDS) dated [DATE] documents R1 is usually understood and sometimes understands, wanders daily, and has severe impairment with daily decision making. R1 transfers and walks with setup assistance and supervision from staff. This MDS and R1's Brief Interview for Mental Status (BIMS) dated 6/15/23 documents R1 has short- and long-term memory loss. R2's BIMS dated 6/2/23 documents a score of 6, indicating severe cognitive impairment. R3's BIMS dated 5/10/23 documents a score of 13, indicating R3 is cognitively intact.
On 6/15/23 at 2:46 PM V7 CNA stated on 6/13/23 at approximately 4:30 PM V7 CNA witnessed R1 in R2's room standing over R2's bed. R1 told V7 that R1 was washing R2's penis. V7 did not witness R1 touch R2, and V7 redirected R1 back to R1's room. V7 stated right after the incident V7 reported R1's/R2's incident to the nurse.
On 6/15/23 at 10:00 AM V9 CNA stated V9 passed by R3's room at approximately 4:30 PM- 4:45 PM on 6/13/23 and witnessed R1 bent forward towards R3 who was sitting in the recliner. R1 pulled R1's gown down exposing R1's breasts and R3's mouth was on R1's breast. V9 stated both residents were not upset by the incident and were actively engaged. V9 told R1 to get out of R3's room and R1 went into the hallway. V9 did not report the incident to anyone since V9 did not consider the incident to be abuse and R1 and R3 were both actively engaged in the sexual activity.
On 6/15/23 at 9:34 AM V8 Registered Nurse stated on 6/13/23 at an unidentified time V7 CNA reported to V8 that R1 touched R2's genitals. V8 stated following the incident, V9 witnessed R1 enter R3's room, R1 exposed R1's breast and R3 was sucking on R1's breast. Both incidents occurred between 5:00 PM and 6:00 PM. At 11:51 AM V8 stated V8 did not report R1's/R2's and R1's/R3's incidents to V1 Administrator until after the second incident, because the CNAs reported both incidents at the same time to V8.
On 6/15/23 at 11:21 AM V1 stated V8 called V1 at approximately 6:30 PM to report R1's/R2's and R1's/R3's incidents. V1 did not report the incidents to the local police since R2 and R3 are able to consent to sexual activity. V1 stated R1 implied consent because R1 initiated the sexual activity.
The facility's Abuse, Neglect, and Exploitation policy dated 2/28/23 documents: Reporting/Response
A.
The facility will have written procedures that include:
1.
Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:
a.
Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or
b.
Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.
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 implement interventions to prevent further sexual abus...
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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 implement interventions to prevent further sexual abuse while an abuse allegation was under investigation. This failure affects three of five residents (R1, R2, R3) reviewed for abuse in the sample list of ten.
Findings include:
The facility's Initial Report dated 6/13/23 documents: The facility reported physical contact between confused residents (R1, R2, R3). R1 was seen in R2's room standing beside the bed touching R2's genitals, and it was unclear if this contact was direct or over top of the sheet. R1 was removed from R2's room and later that same day R1 was found in R3's room with R1's shirt pulled up and R3's mouth on R1's breast. R1 was removed from R3's room and was placed on one-to-one supervision. The immediate intervention documents to contact R1's family about a room change.
V7 Certified Nursing Assistant (CNA) statement documents: (V7) was walking down the hall and saw (R1) in (R2's) room with what appeared to be physical contact happening. Resident (R1) had their back to the door blocking a clear view. (V7) asked resident (R1) what they were doing and (R1) stated (R1) was washing (R2's) penis. (V7) approached the residents (R1, and R2) as (V7) could see (R1's) hand appeared to be by (R2's) privates, but by the time (V7) arrived at the bed (R1's) hand was moved. At that point (V7) escorted (R1) out of the room and back to (R1's) room to keep separated from other residents.
V9 CNA written statement dated 6/20/23 documents: V9 walked past R3's room and saw R3 sitting in the recliner. R1 was leaning over R3, R1's dress was low, and R3's mouth was on R1's breast.
R1's Minimum Data Set (MDS) dated [DATE] documents R1 is usually understood and sometimes understands, wanders daily, and has severe impairment with daily decision making. R1 transfers and walks with setup assistance and supervision from staff. This MDS and R1's Brief Interview for Mental Status (BIMS) dated 6/15/23 documents R1 has short- and long-term memory loss. R1's Care Plan dated 9/6/21 documents R1 wanders aimlessly and without regards to needs or safety. R1's Care Plan revised 1/26/23 documents R1 is at risk for abuse/neglect related to diagnoses of dementia with behavioral disturbances and anxiety. R1's census documents R1 changed rooms on 6/14/23 at 3:44 PM (almost 24 hours after R1's/R2's and R1's/R3's incidents).
R2's BIMS dated 6/2/23 documents a score of 6, indicating severe cognitive impairment. R3's BIMS dated 5/10/23 documents a score of 13, indicating R3 is cognitively intact.
On 6/15/23 at 9:28 AM and at 11:55 AM R1 was in bed in R1's room. There were no staff present in R1's room or sitting outside of R1's doorway.
On 6/20/23 at 9:08 AM there were no staff present in R1's room. R1 walked out of R1's room down the hall towards the nurses' station. V37 CNA told R1 to go back to R1's room, and R1 walked back into R1's room.
On 6/15/23 at 10:08 AM R3 stated: The other night R1 came into R3's room. R3 was sitting in the recliner. R1 pulled down the top of R1's gown and exposed R1's breasts. R3 touched R1's breast with R3's hand. R1 told R3 to stop, and R3 complied. R1 is confused and did not ask R3 to touch R1. R3 knows R3 probably should not have touched R1, but R3 did. There was a staff person who witnessed the incident from the doorway. The staff did not intervene, but R1 left R3's room.
On 6/15/23 at 10:00 AM V9 CNA stated V9 passed by R3's room at approximately 4:30 PM- 4:45 PM on 6/13/23 and witnessed R1 bent forward towards R3 who was sitting in the recliner, R1 pulled R1's gown down exposing R1's breasts, and R3's mouth was on R1's breast. V9 stated both residents were not upset by the incident and were actively engaged. V9 told R1 to get out of R3's room and R1 went into the hallway.
On 6/15/23 at 9:34 AM V8 Registered Nurse stated: On 6/13/23 between 5:00 PM and 6:00 PM V7 CNA reported to V8 that R1 touched R2's genitals. V9 reported that V9 witnessed R1 enter R3's room. V9 went to R3's room and R1 exposed R1's breast and R3 was sucking on R1's breast. After the incident with R1/R2 we brought R1 to the nurse's station to keep a close eye on R1, but R1 just gets up and goes. After R1's/R3's incident R1 was placed on one-to-one supervision, but not continuous supervision. V8 stated staff checked on R1 frequently and observed R1 in the hallway.
On 6/15/23 at 2:46 PM V7 CNA stated on 6/13/23 at approximately 4:30 PM V7 CNA witnessed R1 in R2's room standing over R2's bed. R1 told V7 that R1 was washing R2's penis. V7 did not witness R1 touch R2. V7 redirected R1 back to R1's room which was across the hall from R2's room and left R1 unattended. V7 stated there were no staff assigned to provide continuous supervision of R1 on 6/13/23. V7 was unsure what interventions were implemented to prevent sexual activity involving R1.
On 6/15/23 at 11:21 AM V1 stated V8 called V1 at approximately 6:30 PM to report R1's/R2's and R1's/R3's incidents. V1 instructed staff that night to place R1 on one-to-one supervision and move R1's room.
On 6/15/23 at 10:48 AM V2 Regional Nurse stated V2 received a call from V1 Administrator on the evening of 6/13/23 informing V2 of the incidents involving R1, R2, and R3. V2 stated V2 instructed to implement one to one supervision after R1's/R3's incident. One to one means if R1 is sleeping staff are to sit outside R1's room and if R1 is outside R1's room then a staff person is assigned to be with R1. The staff had initially asked V2 about 15-minute checks for R1 and V2 told the staff that is not enough, because that would allow for periods of time for R1 to be unsupervised. At 3:45 PM V2 stated R1's one to one continuous supervision is still ongoing at this time.
On 6/15/23 at 11:55 AM V32 Licensed Practical Nurse stated R1 did not change rooms until after 2:00 PM on 6/14/23 (almost 24 hours after R1's/R2's and R1's/R3's incidents).
On 6/20/23 at 8:58 AM V16 CNA stated following the incidents involving R1, R1 had a room change and we try to keep R1 in R1's room or involved in activities. V16 stated there are no staff assigned to do one to one supervision of R1. On 6/20/23 at 9:08 AM V37 CNA confirmed there were no staff assigned to provide one to one continuous supervision of R1.
The facility's Abuse, Neglect, and Exploitation policy dated 2/28/2023 documents: Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator.
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 F0659
(Tag F0659)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was scheduled for and/or was taken to physician o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was scheduled for and/or was taken to physician office visits. This failure affects one of three residents (R4) reviewed for physician visits on the sample of 10.
Findings include:
R4's Discharge Transfer Orders dated 4/25/23 document R4 will need a podiatry follow up appointment. These orders document R4's Future Appointments for follow-up with the Pacemaker Device Clinic on 4/25/23 at 3:15 PM, with a contact telephone number listed. These orders also document R4 is to follow-up with V39, Infectious Disease Physician on 4/27/23 at 11:20 AM, with a contact telephone number listed.
R4's Census List documents R4 admitted to the facility on [DATE] at 4:07 AM. This list documents R4 discharged from the facility on 5/6/23 and was expected to return to the facility.
There is no documentation in R4's medical records that the facility attempted to transport R4 to/reschedule R4's Pacemaker Device Clinic appointment. There is no documentation the facility transported R4 to R4's follow-up appointment with V39 on 4/27/23 or attempted to reschedule. There is no documentation of an appointment being made by the facility for R4 going to an appointment with podiatry.
On 6/20/23 at 11:10 AM, V36, R4's Family stated R4 was supposed to follow up with appointments with multiple physicians after R4 admitted to the facility. V36 stated the facility did not ensure this was done, including R4's appointment with V26, R4's Podiatrist on 5/19/23.
On 6/21/23 at 9:55 AM, V20, Scheduler stated R4 was a no show to R4's appointment with V39, R4's Infectious Disease Physician on 4/27/23 at 11:20 AM. V20 stated there is no documentation of that appointment being rescheduled.
On 6/21/23 at 1:00 PM, V27, Scheduler stated R4 did not show for R4's appointment with V26, Podiatrist that was scheduled on 5/19/23 at 2:10 PM. V27 stated there was an issue with the facility and attempting to get a hold of the facility/communication with the facility when V26's office attempted to reschedule R4's appointment with the facility multiple times.
On 6/22/23 at 2:40 PM, V2, Regional Nurse stated the facility should follow physicians' orders including orders for follow-up appointments with physicians.
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 implement hospital physician's orders for Diabetic Foot Care. The facility also failed to document completion of treatments to a resident's...
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Based on interview and record review, the facility failed to implement hospital physician's orders for Diabetic Foot Care. The facility also failed to document completion of treatments to a resident's Diabetic Foot wounds as ordered and failed to notify the physician of new open wounds. These failures affect two of three residents (R4, R7) reviewed for wounds on the sample list of 10.
Findings include:
1. R4's hospital Discharge Transfer Instructions dated 4/25/23 and 5/12/23 document R4's physician's orders including orders for wound/incision care instructions. These orders document to wash feet including between toes daily with soap and water and dry completely. These orders document to avoid pressure to the location of the ulcer. There is no documentation these orders were transcribed and/or implemented.
On 6/22/23 at 1:40 PM, V29, Wound Nurse stated the floor nurses are to transcribe physicians' orders to each resident's electronic medical record orders. V29 stated the facility documents when treatment orders are completed on the Treatment Administration Record (TAR).
2. On 6/21/23 at 1:29 PM, V31, Licensed Practical Nurse (LPN) completed treatments to R7's skin. At this time, R7 was noted to have a pencil point open area on top of the second toe of the left foot, next to the great toe in the area of the mid knuckle. V31 stated this area was new and V31 was unsure of what caused the alteration.
R7's Progress Notes do not document V29, Wound Nurse or V30, Wound Physician were notified of R7's area to the left second toe. There is no documentation of treatment orders for this toe alteration.
On 6/22/23 at 1:40 PM, V29, Wound Nurse stated the floor nurses should notify V29 and/or V30 for any new skin impairments/pressure ulcer development.
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 F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a resident attended a podiatrist appointment as ordered. This failure affects one of three residents (R4) reviewed for physician's v...
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Based on interview and record review, the facility failed to ensure a resident attended a podiatrist appointment as ordered. This failure affects one of three residents (R4) reviewed for physician's visits on the sample list of 10.
Findings include:
R4's hospital Discharge Transfer Orders dated 4/25/23 document R4 will need a podiatry follow up appointment.
R4's hospital Discharge Transfer Orders dated 5/12/23 document R4 is to follow-up with R4's podiatrist in 1 to 2 weeks.
R4's medical records do not document R4 attended an appointment with a podiatrist while a resident at the facility.
On 6/22/23 at 1:40 PM, V29, Wound Nurse stated V29 overlooked that R4 was to be seen by a podiatrist for R4's Diabetic Foot wounds instead of V30, Wound Physician treating/monitoring. V29 stated the floor nurses schedule appointments with physicians/make sure transportation is aware.
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 F0744
(Tag F0744)
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 behavior monitoring, develop/implement nonpharmacological ...
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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 behavior monitoring, develop/implement nonpharmacological interventions, and assess for underlying medical cause of newly identified behaviors prior to initiating a psychotropic medication for one (R1) of five residents reviewed for abuse in the sample list of ten.
Findings include:
The facility's Initial Report dated 6/13/23 documents: The facility reported physical contact between confused residents (R1, R2, R3). This report documents R1 was seen in R2's room standing beside the bed touching R2's genitals, and it was unclear if this contact was direct or over top of the sheet. R1 was removed from R2's room and later that same day R1 was found in R3's room with R1's shirt pulled up and R3's mouth on R1's breast. R1 was removed from R3's room and was placed on one-to-one supervision. R1's family was contacted regarding a room change. The Nurse Practitioner will assess R1 for any physical problems that may be contributing to R1's behaviors.
R1's Minimum Data Set (MDS) dated [DATE] documents R1 is usually understood and sometimes understands, wanders daily, and has severe impairment with daily decision making. R1 transfers and walks with setup assistance and supervision from staff. This MDS and R1's Brief Interview for Mental Status (BIMS) dated 6/15/23 documents R1 has short- and long-term memory loss. R1's Care Plan dated 9/6/21 documents R1 wanders aimlessly and without regards to needs or safety. R1's Care Plan revised 1/26/23 documents R1 is at risk for abuse/neglect related to diagnoses of dementia with behavioral disturbances and anxiety. R1's diagnoses include Alzheimer's Disease. This care plan does not address R1's sexual behaviors or interventions to address these behaviors.
There is no documentation in R1's medical record that R1's sexual behaviors are tracked/monitored or nonpharmacological interventions/responses for this behavior. There is no documentation that laboratory values were ordered to determine possible underlying medical cause is contributing to R1's sexual behaviors prior to implementing Buspirone (antianxiety medication). There is no documentation that R1 was assessed for the use of Buspirone.
R1's Progress Note dated 6/14/23 recorded by V38 Nurse Practitioner documents: R1 was evaluated for inappropriate sexual behavior. R1 was unable to recall the behavior and the behavior is likely related to R1's dementia. R1's recent laboratory results are dated as 12/21/20 and 1/26/23. V38 ordered Buspirone 5 milligrams twice daily to attempt to decrease R1's libido. R1's Progress Note dated 6/15/23 recorded by V38 documents R1's Power of Attorney (V14) refused to implement Buspirone and requested behavioral reinforcement and increased monitoring.
R1's June 2023 Medication Administration Record (MAR) documents R1 received Buspirone on 6/15/23 at 9:00 AM. This MAR does not document monitoring of R1's sexual behaviors or nonpharmacological interventions to respond to these behaviors.
On 6/15/23 at 10:08 AM R3 stated: The other night R1 came into R3's room. R3 was sitting in the recliner. R1 pulled down the top of R1's gown and exposed R1's breasts. R3 touched R1's breast with R3's hand. R1 told R3 to stop, and R3 complied. R1 is confused and did not ask R3 to touch R1. R3 knows R3 probably should not have touched R1, but R3 did. There was a staff person who witnessed the incident from the doorway. The staff did not intervene, but R1 left R3's room.
On 6/15/23 at 10:00 AM V9 Certified Nursing Assistant (CNA) stated V9 passed by R3's room at approximately 4:30 PM- 4:45 PM on 6/13/23 and witnessed R1 bent forward towards R3 who was sitting in the recliner, R1 pulled R1's gown down exposing R1's breasts, and R3's mouth was on R1's breast. V9 stated R1 has not had a history of similar behaviors.
On 6/15/23 at 2:46 PM V7 CNA stated on 6/13/23 at approximately 4:30 PM V7 CNA witnessed R1 in R2's room standing over R2's bed. R1 told V7 that R1 was washing R2's penis. V7 did not witness R1 touch R2. V7 stated V7 was not aware of any prior sexual behaviors/incidents involving R1.
On 6/15/23 at 11:21 AM V1 Administrator stated R1's/R2's and R1's/R3's incidents were reported to V1 at approximately 6:30 PM on 6/13/23. V1 stated V1 was not aware of any other sexual abuse allegations or sexual behaviors involving R1.
On 6/20/23 at 10:04 AM V15 Social Services stated R1 has no prior history of in inappropriate sexual touching or sexual behaviors. V15 stated behaviors are updated on the resident's care plan, behavior tracking is overseen by the nurses and documented in a nursing note. V15 stated V15 thinks V2 Regional Nurse is responsible for completing psychotropic medication assessments.
On 6/15/23 at 3:45 PM V2 Regional Nurse stated residents who exhibit a desire for intimate relationships with a BIMS score of 10 or greater have the ability/capacity to consent to sexual activity. V2 stated this type of behavior is not ok in these incidents (R1/R2 and R1/R3). On 6/20/23 at 10:35 AM V2 stated behavior tracking is documented on the MAR, and V2 confirmed R1's June 2023 MAR does not document monitoring/interventions for R1's sexual behaviors. V2 stated V2 does not complete psychotropic medication assessments. At 1:06 PM V2 confirmed R1 did not have a psychotropic medication assessment completed. V2 confirmed there were no laboratory results ordered following R1's/R2's and R1's/R3's behaviors to rule out any underlying medical cause of R1's sexual behaviors prior to initiating Buspirone on 6/14/23.
The facility's Antipsychotic/Psychotropic Medication Use policy dated as revised January 2022 documents: These medications will be considered for elderly residents especially to those with dementia and after medical, physical, functional, psychological, emotional, psychiatric, social and environmental causes have been identified and addressed. The facility will attempt to determine underlying causes for behavioral symptoms so appropriate non-pharmacological interventions can be utilized prior to medication use. Staff will monitor an individual's behavior and mood symptom.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have a policy to determine a resident's ability or capacity to conse...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have a policy to determine a resident's ability or capacity to consent to sexual activity. This failure affects three of five residents (R1, R2, R3) reviewed for abuse in the sample list of ten. This failure has the potential to affect all 143 residents residing in the facility.
Findings include:
The facility's Initial Report dated 6/13/23 documents the facility reported physical contact between confused residents (R1, R2, R3). The section for sexual abuse allegation is not marked. This report documents R1 was seen in R2's room standing beside the bed touching R2's genitals, and it was unclear if this contact was direct or over top of the sheet. R1 was removed from R2's room and later that same day R1 was found in R3's room with R1's shirt pulled up and R3's mouth on R1's breast. R1 was removed from R3's room and was placed on one-to-one supervision. Immediate actions include contacting R1's family about a room change.
V7 Certified Nursing Assistant (CNA) statement documents: (V7) was walking down the hall and saw (R1) in (R2's) room with what appeared to be physical contact happening. Resident (R1) had their back to the door blocking a clear view. (V7) asked resident (R1) what they were doing and (R1) stated (R1) was washing (R2's) penis. (V7) approached the residents (R1, and R2) as (V7) could see (R1's) hand appeared to be by (R2's) privates, but by the time (V7) arrived at the bed (R1's) hand was moved. At that point (V7) escorted (R1) out of the room and back to (R1's) room to keep separated from other residents.
V9 CNA written statement dated 6/20/23 documents: V9 walked past R3's room and saw R3 sitting in the recliner. R1 was leaning over R3, R1's dress was low, and R3's mouth was on R1's breast.
R1's Minimum Data Set (MDS) dated [DATE] documents R1 is usually understood and sometimes understands, wanders daily, and has severe impairment with daily decision making. R1 transfers and walks with setup assistance and supervision from staff. This MDS and R1's Brief Interview for Mental Status (BIMS) dated 6/15/23 documents R1 has short- and long-term memory loss. R1's Care Plan dated 9/6/21 documents R1 wanders aimlessly and without regards to needs or safety. R1's Care Plan revised 1/26/23 documents R1 is at risk for abuse/neglect related to diagnoses of dementia with behavioral disturbances and anxiety.
R2's BIMS dated 6/2/23 documents a score of 6, indicating severe cognitive impairment. R3's BIMS dated 5/10/23 documents a score of 13, indicating R3 is cognitively intact.
There is no documentation in R1's, R2's, or R3's medical records that R1, R2, and R3 were assessed for the ability or capacity to consent to sexual activity.
On 6/15/23 at 10:08 AM R3 stated: The other night R1 came into R3's room. R3 was sitting in the recliner. R1 pulled down the top of R1's gown and exposed R1's breasts. R3 touched R1's breast with R3's hand. R1 told R3 to stop, and R3 complied. R1 is confused and did not ask R3 to touch R1. R3 knows R3 probably should not have touched R1, but R3 did. There was a staff person who witnessed the incident from the doorway. The staff did not intervene, but R1 left R3's room.
On 6/15/23 at 2:46 PM V7 CNA stated on 6/13/23 at approximately 4:30 PM V7 CNA witnessed R1 in R2's room standing over R2's bed. R1 told V7 that R1 was washing R2's penis. V7 did not witness R1 touch R2. V7 redirected R1 back to R1's room and left R1 unattended.
On 6/15/23 at 10:00 AM V9 CNA stated V9 passed by R3's room at approximately 4:30 PM- 4:45 PM on 6/13/23 and witnessed R1 bent forward towards R3 who was sitting in the recliner, R1 pulled R1's gown down exposing R1's breasts, and R3's mouth was on R1's breast. V9 stated both residents were not upset by the incident and were actively engaged. V9 told R1 to get out of R3's room and R1 went into the hallway. V9 did not report the incident to anyone since V9 did not consider the incident to be abuse and R1 and R3 were both actively engaged in the sexual activity.
On 6/15/23 at 9:34 AM V8 Registered Nurse stated: R2 yells out at times, is confused, and alert/oriented to person only.
V8 stated R3 is alert/oriented to person, place, time, and situation.
V8 stated R1 wanders into everyone's rooms. On 6/13/23 between 5:00 PM and 6:00 PM V7 CNA reported to V8 that R1 touched R2's genitals. V9 reported that R1 entered R3's room, R1 exposed R1's breast and R3's mouth was on R1's breast. At 11:51 AM V8 stated residents are only able to consent to sexual activity if they are alert and oriented to person, place, time, and situation.
