SHELBYVILLE MANOR
Non profit - Corporation
109 Beds
UNLIMITED DEVELOPMENT, INC.
Data: November 2025
Trust Grade
25/100
#402 of 665 in IL
Photo by Shelbyville Manor
Photo by Shelbyville Manor
Photo by Shelbyville Manor
1 / 5 photos
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Shelbyville Manor has a Trust Grade of F, indicating significant concerns about the quality of care provided at this facility. It ranks #402 out of 665 nursing homes in Illinois, which places it in the bottom half of all facilities, but it is the best option among the three homes in Shelby County. The facility’s trend is stable, with 12 issues reported consistently over the last two years, but it has serious problems, including incidents of staff abuse and inadequate supervision, which resulted in harm to residents. While staffing is a strength with a rating of 4 out of 5 stars and a turnover rate lower than the state average, the home lacks a Certified Dietary Manager, potentially affecting meal quality for residents. Although there have been no fines assessed, the overall low performance ratings and specific incidents raise red flags for families considering this home for their loved ones.
- Trust Score
- F
- In Illinois
- #402/665
- Safety Record
- High Risk
- Inspections
- Holding Steady
- Staff Stability ○ Average
- 42% turnover. Near Illinois's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Illinois facilities.
- Skilled Nurses ✓ Good
- Each resident gets 43 minutes of Registered Nurse (RN) attention daily — more than average for Illinois. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 33 deficiencies on record. Higher than average. Multiple issues found across inspections.
25/100
Bottom 40%
Review needed
12 → 12 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 12 issues
2025: 12 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (42%)
6 points below Illinois average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
2-Star Overall Rating
Below Illinois average (2.5)
Below average - review inspection findings carefully
Staff Turnover: 42%
Near Illinois avg (46%)
Typical for the industry
Chain: UNLIMITED DEVELOPMENT, INC.
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 33 deficiencies on record
2 actual harm
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
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 staff to resident physical abuse to the state ...
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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 staff to resident physical abuse to the state survey agency for two of 18 residents (R1, R5) reviewed for abuse in the sample list of 18.1.) R1's Minimum Data Set (MDS) dated [DATE] documents R1 has moderate cognitive impairment.R1's Nursing Note dated 7/21/2025 at 5:10 PM documents V16 (R1's Family) spoke to V9 Licensed Practical Nurse (LPN) about incident and R1 experienced pain during repositioning. V16 was dissatisfied with the incident and stated V16 just wanted R1 safe. R1's Nursing Note dated 7/21/2025 at 5:20 PM documents V1 was notified of the incident, and Certified Nursing Assistant (CNA) was sent home until further investigation. R1's Nursing Note dated 7/21/25 at 5:25 PM documents Nurse Practitioner was notified of incident and increased right hip pain, and orders received to send R1 to the emergency room for further evaluation and right hip x-ray.R1's emergency room Note dated 7/21/25 at 7:07 PM documents R1 had a fall on 6/26/25 that resulted in fracture of right distal femur involving the arthroplasty component, R1 was transferred to another hospital for surgical repair of the fracture and discharged on 6/30/25. R1 presented today for complaints of significant pain in groin area while CNA turned R1 side to side in the bed, and R1 reported they were handling (R1) very rough.On 7/22/25 at 11:11 AM V9 LPN stated last evening around 4:50 PM, V9 was called back from her break because V14 (R1's Family) had called the facility and spoke with V10 LPN. V16 (R1's Family) called the facility and spoke with V9, and V16 suspected abuse of R1. V9 stated R1 had a recent fall with hip fracture, so has the potential for pain. V9 stated R1 reported a Certified Nursing Assistant (CNA) had repositioned R1 in bed causing R1 hip pain, and R1 called V14 to report this incident. V9 stated V9 immediately reported R1's abuse allegation to V1 Administrator. V9 stated at first R1 was unclear if the abuse involved more than one staff person, so V9 took V8 CNA, who was assigned to R1's hall, into R1's room and confirmed with R1 that V8 was the CNA.On 7/22/25 at 11:30 AM V10 LPN stated V10 received the phone call from V14 shortly after 5:00 PM last evening. V10 stated V14 wanted to know what was going on and R1 had told him that people were being rough with R1. V10 stated V10 was not assigned to R1's hallway and went to get R1's nurse (V9) and also notified V2 Director of Nursing.The initial report of R1's abuse allegation submitted to IDPH on 7/22/25 at 10:25 AM, provided by V1, documents the following: On 7/21/25 V16 contacted V9 to report a staff member had hurt R1 during repositioning, and V16 felt this was abuse. R1 was unsure of the employee's name but indicated V8 CNA had repositioned R1. V8 was placed on suspension pending results of the investigation.On 7/22/25 at 11:03 AM V1 Administrator stated the initial report of R1's allegation was submitted to IDPH this morning due to not being able to interview R1 last night since R1 was at the hospital. V1 confirmed the report was submitted at 10:25 AM on 7/22/25. At 2:48 PM V1 stated V1 thought V1 had 24 hours to report abuse allegations to IDPH.2.) R5's Nursing Note dated 07/18/2025 at 6:37 PM documents R5 reported to CNAs that during his shower today a male CNA cleaned his perineal area a little hard and when R5 told the CNA it hurt, the CNA replied, it will heal. This note documents a CNA reported R5 was bleeding in scrotum area. R5's Nursing Note dated 07/18/2025 at 6:39 PM documents V10 LPN assessed R5's scrotum which had a 2 centimeter (cm) by 1 cm open area, like skin was ripped, and blood noted in brief. This note documents R5 reported that he did not have a shower today but had one a couple days ago. V10 looked at the shower schedule and R5's showers are scheduled for Mondays and Thursdays. V10 obtained orders to apply barrier cream and Vitamin A & D ointment until healed. R5's Nursing Note dated 7/18/25 at 7:01 PM documents V1 Administrator returned call to the facility and was notified of R5's reported incident. R5's Nursing Note dated 07/18/2025 at 7:02 PM documents POA (Power of Attorney) was called about open area to scrotum and that due to the circumstance of how resident told how area got there will be investigated by administrator.On 7/22/25 at 11:30 AM V10 LPN was asked to describe any abuse allegations in the facility. V10 stated on 7/18/25 around 5:30 PM R5 had a bleeding scrotal skin tear and R5 reported to the CNAs that V13 CNA had given R5's shower that day and washed R5 hard, R5 told V13 to stop, and V13 said it will heal. V10 stated R5 had a 2 cm skin tear to his scrotum and R5 told V10 that it happened a few days prior. V10 stated V10 reported R5's allegation to V1 Administrator and R5's family immediately.On 7/22/25 at 12:36 PM V11 CNA stated on 7/18/25 around 5:30 PM V11 overheard R5 tell V15 CNA that V13 CNA gave R5 a shower on first shift, and V13 rubbed R5's scrotal area hard. V11 stated per R5, R5 told V13 to stop and V13 said it would be ok, it would heal. V11 stated the underside of R5's scrotum was bleeding and V10 was notified. V11 stated V11 considered this to be an abuse allegation and V10 reported the incident to V1.On 7/22/25 at 2:33 PM V15 CNA stated on the evening of 7/18/25 R5 told V15 that unidentified male CNA was rough with R5 during R5's shower. V15 stated R5 said R5 told the CNA to be more gentle and the CNA replied that he was just trying to get R5 clean. V15 stated there was blood in R5's brief and V15 reported this to the nurse.On 7/22/25 at 2:48 PM V1 Administrator stated on the evening of 7/18/25 R5 reported to staff that during his shower V13 CNA scrubbed a little hard and that it hurt. V1 stated that was all that was reported to V1. V1 stated V1 looked at R5's shower documentation and V13 had not given R5 a shower. V1 stated V13 is the only male CNA that works on R5's hallway. V1 stated V1 spoke with V13 who denied giving R5 a shower. V1 stated V1 spoke with R5 about the incident and R5 did not know what V1 was talking about. V1 stated V1 did not consider this to be an abuse allegation, therefore it was not reported to IDPH.The facility's Abuse Prohibition and Reporting policy dated 11/28/19 documents alleged abuse should be immediately reported to the facility's administrator, and if the matter involves alleged abuse or results in serious bodily injury, the administrator, or designee, shall submit an initial notice to the Illinois Department of Public Health (IDPH) no more than two hours after the matter becomes known.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to protect from further abuse by staff following a staff to resident abuse allegation for 14 of 18 residents (R5, R6, R7, R8, R9, R10, R11, R12...
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Based on interview and record review the facility failed to protect from further abuse by staff following a staff to resident abuse allegation for 14 of 18 residents (R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18) reviewed for abuse in the sample list of 18. R5's Nursing Note dated 07/18/2025 at 6:37 PM documents R5 reported to Certified Nursing Assistants (CNAs) that during his shower today a male CNA cleaned his perineal area a little hard and when R5 told the CNA it hurt, the CNA replied, it will heal. This note documents a CNA reported R5 was bleeding in scrotum area. R5's Nursing Note dated 07/18/2025 at 6:39 PM documents V10 Licensed Practical Nurse (LPN) assessed R5's scrotum which had a 2 centimeter (cm) by 1 cm open area, like skin was ripped, and blood noted in brief. This note documents R5 reported that he did not have a shower today but had one a couple days ago. V10 looked at the shower schedule and R5's showers are scheduled for Mondays and Thursdays. V10 obtained orders to apply barrier cream and Vitamin A & D ointment until healed. R5's Nursing Note dated 7/18/25 at 7:01 PM documents V1 Administrator returned call to the facility and was notified of R5's reported incident. R5's Nursing Note dated 07/18/2025 at 7:02 PM documents POA (Power of Attorney) was called about open area to scrotum and that due to the circumstance of how resident told how area got there will be investigated by administrator.On 7/22/25 at 11:30 AM V10 LPN was asked to describe any abuse allegations in the facility. V10 stated on 7/18/25 around 5:30 PM R5 had a bleeding scrotal skin tear and R5 reported to the CNAs that V13 CNA had given R5's shower that day and washed R5 hard, R5 told V13 to stop, and V13 said it will heal. V10 stated R5 had a 2 cm skin tear to his scrotum and R5 told V10 that it happened a few days prior. V10 stated V10 reported R5's allegation to V1 Administrator and R5's family immediately.On 7/22/25 at 12:36 PM V11 CNA stated on 7/18/25 around 5:30 PM V11 overheard R5 tell V15 CNA that V13 CNA gave R5 a shower on first shift, and V13 rubbed R5's scrotal area hard. V11 stated per R5, R5 told V13 to stop and V13 said it would be ok, it would heal. V11 stated the underside of R5's scrotum was bleeding and V10 was notified. V11 stated V11 considered this to be an abuse allegation and V10 reported the incident to V1.On 7/22/25 at 2:33 PM V15 CNA stated on the evening of 7/18/25 R5 told V15 that unidentified male CNA was rough with R5 during R5's shower. V15 stated R5 said R5 told the CNA to be more gentle and the CNA replied that he was just trying to get R5 clean. V15 stated there was blood in R5's brief and V15 reported this to the nurse.V13's Timecard dated 7/13/25-7/26/25 documents V13 worked on the following dates: 7/18/25 from 5:31 AM until 2:05 PM. 7/19/25 from 5:32 AM until 10:11 PM. 7/20/25 from 5:30 AM until 10:34 PM. The CNA Daily Assignment Sheets dated 7/19/25 and 7/20/25 document V13 worked on the Independence Place unit. The facility's Resident Bed List Report dated 7/22/25 documents R6-R18 reside on the Independence Place unit. On 7/22/25 at 2:48 PM V1 Administrator stated on the evening of 7/18/25 R5 reported to staff that during his shower V13 CNA scrubbed a little hard and that it hurt. V1 stated that was all that was reported to V1. V1 stated V1 looked at R5's shower documentation and V13 had not given R5 a shower. V1 stated V13 is the only male CNA that works on R5's hallway. V1 stated V1 spoke with V13 who denied giving R5 a shower. V1 stated V1 spoke with R5 about the incident and R5 did not know what V1 was talking about. V1 stated V6 CNA who said V7 CNA gave R5's shower that Friday, but V7 said V7 didn't give R5's shower. V1 stated 7/14/25 was R5's only documented shower, which was given by V21 CNA. V1 stated V1 did not consider this to be an abuse allegation, therefore it was not reported to IDPH. V1 stated no alleged perpetrator was identified. V1 confirmed V13 CNA, alleged perpetrator reported by R5, was not placed on suspension pending investigation of this allegation. On 7/22/25 at 3:19 PM V2 Director of Nursing confirmed the CNA Daily Assignment Sheets 7/19/25 and 7/20/25 accurately reflect the staff's hall assignments and V13 worked on the Independence Place unit. The facility's Abuse Prohibition and Reporting policy dated 11/28/19 documents if the alleged abuse involves an employee as the perpetrator, then the administrator shall immediately suspend the suspected employee without pay pending the investigation of the incident.
