SOUTH ELGIN LIVING & REHAB CENTER
For profit - Corporation
90 Beds
Independent
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
3/100
#633 of 665 in IL
Photo by South Elgin Living and Rehab Center LLC
Photo by South Elgin Living and Rehab Center LLC
Photo by Google Street View
1 / 5 photos
Last Inspection: May 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
South Elgin Living & Rehab Center has received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranking #633 out of 665 facilities in Illinois places it in the bottom half, and at #24 out of 25 in Kane County, it is one of the least favorable options in the area. The facility is worsening, as it saw an increase in issues from 9 in 2023 to 30 in 2024. Staffing is a relative strength with a 2/5 star rating, and turnover is on par with the state average at 46%, but more positively, it offers more RN coverage than 97% of Illinois facilities, which can help catch potential problems. However, the facility has incurred $148,321 in fines, suggesting ongoing compliance issues, and there have been serious incidents, such as a lack of handwashing facilities due to broken pipes and failure to follow medication protocols that led to inappropriate dosages for residents. Overall, while the staffing levels are somewhat reassuring, the facility’s numerous deficiencies and poor ratings raise significant red flags for families considering care for their loved ones.
- Trust Score
- F
- In Illinois
- #633/665
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 46% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $148,321 in fines. Higher than 55% of Illinois facilities. Some compliance issues.
- Skilled Nurses ✓ Good
- Each resident gets 70 minutes of Registered Nurse (RN) attention daily — more than 97% of Illinois nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 54 deficiencies on record. Higher than average. Multiple issues found across inspections.
3/100
Bottom 5%
Review needed
9 → 30 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2023: 9 issues
2024: 30 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Illinois average (2.5)
Significant quality concerns identified by CMS
Staff Turnover: 46%
Near Illinois avg (46%)
Higher turnover may affect care consistency
Federal Fines: $148,321
Well above median ($33,413)
Significant penalties indicating serious issues
The Ugly 54 deficiencies on record
1 life-threatening 2 actual harm
Sept 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to safely repair an exposed ceiling area located outside ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to safely repair an exposed ceiling area located outside residents' (R8, R9, and R10) rooms.
This applies to 3 of 8 residents reviewed for environmental hazards.
The findings include:
On 9/12/2024 at 8:32 AM, during the facility's environmental rounds, there was an open ceiling area with exposed pipes above the entrance of the housekeeping room. The housekeeping room was in the the resident hall in front of R8, R9, and R10's rooms. The cut-out open ceiling area had a loose plastic covering with a moderate amount of drywall debris. The plastic covering was not properly secured it had scattered pieces of blue painter's tape. At 11:45 AM, V4 (Housekeeper Supervisor) said approximately three weeks ago there had been a pipe leak above the housekeeping room entrance area. V4 said the facility did not have maintenance staff available to fix the open ceiling drywall area. V4 said the open ceiling area had remained with the same plastic covering and tape. V4 said the facility's corporate management was planning to send someone to patch up the ceiling but was unsure when.
On 9/12/2024 at 12:05 PM, V1 (Administrator) said approximately a month ago the nursing staff informed her there was a ceiling leak outside the housekeeping room. V1 said an outside plumbing company fixed the leak but the ceiling area remained open with exposed pipes. V1 said the opening measured approximately 3 x 3 ft (feet). V1 said the facility did not have maintenance staff to repair the ceiling. V1 said she requested the corporate management to send someone to patch up the ceiling but was unsure when it would be repaired.
The facility's resident roster report dated 9/12/2024 showed R8's room and R9 and R10's room were located directly across from the housekeeping room.
The facility's undated document titled Maintenance Minute showed The Maintenance Minute is a one to two page quick update on maintenance [NAME], some tips for routine maintenance and refreshers for Life Safety .maintenance Training Quick Guide .Repair any wall or ceiling damage as soon as possible to maintain smoke barrier.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow the State Department of Public Health and the L...
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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 follow the State Department of Public Health and the Local County Health Department instructions to obtain appropriate facility-wide testing, initiate treatment for a resident (R1) with positive test results, and adhere to the mandated facility-wide masking for the management of their group A streptococcal disease outbreak.
This applies to all the residents residing at the facility.
Findings include:
The facility's resident roaster dated 9/12/2024 showed a census of 56 residents.
1. The CDC (Center for Disease Control and Prevention) website link https://www.cdc.gov/group-a-strep/about/index.html dated 3/1/2024 documents, Group A Streptococcus (group A strep bacteria) can cause serious and deadly clusters or outbreaks. Group A strep bacteria are very contagious. Some people infected with group A strep bacteria don't have symptoms or seem sick. They can still spread the bacteria to others. Generally, people spread the bacteria to others through respiratory droplets or direct contact. The link continued to document, CDC developed these investigation tools to provide detailed approaches to investigating and controlling GAS (Group A Streptococcus) infections and outbreaks in LTCFs (Long Term Care Facilities) .Collaboration is key LTCF staff should work with their local public health departments when investigating suspected GAS outbreaks.
On 9/12/2024 at 2:45 PM, V12 (Certified Nurse Assistant/CNA) said she had tested positive for Strep A during the facility's wide outbreak testing for Strep A on 8/1/2024. V12 said she was asymptomatic but received and completed her antibiotic treatment. V12 said she did not believe there was currently an active case of Strep A infection at the facility.
On 9/12/2024 at 3:40 PM, V1 (Administrator), V2 (Director of Nursing), and V3 (Assistant Director of Nursing/Infection Preventionist) said the facility had an active Strep A infection outbreak. They said they were all new to their roles at the facility. They said they were not sure when the outbreak started, how many cases there were, and which residents were associated with the facility's outbreak. They continued to say they were aware of the facility's mandated masking for all residents, staff, and visitors from the State Department of Public Health and the Local County Health Department. V1 said on 8/1/2024 the Local Health Department's lab went to the facility to perform the facility-wide testing on all the residents and staff. V1 said she was notified R1's right foot wound culture and V12's (Certified Nurse Assistant/CNA) throat culture resulted positive for Strep A. V1 continued to say that on 8/28/2024 the Local Health Department's lab went back to the facility to retested R1 and V12. V1 said on 9/11/2024 she was notified that R1's right foot wound culture continued to test positive for Strep A.
On 9/13/2024 at 9:25 AM, V14 (IDPH Infection Control Coordinator) said he and the Local Health Department had initiated a retrospective investigation and had identified 5 resident iGAS Strep A infections at the facility. V14 said the State Department of Public Health and the Local County Health Department used the CDC's (Center for Disease Control and Prevention) guidelines for Group A Streptococcus Infections in Long-Term Care Facilities to assist the facility with their outbreak management including testing and infection control practices. V14 said the facility's prior management was notified of the facility's outbreak in May 2024 and routine onsite visitations were conducted at the facility to assist them with their outbreak. V14 said the facility's prior management had failed to obtain accurate employee assessment survey questionnaires and perform facility-wide testing for staff in June 2024 as instructed. V14 said the facility had also failed to obtain proper cultures for residents identified at risk in July 2024 as instructed. V14 said because the facility failed to assist the State Department of Public Health and the Local County Health Department with the facility's outbreak management and investigation they decided to mandate masking for all residents, staff, and visitors at the facility in July 2024. V14 said then the Local County Health Department assisted the facility with obtaining appropriate testing for staff and residents on 8/1/2024. V14 said that during the facility's wide-testing 2 additional cases were identified (R1 and V12). V14 said the facility was notified that their mandated masking had to continue till December 2024. V14 said he was concerned during his last onsite visit on 9/9/2024 because he observed several staff and residents without masks.
On 9/13/2024 at 3:40 PM, V13 (Local County Health Department Communicable Disease Supervisor) said she notified the facility they had an iGAS Strep A outbreak in May 2024. V13 said she and V14 (State Department of Public Health Infection Control Coordinator) have been trying to guide the facility with their management of the outbreak. V14 said they have been providing the facility with guidance tools and conducting routine onsite visits to further assist them. V13 said they have continued to identify serious infection control concerns regarding the facility's lack of response to their recommendations with obtaining appropriate facility-wide testing and adherence to the facility-wide masking mandate. V14 said the facility is still in an outbreak. V14 said the facility's retrospective investigation is ongoing to further identify any additional iGAS Strep A infections associated with the facility.
The document titled Local County Health Department Meeting Minutes dated 6/4/2024 showed the facility was instructed on infection control interventions based on the onsite visitation conducted by the State Department of Public Health and the Local County Health Department for management of their current outbreak of invasive group A streptococcal disease at the facility. The document said, [V14] explained that specimen collection sites must be decided based on the presence of symptoms or conditions; a standard throat swab cannot be utilized for all; [facility] team confirmed that new specimens will be collected from the residents accordingly, and cultures will be made. The document also said, [V13 and V14] reinforced the importance of staff responding the survey accurately to allow for identification of symptomatic individuals (for GAS or iGAS) and appropriate selection of specimen collection sites (i.e., if they have skin or nail wounds, specimen must be collected from those sites) .[V13] recommended that the facility tries to identify and test by culture all epi-linked staff (staff who provide direct care for the case with the last onset date); if this is not feasible, all staff must be cultured. The document continued to say the facility agreed the next steps would be taken, [Facility] will reassess residents and do additional testing as needed for individuals with wounds or ostomy sites. [Facility] will complete reassessment for GAS. [Facility] will identify and test epi-linked staff regardless of symptoms; if unable to identify epi-linked staff, all staff members will be tested (and treated accordingly).
The document titled Local County Health Department Meeting Minutes dated 7/10/2024 said, the staff assessment and reassessment had not been completed by the facility. The document continued to document that the facility was again educated and provided basic containment guidance for the management of their Strep A iGAS outbreak.
The document titled Local County Health Department Meeting Minutes dated 7/15/2024 showed the facility was notified that a total of 5 cases had been identified as part of the facility's retrospective investiation outbreak and it was highly suspected that disease transmission was ongoing at the facility. The document said, [Physician] (Regional Infection Prevention Program-[NAME]) pointed out to the fact that, since only 2 of the 5 cases in the outbreak had wounds, droplet must be considered as the main mode of transmission; considering that culture screenings from residents were negative, and that no staff has been tested yet, adoption of broad masking is a simple containment measure and should be implemented during the outbreak. The document continued to say the recommended next steps would be taken, Recommended implementing universal masking at [facility]. Recommend testing by culture all facility employees, including contractors, EVS, and non-clinical employees; throat swab is the recommended specimen collection method. Contact (laboratory) to discuss screening of staff at the occasion of specimen collection. If any wounds are identified, (Laboratory) to collect specimens from wounds as well.
The facility's document titled Resident Infection Control and Antimicrobial Log dated August 2024 showed on 8/1/2024 lab wound specimen cultures were obtained from R1-R6 and R11-R13. The report said R1 tested positive for Strep A and R1-R3, R5, R6, and R11-R13 also tested positive for MRSA (Methicillin-resistant Staphylococcus aureus).
The CDC's (Center for Disease Control and Prevention) document titled Decision Tool for Investigating Group A Streptococcus Infections in Long-Term Care Facilities dated 3/1/2024 said LTC (long-term care) facilities should identify additional symptomatic cases, identify potential asymptomatic carriers, assess infection control measures, and conduct an epidemiologic and laboratory investigation when they have an iGAS outbreak. The document said, Footnotes a. If GAS is isolated from a wound AND accompanied by necrotizing fasciitis or streptococcal toxic shock syndrome, then it is considered an invasive GAS infection case .b. Often cases of invasive GAS will first be identified either by an acute care hospital where the resident of an LTCF has been transferred for additional evaluation and medical care or by a laboratory that processes specimens collected at LTCFs. Thus, these facilities should ensure that invasive GAS infection or positive GAS cultures collected from normally sterile body sites are reported to local public health authorities and the LTCF where the patient resides. Additionally, these facilities should save the isolate for possible future assessments of strain relatedness in case additional cases are identified .Note: Continued use of a facemask by HCP during all wound care activities or when handling invasive medical devices is recommended until the outbreak is over .
The facility's policy titled Infection Control Surveillance and Monitoring with a revised date of 4/11/2022 said Policy: It is the policy of the facility to do routine surveillance and monitoring of the facility to determine if compliance with infection control practices is maintained .Procedure: 1. Monitoring the effectiveness of the facility work practices and protective equipment will be conducted by the Administrator, ICP, and DON. This includes but is not necessarily limited to: a. Surveillance of the facility to ensure that required work practices are observed and protective clothing and equipment are provided and properly used; b. Investigation of known or suspected parenteral exposure .c. Improvement in training, work practices, or protective equipment to prevent recurrence. d. Maintain a procedure of notification to physicians, and (State Department of Public Health) as required by regulation, of any infectious cases. e. Review all policies, procedures, and programs relating to infection control including environmental controls .
2. R1's Medical Record showed an admission date of 9/15/2023 with diagnoses of necrotizing fasciitis to his right foot wound, non-pressure chronic ulcer of the right heel and midfoot with fat layer exposed, and soft tissue disorders.
On 9/12/2024 at 10:15 AM, V3 (Assistant Director Nursing/ADON) said she was the facility's IP (Infection Preventionist). At 10:30 AM during the facility's infection control observation round done with V3, R1's room had an EBP (Enhanced Barrier Precaution) sign tapped outside his room. V3 said that was incorrect because R1 was supposed to be under Contact Precautions because of his Strep A wound infection to his right foot wound. V3 said R1 had tested positive for Strep A to his right foot wound on 8/1/2024 during the facility's Strep A outbreak testing. V3 said R1 was placed on contact precautions and started on an oral antibiotic on 8/9/2024. V3 said R1's wound was retested for Strep A on 8/28/2024 as part of the facility's outbreak management. V3 said the facility was notified on 9/11/2024 that R1 had again tested positive for Strep A. V3 said she notified R1's physician and received an order for an oral antibiotic and to continue with contract precautions. V3 continued to say R1 frequently went out on pass overnight and he was currently out on pass. V3 said R1 went out on pass on 9/11/2024 and was not expected back for 8 days. V3 said she had called R1 and notified him of his test results and the antibiotic order. V3 said she was waiting to hear back from R1 to call in his antibiotic prescription to a local pharmacy. On 9/13/2024 at 10:30 AM, V3 said she still had not made contact with R1 and was planning to call him later that day.