On 6/15/23 at 3:45 PM V2 Regional Nurse stated residents who exhibit a desire for intimate relationships with a BIMS score of 10 or greater have the ability/capacity to consent to sexual activity. V2 stated this type of behavior is not ok in these incidents (R1/R2 and R1/R3). V2 confirmed R1 does not have the ability/capacity to consent to sexual activity.
On 6/15/23 at 11:21 AM V1 Administrator stated V8 called V1 at approximately 6:30 PM to report R1's/R2's and R1's/R3's incidents. V1 did not report the incidents to the local police since R2 and R3 are able to consent to sexual activity. V1 stated a resident's ability to consent to sexual activity is based on the BIMS score and is situational. V1 stated that there is no set BIMS score to identify when a resident is not able to consent. V1 confirmed the facility does not use any other assessment tool to determine residents' ability/capacity to consent to sexual activity. V1 was asked about R1's cognition and ability to consent to sexual activity. V1 stated That is a good point. V1 stated R1 implied consent because R1 initiated the sexual activity. On 6/20/23 at 11:02 AM V1 stated the facility does not have a policy for how they determine residents' ability to consent to sexual activity.
The facility's Daily Census dated 6/15/23 documents 143 residents reside in the facility.
The facility's Abuse, Neglect, and Exploitation policy dated 2/28/23 documents Prevention of Abuse, Neglect and Exploitation: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship. This policy does not identify the process for determining a resident's ability or capacity to consent to sexual activity.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to employ a full-time Director of Nursing. This failure affects all 143 residents residing in the facility.
Findings include:
The facility's F...
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Based on interview and record review, the facility failed to employ a full-time Director of Nursing. This failure affects all 143 residents residing in the facility.
Findings include:
The facility's Facility Assessment Tool dated December 2022 through November 2023 documents the facility's staffing plan. This staffing plan documents the facility follows the required minimum staffing as set forth by the State Department of Public Health including a Director of Nursing (DON) for 40 hours per week.
On 6/15/23 at 8:30 AM, V2, Regional Nurse stated V2 is only at the facility about 30 hours a week. V2 stated V2 is splitting time between another facility as it is closing and this facility. V2 stated the facility has not had a full time DON since sometime in April 2023/May 2023. On 6/15/23 at 9:40 AM, V2 stated V5, former Interim DON was here from 4/10/23-5/13/23.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Social Worker
(Tag F0850)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have a qualified social worker on staff. This failure has the potent...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have a qualified social worker on staff. This failure has the potential to affect all 143 residents residing in the facility.
Findings include:
The facility's Facility assessment dated [DATE] documents: The facility is licensed to provide care for a maximum of 213 residents. The facility's minimum staffing includes a Master of Social Work for 40 hours per week for behavioral healthcare services.
On 6/22/23 at 11:48 AM V34 Social Services Director stated V34 has been the facility's Social Services Director since 5/1/23 and V34 is not a Licensed Clinical Social Worker (LCSW). V34 stated V34 has a Bachelor's Degree in Political Science. V34 stated that is why the facility uses LCSW consultants, and V34 confirmed these consultants are not in the facility on a full-time basis.
On 6/22/23 at 12:30 PM V2 Regional Nurse confirmed the facility does not have a full time qualified social worker.
The facility's Daily Census dated 6/15/23 documents 143 residents reside in the facility.
Apr 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
Deficiency F0687
(Tag F0687)
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 foot care for two (R2, R3) of four residents r...
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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 foot care for two (R2, R3) of four residents reviewed for foot care in the sample list of six.
Findings include:
1.) On 4/12/23 at 10:31 AM V19 Hospice Registered Nurse was observed removing R2's socks. R2's toenails were long past the tips of R2's toes. R2's right great toenail had a dark black area at the base of the nailbed and R2's right 5th toenail had a black area. V19 stated V19 just spoke with V8 (R2's Spouse) who mentioned that R2's toenails are long and V8 reported this to facility staff on 4/9/23. V19 stated V19 will trim R2's toenails and will follow up to ensure toenail care is added to R2's hospice plan of care.
R2's Diagnosis List dated 4/12/23 does not document R2 is diabetic or has a diagnosis of circulatory impairment. R2's Minimum Data Set (MDS) dated [DATE] documents R2 has short- and long-term memory loss and requires extensive assistance of one staff person for personal hygiene. R2's Shower Sheets dated 3/6/23 through 4/12/23 do not document R2 needs R2's toenails trimmed or that R2's toenails were trimmed. There is no documentation that R2 was evaluated by a podiatrist within the last 3 months, after admitting to the facility in December 2022.
On 4/12/23 at 1:13 PM V8 stated R2 did not have any black areas on R2's toenails when R2 was admitted to the facility in December 2022 and was unsure how long the blackened areas had been there. V8 noticed R2's blackened toenails on 4/8/23. V8 told the facility in December 2022 that R2's toenails needed trimmed, and V20 Former Social Services said R2 was added to the podiatry list for January and February 2023. V8 stated R2's toenails have not been trimmed since December 2022.
On 4/12/23 at 2:45 PM V21 Licensed Practical Nurse stated the nurses do not trim residents' toenails. Social Services is responsible for reviewing shower sheets to see if toenails need trimmed and referring the resident to podiatry.
On 4/12/23 at 3:58 PM V2 Director of Nursing stated R2 is on hospice and Medicare will not pay for R2 to be seen by a podiatrist, so nursing staff are responsible for trimming R2's toenails and coordinating with hospice.
2.) On 4/12/23 at 10:36 AM R3 was observed lying in bed. V18 Certified Nursing Assistant (CNA) removed R3's socks. R3's toenails were long and curved past the tips of R3's toes. V18 stated the CNAs do not trim any residents' toenails. V18 confirmed R3's toenails were long and needed to be trimmed.
R3's Diagnoses List dated 4/12/23 documents R3 is diabetic. R3's MDS dated [DATE] documents R3 has severe cognitive impairment and requires extensive assistance of one staff person for personal hygiene. R3's Shower Sheets dated 3/9/23 - 4/11/23 document the question if toenails need trimmed, and these forms do not answer this question until 4/6/23. The 4/6/23 Shower Sheet documents R3's toenails need trimmed but does not document that R3's toenails were trimmed. There is no documentation in R3's medical record that R3 has seen a podiatrist within the last 3 months.
On 4/12/23 at 2:45 PM V21 Licensed Practical Nurse stated the nurses do not trim resident toenails. Social Services is responsible for reviewing shower sheets to see if toenails need trimmed and referring the resident to podiatry.
On 4/12/23 at 3:51 PM V3 Regional Nurse Consultant stated if residents are diabetic their toenails are trimmed by the nurse or podiatrist. At 3:58 PM V3 stated R3 has not been seen by a podiatrist, and R3 has now been added to the podiatry list.
On 4/12/23 at 4:18 PM V4 Social Services provided the podiatry lists from December 2022 through April 2023. V4 stated R2 and R3 were not on the podiatry lists and were not seen by a podiatrist.
The facility's undated Care of Fingernails/Toenails policy documents: 1. Proper nail care can aid in the prevention of skin problems around the nail bed. 2. Unless otherwise permitted, do not trim the fingernails of diabetic residents or residents with circulatory impairments. Assist the resident or family in making appointments to see their physician for nail trimming/care. 3. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. 4. Watch for and report any changes in the color of the skin around the nail bed, any signs of poor circulation, cracking of the skin between the toes, any swelling, bleeding, etc. (etcetera). 5. Stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease.
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
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain safe food temperature and storage to prevent ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain safe food temperature and storage to prevent foodborne illness. This failure affects one of six residents (R1) reviewed for feeding assistance in the sample list of six.
Findings include:
On 4/12/23 at 9:28 AM R1 was observed lying in bed asleep. R1's breakfast tray was observed on R1's overbed table, the tray contained two unopened cartons of 2% milk, one pancake, scrambled eggs, and oatmeal. R1's silverware was unwrapped. On 4/12/23 at 10:39 AM R1 was observed sitting in a wheelchair in R1's room. R1's breakfast tray was observed on R1's overbed table. R1's plate was empty. R1 ate all of R1's breakfast and drank R1's milk.
R1's Minimum Data Set, dated [DATE] documents R1 has short- and long-term memory impairment and has moderate impairment with making daily decisions. R1's meal intake documents R1 ate 75-100% of the noon meal on 4/12/23.
On 4/12/23 at 3:32 PM V11 Certified Nursing Assistant stated R1 ended up eating breakfast shortly after 9:30 AM. R1 had not been feeling well the night before, so V11 let R1 sleep in. V11 was not sure what time R1's breakfast tray was delivered to R1's room. V11 stated V11 gave R1 the meal tray that was in R1's room and did not get R1 a different breakfast tray.
On 4/12/23 at 4:03 PM V5 Dietary Manager stated room trays should start being collected about 45 minutes after the meal trays are distributed. Breakfast trays were sent to R1's unit at 7:05 AM. V5 confirmed two and a half hours is an unsafe amount of time for food/milk to be at room temperature and the food/milk should not be consumed. V5 stated that time frame is unacceptable, and the staff should have called the kitchen to get R1 a different meal tray. V5 stated sometimes the staff let residents sleep in and they leave the meal tray at the bedside until the resident gets up.
The facility's Food Safety Requirements policy dated 3/23/23 documents the following: Food should be stored in a way that prevents food deterioration, contamination, and bacterial growth. This process includes monitoring food temperatures when food is held for delivery to ensure proper food temperatures are maintained. Food and drinks will be distributed/served in a way that prevents contamination and maintains safe food temperatures. This process includes timely distribution of meal trays.
Apr 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
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide feeding assistance to residents according to ...
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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 feeding assistance to residents according to their assessed needs, therapist recommendations, physician orders, and care plans. This failure affects two residents (R3 and R10) out of 12 reviewed for feeding assistance on a sample of 17.
Findings include:
R10's Minimum Data Set (MDS) dated [DATE] documents R10 requires supervision and physical assistance from 1 staff member to eat. This same MDS documents R10 experiences loss of food and liquids from mouth when eating.
R10's Speech Therapist Progress Note and Updated Plan of Care dated 7/5/22 documents, (R10) continues to demonstrate inconsistent s/s (signs and symptoms) of aspiration during PO (oral) intake, especially towards the end of meals, and delayed coughing after meals. (R10) continues to demonstrate chest congestion and congested coughing outside of (oral) intake. This same Updated Plan of Care documents, Precautions: direct supervision and assist with feeding, pureed texture, thin liquids, medications crushed. staff to provide positioning assist with pillow props (due to) left leaning at meals, position at 90-degree angle during and 20 minutes after oral intake, aspiration risk.
R10's Care Plan dated 7/27/22 documents R10 is a Potential for aspiration or choking due to advanced age, on therapeutic diet, quadriplegia, history of CVA (stroke), dysphagia oropharyngeal phase. Nursing interventions for R10's aspiration risk are documented including, Aspiration precautions, check for pocketing food or medications during meals, cue resident to take double swallows each bite, direct feed assist during meals or supervision in the dining room, encourage to eat slowly, ensure (R10) is sitting up at 90 degrees during meals, and frequent drinks during meals to facilitate clearing of oral cavity.
On 4/4/23 at 11:25 am, R10 was observed laying in bed in R10's own room with a lunch tray placed on the overbed table. R10 was laying on her left side with the head of the bed up no more than 30 degrees. There were no pillows placed to prevent R10 from leaning to the left side. R10 was actively eating from the lunch tray and there was no staff member present nor monitoring R10 to provide the required cues and direct feeding assistance.
The facility's policy Feeding Program/ Meal Assistance and Supervision, dated September 2022, documents, Nursing staff will follow the providers order for intervention, which may include feeding programs and swallow precautions.
R3 was admitted to the facility on [DATE] with the diagnoses of Malignant Neoplasm of Prostrate.
According to R3's face sheet dated 3/24/23. R3's Minimum Data Set (MDS) dated [DATE] documents R3 is severely cognitively impaired and requires extensive assistance for activities of daily living (ADL's). The ADL's include dining-eating, including meals and snacks. This same MDS documents R3 requires extensive assistance during meals. R3's baseline care plan dated 3/24/23 documents R3 exhibits self-care deficits and requires assistance with activities of daily living including assistance while eating and meal set-up.
On 4/4/23 at 11:00 AM, V5, Activity Director, served R3 his noon meal. V5 sat R3 up in his bed, raised the head of his bed, placed his lunch tray on the over-bed table, and moved the table next to R3 so R3 was able to reach the lunch tray. V5 stated after being asked about R3 feeding self and V5 stated she was told R3 could feed himself.
R3 was observed at 11:25 AM to be in his room without assistance. R3 had pulled his plate from the over-bed table into his lap. Food was observed in the bed on the top sheet. R3 was picking at the food trying to feed himself.
At 11:40 AM R3 was observed still picking at his food, no food has reached his mouth. No staff came around to see how R3 was doing in feeding himself.
R3 had a sign on the wall above R3's bed which reads (R3 name), (Wife's name and phone number), needs assistance to eat and encouragement. Both daughters name and phone number were on the sign. The sign continued Mr. (R3) has low vision and hard of hearing. Smile you may be on camera.
At 11:50 AM staff came and picked up R3's tray and changed his top sheet. Staff left his juice in a cup with straw and two unopened containers of apple sauce and pack of graham crackers on the table. The menu for lunch was butter peas, chicken and dumplings, and pineapple tiblets. R3's plate did not look like it had been touched. R3 did drink his apple juice.
V14, CNA (Certified Nursing Assistant) stated at 11:21 am on 4/5/23, I was the CNA for (R3) yesterday, which was my first time caring for (R3). I thought (R3) was able to feed himself but he is not able.
Facility policy titled Feeding Program/Meal Assistance and Supervision revised September2022 documents,
Nursing and/ or CNAs will daily assist feeding residents and monitor a resident's intake at each meal.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to implement measures to help prevent the development of infections according to facility policy. This failure affects one resid...
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Based on observation, interview, and record review, the facility failed to implement measures to help prevent the development of infections according to facility policy. This failure affects one resident (R2) out of three reviewed for urinary catheters on the sample of 17.
Findings include:
On 4/4/23 at 11:10 am, R2 was observed in a low bed in R2's room with a supra-pubic urinary catheter present and the urinary collection bag was observed laying directly on the floor surface.
On 4/4/23 at 11:12 am, V7 Licensed Practical Nurse/ Floor Manager, stated, (urinary) catheter bags should not be on the floor.
On 4/4/23 at 11:15 am, V8, Licensed Practical Nurse, stated, (urinary) catheter bags are not supposed to be on the floor.
The facility's policy Catheter Care, Urinary, dated 3/17/22 documents, For infection control, be sure catheter tubing and drainage bags are kept below the level of the bladder and kept off the floor.
On 4/5/23 at 2:35 pm, V2 Regional Nurse, stated, I just gave all the staff an in-service yesterday about keeping (urinary) collection bags off the floor.
Mar 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
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a current copy of a resident's advance directive was in the 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 ensure a current copy of a resident's advance directive was in the resident's medical record and failed to follow facility policy for implementing advance directives for one (R1) of three residents reviewed for advance directives in the sample list of four.
Findings include:
The facility's Do Not Resuscitate Order policy dated as revised [DATE] documents, A Do Not Resuscitate Order (DNRO) form must be completed and signed by the Attending Physician and resident (or resident's legal surrogate, as permitted by State law) and placed in the front of the resident's medical record. Should the resident be transferred to the hospital, a photocopy of the DNRO form must be provided to the EMT (Emergency Medical Technician) personnel transporting the resident to the hospital.
The facility's Advance Directives policy dated as revised [DATE] documents, Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. Do Not Resuscitate- Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used. The Nurse Supervisor will be required to inform emergency medical personnel of a resident's advance directive, regarding treatment options and provide such personnel with a copy of such directive when transfer from the facility via ambulance or other means is made.
R1's Physician's Order dated [DATE]-[DATE] documents Do Not Resuscitate (DNR). R1's medical record does not contain a DNR order that is signed by a physician and V10 (R1's Power of Attorney). There is no documentation in R1's medical record that attempts were made to contact V10 to review R1's advance directives prior to [DATE].
R1's Social Service History & Initial assessment dated [DATE] documents R1 has severe cognitive impairment and limited communication ability. R1's Plan of Care Note dated [DATE] at 6:48 PM documents V10 was contacted to review R1's goals and plan of care. This note documents R1's code status as Full Code. R1's code status was not changed in R1's medical record until [DATE].
R1's Nursing Notes document on [DATE] at 12:03 AM R1 was transported to the hospital by ambulance for changes in respiratory status. On [DATE] at 1:27 AM the hospital contacted the facility asking about R1's DNR code status. The nurse (V6 Registered Nurse) was unable to locate and provide documentation of R1's DNR status. The hospital instructed V6 to contact V11 Physician to verify R1's code status. V6 notified V11, who was unable to verify R1's DNR status.
R1's Hospital History & Physical dated [DATE] at 5:59 AM documents R1 as full code status. R1's POLST (Physician Order for Life Sustaining Treatment) dated [DATE] documents R1's code status as Full Code and full treatment when in cardiac arrest.
On [DATE] at 12:48 PM V10 stated: R1 was confused prior to admitting to the facility, and R1 was unable to make decisions regarding R1's care. V10 told the hospital that V10 wanted everything done for R1, and R1's code status should be Full Code prior to R1's admission to the facility on [DATE]. R1 should not have had a DNR order.
On [DATE] at 1:07 PM V12 Social Services stated V13 Admissions Coordinator completes the POLST form and admission paperwork with residents/resident representatives upon admission. V12 reviews the code status again with the resident/representative. V12 was originally told that R1 had a DNR order upon admission and did not have a completed POLST (Physician Order for Life Sustaining Treatment) form upon admission. V12 was on vacation when R1 was admitted to the facility. The resident should have a completed POLST form indicating they have a DNR order. V12 spoke with V10 on [DATE] and V10 stated R1's code status was to be Full Code.
On [DATE] at 1:13 PM V13 Admissions Coordinator confirmed V13 completed R1's admission paperwork and R1's code status on admission was DNR. V13 stated R1 did not have a completed POLST form documenting DNR upon admission. V13 attempted to contact V10 (R1's Power of Attorney) to review R1's code status but was unable to reach V10. V13 stated V13 contacted the hospital to request a copy of R1's signed POLST or DNR order, and the hospital said they did not have one on file. V13 confirmed R1's medical record did not contain a POLST or DNR order signed by a physician and V10 prior to [DATE].
On [DATE] at 1:33 PM V6 Registered Nurse stated R1 had respiratory changes noted during night shift on [DATE] and was transferred to the hospital by ambulance. The hospital contacted V6 requesting a copy of R1's POLST form to support R1's DNR code status. R1 did not have a signed DNR order or POLST form in R1' medical record. In the past, if the resident does not have a signed POLST form documenting DNR, then the resident's code status was Full Code. The nurses look at the resident's heading of the electronic medical record to determine code status, and R1's code status was DNR when R1 was sent to the hospital on [DATE]. When the order for DNR is entered into the electronic medical record it prompts to confirm there is a signed POLST indicating DNR on file. I assumed that the person who entered R1's DNR order verified that a POLST form was on file to support R1's DNR status. The nurse's desk now has a binder containing resident POLST forms, but this was not in place prior to R1's hospital transfer.
Mar 2023
2 deficiencies
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow the Centers for Disease Control and Local Health Department 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 follow the Centers for Disease Control and Local Health Department recommendations for employees returning to work after testing positive for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). This failure has the potential to affect all 117 residents in the facility.
Findings include:
The facility provided census dated 3/8/23 documents 117 residents in the facility.
On 3/8/23 at 8:30AM, V3 Infection Preventionist stated that since 2/20/23, 10 employees had tested positive for the SARS-CoV-2 virus and that the facility had been in outbreak status since 2/25/23 with 32 resident positive cases in the building.
On 3/8/23 at 1:08PM, V3 Infection Preventionist stated, If they test on day zero as positive, they can test again on day 3 and if they are negative, they can return to work.
On 2/24/23, the facility Covid Positive Staff Tracking Sheet documents that V8 Certified Nursing Assistant (CNA) tested positive for SARS-CoV-2 on 2/24/23 with the symptom of a sore throat. V8's facility provided timecard documents V8 returning to work on 2/27/23, three days posttest.
On 3/4/23, the facility Covid Positive Staff Tracking Sheet documents that V11 Certified Nursing Assistant (CNA) tested positive for SARS-CoV-2 on 3/4/23 with the symptom of nausea. V11's facility provided timecard documents V11 returning to work on 3/8/23, four days posttest.
On 3/4/23, the facility Covid Positive Staff Tracking Sheet documents that V16 CNA tested positive for SARS-CoV-2 on 3/4/23. V16's facility provided time card documents V16 returning to work on 3/7/23, three days posttest.
On 3/14/23 at 10:45AM V6 Human Resources Director stated that certified nursing assistant staff work all over the building, on all units.
The Centers for Disease Control, Interim Guidance for Managing Healthcare Personnel with Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2) Infection or Exposure to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) dated 9/23/22 documents, (Health Care Providers) with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: At least 7 days have passed since symptoms first appeared if a negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and At least 24 hours have passed since last fever without the use of fever-reducing medications, and symptoms (e.g., cough, shortness of breath) have improved.
On 3/9/23 at 8:32AM, V17 Communicable Disease Investigator at the [NAME]-Urbana Public Health Department stated, Allowing employees to return to work less than 5 days has never been the guidance. I will send V3 Infection Preventionist some follow up information so that she has information on that.
On 3/8/23 at 9:02 V1 Administrator and V2 Director of Nursing stated that if a staffing crisis were to occur there are managers and non-clinical staff who could work the floors, overtime would be mandated and there are local sister facilities who could provide additional staffing along with agency staff and that they were not in crisis staffing during this outbreak.
On 3/13/23 at 8:00AM, V1 Administrator stated, I was not aware that we were allowing staff to come back after three days.
On 3/9/23 at 2:09 V17 Infection Control Investigator at the [NAME] Urbana Public Health District stated, I went to discuss this with my supervisor and told him that the facility was in outbreak and was allowing employees to return in less than five days after testing positive and we think that this certainly could have contributed to the outbreak.
On 3/14/23 at 11:30AM, V1 Administrator stated, We should not have let them come back as early as we did, and we have a plan to educate our staff including V3 Infection Preventionist so that this won't happen again.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0886
(Tag F0886)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to ensure that all employees were tested twice weekly during a Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) outbreak. This fail...
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Based on interview and record review the facility failed to ensure that all employees were tested twice weekly during a Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) outbreak. This failure has the potential to affect all 117 residents in the facility.
Findings include:
The facility provided census dated 3/8/23 documents 117 residents in the facility.
On 3/8/23 at 8:30AM, V3 Infection Preventionist stated that since 2/20/23, 10 employees had tested positive for the SARS-CoV-2 virus and that the facility had been in outbreak status since 2/25/23 with 32 resident positive cases in the building.
On 3/8/23 at 9:08AM, V3 Infection Preventionist stated, We are in outbreak now. We are testing all staff and residents twice weekly, on Tuesday and Friday. Staff get (antigen tests) and residents get (polymerase chain reaction) tests. Our community (transmission) level is substantial.
The revised facility COVID-19 Facility Staff Testing dated 3/24/22 documents, If the community transmission level is substantial, twice a week testing is required.
V21 CNA's facility provided timecard documents that V21 worked on 2/28/23, 3/2/23, 3/5/23 and 3/6/23.