May 2025
10 deficiencies
2 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent an incident of staff to resident physical and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent an incident of staff to resident physical and verbal abuse and failed to provide adequate supervision to prevent a resident-to-resident incident of physical abuse. This failure affects two residents (R76 and R62) out of four reviewed for abuse on the sample list of 35. This failure resulted in R62 suffering a high level of pain and a bump on the head.
Findings include:
1. The facility's Initial Incident Report dated 3/21/25 documents an allegation reported from a family member (V23) that a Certified Nursing Assistant (V22) had used profanity towards a resident (R76) and then had put his hands on the shoulders of R76 to restrict and confine R76 to stay seated in the wheelchair.
On 4/29/25 at 10:26 AM, R76, having severe cognitive impairment and Dementia, stated he had no recollection of the incident involving the allegations against V22.
On 5/1/25 at 11:01 AM, V1, Administrator, confirmed there was an allegation against V22 reported by the family member of R2 alleging that V23 had used profanity and pushed R76 into his wheelchair. V1 further confirmed V22 had been terminated for his comments (profanity). V1 stated she had spoken with V22 who told her he did place his hands on R76's shoulders to guide him from getting up from the wheelchair but that V22 told her he did not put any pressure on R76's shoulders.
On 5/1/25 at 1:50 PM, V23, Family Member of R2, stated R2 was admitted to the facility on [DATE]. V23 stated she had been at the facility with R2 less than one hour when she noticed R76 seated by the entrance door for the facility's Dementia unit. V23 stated R47 was standing next to R76 and R47 had his hand on R76's wheelchair armrest. V23 stated R76 leaned forward like he was going to try to see if the door would open, then V23 witnessed V22, Certified Nursing Assistant, come up behind R76's wheelchair and violently, aggressively, and quickly jerk R76's wheelchair backwards. V23 stated at that time, V22 said to R76, Where the f**k (expletive) do you think you're going? V23 stated that R76 never did try to stand up, just leaned forward as if to try to open the door. V23 stated she was surprised that when V22 jerked the wheelchair, that R76 did not fall out, and was surprised that R47 did not get knocked to the floor. V23 stated she had worked as a Certified Nursing Assistant off and on for about 30 years and had never witnessed anything like what V22 did.
R2's Face Sheet dated 5/1/25 confirmed R2 was admitted to the facility 3/21/25.
Through the survey period 4/29/25 through 5/2/25, V22 was not available for a requested interview.
V22's Employee Disciplinary Action form dated 3/21/25 documents V22 was dismissed/ terminated from employment due to violating facility policy by being discourteous, rude, and harassing a customer.
V22's Employee Disciplinary Action dated 1/21/25 documents V22 received a written warning for using profanity while working in the hallway in the presence of residents, as reported by a (unidentified) family member.
V22's Employee disciplinary Action dated 10/17/24 documents V22 received a written warning for, as reported by a (unidentified) family member, being in the dementia unit office using his cell phone while leaving residents unsupervised, and this family member found his beloved resident to be incontinent of a large amount of urine and having soiled clothing.
The facility's Abuse Prohibition and Reporting policy dated 11/28/19 documents the facility actively prohibits resident abuse including corporal punishment and protects residents from any kind of abuse such as verbal, physical, and corporal punishment. This policy defines verbal abuse as oral disparaging and derogatory remarks to a resident or their families within their hearing. This policy defines physical abuse as any infliction of injury on a resident by any means other than accidental, including attempting to control behavior by corporal punishment.
2. Throughout the survey period 4/29/25 through 5/2/25, R76 was observed being in a one-to-one supervision from facility staff.
On 4/29/25 at 10:30 AM, V5, Certified Nursing Assistant, stated the reason why she was sitting in a one-to-one duty with R76 was because R76 had hit another resident (R62) with a plastic bubble wand. At this same date and time R76 stated he had no recollection of this incident.
On 5/1/25 at 11:01 AM, V1, Administrator, confirmed there had been an incident when R76 hit R62 with a plastic bubble wand.
The facility's Initial Incident Report dated 4/3/25 documents an allegation made by a facility Certified Nursing Assistant (V26) that R76 had entered the room of R62, both V26 and R62 told R76 to leave the room but R76 did not comply with the request and picked up an object, later determined to be a plastic bubble wand, and began to hit R62 in the head and face.
On 5/1/25 at 3:40 PM, R62 stated she had no recollection of the incident.
On 5/1/25 at 3:52 PM, V26, Certified Nursing Assistant, stated he was in a resident's room directly across the hall from R62's room when he saw R76 go into R62's room. V26 stated he had called out to R76 to not go into that room, but he could not leave the resident he was providing care to. V26 stated R76 did not comply with his request to not go into the room. V26 stated that R62 likewise told R76 to get out of her room, but again, R76 did not comply. V26 stated R76 then picked an object up from R62's dresser and began to hit R62 on the head and face with it, causing R62 to fall to the floor. V26 stated when he was able to get to R76, the object was a plastic bubble wand. V26 stated he asked a co-worker to report this incident to the nurse (V28) while he monitored R76.
R76's Nurses Note dated 4/3/25 at 1:21 AM, documented by V28, Licensed Practical Nurse, documents R76 struck another resident (R62) in the head with a bubble wand causing injury to R62. R76's Nurses Notes document multiple weekly incidents of R76 being verbally and physically aggressive towards staff.
R62's Nurses Note dated 4/3/25 at 12:15 AM, documented by V28, Licensed Practical Nurse, documents R62 was noted to have a bump on the side of her head measuring 3 centimeters long by 2 centimeters wide by 3 centimeters high and slight purple bruising on her left ear. This note further documents R62 was complaining of dizziness and a headache, with a pain rating of eight out of ten.
SERIOUS
(G)
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 record review and interview, the facility failed to provide a cognitive impaired resident, who required substantial to ...
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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 a cognitive impaired resident, who required substantial to maximum staff assistance, with a safe transfer and toileting. This failure resulted in R57 sustaining two fractures on 3/12/25, that required emergency medical attention and surgical repair. The facility also failed to initiate targeted post-fall interventions to address the root cause of self-toileting. These failures affected one of three residents (R57) reviewed for falls on the sample list of 35.
Findings include:
R57's Minimum Data Set, dated [DATE] documents R57's Brief Interview for Mental Status score was 12 out of a possible 15, indicating moderate cognitive impairment. The same MDS inaccurately (according to V20, MDS/Care Plan Coordinator and V27, Nurse Practitioner below interviews) documents R57 had no falls prior to admission to the facility.
R57's Face Sheet documents his admission date as 3/6/25. The same Face Sheet includes the following diagnoses: Dementia in Other Diseases, Classified Elsewhere, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Other Lack of Coordination, Difficulty in Walking, Not Elsewhere Classified, Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Sites.
R57's admission assessment dated [DATE], documents: R57's Fall Risk Score of 16 (High Risk), using the following fall risk scale: Scoring: 0-5 Total Points equals Low Fall Risk, 6-13 Total Points equals Moderate Fall Risk, greater that 13 Total Points equals High Fall Risk.
R57's Physical Therapy (PT) Evaluation and Plan of Treatment dated 3/6/25 documents R57's diagnoses as follows: Urinary Tract Infection, Site Not Specified, Difficulty in Walking, Not Elsewhere Classified, and Muscle Wasting and Atrophy, not elsewhere classified, Multiple Sites. The same PT evaluation document: R57 required substantial/maximal staff assistance with transfers.
R57's Resident Care Information Certified Nursing Assistants Task sheet dated 3/10/25 directs staff to transfer R57 with one assist, front wheeled walker and to use a gait belt.
R57's Safety - Fall Event report documents R57 fell on [DATE] at 1:00 pm. The same report documents: Staff report resident (R57) noted to be in (on the) floor. Upon arrival, resident noted to be laying on back in (sic) floor, in front of (the) doorway, with (his) head facing (the) doorway and (his) feet facing (the) window. W/C (wheelchair) noted to be parked at foot of bed, facing window. No O2 (oxygen) on. Resident states 'I was trying to go to the bathroom, and I tripped over my heel'. Environment free of clutter. Room well lit. Call light not activated. Non-skid shoes on. Resident c/o (complained of) pain 10/10 (on a scale of 0-10, 10 being the worst pain level on the scale) to left shoulder and left hip, unable to complete ROM (range of motion). Resident states he did not hit his head, neuros (neurological assessment) WNL (within normal limits). VS (vital signs) Temperature:97.6, Pulse:70, Respirations:18, Blood Pressure: 136/72, Oxygen Saturation (blood saturation level): 90% RA (room air), Oxygen placed on resident, at 2 L/min (two liters per minute) (via) NC (nasal cannula). Resident made comfortable on floor. MD (unidentified physician) notified, N.O. (new order). Send to ER (hospital emergency room) for eval (evaluation) and tx (treatment).
The same Safety-Fall Event documents: On 3/12/2025 at 3:36 pm, received call from (local hospital) ER (emergency room), ER (unidentified) nurse states resident has a fractured left shoulder and a fractured left hip and will be transferred to a higher level of care hospital. ER nurse does not know which hospital resident is being sent to at this time but will contact facility as soon as information becomes available. DON/Administrator (V2, Director of Nursing/V1, Administrator) notified.
R57's Regional Level 1 Trauma Center, Acute Care Surgery Service: Emergency Surgery. Trauma, Surgical Critical Care Hospital (hospital, long distance from the facility) record, documents the following: HOSPITAL COURSE: (R57's name and age) who presented on 3/12/2025 at 6:30 PM, as a transfer from (hospital, shorter distance from the facility) after he suffered a mechanical fall at his nursing home. He was found to have left humerus fracture and left femoral neck fracture. A (name brand indwelling urinary catheter) was inserted at the previous hospital prior to transfer. Orthopedic Surgery was consulted and planned for operative intervention the next day.
The same hospital record documents: He (R57) underwent in-situ fixation (surgical repair) of left femoral neck fracture on 3/13/25 with (Orthopedic Surgeon). His humeral fracture is being managed non-operatively with a sling. He is weight-bearing as tolerated to the left lower extremity, and non-weight bearing to the left upper extremity.
On 4/30/25 at 10:40 am V2, DON stated (R57) was not to ambulate unless he was working with therapy. V2, DON also stated V7, Certified Nursing Assistant (CNA) was the staff member that found R57 on the floor post fall.
On 4/30/25 at 10:55 am V7, CNA walked down to the empty room on 400-hall that R57 resided in when he fell 3/12/25. V7, CNA confirmed V2, DON's observation and stated (R57's) head was close to the open door of his room. His feet were directed towards the window where his wheelchair was at. I did not pay attention to if his wheelchair was locked or unlocked. I was focused on the patient (R57). (R57) said he was going to the bathroom when he fell. The bathroom is pretty far from here, where he laid. (approximately 8 feet away). I don't know if he was incontinent at the time of his fall. He was not wet on the outside of his clothes. The last time I saw him, he was in the small dining room eating about a half hour before he fell. I did not take him to the bathroom before lunch. He always took himself. He was independent (per admission and therapy notes above R57 required substantial to maximum staff assistance with transfer) when I worked. He never asked for help. For the most part he was alert and oriented (diagnoses documented above as Dementia). I don't know if he had a history of falls, he had not been here very long (admitted six days prior to the fall).
On 4/30/25 at 12:40 pm V2, Director of Nursing stated (R57) was moved to the room closer to the nursing station when he returned from the hospital post fall (3/12/25). That was the intervention to increase supervision. It makes sense that we should have identified why he was trying to self-transfer. He should have had assistance. He was going into bathroom. His intervention should have included increased toileting, in addition to increasing (R57's) supervision.