On 9/12/2024 at 2:45 PM, V12 (Certified Nurse Assistant/CNA) said she was familiar with R1 and had taken care of him. V12 said she had tested positive for Strep A during the facility's wide outbreak testing for Strep A on 8/1/2024. V12 said she had been asymptomatic but received and completed her antibiotic treatment. V12 said she did not believe there was currently an active case of Strep A infection at the facility. V12 said she believed R1's wound infection was not Strep A. V12 said she uses the precaution signs outside residents' rooms to instruct her what type of precautions and PPE (Personal Protective Equipment) she needed to use when entering the rooms to protect herself and others.
On 9/13/2024 at 11:30 PM, V1 (Administrator) said R1 frequently went out on pass overnight. V1 said R1 was frequently non-compliant with his right foot's wound care. V1 said R1 had not started his oral antibiotic treatment ordered on 9/11/2024 for his known Strep A wound infection. V1 said she was unable to locate a facility's out-of-pass policy.
R1's Wound Evaluation and Management Summary dated 9/4/2024 said R1 had a full-thickness post-surgical wound to his right dorsal foot. The summary said the wound measured 8.1 x 4.0 x 0.1 cm (centimeters) and had heavy serosanguinous exudate. The summary continued to say that R1 now required daily dressings.
R1's physician orders dated 9/11/2024 said start Amoxicillin (antibiotic) 500 mg PO TID x 10 days for Strep group A on foot wound and continue contact isolation for Strep group A on wound.
R1's progress note dated 9/11/2024 said R1 was to start Amoxicillin 500mg PO TID x 10 days to start when resident comes back from out on pass for 8 days, resident was called and notified.
R1's progress note dated 9/3/2024 said R1 complained of his right foot wound dressing being saturated through his sock. The progress noted said when the dressing was removed it was noted with abnormal smelling and large amount of drainage. The progress note said R1's nurse practitioner was notified and an order for daily dressing changes was obtained.
R1's right foot wound culture dated 8/04/2024 showed R1 had a positive culture for Moderate Growth Beta Hemolytic Strep Group A (Abnormal).
R1's care plan dated 9/12/2024 showed R1 had a beta hemolytic strep group A infection on his foot initiated on 8/15/2024. The care plan had multiple interventions including Educate resident/family/staff regarding preventive measures to contain the infection and Place in private room with contact isolation precautions initiated on 8/15/2024.
R1's care plan also showed that R1 had a behavior problem related to not following the facility's policies regarding the out-on pass initiated on 3/19/2024. R1's care plan said, Resident has a wound on his right lower leg that needs attention, daily dressing change is important which is not done when he is not in the facility overnight. The care plan had multiple interventions including Explain all procedures to the resident before starting .If reasonable, discuss resident's behavior. Explain/reinforce why behavior is inappropriate and /or unacceptable to the resident initiated on 3/19/2024.
The CDC's (Center for Disease Control and Prevention) document titled Decision Tool for Investigating Group A Streptococcus Infections in Long-Term Care Facilities dated 3/1/2024 said, Additional PPE use, as described below, is recommended to control a GAS outbreak. Residents with suspected or confirmed GAS infection from a wound, ostomy, or device-insertion site should remain on Contact and Droplet Precautions until 24 hours after the initiation of effective antibiotic therapy and any wound drainage stops or can be contained by a dressing. HCP should then return to use of EBP (Enhanced Barrier Precautions).
3. On 9/12/2024 at 8:230 AM, R6 and R7 were unmasked in the facility's common areas. R6 was sitting in the hallway leading to the open dining room area and R7 was sitting in the open dining room area. At this time other residents were being transported in and out of the dining room. At 9:05 AM V9 (Activity Aide) was unmasked while walking across the dining room where there were residents in the area. At 1:40 PM V9 was talking to R7 in the dining room where there were other residents. V9's surgical mask was placed underneath her nose and R7 was unmasked. At 1:43 PM V9 said she was unmasked in the morning because she entered the facility from the back-side entrance where there were no surgical masks available. V9 continued to say she was required to wear a surgical mask to cover her nose and mouth to protect herself and others.
On 9/12/2024 at 3:40 PM, V3 (Assistant Director of Nursing/ADON) said all facility staff, residents, and visitors had to be masked because of the facility's Strep A outbreak. V3 said failure to adhere to the mandated facility-wide masking can result in the spread of the disease.
The facility's policy titled Face Mask/Face Shield/Goggles dated 12/2009 showed Policy: Varies types of protective apparel are worn to prevent contamination and the possibility of splattering of blood or body fluids. Protective equipment is to be worn according to the Center for Disease Control Guidelines .A surgical mask is generally worn to provide protection against spread of infectious large-particle droplets that are transmitted by close contact .
Aug 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
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 ensure a nurse was competent to administer medications as ordered an...
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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 nurse was competent to administer medications as ordered and transcribe orders for 4 of 4 residents (R3, R4, R7 and R8) reviewed for nursing services in the sample of 8.
Findings include:
1. R3's Face Sheet shows that she admitted to the facility on [DATE] with diagnoses of: polyneuropathy, schizoaffective disorder, neuromuscular dysfunction of the bladder, anxiety, hypothyroidism, insomnia and hyperlipidemia. R3's Minimum Data Set (MDS) assessment dated [DATE] shows that her cognition is intact.
R3's August Medication Administration Record (MAR) shows that she takes lamotrigine (anticonvulsant) 25 milligrams (mg)-3 tablets once daily at 8:00 AM for mood stabilization, aripiprazole (antispychotic) 10 mg daily at 8:00 AM for mood and paranoia and gabapentin (anticonvulsant) 300 mg three times a day at 8:00 AM, 12:00 PM and 6:00 PM for anxiety/pain.
On 8/13/24 at 10:05 AM, R3 said that V3 (Registered Nurse) gave her her 8:00 AM medication one day and she was missing 2 of the 3 tablets of lamorigine, her aripiprazole and her gabapentin. R3 said that she had to tell V3 that she was missing them and then she corrected it.
2. R4's Face Sheet shows that she admitted to the facility on [DATE] with diagnoses of: seizures, diabetes mellitus, hypothyroidism, hypertension, edema, gastro-esophageal reflux, high cholesterol, morbid obesity, depression, schizoaffective disorder and obstructive sleep apnea. R4's MDS dated [DATE] shows that her cognition is intact.
R4's August MAR shows that she receives the following medications at 8:00 PM: metformin (antidiabetic) 1000 mg, pravastatin (statin) 10 mg, bumetanide (diuretic) 2 mg, divalproex (anticonvulsant) 500 mg, famotidine (acid reducer) 20 mg, levetiracetam (anticonvulsant) 500 mg and ferrous sulfate (supplement) 325 mg. R4's August MAR shows that she receives the following medications at 9:00 PM: mirtazapine (antidepressant) 7.5 mg and olanzapine (antipsychotic) 15 mg.
On 8/13/24 at 9:45 AM, R4 said that V3 came to her room awhile back to give her her evening pills. R4 said that she only had 4 pills in the cup and she usually takes 9 pills at bedtime. R4 said she told V3 that she takes more pills than that and she left the room with the pills and then another nurse brought her the correct amount of pills. R4 said that again last Friday, V3 brought her evening pills in and there was only 8 pills in the cup. R4 said that she showed V3 the list of medications that she takes and she said that she must have forgotten the mirtazapine and went and got her another pill. R4 said that she has told the manager that she does not feel comfortable with V3 giving her her pills any longer.
3. R8's MDS dated [DATE] shows that her cognition is intact.
R8's August MAR shows that she takes quetiapine (antipsychotic) 25 mg-2 tablets at bedtime for agitation/restlessness and melatonin (supplement) 3 mg- 3 tablets at bedtime.
On 8/13/24 at 10:26 AM, R8 said that one evening she was out in the common area when V3 came up to her and gave her one pill in a cup. R8 said that she gave the cup back and told her that it did not look like any of the pills that she takes and she takes more than one pill. R8 said that she then brought me the pills I usually take. R8 said that she has no idea what pill she was about to give her but it was not her pill. R8 said that she does not trust that V3 is giving the right pills. R8 said that she knows her pills so she can tell the nurse when they are wrong but she is really concerned about the residents who can not speak for themselves.
4. R7's July Physician's Order Sheet shows an order entered by V3 for: Haldol (antipsychotic) 5 mg po (by mouth) or IM (intramuscular) PRN (as needed) Q6 hours (every 6 hours) for aggitation (sp) To the left of the order in large writing and underlined twice was Haldol Lactate and signed by V4 (Physician) on 7/9/24.
On 8/13/24 at 12:43 PM, V4 said that he gave V3 a telephone order for Haldol lactate for a resident and she transcribed it wrong. V4 stated, I was mad.
V3's Supervisor Report of Counsel Form dated 7/11/24 shows, On or around 7/11/24 [V3] was found to have administered medication inappropriately. [V3] was advised to ask for help or additional training to prevent this from occurring and failed to do so.
V3's Personnel File did not contain any Nurse Competency Checklists.
On 8/13/24 at 11:16 AM, V3 said that she started working at the facility in July. V3 said that during one of her medication passes with R4, she had missed a page of medications but it was corrected and the resident received all her ordered medications. V3 said that since then, she brings all of R4's medications into her so she can review them before taking them in pudding. V3 said that the other night while R4 was reviewing her medications, she was short one pill. V3 said that she went back and got the missing pill for R4. V3 said, When its late, your tired and trying to get things done, it can happen so now I have her verify that I am giving the right medications. V3 said that she is unaware of any medication issues with R3 or R8. At 12:11 PM, V3 said that she did transcribe R7's orders for his Haldol wrong but she already apologized to the doctor. At 2:55 PM, this surveyor showed V3 a Nurse Competency Checklist that was provided by the facility and she said that she has never seen the checklist before and has never had any competency evaluations that she is aware of.
On 8/13/24 at 11:55 AM, V2 (Previous Director of Nursing) said that they have had a few issues with V3. V2 said that a good nurse requires good thinking skills and assessment skills and she feels that V3 lacks those skills. V2 said that she has concerns with V3's thoroughness and her competency to provide care.
On 8/13/24 at 2:07 PM, V7 (Director of Nursing) said that all nurses should go through an orientation with another nurse for a few days and the nurse should fill out a competency form to ensure the nurse is competent to work with the residents.
The facility Resident Council Minutes for July shows, Nurse [V3] needs a little improvement.
The facility's undated Job Summary for a Registered Nurse shows, Executes procedures consistent with interdisciplinary nursing care plans, the regulatory manual .consistently demonstrates proficiency in skills applicable to nursing Provides for the safety and security needs of assigned residents .
The facility said that they do not have a policy on nurse competencies.
Jun 2024
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, record review, the facility failed to provide structured activities to residents.
This applies to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, record review, the facility failed to provide structured activities to residents.
This applies to 7 of 8 residents (R4, R5, R6, R7, R8, R9, R10) reviewed for activities.
The findings include:
On Saturday 6/8/24 at random times, residents were in the day room or in their rooms without any activities. The following observations were made:
1. On Saturday 6/8/24 at 11:29 AM, R4 stated, There are no activities on the weekend. I would like some. I know they are working on it. Activities are only between Monday through Friday. I have nothing to do.
R4's face sheet shows he was admitted [DATE].
R4's face sheet shows diagnoses of anoxic brain damage and depression.
R4's MDS (Minimum Data Set) dated 4/4/24 shows a BIMS (Brief Interview for Mental Status) score of 13, which means he is cognitively intact.
2. On 6/8/24 at 11:31 AM, R5 stated, I would like some activities on the weekend. We have not had activities during the weekend in a long time. They don't offer anything.
R5's face sheet shows he was admitted to the facility on [DATE].
R5's face shows a diagnosis of depression.
R5's MDS dated [DATE] shows a BIMS score of 15, which means he is cognitively intact.
3. On 6/8/24 at 11:36 AM, R6 stated, They don't really provide activities on the weekend. I would like to do some stuff.
R6 face sheet shows he was admitted on [DATE].
R6's face sheet shows diagnoses of paranoid schizophrenia and bipolar disorder.
R6's MDS dated [DATE] shows a BIMS score of 11, which means he is moderately impaired in cognition.
4. On 6/8/24 at 11:38 AM, R7 stated, Sometimes there is activities and sometimes not. I have not seen them in a long time, especially on the weekends. I would like to play Bingo and cards.
R7's face sheet shows he was admitted on [DATE].
R7's face sheet shows diagnoses of unspecified psychosis not due to a substance or know physiological condition, major depressive disorder, vascular dementia, unspecified severity, with anxiety, depressive and anxiety disorders.
Facility did not provide a MDS.
5. On 6/8/24 at 11:41 AM, R8 stated, There are really no activities here on the weekend. I wish there were some. When there's nothing to do, it's boring, man.
R8's face sheet shows he was admitted on [DATE].
R8's face sheet shows diagnoses of schizophrenia and bipolar disorder.
R8's MDS dated [DATE] shows a BIMS score of 14 which means she is cognitively intact.
6. On 6/8/24 at 1:10 PM, R9 and R10 were lying in bed in their room. Both of them stated that they never have activities on the weekend. They said, It's boring!
R9's face sheet shows he was admitted to the facility on [DATE].
R9's face sheet shows diagnoses of major depressive disorder, severe with psychotic features, anxiety disorder, and schizoaffective disorder.
R9's MDS dated [DATE] shows a BIMS score of 12, which means moderate impairment in cognition.
R10's face sheet shows an admission date of 8/26/2014.
R10's face sheet shows a diagnosis of personal history of traumatic brain injury.
R10's MDS dated [DATE] shows a BIMS score of 12, which means moderate impairment in cognition.
On 6/8/24 at 11:33 AM, V9 (CNA--Certified Nursing Assistant) stated, I don't know what happened this time. Usually there's activities.
On 6/8/24 at 1:05 PM, V1 (Administrator) stated, I will talk to the activity director. We are in the process of revising our activity schedules. Activities should be provided 7 days a week for the residents. On the weekends, if the activity aides are not working, then they should leave the activities like games, puzzles, and/or sheets on the table in the dining room for the residents. It's the MOD (Manager on Duty) and nurse's jobs to administer those activities during the weekend.
On 6/11/24 at 12:40 PM, V11 (Activity Aide) stated, There's supposed to be someone on the weekends to do the activities. If the activity aides are not working on the weekend, someone is supposed to leave the activity on the table for the resident. That ain't good if no one didn't leave anything for the residents on Saturday. They will get bored. They always need something to do.