V22 Licensed Practical Nurse's facility provided timecard documents that V22 worked on 2/28/23 and 3/8/23.
V23 CNA's facility provided timecard documents that V23 worked on 2/28/23, 3/1/23, 3/2/23, 3/4/23, 3/5/23, 3/7/23, and 3/9/23.
The facility provided testing logs dated 2/27/23-3/4/23 and 3/5/23-3/11/23 document V21 Certified Nursing Assistant (CNA), V22 Licensed Practical Nurse and V23 CNA documented zero SARS-CoV-2 tests taken from 2/27/23 through 3/11/23.
On 3/14/23 at 11:30AM, V1 Administrator stated, The staff should have been testing twice weekly. We are addressing these issues with our staff and putting a new process into place to prevent this from happening again.
Sept 2022
34 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B.) Based on interview and record review the facility failed to prevent a resident-to-resident altercation for two (R89, R95) of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B.) Based on interview and record review the facility failed to prevent a resident-to-resident altercation for two (R89, R95) of seven residents reviewed for abuse in the sample list of 99.
Findings include:
b.)1.) The facility's Abuse Prevention Program dated November 28, 2017, documents: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.
The facility's Final Incident Investigation Report dated 9/2/22 documents the following: On 8/28/22 staff observed R95 attempt to inappropriately touch another resident R89. V12 Certified Nursing Assistant (CNA) initially reported that V12 witnessed R95 touch R89 on R89's private (genital) area. V12 intervened and separated R95 from R89. V12 later clarified to local police that R95 was attempting to grab and unbutton R89's pants, and R89 was shaking and pushing R95 away with both of R89's hands. R95's hands were touching and grabbing towards R89's private (genital) area.
R95's undated Diagnosis List documents R95 has diagnosis of Bipolar Disorder. R95's Minimum Data Set (MDS) dated [DATE] documents R95 has severe cognitive impairment, requires supervision of one staff person for locomotion on R95's unit. R95's Care Plan revised on 5/5/22 documents R95 has the potential to be physically aggressive towards other residents and has a history of a physical altercation with another resident. R95's Care Plan revised on 5/31/22 documents R95 has a behavior problem of exposing R95's self in R95's room and inappropriately touching female staff. This care plan includes an intervention Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. R95's Nursing Note dated 10/22/2021 at 11:51 PM documents R95 appeared in the common area wearing only an incontinence brief and shirt. R95 was asked what R95 was doing and replied that R95 wanted some. R95 was told that R95 was inappropriate and redirected back to R95's room. R95's Nursing Note dated 8/28/2022 at 2:24 PM documents R95 was touching a female resident (R89) and trying to unbutton her pants.
R89's undated Diagnosis List documents R89 has a diagnosis of Alzheimer's Disease. R89's MDS dated [DATE] documents R89 is rarely/never understood, has short- and long-term memory impairment, R89's Care Plan dated 6/17/22 documents R89 is at risk for abuse and neglect per the facility's assessment tool. R89's Nursing Note dated 8/28/2022 at 2:39 PM documents R89 was sent to the hospital for evaluation after R89 was touched in groin area by another male resident (R95).
On 8/29/22 at 3:56 PM V22 Licensed Practical Nurse (LPN) stated: R95 has made sexual comments to staff and residents while passing them in the hallway. R95 would say things such as you can come sit on my lap, or I'll help you undo your pants. This has been an ongoing behavior. We try to keep a close eye on R95 and have R95 near the nurse's station. R95 does wander at times.
On 8/30/22 at 9:38 AM V12 CNA stated: On 8/28/22 around 1:50 PM, R95 was in the television room facing the window, and R89 was facing the television. R95 had R89's hands on R89 trying to unbutton R89's pants. R89 is nonverbal. R89 used R89's hands to try and push R95's hands off of R89, while R95 continued to attempt to unbutton R89's pants. V12 immediately separated R95 from R89. R95 is confused, and during incontinence care has made sexual comments in regards to female staff's breasts.
On 8/31/22 at 3:30 PM V39 LPN stated: About a month ago during shift change, V39 saw R89 and R95 in the television room. R95's back was facing V39, and R95's arm was near R89. V39 was not able to see R95's hands. V39 approached R95, and R95 acted startled and said I'm not doing anything. It (the situation) didn't sit well with me (V39). R95 and R89 were immediately separated. V39 reported the incident to V13 Previous Administrator, and V13 told V39 it sounds like two residents with Dementia. After that incident, whenever V39 worked V39 had the female residents sit in the hallway for monitoring. R95 required close supervision.
Identified failures require more than one deficient practice statement.
A.) Based on interview and record review the facility failed to ensure R52, R64, and R88 were not to subjected mental, verbal, and physical abuse by R46. This failure puts these residents at risk for severe, life threatening, and potentially fatal injuries. R46, R52, R64 and R88 are four of seven residents reviewed for abuse in the sample list of 99.
This failure resulted in an Immediate Jeopardy.
While the immediacy was removed on 9/7/22, the facility remains out of compliance at severity level 2. While the facility continues to develop and implement measures for each identified resident to address tendencies and triggers that could lead to physical aggression towards others.
Findings include:
The facility's Abuse Prevention Program policy with an effective date of 11/28/17 documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to resident or families, or within their hearing distance, regardless of an individuals' age, ability to comprehend, or disability. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention (77 Ill. Adm. Code 300.330). Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment (42 CFR 483.12 Interpretive Guidelines). Pre-admission Screening of Potential Residents. The facility shall check the criminal history background on any resident seeking admission to the facility in order to identify previous criminal convictions. For residents who are identified offenders, the facility shall incorporate the Identified Offender Report and Recommendation Report into the identified offender's plan of care including the security measures listed. Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility. In addition, the facility shall take all steps necessary to ensure the safety of resident including, but not limited to, the separation of the residents.
R46's Face Sheet dated 8/19/22 documents an admission date of 6/18/22. R46's admission Minimum Data Set (MDS) dated [DATE] documents diagnoses including Schizophrenia, Wernicke's Encephalopathy, Alcohol Abuse with Intoxication and Unspecified Mood Disorder. This MDS documents a BIMS (Brief Interview for Mental Status) score of 9/15 indicating moderately impaired cognition.
R46's Care Plan dated 6/20/22 documents R46 has a history of criminal behavior and documents a care plan updated 8/26/22 that since admission R46 has had some aggressive behaviors towards others with interventions to promote safety, intervene when inappropriate behavior is observed. This Care Plan documents R46 is a wanderer and (R46) goes in other resident's rooms and can be difficult to redirect with a revision date of 6/27/22.
R46's Nurse's Notes in June 2022 documents R46 curses and yells at residents and staff and goes into other residents' rooms and gets agitated and does not want to leave easily.
R46's Nurse's Notes in July 2022 documents R46 was physically and verbally abusive to staff.
R46's Nurse's Notes in August 2022 continue to document verbal abuse and being combative with staff.
R46's Nurse's Note dated 8/26/22 at 2:55 PM, documents R46 was sent to a Psychiatric hospital.
R46's Nurse's Note dated 8/26/22 at 4:20 PM documents R46 was being issued a 30-day discharge notification due to recent incidents and behaviors which were affecting other residents.
a.)1.) The facility's Preliminary Incident Investigation Report dated 8/19/22 at 12:20 PM, documents (R46) were ambulating in (R46's) wheelchair behind (R52) and (R64). (R46) said f*** you (expletive) and (R64) responded by saying the same to (R46). (R46) then propelled (R46's) wheelchair towards (R52) and (R64) and they fell to the ground. The residents were separated, and (R46) is being monitored 1:1 (one to one) pending orders received for (R46) to be sent out for evaluation. Following nurse assessments of the residents, no injuries were noted for any of the three residents. Residents will be monitored for signs and symptoms of distress. Physicians and POAs (Power of Attorneys) were notified.
R46's Nurse's Note dated 8/19/22 at 12:20 PM, R46 became agitated with two other female residents (R52, R64). R46 was in a wheelchair on R46's way back from the dining room. (R52 and R64) were ambulating back from lunch. R46 was heard yelling F*** you to (R52 and R64). One of the female residents yelled F*** you back to R46. R46 sped up the wheelchair and hit (R52 and R64) directly knocking them to the ground. R46 stated that they deserved it, they shouldn't talk to R46 like that. R46 on 1:1 supervision from time of incident.
On 9/1/22 at 9:42 AM, V14 LPN (Licensed Practical Nurse) stated V14 witnessed R46 run R46's wheelchair into R52 and R64 on 8/19/22 and knock them to the ground. V14 stated V14 heard bickering and cuss words being yelled and V14 saw R46 plow R46's wheelchair towards R52 and R64 and knock them to the ground. V14 stated when R52 and R64 were on the ground they were yelling cuss words at R46 and calling R46 a SOB (Son of a B****) (expletive). V14 stated V14 separated R46, R52 and R64. V14 stated V14 asked R46 why R46 knocked R52 and R64 down and R46 told V14 that they were making fun of R46 and R46 told V14 that R46 would do it again. V14 stated R46 stayed with V25 Social Services Director after the incident.
R52's Order Summary Report dated 8/30/22 documents diagnoses including Major Depressive Disorder, Cerebral Infarction and Unspecified Dementia without Behavioral Disturbance.
R52's Nurse's Note dated 8/19/22 at 12:20 PM, documents fall was witnessed and occurred in the hallway. R52 was ambulating back from the dining room and the reason for the fall was evident. Another resident knocked R52 over. R52 was ambulating down the hallway and a male resident (R46) yelled F*** you and R52 yelled it back. This prompted (R46) to speed toward R52 in R46's wheelchair knocking R52 to the ground. V14 LPN/writer witnessed the fall. No head trauma. Parties separated. Nursing Assessment completed. Vital signs recorded. No complaints of pain. Able to move all extremities. Assisted to standing with two assists. Able to ambulate back to room without difficulty.
R52's BIMS Evaluation dated 8/19/22 documents a score of 9/15 indicating moderately impaired cognition.
R64's Order Summary Report dated 8/30/22 documents diagnoses including Alzheimer's Disease, Unspecified Dementia with Behavior Disturbances and Anxiety Disorder.
R64's Nurse's Note dated 8/19/22 at 2:05 PM, documents at 12:20 PM R64 was ambulating back to room from dining room, talking with roommate. Another male resident (R46) became agitated, yelled F*** you at R64, R64 yelled it back. This prompted R46 to speed toward R64 in R46's wheelchair knocking R64 to the ground. V14/writer witnessed fall. No head trauma. Parties separated. Nursing assessment completed. Vital signs recorded. No complaints of pain. Able to move all extremities. Assisted to standing with two assists. Able to ambulate back to room without difficulty. Primary Care Provider notified. POA notified.
R64's BIMS Evaluation dated 8/19/22 documents a score of 3/15 indicating severely impaired cognition.
a.)2.) The facility's Preliminary Incident Investigation Report dated 8/30/22 documents the incident happened on an unknown date. (R88) stated another resident (R46) called me a f***ing b**** (expletives) and double fist hit my nose so bad around a month ago.
R88's Order Summary Report dated 8/31/22 documents diagnoses including Transient Cerebral Ischemic Attack and Repeated Falls. This Order Summary documents an order for Clopidogrel (Plavix/Anticoagulant) 75 mg (milligrams), one tablet by mouth once a day related to Cerebral Infarction with a start date of 5/18/21.
R88's Nurse's Note dated 8/30/22 at 2:50 PM, documents (R88) reported to Administrator (V1) that a month or so ago, another resident called me F---in b---- and double fist hit my nose so bad. (R88) reported that (R88) still felt pain on (R88's) nose bridge every now and then from the alleged incident.
R88's BIMS Evaluation dated 7/14/22 documents a score of 10/15 indicating moderately impaired cognition.
On 8/30/22 at 11:12 AM, during resident council meeting, R32 reported there was a physical altercation R32 witnessed that occurred between two residents in R32's room but asked to identify the residents and details in private.
On 8/30/22 at 12:20 PM, (R32) requested the State Survey Agency come with R32 to R32's room after resident council meeting finished at this time. R32 stated R46 punched (R88) right in the face. R32 stated R32 witnessed this occur as it occurred right inside the doorway to R32's room. R32 stated R88 and R32 were in R32's room talking when R46 entered the doorway of R32's room. R32 stated R88 asked R46 to please move so R88 could leave R32's room and that is when R46 punched R88 with a closed fist. R32 stated R88's glasses went flying across the floor in R32's room and R88 started crying. R32 stated R46 got very hostile when this happened.
On 8/30/22 at 1:25 PM, (R88) stated the picture the State Survey Agency showed R88 was R46. R88 stated R46 called R88 a fat f***ing b**** (expletives) a few different times. R88 stated around a month ago, R46 hit R88 so hard across the nose that R88 glasses fell off R88's face. R88 stated R88 hurt so bad and R88 was experiencing headaches and dizziness that R88 still gets from time to time since R46 hit R88. R88 stated R88 developed a little bruising to R88's nose. R88 stated R88 started crying and was afraid that R46 would come at R88 again. R88 stated, nothing would surprise (R88) with what (R46) could or would do to anyone in the facility. At this time R88 became tearful and began sobbing and crying again. R88 stated the facility would be stupid to ever let that f***ing a**hole (expletives) back in. R88 stated, (R88) just wants to feel safe.
8/30/22 at 1:41 PM, (R32) stated R32 is, very much so afraid of (R46) and that R46 has a bad temper.
On 8/30/22 at 1:55 PM, (R88) began crying when discussing R46 hitting R88 across the nose. R88 stated R46 doubled up (R46) fist and hit R88 right across the nose. R88 stated, (R88) never hurt so bad as R88 did after R46 hit R88 with a closed fist. R88 stated it felt like R88's nose was split in half and R88's nose began bleeding after R46 hit R88. R88 stated R88 notified the staff nurses who R88 could not identify. R88 stated R88 nose still bleeds a little from time to time when R88 blows it. R88 stated staff had even taken stuff to clean R88's blood from R88's nose. R88 stated R88's nose still hurts. R88 agreed to go to the hospital for testing and/or radiology testing if the doctor says R88 needs to. On 8/30/22 the facility provided a list of interviewable residents on the second floor of the facility which also indicates all of the residents that could potentially be affected by R46's aggressive behavior.
An Immediate Jeopardy situation was identified on 8/30/22.
The Immediate Jeopardy was identified to have begun on 8/19/22 when the facility failed to
ensure interventions were implemented related to R46's aggressive behaviors to prevent R46 from deliberately assaulting R52 and R64.
On 9/2/22 at 11:23 AM, V1 Administrator was notified of the Immediate Jeopardy situation.
On 9/6/22 at 1:05 PM, the surveyor confirmed through record review and interview that the facility took the following actions to remove the Immediate Jeopardy:
1.) R52 and R64 were interviewed. An initial abuse allegation report was completed on 8/19/22 by V24 Corporate Administrator and the final abuse investigation was completed on 8/26/22 by V1 Administrator for the incident of 8/19/22. R52 and R64 were assessed and monitored.
2.) R88 was interviewed. An initial abuse allegation report was completed on 8/30/22 by V1 and a final abuse investigation was completed on 9/2/22 for an allegation reported on 8/30/22.
3.) R46 was involuntarily discharged to a Psychiatric hospital on 8/26/22 with paperwork completed by V3 Nurse Manager and a 30-day Discharge was issued to R46 on 8/26/22 completed by V1 Administrator.
4.) On 9/7/22, V25 Social Services Director and V34 Social Services Assistant completed a review of residents and identified residents who were predisposed to physical violence and the identified residents were assessed and evaluated for their ability to safely co-exist with other residents.
5.) All facility staff, including contracted agency staff, to complete training on abuse prevention policy and how to recognize triggers to prevent resident to resident abuse. This action was initiated on 9/2/22 and completed by V1 Administrator and V24 Corporate Administrator.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
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 timely identify and address significant weight loss, c...
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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 timely identify and address significant weight loss, complete thorough nutritional assessments, and implement physician ordered nutritional recommendations for four (R13, R70, R95, R63) of 12 residents reviewed for nutrition in the sample list of 99. These failures resulted in R13 sustaining a severe weight loss of 6.11 % in 15 days.
Findings include:
The facility's Nutritional Assessment policy dated as revised December 2011 documents: Nutritional assessments will be completed upon admission and with changes in condition that put the resident at risk for impaired nutrition. Nutritional assessments will be conducted by the interdisciplinary team and the dietitian will include an estimate of the resident's calorie, protein, nutrient, and fluid needs.
The facility's Weight Assessment and Intervention policy dated as revised June 2012 documents: Nursing staff are responsible for obtaining resident weights. An unplanned weight loss of 5% in one month, 7.5 % in 3 months, and 10 % in 6 months is considered significant, and greater than 5% in 1 month, 7.5 % in 3 months, and 10 % in 6 months is considered severe. The dietitian will be notified of weight changes in writing, and the dietitian should respond within 24 hours of receiving the notification. Interventions for undesirable weight loss include consideration of the use of supplements and nutrition/hydration needs.
1.) R13's Minimum Data Set (MDS) dated [DATE] documents R13 has severe cognitive impairment, R13 is not on a prescribed weight loss regimen, and R13 has had a weight loss of 5% or more in one month or 10% or more in six months. R13's Care Plan dated 6/21/22 documents R13 has a potential nutritional problem secondary to wound healing and includes interventions to prescribe diet as ordered and Registered Dietitian to evaluate and make dietary changes as needed. This care plan has not been updated to include R13's significant weight loss.
R13's undated weight log documents R13's weights and identified significant weight loss as follows: 118.6 lbs. (pounds) on 4/27/22, 118.7 lbs. on 5/3/22, 109.7 lbs. on 5/9/22 (7.58 % loss), 103.6 lbs. on 5/12/22 (5.56% loss in 4 days), 103 lbs. on 5/24/22 (6.11 % loss from 5/9/22), and 101 lbs. on 8/22/22 (a 10% loss since 4/27/22.)
R13's Physician's Order Summary Report dated 8/31/22 documents R13's diet is regular with ice cream once daily, and a frozen nutritional supplement once daily, and orders dated 7/22/22 to give ice cream daily in the afternoon and a frozen nutritional supplement in the evening for low BMI (Body Mass Index) and weight loss. R13's August 2022 Medication Administration Record (MAR) documents R13's ice cream is scheduled to be given at 12:00 PM.
R13's Nutrition Note dated 4/28/22 at 12:48 PM recorded by V47 Registered Dietitian (RD) documents R13 was reviewed for recent admission, R13's BMI (Body Mass Index) was 21.6 and was adjusted for above knee amputation. This note documents, Will monitor for need to modify nutrition. R13's Nutrition Note dated 5/26/2022 at 9:50 recorded by V47 documents R13 was evaluated for wounds and weight loss noted. R13's weight is down 15 lbs. since R13 admitted in late April 2022. R13 has a low BMI of 18.8, adjusted for left above knee amputation. V47 requested to change multivitamin to multivitamin with minerals, offer double protein at breakfast, a frozen nutritional supplement once daily, whole milk at meals, and change diet from Low Concentrated Sweets to regular. R13's Dietary Note dated 7/21/2022 at 12:04 recorded by V47 documents V47 requested to add ice cream with lunch.
There is no documentation that R13's significant weight loss first noted on 5/9/22 was identified and reported to V47 until 5/26/22, and that nutritional interventions were implemented after 4/28/22 and prior to 5/26/22. There is no documentation that the frozen nutritional supplement was implemented prior to R13's hospital discharge on [DATE].
On 8/29/22 at 10:18 AM V38 (R13's Family) stated R13 has lost weight recently but was unsure how much weight R13 has lost. On 8/31/22 at 12:23 PM V38 stated V38 was not sure what the facility was doing to help with R13's weight loss.
On 8/29/22 at 12:39 PM R13 at all of the noodles with tomato sauce, mixed vegetables, and garlic bread. R13's meal tray did not contain whole milk or ice cream. On 8/31/22 at 12:17 PM R13's meal tray was delivered and contained ice cream but did not include whole milk. R13's meal ticket documented ice cream. On 8/31/22 at 12:22 PM V38 entered R13's room and requested V40 Certified Nursing Assistant get R13 a carton of milk. V40 returned with a carton of 2 % milk. On 8/31/22 at 12:25 PM V40 was passing drinks to residents. V40 stated: V40 knows what drinks to serve each resident based on knowing the residents. V40 usually works night shift, and V40 asks other staff as well.
On 9/06/22 at 10:43 AM V3 Infection Preventionist confirmed R13's frozen nutritional supplement was not added to R13's orders/MAR until 7/21/22. On 9/06/22 at 3:26 PM V3 stated V47 assessed R13 on 4/28/22 and not again until 5/26/22, and there were no nutritional interventions implemented prior to 5/26/22.
On 9/06/22 at 12:31 PM V47 RD stated: Often times residents will drink better than they eat, so V47 recommends juice and milk with meals. The facility notifies me of weight loss when V47 is in the facility, or by telephone and electronic mail. V47 expects V47's recommendations to be implemented within 1-2 days, and V47 provides the recommendations to the facility on the same day V47 completes the evaluations. V47 assessed R13 on 5/26/22 for R13's significant weight loss. V47 cannot recall when V47 was notified of R13's significant weight loss. V47 would have given V47's recommendations sooner (than 5/26/22) if V47 was notified. V47 was in the facility on 5/5, 5/12, 5/23, and 5/26/22. V47 recommended Ice cream, whole milk, and the frozen nutritional supplement to promote weight gain.
2.) R70's MDS dated [DATE] documents R70 has severe cognitive impairment, is not on a prescribed weight loss regimen, and has a weight loss of 5% or more in the last month or 10 % or more in the last six months. R70's Care Plan revised on 7/17/22 does not address nutrition/weight loss or interventions.
R70's undated weight log documents R70's weights as follows: 121.3 lbs. on 4/11/22, 110.4 lbs. on 6/14/22 (8.99 % loss since 4/11/22), 103.2 lbs. on 7/31/22 (6.52 % loss since 6/14/22), and 107 lbs. on 8/31/22.
R70's Nutrition Note dated 4/21/2022 at 1:19 PM by V47 RD documents R70 was reviewed for weight loss, R70 has history of fluid issues and receives a diuretic. This note documents a recommendation to add whole milk and juice with all meals. R70's Nutrition Note dated 8/11/2022 at 1:56 PM by V47 documents: R70 was reviewed for weight loss at 1, 3, and 6 months and R70 has a healing stage III wound. V47 recommended a frozen nutritional supplement once daily to provide an additional 290 kilocalories and 9 grams of protein.
R70's Physician Order Summary Report dated 8/31/22 documents R70's diet order includes whole milk and juice at meals, and a frozen nutritional supplement once daily. There is no identified time of when the frozen nutritional supplement is scheduled to be given or documentation that R70 receives the frozen nutritional supplement daily as ordered.
On 8/29/22 at 12:14 PM R70's lunch tray included noodles with tomato sauce, mixed vegetables, garlic bread, mandarin oranges, and coffee. R70's meal ticket documents whole milk and juice with meals and does not document a frozen nutritional supplement. On 8/29/22 at 12:25 PM R70's meal tray did not include milk or juice. On 8/31/22 at 12:41 PM R70 ate 50 % of carrots, 75 % of mashed potatoes, all of the pears, and bites of roast beef. R70's meal tray did not include milk, juice, or a frozen nutritional supplement for the noon meals on 8/29 and 8/31/22.