On 5/1/25 at 3:30 pm V27, Nurse Practitioner stated I have known (R57) long before he was a resident in the facility. He had numerous falls when he was at home. He had a very unstable gait. He should have had assistance with ambulation, transfers and toileting. He was somewhat impulsive. I was not surprised when I heard he had the fall with the fractures. I did not realize staff were not providing him the assistance he needed. He was admitted to the facility and was receiving PT (Physical Therapy) for strengthening. Yes, he should have been toileted by staff. He was trying to toilet himself, from what I understand, that was the root cause of his fall.
On 5/2/25 at 1:30 pm V20, Minimum Data Set (MDS)/Care Plan Coordinator, stated R57's MDS did not document that R57 had previous falls, because the facility did not have his history when he was admitted [DATE]. He is moderately impaired and did not remember falling prior to admission. Now we know his history. The fall here in the facility 3/12/25 with fractures, is listed (documented) on the MDS because his assessment goes until midnight on 3/12/25.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the dignity of one resident (R68) out of one rev...
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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 one resident (R68) out of one reviewed for dignity in a sample list of 35.
Findings include:
R68's undated Face Sheet documents R68's medical diagnoses as Alzheimer's Disease, Anxiety, Schizoaffective Disorder Bipolar Type, Difficulty in Walking, Abnormal Posture, Violent Behavior, Syncope and Collapse.
R68's Minimum Data Set (MDS) dated [DATE] documents R68 as severely cognitively impaired. This same MDS documents R68 as being dependent on staff for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers.
On 4/29/25 at 2:55 PM, V17 and V18, Certified Nurse Aides (CNAs) were assisting R68 from his room on 700-hall to the shower room on the 100-hall. R68 was reclined back in a mesh slatted shower recliner chair with his left shoulder, left trunk, left buttock and left thigh all visible. R68 was wearing only a thin bath blanket laid over the top of him. Another resident and staff members were sitting at the nurse's station at the same time V17 and V18 pushed R68 by to the shower room.
On 4/29/25 at 2:57 PM V8, Licensed Practical Nurse (LPN), stated the staff will undress R68 in his room and then transport him to the shower room. V8 stated it is too much work for the staff to transfer R68 in the shower room.
On 4/29/25 at 3:45 PM V9, R68's Power of Attorney (POA), stated R68 was a minister his entire life and would not appreciate being unclothed in public. V9 stated R68 has advanced Alzheimer's Disease and is not able to speak for himself but was very modest in his earlier years and would be very embarrassed by being exposed in public.
On 4/30/25 at 11:00 AM, V1, Administrator, stated all residents should be covered appropriately when being transferred to the shower room. V1 stated the 100-hall shower room is large enough to accommodate the total body mechanical lift and the reclining shower chair.
The facility policy titled Resident Rights revised 11/28/2017 documents the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance of enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
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 a Level 2 Pre-admission Screening and Record Review (PASRR) 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 obtain a Level 2 Pre-admission Screening and Record Review (PASRR) for one resident (R46) out of six reviewed for PASRR's in a sample list of 35.
Findings include:
R46's undated Face Sheet documents R46 admitted to the facility on [DATE]. This same face sheet documents R46 was diagnosed with Major Depressive Disorder with recurrent Psychotic Symptoms on 2/5/2025.
R46's Level 1 Preadmission Screen and Record Review (PASRR) dated 6/5/2020 documents R46 does have an Intellectual Disorder (ID).
The facility is unable to provide documentation of a Level 2 PASRR being completed.
On 5/2/25 at 9:00 AM V1 Administrator stated the facility had only been completing the Level 2 PASRR's with a significant change. V1 Administrator stated she was not aware that the facility needed to complete a Level 2 PASRR with anyone with an Intellectual Disability (ID). V1 Administrator stated the facility will be obtaining this Level 2's from this point forward.
The facility policy titled Pre-admission Screening and Resident Review (PASRR) adopted 2/17/25 documents the facility will complete a Level 1 PASRR and a Level 2 PASRR if required. Residents with Mental Illness (MI) diagnoses or Psychotropic medications may have a determination indicating that a PASRR Level 2 is required. If this is indicated, the facility shall ensure that any recommendations identified on the Level 2 screen have been incorporated into the care plan. The facility shall resubmit a PASRR for any resident who has had a significant change in status, as identified through the Minimum Data Set (MDS) process, received an order for a first-time psychotropic medication, and/or receives a new MI diagnosis.
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 transcribe the complete physician order of the oxygen rate to be administered, and failed to ensure a Licensed nurse administer...
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Based on observation, interview and record review the facility failed to transcribe the complete physician order of the oxygen rate to be administered, and failed to ensure a Licensed nurse administered the oxygen. This failure affects one of one resident (R185) reviewed for oxygen administration on the sample list of 35.
Findings include:
R185's Physician Order Report sheet (POS) dated 5/1/25 documents the following diagnosis: Pneumonia, Unspecified Organism (Primary, admission Diagnosis, 4/22/25), Emphysema, Unspecified, and Viral Pneumonia, Unspecified, and Pressure Ulcer of Sacral Region, Stage II.
R185's same POS documents: O2 (oxygen) at ______ (left blank) L (liters) nasal cannula continues for SOB (Shortness of Breath).
On 5/1/25 at 2:00 pm V3, Registered Nurse/Wound Nurse (RN), and V7, Certified Nursing Assistant (CNA) performed hand hygiene, donned gowns and gloves and entered R185's room to provide R185's pressure ulcer treatment. R185 laid in bed with an oxygen nasal cannula prong in his nares. R185's oxygen concentrator was not turned on for R185's oxygen administration. V7, CNA, stated (R185) asked for his oxygen when he laid down. I put the nasal cannula on him. I just forgot to turn on the concentrator. R185 then stated Yeah, there is nothing coming out. V7, CNA, walked over to R185's oxygen concentrator, turned it on to deliver the oxygen, and V7, CNA set the rate of oxygen to be dispensed at two liters per minute. R185 then stated That is better, you can see the bubbles in the water bottle. Now, I am getting air. V3, RN stated to V7, CNA, from the opposite side of R185's bed, Two liters (of oxygen per minute) is correct.
On 5/2/25 at 9:15 am V1, Administrator/ RN provided the facility oxygen administration policy and stated she will scan the policy to this surveyor. V1 confirmed R185's oxygen order should have included the rate of oxygen to be delivered. V1 also stated Only licensed Nurses are to administer oxygen. It is the standard of practice, and our policy.
The facility policy Oxygen Therapy and Safety dated 04/09/20 documents: It is the policy of this facility to provide a safe environment for residents, staff, and the public.
Purpose: To provide a source of oxygen to persons experiencing an insufficient supply of same and to address the use and storage of oxygen and oxygen equipment. The same policy documents: Licensed Nurses are to administer residents' oxygen, and a Physician order will provide the following information: when to use, how often, liter flow, and whether to use cannula or mask.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain a residents call light and bedside table withi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain a residents call light and bedside table within reach, resulting in a delay in pain medication administration.
This failure affected one of two residents (R189) reviewed for pain on the sample list of 35.
Findings include:
R189's Face Sheet documents R189 was admitted to the facility 4/14/25 with the following diagnoses: Pain, Unspecified, Age-related Osteoporosis Without Current Pathological Fracture, Difficulty in Walking, Not Elsewhere Classified, Other Lack of Coordination, and Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Sites.
R189's Minimum Data Set, dated [DATE] documents the following: R189's Brief Interview of Mental Status score as 14 out of a possible 15, indicating no cognitive impairment.
R189's current Physician Order Report sheet (POS) documents the following medication order: Tramadol - Schedule IV (Narcotic pain medication) tablet; 50 mg; Amount to Administer: 1/2 tablet (25 mg); oral, twice A Day - PRN (as needed) Pain.
On 04/29/25 at 12:20 pm R189 was seated in a bedside chair. R189 stated the only issue R189 has had since admission 4/14/25, was that one night in the past week (later identified as night shift 4/27/25) she laid in bed for hours with her leg hurting really bad. R189 stated the call light was not within reach and R189 tried to yell out for help, but her voice was too soft, no one heard her. R189 also said she does not have a roommate to call to assist R189 and laid in pain for hours. She stated she reported this incident that same morning (4/28/25) to a nurse, (later identified as V13, Registered Nurse), and was reassured this would never happen again.
R189's Medication Administration Record (MAR) documents V13, Registered Nurse (RN)administered R189's Tramadol narcotic pain medication, on April 28 at 6:56 am. V13, RN did not document the level of pain R189 had experienced.
On 4/30/25 at 2:55 pm V13, RN stated (R189) told me at breakfast that she (R189) had a bad night and was having leg pain. She (R189) said the call light and bedside table were out of her reach and she could not get a hold of staff. I do not remember off the top of my head what her pain level was. I did not chart it and should have. She (R189) is alert and oriented x4 (person, place, time and situation). She said her call light and bedside table were out of reach, overnight, she was hurting and needed staff. She was up in the dining room when I talked to her. I told (V15, Certified Nursing Assistant) to make sure both were in reach.
On 4/30/25 at 3:00 pm V15, CNA confirmed she had been informed R189's bedside table and call light were out of reach. V15, CNA stated she passed this information on in report to V16, Agency CNA night shift 4/28/25.
On 4/30/25 at 3:10 pm, V16, Agency CNA, confirmed she had been informed R189's bedside table and call light were out of reach overnight 4/27/25. V16 stated she worked 4/27/25 on R189's hall, night shift with another (unidentified CNA). V16 stated the other CNA provided R189's last round of toileting. V16, CNA stated Everybody's call light should be within reach at all times.
On 5/1/25 at 3:30 pm V27, Nurse Practitioner stated She (R189) has Tramadol for pain. I had not heard from her or staff that (R189's) call light and bedside table were not available to her. This is a given. She could have used the call light to alert the nurse. She should not have had to wait until morning if she was having pain overnight.
The facility Call Light policy dated 01/2004 documents: Objective: is to respond to residents request and needs.
The facility policy Pain Management dated 03/03/2022 documents the following: Policy:
The Facility is dedicated to the philosophy that all residents should be as free of pain as possible, through a combination of medical intervention and functional therapy.
Purpose: To identify residents experiencing pain to establish control of pain to the resident's satisfaction and to relieve related symptoms. The same policy documents the facility will assess residents' level of pain every shift and document the residents level of pain using the standard pain scale of one to ten with ten being the highest level of pain.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
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 behavioral health services, failed to provide b...
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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 behavioral health services, failed to provide behavioral services training, and failed to prevent minor injuries for one (R68) resident out of two reviewed for behavioral health in a sample list of 35.
Findings include:
The Facility assessment dated [DATE] documents the facility has admitted 64 residents prescribed Antipsychotic Medications, and admitted 39 residents with Behavioral Health Care Needs, in the previous year.
R68's undated Face Sheet documents R68 admitted to the facility on [DATE]. This same Face Sheet documents R68's medical diagnoses as Alzheimer's Disease, Anxiety, Schizoaffective Disorder Bipolar Type, Difficulty in Walking, Abnormal Posture, Violent Behavior, Syncope and Collapse.
R68's Minimum Data Set (MDS) dated [DATE] documents R68 as severely cognitively impaired. This same MDS documents R68 as being dependent on staff for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers.
R68's Care Plan intervention dated 4/3/24 instructs staff when (R68's) physical behaviors occurs, ensure safety and re-approach at a later time utilizing a different staff member.
R68's Nurse Progress Note dated 2/15/25 at 9:03 PM documents R68 was combative with staff during bedtime cares, where R68 was attempting to strike staff, and subsequently acquired 2.0 centimeters (cm) long by 2.0 cm wide skin tear on R68's right forearm when he made contact with mobility equipment. This same note documents staff applied pressure to R68's right forearm to control bleeding.
R68's Nurse Progress Note dated 3/18/25 at 6:22 AM documents R68 has four skin tears. Three of R68's skin tears are V shaped and measure 2.0 cm wide by 1.0 cm wide to right forearm. This same note documents R68 was physically combative when staff assisted R68 for a transfer.