Facility was unable to provide a policy on activities for residents.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to have a Director of Nursing on a full-time basis. This has the potential to affect all 60 residents who reside in the facility...
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Based on observation, interview, and record review, the facility failed to have a Director of Nursing on a full-time basis. This has the potential to affect all 60 residents who reside in the facility.
Findings include:
On 6/8/24 at 2:52 PM, V1 (Administrator) submitted a resident roster and facility data sheet that showed 60 residents were in the facility.
On 6/8/24 at 10:49 AM, surveyor asked V5 (RN-Registered Nurse) that if she can let the DON (Director of Nursing) know that surveyor is in the building. V5 stated, We don't have a DON. It's been some time now. The administrator is on her way. We used to have an ADON (Assistant Director of Nursing), but she is no longer with us. Someone from corporate is helping us.
On 6/8/24 at 11:08 AM, V6 (LPN-Licensed Practical Nurse) stated, We don't have a DON here. But we have a regional lady and we have someone from our sister facility that is helping us.
On 6/11/24 at 9:15 AM, V1 stated, (V13--Former DON--Director of Nursing) resigned on 3/29/24. Then (V14--2nd Former DON) took over on 3/30/24. (V14) then worked for a couple of weeks. Then we had both (V3--Regional Director of Clinical) and (V2--Acting DON) cover as DON. (V3) covers for 3 days and (V2) covers for 2 days. (V2) also covers as DON at our sister facility for 3 days. (V3) was not here last week because she has something personal going on and had appointments. (V2) was here last Tuesday but was not here Wednesday to Friday because she was sick.
On 6/11/24 at 9:20 AM, V3 (Regional Director of Clinical) stated, I was just diagnosed with [medical condition] during the facility's annual survey (5/28-5/31). I try to come here 3 times a week, but I have other homes that I'm responsible for. (V2) who works in our sister facility also helps out 2 days a week here. There are times when I couldn't come here because I had doctor appointments. I've been assisting, but mainly (V2) is the one doing the job as DON. Surveyor asked V3 if the facility was meeting the federal regulations of having a full time DON. V3 stated, Honestly, not at 100%. We don't have someone here full time to do the duties of a DON the whole time. We are hiring a DON and ADON (Assistant Director of Nursing). I believe they will take the position today.
On 6/11/24 at 9:47 AM, V2 (Acting DON) stated, I'm the full time DON at our sister facility. (V3) told me I have to work 20 hours here as well. I started here approximately May 15, 2024. Intermittently, I would go to both places. When I came here, we didn't have a structured clinical meeting on what my job duties were to be. They told me to focus on infection control.
On 6/11/24 at 11:55 AM, telephone interview was done with V12 (Health Department Communicable Disease Supervisor). V12 stated, (V2) is the DON for two sister facilities. This shouldn't be happening. She shouldn't be dividing her time. She has to focus on infection control and the outbreaks at this facility.
On 6/11/24 at 12:12 PM, V2 (Acting DON) stated, When I do my required 2 days a week here, I work 10 hours a day. This morning, I stopped the by the sister facility for a few hours and now I'm here. I don't have a ADON (Assitant Director of Nursing) here to help me. I know some changes had to happen when I walked in the door. I knew it was going to be challenging. It's unfortunate that we got all the tags that happened during our annual.
Facility's job description of Director of Nursing (Unknown Date) shows the following: Job Summary: To plan, organize, develop, and direct the overall operation of our nursing service department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility and as may be directed by the Administrator and the Medical Director to ensure that the highest degree of quality care is maintained at all times. 7. Must possess the ability to plan, organize, develop, implement and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality care. 8. Make daily rounds of the nursing service departments to ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards. 9. Schedule daily rounds to observe residents and to determine if nursing needs are being met in accordance with the resident's needs. 10. Monitor medication passes and treatment schedules to ensure that medications are being administered as ordered and that treatments are provided as scheduled.
May 2024
16 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Medication Errors
(Tag F0758)
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 follow physician's orders for psychotropic medication ...
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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 follow physician's orders for psychotropic medication administration (R36). The facility failed to follow its psychotropic medication policy by failing to monitor residents (R1, R14, R36) for Extrapyramidal Symptoms due to antipsychotic medication use and failing to attempt/request a Gradual Dose Reduction of a Benzodiazepine medication for a resident (R14) no longer exhibiting anxiety behaviors. These failures resulted in the R36 receiving the wrong psychotropic medications and at excessive dosages. R36 experienced side effects of increased abnormal involuntary movements.
This applies to 3 of 5 residents (R1, R14, and R36) reviewed for psychotropics in a sample of 19.
The findings include:
1. R36's Medical Record (MR) showed R36 was receiving psychiatric care for major depression, anxiety, and insomnia. R36's MDS (Minimum Data Sheet) dated 5/02/2024 showed R36 was cognitively impaired and did not show any mood symptoms such as feeling depressed.
On 5/28/2024 at 10:26 AM, R36 was sitting in her wheelchair in the dining room. R36 was observed displaying abnormal truck, facial, and oral movements such as rocking, lip-smacking, puckering, and her tongue moving in and out of her mouth repeatedly.
On 5/30/2024 at 8:01 AM, V3 (Registered Nurse/RN) said R36 was receiving psychotropic medications including antipsychotics. V3 said R36 was no longer exhibiting mood behaviors such as depression or anxiety. V3 said he did not believe R36 was having any side effects related to her psychotropics such as abnormal involuntary movements.
R36's care plan reviewed on 5/30/2024 showed psychotropic medication (med) use related to behaviors of depression and agitation. The care plan had multiple interventions including Administer anti-psychotic medication as ordered-See POS (Physician's order Sheets) for current med, dose and schedule. Observe for antipsychotic side effects: .parkinsonism .tardive dyskinesia .extrapyramidal reactions, dystonia . Refer to psychiatrist or neuro-psychologist for effective and safe behavior and med management. Assess/record/report drug related Tardive Dyskinesia symptoms. Perform AIMS (Abnormal Involuntary Movement Scale) assessment at least q (every) 6 months. Review quarterly w (with)/plan of care and prn (as needed) change in antipsychotic medication and changes in condition. Report changes in AIMS reported values to MD (Medical Doctor) for consideration and follow up.
R36's Abnormal Involuntary Movement Scale (AIMS) assessment dated [DATE] showed a score of 0, for displaying any abnormal involuntary movements including facial, oral, and trunk movements.
R36's pharmacy consultation report dated 4/23/2024 said there was a ***TIME SENSITIVE RECOMMENDATION: PRESCRIBER RESPONSE AND FACILITY ACTION REQUIRED BY 11:59 PM ON APRIL 24 2024 . The report said R36's MR was reviewed and multiple irregularities with her psychotropic medications were identified, **Per [V14's (Psychiatric Nurse Practitioner/NP)] progress notes from 2/19/24, Abilify was decreased twice from 20 mg to 5 mg at bedtime daily. Currently, the order is still for 20 mg***Per [V14's] progress notes from 12/23/23 Seroquel (Quetiapine) (Antipsychotic) was replaced with Trazodone (Antidepressant), however, there is an active order for Quetiapine 25 mg at bedtime and NO order for Trazodone. The report showed a notation that nursing staffing was made aware and per the nurse clarification from psychiatric NP would be obtained, but the report did not show acknowledgment or response to the recommendation.
R36's POS (Physician Order Sheets) showed an order dated 5/02/2024 Decrease Aripiprazole (Atyplical Antipsychotic) to 10 mg PO (by mouth) daily QHS (every eveing) x 1 week and then decrease to 5 mg PO QHS x 1 week and then DC (discontinue) and an order dated 5/30/2024 (ordered during the survey) D/C Seroquel 25 mg at bedtime.
R36's MAR (Medication Administration Record) from 5/01/2024-5/31/2024 showed R36 received Aripiprazole (Abilify) antipsychotic 20 mg (milligrams) at bedtime on 5/01/2024 through 5/13/2024, and additionally received 10 mg at bedtime on 5/02/2024 through 5/08/2024 and then continued to receive an additional dose of 5mg at bedtime on 5/09/2024 through 5/15/2024. The MAR showed R36 received Quetiapine (Seroquel) antipsychotic 25 mg at bedtime on 5/01/2024 through 5/29/2024. The MAR did not show any order for Trazodone.
R36's psychiatric consultation report dated 2/19/2024 showed R36 was receiving ongoing psychiatric care services for behavior and mood management. The report said V14 (NP) had made psychotropic medication adjustments in 2022, During my prior visit with her on 9/5/2022, I replaced her Seroquel with Trazodone as she only uses Seroquel for sleep .I saw her again on 10/24/2022, I decreased her Aripiprazole from 20 mg to 10 mg QHS due to increased lethargy, sedation, falls, hand shaking and trunk rocking. During my prior visit with her on 11/16/2022, I Decreased her Aripiprazole from 10 mg to 5 mg QHS due to increased lethargy, sedation, falls, hand shaking and trunk rocking. The report continued to show R36 was to continue to receive Aripiprazole 5 mg at bedtime for major depression and anxiety, and Trazodone 50 mg at bedtime for insomnia. The facility was unable to provide R36's last psychiatric consultation report from 5/02/2024.
On 5/30/2024 at 9:43 AM, V14 (Psychiatric Nurse Practitioner/NP) said he was managing R36's psychiatric behaviors and psychotropic medications. V14 said he expected staff to appropriately monitor residents and report psychotropic medication side effects to safely manage their psychiatric therapy. V14 continued to say he expected his orders to be followed, his consultation reports to be reviewed, and recommendations followed. V14 said he had ordered R36's Aripiprazole be tapered and discontinued because he noted R36 was displaying side effects including ESP (extrapyramidal symptoms), and her Seroquel be switched to Trazodone in 2022. V14 said R36 should have never been back on Aripiprazole. V14 said on his last visit on 5/02/2024 he was notified of R36's medication discrepancy for Aripiprazole, and he again ordered the medication to be safely tapered and discontinued. V14 said he was not notified of the medication discrepancy for Seroquel and Trazadone. V14 said he expected to be notified of medication discrepancies in a timely manner to prevent additional side effect complications. V14 said during his visit on 5/02/2024 he did not observe R36 displaying abnormal involuntary facial or oral movements such as lip smacking or repetitive tongue movements. V14 continued to say he was never notified of R36's new abnormal involuntary facial and oral movements nor R36's new medication error. V14 said he was never notified his order from 5/02/2024 was not carried out correctly which resulted in R36 receiving increased doses of Aripiprazole and an inappropriate tapering of the medication.
The facility policy titled Reduction of Psychotropic Medications Protocol with the reviewed date of 8/22/2018 showed Policy: Residents who must receive medications are to be maintained at the safest, lowest dosage necessary to control the resident's condition .Procedure . 5. Each resident taking psychotropic medications shall have their psychotropic medications reviewed and documented as such by the physician. The consulting Registered Pharmacist will review psychotropic medications on a monthly basis. Any resident receiving psychotropic medications will be reviewed at a minimum of every quarter by the interdisciplinary team. Reduction shall be attempted at least twice in one year, unless the physician documents the need to maintain the resident regimen according to the Regulatory Guidelines for such. 6. These medications shall be used when deemed necessary by each resident attending physician and/or psychiatric consultant. Each resident will be maintained on as low dosage of these medications as possible. Dosage reductions may be attempted whenever the resident's behavior patterns indicate to the attending physician that a dosage reduction may be appropriate. 7. Nursing personnel will report any side effects observed to the appropriate charge nurse. Any side effects shall be charted in the resident's clinical record and the physician shall be notified .11. Individual resident response and/or progress will be documented at least monthly by a Licensed nurse in the clinical record.
The facility policy titled Psychotropic Medication Policy with a revised date of 11/28/1017 showed Policy: It is the policy of this facility that residents shall not be given unnecessary drugs. Unnecessary drugs is any drug used: 1. In an excessive dosage, including in duplicative therapy 2. For excessive duration 3. Without adequate monitoring .5. In the presence of adverse consequences that indicate the drugs should be reduced or discontinued. That these medications be withheld if the resident is lethargic and/or exhibiting any sign of over sedation and the physician will be contacted if these conditions persist .Procedure .9. Residents who use antipsychotic drugs shall receive gradual dose reductions and behavior interventions, unless clinically contraindicated, in an effort to discontinue the drugs. Any resident receiving psychotropic medications will be reviewed at a minimum of every quarter by the interdisciplinary team .12. The consultant Pharmacist will request medication reductions as decided on a monthly basis. Recommendations will be printed and sent to the physician in a timely manner. 13. Licensed Nurses will transcribe any new recommendations from the Physician as received to the facility .16. The nurse will monitor for side effects such as drooling, shuffling gait, joint rigidity, mask like face, akathisia, significant weight changes, increased lethargy, decreased appetite, decrease in ADLs, decreased cognition, tardive dyskinesia and document by exception. 17. Any resident receiving psychotropic medications will have an AIMS assessment done at a minimum of every six (6) months .20. Quarterly documentation will be done on a progress note of any resident that currently receives psychotropic medications. This is to include, but is not limited to, individual resident response and/or progress, psychotropic medication assessment, behaviors exhibited, problems or issues which the resident may be having, current medications, recent medication changes, and tolerance of medication regimen .
2. R1's MR showed R1 was receiving psychiatric care for schizoaffective disorder, bipolar disorder, depression, and psychosis. R1's MDS dated [DATE] showed R1 was cognitively impaired.
On 5/28/2024 at 10:03 AM, R1 was in bed. R1 was unable to engage in the interview, his speech was incohesive and disorganized. R1 was making inappropriate sexual gestures. R1 was observed displaying abnormal oral movements such as lip smacking with his mouth opening with his tongue moving in and out of his mouth repeatedly.
On 5/30/2024 at 08:01 AM, V3 (RN) said R1's behaviors were screaming and making inappropriate sexual comments. V3 said R1 was receiving psychotropic medications including an antipsychotic. V3 said he did not believe R1 was having any side effects related to his psychotropics and R1's abnormal movement were not new.
R1's Abnormal Involuntary Movement Scale (AIMS) assessment dated [DATE] showed a score of 1 for facial muscle expression not including abnormal movements of the lips, perioral area, jaw, or tongue.