On 8/31/22 at 3:30 PM V39 Licensed Practical Nurse (LPN) stated: Frozen nutritional supplements and ice cream are delivered by dietary staff on the meal trays. The frozen nutritional supplement is documented on the MAR. R70 does not get a frozen nutritional supplement in the evening.
On 9/06/22 at 12:31 PM V47 stated V47 recommended milk, juice, and a frozen nutritional supplement to promote weight gain for R70.
3.) R95's MDS dated [DATE] documents R95 has severe cognitive impairment, is not on a prescribed weight loss regimen, and has a weight loss of 5 % or more in 1 month or 10% or more in 6 months. R95's Care Plan dated as revised on 8/27/21 documents R95's diet is regular and R95 is at risk for altered nutrition due to new admission to the facility. This care plan includes interventions that R95 will be reviewed by the RD as needed, and this care plan has not been updated to reflect R95's significant weight loss and nutritional interventions to address weight loss.
R95's undated weight log documents R95's weights as follows: 136.7 lbs. on 5/31/22 and 6/8/22, and 129.8 lbs. on 7/7/22 and 8/2/22 (5.05 % loss).
R95's Nutrition Notes dated 7/21/22, 3/7/22, 2/26/22, and 9/9/21 and recorded by V47 RD, do not document an estimate of R95's calorie, protein, nutrient, and fluid needs . There are no documented thorough/complete nutritional assessments in R95's medical record since 7/24/21. R95's Nutrition Note dated 7/21/2022 at 11:35 AM documents R95 was reviewed for weight loss for the past month, and R95's BMI remains low at 21.6 with a goal of 23. R95's diet includes a nutritional shake 120 cc (cubic centimeters) four times daily. V47 suggested adding a frozen nutritional supplement for additional kilocalories. There is no documentation that R95 was evaluated by V47 after 3/7/22 until 7/21/22.
R95's Physician Order Summary Report dated 8/29/22 documents an order on hold dated 2/28/22 for a nutritional supplement 120 cc four times daily, and an order dated 8/5/22 for a nutritional shake three times a day. R95's August 2022 MAR documents R95's nutritional shake is scheduled three times daily at 9:00 AM, 12:00 PM, and 5:00 PM. This MAR does not document the amount of the shake that R95 consumes or that R95 received the nutritional supplement on 5 times and refers to R95's Nursing Notes. R95's August 2022 Nursing Notes do not document R95 received the nutritional supplement as ordered 5 scheduled times during the month.
On 8/29/22 at 12:33 PM R95 was eating in R95's room. R95's meal contained noodles with tomato sauce, mixed vegetables, garlic bread, mandarin oranges, and an orange drink. R95's meal ticket listed a nutritional shake for the noon meal. R95's meal did not contain a nutritional shake.
On 9/6/22 at 9:15 AM V3 Infection Preventionist stated the facility was out of the (nutritional supplement) for a while and we replaced it with (nutritional shake). The nutritional shake is served by dietary staff on the meal trays. On 9/06/22 at 10:43 AM V3 provided R95's nutritional assessment dated [DATE] and stated that was the last full RD nutritional assessment V3 could locate for R95.
On 9/06/22 at 12:31 PM V47 stated: R95's BMI was low. On 7/21/22 V47 recommended a frozen nutritional supplement. The nutritional supplement and shake are to promote weight gain and improve BMI. The goal is to have a BMI of at least 23 for age [AGE] and older. There was a shortage of the nutritional supplement, and we had switched to using the nutritional shake. V47 was off work during the first two weeks of July, and there was another RD who should have covered in V47's place.
4.) R63's Order Summary Report dated 9/8/22 documents diagnoses including Unspecified Dementia, Unspecified Severity Without Behavioral Disturbances, Dysphagia and Psychotic Disturbance. This Order Summary documents an order for a regular diet, mechanical soft texture, regular/thin consistency, ground meat, whole milk and juice at all meals, add frozen nutritional supplement daily with a start date of 3/30/22.
On 5/12/22 at 12:22 PM, V47 Dietician documented R63 was reviewed for weight loss at one and three months, BMI (Body Mass Index) 24.9, diet is regular/mechanical soft, and appetite has declined. Will request whole milk and juice at all meals and review as needed for need to further modify.
R63's Weights and Vitals Summary report dated 9/8/22 documents R63's weight on 3/1/22 was 159.8 pounds and on 9/4/22 R63's weight was 135.8 pounds which was a 15.02% (percent) weight loss in six months.
On 8/31/22 at 12:29 PM R63's meal tray only contained a 2% carton of milk. There was no whole milk on R63's tray as ordered.
On 9/6/22 at 12:31 PM, V47 confirmed R63's recommendation for whole milk was for weight loss. V47 stated often times residents drink better than they eat, so V47 recommends milk and juice at meals.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
Based on observation, interview and record review the facility failed to provide residents with pain control and pain assessments. The facility also failed to provide timely treatment of pain for a re...
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Based on observation, interview and record review the facility failed to provide residents with pain control and pain assessments. The facility also failed to provide timely treatment of pain for a resident post above knee amputation. This failure affects two of three residents (R3, R214) reviewed for pain in the sample of three from a total sample list of 99. These failures resulted in R3 experiencing unrelieved pain and the ability to receive physical therapy post above knee amputation.
Findings include:
1. R3's progress notes dated 8/5/22 document that R3 returned to the facility after sustaining a right above knee amputation due to osteomyelitis and Methicillin Resistant Staphylococcus Aureus of the right leg.
On 8/15/22 R3's Brief Interview Mental Status is documented as moderately impaired.
R3's physician orders dated 8/5/22 document an order for Oxycodone 5 milligrams by mouth every 6 hours as needed for severe pain for the above the knee amputation. The last comprehensive pain assessment was completed on 5/5/22.
R3's care plan dated 8/7/22 documents to give analgesics as ordered by the physician and monitor and document for side effects and effectiveness.
R3's medical record first documented dose of pain medication (Oxycodone 5 milligrams) was on 8/6/22 at 3:40 PM. From 8/6/22 to 8/29/22, 29 of a possible 72 doses of Oxycodone were given to R3 for pain.
On 8/14/22, R3's progress notes document R3's indicator of pain was vocal complaints of the right thigh generalized as sharp, stabbing and aching. On 8/14/22 Methocarbamol 750 Milligrams was ordered every six hours as needed for muscle aches and muscle spasms. From 8/14/22 to 8/29/22, 14 of a possible 52 doses of Methocarbamol was given for muscle aches and spasms.
R3's 8/25/22 progress notes document verbal complaints of pain.
On 8/29/22 10:00AM R3 was observed laying in bed while grimacing and yelling, Help! and holding his right stump. On 8/29/22 at 10:30AM, R3 continued to yell, Help, I hurt! V12 Certified Nursing Assistant stated, He yells a lot.
On 8/29/22 at 3:45 PM, R3 was yelling at R5 Certified Nursing Assistant, My leg hurts! My right leg!
On 8/31/22 at 8:25 AM V10 Certified Nursing Assistant stated, He had been yelling for months, I have pain, I have pain. I need medication!
On 8/29/22 at 4:05PM, V7 Licensed Practical Nurse stated, I called V11 Medical Doctor at 3:55PM for something for (R3's) pain. (R3) complains of pain a lot. Even before his amputation he yelled out in pain, but then he had Osteomyelitis, so who knows. (R3) recently told me that even air hitting the stump made him hurt. He needs something for breakthrough pain.
On 8/29/22 at 4:15PM, V7 Licensed Practical Nurse stated that V11 Medical Doctor had called with an order for Tylenol 1000mg for breakthrough pain.
R3's August 29, 2022, medication administration record does not document any Tylenol given for breakthrough pain.
On 8/31/22 at 10:29 AM, V17 Physical Therapist stated, (R3) was in such pain that I couldn't even touch him to work on him. I told the staff, but he just couldn't tolerate therapy.
Physical therapy discharge notes dated 8/16/22 documents, Poor tolerance to stretching due to severe pain.
On 8/31/22 at 10:47 AM, V19 Nurse Practitioner stated that the last time she saw R3 was on 8/24/22 and the staff didn't tell her that R3 was having increased pain.
The facility pain policy dated 2/23/22 documents, The purposes of this procedure are to help the staff identify pain in the resident and to develop intervention that are consistent with the resident goals and needs and that address the underlying causes of pain. 1. The pain management program is to provide comfort to the resident. 2. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain b. Effectively recognizing the presence of pain. c. Identifying the characteristics of pain. d. Addressing the underlying causes of the pain. e. Developing and implementing approaches to pain management. f. Identifying and using specific strategies for different levels and sources of pain g. Monitoring to the effectiveness of interventions and h. modifying approaches as necessary.
2. R214's Brief Interview for Mental Status dated 8/11/22 documents R214 is cognitively intact.
On 8/29/22 at 10:50 AM, R214 stated she is in a lot of pain, but her pain medications are effective most of the time. R214 stated one day she had to wait 3.5 hours to get her call light answered. R214 stated she was needing pain medication. R214 stated she called her daughter (V20) because she was in so much pain and no one was coming to her room. R214 stated she was in so much pain that she couldn't breathe. R214 stated the nurse finally came in and gave her some pain medication but that soon after the paramedics showed up to get her because V20 called 911 to get her help. R214 stated it turns out my call light wasn't working correctly so no one knew I needed pain medicine.
On 8/31/22 at 8:51 AM, V20 stated R214 called her the evening of 8/26/22. R214 stated, She called me and told me she was in so much pain she couldn't stand it. She was crying and told me she had to wait too long to get a pain pill and that the pain pill wasn't touching her pain. I called the ambulance because no one at the facility would answer the phone and I was scared because she was in so much pain and told me she had a bump behind her knee. I was afraid she had a blood clot. I drove to the facility right after I called 911. When I got there, she was leaving by ambulance and was still in pain.
R214's nurse's note dated 8/26/2022 at 7:13 PM documents, Medical team came in stating (R214) called 911 and complains of severe leg pain and wanted to go to hospital. She took Norco about 30 min (minutes) ago. Upon leaving the facility daughter came in and (R214) will go to (hospital).
On 8/31/22 at 2:30 PM, V43 stated on 8/26/22 at 6:30 PM, I was working down the other side of the hall. A kitchen aide (unknown) told me R214 was having pain and that she was wanting pain medication. I gave her a Norco (Hydrocodone Acetaminophen 5-325 milligrams). Then I heard people coming in and it was the paramedics. I didn't know they were coming. They arrived thirty minutes after I gave her pain medication. V43 stated she was in severe pain, and I am not sure how long she waited. V43 stated when the paramedics came her pain wasn't relieved and she was still in a lot of pain, so she went to the hospital. V43 stated V43 didn't know her call light wasn't working that night.
On 8/30/22 at 9:52 AM, V50 Maintenance Assistant stated he fixed R214's call light on 8/26/22. V50 stated when he pushed her call light, he discovered her light above the door didn't light up. He had to replace the light bulb. V50 stated he doesn't remember the time but it was late in the day.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0919
(Tag F0919)
A resident was harmed · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure the emergency nurse call system had a functioning light for R214 and a properly functioning emergency nurse call device...
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Based on observation, interview, and record review the facility failed to ensure the emergency nurse call system had a functioning light for R214 and a properly functioning emergency nurse call device for R100. R214 and R100 are two of 24 residents reviewed for call lights on the sample list of 99. This failure resulted in R214 having excruciating pain for three hours and requiring R214 to be sent to the emergency room for evaluation.
Findings include:
1.) R214's Brief Interview for Mental Status dated 8/11/22 documents R214 is cognitively intact.
On 8/29/22 at 10:50 AM, R214 stated she is in a lot of pain, but her pain medications are effective most of the time. R214 stated one day she had to wait 3.5 hours to get her call light answered. R214 stated she was needing pain medication. R214 stated she called her daughter (V20) because she was in so much pain and no one was coming to her room. R214 stated she was in so much pain that she couldn't breathe. R214 stated the nurse finally came in and gave her some pain medication but that soon after the paramedics showed up to get her because V20 called 911 to get her help. R214 stated it turns out my call light wasn't working correctly so no one knew I needed pain medicine.
On 8/31/22 at 8:51 AM, V20 stated R214 called her the evening of 8/26/22. R214 stated, she called me and told me she was in so much pain she couldn't stand it. She was crying and told me she had to wait too long to get a pain pill and that the pain pill wasn't touching her pain. I called the ambulance because no one at the facility would answer the phone and I was scared because she was in so much pain and told me she had a bump behind her knee. I was afraid she had a blood clot. I drove to the facility right after I called 911. When I got there, she was leaving by ambulance and was still in pain.
R214's nurse's note dated 8/26/2022 at 7:13 PM documents, Medical team came in stating (R214) called 911, complains of severe leg pain and wanted to go to hospital. She took Norco about 30 min (minutes) ago. Upon leaving the facility daughter came in and (R214) will go to (hospital).
On 8/31/22 at 2:30 PM, V43 stated on 8/26/22 at 6:30 PM, I was working down the other side of the hall. A kitchen aide (unknown) told me R214 was having pain and that she was wanting pain medication. I gave her a Norco (Hydrocodone Acetaminophen 5-325 milligrams). Then I heard people coming in and it was the paramedics. I didn't know they were coming. They arrived thirty minutes after I gave her pain medication. V43 stated she was in severe pain, and I am not sure how long she waited. V43 stated when the paramedics came her pain wasn't relieved and she was still in a lot of pain, so she went to the hospital. V43 stated V43 didn't know her call light wasn't working that night.
On 8/30/22 at 9:52 AM, V50 Maintenance Assistant stated he fixed R214's call light on 8/26/22. V50 stated when he pushed her call light, he discovered her light above the door didn't light up. He had to replace the light bulb. V50 stated he doesn't remember the time, but it was late in the day.
2.) On 8/29/22 at 11:00 AM, R100 was lying in bed. R100's call light was attached to the mattress. V36 stated when she pushes it, it does not go off (activate the nurse call system). At that time, R100 attempted to activate call light device and it did not activate the call system. The call light device button, when pushed slowly, did not activate the nurse call system. The call light system did activate only when the button on the device was pushed fast and hard.
SERIOUS
(H)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0740
(Tag F0740)
A resident was harmed · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to comprehensively assess a resident's aggressive behaviors upon admiss...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to comprehensively assess a resident's aggressive behaviors upon admission for one of one resident (R46) reviewed for behaviors in the sample list of 99. This failure has the potential to affect 65 residents (R36, R42, R164, R365, R47, R88, R109, R17, R79, R92, R37, R18, R69, R3, R71, R22, R366, R76, R9, R64, R49, R63, R30, R67, R60, R72, R40, R57, R105, R113, R50, R85, R54, R44, R86, R48, R38, R23, R96, R16, R104, R12, R2, R53, R20, R78, R70, R33, R59, R5, R34, R6, R82, R32, R81, R13, R103, R110, R56, R29, R91, R77, R95, R55, R165) residing on the second floor of the facility. Staff allowed R46 unsupervised access to residents who are unable to protect themselves from R46's behaviors.
Findings include:
The facility's Behavior Monitoring policy dated 10/2015 documents, Problematic behaviors will be identified and managed appropriately. The facility staff and Attending Physician will identify individuals with a history of impaired cognition (e.g., dementia, mental retardation), problematic behavior, or mental illness (e.g., bipolar disorder or schizophrenia).
R46's Face Sheet dated 8/19/22 documents an admission date of 6/18/22. R46's admission Minimum Data Set (MDS) dated [DATE] documents diagnoses including Progressive Neurological Conditions, Schizophrenia, Wernicke's Encephalopathy, Alcohol Abuse with Intoxication and Unspecified Mood Disorder. This MDS documents a BIMS (Brief Interview for Mental Status) score of 9/15 indicating moderately impaired cognition.
R46's MDS dated [DATE] documents R46 had behaviors that put others at significant risk for physical injury, significantly intruded on the privacy of others, significantly disrupted care or living environment and wandering significantly intrudes on the privacy or activities of others.
R46's Baseline Care Plan dated 6/20/22 documents the only behavioral concern was wandering.
R46's Social Services Behavior Conditions Review dated 8/26/22 (after R46 was discharged to the Psychiatric hospital) documents R46's new or worsening behavior as aggressive behaviors towards staff and other residents. This Review documents R46 had exhibited physically aggressive behaviors towards residents.
R46's Nurse's Progress Note dated 6/20/22 at 1:54 PM documented by V22 Licensed Practical Nurse (LPN) documents, (R46) having behaviors noted on this shift/ refusing medication. and (cussing) at nursing staff. NP (Nurse Practitioner) notified. Will continue to monitor.
On 6/20/22 at 8:37 PM, V22 documents, (R46) noted having behaviors on this shift. (R46) was cursing/ yelling while (R46) was in (R46's) room. When staff tried to redirect (R46) continued to curse and yell. (R46) is now calm in bed call light within reach. Will continue to monitor.
R46's Nurse's Progress Note dated 6/24/22 at 11:17 AM by V44 Licensed Practical Nurse (LPN) documents, (R46) has been trying to go to other (resident's) room with redirection. After being informed to not go into other (people's) (rooms) (R46) continued to do so. (R46) unplugged (R12's) air mattress and spilled water all over the floor. (R46) refused to come out by staff. (R46) was finally able to be redirected to (R46's) room. (R46) is now in (R46's) room in bed. Facility management notified.
R12's Diagnosis Report dated 9/8/22 documents diagnoses including Quadriplegia and Tracheostomy status.
On 7/8/22 at 4:25 PM, V4 LPN documents, (R46) Behavior: E) Hallucinations/Delusions/Psychosis 1) Able to redirect and refocus 3) Medication given 2) Keep redirecting every shift.
On 7/14/22 at 9:33 PM, V44 documents, (R46) having behaviors this evening. (R46) was being physically and verbally abusive to staff. (R46) stated I will punch you and give you two black eyes to the writer. (R46) was redirected and was unsuccessful. (R46) started to become a threat to staff, (residents), and self. (R46) started to push and shove furniture. MD (Medical Doctor) notified. (R46) is to be sent to (hospital) for altered mental status evaluation. When paramedics arrived (R46) became aggressive with EMT (Emergency Medical Technicians) by telling them Bet nobody touches me and screaming. Notified (POA) and facility (Administrator). Will continue to monitor.
On 8/11/22 at 7:03 PM, V4 documents, (R46) Behavior: B) Combative/hitting/kicking staff/resists care C) Crying/restlessness/agitated E) Hallucinations/Delusions/Psychosis 1) Able to redirect and refocus 3) Medication given 2) Keep redirecting every shift.
On 8/19/22 at 1:53 PM, V14 LPN documents, (R46) became agitated with 2 other female residents (R52, R64). (R46) was in wheelchair on (R46's) way back from dining room. Female patients ambulating back from lunch in the 2 south dining room. Writer heard (R46) yell F*** you to (R52, R64). Writer began going toward the commotion. (R52, R64) yelled back F*** you. (R46) sped up his wheelchair and hit (R52, R64) directly knocking them to ground. Writer interviewed and separated all parties. (R46) stated they deserved it and they shouldn't talk to (R46) like that. PCP (Primary Care Provider) notified states to continue monitoring. emergency contact notified. (Administrator) and nurse managers notified. (R46) on 1-1 supervision at this time from time of incident.
On 8/26/22 at 1:04 AM, V4 documents, (R46) Behavior: C) Crying/restlessness/agitated 1) Able to redirect and refocus 2) Keep redirecting.
On 8/26/22 at 2:58 PM, V14 documents, (R46) left with transport for (Psychiatric) hospital in (the north) at (2:40 PM). Med list (medication list) and face sheet sent with. Writer reached out to (hospital) to give report, they stated they do not need a report just send (R46).
R74's Order Summary Report dated 8/30/22 documents diagnoses including Cognitive Communication Deficit and Difficulty Walking. R74's Minimum Data Set (MDS) dated [DATE] documents diagnoses including Fractures and Other Multiple Trauma and History of TIAs (Transient Ischemic Attacks). R74's BIMS Evaluation dated 7/3/22 documents a score of 7/15 indicating moderately impaired cognition.
The facility's Preliminary Incident Investigation Report dated 8/25/22 at 6:22 PM, documents Employee reported suspicion of unusual event on 8/25/22 approximately 6:22 PM. (R74) was in (R74's) room with door blocked open by a wheelchair belonging to (R46). (R74's) wheelchair was between R74 and the other wheelchair. (R74) was lying on the floor and reported that (R74) had fallen. (R74) was undressed from waist down and soiled depend lying on (R74's) bed. No injury noted by nurse assessing the resident. Both residents (R46 and R74) were sent out for evaluation. Physicians and POA/emergency contacts notified. Police notified. (V15 Police Officer) arrived at facility to interview staff and residents.
R74's Nurse's Note dated 8/25/22 at 5:00 PM, documents CNA (Certified Nursing Assistant) notified nurse that (R74) was on the ground, undressed from the waist down and (R46) was wrapped in (R74's) bed sheet. CNA told second nurse. Nurse notified administrator; statement given. Doctor contacted gave order to send out for assessment. POA notified. (R74) assessed. (R74) Vital Signs WNL (Within Normal Limits). No c/o (complaints of) pain. Sent (R74) to hospital to be assessed.
On 8/29/22 at 3:55 PM, V5 Certified Nursing Assistant (CNA) stated on 8/25/22 around dinner time, 5:00 PM-6:30 PM, V5 noticed R46 standing at the nurse's station with no wheelchair with R46. V5 stated that V5 went to look for R46's wheelchair. V5 looked in a couple of rooms but then came to R74's room and the door would only open a small way.V5 stated that there were wheelchairs blocking the door and R74 was on the floor on the other side of the wheelchairs. V5 stated R74 had no clothes on from the waist down and R74's used incontinent brief was laying on the bed away from R74. V5 stated V5 could not fit through the opening without pushing the wheelchairs into R74 so V5 got the nurse (V6 Licensed Practical Nurse/LPN) and V6 was able to fit through the opening and climbed over the bed to get to the other side of the wheelchairs and rearranged things so V5 could come in and assist. V5 stated they got R74 up off the floor and dressed and during this time R46 returned to the room with R74's personal bed sheet wrapped around R46. V5 stated R46 was screaming at them to get out of R46's house. V5 stated after they got R74 up and R74's pants back on V5 left R74 with V6. V5 stated that R46 is a resident with high behaviors. V5 also stated that R46 is a highly disturbed man that is abusive, mean and nasty.
On 9/8/22 at 10:30 AM, V25 confirmed that there was no behavior assessment completed for R46 upon admission. V25 stated that R46's behavior assessment was not completed until 8/26/22.
The facility's Resident Room Roster provided on 8/30/22 documents 65 residents (R36, R42, R164, R365, R47, R88, R109, R17, R79, R92, R37, R18, R69, R3, R71, R22, R366, R76, R9, R64, R49, R63, R30, R67, R60, R72, R40, R57, R105, R113, R50, R85, R54, R44, R86, R48, R38, R23, R96, R16, R104, R12, R2, R53, R20, R78, R70, R33, R59, R5, R34, R6, R82, R32, R81, R13, R103, R110, R56, R29, R91, R77, R95, R55, R165) reside on the second floor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure medications were consumed during medication administration for one of one resident (R215) reviewed for self-administrat...
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Based on observation, interview, and record review the facility failed to ensure medications were consumed during medication administration for one of one resident (R215) reviewed for self-administration of medication on the sample list of 99.