R68's Nurse Progress Note dated 4/29/25 at 2:50 PM documents R68 was combative when staff were getting him undressed for his shower in his room. This same note documents R68 received a L shape skin tear measuring 2.0 cm wide by 1.5 cm long.
On 4/30/25 at 11:35 AM, V3, Registered Nurse (RN)/Wound Nurse/Infection Preventionist (IP), stated R68 received injuries on 2/15/25, 3/18/25 and 4/29/25 from staff while cares were provided. V3 stated R68 can be combative during care times. V3 stated she was not aware of R68's skin tear on 2/15/25. V3 stated there were not any events opened for either of these two incidents (2/15/25 and 3/19/25). V3 stated the staff should open an event if there is any injury and that way, she is alerted to follow up with a skin evaluation, notifications and orders for treatment if needed. V3 stated those two incidents were never followed up on due to V3 was not aware of the incidents.
On 4/30/25 at 3:00 PM, V17 Certified Nurse Aide (CNA), stated R68 was combative when she was assisting R68 in removing his clothes to get ready for his shower. V17 stated R68 was laying in bed when V17 attempted to remove R68's shirt. V17 stated she had to get R68 ready for his shower when R68 became combative. V17 stated she pushed R68's arm out of his shirt sleeve and R68 got a skin tear on the top of his left hand because he was being combative. V17 stated she should have walked away and tried later or asked someone else to help R68.
On 5/2/25 at 9:45 AM, V2, Director of Nurses (DON), stated the facility did not have any Psychiatric services prior to February 2025 when V30 Psychiatric Nurse Practitioner (NP) started seeing residents from this facility. V2 stated R68 has not yet been seen by V30 Psychiatric NP. V2 stated R68 has had behaviors since his admission in February 2024. V2 stated the facility staff has not had any training on behavioral health and/or ways to provide care for residents with behaviors.
The facility policy titled Pre-admission Screening and Resident Review (PASRR) adopted 2/17/25 documents the facility will complete a Level 1 PASRR and a Level 2 PASRR if required. Residents with Mental Illness (MI) diagnoses or Psychotropic medications may have a determination indicating that a PASRR Level 2 is required. If this is indicated, the facility shall ensure that any recommendations identified on the Level 2 screen have been incorporated into the care plan. The facility shall resubmit a PASRR for any resident who has had a significant change in status, as identified through the Minimum Data Set (MDS) process, received an order for a first-time psychotropic medication, and/or receives a new MI diagnosis.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to transmit (submit) Minimum Data Set Resident Assessment Instruments ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to transmit (submit) Minimum Data Set Resident Assessment Instruments to the Centers for Medicare and Medicaid within the required time frames. This failure affects five residents (R18, R49, R52, R54, and R58) out of five reviewed for Minimum Data Set transmission on the sample list of 35.
Findings include:
1. R58's Minimum Data Set (MDS) dated with an Assessment Reference Date (ARD) of 2/21/25 was documented on the facility's CMS (Centers for Medicare and Medicaid) Submission Report dated 4/29/25, documenting R58's MDS was submitted on 4/29/25.
2. R52's MDS dated with an ARD of 2/4/25 was documented on the facility's CMS Submission Report dated 4/29/25, documenting R52's MDS was submitted on 4/29/25.
3. R49's MDS dated with an ARD of 2/18/25 was documented on the facility's CMS Submission Report dated 4/23/25, documenting R49's MDS was submitted 4/23/25.
4. R18's MDS dated with an ARD of 2/18/25 was documented on the facility's CMS Submission Report dated 4/29/25, documenting R18's MDS was submitted 4/29/25.
5. R54's MDS dated [DATE] was documented as In Process on 4/30/25, documenting this MDS was not yet completed or transmitted.
On 4/30/25 at 3:15 PM, V20, Minimum Data Set Coordinator, confirmed she had just submitted (transmitted) MDSs for R58, R52, and R18 on 4/29/25. V20 further confirmed she had submitted R49's MDS on 4/23/25. V20 stated the MDS for R54 was not yet completely coded into a form to be able to be submitted to CMS. V20 then stated and confirmed that there is a timing process for the MDS in which was there is an allowance for 14 days after the ARD to do the actual assessment of the resident, another 7 days to have the MDS electronically coded in a form to be able to be transmitted, and another 7 days to transmit (submit) the MDS to CMS. V20 concluded by stating R58's MDS should have been transmitted by 3/21/25, R52's MDS should have been transmitted by 3/4/25, R49's and R18's MDS should have been transmitted by 3/18/25, and R54's MDS should have been transmitted by 4/8/25.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R12's Face Sheet dated 5/1/25 documents R12 was admitted to the facility 12/31/18.
R12's original Interagency Certification o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R12's Face Sheet dated 5/1/25 documents R12 was admitted to the facility 12/31/18.
R12's original Interagency Certification of Screening Results (Level 1 PASRR) dated 12/27/18 documents no reasonable basis to suspect R12 had any mental illness or developmental disability diagnoses.
R12's Face Sheet dated 5/1/25 documents R12 was diagnosed with Psychotic Disorder with Delusions (severe mental illness) on 5/28/19.
There was no Level 2 PASRR in R12's comprehensive medical record.
3. R26's Face Sheet dated 5/1/25 documents R26 was admitted to the facility 11/14/19 under hospice services, and did not require a Level 1 PASRR. This same Face Sheet documents R26 was diagnosed with Bipolar Disorder (severe mental illness) on 7/6/20.
R26's original Interagency Certification of Screening Results dated 12/30/20, after R26 no longer required hospice services, documents there was no reasonable basis to suspect R26 had a mental health or developmental disability diagnosis.
There was no Level 2 PASRR in R26's comprehensive medical record.
4. R45's Face Sheet dated 5/1/25 documents R45 was admitted to the facility 9/13/21.
R45's original Interagency Certification of Screening Results dated 9/13/21 documents no reasonable basis to suspect R45 had a mental illness or developmental disability diagnosis.
R45's Face Sheet dated 5/1/25 documents R45 was diagnosed with Psychosis (severe mental illness) on 2/29/24.
There was no Level 2 PASRR in R45's comprehensive medical record.
On 4/30/25 at 10:45 AM, V19, Business Office Manager, stated the facility staff had received training from the (screening agency) back in 2023, when this new PASRR process started, who told the facility staff to do a PASRR on the new residents coming into the facility. V19 further stated the (screening agency) never said anything about doing a PASRR Level 2 on the people who were already in the building.
On 5/1/25 at 11:01 AM, V1. Administrator stated she has become aware of the lack of obtaining Level 2 PASRR's and is understanding the Level 2 needs to be completed for residents with a mental health diagnosis. V1 further stated the facility will be doing the Level 2 PASRR going forward.
Based on interview and record review the facility failed to obtain a Level 2 Pre-admission Screening and Record Review (PASRR) for four (R12, R26, R45, R68) residents out of six reviewed for PASRR in a sample list of 35.
Findings include:
1. R68's undated Face Sheet documents R68 admitted to the facility on [DATE].
R68's Pre-admission Screening and Record Review (PASRR) dated 1/26/24 documents R68 did not require a Level 2 PASRR.
R68's Face Sheet documents R68 was diagnosed with Schizoaffective Disorder, Bipolar type on 10/16/2024.
The facility was unable to provide documentation of a Level 2 PASRR being completed after R68 was diagnosed with a new mental health disorder on 10/16/2024.
On 4/30/25 at 3:00 PM V19 Business Office Manager (BOM) stated the facility did not complete a Level 2 PASRR for R68. V19 stated V19 was under the impression after admission a Level 2 PASRR would only be completed if the resident had a significant change.
On 5/2/25 at 9:00 AM V1 Administrator stated the facility had only been completing the Level 2 PASRR's with a resident's significant change. V1 Administrator stated she was not aware that the facility needed to complete a Level 2 PASRR with any resident who is diagnosed with a Mental Illness after admission. V1 Administrator stated the facility will be obtaining this Level 2's from this point forward.
The facility policy titled Pre admission Screening and Resident Review (PASRR) adopted 2/17/25 documents the facility will complete a Level I PASRR and a Level 2 PASRR if required. Residents with Mental Illness (MI) diagnoses or Psychotropic medications may have a determination indicating that a PASRR Level 2 is required. If this is indicated, the facility shall ensure that any recommendations identified on the Level 2 screen have been incorporated into the care plan. The facility shall resubmit a PASRR for any resident who has had a significant change in status, as identified through the Minimum Data Set (MDS) process, received an order for a first-time psychotropic medication, and/or receives a new MI diagnosis.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R16's Minimum Data Set, dated [DATE] documents R16 has an Indwelling Urinary Catheter for the diagnoses of Obstructive Uropat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R16's Minimum Data Set, dated [DATE] documents R16 has an Indwelling Urinary Catheter for the diagnoses of Obstructive Uropathy.
R16's current Physician Order Sheet documents the following: (name brand indwelling urinary) catheter care Q (every) shift.
R16's Urine Bacteria Culture laboratory report dated 01/17/25 that documents the following urinary tract infection: Klebsiella Pneumoniae (Multi-drug Resistant Organism) equal or greater than 100,000 colony forming units per milliliter and Methicillin Resistant Staphylococcus Aureus (Multi-drug Resistant Organism) equal or greater than 100,000 colony forming units per milliliter.
On 5/2/25 at 11:20 am, V33, Certified Nursing Assistant (CNA), with V2, Director of Nursing (DON), entered R16's room. V2 was present to provide R16 assistance with positioning while V33, provided indwelling urinary catheter care. R16 had a bedside, indwelling urinary catheter drainage bag, that hung from R16's bed frame. R16 had cloudy, beige sediment adhering to the inside of the indwelling catheter tubing. R16 was assisted to a back lying position with R16's legs separated. R16's urinary catheter insertion site, at the tip of the penis and the extending catheter, approximately two inches down on the external indwelling catheter tube, was soiled with dried, crusted, yellow and light brown body fluid. V33, removed her gloves after positioning and washed her hands in the bathroom. V33 donned new gloves and cleaned R16's upper inner thighs and sides of R16's testicles using disposable wipes. V33 again washed her hands and donned new gloves. V33 then used disposable wipes, and swiped R16's penis repeatedly from the base up his penis shaft, up and over the opening at the catheter insertion site, cross contaminating tip of R16's penis and catheter. V33 then used a disposable wipe with one swipe, to clean the indwelling catheter external tube, from R16's insertion site down to the junction with the bedside drainage bag tubing. V33 removed her gloves, washed her hands, donned new gloves and assisted V2 in repositioning R16 to a side lying positron. V33 repeated hand hygiene and re-gloving appropriately and V33, cleaned feces off of R16's buttocks and buttocks crease. R16 was then repositioned by V2 and V33 to a back lying position. As V33 began to pull R16's blankets up over R16, V33 confirmed she had completed R16's indwelling urinary catheter and incontinence care. This surveyor then asked V33 if she could see the external indwelling urinary catheter remained soiled with the dried, crusted, yellow and light brown body fluid. V33 confirmed R16's catheter remained soiled.
On 5/2/25 at 11:40 am V2, DON stated I saw (V33, CNA) cleansed (R16's) penis in the wrong direction (towards, instead of away from the meatus). I know you wrote it down. Yes, that is cross contamination. I think she (V33, CNA) was just nervous.
Based on observation, interview and record review the facility failed to prevent cross contamination during indwelling urinary catheter care for two (R16, R65) residents, and incontinence care for one (R68) resident out of four reviewed for incontinence care in a sample list of 35.
Findings include:
1. R65's Minimum Data Set (MDS) dated [DATE] documents R65 as cognitively intact. This same MDS documents R65 is dependent on staff for toileting, dressing, bathing, bed mobility, personal hygiene and transfers.
R65's Physician Order Sheet (POS) dated May 2025 documents a physician order to provide urinary catheter care every shift.
R65's Physician Order Sheet (POS) dated May 2025 documents a physician order starting 4/21/25 to insert a indwelling urinary catheter monthly and as needed. R65's face sheet documents a diagnosis of Neuromuscular Dysfunction of the Bladder on 4/17/2024.