R1's care plan reviewed on 5/30/2034 showed psychotropic medication use related to behaviors of aggression, physically abusive, uncontrollable screaming, and auditory hallucinations. The care plan had multiple interventions including Assess/record report drug related Tardive Dyskinesia symptoms. Perform AIMS assessment at least q 6 mo. Review quarterly w/plan to care and prn with changes in antipsychotic medication and changes in condition. Report changes in AIMs reported values to MD for consideration and follow up .Observe for antipsychotic side effects: .parkinsonism .extrapyramidal reactions .Notify MD of noted side effects to determine if benefits of therapy outweigh side effects
R1's psychiatric consultation report dated 5/22/2024 showed R1 was receiving ongoing psychiatric care services. The report showed R1 was receiving medication treatment for EPS (extrapyramidal symptoms).
On 5/30/2024 at 9:43 AM, V14 (Psychiatric Nurse Practitioner/NP) said he was managing R1's psychiatric behaviors and for his ongoing EPS side effects. V14 said he expected staff to appropriately monitor residents and report psychotropic medication side effects to safely manage their psychiatric therapy.
3. R14's MR showed R14 was receiving psychiatric care for anxiety and adjustment disorder with depressed mood. R14's MDS dated [DATE] showed R14 was cognitively impaired.
On 5/29/2024 at 10:00 AM and 5/30/2024 at 11:42 AM, R14 was observed in bed sleeping. R14 was unable to engage in the interview, R14 appeared fatigued and confused. On 5/29/2024 at 1:10 PM, V13 (Activity Aide) said she was familiar with R14, and R14 was always slepping a lot throughout the day.
On 5/30/2024 at 8:01 AM, V3 (RN) said R14's behaviors were resisting care and refusing to get out of bed. V3 said R14 was receiving psychotropic medications including an anxiolytic. V3 also said R14 slept a lot throughout the day.
R14's care plan reviewed on 5/30/2024 showed psychotropic medication use related to behaviors of sadness, agitation, irritability, and refusing care. The care plan's goal was Will respond cooperatively to behavior interventions resulting in maintenance on lowest therapeutic dose of medication and had multiple interventions including Administer anti-anxiety medication as ordered .Observe for antianxiety side effects: drowsiness, sedation, somnolence, difficulty speaking, impaired coordination, memory impairment, fatigue, depression, confusion .
R14's pharmacy consultation report dated 2/21/2024 said R14 had been receiving Lorazepam/Ativan (Benzodiazepine) 0.5 mg (milligrams) twice daily since 7/06/2022. The report showed a recommendation to attempt a gradual dose reduction (GDR). The report did not show acknowledgment or response to the recommendation.
R14's psychiatric consultation report dated 2/19/2024 showed R14 was receiving ongoing psychiatric care services for mood behavior. The report showed R14's Mirtazapine (antidepressant) was discontinued on 11/16/2022 due to sedation and drowsiness, especially during the day. The report continued to show R14 was to continue with Ativan for anxiety and Lexapro for depression.
On 5/30/2024 at 9:43 AM, V14 (Psychiatric Nurse Practitioner/NP) said he was managing R14's psychotropic medications and behaviors. V14 said he could not remember if he received R14's pharmacy recommendation, but felt a GDR was not recommended because R14 had cycled episodes of being anxious and did not want to take the risk. V14 continued to say he had discontinued R14's Mirtazapine because he was sleepy in the past and R14's Ativan could be causing him to be sleepy currently. V14 said R14's sleepiness throughout the day was a concern.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to give residents appropriate written notices that their Medicare Coverage was coming to an end. This applies to 2 of 2 residents (R36, R41) r...
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Based on interview and record review, the facility failed to give residents appropriate written notices that their Medicare Coverage was coming to an end. This applies to 2 of 2 residents (R36, R41) reviewed for Medicare coverage in a sample of 19.
The finding include:
On 5/28/24 at 9:45 AM, entrance conference was completed with V1 (Administrator). Surveyor gave V1 the form titled Beneficiary Notice-Residents discharged Within the Last Six Months. Surveyor asked V1 to fill out the sheet with the names of residents who were discharged from a Medicare covered Part A stay with benefit days remaining in the past 6 months.
On 5/29/24 at 1:00 PM, V1 returned the form back to surveyor with only two resident's names (R36 and R41) on the form. V1 stated that V18 (Business Office Manager) completed the form.
On 5/29/24 at 1:46 PM, V18 (Business Office Manager) stated, I started on 4/22/24. I'm new. I don't have a list of residents who were given a NOMNC (Notice of Medicare Non-Coverage) form and SNF-ABN (Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage) in the last 6 months. I just know of 2 residents (R36 and R41). I told them verbally that they had so many days remaining. I don't remember exactly how many days remaining they had. I was not aware that you need to give something in writing. I don't know what the NOMNC and SNF-ABN forms are. I don't have the names of the residents who had benefit days remaining.
On 5/29/24 at 1:52 PM, surveyor submitted two forms titled SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review to V18. V18 filled out both forms for R36 and R41. On both forms, V18 wrote she did not give the NOMNC and SNF-ABN forms to both R36 and R41 because she was not aware of the forms.
1. On 5/29/24 at 2:35 PM, surveyor asked R36 if V18 ever told her that she had this many remaining days with Medicare or was given anything in writing. R36 stated, No! (V18) never told me anything and I never got anything in writing from her.
R36's face sheet shows an admission date of 7/30/20. Payer information shows she has Medicaid Pending and Medicare B.
R36's MDS (Minimum Data Set) dated 5/2/24 shows a BIMS (Brief Interview for Mental Status) score of 15 which means she is cognitively intact.
Review of R36's medical record shows no NOMNC and SNF-ABN forms.
2. On 5/29/24 at 2:45 PM, surveyor asked R41 if V18 ever told him how many remaining days he had left with Medicare or was given anything in writing. R41 stated, She never told me anything and she never gave me anything in writing.
R41's face sheet shows an admission date of 10/5/21. Payer information shows he is private pay and has Medicare B.
R41's MDS (Minimum Data Set) dated 4/30/24 shows a BIMS score of 9, which means he is moderately impaired in cognition.
Review of R41's medical record shows no NOMNC and SNF-ABN forms.
Facility was unable to provide a policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide privacy during pressure ulcer dressing changes. This applies to 2 of 2 residents (R47, R50) reviewed for privacy in a...
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Based on observation, interview, and record review, the facility failed to provide privacy during pressure ulcer dressing changes. This applies to 2 of 2 residents (R47, R50) reviewed for privacy in a sample of 19.
The findings include:
1. R47's care plans show he has a gtube and stage 3 pressure ulcer to his right heel.
V4's (Wound Doctor) note dated 5/22/24 shows that R47 has a stage 3 pressure wound to the right heel. Primary dressing: Alginate rope with silver. Apply once daily for 23 days. Secondary dressing: Foam silicone border. Apply once daily for 23 days.
On 5/29/24 at 12:25 PM, V3 (RN-Registered Nurse) put on gloves and entered R47's room without wearing a gown. V3 removed R47's dressing on his right foot. V4 (Wound Doctor) put on gloves and came inside without wearing a gown. V4 measured (R41's) pressure sore wound on his foot. V3 then completed the dressing change on R47's foot as per the physician's orders. During the procedure, the door was left open and the curtain was only pulled halfway. R47's roommate was present in the room as well.
2. R50's face sheet shows a diagnosis of pressure ulcer of left heel, stage 3.
R50's care plans show R50 has a pressure sore.
V4's wound note dated 5/22/24 shows that he has a stage 4 pressure wound to the left heel. Primary dressing: Iodosorb get apply once daily for 30 days. Secondary dressing: Foam silicone border-apply once daily for 30 days.
On 5/29/24 at 12:37 PM, V3 (RN) entered R50's room. V3 removed R50's heel boots, socks, and dressing on his left foot. V4 (Wound Doctor) came in wearing gloves, but no gown. He applied pain medicine (Benzocaine Aerosol Spray) and debrided the wound. V3 then applied the treatment which included wound cleanser Idosorb, and foam dressing. Throughout the procedure, R50's blinds were open. There was a house in view of the window.
On 5/29/24 at 1:02 PM, V2 (DON-Director of Nursing) stated, When you give care like wound dressing changes, you need to close the door and blinds to maintain privacy.
Facility's policy titled AM Care (3/20/23) shows: 3. Provide privacy. Pull window curtains and privacy curtains.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to provide the necessary services to maintain good personal hygiene for 1 of 11 residents (R11) reviewed for activities of daily ...
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Based on observation, interview, and record review the facility failed to provide the necessary services to maintain good personal hygiene for 1 of 11 residents (R11) reviewed for activities of daily living in the sample of 19.
The findings include:
On 5/28/24 at 9:39 AM, observed R11 lying in bed. R11's mouth was crusty and lips dry. R11 had very strong foul odor.
On 5/28/24 at 2:30 PM, V5 (RN-Registered Nurse) stated, the foul odor on R11 is from his mouth and that it is because of some periodontal issue that R11 had.
On 5/30/24 at 12:05 PM, V10 (CNA- Certified Nursing Assistant) stated, Mouth care is provided to prevent odor or to clear bad smell. Also to prevent any infection in the gums. V10 (CNA) stated, R11 had a strong mouth odor. V10 stated, sometimes, (R11) resists care and does not open his mouth and at other times he does. V10 stated, he had informed nurses multiple times in the past that R11's mouth smells bad.
On 5/29/24 at 12:11 PM, V2 (DON-Director of Nursing) stated, she is not aware of any periodontal condition that R11 has. V2 stated, R11's mouth had very foul odor due to poor oral hygiene.
On 5/29/24, at 2:00 PM, reviewed R11's medical records. R11's face-sheet did not show any diagnosis related to his mouth or teeth or gums.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to safely transfer a resident (R10) and safely position a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to safely transfer a resident (R10) and safely position a resident (R14) when assisting with feeding in bed.
This applies to 2 of 2 residents (R10 and R14) reviewed for accidents in a sample of 19.
The findings include:
1. R10's Medical Record (MR) showed multiple diagnoses including general convulsant epilepsy intractable seizure disorder, left hemiparesis secondary to encephalitis, left homonymous hemiopia, and degenerative joint disease with arthritis. R10's MDS (Minimum Data Set) dated 4/07/2024 showed R10 required substantial to maximal staff assistance with transfers.
On 5/28/2024 at 9:53 AM, R10 was sitting on the edge of her bed leaning on her left side, and was barefoot. V11 (Certified Nurse Assistance/CNA) said R10 was scheduled for a shower, and V11 proceeded to transfer R10 from the bed to the shower chair. V11 pulled and lifted R10 from her armpits when transferring into the shower chair, V11 did not use a gait belt.
On 5/29/2024 at 3:57 PM, V2 (Director of Nursing/DON) said staff should use a gait belt for residents that require one-person assistance and ensure residents have proper footwear when assisting with transfers for safety.
R10's care plan was reviewed on 5/30/2024 and showed an activity daily living problem related to self-care deficit to assist to complete quality care. The care plan showed multiple interventions including Assist to Transfer using 1 staff assist. Use gait belt for all hands on transfers from one surface to another .Reassure of safety as needed.
The facility's policy titled Transfer Belts/Gaitbelt Policy undated showed To promote safety in transferring and ambulating residents, a gait belt will be utilized by nursing or therapy staff .All Certified Nurses Aids (C.N.A.'s) and licensed nursing personnel engage in the lifting and transferring of residents will use gait belts .The use of gait belts and mechanical lifts is essential to reduce the risk of accident and injury to both residents and employees .Procedure: .1. Direct resident care personnel will routinely have a gait belt on their person .3. Gait belt is placed around the resident's waist .
2. R14's MR showed multiple diagnoses including cerebral infarction, muscle weakness, and lack of coordination. R14's MDS dated [DATE] showed R14 required partial to moderate staff assistance with bed mobility.
On 5/29/2024 at 8:06 AM, V14 (CNA) was feeding R14 in bed. R14 was in a slouched position, his buttock was lower than the bend of the bed. V12 (CNA) said sometimes R14 was able to feed himself if sitting up.
On 5/30/2024 at 2:36 PM, V2 (DON) said residents being fed in bed should be in a safe position not slouched. On 5/30/2024 the facility said they did not have a policy for feeding or positioning in bed.
R14's care plan was reviewed on 5/30/2024 and showed a bed mobility problem with multiple interventions including Assess need for adaptive equipment or enablers to maintain safety and increase independence in bed mobility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
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 monitor and ensure that a resident with orders for a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor and ensure that a resident with orders for a double protein diet received the diet as ordered by the physician. The facility failed to ensure weight interventions were followed per policy. This failure resulted in a -10.16 % weight loss from November 2023 to May 2024.
This applies to 1 of 1 resident (R40) who was reviewed for double protein diet in a sample of 19 residents.
The findings include:
On 05/29/2024 at 12:24 PM, R40 was in the dining room, not interviewable, and appeared emaciated and weak. At 12:15 PM, staff served R40 a meal tray. R40's meal card showed diet pureed, honey thick, double protein. R40's meal tray was served with regular portions of pureed meat, green beans, and smashed potatoes.
R40's face sheet showed R40 is a [AGE] year-old female with diagnoses including type 2 diabetes mellites, iron deficiency anemia, chronic kidney disease, cerebral vascular accident, and dysphagia.
R40's medical records did not have weight recordings after March 2024. The weight document obtained from the weight log of residents from the Dietary Manager's folder showed the following weights:
on 11/2023, 125.0 pounds;
on 12/2023, 120.9 pounds;
on 01/2024, 121.0 pounds;
on 02/2024, 119.6 pounds;
on 03/2024, 110.1 pounds;
on 04/2023, 109.9 pounds;
on 05/2023, 112.3 pounds;
On 11/2023, the resident weighed 125 pounds; on 05/2024, the resident weighed 112.3 pounds, a -10.6 % loss from November 2023 to the current month.
R40's physician order dated 03/12/2024 showed double protein with lunch and dinner. The dietician's quarterly assessment dated [DATE] showed weight loss for three months to add double protein at lunch and dinner and continue weight weekly.
On 05/28/24 at 12:32 PM, V6 (Dietary Manager) saw R40's meal tray and said staff should have served double protein and it's ordered for her weight loss. V6 said the cook should set up meal trays per the meal card's directions. At 12:36 PM, V17, [NAME] said she set up R40's meal tray, forgot to set up double protein, and acknowledged that she should have done it correctly. V6 and V17 said they could give one now.
On 05/30/2024 at 11:30 AM, V7 ( Registered Dietician) recommended that R40 eat double protein for lunch and dinner to prevent weight loss. R40 should have received his double portion as ordered to prevent further weight loss.