Finding include:
On 8/30/22 at 10:45 AM, a medication cup full of medications was sitting on R215's bed side table. R215 was sitting up at the table watching television. When asked if the medication in the cup were his morning medications, R215 stated, I guess, I don't know. R215 then picked up the medications and took them. At that time, V35 Licensed Practical Nurse was at the nurses' station and stated she sat a cup of medications on his bed side table earlier and that the medications in the cup were his morning medications. V35 stated she left them for him to take. V35 stated inside the cup was Baby Aspirin, Furosemide, Lisinopril, Magnesium, Metoprolol, Multivitamin, Pantoprazole, Senna, and Spironolactone.
R215's Medication Administration Record dated 8/1/22 through 8/31/22 documents R215 is to receive the following medications at 9:00 AM: Aspirin 81 milligrams (MG), Lisinopril 2.5 mg, Multivitamin, Pantoprazole 40 mg, Spironolactone 25 mg, Metoprolol Succinate Extended Release, Magnesium Oxide 400 mg, Lasix 20 mg two tablets, and Senna-Docusate 8.6 - 50 milligrams.
R215's Electronic Medical Record did not contain an assessment for self-administration of medications.
The facility's undated Resident Rights, Privacy and Dignity policy documents, n. The resident has the right to self-administer medication, if the interdisciplinary care planning team determines it is safe.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the resident's physician and family of significant weight los...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the resident's physician and family of significant weight loss for three (R13, R70, R95) of twelve residents reviewed for nutrition in the sample list of 99.
Findings include:
The facility's Change in a Resident's Condition or Status policy with a revised date of December 2016, documents the facility will promptly notify the resident, resident's physician, and resident's representative of changes in a resident's physical, emotional, and mental condition.
1.) R13's Minimum Data Set (MDS) dated [DATE] documents R13 has severe cognitive impairment, R13 is not on a prescribed weight loss regimen, and R13 has had a weight loss of 5% or more in one month or 10% or more in six months.
R13's undated weight log documents R13's weights and identified significant weight loss as follows: 118.6 lbs. (pounds) on 4/27/22, 118.7 lbs. on 5/3/22, 109.7 lbs. on 5/9/22 (7.58 % loss), 103.6 lbs. on 5/12/22 (5.56% loss in 4 days), 103 lbs. on 5/24/22 (6.11 % loss from 5/9/22), and 101 lbs. on 8/22/22 a 10% loss since 4/27/22.
R13's Nutrition Note dated 5/26/2022 at 9:50 recorded by V47 Registered Dietitian documents R13 was evaluated for wounds and weight loss noted. R13's weight is down 15 lbs. since R13 admitted in late April 2022. R13 has a low BMI (Body Mass Index) of 18.8, adjusted for left above knee amputation. V47 requested to change multivitamin to multivitamin with minerals, offer double protein at breakfast, a frozen nutritional supplement once daily, whole milk at meals, and change diet from Low Concentrated Sweets to regular. R13's Dietary Note dated 7/21/2022 at 12:04 recorded by V47 documents V47 requested to add ice cream with lunch. There is no documentation in R13's medical record that R13's family and physician were notified of R13's significant weight loss in May and August 2022.
2.) R70's MDS dated [DATE] documents R70 has severe cognitive impairment, is not on a prescribed weight loss regimen, and has a weight loss of 5% or more in the last month or 10 % or more in the last six months.
R70's undated weight log documents R70's weights as follows: 121.3 lbs. on 4/11/22, 110.4 lbs. on 6/14/22 (8.99 % loss since 4/11/22), 103.2 lbs. on 7/31/22 (6.52 % loss since 6/14/22), and 107 lbs. on 8/31/22.
R70's Nutrition Note dated 4/21/2022 at 1:19 PM by V47 RD documents R70 was reviewed for weight loss, R70 has history of fluid issues and receives a diuretic. This note documents a recommendation to add whole milk and juice with all meals. R70's Nutrition Note dated 8/11/2022 at 1:56 PM by V47 documents: R70 was reviewed for weight loss at 1, 3, and 6 months and R70 has a healing stage III wound. V47 recommended a frozen nutritional supplement once daily to provide an additional 290 kilocalories and 9 grams of protein.
There is no documentation that R70's family and physician were notified of weight loss in June and July 2022.
3.) R95's MDS dated [DATE] documents R95 has severe cognitive impairment, is not on a prescribed weight loss regimen, and has a weight loss of 5 % or more in 1 month or 10 % or more in 6 months.
R95's undated weight log documents R95's weights as follows: 136.7 lbs. on 5/31/22 and 6/8/22, and 129.8 lbs. on 7/7/22 and 8/2/22 (5.05 % loss).
R95's Nutrition Notes dated 7/21/22, 3/7/22, 2/26/22, and 9/9/21 and recorded by V47 RD, do not document an estimate of R95's calorie, protein, nutrient, and fluid needs. There are no documented thorough/complete nutritional assessments in R95's medical record since 7/24/21. R95's Nutrition Note dated 7/21/2022 at 11:35 AM documents R95 was reviewed for weight loss for the past month, and R95's BMI remains low at 21.6 with a goal of 23. R95's diet includes a nutritional shake 120 cc (cubic centimeters) four times daily. V47 suggested adding a frozen nutritional supplement for additional kilocalories.
There is no documentation in R95's medical record that R95's family and physician were notified of significant weight loss in July 2022.
On 9/6/22 at 9:15 AM V3 Infection Preventionist stated family and physician notification of significant weight loss should be documented in a nursing note. On 9/6/22 at 10:43 AM V3 stated V3 did not find documentation of family and physician notification for weight loss for R13, R70, and R95.
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 ensure a Preadmission Screening and Resident Review (PASARR) level I...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) level II was conducted after a resident was diagnosed with Bipolar Disorder for one (R95) of five residents reviewed for PASARR in the sample list of 99.
Findings include:
The facility's undated policy on PASRR & OBRA (Omnibus Budget Reconciliation Act) Screening documents The facility shall follow Illinois Department of Human Services requirements for PASRR and OBRA Screenings. All residents are required to go through this screening process and copy of the screening shall be maintained in the resident's record. Only those residents who screen as appropriate for long-term facility placement shall be admitted . Resident(s) who are appropriate for long-term care placement with special needs (e.g. (example) DD (Developmental Disability) and/or serious mental health issues shall be assessed for needs and an individualized plan of care shall be developed and implemented.
R95's undated census list documents R95 admitted to the facility on [DATE]. R95's Illinois Department of Healthcare and Family Services Interagency Certification of Screening Results dated 10/16/20 documents Developmental Disability or Mental Illness were not suspected, and there for a Level II PASARR was not completed.
R95's undated Diagnosis List documents a diagnosis of Bipolar Disorder was added on 10/7/21. There is no documentation in R95's medical record that a PASARR Level II was conducted after R95 was diagnosed with Bipolar Disorder.
R95's Nursing Notes document the following: On 9/12/21 R95 was combative and involved in a physical altercation with another unidentified resident. V53 Psychiatrist evaluated R95 on 9/17/22 for mood swings and changes in behavior. V53 documents R95's is Bipolar, manic without psychosis, and has cognitive impairment.
V53 ordered Depakote (mood stabilizer) 125 milligrams twice daily. On 9/23/22 V53 prescribed Seroquel (antipsychotic). R95 transferred to an inpatient psychiatric hospital on 8/29/22.
On 9/26/22 at 10:23 AM V34 Social Services Assistant stated V34 does not assist with setting up PASARRs, and either V51 Guest Relations or V52 Business Office Manager is responsible for scheduling PASARRs. On 9/26/22 at 10:25 AM V51 stated V51 does not schedule PASARRs.
On 9/26/22 at 10:27 AM V52 stated V52 only schedules PASARR screenings for residents upon admission and does not schedule PASARRs after a resident admits to the facility. V52 was asked who is responsible for scheduling PASARR Level II screenings after a resident is newly diagnosed with mental illness. V52 stated I'm not sure who does that, maybe (V34 Social Services Assistant). We have been behind in PASARRs. V52 confirmed a PASARR Level II was not completed for R95 after R95's Bipolar Diagnosis was added in October 2021.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop an initial baseline care plan for one of 24 residents (R74) ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop an initial baseline care plan for one of 24 residents (R74) reviewed for care plans in the sample list of 99.
Findings include:
The facility's Care Plan Process policy dated 6/2015 documents, 2. The admitting nurse initiates the interim care plan, under Observations labeled initial Care plan. 3. The remainder of the interdisciplinary team will assess the resident within 72 hours of admission and add any issues to the initial care plan to address any immediate care needs.
R74's admission Minimum Data Set (MDS) dated [DATE] documents R74 was admitted to the facility on [DATE] with diagnoses including Fractures and Other Multiple Traumas, Anemia, Unspecified Fall and history of TIA (Transient Ischemic Attack). R74's MDS documents R74 had one fall in the last month and had one fall resulting in a fracture in the last six months.
R74's Care Plan does not have any fall interventions until 8/6/22 when an actual fall took place.
R74's initial Fall Risk assessment dated [DATE] documents R74 is at risk for falls and has had 1-2 falls in the last three months.
On 9/6/22 at 10:10 AM, V21 MDS/CPC (Minimum Data Set/Care Plan Coordinator) confirmed there was no initial baseline care plan initiated for R74's falls.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide assistance with showers, nail care, shaving an...
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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 assistance with showers, nail care, shaving and dressing for two (R70, R215) of four residents reviewed for activities of daily living in a sample list of 99.
Findings include:
The facility's Shower Sheets policy dated February 2022, documents shower worksheets will be completed for resident showers and resident shower refusals, and the worksheets are signed by the nurse.
The facility's Care of Fingernails/Toenails policy dated as revised January 2019 documents Nail care includes daily cleaning and regular trimming. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.
The facility's undated Quality of Life-Dignity policy documents: Residents shall be groomed as they wish to be groomed (hairy styles, nails, facial hair, etc. (etcetera). Residents shall be encouraged and assisted to dress in their own clothes rather than in hospital gowns.
1.) On 8/29/22 at 12:05 PM R70 was sitting in the lounge on the 2nd floor. R70's thumb nails were long and extended approximately 1/2 inch past R70's fingertips. R70 stated R70 would like R70's nails trimmed, and they (R70's thumb nails) look terrible.
On 8/31/22 at 10:52 AM R70 was lying in bed, and R70's thumb nails were long past R70's fingertips. R70's hair appeared greasy. V12 Certified Nursing Assistant (CNA) confirmed R70's thumb nails were long, R70's other fingernails were short and did not extend past R70's fingertips. V12 stated the nurses are responsible for trimming resident's nails, and R70's fingernails are short because R70 bites R70's fingernails off.
R70's Minimum Data Set, dated [DATE] documents R70 has severe cognitive impairment and requires extensive assistance of one staff person for personal hygiene and bathing. R70's Order Summary Report dated 8/31/22 documents R70's showers are scheduled for Mondays and Thursdays on the evening shift.
R70's July and August 2022 Shower Sheets provided by V3 Infection Preventionist, do not document R70 received showers as scheduled between 7/2-7/7/22, 7/13-7/17/22, 7/19-7/30/22, 8/1-8/7/22, or after 8/18/22.
On 8/31/22 at 11:19 AM V52 CNA stated showers are documented on paper shower sheets and given to the nurses to sign, and then turned into the nurse managers.
On 8/31/22 at 11:26 AM V23 Licensed Practical Nurse stated residents are scheduled for showers/baths twice per week and as needed. If the resident refuses, the refusal should be documented, and the shower is rescheduled within 48 hours.
On 9/6/22 at 9:15 AM V3 confirmed all of R70's July and August 2022 shower documentation was provided. V3 stated fingernails are to be trimmed by the CNAs or activity staff, unless the resident is Diabetic. V3 stated nail care should be done with showers.
2. On 8/30/22 at 10:00 AM, R215 was sitting in a wheelchair in R215's room. R215's face was covered with unkempt scraggly facial hair and R215 was wearing a hospital gown. R215 stated he prefers to be clean shaven and dressed but he can't do it himself.
R215's care plan includes an intervention dated 8/26/22 to assist R215 with his ADL's (activity of daily living) needs.
R215's 8/27/22 admission Minimum Data Set Assessment documents R215 requires extensive assistance of one person for dressing and personal hygiene.
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** 3) R17's undated diagnosis list documents the following diagnoses including Neuromuscular Dysfunction of Bladder, Generalized An...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) R17's undated diagnosis list documents the following diagnoses including Neuromuscular Dysfunction of Bladder, Generalized Anxiety Disorder, Cognitive Communication Deficit, Unspecified Psychosis, Hypothyroidism, Major Depressive Disorder, Urinary Tract Infections and Retention, Syncope, Congenital Hydrocephalus, Spinal Stenosis, and Dysphagia.
R17's brief interview for mental status dated 5/17/22 documents R17 as moderately cognitively impaired.
R17's progress notes dated 7/4/22, 7/14/22, 7/25/22, 9/1/22 document resident falls from the bed, identified as behaviors of throwing self onto floor.
R17's care plan dated 4/23/21, documents, Increase activities of his choice when resident is exhibiting behaviors and intentionally putting himself on the floor.
On 8/29/22 and 8/30/22 from 9:00 AM to 4:00 PM no group activities with residents were observed.
During this survey; no 1:1 activities were observed including R17.
On 8/30/22 at 11:00 AM, R17 stated that no one provided activities for him.
On 8/29/22 at 10:00 AM and 2:00 PM, 8/30/22 at 9:30 AM and at 3:00 PM, 8/31/22 at10:30 AM and at 1:30 PM, 9/6/22 at 10:45 AM and at 3:30 PM and on 9/7/22 at 10:30 AM R17 was observed in his room, in bed.
On 9/6/22 V22 Licensed Practical Nurse stated, They need to get him out of his bed. He is bored and that's why he keeps throwing himself out of bed. They used to do activities with everyone in the dining room but since COVID, (R17) and the others are just bored. They give them a paper and that's it.
On 9/6/22 at 10:36 AM, V28 Activity Director stated, I haven't tried to get (R17) up for activities since March. I was told by V29 Administrator that I wasn't supposed to do group activities. I was doing 1:1 but (R17) is hard. I know that it is better for them to socialize. I was just doing what I was told.
2. R21's Care Plans dated 1/31/22 document R21 can potentially have a fall. There is no documentation of R21 sustaining falls and/or post fall intervention updates for R21's fall on 8/29/22.
On 08/29/22 at 11:53 AM R21 fell forward out of R21's wheelchair. At this time V28, Activities Director was walking behind R21. V28 stated He threw himself on the floor out of the chair. R21's leg dropped after R21 had lifted it and R21 fell to the floor on R21's knees. V41, Assistant Director of Nursing (ADON) asked V28 if there were any additional witnesses to R21's fall. V28 stated there were no additional witnesses to R21's fall out of R21's wheelchair.
On 09/01/22 at 09:36 AM R21 stated R21's back of leg bothers R21. R21 stated R21's leg slipped off as R21 tried to move R21's upper leg and R21's leg got stuck dropped and R21 fell.
On 9/1/22, after speaking with R21 at 9:36 AM, V1, Administrator was notified of R21's fall that had occurred on 8/29/22 and that this fall was not documented in R21's medical records. V1 stated staff should complete an investigation into a report of a fall and document in the resident's medical records.
On 9/6/22 at 11:50 AM, V1, Administrator stated the facility should not just assume or consider a fall a behavior without investigating and that is what V1 feels the facility potentially did for R21's fall.
Based on observation, interview and record review the facility failed to investigate fall occurrences and implement fall interventions for three of four residents (R74, R21, R17) reviewed for falls in the sample list of 99.
Findings include:
The facility's Falls Prevention Program policy with a revised date of 11/2017 documents, Fall prevention program will be implemented to ensure all resident's safety in the facility whenever possible. This program should include a measure that determines each resident's needs by assessing the risks for falls and implementing appropriate interventions to provide the necessary supervision, and assistive devices are utilized as necessary. Post Fall Incidents: 4. Identify the root causes of the fall incident, which could be related to the resident's current or declining medical condition or worsening behavior. 5. The staff will evaluate, and document falls that occur while the individual is in the facility, for example, when and where they happen, any observations of the events, etc. (etcetera). 6. For an individual who has fallen, staff will attempt to define possible root cause(s) of the fall. a. Causes refer to factors that are associated with or that directly result in a fall; for example, a balance problem caused by an old or recent stroke. b. Often, multiple factors in varying degrees contribute to a falling problem. 10. Collect and evaluate any information until either the cause of the falling is identified or can be speculated as to what was the resident trying to do causing the fall, or it is determined that the cause cannot be found or that finding a cause would not change the outcome or the management of falling and fall risk. Treatment/Management 1. Based on the preceding assessment, the staff and or physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. 2. If the underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment until falling reduces or stops or until a reason is identified for its continuation. Monitoring and Follow-Up If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions.
1.) R74's Order Summary Report dated 8/30/22 documents diagnoses including Difficulty in Walking, Muscle Weakness and Cognitive Communication Deficit. R74's Minimum Data Set (MDS) dated [DATE] documents R74 requires extensive assistance of one staff for transfers and toileting and total dependence on one staff for walking in R74's room. R74's Census List dated 9/8/22 documents R74 was admitted to the facility on [DATE].
R74's Fall Risk Assessments dated 7/1/22, 7/14/22, 8/6/22 and 8/25/22 all document that R74 is at risk for falls. R74's MDS dated [DATE] documents R74 had one fall in the last month prior to admission and one fall with a fracture in the last six months prior to admission which triggered Falls on the CAAs (Care Area Assessments). The Assessment documents falls as a concern for R74 with instructions to proceed to care planning. R74's Care Plan does not document any fall interventions prior to 8/8/22.
On 9/6/22 at 10:10 AM, V21 MDS/CPC (Minimum Data Set/Care Plan Coordinator) confirmed there was no initial fall care plan for R74 with no fall interventions developed until 8/6/22.
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 implement physician's orders for a urinary catheter, 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 implement physician's orders for a urinary catheter, failed to develop and implement a plan of care related to the urinary catheter use. This failure affects one of four residents (R101) reviewed for urinary catheter use on the sample list of 99.
Findings include:
R101's Face Sheet documents R101 admitted to the facility on [DATE].
R101's Hospitalist Progress Note dated 7/26/22 documents R101 developed Acute Urinary Retention on 7/25/22 and a urinary catheter was placed. R101 is to follow-up with Urology as an outpatient. R101's urinary catheter was placed on 07/25/2022. (R101) will need Urology follow-up as an outpatient. This note also documents R101 is to follow-up with Urology for voiding study.
R101's Post-Acute Care Transition Document dated 7/27/22 documents R101's urinary catheter as a Coude urinary catheter (slight curve near the insertion end of the urinary catheter tubing) size 14 french. This document also documents Discharge Instructions, Follow-up with Urology for voiding study.
On 08/29/22 10:55 AM R101's urinary catheter tubing was red/brown.
R101's Progress Notes dated 8/1/22 at 11:31 PM documents an order was received for a urinalysis to be obtained due to Hematuria. R101 to have f/u (follow-up) with Urology regarding Hematuria. R101's Order Summary Report dated 9/5/22 documents an order dated 8/1/22 to, Refer (R101) to Urology related to Hematuria. This report also documents to change R101's urinary catheter every four weeks but does not document R101's use of a Coude urinary catheter. There is no documentation R101 has had a follow-up appointment with a Urologist as ordered on admission as well as ordered on 8/1/22 by the facility.
R101's Care Plans dated 8/27/27 document R101 has a urinary catheter due to Urinary Retention. These Care Plans do not document R101 has a Coude urinary catheter or size of R101's urinary catheter. These Care Plans also do not document R101's follow-up with a Urologist for voiding trials.
On 9/8/22 at 1:00pm, V41, Assistant Director of Nursing (ADON) stated the facility did not call until 9/6/22 for an appointment for R101 at a local Urology clinic.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure a resident had physician's orders for use of a Continuous Positive Airway Pressure (CPAP) device. The facility also fai...
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Based on observation, interview and record review, the facility failed to ensure a resident had physician's orders for use of a Continuous Positive Airway Pressure (CPAP) device. The facility also failed to ensure the resident had supplies for the device and failed to ensure the supplies were stored to prevent cross-contamination of the mask for the CPAP device, and to label Oxygen tubing and a humidification bottle. These failures affect two of two residents (R3, R21) reviewed for respiratory on the sample list of 99.
Findings include:
1. R21's Order Summary Report dated 9/6/22 does not document a current physician's order for R21's Continuous Positive Airway Pressure (CPAP) device.
On 08/29/22 at 12:30 PM, R21's CPAP device was observed dusty/unclean. R21's mask for R21's CPAP treatment was attached to the tubing which was attached to the machine and was in R21's dirty linen basket, uncovered. The CPAP device water reservoir compartment was dry.
On 09/01/22 09:36 AM R21's Continuous Positive Airway Pressure (CPAP) device was on R21's night stand next to R21's bed. The device had appeared to have dust like debris/unclean on the surface. R21's CPAP tubing hanging down with R21's mask in R21's dirty linen basket and the water reservoir compartment was dry. The CPAP mask appears unclean with a film covering the inside of the mask and the cushion around the edges of the mask were unclean and yellowed in color. R21 stated R21 has told multiple staff R21 needed water for R21's CPAP machine and they have not brought/provided any for a while. R21 stated R21 would wear it if they would bring the water for the device. R21 stated R21's throat gets irritated and dried out and needs the water to be able to tolerate wearing the CPAP.
R21's Care Plans dated 9/14/21 document R21 is at risk for respiratory failure due to noncompliance with respiratory management like oxygen therapy and the use of CPAP with interventions including to encourage R21 to wear CPAP at night. These care plans do not document R21's CPAP settings or maintenance/cleaning of CPAP machine.
On 9/8/22 at 12:45 PM, V41, Assistant Director of Nursing (ADON) stated R21's CPAP mask should be placed in a plastic bag for storage when not in use. V41 stated R21's CPAP mask and CPAP machine should be cleaned every shift.
The facility's CPAP-BIPAP (Bilevel Positive Airway Pressure) Support policy dated November 2015 documents to obtain a physician's order for the use of the device with details. Resident or staff should rinse and wipe down the mask on a daily basis to eliminate facial oil build up. If the headgear becomes soiled, wash with soap and water and rinse well and air dry.
2. R3's Order Summary Report dated 8/6/22 documents R3's physician's orders including Oxygen at 2L (liters)/nasal cannula (NC) to keep Oxygen Saturation above 90% as needed.
On 08/29/22 2:15 PM and 8/30/22 at 9:50 AM, R3's Oxygen tubing and humidification bottle were not labeled/dated.
On 9/1/22 V23 LPN stated, The oxygen tubing and water (humidification) bottles are supposed to be dated.
The facility's undated Oxygen Administration policy documents the facility is to change the nasal cannula tubing weekly or as needed, change the humidifier prefilled bottle once the contents are consumed and if the oxygen tubing/facemask or nasal cannula is not being used, it is to be properly stored in a clean plastic bag. This policy does not document the facility is to document/label oxygen tubing or humidifier bottle.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0696
(Tag F0696)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a resident received orders for care of/maintenance for a resident's artificial eyes. This failure affects one of one resident (R101)...
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Based on interview and record review, the facility failed to ensure a resident received orders for care of/maintenance for a resident's artificial eyes. This failure affects one of one resident (R101) reviewed for vision on the sample list of 99.