On 4/30/25 at 2:30 PM, V17 and V18, Certified Nurse Aides (CNAs) completed perineal and indwelling urinary catheter care for R65. R17 CNA did not change her gloves nor use hand hygiene after providing frontal perineal care before providing R65's rear perineal care. R65's indwelling catheter drainage bag cover fell to the floor as V17 and V18 were repositioning R65. V17 picked up R65's urinary drainage bag cover and placed it back over R65's urinary drainage bag. V17 and V18 did not apply barrier cream after providing perineal care for R65.
On 4/30/25 at 2:50 PM, V17, Certified Nurse Aide (CNA), stated she should have changed her gloves and completed hand hygiene between cleansing R65's front and rear perineal areas. V17 stated barrier cream should have been applied.
On 4/30/25 at 3:10 PM, V2, Director of Nurses (DON), stated the staff should change their gloves when moving from one area to another if the gloves become contaminated. V2 stated V17 should have changed her gloves, provided barrier cream and obtained a new drainage dignity cover. V2 stated the facility has 'tons of dignity bags' and it is encouraged to keep them off of the floor due to infection control purposes. V2 stated the facility does not have a policy for the dignity bags but it is the expectation that staff do not put contaminated products over a urinary drainage bag.
The facility policy titled Catheter Care revised June 2005 documents staff should remove gloves and wash hands after providing catheter care.
The facility policy titled Perineal Care revised November 2018 documents staff should apply skin care product after completion of perineal care.
2. R68's Minimum Data Set (MDS) dated [DATE] documents R68 as severely cognitively impaired. This same MDS documents R68 as being dependent on staff for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers.
R68's Care Plan intervention dated 4/3/24 instructs staff when (R68's) physical behaviors occurs, ensure safety and re-approach at a later time utilizing a different staff member.
On 5/1/25 at 10:35 AM, V31 and V32, Certified Nurse Aides (CNAs), provided incontinence care for R68. R68 was incontinent of bladder and bowel. V32 cleansed urine and bowel movement from R68's buttocks, then applied a clean incontinence brief to R68 without changing gloves and/or using hand hygiene.
On 5/1/25 at 10:50 AM, V32 Certified Nurse Aide (CNA), stated she should have removed her gloves after providing incontinence care and prior to applying a clean incontinence brief.
On 5/1/25 at 11:15 AM, V2, Director of Nurses (DON), stated hand hygiene should be performed after providing incontinence care and applying a new brief.
Jun 2024
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to report an allegation of verbal and physical abuse of a resident by a staff member to the Abuse Coordinator. This failure affects one (R1) re...
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Based on interview and record review the facility failed to report an allegation of verbal and physical abuse of a resident by a staff member to the Abuse Coordinator. This failure affects one (R1) resident reviewed for abuse on the sample list of 35.
Findings include:
R1's undated Face Sheet documents R1's medical diagnoses of Postural Kyphosis, Hypertension, Anxiety Disorder, Altered Mental Status, Dysuria, Overactive Bladder, Open Angle Glaucoma, Corneal Edema and Macular Degeneration.
R1's Abuse Investigation dated 4/12/24 documents V29 (R1's Power of Attorney/POA) alleged that V28 Certified Nurse Aide (CNA) was 'rough' with R1 during cares, yelled at and was rude to R1 and left R1 in wet clothes after providing a shower to R1.
On 6/6/24 at 11:50 AM V1 Administrator stated V1 was made aware of this incident on 6/6/24. V1 Administrator stated I never knew anything about this. It was not reported because this is the first, I am hearing about it. I will report it now.
On 6/6/24 at 12:00 PM V2 Director of Nurses (DON) stated V28 Certified Nurse Aide (CNA) was given a written warning after R1's family complained about his care for R1. V2 stated there was an investigation done at that time and V28 CNA was suspended. V2 DON stated V28 was also on vacation, so the suspension overlapped V28's vacation time. V2 DON stated V28 was not in the facility until the investigation was completed.
The facility policy titled 'Abuse Prohibition and Reporting' revised 11/28/2019 documents the facility employee or agent who becomes aware of alleged abuse or neglect of a resident should immediately report the matter to the facility Administrator or designee. If the allegation involves the Administrator, then the facility employ or agent should immediately report the matter to the facility Director of Nurses (DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to follow physician orders one (R339) resident reviewed for infection in the sample list of 35 residents.
Findings include:
R339's undated Fac...
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Based on interview and record review, the facility failed to follow physician orders one (R339) resident reviewed for infection in the sample list of 35 residents.
Findings include:
R339's undated Face Sheet documents R339's diagnosis as: Enterocolitis due to Clostridium Difficile, not specified as recurrent.
R339's Care Plan dated 5/24/24, documents administer antibiotics as ordered.
R339's Discharge Documentation dated 5/23/24, documents R339 discharged on 5/23/24. This same discharge documents R339's Primary Discharge Diagnosis as Clostridium Difficile.
R339's Patient Discharge Instructions dated 5/23/24, documents Fidaxomicin 200 milligrams (mg) oral tablet 1 tablet oral two times a day for ten days; last dose 5/23/24 AM, next dose 5/23/24 PM.
R339's Medication Administration Record (MAR) dated 5/23/24 - 6/7/24, documents Dificid (fidaxomicin) 200 mg tablet by mouth twice a day. This same MAR documents this antibiotic as not given on 5/23/24 PM dose as it documents on the discharge instructions to be given; not given on 5/26/24, twice a day; and 5/27/24 not given the AM dose.
On 6/7/24, V3 Registered Nurse (RN) stated it look like Dificid (fidaxomicin) was not given to R339 on 5/23/24, PM dose, not given at all on 5/26/24, not given on 5/27/24 AM dose, not given on 5/29/24 AM dose. V3 stated the nurses should follow the physician orders and give medications as ordered.
The facility's Medication Administration Policy dated Revised 2/04, documents to provide the resident with medications deemed necessary by the physician to improve/stabilize specified diagnoses of the resident.
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 prevent cross contamination during urinary catheter ca...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to prevent cross contamination during urinary catheter care for one (R55) resident out of four residents reviewed for Catheter Care in a sample list of 35 residents.
Findings include:
R55's undated Face Sheet documents R55's medical diagnoses as Parkinson's Disease, Malignant Neoplasm of Prostate, Bladder-Neck Obstruction, Emphysema, Macular Degeneration, Muscle Wasting and Atrophy, Weakness, and history of Traumatic Subdural Hemorrhage with loss of conscious and Shortness of Breath
R55's Physician Order Sheet (POS) dated June 2024 documents a physician order to provide urinary catheter care every shift.
R55's Minimum Data Set (MDS) dated [DATE] documents R55 as cognitively intact. This same MDS documents R55 as dependent on staff for bathing, personal hygiene, and toileting.
On 6/6/24 at 10:30 AM V11 Certified Nurse Aide (CNA) completed urinary catheter care for R55. V11 CNA wore the same pair of gloves through the entire procedure. V11 CNA did not change gloves nor use hand hygiene after contaminating gloves with stool and then cleaning R55's urinary catheter tubing. V11 CNA swiped back of V11's Right Hand in R55's stool causing visible layer and streaks of stool on back of V11's Right Hand. V11 CNA then used contaminated gloves to provide urinary catheter care for R55.
On 6/6/24 at 10:40 AM V11 Certified Nurse Aide (CNA) stated V11 should have changed gloves after providing bowel incontinence care and catheter care for R55.
On 6/6/24 at 11:00 AM V9 Infection Preventionist (IP) stated hand hygiene is an important part of reducing the risk of infections. V9 IP stated staff should always change gloves when gloves become contaminated. V9 IP stated R55 could be at a higher risk of infection due to improper urinary catheter care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to complete Psychotropic Medication Assessments for two of five (R43, R343) residents reviewed for Unnecessary Medications in the sample list o...
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Based on interview and record review the facility failed to complete Psychotropic Medication Assessments for two of five (R43, R343) residents reviewed for Unnecessary Medications in the sample list of 35.
Findings Include:
The Psychopharmacological Drug Usage Procedure dated 10/18/17 documents a Psychopharmacological Drug is a medication used for managing behavior, stabilizing mood, or treating psychiatric disorders. Residents using psychopharmacological medications must have an initial assessment with quarterly reassessments to provide a data base for the Care Plan and Gradual Dose Reduction Program.
1. R43's Face Sheet dated June 2024 documents R43 is diagnosed with Dementia with Behavioral Disturbances and Depression.
R43's Physician Order Sheet dated June 2024 documents R43 is prescribed Citalopram (Antidepressant) 15 milligrams daily and Olanzapine (Antipsychotic) 2.5 milligrams daily.
On 6/6/24 at 3:30 PM V3 Registered Nurse (RN) Nurse Manager confirmed R43 has not had a Psychopathological Observation (Assessment) in the last year.
2. R343's Face Sheet dated June 2024 documents R343 is diagnosed with Depression and Generalized Anxiety.
R343's Physician Order Sheet dated June 2024 documents R343 is prescribed Buspar 15 milligrams twice per day and Citalopram 20 milligrams daily.
On 6/6/24 at 3:30 PM V3 Registered Nurse (RN) Nurse Manager confirmed R343 has not had an Initial Psychopathological Observation (Assessment). R343 was admitted on the medications and should have has an assessment on admission.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
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 meals at a palatable temperature for two resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide meals at a palatable temperature for two residents (R51, R52) out of two residents reviewed for meal service in a sample list of 35 residents.
Findings include:
The facility dietary spreadsheet titled 'Week at a Glance Week One' documents the lunch meal for 6/5/24 consisted of beef cutlet with gravy, baked potato with sour cream and margarine, copper penny salad, bread and margarine, Jello cake with whipped topping and a beverage.
1.) R51's Minimum Data Set (MDS) dated [DATE] documents R51 as cognitively intact.
R51's Physician Order Sheet (POS) dated June 2024 documents a physician order for a regular consistency diet.
On 6/5/24 at 12:29 PM R51 stated the food is cold. R51 stated By the time the food gets to my room it is cold. I don't like eating in the dining room like cattle. The gravy on today's meat was ice cold. I tried one bite and that was enough.
On 6/5/24 at 12:00 PM V24 walked R51's lunch meal from holding bin sitting at entrance of hall to R51's room (four rooms down from holding bin) without a cover over food.
On 6/5/24 at 12:30 PM R51 was sitting in her recliner chair in her room. R51's ate approximately 10% of her lunch. R51 had taken one bite out of her beef cutlet with gravy.
2.) R52's Minimum Data Set (MDS) dated [DATE] documents R52 as moderately cognitively intact.
R52's Physician Order Sheet (POS) dated June 2024 documents a physician order for a regular consistency diet.
On 6/5/24 at 12:00 PM V24 walked R52's lunch meal from holding bin sitting at entrance of hallway to R52's room (five rooms down from holding bin) without a cover over food.
On 6/5/24 at 12:32 PM R52 was sitting in her wheelchair in her room. R52 ate approximately 25% of her lunch meal. R52 had taken two bites out of her beef cutlet with gravy.
On 6/5/24 at 12:33 PM R52 stated My food is usually cold. That gravy was as cold as ice. I don't eat cold food. They (staff) should know better.
On 6/5/24 at 12:40 PM V24 [NAME] stated the staff do not cover the residents food trays when delivering the meals to the residents. V24 stated That would be a good idea. There are usually some residents who complain the food is cold.
On 6/6/24 at 2:45 PM V3 Nurse Manager stated the resident's meal trays should be covered when the staff are carrying the food trays from the holding bin to the resident rooms. V3 stated the food would likely be cold if it is not kept covered. V3 Nurse Manager stated I don't think there is a policy on this, but it would just make sense. That way the residents would complain less about getting served cold food.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
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 serve a modified diet as ordered for one (R41) of six ...
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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 serve a modified diet as ordered for one (R41) of six residents reviewed for dining on the sample list of 35.
Findings include:
R41's Minimum Data Set, dated [DATE] documents R41 has severe cognitive impairment.
R41's Physician Order Sheet documents R41's diet order start date was 7/22/22 as follows: Diet is to be liquidized with nectar thick liquids.