R40's care plan revision, dated 03/04/2024, was reviewed for the focus area of risk for weight loss. However, the care plan was not updated on significant weight loss and double protein meals for lunch and dinner, and the facility failed to have/provide evidence of weekly meetings and consistent monitoring of weekly weights from the recommended date of 03/04/2024 to current.
The facility weight committee-food service responsibilities policy revised dated October 2016 in part showed the weight committee meets once a week to discuss weight changes of residents based on monthly/weekly weight. The facility policy resident weight monitoring revised dated March 2019 showed in part residents with increased risk for weight loss will be put on weekly weight for four weeks and after four weeks if a weight has stabilized monthly will be reestablished.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
.
3. On 5/28/24 at 9:39 AM, observed R11 lying in bed. GTF (Gastrostomy feed) - Diabetisource 1.2, running at 80 ml/hr via pump. The bag had no label to show the date and time the feeding was started,...
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3. On 5/28/24 at 9:39 AM, observed R11 lying in bed. GTF (Gastrostomy feed) - Diabetisource 1.2, running at 80 ml/hr via pump. The bag had no label to show the date and time the feeding was started, who started the feeding and how much quantity to be given.
On 5/28/24 at 2:30 PM, V5 (RN-Registered Nurse) stated, the bag of feed should have included a label showing date and time the feed started, signature of the person who started it and the quantity to be fed.
On 5/29/24 at 12:11 PM, V2 (DON-Director of Nursing) stated, the GTF bag must be labeled with the resident's name, type of feed, rate, date, start time and nurse's initials.
Based on observation, interview, and record review, the facility failed to ensure they had supply of gastrostomy tube feeding formula for residents per order, failed to label and date gastrostomy tube feedings and failed to follow physician's orders for feedings. This applies to 3 of 3 residents (R11, R12, R47) reviewed for gastrostomy tubes in a sample of 19.
The findings include:
1. R12's face sheet shows diagnoses of quadriplegia, gastrostomy (g-tube) status, and dysphagia.
R12's May POS (Physician Order Sheet) shows an order for Isosource HN (high nitrogen) at 80 ML/HR (milliliters/hour) per g-tube x 20 hours (may substitute with Jevity 1.5 if n/a): On at 9:00 AM and off at 5:00 PM.
R12's care plan shows he receives enteral nutrition support. He has diagnosis of TBI (Traumatic Brain Injury) from motor vehicle accident. Current feeding Isosource 1.5 at 70 ML/HR x 20 hours with flushing water 325 ML every 6 hours (may substitute jevity 1.5 if Isosource is not available).
On 5/28/24 at 10:41 AM, R12 was in bed. R12 is non-verbal. He was connected to a g-tube machine which was running at 70 ML/HR (Milliliters/Hour). There was a bag with therapeutic nutrition inside. The bag was not labeled or dated.
2. R47's face sheet shows diagnoses of cerebral infarction due to thrombosis of basilar and gastrostomy status.
R47's May POS shows orders for Jevity 1.5 cal at 60 ML/HR continuous 10 to 6, 6 to 2, and 2-10.
R47's care plan documents the resident to receive nutrition via tube feeding. Intervention: The resident is dependent with tube feeding and water flushes. See MD (Medical Doctor) orders for current feeding orders.
On 5/28/24 at 10:45 AM, R47 was in bed. R47 is non-verbal. He was connected to a g-tube machine which was running at 55 ML/ HR. There was a bag with therapeutic nutrition inside. The bag was not labeled or dated.
On 5/28/24 at 10:50 AM, V3 (RN-Registered Nurse) stated, (R12) and (R47) are both getting these cartons of Isosource. We ran out of the feedings last Thursday. In the meantime, I use these cartons of Isosource 1.5 and put in the Kangaroo bag. Then I flush it every 6 hours.
On 5/29/24 at 9:38 AM, surveyor showed V3, R47's May POS which says an order for Jevity 1.5 cal at 60 ML/HR continuous. V3 stated, I don't know why that order is there. Whoever nurse transcribed it, did it wrong. That order should not be there. Jevity is the equivalent to Isosource. I don't know why R47 doesn't have an order for Isosource. We ran out of the Isosource feeding last Thursday. Now we are using the cartons and putting it in the Kangaroo bag. It's management's job to order more. Yes, we have to label and date the feeding tube bags.
On 5/28/24 at 12:57 PM, V2 (DON-Director of Nursing) stated, We have to label and date the g-tube bag for validation and authenticity. I was not made aware that we ran out of feeding. The nurses should be following doctor's order. I'm new here.
Facility's policy titled Enteral Feedings (2/2008) shows: Procedure: 1. The Dietician/Consultant will monitor all diet orders for tube feedings and will recommend as appropriate changes in product according to resident need. 2. Commercially prepared tube feedings are ordered by the attending physician and dispensed from the nursing department with preference given to closed systems. 6. Physician order will be obtained for all infusion orders prior to initiation of feeding. 13. If a closed system is not used, tubing, bag, and syringe will be replaced and labeled every 24 hours by the third shift.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to store narcotic medications under double-lock and failed to properly store an inhaler.
This applies to 2 out of 7 residents (R2...
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Based on observation, interview and record review, the facility failed to store narcotic medications under double-lock and failed to properly store an inhaler.
This applies to 2 out of 7 residents (R2 and R32) reviewed for medication storage in a sample of 19.
The findings include:
1. On 5/29/2024 at 9:41 AM, facility's medication room was inspected with V5 (RN-Registered Nurse). It was observed that the medication refrigerator had no lock. Inspection of the refrigerator showed R2's opened Lorazepam Concentrate 2mg (milligrams)/ml (milliliter). The medication was opened on 3/19/2024.
R2's May 2024 POS (Physician Order Sheet) shows order for Lorazepam Oral Solution 2 mg/ml, take 0.25 ml - 0.5 ml orally or sublingually every two hours as needed for agitation or restlessness.
On 5/29/2024 at 9:41 AM, V5 said the refrigerator is never locked. On 5/30/2024 at 11:37 AM, V5 said all narcotics should be double locked to prevent theft and diversion of medication. She confirmed that R2's Lorazepam was in the unlocked refrigerator in the medication room. She again said that the refrigerator in the medication room is never locked.
On 5/30/2024 at 11:40 AM, V8 (ADON-Assistant Director of Nursing) said all narcotics should be double locked to reduce the chances of theft or diversion. She said she was not aware that the refrigerator in the medication room had no lock.
Facility's Policy on Procurement and Storage of Medication dated 10/06 and revised on 11/6/18 does not address storage of Lorazepam.
2. On 05/28/24 at 10:50 AM, observed Albuterol inhaler on R32's bedside table. R32 stated, that is his rescue inhaler and that he uses it as needed when he cannot breathe.
On 05/29/24 at 12:37 PM, DON (Director of Nursing) stated, a doctor's order is needed to keep medicines at the resident's bedside. DON stated, R32 does not have any orders to keep medications at his bedside.
On 5/29/24 at 2:00 PM, reviewed R32's POS (Physician Order Sheet). R32's POS did not show any order for R32 to self medicate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to store resident food that requires refrigeration in the refrigerator, remove expired food, place a thermometer in the fridge, ...
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Based on observation, interview, and record review, the facility failed to store resident food that requires refrigeration in the refrigerator, remove expired food, place a thermometer in the fridge, and complete temperature logs. This applies to 2 of 2 residents (R28, R51) reviewed for refrigerators in sample of 19.
The findings include:
1. On 5/28/24 at 10:23 AM, during initial tour, surveyor went to R51's room. R51 was in the bathroom. On top of his dresser, he had the following opened items. Smooth ranch dip, two jars of 12 fluid oz (ounces) Miracle Whip, 1 bottle of 14 fluid oz of yellow mustard, 1 jar of 16 oz of extra hot giardiniera. On the items, it says refrigerate after opening. R51 did not have a refrigerator in his room. There was a package of ½ loaf of Brioche bread with a best by date of 4/26/24.
On 5/30/24 at 10:05 AM, surveyor went back to R51's room to talk to R51. However, R51 was sleeping and surveyor could not interview him. The items were still on top of his dresser.
2. On 5/28/23 at 11:14 AM, surveyor went to R28's room. R28 had a fridge in his room. Inside there was mayonnaise, peppers in jars, cola, butter, ranch dressing, mustard, hot sauce, creamer, a container of mustard potato salad with a sell by date of 5/13/24 and a container of American potato salad with a sell by date of 5/2/24. There was no thermometer inside the refrigerator. There was no refrigerator temperature log. R28 stated, They (staff) never check my refrigerator.
On 5/29/24 at 2:15 PM, V1 (Administrator) stated, Residents are supposed to have thermometers in their fridges and temperature logs for them. The logs should be kept close by. If there are expired items, they should be removed. Food that needs to be refrigerated should be refrigerated or it may cause possible contamination.
On 5/29/24 at 9:57 AM, V8 (Licensed Practical Nurse/Assistant Director of Nursing) stated, I check the temperatures in the morning or if I'm not here, one of my nurses does it. There were some residents that didn't have thermometers inside, so I just completed the logs now. I use the red infrared thermometer to take the temperature of the refrigerators that don't have thermometers. Surveyor asked V8 to bring the infrared thermometer so the surveyor can see it. V8 never brought the thermometer to the surveyor during the course of the survey.
Facility's policy titled Food From Outside Sources/Personal Food Storage (4/17) shows the following: 6. Foods that do not require refrigeration may be stored in the resident's room in closed storage containers provided by residents and/or resident's responsible party. Other or beverages may be stored in facility refrigerators, freezers or resident's personal room refrigerators. 7. Food and beverages brought in from outside sources, that are to be stored in the facility refrigerators and freezers, will be checked by a dietary staff member. Any suspicious or obviously contaminated food or beverage will be discarded immediately. Food and beverages will be labeled with resident's name, food item and date. These foods and/or beverages will be placed on a designated tray/shelf. Facility storage procedures apply. 9. Each resident refrigerator shall have a temperature log. Housekeeping staff, or designee, will monitor and document refrigerator temperatures daily. All resident refrigerators will have an internal thermometer to monitor for his safe food storage temperatures. 12. All food stored in resident refrigerators will be monitored by resident and/or resident's responsible party. The facility has the right to discard any food or beverage items at any time should the item be deemed not suitable for resident consumption.
Facility's policy titled Visitor Rules (Unknown Date) shows: 7. All items brought for the resident should be checked in the nurse's station prior to distributing to the resident. This is to insure proper storage and diet tolerance of foods
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to follow a physician's laboratory order for management of anticonvulsant medication.
This applies to 1 of 3 residents (R10) reviewed for labs ...
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Based on interview and record review the facility failed to follow a physician's laboratory order for management of anticonvulsant medication.
This applies to 1 of 3 residents (R10) reviewed for labs in a sample of 19.
The findings include:
R10's Medical Record (MR) showed multiple diagnoses including general convulsant epilepsy intractable seizure disorder, encephalomalacia, and encephalitis. R10's MR showed R10 was receiving phenobarbital (anticonvulsant) medication and an order dated 1/31/2024 for phenobarbital trough level laboratory (lab) draw.
On 5/29/2024 at 12:54 PM, V3 (Registered Nurse/RN) said R10 was receiving phenobarbital for her seizure disorder and R10's medication blood levels should be monitored as ordered. Surveyor asked V3 to provide R10's last phenobarbital trough level lab draw, V3 said he reviewed R10's labs from present to 11/2023 and was unable to find the lab result.
On 5/29/2024 at 3:57 PM, V2 (Director of Nursing/DON) said nurses are expected to follow physician lab orders to monitor blood levels.
On 5/29/2024 R10's lab results for the past six months were provided and reviewed, and no phenobarbital trough level was found.
R10's pharmacy consultation report dated 1/29/2024 said R10's MR did not have phenobarbital trough level within the previous six months. The report continued to show a recommendation to please monitor a Phenobarbital trough concentration on the next convenient lab day, 1 week after dosing changes, every 6 months, and as clinically indicated and the recommendation was accepted by R10's physician on 1/31/2024.
R10's care plan reviewed on 5/30/2024 showed a neurological problem for seizure disorders with multiple interventions including labs as ordered, notify MD ASAP for abnormalities and monitor for adverse reactions and med toxicity, notify MD.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
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 follow its policy on behavior monitoring for residents...
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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 follow its policy on behavior monitoring for residents with known behaviors and receiving psychotropic medications.
This applies to 5 of 5 residents (R1, R8, R14, R36, and R39) reviewed for behaviors in a sample of 19.
Findings include:
1. R1's Medical Record (MR) showed multiple diagnoses including schizoaffective disorder, bipolar disorder, depression, and psychosis. R1's MDS (Minimum Data Sheet) dated 3/13/2024 showed R1 was cognitively impaired and did not show any behaviors such as screaming or public sexual acts.
On 5/28/2024 at 10:03 AM, R1 was in bed. R1 was unable to engage in the interview, his speech was incohesive and disorganized. R1 was making inappropriate sexual gestures. On 5/29/2024 at 8:09 AM, R1 was in bed again making inappropriate sexual gestures.
R1's care plan reviewed on 5/30/2034 showed psychotropic medication use related to behaviors of aggression, physically abusive, uncontrollable screaming, and auditory hallucinations. The care plan had multiple interventions including Perform Behavior Management Program and behavior monitoring tracking. Monitor behaviors and document on behavior flowsheet.
On 5/30/2024 at 8:01 AM, V3 (Register Nurse/RN) said R1's behaviors were screaming, making inappropriate sexual comments, and hallucinations. V3 said the facility's social worker sometimes provided behavior-tracking documentation sheets, but he was not documenting behaviors for any of his assigned residents.
2. R8's MR showed multiple diagnoses including bipolar disorder, schizophrenia, dementia, psychosis, and anxiety. R8's MDS dated [DATE] showed R8 was cognitively intact and was showing psychotic behaviors such as hallucinations.
R8's care plan reviewed on 5/30/3034 showed psychotropic medication use related to behaviors of paranoia, auditory hallucinations, refusing care, and getting out of bed. The care plan had multiple interventions including Perform Behavior Management Program and behavior monitoring tracking. Monitor behaviors and document on behavior flowsheet.
On 5/30/2024 at 8:01 AM, V3 (Register Nurse/RN) said the facility's social worker sometimes provided behavior-tracking documentation sheets, but he was not documenting behaviors for any of his assigned residents. V3 continued to say R8 had behaviors related to her visual and auditory hallucinations.