Findings include:
R101's Progress Notes dated 7/27/22 document R101 is legally blind with artificial eyes. R101's Progress Notes dated 7/27/22 at 11:56 PM document R101 is legally blind with artificial eyes.
R101's Progress Notes dated 8/1/22 at 4:27 PM document R101 has artificial eyes and eye matting.
R101's Baseline Care Plans are incomplete and do not include R101's bilateral artificial eye care needs. There is no documentation in R101's Care Plans dated 8/27/22 documenting a plan of care related to R101's bilateral artificial eyes and care of them.
On 9/6/22 at 11:50 AM, V1, Administrator stated the facility should have contacted R101's physician to get orders/direction on how to care for R101's artificial eyes and should have a care plan in place for them.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
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 psychological medication assessments, complete Abnormal Inv...
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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 psychological medication assessments, complete Abnormal Involuntary Movement Scales, and to provide rationale for gradual dose reduction (GDR) refusals for one (R81) of two residents reviewed for psychotropic medications from a total sample list of 99.
Findings include:
R81's undated diagnoses list documents R81's diagnoses include Alzheimer's Disease, Vascular Dementia with Behavioral Disturbances, and Unspecified Psychosis. R81's Minimum Data Set, dated [DATE] documents R81 has severe cognitive impairment, R81 receives an antipsychotic medication routinely, a GDR has not been attempted and a GDR has not been documented by a physician as clinically contraindicated.
R81's Order Summary Report dated 8/31/22 documents orders dated 3/6/22 for Seroquel (antipsychotic) 25 mg (milligrams) one tablet by mouth daily and two tablets by mouth daily at bedtime.
R81's February 2022 Medication Administration Record documents R81 received Seroquel 25 mg twice daily as of 5/18/21.
R81's medical record documents a Psychotropic Medication Assessment for the use of Seroquel and Abnormal Involuntary Movement Scale (AIMS) were completed on 7/28/22. There are no other documented Psychotropic Medication Assessments or AIMS in R81's medical record.
R81's Medication Regimen Review (MRR) dated 2/3/22 documents the pharmacy recommended to reduce Seroquel from 25 mg twice daily to 12.5 mg every morning and 25 mg every evening. V11 Physician approved the dose reduction. There is no documentation that this recommendation was implemented prior to 3/5/22. V11's Progress Note dated 3/5/22 documents R81 refuses care, bites, hits, and to continue all of R81's medications including Seroquel 25 mg twice daily.
R81's Note to Attending Physician/Prescriber dated 8/2/22 documents a pharmacy recommendation to reduce R81's Seroquel to 25 mg twice daily. V11 signed this form on 8/14/22 and marked the box for Patient has had good response to treatment and requires the dose for condition stability. Dose reduction is contraindicated because benefits outweigh risks for this patient and a reduction is likely to impair the resident's function and/or cause psychiatric instability. (Please elaborate with patient specific information.) V11 did not document a clinical rational or patient specific information for why the dose reduction was declined.
On 9/6/22 at 1:18 PM V54 Registered Nurse stated R81 is on Seroquel for combative behaviors during care, yelling out, and resisting care. R81's Seroquel dosage was increased in March due to an increase in these behaviors. V54 stated the GDR in February was initially approved, but the provider and was informed that there was an increase in behaviors so the same dosage was continued. V54 confirmed V11 did not document a clinical rational for declining R81's Seroquel dose reductions in February and August 2022. V54 stated Psychotropic Medication Assessments and AIMS are completed upon admission, with increased dosages, and quarterly.
On 9/06/22 at 1:35 PM V3 Infection Preventionist confirmed there are no other documented Psychotropic Medication Assessments or AIMS (besides 7/28/22) for R81. V3 stated R81 should have had a Psychotropic Medication Assessment completed for the increase in Seroquel in March 2022.
The facility provided Psychotropic Medication Policy dated 2/15 documents GDR (Gradual Dose Reduction) consideration for residents with a diagnosis of dementia and on antipsychotic medications- within the first year in which the resident is admitted on antipsychotic therapy or after the facility has initiated an antipsychotic medication, the facility shall attempt a GDR (Gradual Dose Reduction) in two (2) separate quarters (with at least one month in between the attempts) unless contraindicated. After the first year, GDR (Gradual Dose Reduction) shall be attempted annually unless clinically contraindicated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) R80's undated diagnosis sheet documents the following diagnoses including Metabolic Encephalopathy, Catatonic Schizophrenia, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) R80's undated diagnosis sheet documents the following diagnoses including Metabolic Encephalopathy, Catatonic Schizophrenia, Stage four kidney disease, Chronic Atrial Fibrillation, Anxiety, Depression, Congestive Heart Failure, Atherosclerotic Heart Disease, Peripheral Vascular Disease, and History of Stroke.
R80's hospital discharge/transfer notes dated 4/12/22 document R80 has a diagnoses of Paroxysmal Atrial Fibrillation (PAF) and takes Eliquis 5 milligrams twice a day for PAF.
R80's care plan dated 8/27/22 documents that R80 is at risk for discolorations and bleeding due to anticoagulant medication for treatment of Atrial Fibrillation with Eliquis as the medication being used to treat.
R80's August medication administration record documents Eliquis stopped on 8/7/22 and not resumed in the month of August. R80's September medication administration record documents no Eliquis given from September 1, 2022, through September 13, 2022.
On 9/13/22 at 1:00 PM, V63 Medical Doctor stated, If (R80) was on Eliquis for Atrial Fibrillation, then she should be restarted on it. I was not the doctor who started her on this medication, nor did I stop it.
On 9/13/22 at 2:54 PM, V61 Registered Nurse stated, (V62 Medical Doctor) wanted me to relay that the Eliquis should not have been stopped, should be restarted, and that the potential for harm is great with a moderate level of risk for Stroke recurrence.
On 9/14/22 at 9:45AM, V1 Administrator stated that the facility could not determine why the Plavix had been stopped, but that they had received an order on 9/14/22 to restart the medication for R80.
Based on interview and record review the facility failed to administer medications per physician's order for two of two residents (R215, R80) reviewed for significant medication errors on the sample list of 99.
Findings include:
1) R215's hospital summary dated 8/20/22 documents R215 was hospitalized for Right Foot Gangrene with Cellulitis Osteomyelitis status post 4th and 5th digit amputation and followed by 2nd and 3rd metatarsal amputation with graft and Diabetes Mellitus type 2 Chronic with Neuropathy and Nephropathy.
R215's Electronic Medical Record documents R215 was admitted to the facility on [DATE]. R215's physician orders documents orders dated 8/20/22 for Ertapenum Sodium 1 gram intravenously for right 4th and 5th toe amputation, Empagliflozin 20 milligrams every day for Diabetes Mellitus Type II, and Protonix (Gastric Acid Secretion Reducer) 40 milligrams every day for Gastrointestinal Reflux Disorder.
R215's Medication Administration Record dated 8/1/2022 through 8/31/22 documents that R215 did not receive the physician ordered doses of Ertapenum Sodium (Antibiotic), Empagliflozin (Antihyperglycemic) 20 milligrams, or Protonix 40 milligrams on 8/21/22 and 8/22/22. R215's nurse's notes dated 8/21/22 and 8/22/22 documents, awaiting pharmacy.
On 8/31/22 at 1:10 PM, V3 Registered Nurse Manager stated when R215 was admitted , R215's face sheet was not sent to the pharmacy as required so the pharmacy did not send R215's medications. V3 stated the nurse's on duty that weekend should have notified someone that R215 did not receive the medications from the pharmacy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to offer COVID-19 (Human Coronavirus Infection) immunizations for three...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to offer COVID-19 (Human Coronavirus Infection) immunizations for three (R9, R99, and R31) of five residents reviewed for immunizations in the sample list of 99.
Findings include:
The facility's Prevention of Coronavirus (COVID-19) Infection Control Policy dated as reviewed 8/29/22 documents 4. Resident/patients will receive recommended immunization per CDC (Centers for Disease Control) recommendation. 5. Staff will obtain consent for COVID-19 vaccination from the resident or appropriate decision maker (POA (Power of Attorney)). Document the declination and approval of vaccines. 6. The physician will order the type of vaccination available. 7. Nursing staff will administer and document the COVID Vaccine as ordered when available.
The facility's COVID Vaccination Log for residents dated 8/25/22 does not document that R94, R99, R31 have received any primary doses of the COVID-19 vaccine.
The facility's Staff Testing Positive for COVID-19 logs dated 1/8/22-8/15/22 documents 11 staff have tested positive for COVID-19 since 7/25/22. The facility's Resident Testing Positive for COVID-19 logs dated 1/4/22-7/30/22 documents 1 resident has tested positive since 7/25/22.
1.) R94's undated diagnoses list documents R94's diagnoses include Type II Diabetes Mellitus, Hypertension, and History of Transient Ischemic Attack and Cerebral Infarction. R94's undated census report documents R94 admitted to the facility on [DATE]. There is no documentation in R94's medical record of R94's COVID-19 vaccination status, or that R94 was offered the vaccine and if R94 accepted or refused the vaccine.
2.) R99's undated diagnoses list documents R99's diagnoses include Type II Diabetes Mellitus, Chronic Kidney Disease Stage III, and Hypertension. R99's undated census report documents R99 admitted to the facility on [DATE]. There is no documentation in R99's medical record of R99's COVID-19 vaccination status, or that R99 was offered the vaccine and if R99 accepted or refused the vaccine.
3.) R31's undated diagnoses list documents R31's diagnoses include Parkinson's Disease, Type II Diabetes Mellitus, Chronic Kidney Disease Stage III, and Hypertension. R31's undated census report documents R31 admitted to the facility on [DATE]. There is no documentation in R31's medical record of R31's COVID-19 vaccination status, or that R31 was offered the vaccine and if R31 accepted or refused the vaccine.
On 8/31/22 at 1:50 PM V3 Infection Preventionist stated: COVID-19 vaccinations are administered by an outside pharmacy that comes to the facility monthly. R31 is on hospice and R31's family declined the COVID-19 vaccination. The COVID-19 consent/declination forms were used before V3 was hired, and V3 was unsure if a form is currently used. V3 does not have documentation that R94, R99, and R31 were offered the COVID-19 vaccine, and if they accepted or declined the vaccine. V3 was waiting for Veterans Affairs to provide R94's vaccination information.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to promote residents' dignity by failing to ensure residents were served meals at the same time, ensure staff did not stand over ...
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Based on observation, interview, and record review the facility failed to promote residents' dignity by failing to ensure residents were served meals at the same time, ensure staff did not stand over residents while providing feeding assistance, ensure staff did not enter without knocking before entering a resident's bathroom, ensure staff provide assistance with dressing and shaving, and ensure staff removed institutional identification (hospital bracelets) and gait belts for 12 (R56, R42, R70, R92, R50, R86, R47, R104, R96, R91, R215, R14) of 24 residents reviewed for dignity in the sample list of 99.
Findings include:
The facility's undated Resident Rights, Privacy and Dignity policy documents: The resident has the right to be treated with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility may encourage and assist the residents to dress in their own clothes, rather than hospital type gown and appropriate footwear for the time of the day and individual preferences. Resident's appearance should be consistent with his or her choice. The facility must promote resident's independence and dignity while dining: c. Staff standing over residents while assisting them to eat.
The facility's undated Quality of Life-Dignity policy documents: Residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc. (etcetera). Resident's private space and property shall be respected at all times. a. Staff will knock and request permission before entering resident's rooms.
1.) On 8/29/22 the following occurred: At 11:33 AM R56, R42, R70, R92, R50, R86, R47, R104 and R96 were sitting in the lounge on the 2nd floor. Lunch meal trays were delivered to the 2nd floor. At this time R56 and R42 were served their meals and began eating. At 11:40 AM R70 stated I'm hungry, hungry, hungry. R70 did not have R70's meal, and was sitting directly beside R42. At 11:45 AM R92's meal was served. At 11:50 AM R42 finished R42's meal and left the lounge. R70 stated (R42) already finished eating and left. I'm hungry. I haven't ate yet. Why haven't I ate yet? At 11:54 AM V27 Certified Nursing Assistant (CNA) collected R42's and R56's meal trays. R70 asked V27 about R70's meal tray and R70 said R70 was hungry. V27 told R70 your (R70's) food is coming. At 12:02 PM a second meal tray cart was delivered to the 2nd floor and distributed down the [NAME] Hall. At this time R50's meal was served. V23 Licensed Practical Nurse (LPN) was standing and feeding R50. R70 stated sure would be nice to get something to eat. I (R70) haven't had anything to eat. V23 told R70 that V23 will check on R70's meal tray. At 12:07 PM R86's meal was served. R70 continued to repeatedly ask about R70's meal. At 12:11 PM (38 minutes after meal trays were served to R56 and R42) meal trays were delivered to R47, R104, R96 and R70.
On 9/1/22 at 11:40 AM V3 Infection Preventionist stated: Staff should not be standing while feeding residents. Staff should serve meal trays for residents sitting in dining areas together and then distribute trays by hall.
2.) On 8/31/22 at 12:45 PM V42 Central Supply Clerk entered R91's bathroom, and did not knock before entering. R91 was sitting on the toilet in view of V42. V42 stated Oh my, I'm sorry. I didn't know you were in here.
On 9/1/22 at 9:15 AM V3 Infection Preventionist confirmed staff are expected to knock before entering resident rooms and bathrooms.
3.) On 8/30/22 at 10:00 AM, R215 was sitting in a wheelchair. R215 was wearing a hospital gown and had a fall risk bracelet and hospital band on his wrist. R215 stated, I don't know why they haven't taken it off and I am not sure why I'm not dressed. R215 was noted to have an overgrowth of facial hair and stated he doesn't usually wear a beard and is not sure why they don't shave him. R215 stated he would like to be shaved and dressed.
4.) On 8/29/22 at 11:11 AM, R14 was propelling self around the common area by the nurses' station. R14 had a bright yellow fall risk band on his wrist and bright yellow gait belt around waist. At that time, V35 Licensed Practical Nurse stated, I am not sure why (R14) is wearing a fall risk band. It was applied at the hospital and should be taken off.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to keep residents' emergency nurse call light devices 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 keep residents' emergency nurse call light devices within reach (R3, R36 and R371) and failed to provide a call light device that was appropriate for resident capability (R100), in four of 24 residents reviewed for call lights in a total sample list of 99.
Findings include:
The facility Use of Call Light policy dated October 2010 documents, The purpose of the call light procedure is to respond to the residents' request and needs. 3) Ask the resident to return the demonstration so that you will be sure that the resident can operate the system. 6) When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident.
1) On 8/29/22 at 10:00 AM, R3's call light device was laying on the floor out of reach of R3. R3 stated, I don't know where it is. I hurt!
2) On 8/29/22 at 10:36 AM, R36 was lying in bed while R36's call light device was tied across the room. R36 could not access the call light across the room and stated, It's hers (roommate).
3. On 8/29/22 at 11:00 AM, R100 was lying in bed. R100's call light was attached to the mattress. V36 (R100's Family Member) stated she cannot use the call light. V36 stated when she pushes it, it does not go off. At that time, R100 attempted to activate call light and it did not activate. The call light when pushed slowly did not activate. The call light did activate when pushed fast and hard. V36 was not able to push it fast and hard enough for it to activate. V36 stated R100 has had that type of call light since admission [DATE]).
On 9/7/22 at 12:09 PM, V16 Maintenance Director stated V16 went and checked R100's call light on 8/29/22. V16 stated R100 had the soft bulb call light that has to be squeezed and that she could not activate it when he asked her to activate it. V16 stated V16 switched it to the regular push button call light that she could easily activate. V16 stated nursing staff is responsible for ensuring that the residents are able to use the call light.
4.) On 8/29/22 at 10:45 AM, R371's was lying in bed. R371's call light device was lying on the floor and not within R317's reach.
R371's care plan dated 8/10/22 documents to keep R371's call light within reach.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) The facility's abuse allegation investigative files from March 2022-August 2022 were reviewed. The only documented abuse all...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) The facility's abuse allegation investigative files from March 2022-August 2022 were reviewed. The only documented abuse allegation between R89 and R95 was for an incident that occurred on 8/28/22. The facility's Final Incident Investigation Report dated 9/2/22 documents the following: On 8/28/22 staff observed R95 attempt to inappropriately touch another resident R89. V12 Certified Nursing Assistant (CNA) initially reported that V12 witnessed R95 touch R89 on R89's private (genital) area. V12 intervened and separated R95 from R89. V12 later clarified to local police that R95 was attempting to grab and unbutton R89's pants, and R89 was shaking and pushing R95 away with both of R89's hands. R95's hands were touching and grabbing towards R89's private (genital) area. R95 was placed on 15-minute checks.
R95's undated diagnosis list documents R95 has a diagnosis of Bipolar Disorder. R95's Minimum Data Set (MDS) dated [DATE] documents R95 has severe cognitive impairment, requires supervision of one staff person for locomotion on R95's unit. R95's Care Plan revised on 5/5/22 documents R95 has the potential to be physically aggressive towards other residents and has a history of a physical altercation with another resident. R95's Care Plan revised on 5/31/22 documents R95 has a behavior problem of exposing R95's self in R95's room and inappropriately touching female staff.
R95's Nursing Note dated 10/22/2021 at 11:51 PM documents R95 appeared in the common area wearing only an incontinence brief and shirt. R95 was asked what R95 was doing and replied that R95 wanted some. R95 was told that R95 was inappropriate and redirected back to R95's room.
R95's Nursing Note dated 8/28/2022 at 2:24 PM documents R95 was touching a female resident (R89) and trying to unbutton her pants. R95 was transferred to the local emergency room and returned to the facility on 8/28/22 at 8:48 PM. R95 was transferred to an inpatient psychiatric hospital on 8/29/22 at 2:00 PM.
R95's 15 Minute Sign Off for 1:1 Supervision form documents R95 was checked on at 15-minute intervals from 8/28/22 at 8:00 PM until 2:00 PM on 8/29/22. R95's undated census report documents R95 resides on the 2nd floor of the facility.
On 8/29/22 at 10:54 AM R95 was lying in bed, and there were no staff present in R95's room.
On 8/29/22 at 3:56 PM V22 Licensed Practical Nurse (LPN) stated: R95 has made sexual comments to staff and residents while passing them in the hallway. R95 would say things such as you can come sit on my lap, or I'll help you undo your pants. This has been an ongoing behavior. We try to keep a close eye on R95 and have R95 near the nurse's station. R95 does wander at times.
On 8/30/22 at 9:38 AM V12 CNA stated: On 8/28/22 around 1:50 PM, R95 was in the television room facing the window, and R89 was facing the television. R95 had R89's hands on R89 trying to unbutton R89's pants. R89 is nonverbal. R89 used R89's hands to try and push R95's hands off of R89, while R95 continued to attempt to unbutton R89's pants. V12 immediately separated R95 from R89. R95 is confused, and during incontinence care has made sexual comments in regard to female staff's breasts.
On 8/31/22 at 3:30 PM V39 LPN stated: About a month ago during shift change, V39 saw R89 and R95 in the television room. R95's back was facing V39, and R95's arm was near R89. V39 was not able to see R95's hands. V39 approached R95, and R95 acted startled and said I'm not doing anything. It (the situation) didn't sit well with me (V39). R95 and R89 were immediately separated. V39 reported the incident to V13 Previous Administrator, and V13 told V39 it sounds like two residents with Dementia. V39 did not report the incident to anyone else.
On 8/31/22 at 4:15 PM V1 Administrator confirmed there is no investigative file or report of an allegation of abuse between R95 and R89 prior to 8/28/22. V1 stated: After the incident on 8/28/22 R95 was placed on one-to-one supervision until R95 transferred to the psychiatric hospital on 8/29/22. We do not provide continuous one to one, our one to one is 15-minute checks.
The Preliminary Incident Investigation Report dated 8/31/22 documents On 8/31/22 V39 verbalized an incident, a while ago, between residents (R95) and (R89) of what seems to be inappropriate interaction. V39 stated that R95's back was towards V39, and V39 observed R95's arm to be moving back and forth on what seemed like R89's lap. V39 immediately reported to V13 Previous Administrator, and V13 told V39 that the conclusion was two dementia residents having behaviors. This report documents an investigation was initiated.
3.) The facility's verbal abuse allegation investigation for R99 and V31, Certified Nursing Assistant (CNA) documents the incident occurred on 8/18/22 at 8:00 AM.
V31, CNA's Copy of Timecard Report dated 8/18/22 to 8/24/22 documents V31 worked as follows: 8/18/22 6:16 AM to 8:54 AM and 9:15 AM to 11:51 AM. 8/22/22 6:06 AM to 9:15 AM.
On 9/6/22 at 10:35 AM, V32, Housekeeper stated V32 overheard V31, Certified Nursing Assistant (CNA) speaking in a negative tone to R99 on 8/18/22 between 6:30 AM and 8:00 AM.
On 9/6/22 at 11:50 AM, V1, Administrator stated the facility should not have allowed V31, CNA to continue working on 8/18/22 after R99's alleged verbal abuse against V31. V1 Administrator stated V31 was to have been suspended pending the completion of the investigation and should not have worked on 8/22/22 either. V1 stated the investigation was completed 8/24/22.
On 9/8/22 at 3:30 PM, V1, Administrator stated staff are not hired nor always scheduled to work the same unit and have the potential to work throughout the facility.
Based on observation, interview and record review the facility failed to protect R52, R64, R89, and R99 from potential/further abuse pending investigation, following witnessed instances of physical, sexual, and mental/verbal abuse by R46 and V31. These failures impact six of seven residents (R46, R52, R64, R89, R95, R99) reviewed for abuse in the sample list of 99.
Findings include:
The facility's abuse policy documents, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. This will be done by: immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; VI. Protection of Residents. The facility will take steps to prevent potential abuse while the investigation is underway. Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility. In addition, the facility shall take all steps necessary to ensure the safety of residents including, but not limited to, the separation of the residents. Accused individuals not employed by the facility will be denied unsupervised access to the residents during the course of the investigation. Supervisors shall immediately inform the administrator or person designated to act in the administrator's absence of all reports of incidents, allegations or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property. Upon learning of the report, the administrator or a designee shall initiate an incident investigation.
1.) R46's admission Record/Face Sheet documents R46 was admitted to the facility on [DATE]. R46's admission Minimum Data Set (MDS) dated [DATE] documents diagnoses including Schizophrenia, Wernicke's Encephalopathy, Alcohol Abuse with Intoxication and Unspecified Mood Disorder. This MDS documents a BIMS (Brief Interview for Mental Status) score of 9/15 indicating moderately impaired cognition.
The facility's Preliminary Incident Investigation Report dated 8/19/22 at 12:20 PM, documents circumstances of the alleged incident: Resident (R46) was ambulating in (R46's) wheelchair behind (R52) and (R64). (R46) said 'f*** you' (expletive) and (R64) responded by saying the same to (R46). (R46) then propelled (R46's) wheelchair towards (R52) and (R64), and they fell to the ground. The residents were separated, and (R46) is being monitored 1:1 (one to one) pending orders received for (R46) to be sent out for evaluation.
R46's Nurse's Note written by V14 Licensed Practical Nurse (LPN) dated 8/19/22 and written at 1:53 PM, documents the incident between R46, R52 and R64 and documents R46 was placed on 1:1 supervision at this time from time of incident.
R46's Nurse's Note written by V43 Registered Nurse (RN) on 8/19/22 at 3:03 PM documents V45, R46's Physician, gave an order to send R46 to the hospital for evaluation.