On 6/5/24 at 12:00 PM, R41 being fed by V13, Certified Nursing Assistant (CNA). V13, CNA feed R41 by pouring R41's pureed liquidized foods by nosey cups into R41's mouth. The pureed food was pureed then thickened to a nectar consistency. R41's meal consisted of a beef cutlet with gravy, mashed potatoes and strawberry cake, and thickened nectar consistency beverages. R41's also had watered down-like tomatoes soup, un-thickened. V13, CNA fed R41 the watered down like tomatoes soup via a nosey cup. R41 started coughing, immediately and repeatedly. V10, Licensed Practical Nurse/Minimum Data Set Coordinator who was across the table assisting another resident. V10 directed V13, CNA to 'give R41 a break'. V13 stopped feeding R41 who continued to cough repeatedly for several minutes.
On 6/5/24 at 12:35 PM V13, CNA stated I stopped giving her (R41) the tomatoes soup. That is what she was choking on. It was too thin. The kitchen is supposed to thicken (R41) drinks before we serve them.
On 6/6/24 at 9:38 am V24, cook stated I was training (V25, Cook) yesterday. (R41) gets tomatoes soup instead of some vegetables. (R41) is the only resident that received the tomatoes soup yesterday. (V25) prepared (R41's) soup, but I will take full responsible for not thickening it. I know it was supposed to be and I missed it when training (V25).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
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 honor residents' right to dignity by failing to provid...
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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 honor residents' right to dignity by failing to provide timely toileting needs for a resident and by staff talking amongst themselves throughout residents' meal service, while providing feeding assistance to residents. These failure affected seven residents (R5, R27, R30, R41, R46, R62 and R80) out of 35 residents reviewed for dignity on the sample list of 35.
Findings Include:
1.) On 6/4/24 at 11:30 am, R62 stated she uses a bedpan. Staff has to help her, and she waits for long periods to go, and has to hold it. If they don't come quick enough R62 (voids of bowel and bladder) in the bed, then staff have to clean her up.
R62's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 13 out of a possible 15, indicating no cognitive impairment. The same MDS documents R62 is always continent of bowel and bladder.
R62's Care Plan dated 05/05/2024 documents the following: (R62) requires assistance of 2 (two) staff for transfers, ambulation, and bed mobility due to decreased strength. Category: Activities of Daily Living Functional Status/Rehabilitation Potential The same Care plan documents: (R62) will ambulate to bathroom, in her room utilizing staff assist x 2 (x/times two staff) and FWW (front wheeled walker).
On 6/5/24 at 11:20 am R62 was lying in a bariatric bed. V62 stated she cannot reposition herself without staff assistance. R62 then stated I really hate to lay in (bladder and bowel excretions). It has happened repeatedly where I am left laying in it. I haven't wet the bed since I was a child. This is terribly humiliating. I can't tell you how bad it makes me feel. R62 also stated I have told the CNA's and nurses that this is unacceptable. It falls on deaf ears. I have had to wait close to an hour, dirty (soiled in incontinence).
On 6/6/24 at 12:45 am V1, Administrator/ Registered Nurse stated V1 is aware R62 has verbalized Certified Nursing Assistants have delayed answering R62 call light. V1 also stated I don't think anyone would want to lay in bed soiled, for any length of time. Yes, this is a dignity issue.
The facility policy Call Light dated revised: January 2004 documents the following:
Objectives: 1. To respond to resident's request and needs.
Equipment: 1. Functioning call light.
Procedure:
Key Points:
1. Answer call light promptly.
2.
Knock before entering room.
3.
Turn off call light.
4.
Listen to resident's request. Do not make him/her feel that you are too busy to help.
5.
Respond to request. If item is not available, or request questionable, get assistance from nurse. Return to resident with prompt reply.
2.) R5's Minimum Data Set (MDS) dated [DATE] document R5 has severe cognitive impairment.
R27's MDS documents dated 5/22/24 R27 has severe cognitive impairment.
R30's MDS dated also 5/22/24 documents R30 has severe cognitive impairment.
R41's MDS dated [DATE] documents R41 has severe cognitive impairment.
R46 MDS dated [DATE] documents R46 has severe cognitive impairment.
R80's MDS dated [DATE] documents R80 has severe cognitive impairment.
On 6/5/23 at 12:12 PM - 12:20 PM V10, MDS Coordinator/Licensed Practical Nurse (LPN) sat down to provide feeding assistants to R46. V10, talked to V13, Certified Nursing Assistant (CNA) who was providing feeding assistance to R41, and V16, CNA was providing feeding assistance for R46. V10, MDS Coordinator/LPN, V13 CNA and V16 CNA engaged in conversation with each other about their off-work activities. V10, V13 and V16 would intermittently pause from personal conversations to give short directions to the residents, (i.e drink, open your mouth, bite). R5 slept at the table after limited offers by V10, to take a bite of food.
On 6/5/24 at 12:25 PM -12:30 V13, CNA and V16, CNA remained at the first table providing feeding assistance. V16, CNA was assisting R46. V13, CNA continued to assist R41. R5 remained asleep at the table. At a second table in the main dining room, approximately, six feet away from the first assisted dining table, V9, Registered Nurse (RN), was providing assistance to R30, and V15, CNA was feeding R80. V8, CNA, V9, RN, V15, CNA talked across the room to the staff at the first table still assisting residents to dine. The staff were loud and spoke minimally to the residents and continued to speak of events outside/unrelated to the facility or resident care.
On 6/5/24 at 12:40 PM V10, LPN acknowledged staff were engaged in personal conversations and should have been talking to the residents.
3.) On 6/6/24 at 12:20 PM -12:35 PM at the first table, in the main dining room V11, CNA was providing feeding assistance to R46. V27, CNA was providing feeding assistance to R5, V9 RN was providing feeding assistance to R41, and V10, LPN was providing feeding assistance to R27. All staff at the first table were minimally interacting with their respective resident. Staff discussed outside of work family activities with short directions given to the residents to open their mouth, take a drink, swallow etc. while talking about events outside of work.
On 6/6/24 at 12:45 am V1, Administrator/ Registered Nurse acknowledged it is a dignity issue for staff to engage in conversation unrelated to work. Staff should be engaging in conversations with the residents.
The facility Residents' Rights Pamphlet revised November 2018 documents the following:
for People in Long-Term Care Facilities documents the following: As a long-term care resident in Illinois, you are guaranteed certain rights, protections and privileges according to state and federal laws. and
Your rights to dignity and respect,
*
You have a right to make your own choices.
*
Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.
*
Your facility must provide equal access to quality care regardless of diagnosis, condition, or payment source.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) R55's undated Face Sheet documents R55's medical diagnoses as Parkinson's Disease, Malignant Neoplasm of Prostate, Bladder-N...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) R55's undated Face Sheet documents R55's medical diagnoses as Parkinson's Disease, Malignant Neoplasm of Prostate, Bladder-Neck Obstruction, Emphysema, Macular Degeneration, Muscle Wasting and Atrophy, Weakness, and history of Traumatic Subdural Hemorrhage with loss of conscious and Shortness of Breath
R55's Physician Order Sheet (POS) dated June 2024 documents a physician order for R55 to use Two liters of Oxygen per nasal cannula continuously.
R55's Minimum Data Set (MDS) dated [DATE] documents R55 as cognitively intact. This same MDS documents R55 as dependent on staff for bathing, personal hygiene, and toileting.
On 6/6/24 at 10:40 AM R55 was lying in bed wearing his nasal cannula connected to R55's Oxygen humidifier bottle. R55's Oxygen humidifier bottle was sitting on the floor next to R55's Oxygen Concentrator. R55's floor was littered with multiple pieces of small debris and dust.
On 6/6/24 at 12:40 PM V9 Infection Preventionist confirmed R55's Oxygen humidifier bottle was sitting on R55's dirty floor. V9 IP stated all Oxygen supplies should be off of the floor and maintained in a 'more hygienic way'. V9 IP stated R55's Oxygen concentrator has a specialized area to contain the humidifier bottle but that the strap to hold in the humidifier bottle had broken. R30's undated Face Sheet documents R30's medical diagnoses as Dementia, Respiratory Distress, Wheezing, Hypoxemia, Shortness of Breath, and Dyspnea.
4.) R30's Physician Order Sheet (POS) dated June 2024 documents a physician order for Albuterol Sulfate 0.083% solution for nebulization; 2.5 milligram (mg) /3 milliliter (ml) per vial. Give one vial per inhalation every four hours as needed. This same POS documents a physician order to change the Nebulizer tubing every two weeks.
On 6/4/24 at 11:00 AM R30's nebulizer face mask was dated 3/10/24 and sitting on top of a dirty sock on top of R30's bedside dresser. R30's nebulizer face mask was not in a bag.
On 6/6/24 at 1:00 PM V3 Nurse Manager stated all Nebulizer tubing should be placed in a plastic bag when not in use.
Based on observations, interviews, and record review the facility failed to maintain and store respiratory equipment in a clean sanitary manner, off the floor and failed to date respiratory equipment when changed. These failures affected four of seven residents (R8, R30, R33, R55) reviewed for respiratory/oxygen on the sample list of 35.
Findings Include:
The facility's Oxygen Therapy policy dated 3/16/17 documents it is the policy of the facility to provide a source of oxygen to persons experiencing an insufficient supply of oxygen. The humidifier bottles will be attached to the tank flow meter. Oxygen set-up (cannula/mask, tubing) must be exchanged every seven days.
On 6/6/24 at 12:30 PM V3 Registered Nurse/Nurse Manager confirmed respiratory equipment should be stored in a sanitary way (a bag) in order to keep tubing and masks off of the floor and other surfaces. V3 also confirmed oxygen humidifier bottles should be off the floor and connected to the oxygen concentrator. V3 also confirmed nebulizer masks, tubing and nasal cannula tubing should be dated with the date it was last changed.
1) R8's Face Sheet dated June 2024 documents R8 is diagnosed with Pneumonia and Bronchitis.
R8's Physician Order Sheet dated June 2024 documents an order for Oxygen 2-4 liters per nasal cannula as needed for shortness of breath.
On 6/05/24 at 12:37 PM R8's oxygen concentrator was in her room with oxygen tubing attached. There was no date on the tubing and tubing was laid over the bed and bed frame with no bad available for sanitary storage.
2.) R33's Face Sheet dated June 2024 documents R33 is diagnosed with Pneumonia, Shortness of Breath, and Chronic Obstructive Pulmonary Disorder.
R33's Physician Order Sheet dated June 2024 documents an order for Oxygen at 2 liters per nasal cannula continuously for Shortness of Breath.
On 6/05/24 at 12:35 PM R33's oxygen concentrator was in her room with tubing attached. The tubing was on the floor and bed with no bag available for sanitary storage.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to prevent cross contamination during meal service by not...
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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 cross contamination during meal service by not using hand hygiene when assisting residents to eat for five (R27, R40, R46, R56, R80) residents out of five residents reviewed for Infection Control in a sample list of 35 residents.
Findings include:
1.) R56's undated Face Sheet documents R56's medical diagnoses as Diabetes Mellitus Type II, Dysphagia, Anemia, History of Methylicillin Resistant Staphaureus (MRSA), History of Skin Infection, Morbid Obesity and Heart Failure.
R56's Minimum Data Set (MDS) dated [DATE] documents R56 as requiring assistance with setting up her meal tray.
On 6/5/24 at 11:40 AM V8 Certified Nurse Aide (CNA) used V8's bare hand to move R56's cut pieces of beef cutlet from one side of R56's plate to the other side. V8 did not use hand hygiene and was not wearing gloves. R56 then picked up her fork and ate the same pieces of beef cutlet that V8 CNA had moved with her bare hand.
On 6/6/24 at 11:05 AM V8 Certified Nurse Aide (CNA) stated V8 should not have touched R56's food with her bare hands. V8 CNA stated V8 should have worn gloves or used R56's utensils to move food around on R56's plate.
2.) R27's undated Face Sheet documents R27's medical diagnoses as Alzheimer's Disease, Dysphagia, Major Depression Disorder, Chronic Pain, and Tremors.
R27's Minimum Data Set (MDS) dated [DATE] documents R27 is dependent (helper does most or all of the work) on staff for assistance with eating.
R46's undated Face Sheet documents R46's medical diagnoses as Alzheimer's Disease, Vascular Dementia, Dysphagia, Cerebral Infarction, Gastro-Esophageal Reflux Disease (GERD) and Vitamin Deficiency.
R46's Minimum Data Set (MDS) dated [DATE] documents R46 as dependent (helper does all of the effort) with assistance in eating.