3. R39's MR showed multiple diagnoses including autism, developmental delay, and anxiety. R39's MDS dated [DATE] showed R39 was cognitively impaired and did not show any behaviors such as screaming.
R39's care plan reviewed on 5/30/2024 showed psychotropic medication use related to behaviors of anxiety, yelling, hitting hard objects, temper tantrums, and crying. The care plan had multiple interventions including Administer antidepressant medication as ordered by physician. Monitor/document side effects and effectiveness q-shift.
On 5/30/2024 at 8:01 AM, V3 (Register Nurse/RN) said the facility's social worker sometimes provided behavior-tracking documentation sheets, but he was not documenting behaviors for any of his assigned residents. V3 continued to say R39's behavior was yelling frequently.
4. R14's MR showed multiple diagnoses including anxiety and adjustment disorder with depressed mood. R14's MDS dated [DATE] showed R14 was cognitively impaired and was having recurrent behavior of rejecting care.
R14's care plan reviewed on 5/30/2024 showed psychotropic medication use related to behaviors of sadness, agitation, irritability, and refusing care. The care plan had multiple interventions including Administer psychotropic medication as ordered by physician. Monitor for side effects/effectiveness.
On 5/30/2024 at 8:01 AM, V3 (Register Nurse/RN) said the facility's social worker sometimes provided behavior-tracking documentation sheets, but he was not documenting behaviors for any of his assigned residents. V3 continued to say R14's behaviors were resisting care and refusing to get out of bed.
5. R36's MR showed multiple diagnoses including major depression, anxiety, and insomnia. R36's MDS dated [DATE] showed R36 was cognitively impaired and did not show any mood symptoms such as feeling depressed.
R36's care plan reviewed on 5/30/2024 showed psychotropic medication use related to behaviors of depression and agitation. The care plan had multiple interventions including refer to psychiatrist or neuro-psychologist for effective and safe behavior and med management.
On 5/29/2024 at 3:56 PM, V2 (Director of Nursing/DON) said social services provides behavioral tracking sheets to the nurses. V2 said she expects nurses to assess and document resident behaviors for those receiving psychotropic medications or exhibiting behaviors daily in their behavioral tracking sheets.
On 5/30/2024 at 8:01 AM, V3 (Register Nurse/RN) said the facility's social worker sometimes provided behavior-tracking documentation sheets, but he was not documenting behaviors for any of his assigned residents. V3 continued to say R36 was no longer exhibiting mood behaviors such as depression or anxiety.
On 5/30/2024 at 9:43 AM, V14 (Psychiatric Nurse Practitioner/NP) said he was treating R1, R8, R14, R36, and R39 for psychiatric behavioral care services. V14 said he depends on facility staff to monitor and report resident behaviors to assist in managing their psychiatric services.
The facility's policy titled Reduction of Psychotropic Medications Protocol with the reviewed date of 8/22/2018 showed Policy: Residents who must receive psychotropic medications are to be maintained at the safest, lowest dosage necessary to control the resident's condition .Procedure: .2. The Behavioral Tracking sheet of the facility will be implemented at this time to ensure behaviors are being monitored.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure medications were available for administration to residents with physician's orders.
This applies to 5 out 5 (R5, R13, R...
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Based on observation, interview and record review, the facility failed to ensure medications were available for administration to residents with physician's orders.
This applies to 5 out 5 (R5, R13, R23, R30 and R48) reviewed for medication administration.
The findings include:
1. On 5/29/2024 at 8:05 AM, during medication pass, V5 (RN-Registered Nurse) said there was no available Ascorbic Acid (supplement) 500 MG (Milligrams) so she could not administer it to R13. V5 said Ascorbic Acid 250 mg and Ascorbic Acid 500 mg were both not available in her medication cart. V5 said there was also no Ascorbic Acid in the medication room and in the small closet they keep the extra house stock in. She said Ascorbic Acid medications were not available since Monday, May 27, 2024. V5 went into the closet where house stocks are stored but did not find any Ascorbic Acid.
Review of R13's POS (Physician Order Sheet) showed an order for Ascorbic Acid 500 mg, 1 tablet due at 8:00 AM.
2. On 5/29/2024 at 8:20 AM, during medication pass, V5 was observed administering a total of six medications to R30 that did not include Ascorbic Acid 500 mg, 1 tablet due at 8:00 AM.
Review of R30's May POS showed an order for Ascorbic Acid 500 mg, 1 tablet due at 8:00 AM.
Review of MAR (Medication Administration Record) of the facility's back nursing station showed R5, R23 and R48 had orders for Ascorbic Acid.
May 2024 MAR for R48 showed Ascorbic Acid 500 mg, 1 tablet was signed NA (Not Available) from 5/27/2024 to 5/29/2024.
On 5/29/2024 at 10:38 AM, V2 (Acting DON - Director of Nursing) said V5 did not try to look for Ascorbic Acid. She said V5 did not inform her that she did not have Ascorbic Acid to administer since May 27, 2024. V2 said she expects the nurses to look in the medication room, the little closet space where house stocks are kept and in the DON office. V2 said she also expects nurses to inform her immediately if house stocks are depleted so she can order some more.
On 5/30/2024 at 11:37 AM, V5 (RN) said if house stocks are not available, she informs a staff member who used to order house stocks. V5 said she informed V8 (ADON-Assistant Director of Nursing) that she did not have Ascorbic Acid to administer on May 27, 2024. She said she had no Ascorbic Acid to administer on May 27, 2024, to May 29,2024 to residents who needed it. She said she might have signed the MAR in mistake that it was given to some residents with order for Ascorbic Acid.
On 5/30/2024 at 11:40 AM, V8 said V1 (Administrator) is responsible for ordering house stocks since she started to work in the facility on March 1. 2024. V8 said she does not work on Mondays so V5 did not inform her on the missing medication on Monday, May 27, 2024. She said she expects the nurses to inform her or V2 if house stocks are missing so they can let V1 know to order some more.
Facility's Policy on Procurement and Storage of Medication dated 10/06 and revised on 11/6/18 does not address procurement of house stocks.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to administer medications as ordered by the physician. There were 37 opportunities with 4 medication administration errors result...
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Based on observation, interview and record review, the facility failed to administer medications as ordered by the physician. There were 37 opportunities with 4 medication administration errors resulting in a 10.81% medication error rate.
This applies to 3 out of 4 residents (R13, R19 and R30) reviewed for medication administration in the sample of 19.
Findings include:
1. On 5/29/2024 at 8:05 AM, V5 (RN-Registered Nurse) was administering medication to R13. V5 administered the following medications: Fish Oil (supplement) 1000 mg (milligrams), 1 capsule; Allopurinol (Uric Acid Inhibitor) 100 mg, 1 tablet; Daily-vite (supplement), 1 tablet; Divalproex (antiepileptic) Na (Sodium) ER (Extended Release) 250 mg, 1 tablet; Divalproex Na ER 500 mg, 2 tablets; Polyethylene Glycol (stool softener) 17 gm (gram); and Metoprolol (Antihypertensive) 25 mg, 1 tablet. V5 said there was no available Ascorbic Acid (supplement) 500 mg so she could not administer it to R13. V5 said Ascorbic Acid 250 mg and Ascorbic Acid 500 mg were both not available in her medication cart. V5 said there was also no Ascorbic Acid in the medication room and in the small closet they keep the extra house stock in. She said Ascorbic Acid medications were not available since Monday, May 27, 2024. V5 went into the closet where house stocks are stored but did not find any Ascorbic Acid. V5 counted and administered a total of seven pills and Polyethylene Glycol dissolved in water.
Review of R13's POS (Physician Order Sheet) showed an order for Ascorbic Acid 500 mg, 1 tablet due at 8:00 AM.
2. On 5/29/2024 at 8:20 AM, V5 was administering medication to R30. V5 administered Vitamin B1 (supplement) 1000 mg , 1 tablet; Vitamin D3 (supplement) 50 mcg (micrograms), 1 tablet; Escitalopram (Antidepressant) 20 mg, 1 tablet; Famotidine (Acid Reducer) 20 mg, 1 tablet; Multivitamin with minerals (supplement), 1 tablet; and Polyethylene Glycol (stool softener) 17 gm. V5 counted the medication in the cup, there were 5 pills in the cup and the Polyethylene Glycol she dissolved in water. V5 gave a total of six medications.
Review of R30's May POS showed an order for Calcium 600 mg/Vitamin D3 (supplement) 400 mg, 1 tablet and Ascorbic Acid 500 mg, 1 tablet due at 8:00 AM. Both medications were not administered at 8:00 AM as ordered.
3. On 5/29/2024 at 8:30 AM, V5 was administering medication to R19. V5 administered Diltiazem (Calcium Channel Blocker) 30 mg, 1 tablet; Valproic Acid (anticonvulsant) 250 mg, 2 capsules; Losartan (antihypertensive) 25 mg, 1 tablet; Vitamin D3 (supplement) 125 mcg, 1 capsule and Baclofen (muscle relaxant) 10 mg, 1 tablet. V5 counted and administered five medications to R19.
Review of R19's POS showed that V5 did not administer Docusate Na (stool softener) 100 mg, 1 capsule due at 8:00 AM as ordered.
Facility's Policy on Medication Administration dated 10/07 and revised on 7/3/13/ and 11/18/17 states the following: .Definition .The complete act of administration entails removing an individual dose form a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the time and dose given.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
3. R30 has a suprapubic catheter for diagnoses of neuromuscular dysfunction of bladder and urinary retention.
On May 28, 2024, at 1:44 PM, R30's suprapubic catheter care observed done by V5 (RN-Regis...
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3. R30 has a suprapubic catheter for diagnoses of neuromuscular dysfunction of bladder and urinary retention.
On May 28, 2024, at 1:44 PM, R30's suprapubic catheter care observed done by V5 (RN-Registered Nurse). V5 performed hand hygiene and applied gloves. V5 said suprapubic catheter care is done every shift. V5 unfastened the incontinent brief. She squeezed NSS (Normal Saline Solution) onto a gauze and proceeded to clean the catheter. V5 observed to be cleaning the catheter towards the base of the catheter more than ten times with the same gauze. There was minimal bleeding noted at the base of the catheter and V5 said R30's skin gets irritated at times but always dries up. Using the same glove, V5 took a gauze from the treatment cart, opened the package, and cut the gauze with scissors. V5 then took gloves off, applied hand sanitizer and applied new gloves.
On May 30, 2024, at 11:37 AM, V5 said when cleaning catheters, the motion should be away from the base to prevent urinary tract infections.
On May 30, 2024, at 11:40 AM, V8 (ADON-Assistant Director of Nursing) said she expects the nurse to perform suprapubic care every shift. She said the nurse should wipe the catheter clean and should clean away from the base. She said if the catheter is cleaned towards the base, the dirt and germs are being brought back to the site and might cause infections.
Facility's Policy on Suprapubic Catheter Care dated 1/2002 and reviewed on 2/2028 and 3/15/2023 does not address how catheter tubing should be cleaned.
4. On 5/28/24 at 2:30 PM, observed V5 (RN-Registered Nurse) change GT (gastrostomy) dressing for R11. V5 (RN) did not wear PPE (Personal Protective Equipment) as required for a resident on EBP (Enhanced Barrier Precaution). V5 wore gloves and removed the soiled dressing. Did not do any hand hygiene before or after removing the soiled dressing. With the same gloves, V5 (RN) took clean gauze and cleaned the site with normal saline. With the same gloves and no hand hygiene, V5 (RN) took a split gauze and placed it around the gastrostomy tube. V5 (RN) did not secure the split gauze with a tape nor label the dressing with date, time and signature of the nurse. With the same used gloves and no hand hygiene, V5 (RN) patted R11 on his arms to reassure him. V5 removed gloves and discarded into the trash bag. Did not wash hands or use hand sanitizer. Replaced all the remaining clean items back in the drawers. Then used hand sanitizer on her hands and wheeled the cart out of the room.
On 5/29/24 at 12:11 PM, V2 (DON-Director of Nursing) stated, R11 was on GT feeding and hence on EBP. V2 stated, the nurse should have washed her hands before starting the procedure of GT care. V2 (DON) stated, after cleaning the site, V5 should have washed her hands or done hand sanitization. V2 stated, touching clean items and clean surfaces with soiled gloves is a potential for contamination of the clean items and possible infection.
Facility policy on 'Hand Hygiene' updated 8/14/2023 showed, . Indications for Hand-Washing . 2. Before and after direct resident care .Indications for ABHR (Alcohol Based Hand Rub) - When hands are not visibly soiled, . 3. After contact with resident's intact skin, 4. After contact with inanimate objects, 5. After removing gloves.
Facility policy on 'Dressing Change' reviewed on 3/16/23 showed, ' . Procedure 7. Set up clean area for supplies. 8. Wash your hands. 9. Put on non-sterile gloves 23. Discard all equipment appropriately. 24. Wash your hands .
Based on observation, interview, and record review, the facility failed to wear appropriate Personal Protective Equipment in enhanced barrier precaution rooms. The facility failed to provide proper catheter care and perform hand hygiene during gastrostomy tube care. This applies to 4 of 4 residents (R11, R30, R47, R50) reviewed for infection control in sample of 19.
The findings include:
1. On 5/28/24 at 10:41 AM, during initial tour, surveyor went to R47's room. R47 had a G-Tube (Gastrostomy Tube) running and as per the floor nurse V3 (RN-Registered Nurse), R41 also has a pressure sore to his right heel. There was no sign on R47's door about enhanced barrier precautions.
On 5/29/24 at 12:20 PM, there were signs posted on R47's door. One sign said, Stop and See Nurse. The other sign showed, Stop! Enhanced Barrier Precautions. Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities: Dressing, Bathing/Showering, Transferring, Changing linens, Providing hygiene, Changing briefs for assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing.
On 5/29/24 at 12:25 PM, V3 (RN) stated, I don't know why those signs are there. (R47) is not on isolation. I don't know what enhanced barrier precautions are. Please ask the ADON (Assistant Director of Nursing. V3 put on gloves and entered R47's room without wearing a gown. V3 removed R47's dressing on his right foot. V4 (Wound Doctor) put on gloves and came inside without wearing a gown. V4 measured (R47's) pressure sore wound on his foot. V3 then completed the dressing change on R47's foot as per the physician's orders.
R47's face sheet shows a diagnosis of gastrostomy status.