V43 wrote in R46's Nurse's Notes the same day, 8/19/22 at 8:29 PM that R46 returned from the hospital with no new orders.
V44 LPN wrote in R46's Nurse's Notes on 8/20/22 at 1:35 PM, writer did 1:1's with (R46) and documents that R46 came out of R46's room to mingle for a little.
On 8/29/22 at 1:06 PM, V1 Administrator confirmed that when they document 1:1 monitoring they are meaning the resident is on 15 minutes checks.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R70's Minimum Data Set (MDS) dated [DATE] documents R13 has severe cognitive impairment, is not on a prescribed weight loss r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R70's Minimum Data Set (MDS) dated [DATE] documents R13 has severe cognitive impairment, is not on a prescribed weight loss regimen, and has a weight loss of 5% or more in the last month or 10 % or more in the last six months.
R70's undated weight log documents R70's weights as follows: 121.3 lbs. on 4/11/22, 110.4 lbs. on 6/14/22 (8.99 % loss since 4/11/22), 103.2 lbs. on 7/31/22 (6.52 % loss since 6/14/22), and 107 lbs. on 8/31/22.
R70's Care Plan revised on 7/17/22 does not include a problem area, goals, and interventions for nutrition or weight loss.
On 9/7/22 at 11:30 AM V21 MDS/Care Plan Coordinator stated V21 assists with updating care plans. V21 stated nutrition and weight loss should be addressed on the resident's care plan. V21 confirmed R70 does not have a nutrition or weight loss care plan.
Based on observation, interview and record review the facility failed to develop and implement a Comprehensive Care Plan for falls, bilateral hearing aide use, nutrition, weight loss and anticoagulant medication use for four of 24 residents (R74, R21, R101, R70) reviewed for Care Plans in the sample list of 99.
Findings include:
The facility's Care Plans-Comprehensive policy with a revised date of 1/2011 documents, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 2. A comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS (Minimum Data Set). 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. incorporate risk factors associated with identified problems; g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; 4. Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) before interventions are added to the care plan. 5. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem areas(s), rather than addressing only symptoms or triggers. 7. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS). 8. Assessment of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.
1. R74's admission Minimum Data Set (MDS) dated [DATE] documents R74 was admitted to the facility on [DATE] with diagnoses including Fractures and Other Multiple Traumas, Anemia, Unspecified Fall and history of TIA (Transient Ischemic Attack). This MDS documents R74 had one fall in the last month and had one fall resulting in a fracture in the last six months. This MDS's Care Area Assessment Summary documents the trigger for Falls and documents Falls should be carried over to R74's Care Plan.
R74's Fall Risk Assessments dated 7/1/22, 7/14/22, 8/6/22 and 8/25/22 all document R74 is at risk for falls. R74's Care Plan documents the first mention of a fall risk is dated 8/6/22 with the first fall intervention dated 8/6/22. R74's Nurse's Notes dated 8/6/22 at 7:00 AM documents R74 was found on the floor in R74's room.
On 9/6/22 at 10:10 AM, V21 MDS/CPC (Minimum Data Set/Care Plan Coordinator) confirmed there was no comprehensive Care Plan developed for falls on admission or even after the admission MDS was completed for R74. V21 confirmed the first fall documentation on R74's Care Plan is after R74 fell at the facility on 8/6/22.
Surveyor: [NAME], [NAME]
2. R21's Order Summary Report dated 8/1/21-9/30/22 documents R21's medication orders including Xarelto (Anticoagulant) 20mg (milligrams) by mouth in the evenings for a diagnosis of Deep Vein Thrombosis.
R21's Care Plans dated 2/16/22 does not document a Care Plan for R21's use of Anticoagulation medication and side effects to monitor for.
R21's Progress Notes dated as follows documents:
7/17/22 at 7:48pm document R21 was actively bleeding from R21's right front tooth, pressure was applied and mouth rinsed with cool water and that bleeding continues.
7/17/22 at 8:37am documents to apply gauze and pressure until bleeding stops as needed to upper right tooth and monitor R21.
On 9/6/22 at 11:50am, V1, Administrator confirmed V1 did not see a Care Plan for R21's Anticoagulation medication.
The facility's Anticoagulation Clinical Protocol policy dated October 2015 documents the staff and physician will identify and address potential complications in individuals receiving anticoagulation. The staff and physician will monitor for possible complications in individuals who are being anticoagulated and manage related problems.
3. On 08/29/22 10:55 AM R101 was in R101's bed. During attempt to talk with R101, it was noted R101's hearing aids were not in R101's ears. At this time there is a sign on R101's bedside table documenting R101 is fully blind and has hearing aids. R101 unable to see or communicate at this time.
R101's Progress Notes dated 7/27/22 at 11:56pm document R101 has hearing aides. R101's Minimum Data Set (MDS) dated [DATE] does not document R101 requires hearing aids. R101's Care Plans dated 8/27/22 do not document a plan of care for R101's hearing aid use.
On 9/6/22 at 11:50am, V1, Administrator confirmed R101 should have a plan of care for R101's hearing aid use.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R13's Minimum Data Set (MDS) dated [DATE] documents R13 has severe cognitive impairment, R13 is not on a prescribed weight lo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R13's Minimum Data Set (MDS) dated [DATE] documents R13 has severe cognitive impairment, R13 is not on a prescribed weight loss regimen, and R13 has had a weight loss of 5% or more in one month or 10% or more in six months.
R13's undated weight log documents R13's weights and identified significant weight loss as follows: 118.6 lbs. (pounds) on 4/27/22, 118.7 lbs. on 5/3/22, 109.7 lbs. on 5/9/22 (7.58 % loss), 103.6 lbs. on 5/12/22 (5.56% loss in 4 days), 103 lbs. on 5/24/22 (6.11 % loss from 5/9/22), and 101 lbs. on 8/22/22 (a 10% loss since 4/27/22.)
R13's Nutrition Note dated 4/28/22 at 12:48 PM recorded by V47 Registered Dietitian (RD) documents R13 was reviewed for recent admission, R13's BMI (Body Mass Index) was 21.6 and was adjusted for above knee amputation. This note, documents Will monitor for need to modify nutrition. R13's Nutrition Note dated 5/26/2022 at 9:50 recorded by V47 documents R13 was evaluated for wounds and weight loss noted. R13's weight is down 15 lbs. since R13 admitted in late April 2022. R13 has a low BMI of 18.8, adjusted for left above knee amputation. V47 requested to change multivitamin to multivitamin with minerals, offer double protein at breakfast, a frozen nutritional supplement once daily, whole milk at meals, and change diet from Low Concentrated Sweets to regular. R13's Dietary Note dated 7/21/2022 at 12:04 recorded by V47 documents V47 requested to add ice cream with lunch.
R13's Care Plan dated 6/21/22 documents R13 has a potential nutritional problem secondary to wound healing and includes interventions to provide diet as ordered and Registered Dietitian to evaluate and make dietary changes as needed. This care plan has not been updated to include R13's significant weight loss and nutritional interventions.
On 9/7/22 at 11:20 AM V21 MDS/Care Plan Coordinator stated nutrition and weight loss should be addressed on the care plan. V21 confirmed R13's care plan has not been updated to reflect R13's weight loss.
4. R95's MDS dated [DATE] documents R95 has severe cognitive impairment, is not on a prescribed weight loss regimen, and has a weight loss of 5 % or more in 1 month or 10 % or more in 6 months.
R95's undated weight log documents R95's weights as follows: 136.7 lbs. on 5/31/22 and 6/8/22, and 129.8 lbs. on 7/7/22 and 8/2/22 (5.05 % loss).
R95's Nutrition Notes dated 7/21/22, 3/7/22, 2/26/22, and 9/9/21 recorded by V47 RD, do not document an estimate of R95's calorie, protein, nutrient, and fluid needs There are no documented thorough/complete nutritional assessments in R95's medical record since 7/24/21. R95's Nutrition Note dated 7/21/2022 at 11:35 AM documents R95 was reviewed for weight loss for the past month, and R95's BMI remains low at 21.6 with a goal of 23. R95's diet includes a nutritional shake 120 cc (cubic centimeters) four times daily. V47 suggested adding a frozen nutritional supplement for additional kilocalories. There is no documentation that R95 was evaluated by V47 after 3/7/22 until 7/21/22.
R95's Care Plan dated as revised on 8/27/21 documents R95's diet is regular and R95 is at risk for altered nutrition due to new admission to the facility. This care plan includes interventions that R95 will be reviewed by the RD as needed, and this care plan has not been updated to reflect R95's significant weight loss and nutritional interventions to address weight loss.
On 9/7/22 at 11:20 AM V21 MDS/Care Plan Coordinator confirmed R95's care plan has not been updated to address R95's weight loss.
2. On 8/29/22 at 11:56 AM, V36 (R100's Family Member) stated she has been here a month and he has not been to a care plan meeting. V36 stated he does not know the plan for his mom's (R100) discharge or the progress she has made. V36 stated he would like to know what is going on with her progress and plan of care.
On 8/31/22 at 3:02 PM, V21 Care Plan Coordinator stated the facility hasn't been having care plan meetings. V21 stated they should have had R100's care plan after her 5 Day/admission Minimum Data Set assessment (MDS).
R100's Electronic Medical Record documents R100's admission MDS was completed on 8/3/22.
Based on interview and record review the facility failed to update resident Care Plans with falls, nutrition and weight loss concerns. The facility failed to conduct a Care Plan meeting with a resident's family and failed to invite a resident to the resident's Care Plan meeting for four of 24 residents (R74, R100, R95, R13) reviewed for Care Plans in the sample list of 99.
Findings include:
The facility's Care Plans-Comprehensive policy with a revised date of 1/2011 documents, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 7. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS). 8. Assessment of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.
The facility's Care Planning-Interdisciplinary Team policy with a revised date of 11/2010 documents, 3. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. 4. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family.
1. R74's admission Minimum Data Set (MDS) dated [DATE] documents R74 was admitted to the facility on [DATE] with diagnoses including Fractures and Other Multiple Traumas, Anemia, Unspecified Fall and history of TIA (Transient Ischemic Attack). This MDS documents R74 had one fall in the last month and had one fall resulting in a fracture in the last six months. This MDS's Care Area Assessment Summary documents the trigger for Falls and documents Falls should be carried over to R74's Care Plan.
R74's Nurse's Notes document R74 was found on the floor in R74's room on 8/6/22 and on 8/25/22. R74's Care Plan provided by V1 Administrator on 8/29/22 documents one fall on 8/6/22 but does not document any other falls for R74.
On 9/6/22 at 10:10 AM, V21 MDS/CPC (Minimum Data Set/Care Plan Coordinator) stated that V21 is aware that there is an issue with Care Plans being updated. V21 stated V21 has not had time to get to all of the Care Plans for the entire facility of 120 plus residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.) R372's Orthopedic after care notes document a post operative appointment on 5/18/22. The post operative visit notes dated 5/...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.) R372's Orthopedic after care notes document a post operative appointment on 5/18/22. The post operative visit notes dated 5/18/22 document that R372 is to follow up with another post operative appointment and Xray on 6/29/22. R372's medical record does not document R372 attending any appointments on 6/29/22, nor does it document the appointment being rescheduled. Additionally, R372's medical record does not document an Xray being done.
On 9/13/22 at 9:27AM, V21 Minimum Data Set Coordinator/Care Plan Coordinator stated, After a surgery like R372 had, she should have been seen by Orthopedics as ordered and have gotten an Xray.
On 9/13/22 at 11:00 AM, V34 Social Services Assistant/Appointment Scheduler stated that she did not know about this appointment. On 9/13/22 at 12:00 PM, V1 Administrator confirmed that R372 did not attend this appointment and that the facility could not explain why this error occurred.
Based on observation, interview, and record review the facility failed to identify and document a wound, adjust wound treatments, implement physician ordered wound treatments and interventions, schedule follow up Orthopedic appointments, and monitor weights as ordered for four (R13, R34, R215, R372) of 24 residents reviewed for quality of care in the sample list of 99.
Findings include:
1. ) On 8/29/22 at 10:18 AM V38 (R13's Family) stated R13 had a toe amputation a few months ago due to Diabetic wounds. V38 had visited several times where R13's wound dressings weren't on, and R13's wounds were uncovered/exposed. V38 stated R13 is supposed to wear a surgical boot. V38 removed R13's sock and R13's right foot was wrapped with a dressing dated 8/28/22. On 8/31/22 at 1:02 PM V38 stated V38 had previously requested an order for R13 for Vitamin E oil and a petroleum-based ointment, but the facility never implemented the treatment.
R13's Minimum Data Set (MDS) dated [DATE] documents: R13 has severe cognitive impairment and requires extensive assistance of one staff person for toileting and dressing.
R13's Physician's Orders dated 8/31/22 documents an order with a start date of 6/14/22 to apply moisture barrier to perineal area and buttocks every shift, an order to cleanse the 5th toe arterial wound, pat dry, apply Santyl ointment to wound, apply gauze moistened with 1/4 strength Dakin's solution, cover with an abdominal pad, and wrap with gauze twice daily and as needed, apply Betadine twice daily to the right 3rd and 4th toe wounds, and an order dated 6/20/22 for a surgical boot to the right foot to be worn with ambulation.
R13's Wound Evaluation & Management Summaries recorded by V46 Wound Physician document: On 5/12/22 R13's right 5th toe arterial wound measured 1.5 cm (centimeters) long x 1.2 cm wide x no measurable depth. The wound was 100 % covered with black, necrotic tissue, and had gangrene. V46 ordered Betadine applied topically twice daily. On 8/25/22 R13's right 5th toe wound measured 3.5 cm x 2 cm x 1.2 cm and contained 20% necrotic tissue. R13's right 4th toe arterial wound measured 2 cm x 1.5 cm x no measurable depth, was 100 % necrotic with gangrene. R13's right 3rd toe arterial wound measured 1.2 cm x 1 cm, was 100 % necrotic with gangrene.
R13's Skin assessment dated [DATE] documents R13 has Moisture Associated Skin Damage (MASD) that is no blanchable, an initial treatment was administered, and R13's family and physician were notified. There is no documentation of R13's MASD prior to 8/31/22, or that treatments were altered to treat R13's MASD.
R13's May 2022 Treatment Administration Record (TAR) documents the right 5th toe Betadine order was not implemented until the night shift on 5/16/22 (4 days after it was ordered.) This treatment is not signed out as administered on 5 days.
R13's July 2022 TAR documents R13's right 3rd and 5th toe wound treatments are not signed out as administered on 7 days. R13's August 2022 TAR documents R13's right 3rd, 4th, and 5th toe wound treatments are not signed out as administered on 3 days.
On 8/29/22 at 3:50 PM R13 was self-propelling R13's wheelchair in the hallway. R13 was not wearing a boot on the right foot. On 8/31/22 at 3:12 PM R13 was sitting on the side of the bed with R13's right foot on the floor. R13 was not wearing a boot on the right foot.
On 8/31/22 at 12:57 PM V38 told V12 Certified Nursing Assistant (CNA) that R13 needed assistance and that R13 was incontinent of bowel movement. V38 pulled down R13's incontinence brief which contained a small amount of bowel movement. R13's buttocks were red and excoriated. V38 stated the area had looked better on Sunday (8/28/22), but it looks worse today. On 8/31/22 at 1:02 PM V38 applied Vitamin E oil and a petroleum-based ointment. On 8/31/22 at 1:14 PM V12 CNA stated: R13's buttock excoriation was showing improvement, and last week it was not as red. Today it looks worse. The nurse (unidentified) was aware. We don't have access to barrier cream, it is given to us by the nurses to apply, but the nurses have to get an order first.
On 8/31/22 at 3:39 PM V39 Licensed Practical Nurse (LPN) stated nothing has been reported about R13's buttock excoriation, and this is the first time V39 has heard about the excoriation. V39 administered R13's wound treatments to the right 3rd and 4th toe wounds, and 5th toe amputation wound. R13's 3rd and 4th toes were black indicating necrotic/dead tissue. R13's 5th toe was amputated, and there was a large wound with yellow and red tissue. There was tan drainage on the dressing. V39 stated the 5th toe wound has gotten larger and contains more yellow tissue. V39 cleansed the 5th toe wound, applied Santyl and gauze sponges, and wrapped R13's foot with gauze. V39 did not apply Dakin's-soaked gauze to the 5th toe wound. On 8/31/22 at 4:08 PM V39 assessed R13's buttocks. V39 stated the area looks like it is moisture associated that has flared back up. V39 stated V39 will get an order and apply barrier cream. V39 confirmed V39 did not apply Dakin's-soaked gauze to R13's right 5th toe wound. V39 stated V39 must have overlooked the Dakin's-soaked gauze in the order.
On 9/01/22 at 3:22 PM V3 Infection Preventionist stated skin assessments are completed weekly by the nurses. The nurses should document skin issues, obtain a treatment order, and notify the physician if the treatment is not improving. V3 stated R13's right 4th toe wound was identified on 5/11/22, and the Betadine treatment was initiated on 5/16/22. V3 stated nurses should document their initials on the TAR when treatments are administered, and document resident refusals. V3 stated R13's surgical boot has been missing since last week. V39 confirmed there is no documentation of when R13's surgical boot is applied/removed.
The facility's Wound Prevention Program dated February 2022 documents Notify the physician for any changes in the ski condition and obtain wound care treatment orders. Apply wound treatment as ordered by the physician.
2.) R34's MDS dated [DATE] documents R34 has short- and long-term memory loss.
R34's Hospital Discharge summary dated [DATE] documents R34 was diagnosed with a left wrist fracture. R34's discharge instructions document: A follow up for Orthopedic has been ordered for you. You will be contacted by the scheduling center for an appointment. Please schedule an appointment as soon as possible, lf you do not receive a call within 2 days from now, please call the number below for an appointment.
R34's Nursing Note dated 8/13/22 at 3:30 PM recorded by V39 Licensed Practical Nurse (LPN) documents R34 was not wearing the soft cast to the right wrist. The Physician was notified and gave orders to schedule an Orthopedic follow up visit on Monday (8/15/22) for a possible hard cast.
R34's Physician Orders Summary Report dated 8/30/22 documents an active order dated 8/13/22 to schedule R34's follow up Orthopedic appointment, and to discontinue the order once the appointment has been made and family is notified.
R34's Nursing Note dated 8/30/2022 at 10:58 AM documents V29 (R34's Power of Attorney) was notified and agreed with scheduling an Orthopedic follow up appointment. R34's Nursing Note dated 8/30/22 at 12:14 PM documents R34's Orthopedic follow up appointment is scheduled for 9/19/22 at 2:30 PM, V34 Social Services Assistant spoke with R34's family on 8/25/22, and the family preferred that R34 not have a hard cast placed. There is no documentation that R34 was scheduled for an Orthopedic follow up appointment prior to 8/30/22, or that R34's family declined for R34 to have an Orthopedic follow up appointment.
On 8/30/22 at 10:15 AM R34 was self-propelling R34's wheelchair in the hallway, using both hands. R34 was not wearing a soft cast or splint to R34's left arm.
On 8/31/22 at 3:30 PM V39 LPN stated: V39 spoke with R34's family about the order for a follow up Orthopedic appointment due to R34 removing the soft splint cast. R34's family was in agreement with the appointment. I (V39) was off for a few days, and I (V39) guess no one followed up with making (R34) the ortho (Orthopedic) appointment.
On 8/30/22 R 10:29 AM V23 LPN stated V11 Physician recommended R34 have a follow up Orthopedic appointment for a hard cast due to R34's noncompliance with wearing the soft cast. R34's family refused R34's follow up appointment, and it should be documented in a progress note. On 8/30/22 AT 10:38 AM V23 stated V23 spoke with R34's family to confirm their refusal of the follow up Orthopedic appointment. R34's family was in agreement to schedule R34's follow up appointment, and R34's family wants everything the Orthopedist can do for R34.
3.) R215's hospital summary dated 8/20/22 documents R215 has a history of Congestive Heart Failure.
R215's physician order dated 8/24/22 documents to obtain daily weights. Notify physician if weight gain of more than 3 lbs per day or more than 5 lbs in one week.
R215's medical record does not document weights were done daily. R215's medical record from 8/24/22 to 9/8/22 daily weights were only completed on 8/30/22, 9/2/22, and 9/6/22.
R215's Wound Evaluation Form documented by V46 Wound Physician documents R215 has a Diabetic wound to the right ankle. This form includes a recommendation for a calf high heel protector while in bed.
On 8/31/22 at 11:28 AM, R215 was lying in bed on his right side. R215's legs were curled up and R215's feet were crossed. R215 was not wearing a calf high heel protector or any other type of heel protector. At that time, a calf high heel protector was lying on a three-drawer cabinet on the other side of the room.
On 8/31/22 at 11:45 AM, V35 Licensed Practical Nurse stated she was unaware of the recommendation and is not sure when R215 is supposed to be wearing the heel protector. V35 stated is unsure why R215's weights aren't getting completed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0800
(Tag F0800)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to provide meals that met dietary needs and preferences for four (R14, R215, R106, and R214) of 24 residents reviewed for meals o...
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Based on observation, interview, and record review the facility failed to provide meals that met dietary needs and preferences for four (R14, R215, R106, and R214) of 24 residents reviewed for meals on the sample list of 99.
Findings include:
1. On 8/29/22 at 11:11 AM, R14 stated he is supposed to get double portions but does not get his double portions. R14's lunch ticket on the tray documented R14 was to receive double portions.
On 8/31/22 at 11:31 AM, R14 received a lunch tray. R14 stated, See, I didn't get double portions. R14's tray had one serving of roast beef, one scoop of potatoes, one scoop of cauliflower, one piece of bread and one bowl of fruit.
On 8/31/22 at 11:40 AM, V35 Licensed Practical Nurse stated R14 is supposed to receive double portions, but the kitchen never sends him double portions. V35 stated it is a constant problem and that sometimes she will call and tell them they didn't send them, and they tell me they are out or will bring some but half the time they never show up with the double portions.
2. On 8/31/22 at 11:57 AM, R215 was served a piece of roast beef, cauliflower, and a bowl of fruit. R215's lunch ticket documented R215 is to receive a low carbohydrate diet with no starches, bread, or potatoes. R215 stated I don't want starches, so I hardly get any food.
The facility's Daily Spreadsheet for Wednesday 8/31/22 documents the lunch menu as roast beef, baked potato, cauliflower, pears, and dinner roll. This Spreadsheet did not document an option for a low carbohydrate diet.
3. On 8/29/22 at 12:05 PM, R106 was sitting in her room eating lunch. R106 was observed just finishing her meal. R106 stated the facility served spaghetti with curly noodles mixed vegetables, mandarin oranges and bread. R106 stated the facility is aware R106 eats Gluten Free and R106 thinks the noodles and bread were not Gluten Free so she did not eat the bread.
The facility's Daily Spreadsheet for Wednesday 8/31/22 documents the lunch menu as roast beef, baked potato, cauliflower, pears, and dinner roll. This Spreadsheet did not document an option for a Gluten Free diet.
4. On 8/29/22 at 10:30 AM, R214 stated there is no variety in the food and they serve too many starches.
On 8/29/22 at 12:00 PM, R214 was sitting in her room eating lunch. R214 stated I don't want to eat all this starch. R214 was eating noodles with red sauce and chicken. R214's plate also contained mixed vegetables, mandarin oranges, and bread. R214's dietary ticket which was laying on the table documents R214 is receiving a regular diet.