On 6/4/24 at 12:20 PM V10 Licensed Practical Nurse (LPN) assisted both R27 and R46 throughout the lunch meal. V10 assisted R27 and then without using hand hygiene or Alcohol Based Hand Rub (ABHR) assisted R46 multiple times during lunch meal.
On 6/4/24 at 12:25 PM V10 Licensed Practical Nurse (LPN) assisted R27 with eating her lunch. V10 attempted to feed R27 a bite of chocolate cake which touched R27's lips but then fell down onto V10's Left Wrist. V10 shook the piece of cake onto table, moved it towards the center of her table with her Right Hand and then V10 LPN proceeded to use her Right Hand to assist R46 with eating her meal. V10 did not use hand hygiene nor use alcohol-based hand rub (ABHR) prior to assisting R46 to eat her meal.
3.) R40's undated Face Sheet documents R40's medical diagnoses as Hereditary Spastic Paraplegia, Gastro-Esophageal Reflux Disease and Dysphagia.
R40's Minimum Data Set (MDS) dated [DATE] documents R40 as dependent (helper does all of the effort) with assistance in eating.
R80's undated Face Sheet documents R80's medical diagnoses as Anorexia, Alzheimer's Disease, Ventricular Premature Depolarization, Bradycardia, Dilated Cardiomyopathy and Vitamin Deficiency.
R80's Minimum Data Set (MDS) dated [DATE] documents R80 as requiring moderate assistance (helper does less than half the work) for eating and oral hygiene.
On 6/4/24 at 12:15 PM V8 Certified Nurse Aide (CNA) assisted R40 with eating her lunch meal. V8 CNA gave R40 a bite of food, then using both hands grabbed with table to reposition herself closer to R80. V8 then used contaminated Right Hand to pick up R80's drinking cup with palm placed directly over open top of cup and straw positioned in between V8's fingers to give R80 a drink of water.
On 6/6/24 at 11:07 AM V8 Certified Nurse Aide (CNA) stated V8 should have used hand hygiene when assisting two residents (R40, R80) eating their meals at the same time.
The facility policy titled 'Hand Washing Procedure' adopted August 2019 documents proper hand washing is the most effective way to reduce microorganisms to prevent the spread of infection such as Influenza and to prevent foodborne illness such as Norovirus. Facility staff should wash hands after touching clothes, face, body, or hair, after handling soiled equipment, after handling dirty dishes and after engaging in any activity that would contaminate hands. Hand antiseptic may be used AFTER washing hands and is not to be used as a substitute for hand washing.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to employ a Certified Dietary Manager. This failure has the potential to affect all 80 residents residing in facility.
Findings i...
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Based on observation, interview, and record review the facility failed to employ a Certified Dietary Manager. This failure has the potential to affect all 80 residents residing in facility.
Findings include:
The facility Long-Term Care Facility Application for Medicare and Medicaid dated 6/04/2024 documents 80 residents reside in the facility.
On 6/4/24-6/7/24 through daily rounding in the dietary department there were no observations made of a Certified Dietary Manager.
On 6/4/24 at 11:50 AM facility kitchen staff were carrying out the daily dietary duties, plating and serving lunch meal and preparing foods for the next meal.
On 6/4/24 at 11:55 AM V7 Dietary Aide stated the facility has not had a dietary manager in 'almost a year'.
On 6/5/24 at 9:45 AM V1 Administrator confirmed the facility does not have a Certified/Dietary Manager. V1 stated the role has been empty for six months. V1 stated the facility has made an offer to a perspective DM but has not hired anyone yet. V1 stated the Registered Dietician (RD) is onsite monthly and reviews resident charts remotely every week. V1 stated the RD is not onsite full time. V1 Administrator stated the facility does not have a policy that states there must be a Certified Dietary Manager, but facility is supposed to have a Certified Dietary Manager and does not.
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 kitchen equipment in a clean sanitary condition, to prevent potential cross-contamination and potential food-borne i...
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Based on observation, interview, and record review, the facility failed to maintain kitchen equipment in a clean sanitary condition, to prevent potential cross-contamination and potential food-borne illness and failed to dispose of outdated dry storage food products. This failure has the potential to affect all 80 residents residing in the facility.
Findings include:
On 6/6/24 between 9:05 am - 10:45 am during the kitchen tour intermittently with V23, Head [NAME] and V24, Cook.
1.) On 6/6/24 at 9:05 am the commercial ice machine was soiled with a built- up of rust on the bolts of the top angled door that hung inside over the ice. V24 confirmed the observation and stated, 'that needs to be cleaned.'
2.) On 6/6/24 at 9:08 am, the metal shelf under the commercial coffee maker containing numerous steam table pan covers. The shelf was covered in rust. V24 confirmed the observation and stated the facility has had a problem with the coffee maker leaking for a long time, and maintenance will have to look at this.
3.) On 6/6/24 at 9:12 am the countertop, under the commercial juice dispenser machine, had standing water under it. The shelf below the juice dispenser contained four commercial sized multi-gallon boxed containers of juices. The boxes of juice laid on top of the rusted metal shelf. V24, stated I will have to have maintenance fix that leak too.
4.) On 6/6/24 at 9:15 am, the commercial two door refrigerator had two, open gallon plastic container of lime juice. The plastic gallon containers document a manufacturers date to use by May 19, 2024. V24 stated we don't use that very often. The distributor was out of lemon juice and brought this instead. We have a lot of it in storage. We will have to get rid of it. Once opened, we have to discard food items in seven days.
5.) On 6/6/24 at 9:18 am, the facilities commercial grill had a three-inch side, that overhung that abutted the commercial stove. The three-inch overhang had thick, brown and black, grease-like build-up and yellow lines of thick liquid-like drips that adhered to the grease like surface. V24 stated The yellow (substance) is from french toast I made yesterday; the rest (grease like stick build-up) has obviously been there awhile.
6.) On 6/6/24 at 9:22 am the approximately, three foot by two foot, back metal plate of the commercial stove, had copious amount of dark brown and black, sticky grease-like accumulation. V24 stated I will have to take a steel brush to that. It has not been cleaned for a while. We don't really have a cleaning schedule. Looks like we need one though.
7.) On 6/6/24 at 9:25 am the double commercial ovens had charcoal-like build-up approximately an inch in depth across the bottom of the double ovens. V24 stated.
That (oven) will have to be cleaned at night, after it cools off.
8.) On 6/6/24 at 9:28 am the table-top, commercial can opener had a build-up of rust and metal fragments in the gears and the tip of the blade had the silver coating missing. V24 stated, We may have to just get a new can opener. That is in pretty bad shape. We usually run it threw the dishwasher. That is not doing (getting it cleaned) it.
9.) On 6/6/24 at 9:32 am V6, Preparation [NAME] confirmed observations in the dry storage room of the following expired items: One - opened, half used, 14.5 ounce, thick and creamy pouch of instant cheese mix manufactures use by date of 4/24/24, and no opened date. The dry storage room also had nine additional pouches of instant cheese mix, with the same manufactures use by date of 4/24/24.
There were three, opened, five-pound bags of powdered devil food cake mix manufacturers use by date of 2/27/24 and three unopened five-pound bags of devil's food cake with manufacturers used by date of 3/30/24. V24 stated We have several cooks that do not rotate stock. I can tell you; we have used them all recently.
10.) On 6/6/24 at 10:45 am V23, Head [NAME] confirmed the facility commercial dishwashing station had a metal backsplash, approximately six inches high. The backsplash meets the wall, just above the dishwasher running board. The backsplash had cracked, chipped chunks of loose caulking that spanned approximately six feet across and above the dishwasher running board. V23 stated The county health already identified that a couple weeks ago and it has not been fixed yet.
Adopted 08/ l 9 The facility policy Cleaning & Sanitizing Work Surfaces & Equipment Procedure documents the following:
Objective: To provide guidelines to clear, clean and sanitize work surfaces and equipment.
Procedure: STEP 1: CLEARING WORK SURFACES & EQUIPMENT: Clear work surface tables of food, food crumbs, dirty utensils, used cutting board, etc. Clear equipment such as grill, slicer, mixer, etc. of food and food crumbs. Take apart equipment if possible and wash and sanitize parts in 3 compartment sink. If the equipment cannot be washed and sanitized in the 3-compartment sink, follow the procedures below.
The facility Long-Term Care Facility Application for Medicare and Medicaid dated 6/04/2024 documents 80 residents reside in the facility.
Mar 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident was free from abuse by another resident. This fail...
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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 free from abuse by another resident. This failure affects two (R3, R2) of three residents reviewed for abuse in a sample list of three.
Findings Include:
R3's Event Report dated [DATE] at 3:59PM documents (R3) was sitting in hallway when (R3) was approached by (R2) who struck (R3) in her right eye with a clenched hand. (R3) immediately stood up from chair and grabbed the (R2's) wrist and struck (R2) in the right jaw area with a clenched hand. Staff intervened immediately and both residents were separated. (R3's) right eye is slightly bloodshot and a cold compress was applied. (R3) remains angry and staff are sitting with (R3) at present.
R3's Care Plan revised [DATE] documents the following diagnoses: Alzheimer's Dementia with Behavioral Disturbance, Mood Disturbance and Anxiety. This Care Plan also documents (R3) displays rejection of care behaviors such as refusing to change clothes when incontinence occurs, this behavior occurs infrequently. (R3) displays verbal behavior directed toward staff and others such as name calling and cussing. Physical behaviors displayed are hand gestures such as shaking fist at staff. (R3) frequently wanders into other resident's room and is not easily redirected at times. R3's Care Plan does not address R3's vulnerability to abuse.
R2's Care Plan revised [DATE] documents the following diagnoses: Vascular Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. This Care Plan also documents (R2) has dementia with cognitive impairments, depression, brief psychotic disorder. At times (R2) displays behaviors including physical behaviors directed towards others, verbal behaviors directed towards others. (R2) at times will display hallucinations where (R2) sees relatives that are not present, both living and deceased . This is frequently a trigger for behaviors and can also lead to an increase in wandering and exit seeking in an attempt to get home. R2's MDS (Minimum Data Set) dated [DATE] documents R2 is severely cognitively impaired.
R2's progress note dated [DATE] at 10:36AM documents During resident care, (R2) struck female staff member in the face with clenched hand. Staff intervened immediately and separated the two. (R2) redirected to residents' room with staff supervision. R2's Progress note dated [DATE] 10:52AM documents Staff reported to (V14), Dementia Director while in the dining room they observed (R2's) hands on another residents family members shoulder squeezing. Staff intervened immediately and redirected resident back to her room with supervision.
On [DATE] at 2:00PM V3, Assistant Director of Nursing stated We realized R2's behavior was a problem and R2 is now at (behavioral care center) so her behaviors and medications can be assessed and managed. (R3) will return here after (R3) is discharged .
The facility's Abuse Policy revised [DATE] documents If the incident involves alleged abuse and substantiated evidence indicated that another resident of the facility is the is the perpetrator of the abuse, then the Administrator shall take all steps necessary to protect all residents in the facility from abuse until the alleged perpetrator can be evaluated.
Jun 2023
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to accurately document R42's advanced directive in one (R42) of 24 residents reviewed for advanced directives from a total sample list of 30.
F...
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Based on interview and record review the facility failed to accurately document R42's advanced directive in one (R42) of 24 residents reviewed for advanced directives from a total sample list of 30.
Findings include:
On 6/26/23 at 12:06 PM, R42's active physician orders document full code status dated 1/26/23.
On 6/26/23 at 12:07 PM, R42's advanced directive documents a do not resuscitate order dated 1/26/23.
On 6/27/23 at 1:30PM, V9 Social Services Director said that advanced directives should be documented clearly on the chart.
The facility provided policy, Advanced Directives dated February 2018 documents the advanced directives policy is to ensure that the resident's choices regarding advanced directives are followed and that those choices are documented clearly in the medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure a safe transfer for one of 24 residents (R17) reviewed for skin conditions on the sample list of 30.
Findings include:...
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Based on observation, interview, and record review the facility failed to ensure a safe transfer for one of 24 residents (R17) reviewed for skin conditions on the sample list of 30.
Findings include:
On 6/28/23 at 11:00 AM, R17 was laying in bed. When asked how her (R17) head had gotten bruised, R17 pointed to her forehead and stated they hit me with the lift.