R47's POS (Physician Order Sheet) has no orders for enhanced barrier precautions.
R47's care plans show he has a gtube and stage 3 pressure ulcer to his right heel. R41 does not have a care plan for enhanced barrier precautions.
V4's (Wound Doctor) note dated 5/22/24 shows that R47 has a stage 3 pressure wound to the right heel. Primary dressing: Alginate rope with silver. Apply once daily for 23 days. Secondary dressing: Foam silicone border. Apply once daily for 23 days.
2. On 5/28/24 at 10:14 AM, R50 stated he had a pressure sore to his left foot. There was no sign for enhanced barrier precautions on his door.
On 5/29/24 at 12:30 PM, there was still no enhanced barrier precaution sign on R50's door.
On 5/29/24 at 12:37 PM, V3 (RN) applied hand sanitizer to his hands and put on gloves. V3 did not put a gown on. V3 entered R50's room. V3 removed R50's heel boots, socks, and dressing on his left foot. V4 (Wound Doctor) came in wearing gloves, but no gown. He applied pain medicine (Benzocaine Aerosol Spray) and debrided the wound. V3 then applied the treatment which included wound cleanser Idosorb, and Optifoam dressing. Throughout the whole procedure, V3 and V4 did not wear a gown.
R50's face sheet shows a diagnosis of pressure ulcer of left heel, stage 3.
R50's POS shows no order for enhanced barrier precautions.
R50's care plans show R50 has a pressure sore, but there is no care plan for enhanced barrier precautions.
V4's wound note dated 5/22/24 shows that he has a stage 4 pressure wound to the left heel. Primary dressing: Iodosorb get apply once daily for 30 days. Secondary dressing: Foam silicone border-apply once daily for 30 days.
Facility's policy titled Enhanced Barrier Precautions (7/13/23) shows: Enhanced Barrier Precautions (EBP) should be used when contact precautions do not apply, for residents with any of the following: open wounds that require a dressing change, indwelling medical devices, infection or colonized with a MDRO (Multi-Drug Resistant Organism). Enhanced Barrier Precautions require the use of a gown and gloves during high-contact resident care activities that provide opportunities for the transfer of MDRO's to staff hands and clothing. EBP is primarily intended to use for car that occurs within a resident's room, when high-contact resident care activities are bundled together. Procedure: 1. Educate staff on EBP. 3. Review contact precautions to ensure that enhanced barrier precautions are appropriate. 3. Post approved EBP signage that indicates high-contact activities.
On 5/29/24 at 1:02 PM, V2 (DON) stated, Enhanced barrier precautions means standard precautions. Any resident that has enhanced barrier precautions means they have an opening on the skin. Those residents are residents with wounds, gtubes and catheters. I started putting up the signs yesterday. I'm working on it. I did some today. It's a project I'm working on. Staff is supposed to wear gown and gloves when they give care to those residents. (V3-RN) should know that. I just in-serviced him on that yesterday and today. (V3) should have known what enhanced barrier precautions when he took the NCLEX-RN (National Council Licensure Exam-Registered Nurse).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected multiple residents
Based on the interview and record review, the facility failed to utilize a standardized tool to determine the necessity of antibiotic therapy prescribed to residents. This applies to 5 of 5 residents ...
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Based on the interview and record review, the facility failed to utilize a standardized tool to determine the necessity of antibiotic therapy prescribed to residents. This applies to 5 of 5 residents (R10, R12, R22, R50, and R206) reviewed for antibiotics therapy in sample of 19.
The findings include:
1.R10 (Physician Order Sheet) showed Bactrim DS (antibiotic) 800-160 milligrams daily in the evening by mouth for ten days. No reason for antibiotic therapy (ABT) was entered either in the Physician Order sheet or in the medication administration log.
R10 did not have a McGeer's criteria form in the infection control binder or his medical record for April . Further, the infection control and antimicrobial log did not have the reason for the medication administration.
2. R12's Physician Order Sheet dated 4/20/2024 showed Bacitracin (antibiotic) 2 percent ointment to apply to Gastrostomy tube redness and drainage two times daily until healed. The sheet dated 04/29/2024 showed Keflex 500 milligram four times tablet by mouth for ten days left lower extremity cellulitis.
The April monthly infection log showed that R12 did not have a McGeer's criteria form in the infection control binder or his medical record. Further, the onset date for bacitracin in the log did not match the date on the physician's order sheet.
3. R22's Physician Order Sheet dated 05/02/2024 showed Erythromycin (antibiotic) ophthalmic (eye) ointment to apply to the right eye three times a day for five days for blepharitis (infection of the eyelid) and Doxycycline (antibiotic) 100 milligram capsule two times by mouth for seven days.
The May 2024 antibiotic Stewardship log shows a start date of 05/02/2024 and an end date of 05/07/2024 for Erythromycin and no start or end date for Doxycycline. R22 did not have a' McGeer's criteria form in the infection control binder or medical records.
4. R50's Physician Order Sheet dated 05/06/2024 showed Cefadroxil (antibiotic)500 milligram tablet two times a day by mouth for seven days for left foot cellulitis.
The May 2024 antibiotic Stewardship log shows a start date of 05/06/2024 and an end date of 05/13/2024. R50 did not have a McGeer' sMcGeer's criteria form in the infection control binder or his medical records.
5. R206's Physician Order Sheet showed Augmentin (antibiotic) 250 milligrams by mouth for seven days for an ear infection.
The May 2024 antibiotic Stewardship log did not have R206's name or a McGeer's criteria form in the infection control binder or medical records.
On 05/30/2024 at 10:30 AM, V2 (Director of Nursing/Infection Preventionist) stated that she is at the facility for a few weeks only and that the facility should follow McGeer's criteria to ensure residents are not getting antibiotics unnecessarily. Labs are to be done before administering medications, with some exceptions, and she was not sure why it was not done.
At 11:30 AM, V16 (Physician) said he didn't follow McGeer's criteria and did not want to discuss them further.
At 11:46 AM, V3 (Registered Nurse) said when the nurses observe any signs of infection in residents, they call the physician and follow the orders, if any. V3 said he had never heard of McGeer's criteria.
The facility's policy, Infection Control Surveillance and Monitoring, revised date 04/11/2022, stated, Update infection control log on a daily basis to analyze data and identify trends. The facility could not provide an Antibiotic/Antimicrobial Stewardship Program-Mission Statement and Guidelines.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly label, date, seal, and store food items in t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly label, date, seal, and store food items in the kitchen.
This applies to 53 residents that receive oral nutrition and foods prepared in the facility kitchen.
Findings include:
The facility's Longterm-Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 5/29/24 documents that the total census was 56 residents. On 5/30/24 at 10:14 AM, V2 (DON-Director of Nursing) stated, there are three NPO (Nothing by Mouth) residents that do not eat from the facility kitchen.
On 5/28/24 starting at 9:35 AM, the facility kitchen was toured in the presence of V6 (Dietary Manager) and the following was found:
1. Macaroni Elbow pasta, 10 lbs opened bag - no date when it was received, no expiration date.
2. Spaghetti noodles pasta, 10 lbs opened bag - no date when it was received, no expiration date.
3. Macaroni Bow pasta, 10 lbs opened bag - no date when it was received, no expiration date.
4. Half loaf of bread and a bag of 4 buns - no date when it was received, no expiration date.
5. Can of [NAME] tomato soup, 50 oz, Expired on 03/2023.
6. [NAME] Cranberry Juice 33.8 Fl oz - 3 cans - no date when it was received, no expiration date.
7. Orange Juice 33.8 Fl oz - 4 tetra packs - no date when it was received, no expiration date.
8. Clear bag of steak 15 pieces - opened bag - no date when it was received, no expiration date.
9. Clear bag of sausage patties - opened bag - no date when it was received, no expiration date.
10. Clear bag of Breaded fish patties - opened bag - no date when it was received, no expiration date.
11. Unopened Can of Ministrone condensed soup - 4 lbs - no date when it was received, no expiration date.
12. Bread dough for 3 loves in clear plastic in freezer #2 - opened bag - no date when it was received, no expiration date.
On 5/28/24 at 11:00 AM, V6 (Dietary Manager) said all expired items should be discarded, so they are not accidentally given to the residents with the potential to make the residents sick.
On 5/30/24 at 11:30 PM, V7 (Dietician) stated, If expired food is served to residents, they could get sick or get food poisoning
The facility's policy for Food titled, Storage (Dry, Refrigerated and Frozen) last revised on 10/2020 showed, Procedure: 1. All items will be dated upon receipt. Individual cans or bags shall each be dated .
The facility's policy for Food titled, Refrigerator and Freezer Storage last revised on 10/2014 showed, 2. [NAME] container with name of item. [NAME] the date that the original container is opened or date of preparation .
Apr 2024
4 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0825
(Tag F0825)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain orders and provide physical therapy services to residents. T...
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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 orders and provide physical therapy services to residents. This failure resulted in a resident with a functional decline (R103) having a delay in receiving physical therapy and taking longer to return to his baseline function. This applies to 3 of 3 residents (R101, R102, and R103) reviewed for therapy services in the sample of 9.
The findings include:
1. R103's Medical Record showed R103 was admitted to the facility on [DATE], with multiple diagnoses including hypertensive heart disease, epilepsy, dementia, and nontraumatic subarachnoid hemorrhage.
R103's MDS (Minimum Data Set) dated January 28, 2024, showed R103 had moderate cognitive impairment. The MDS continued to show R103 could independently transfer to and from a bed to a chair, toilet transfer, and walk 150 feet.
A progress note dated February 26, 2024, at 4:30 AM, by V18 (RN/Registered Nurse) showed, resident awake and alert, verbally responsive. Breathing non labored and with symmetrical chest wall expansion. Observed that resident no longer takes a walk whenever he is awake. Incontinent of bowel and bladder. Tried to get him up and down but resident unable to do task. Conferred with the night CNA (Certified Nursing Assistant) if she noticed the same thing and she reaffirmed nurse observation. Assessment done: temperature 98.3 degrees, blood pressure 144/90, pulse rate 75, respiratory rate 18, oxygen saturation at room air 95% (percent). Facial expression symmetrical, no drooling noted, no numbness, nor muscle weakness, no mental confusion, repaid involuntary eye movement, hand grasp strong and equal, no difficulty speaking nor slurring of speech. Resident with difficulty of mobility, unable to sit upright without assistance.
A progress note dated February 29, 2024, at 6:00 PM, by V13 (RN) showed, readmitted a [AGE] year old male from [local hospital] via [ambulance company] up in a wheelchair, extensive assist of two with transfer.
On April 22, 2024, at 1:00 PM, V3 (RN/Registered Nurse) said R103 cannot get out of bed and walk. V3 continued to say R103 used to be able to walk independently, but in February, R103 suddenly stopped walking and was sent to the hospital.
On April 22, 2024, at 2:58 PM, V13 (RN) said on February 26, 2024, R103 was walking independently and then stopped walking so R103 was sent to the hospital. V13 said she readmitted R103 to the facility on February 29, 2024, and spoke with V11 (Physician). V13 said she did not get an order for physical therapy for R103. V13 continued to say social services will assist in determining if a resident needs physical therapy. V13 said R103 started receiving therapy on March 22, 2024.
On April 23, 2024, at 11:09 AM, V12 (Social Services Director) said there was a delay in R103 receiving physical therapy because the facility did not have a therapy company to provide residents with physical therapy.
On April 23, 2024, at 9:34 AM, V11 (Physician) said R103 should have been evaluated for therapy when he was readmitted from the hospital on February 29, 2024. V11 said he was not notified of R103's continued functional decline upon readmission to the facility and was not asked about a physical therapy evaluation. V11 continued to say if he would have been notified of R103's continued functional decline, V11 would have ordered a therapy evaluation. V11 said the facility is having issues with funding and the last therapy department left because of funding issues. V11 said R103 should have received therapy sooner and believes R103 did not receive therapy in a timely manner because the facility did not have therapy services.
On April 23, 2024, at 10:36 AM, V5 (Rehab Director) said R103's prior function was supervision, and R103 could ambulate. V5 said R103 was evaluated by physical therapy on March 22, 2024, and the therapist did not walk R103 because R103 could only stand for 10 seconds. V5 continued to say it was a concern R103 was not started on therapy right after being readmitted to the facility on [DATE]. V5 said it will take longer for R103 to get back to his functional baseline because there was a delay in therapy.
R103's Physical Therapy Evaluation and Plan of Treatment dated March 22, 2024, by V17 (Physical Therapist) showed, Functional Mobility Assessment: Ambulation: Walk 10 feet = Not attempted due to medical conditions or safety concerns. Gait Pattern/Deviations: Did not ambulate on evaluation; unable to stand greater than 10 seconds with moderate/maximal assist.
2. R102's Medical Record showed R102 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, anxiety, and urinary tract infection.
R102's MDS dated [DATE], showed R102 was cognitively intact. The MDS continued to show R102 was dependent on facility staff for transfers to and from a bed to a chair, toilet transfers, and bathing.
R102's physician order dated December 23, 2024, showed, Occupational Therapy and Physical Therapy evaluation and treatment order. Physical Therapy clarification order five times a week for 12 weeks.
On April 23, 2024, at 1:27 PM, R102 said she had been receiving physical therapy in February with V19 (Physical Therapist), but then R102 went a month without physical therapy. R102 said she started receiving physical therapy again about three weeks ago.
R102's Physical Therapy Therapist Progress note by V19, dated February 7, 2024, showed, Remaining Functional Deficits/Underlying Impairments: Patient continues to require skilled therapy due to weakness, balance deficit, poor endurance and poor safety which influence ability to perform activities of choice.
R102's Physical Therapy Daily Treatment Note by V19, dated February 16, 2024, showed Patient performed therapeutic exercises to develop strength, endurance, range of motion and flexibility. Effective February 19, 2024, [Rehab Company] will no longer be a therapy provider.
The facility did not have documentation to show R102's therapy was discontinued or ending due to R102 meeting her highest practicable level of function.
The facility did not have documentation to show R102 received physical therapy between February 16, 2024, and March 22, 2024.
On April 23, 2024, at 10:54 AM, V5 said R102 previously received therapy from a different therapy company and when the current rehab company came to the facility on March 22, 2024, R102 was evaluated so therapy services could resume.