On 8/30/22 at 8:51 AM, V20 (R214's family member) stated the food in the facility is not good. V20 stated R214 is a Diabetic and her blood sugar isn't controlled very well and she is always getting too much starch.
R214's diet order dated 8/9/22 documents a low concentrated sweet diet for Diabetes Type II.
On 8/30/22 at 12:45 PM, V18 Certified Dietary Manager stated the facility does not have Gluten Free or low carbohydrate diets. V18 stated the facility has no concentrated sweets diet. V18 stated they do not have substitutions on the spreadsheet if a resident does not want carbohydrates.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to prepare and serve meat that was easily cut and chewed for five (R214, R113, R67, R70, and R13) of 24 residents reviewed for me...
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Based on observation, interview, and record review the facility failed to prepare and serve meat that was easily cut and chewed for five (R214, R113, R67, R70, and R13) of 24 residents reviewed for meals on the sample list of 99.
Findings include:
1. On 8/31/22 at 11:30 AM, R214 was eating lunch in her room. R214 stated her lunch had a good flavor but the roast beef was tough, and she could hardly chew it. R214 was picking at the roast beef, and it appeared dry and leathery.
2. On 8/31/22 at 12:14 PM, V12 Certified Nursing Assistant was assisting R113 with her meal in her room. V12 couldn't hardly cut the meat with the butter knife sawing back and forth R113's meat.
On 8/31/22 at 12:17 PM, V12 Certified Nursing Assistant was picking up the lunch trays from the resident rooms. V12 stated it's all been hard to cut. V12 took a piece of meat off a tray that someone did not eat and had to pull hard to pull it apart.
3. On 8/3/22 at 12:15 PM, R67 was standing up at her bedside table eating her lunch. R67 stated the roast beef was tough and was ripping it apart to eat it.
4. On 8/31/22 at 12:41 PM, R70 was sitting in R70's room just finished eating. R70 had eaten 1/2 of the carrots, 3/4 of potatoes, all of pears, and only taken a couple bites of the roast beef. R70 stated, That meat is too tough for me to chew.
5. On 8/31/22 at 12:44 PM, R13 was observed in her room eating. R13 was having difficulty chewing the roast beef. At that time, V38 (R13's Family Member) stated the meat is kind of tough for her to chew.
On 8/31/22 at 1:00 PM, V18 Certified Dietary Manager stated when V18 was getting ready to cook the roast beef he noticed he had an oven down, so he had to slice the meat prior to cooking it to save time and that was probably the reason it was dry and tough.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to disinfect scissors after a wound treatment, change gloves, perform hand hygiene during incontinence care, implement isolation ...
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Based on observation, interview, and record review the facility failed to disinfect scissors after a wound treatment, change gloves, perform hand hygiene during incontinence care, implement isolation signage, isolation laundry, waste bins for transmission-based precautions, and ensure staff properly wear Personal Protective Equipment (PPE). These failures have the potential to affect for five (R13, R70, R82, R91, R103) of 24 residents reviewed for infection control in the sample list of 99.
Findings include:
1.) R13's Right 5th Toe Wound Culture dated 7/24/22 documents a moderate colony count of Proteus Mirabilis (bacteria) and Methicillin Resistant Staphylococcus Aureus (MRSA, a multidrug resistant organism), indicating an active infection. R13's Order Summary Report dated 8/31/22 documents an order for contact isolation for six weeks that was initiated on 7/25/22.
On 8/29/22 at 10:16 AM there was a sign posted on R13's door indicating R13 was on contact precautions. There was a cart containing PPE located outside of R13's doorway, and isolation bins for linen and waste were in R13's room. V38 (R13's Family) was in R13's room and was not wearing a gown or gloves. V38 stated R13 is not on isolation.
On 8/29/22 at 10:14 AM V23 Licensed Practical Nurse (LPN) stated R13 is not on isolation, and staff must have forgotten to remove the isolation signage from R13's door. On 8/29/22 at 11:01 AM V23 stated V23 clarified R13's isolation status, and R13 is on contact isolation for a wound infection.
On 8/31/22 at 11:58 AM and 3:12 PM R13 was in a different room than observed on 8/29/22. R13's door did not contain isolation signage and there was no cart containing PPE near R13's doorway. R13's room did not contain isolation linen and waste containers.
On 8/31/22 at 3:16 PM V39 LPN prepared to enter R13's room to administer R13's wound treatment. V39 stated V39 needed to get an isolation gown, and that's not (R13's) regular room. At 3:18 PM V39 placed a cart containing PPE outside of R13's doorway. At 3:39 PM V39 used scissors to remove the dressing covering R13's right foot. R13 had necrotic, black tissue to R13's 3rd and 4th toes. R13 had a right 5th toe amputation. R13's right 5th toe wound had red and yellow tissue, and tan drainage on the gauze. V39 laid the scissors inside of the garbage bag used to hold the old dressing removed from R13's right foot wounds, contaminating V39's scissors. V39 cleansed R13's wounds and administered R13's wound treatments. V39 placed the contaminated scissors directly on the sink in the bathroom that adjoined with R91's room. V39 washed the scissors with soap and water, and then placed the scissors back onto the sink. V39 tied the plastic bag containing R13's soiled wound dressings and placed the bag into the waste receptacle on the treatment cart located in the hallway. V39 stated R13 does not have isolation waste and laundry containers in R13's room. V39 confirmed there is no isolation signage posted on R13's door. V39 took the scissors from the sink and placed the scissors into V39's pocket. At 4:08 PM V39 stated V39 is going to have to take the treatment cart and the waste bag to R13's previous room to place the waste into an isolation bag. V39 stated a bleach wipe should be used to disinfect scissors after use.
On 9/01/22 at 10:50 AM V3 Infection Preventionist stated R13's wound culture on 7/24/22 showed MRSA infection. R13 is on contact isolation for the wound infection. Staff should wear a gown in R13's room if there is the potential to come into contact with drainage from R13's wound. Signage should be posted to alert staff and visitors of isolation. R13 should have had isolation signage posted and isolation bins for laundry and waste should have been moved with R13 to R13's temporary room. There should be a PPE cart outside of R13's door. Staff should disinfect scissors with a bleach wipe, and staff should have used a bleach wipe to wipe down R13's sink.
2.) On 8/31/22 at 10:52 AM R70 was laying in bed. V12 Certified Nursing Assistant (CNA) applied gloves, pulled down R70's incontinence brief, and wiped R70's buttocks with a disposable wipe. There was bowel movement visible on the wipe. Without changing gloves and performing hand hygiene, V12 applied R70's clean incontinence brief, pulled up R70's pants, opened R70's nightstand drawer, handed R70 a pen and paper, used R70's bed remote control to lower the bed, pushed back the privacy curtain, opened R70's door and left R70's room. V12 took the waste bag from R70's room and opened the door to the soiled utility room to dispose of the waste. V12 did not perform hand hygiene or remove V12's gloves until after V12 went to the soiled utility room.
On 8/31/22 at 12:52 PM V12 stated V12 did not remove V12's gloves and perform hand hygiene until V12 was in the soiled utility room. V12 stated We don't change our gloves unless they are visibly soiled during care, such as with wound drainage.
On 9/6/22 at 9:15 AM V3 Infection Preventionist stated: Gloves should be changed, and hand hygiene performed when moving from soiled to clean areas during pericare and after pericare is completed. The CNA (V12) should have removed her gloves and not worn them in the hallway.
3.) The Updated Interim Guidance for Nursing Homes and Other Licensed Long-Term Care Facilities updated on 3/22/22 documents: For those residents not suspected to have COVID-19 (Human Coronavirus Infection), HCP (Health Care Professionals) should use community transmission levels to determine the appropriate PPE to wear. When community transmission levels are substantial or high at a minimum, HCP must wear a well-fitted mask at all times and eye protection while present in resident care areas. Facilities might consider having HCP wear N95 respirators at all times while in the facility.
The Centers for Disease Control and Prevention COVID Data Tracker documents on 8/29/22 the facility's county transmission level was high.
On 08/29/22 at 10:00 AM V49 CNA pushed R82 in a wheelchair down the hallway and into the lounge on the 2nd floor of the facility. V49's N95 mask was pulled down, exposing V49's nose and mouth.
On 08/30/22 at 10:10 AM V50 Maintenance Assistant was walking down the East Hall of the 2nd floor, past residents and resident rooms. V50's eye protection was on top of V50's head, and not covering V50's eyes. The lower strap of V50's N95 mask was hanging loosely below V50's chin and was not positioned behind V50's head. At 10:43 AM V50 walked past the nurse's station and walked down the North Hall of the 2nd floor. The lower strap of V50's N95 mask was hanging below V50's chin. V50 stated V50 is assisting housekeeping staff today on the 2nd floor. On 8/31/22 at 11:14 AM V50 walked down the East and South Halls of the 2nd floor. V50 was not wearing eye protection, and V50's lower strap has hanging below V50's chin.
On 08/31/22 at 12:38 PM V56 CNA was standing at the nurse's station wearing an N95 mask positioned below V56's nose, exposing V56's nose. V56 was talking to R91 and R103, who were within six feet of V56 and were not wearing a mask.
On 9/6/22 at 9:15 AM V3 Infection Preventionist stated staff should be wearing eye protection and an N95 mask when in common areas, hallways, and during care of residents. V3 confirmed masks should be worn covering both the nose and the mouth.
The facility's Transmission-Based Precautions policy with a revised date of 3/18/22 documents: In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Infections with multidrug resistant organisms would be an example of an infection that requires Contact Precautions. Wear gloves and a gown when entering the Contact Precautions room. Adequately clean and disinfect resident care equipment before use for another resident. Signage Isolation, see the nurse will be posted to alert staff and visitors.
The facility's Standard Precautions policy revised March 2022 documents Change gloves, as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one.) Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments.
The facility's policy Dressings, Soiled/Contaminated revised 3/18/22 documents Soiled dressings that are heavily soiled with exudate or drainage or from a resident with an infectious condition must be placed in specially designated BIOHAZARD containers for disposal.
The facility's Personal Protective Equipment - Using Protective Eyewear revised 2/3/22 documents Masks and eye protection devices, such as goggles or glasses with solid side shields or chin-length face shields, shall be worn together whenever splashes, spray, spatter or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can be expected.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to address/provide response for concerns voiced during resident council meetings. These failures have the potential to affect all 122 resident...
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Based on interview and record review, the facility failed to address/provide response for concerns voiced during resident council meetings. These failures have the potential to affect all 122 residents residing in the facility.
Findings include:
The facility's Resident Council meeting minutes document resident concerns as follows:
1/18/22 10:30 AM Residents are concerned about food and consistently needing to discuss the food preparations. Residents would like more crunchy foods and more food choices at lunch and dinner. Residents are concerned with the internet and phone situations that were addressed over the holiday season. Residents concerned with shower times.
2/15/22 10:30 AM Residents concerned about the food, consistently. Food preparations needing revisited with the residents. Residents would like more variety in their foods for all meals. Residents concerned with medication pass and shower times.
3/8/22 at 10:30 AM Residents are concerned about the mealtimes and food preparations. Residents would like more variety in their foods for all meals. Residents are concerned about shower times and days.
4/26/22 10:30 AM Residents are concerned about sauces on their foods, like gravy. Residents would also like to know what is on their plate to be the same as on the meal tickets and would like more variety in their foods for all mealtimes. Residents are concerned about their showers/bed baths.
5/24/22 at 10:30 AM Residents are looking for new choices and variety in some of their side dishes when they don't like what is given for a choice. Residents would like more fresh fruits and summer treats.
7/26/22 un-timed - Would like more fresh fruit: bananas, oranges, apples and juices.
There is no documentation in the facility's Resident Council Meeting minutes regarding addressing/following up on resident concerns from the previous Resident Council meetings as above.
On 8/30/22 at 11:12 AM, Resident Council meeting was held with R32, R33, R48, R54, R88 and R109. During this meeting several concerns were presented including concerns with showers/bathing and dietary. At this time, R32 stated the facility does not provide details that concerns are being reviewed and addressed. R32 stated the resident council has concerns that do not get addressed. R32 stated there have been several dietary concerns and concerns related to showers/bathing that the facility has not addressed.
The facility's Resident Census and Conditions of Residents dated 8/29/22 documents 122 residents reside in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review the facility failed to provide a full time Director of Nursing (DON) since January 1, 2022. These failures have the potential to affect all 122 reside...
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Based on observation, interview and record review the facility failed to provide a full time Director of Nursing (DON) since January 1, 2022. These failures have the potential to affect all 122 residents in the facility.
Findings include:
On 8/29/22 there was no Director of Nursing at the facility.
On 8/31/22 at 1:10 PM V3 Infection Control Nurse stated that there had not been a director of nursing in months. On 9/6/22 at 11:00 AM, V30 Wound Nurse stated, We haven't had a Director of Nursing in 8 months and that isn't helping us.
On 9/8/22 at 10:00 AM, V21 Care Plan Coordinator stated that she did not work as a Director of Nursing forty hours per week at any time.
The facility's August 2022 Nursing schedule does not document a Registered Nurse (RN) on the schedule at any time.
The facility's Resident Census and Conditions of Residents form dated 8/29/22 documents 122 residents reside in the building.
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 maintain sanitary food preparation and storage areas. These failures have the potential to affect all 122 residents in the fa...
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Based on observation, interview, and record review, the facility failed to maintain sanitary food preparation and storage areas. These failures have the potential to affect all 122 residents in the facility.
Findings include:
On 8/29/22 at 10:00 AM, Four rolling storage bins were located under a counter in the kitchen. These bins contained oatmeal, sugar, flour, and breadcrumbs. The clear plastic openings on the top of the bins and the sides of these bins were covered with spots of various sticky residue and were streaked with dirt. At that time, V18 Certified Dietary Manager stated that they push these bins to the preparation and cooking areas and that is how they get soiled. V18 stated that these bins needed cleaned.
On 8/29/22 at 10:10 AM, A drawer connected to the underneath of a small food preparation area containing potholders and loose papers had spilled dried puddles of liquids. A three-compartment container containing ladles and scoops had accumulated crumbs and dried spilled areas inside the container where the ladles and scoops were lying. Three clear plastic containers containing cooking utensils had accumulated crumbs and debris. At that time, V18 stated the drawer and containers needed to be cleaned.
On 8/29/22 at 10:15 AM, The four-door refrigerator, the milk/juice cooler, and the two-door freezer were streaked with an unknown substance and the handles on the doors were sticky when grabbed.
The clean dish cart containing plastic drinking tumblers, bowls, and plates had dried crumbs lying with the clean dishes.
The inside of a microwave had areas of sticky residue on the sides, top, and on the top of the cooking surface. A warming cabinet containing five warming trays were covered with accumulated crumbs. V18 stated that all areas in the kitchen needed cleaned.
The facility's Census and Conditions of Residents report dated 8/29/22 signed by V21 Registered Nurse documents there are 122 residents residing in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0837
(Tag F0837)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to designate and operationalize an effective governing body, impacting ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to designate and operationalize an effective governing body, impacting the operations of the facility. This failure had the potential to affect all 122 residents residing in the facility.
Findings include:
The facility's Facility assessment dated [DATE] through 5/1/23 documents V13 (Former Administrator) as the Administrator and the Governing Body of the facility. This assessment does not document who the Administrator reports to concerning the management and operation of the facility.
On 9/8/22 at 1:44 PM, V2 [NAME] President of Clinical and Reimbursement stated V2 is not sure who the governing body of the facility is and that she is over nursing only. V2 stated she does not oversee the Administrator or her duties in the facility. V2 stated the Administrator completed the facility's Facility Assessment. V2 stated the facility's Facility Assessment is not accurate as the Administrator cannot also be the governing body.
The facility's Census and Condition report signed by V21 Registered Nurse documents there are 122 residents residing in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to implement a quality assurance program within the facility. This failure has the potential to affect all 122 residents residing in the facili...
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Based on interview and record review the facility failed to implement a quality assurance program within the facility. This failure has the potential to affect all 122 residents residing in the facility.
Findings include:
On 9/1/22 at 11:06 AM V1 Administrator stated, I cannot say that (we) have quality projects or a quality assurance performance improvement program.
On 9/7/22 at 2:30P M, V1 Administrator provided quality meeting sign in sheets for 3/25/22, 5/27/22 and 7/22/22. V1 Administrator confirmed that these were the only documented quality meeting sign in sheets that could be found.
The facility Quality Assessment and Assurance Plan dated November 2017 documents, The facility shall develop, implement, and maintain an ongoing, facility-wide Quality Assessment and Assurance Program designed to monitor and evaluate the quality of resident care, pursue methods to improve care quality and resolve identified problems.
The resident census and condition report dated 8/29/22 documents 122 residents residing in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to hold quarterly quality meetings. This failure has the potential to affect all 122 residents residing in the facility.
Findings include:
On 9...
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Based on interview and record review the facility failed to hold quarterly quality meetings. This failure has the potential to affect all 122 residents residing in the facility.
Findings include:
On 9/1/22 at 11:06 AM V1 Administrator stated, (The facility) didn't have quarterly quality meetings.
On 9/1/22 at 11:06 AM V1 Administrator stated, I cannot say that (we) have quality projects or a quality assurance performance improvement program.
On 9/7/22 at 2:30PM, V1 Administrator provided quality meeting sign in sheets for 3/25/22, 5/27/22 and 7/22/22. V1 Administrator confirmed that these were the only documented quality meeting sign in sheets that could be found.
The facility Quality Assessment and Assurance Plan dated November 2017 documents, This committee shall meet quarterly to review reports, evaluate the significance of data and monitor quality-related activities of all departments, services or committees.
The resident census and condition report dated 8/29/22 documents 122 residents residing in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to include the Director of Nursing in quality assurance meetings. This failure has the potential to affect all 122 residents residing in the fa...
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Based on interview and record review the facility failed to include the Director of Nursing in quality assurance meetings. This failure has the potential to affect all 122 residents residing in the facility.
Findings include:
On 9/1/22 at 11:06 AM V1 Administrator stated that the only meetings that could be found were in March, May and June of 2022 and there was no Director of Nursing at the time.
On 9/7/22 at 2:30 PM, V1 Administrator provided quality meeting sign in sheets for 3/25/22, 5/27/22 and 7/22/22 none of the sign in sheets include a Director of Nursing in attendance. V1 Administrator confirmed that these were the only documented quality meeting sign in sheets that could be found.
The resident census and condition report dated 8/29/22 documents 122 residents residing in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to ensure a licensed nurse was vaccinated for COVID-19. This failure has the potential to affect all 122 residents residing in th...
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Based on observation, interview, and record review the facility failed to ensure a licensed nurse was vaccinated for COVID-19. This failure has the potential to affect all 122 residents residing in the facility.
Findings include:
The Vaccination of Facility Staff policy dated as revised 2/23/22 documents: If required, second dose administration shall be received per vaccination requirements, and evidence of this second vaccination shall be submitted for copy into the employee's personnel file and recorded on the Employee Vaccination Roster. Employees failing to obtain the required second vaccination dose per CDC (Centers for Disease Control and Prevention) guidelines shall be removed from the schedule and placed on unpaid administrative leave until meeting this requirement. Failure to meet this requirement within two weeks of this unpaid administrative leave shall be considered a voluntary resignation.
The CDC's Stay Up to Date with COVID-19 Vaccines Including Boosters guidance dated 9/8/22 documents the 2nd primary dose of a twostep series should be given 3-8 weeks after the 1st dose for people aged 18 years and older.
The facility's COVID-19 Staff Vaccination Status log documents V57 Licensed Practical Nurses first primary dose of a twostep series of the vaccine was given on 1/22/22. This log does not document that V57 received the 2nd primary dose of the vaccine. , or that V57 has a pending or approved medical or religious exemption.
V57's COVID-19 Vaccination Record Card documents V57 received the 1st dose of a two-part series on 1/22/22, and does not document that V57 received the 2nd primary dose of the vaccine.
The facility's Daily Schedules document V57 worked on all of the halls of the 1st floor on nine days between 8/17/22 and 8/31/22.
On 9/1/22 at 9:26 AM V3 Infection Preventionist stated V3 does not track employee COVID-19 vaccinations and V48 Human Resources completes the tracking. On 9/01/22 at 10:50 AM V3 stated: V57 is the only employee who has not completed the primary doses of the COVID-19 vaccination. V57 received the first dose and had a panic attack. V3 had V57 scheduled to receive the 2nd dose two times, but V57 did not follow through.
On 9/01/22 at 1:40 PM V48 stated before staff are allowed to work, they must show proof of COVID-19 vaccination or apply for a medical/religious exemption. V48 stated the exemptions have to be approved before the employee is allowed to work. At this time V57 LPN entered V48's office. V57 confirmed V57 has only received the 1st primary dose of a twostep series of the COVID-19 vaccination. V48 stated V57 does not have a qualifying medical or religious exemption. V57 stated V57 is waiting for V57's physician to provide a note. V48 told V57 that V57 has to get the 2nd dose of the vaccine by Monday (9/5/22). V57 stated the 2nd dose of the vaccine is administered 28-29 days after the 1st dose. V57 stated staff should be restricted from working if they are past due for the 2nd dose of the vaccine and they do not have an exemption.
On 9/06/22 at 3:26 PM V3 Infection Preventionist stated V57 primarily works on the 1st floor of the facility, and V57 has also worked on the 2nd floor and the rehabilitation unit (all units of the facility).
The Resident Census and Conditions of Residents dated 8/29/22 documents 122 residents reside in the facility.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 2 life-threatening violation(s), 11 harm violation(s), $179,055 in fines, Payment denial on record. Review inspection reports carefully.
- • 109 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $179,055 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Accolade Healthcare Of Savoy's CMS Rating?
CMS assigns ACCOLADE HEALTHCARE OF SAVOY 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 Accolade Healthcare Of Savoy Staffed?
CMS rates ACCOLADE HEALTHCARE OF SAVOY's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 46%, compared to the Illinois average of 46%.
What Have Inspectors Found at Accolade Healthcare Of Savoy?
State health inspectors documented 109 deficiencies at ACCOLADE HEALTHCARE OF SAVOY during 2022 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 11 that caused actual resident harm, and 96 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 Accolade Healthcare Of Savoy?
ACCOLADE HEALTHCARE OF SAVOY is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by ACCOLADE HEALTHCARE, a chain that manages multiple nursing homes. With 213 certified beds and approximately 178 residents (about 84% occupancy), it is a large facility located in SAVOY, Illinois.
How Does Accolade Healthcare Of Savoy Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, ACCOLADE HEALTHCARE OF SAVOY's overall rating (1 stars) is below the state average of 2.5, staff turnover (46%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Accolade Healthcare Of Savoy?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the below-average staffing rating.
Is Accolade Healthcare Of Savoy Safe?
Based on CMS inspection data, ACCOLADE HEALTHCARE OF SAVOY has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 2 Immediate Jeopardy citations (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 Accolade Healthcare Of Savoy Stick Around?
ACCOLADE HEALTHCARE OF SAVOY has a staff turnover rate of 46%, 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 Accolade Healthcare Of Savoy Ever Fined?
ACCOLADE HEALTHCARE OF SAVOY has been fined $179,055 across 5 penalty actions. This is 5.1x the Illinois average of $34,869. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Accolade Healthcare Of Savoy on Any Federal Watch List?
ACCOLADE HEALTHCARE OF SAVOY 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.