R17's Nurse's noted dated 6/02/2023 at 10:43 PM documents, CNA (V8, Certified Nurse's Aide) reported resident hit head on lift when getting into bed. quarter size, round green bruise observed on forehead. Ice pack applied to area and resident has had no c/o (complaints of) pain.
On 6/27/23 at 9:32 AM, V8 CNA stated V8 was putting R17 to bed and R17 was leaning forward as V8 was bringing the lift closer to R17 to hook up the sling to the mechanical lift. V8 stated the lift arms swiveled and a hook on the arm hit her forehead. V8 stated no one had the swiveling part of the mechanical lift arms stabilized at that time and the lift arms were free to swivel. V8 stated we should have made sure R17 was sitting back when bringing the mechanical lift up to her or stabilized the lift arm.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0847
(Tag F0847)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure resident representatives for two residents understood the binding arbitration agreement they signed for two of three residents (R47 a...
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Based on interview and record review the facility failed to ensure resident representatives for two residents understood the binding arbitration agreement they signed for two of three residents (R47 and R268) reviewed for binding arbitration in a sample list of three residents.
Findings include:
1. R268's face sheet printed 6/28/23 documents R268 was admitted to the facility 6/16/23 and V10 is documented as R268's representative.
The list of residents who do/do not have arbitration agreements provided 6/27/23 documents R268's Power of Attorney has signed a binding arbitration agreement.
On 6/27/23 at 12:22PM V10 stated I wasn't aware I signed a binding arbitration agreement. I don't even know what that is.
2. R47's face sheet printed 6/28/23 documents R47 was admitted to the facility 3/6/20 and V11 is documented as R47's representative.
The list of residents who do/do not have arbitration agreements provided 6/27/23 documents R47's Power of Attorney has signed a binding arbitration agreement.
On 6/27/23 at 12:30 PM V11 stated I don't think I signed anything they called a binding arbitration agreement. I sure can't remember signing anything like that.
On 6/27/23 at 1:26PM V9, Social Service Director stated I am the Admissions Coordinator and it is our policy to make sure all residents or their Power of Attorney are aware of the arbitration agreement in our contract. They are not required to sign it. I do not have any documentation that they understand the agreement.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to provide a properly working bed and door in one (R62's) resident room of 24 resident rooms reviewed for properly working essent...
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Based on observation, interview, and record review the facility failed to provide a properly working bed and door in one (R62's) resident room of 24 resident rooms reviewed for properly working essential equipment, from a total sample list of 30.
Findings include:
On 6/26/23 at 2:38 PM, a sign was on R62's door stating to please keep R62's door closed; however, the door was cracked open.
On 6/26/23 at 2:38 AM, R62 was laying in bed with a right below knee amputation. R62's stump was wrapped, and each side of the electric bed had a small side rail attached near the head of the bed.
On 6/26/23 at 2:39 PM, R62 said that his bed did not work correctly and that it hadn't worked correctly since he was admitted to this room. Additionally, R62 stated that his door would not close without being slammed and that he liked his privacy.
On 6/26/23 at 2:40 PM, R62 demonstrated that the foot portion of the mattress would not elevate nor lower using the bed control and that the left side (side toward the door) side rail was not affixed to the bed.
On 6/27/23 at 1:12 PM, R62's door was closed and reopened. The only way to make it completely shut was to slam the door.
On 6/27/23 at 1:50 PM, R62's side rail remained unaffixed to the bed and the bed would not raise or lower the feet.
On 6/27/23 at 1:52 PM, R62 stated, I want the door to close and the side rail to be like the other one so that I can use it to move in the bed and I would like to be able to move my feet up and down when I'm watching (television).
On 6/27/23 at 2:04 PM V4 RN stated, Yes, that's right. (R62's) door won't shut without slamming it and he really needs those side rails to be stable for positioning.
The facility provided, Maintenance Policy and Procedure dated 2/25/19 documents that it is the facility's policy to provide its residents with an adequate maintenance service and to assure that resident equipment is functional.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to provide a working call light for one (R58) of 24 residents reviewed for call lights from a total sample list of 30.
Findings i...
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Based on observation, interview, and record review the facility failed to provide a working call light for one (R58) of 24 residents reviewed for call lights from a total sample list of 30.
Findings include:
On 6/26/23 at 11:02 AM, V13 Family Member stated, Mom (R58) is blind and her call lights don't work in her room. We sit with her every day and before we leave at night, we unplug the cord from the wall and then plug it back in, so she has at least one push at night while we are gone. We have told them about this, and it still isn't fixed. Obviously, Mom can't unplug it from the wall, so that she can have a call light.
On 6/26/23 at 11:08 AM, V13 Family Member pushed both call lights in R58's room, but neither alarmed.
On 6/26/23 at 11:10 AM, V13 Family Member unplugged the call light from the wall and then plugged it back into the wall, resulting in both call lights working.
On 6/27/23 at 1:15 PM, V3 Maintenance Director stated, Sometimes our call lights get moist with humidity. I went down there this morning and dried off the plug in on the wall. A bunch of them get like that on occasion, this building is just humid.
The facility provided, Maintenance Policy and Procedure dated 2/25/19 documents that it is the facility's policy to provide its residents with an adequate maintenance service and to assure that resident equipment is functional.
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 employ a full time Director of Nursing. This failure has the potential to affect all 66 residents residing in the facility.
Fi...
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Based on observation, interview, and record review the facility failed to employ a full time Director of Nursing. This failure has the potential to affect all 66 residents residing in the facility.
Findings include:
On 6/26/23 from 9:00 AM to 4:00 PM, 6/27/23 from 8:15 AM to 4:00 PM, and 6/28/23 from 8:15 AM to 3:30 PM, a Director of Nursing was not present in the building.
On 6/27/23 at 11:00 AM, V1 Administrator stated there has not been a Director of Nursing employed by the facility since April 28th, 2023.
The facility's Resident Census and Conditions of Residents report dated 6/26/23 documents there are 66 residents residing in the facility with 13 skilled care residents, eight residents with indwelling catheters, two residents on Hospice care, two residents receiving intravenous therapy, three residents with ostomies, 15 residents with injections, and 41 residents receiving psychotropic medications.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 66 reside...
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Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 66 residents residing in the facility.
Findings include:
On 6/27/2023 at 12:05PM, V14 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V14 reported being the full-time manager of the facility food service and reported not being a clinically qualified Certified Dietary Manager or having the equivalent training.
The Resident Census and Conditions of Residents report (6/26/2023) documents 66 residents reside in the facility.
MINOR
(C)
Minor Issue - procedural, no safety impact
Menu Adequacy
(Tag F0803)
Minor procedural issue · This affected most or all residents
Based on observation, interview, and record review, the facility failed to serve bread as planned on the menu. This failure has the potential to affect all 66 residents residing in the facility.
Findi...
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Based on observation, interview, and record review, the facility failed to serve bread as planned on the menu. This failure has the potential to affect all 66 residents residing in the facility.
Findings include:
On 6/27/2023 during the lunch meal, no buttered bread was present at the service line in the facility kitchen and no bread was served to any residents throughout the facility dining areas and resident rooms.
The facility Diet Spreadsheet (6/27/2023) documents all residents were to receive buttered bread during the lunch meal on 6/27/2023.
On 6/27/2023 at 12:05PM, V14 (Dietary Manager) stated They (facility residents) should have been (served buttered bread during the lunch meal) and I don't think any went out (to the dining areas) today.
The Resident Census and Conditions of Residents report (6/26/2023) documents 66 residents reside in the facility.
May 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
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 unknown origin timely for one resident (R2) 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 report an injury of unknown origin timely for one resident (R2) of three residents reviewed for injuries of unknown origin in the sample of nine.
Findings include:
The facility's Long-Term Care Facility & IID - Serious Injury Incident and Communicable Disease report dated 3/25/23 at 5:50 PM, documents R2 was observed to have redness and swelling to R2's right index finger. R2 has a diagnosis of Dementia and is unable to report what happened. R2 rolled from R2's low bed to a mat on 3/20/23. R2 was assessed at that time per V9 Licensed Practical Nurse (LPN). Facility was notified 3/26/23 of fracture to right index finger. The facility's copy of the Patient Report for R2 dated 3/26/23, documents Acute Oblique Comminuted Shaft and Base Fracture of the Proximal Phalanx of the Right Index Finger.
R2's undated Face Sheet documents R1's diagnoses as Fall on same level, unspecified, subsequent encounter; Fracture of Unspecified Part of Neck of Right Femur; Fracture of unspecified Phalanx of Right Index Finger; Dementia in other Diseases classified elsewhere; Disorientation, Unspecified; and Displace Intertrochanteric Fracture of Right Femur.
R2's Minimum Data Set (MDS) dated [DATE], documents R2 is not cognitively intact.
On 4/25/23 at 2:10 PM, V2 Director of Nursing (DON), stated R2 rolled from a low bed to a mat on 3/20/23 and R2 was assessed at that time with no injuries. V2 stated on 3/25/23, V9 Licensed Practical Nurse (LPN) noticed redness and swelling to R2's right index finger at 5:50 PM.
On 4/26/23 at 1:31 PM, R2's index finger and second finger appeared taped together on R2's right hand. R2 is not able to converse when asked questions/comments.
On 5/2/23 at 11:27 am, V10 Certified Nursing Assistant (CNA) stated V10 was interviewed by V11 Director of Memory Care. V11 documented on 3/28/23, V10 stated on 3/24/23 she (V10) noticed the swelling and thought the nurse was aware (of R2's right index finger).
On 5/2/23 at 11:43 AM, V12 CNA and Activity Assistant stated V12 was interviewed by V11 on 3/28/23. V12 stated V12, not sure what day it was, but asked other CNAs at the dining room table what happened to R2's finger, it's swollen? V12 stated V12 should not report resident injuries to another CNA, but to either the nurse, Administrator, or Shift Coordinator, which V12 stated V12 did not do.
On 5/2/23 at 11:50 AM, V1 stated staff should be reporting injuries of unknown origin to the charge nurse, manager on duty and administrator. V1 stated if the administrator is in the building injuries of unknown origin and abuse allegations should be reported immediately to V1. V1 stated V12 CNA should have reported R2's index finger to someone other than a CNA
On 5/2/23 at 3:30 PM, V1 Administrator presented Abuse training logs with signatures and information on abuse training. These abuse training logs indicate V10 CNA, V12 CNA, and V14 CNA, all had abuse training on 5/18/2022.
On 5/3/23 at 10:01 AM, V1 Administrator stated the interviews on R2's investigation are correct and true at the time the interviews were transcribed on 3/28/23.
The facility's Abuse Prohibition and Reporting Policy dated Revised 11/28/19, documents Injuries of Unknown Origin shall be reported immediately to the shift nurse, the Director of Nursing, and the Administrator.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Illinois facilities.
- • 42% turnover. Below Illinois's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 2 harm violation(s). Review inspection reports carefully.
- • 33 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • Grade F (25/100). 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 Shelbyville Manor's CMS Rating?
CMS assigns SHELBYVILLE MANOR an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Illinois, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Shelbyville Manor Staffed?
CMS rates SHELBYVILLE MANOR's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 42%, compared to the Illinois average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Shelbyville Manor?
State health inspectors documented 33 deficiencies at SHELBYVILLE MANOR during 2023 to 2025. These included: 2 that caused actual resident harm, 30 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Shelbyville Manor?
SHELBYVILLE MANOR is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by UNLIMITED DEVELOPMENT, INC., a chain that manages multiple nursing homes. With 109 certified beds and approximately 78 residents (about 72% occupancy), it is a mid-sized facility located in SHELBYVILLE, Illinois.
How Does Shelbyville Manor Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, SHELBYVILLE MANOR's overall rating (2 stars) is below the state average of 2.5, staff turnover (42%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Shelbyville Manor?
Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the substantiated abuse finding on record.
Is Shelbyville Manor Safe?
Based on CMS inspection data, SHELBYVILLE MANOR has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Illinois. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Shelbyville Manor Stick Around?
SHELBYVILLE MANOR has a staff turnover rate of 42%, 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 Shelbyville Manor Ever Fined?
SHELBYVILLE MANOR has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Shelbyville Manor on Any Federal Watch List?
SHELBYVILLE MANOR 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.