On April 23, 2024, at 11:11 AM, V12 (Social Services Director) said R102 was receiving therapy services from the previous therapy company. V12 continued to say R102 was not sent to an outside company to resume therapy services after the previous company stopped services in the facility. V12 said the facility did not send any residents to an outside company for therapy services because the facility thought the new therapy company was starting, but it kept getting delayed. V12 said R102 received therapy when the new company came on March 22, 2024, about a month after the previous therapy company stopped services.
3. R101's Medical Record showed R101 was admitted to the facility on [DATE], with multiple diagnoses including chronic kidney disease, dementia, atrial fibrillation, and anemia.
R101's MDS dated [DATE], showed R101 was cognitively intact. The MDS continued to show R101 required maximal assistance of facility staff for bed mobility, transferring to and from a bed to a chair, and toilet transfers.
R101's ADL (Activity of Daily Living) care plan initiated on April 13, 2023, showed, Self care deficit-needs supervision and/or assist to complete quality care and/or poorly motivated to completed ADLs . R101's care plan continued to show multiple interventions initiated on April 13, 2023, including IDT (Interdisciplinary Team) to review for need of PT (Physical Therapy) services.
R101's Medical Record showed a Physician Order dated January 12, 2024, for Physical Therapy/Occupational Therapy/Speech Therapy evaluation and treatment. Physical Therapy clarification, five times a week for 12 weeks. R101's February 2024 Physician orders showed, Rehabilitation: five times a week times 12 weeks per Plan of Care.
R101's Physical Therapy Therapist Progress note dated February 8, 2024, by V19 Patient continues to require skilled physical therapy services to focus on: therapeutic exercise, neuromuscular reeducation, gait training, manual techniques, group therapy, and therapeutic activities.
The facility did not have documentation to show R101's therapy was discontinued or ending due to R101 meeting his highest practicable level of function.
The facility did not have documentation to show R101 received physical therapy between February 9, 2024, and March 22, 2024.
On April 23, 2024, at 9:47 PM, V11 (Physician) said R101's physical therapy should not have been stopped because R101 was not discharged from therapy. V11 continued to say R101 stopped receiving therapy services because the facility did not have a therapy company to provide services.
On April 23, 2024, at 11:11 AM, V12 said R101 was receiving therapy services from the previous therapy company. V12 continued to say R101 was not sent to an outside company to resume therapy services after the previous company stopped services in the facility. V12 said the facility did not send any residents to an outside company for therapy services because the facility thought the new therapy company was starting, but it kept getting delayed. V12 said R101 received therapy services when the new therapy company started on March 22, 2024, about a month after the previous therapy company stopped services.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to have a full time DON ( Director of Nursing).
This applies to all 57 residents residing in the facility.
The findings include:...
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Based on observation, interview, and record review, the facility failed to have a full time DON ( Director of Nursing).
This applies to all 57 residents residing in the facility.
The findings include:
The Facility Data Sheet dated April 17, 2024, showed the facility census was 57 residents. The area on the Facility Data Sheet designated for the DON (Director of Nursing) information was left blank. No DON was shown on the Facility Data Sheet. The area on the Facility Data Sheet designated for the ADON (Assistant Director of Nursing) was left blank. No ADON was shown on the Facility Data Sheet.
On April 17, April 18, April 22, and April 23, 2024, there was no DON at the facility.
On April 17, 2024, at 9:39 AM, V2 (Interim Business Office Manager) said the facility does not have a DON at this time.
On April 18, 2024, at 9:24 AM, V1 (Administrator) said the facility does not have a DON. V1 continued to say the facility last had a DON on April 3, 2024. V1 said the facility does not have an interim DON.
On April 18, 2024, at 10:23 AM, V1 said the facility does not have a waiver from IDPH (Illinois Department of Public Health) to waive the staffing requirement for a full-time DON.
On April 22, 2024, at 2:55 PM, V13 (RN/Registered Nurse) said it is difficult not having a DON because there is not as much support. V13 said the DON would help in situations when a resident was having a change in condition, and now the nurses don't have someone to support them.
On April 22, 2024, at 3:31 PM, V14 (RN) said the DON is who the nurses would go to if a resident was having an ADL (Activities of Daily Living) decline, but now there is not a DON to go to. V14 continued to say facility staff do not have a clinical management person to go to for support.
The Facility Assessment Tool dated March 7, 2024, showed, Staffing Plan: Staffing is based on the needs of the residents. These needs are discussed daily in our clinical management meeting . Plan: DON: 1, ADON: 1 .
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to employ a licensed administrator to ensure the facility could meet resident needs. The facility administration failed to ensure therapy serv...
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Based on interview and record review, the facility failed to employ a licensed administrator to ensure the facility could meet resident needs. The facility administration failed to ensure therapy services were provided to residents. The facility employed a full-time DON, and the administrator failed to ensure the facility employed a part-time Infection Preventionist. The administration also failed to document evidence for plans of correction and evidence of reporting to the QAPI (Quality Assurance Performance Improvement).
This applies to all 57 residents residing in the facility.
The findings include:
The Facility Data Sheet dated April 17, 2024, showed the facility census was 57 residents. The area on the Facility Data Sheet designated for the Administrator's license number was left blank.
On April 18, 2024, at 9:24 AM, V1 (Administrator) said she has a temporary nursing home administrator license.
On April 18, 2024, at 10:23 AM, V1 said she started working at a different facility and came to work at this facility on March 4, 2024. V1 continued to say her temporary administrator license was completed for the other facility which she started working at on January 8, 2024.
The State of Illinois form entitled Application for Licensure and/or Examination for V1, showed Certification of Acceptance. Applicant: To ensure timely receipt of a temporary license, the completed application packet for licensure must be received in the Department of Financial and Professional Regulation at least 60 days prior to the appointment of the individual as a nursing home administrator. Employer: This is to certify that the above-named applicant has been appointed as a full-time nursing home administrator in the facility as follows . The form continued to show another facility listed as V1's employer, not the facility V1 is currently employed at. V16 (Regional Director of Operations) provided her signature dated January 8, 2024, under the statement I do hereby declare that the above-named applicant has been/will be employed as indicated.
On April 23, 2024, at 1:37 PM, V16 (Regional Director of Operations) said she signed V1's temporary nursing home administrator license on January 8, 2024. V16 continued to say V1's application was for a different facility than the facility V1 is currently working in. V16 said an administrative change form was submitted to the State of Illinois.
On April 23, 2024, at 3:32 PM, V1 said she has provided all the submitted material for her temporary nursing home administrators license that V1 is aware of submitting.
On April 23, 2024, at 1:08 PM, V15 (Illinois Department of Financial and Professional Regulation Representative) said the facility written on the temporary nursing home administrator license is the only facility the temporary administrator can work at unless an addendum to the application is submitted.
The facility does not have documentation to show an addendum was submitted for V1's temporary nursing home administrator license.
On April 25, 2024, at 11:29 AM, V20 (Senior Representative for Illinois Department of Financial and Professional Regulation) said once a temporary nursing home administrator license number is issued, the individual can submit a request to change the facility the individual will be working in. V20 continued to say the Illinois Department of Public Health form Long-Term Care Facility - Administrator Form is not how to change the facility the temporary nursing home administrator is able to work in.
On April 23, 2024, at 9:06 AM, V1 said she does not have evidence to show medication counts were reviewed daily for three months as mandated by the facility's plan of correction for the survey of March 6, 2024 related to missing narcotic medication. In addition, the facility lacked evidence that any of the plan of correction material was submitted to the QAPI committee. V1 continued to say a couple times a week, V1 or a nurse will review the medication sign off sheets. The facility's plan documents, Director of Nursing or designee and QA will review medication counts daily for 1 month and for the next 3 months though the QA process.
On April 18, 2024, at 9:24 AM, V1 (Administrator) said the facility does not have a DON. V1 continued to say the facility last had a DON on April 3, 2024. V1 said the facility does not have an interim DON.
On April 18, 2024, at 2:17 PM, V9 (Regional Director of Clinical Operations) said she is the IP (Infection Preventionist) nurse until the facility hires a DON (Director of Nursing). V9 said she lives about three hours from the facility. V9 continued to say she tries to come to the facility once a week, but due to health issues V9 has had difficulty coming to the facility once a week. The facility was cited for infection control issues on the March 6, 2024 survey. The facility failed to implement adequate PPE (personal protection equipment) during a COVID outbreak.
On April 18, 2024, at 10:23 AM, V1 said the last day the previous rehab company provided rehab services in the facility was February 5, 2024, and the new rehab company started providing services in the facility on March 22, 2024.
On April 23, 2024, at 11:11 AM, V12 (Social Services Director) said when the previous rehab company stopped providing rehab services in the facility, no residents were sent to an outside facility or company for rehab services. V12 continued to say rehab services were not provided in the facility after the previous rehab company left and the new rehab company started in the facility on March 22, 2024.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to have an Infection Preventionist at least part time at the facility.
This applies to all 57 residents residing in the facility.
The finding...
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Based on interview and record review, the facility failed to have an Infection Preventionist at least part time at the facility.
This applies to all 57 residents residing in the facility.
The findings include:
The Facility Data Sheet dated April 17, 2024, showed the facility census was 57 residents.
On April 18, 2024, at 2:17 PM, V9 (Regional Director of Clinical Operations) said she is the IP (Infection Preventionist) nurse until the facility hires a DON (Director of Nursing). V9 said she lives about three hours from the facility. V9 continued to say she tries to come to the facility once a week, but due to health issues V9 has had difficulty coming to the facility once a week. V9 said when she is able to come to the facility, V9 reviews and updates the infection control logs. V9 continued to say the March 2024 log was incomplete.
The Facility Assessment Tool dated March 7, 2024, showed .The facility follows the current CDC (Centers for Disease Control and Prevention) best practices. The facility has an Infections Nurse that oversees the program in its entirety .
Feb 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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement the facility's abuse policy and report and i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement the facility's abuse policy and report and investigate an allegation of abuse.
This applies to one of three residents (R1) reviewed for physical abuse.
The findings include:
The facility's abuse policy dated 10/14/2016 showed This facility affirms the right of our residents to be free from abuse This facility therefore prohibits mistreatment, neglect, or abuse of its residents and has attempted to establish a resident sensitive and resident secured environment. The purpose of this policy is to ASSURE that the facility is doing all that is within control to prevent occurrences of mistreatment, neglect, or abuse of our residents. This will be done by: .Identifying occurrences and patterns of potential mistreatment, neglect, abuse of resident .immediately protecting residents involved in identified reports of possible abuse; Implementing systems to investigate all reports and allegations of abuse . promptly and aggressively and making necessary changes to prevent future occurrences and filing accurate and timely investigative reports.
During the Entrance communication on 2/23/2024 at 9:30 A.M., V2 (Director of Nursing) said that there was no abuse allegation that occurred for the past month (2/1/2024 to current) in the facility.
The MR (Medical Record) showed that R1, a [AGE] year-old male resident, was admitted to the facility on [DATE]. R1's diagnoses included alcoholic cirrhosis, diabetes mellitus type 2, idiopathic peripheral neuropathy, major depressive disorder without psychotic features, morbid obesity, insomnia, eating disorder, obstructive sleep apnea, bipolar disorder, and hypertension.
The MDS (Minimum Data Set) dated 2/16/2024 showed that R1 was cognitively intact with BIMS (Brief Interview Mental Status) score of 15/15.
On 2/23/2024 at 9:45 A.M, R1 stated to the surveyor that V3 (Registered Nurse) pushed him hard back and forth when V3 was checking his blood sugar on 2/14/2024 between 4:00AM and 5:00AM. R1 then stated he called the administrator (V1) that day 2/14/2024 to inform that (V3) had been rough during the blood sugar check, but V1 did not respond. R1 also added that he did not report the incident to anyone else including the nurse aides and nurse on duty for the night and day shift (V6, V7, V8, Certified Nurse Aides and V5 RN). R1 added that he later spoke with V2 (Director of Nursing) that V3 was rough and rocking him during the blood sugar test the morning of 2/14/24.
V2 was interviewed on 2/23/24 at 11:00 A.M, V2 responded that R1 came to her on 2/6/2024 and voiced a grievance that V3 had awaken R1 and (V3) shook his feet. V2 added that she considered this a grievance about the manner V3 checked R1's blood sugar. V2 also stated she was sure that the incident happened on 2/6/2024. V3 also added that she did not implement the abuse policy concerning the resident's allegation. V3 later made a report to the department after re-interviewing the resident.
The POS (Physician Order Sheet) for the month of 2/2024 showed that R1 had a physician order for blood sugar to be checked daily at 6:00 A.M., 11:00 A.M.; 4:00 P.M. and 9:00 P.M.
The MAR (Medication Administration Record) for the month of 2/2024 showed that V3 had signed the MAR indicating she had checked R1's blood sugar at 6:00 A.M on 2/13,14, 15, 19,20,21,22 and 23 of 2024.
Feb 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to apply the correct PPE (Personal Protective Equipment) prior to entering resident rooms who were COVID-19 positive. The facili...
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Based on observation, interview, and record review, the facility failed to apply the correct PPE (Personal Protective Equipment) prior to entering resident rooms who were COVID-19 positive. The facility also failed to post contact isolation and droplet isolation signage outside the rooms of residents who were COVID-19 positive.
This applies to 7 of 7 residents (R1, R2, R3, R4, R5, R6, R7) reviewed for COVID-19 infection control.
The findings include:
On February 13, 2024 at 09:49 AM, V5 (Housekeeper) entered R1 and R2's room wearing a surgical face mask and gloves. R1 and R2's room was under COVID-19 isolation. The signage outside the room showed a gown, gloves, N95, and face shield should be worn prior to entering COVID-19 isolation rooms. V5 finished cleaning the room and exited at 09:55 AM. V5 washed her hands and went to the next room wearing the same surgical face mask. At 10:45 AM, V5 said for residents under COVID-19 isolation, they should wear a gown, N95 face mask, and gloves.
On February 13, 2024 at 11:51 AM, V6 (CNA/Certified Nurse Assistant) entered R3 and R4's room wearing a surgical face mask only. R3 and R4's room was under COVID-19 isolation. After exiting the room, V6 did not change his mask or perform hand hygiene. V6 said the residents were on isolation for COVID-19. V6 said the PPE guideline showed he was supposed to wear a face shield, gown, gloves, and an N95 face mask. V6 said he was supposed to put on all PPE (Protective Personal Equipment) prior to entering the room.
On February 13, 2024 at 10:34 AM, V9 (CNA) entered R1 and R2's room without wearing a face shield. V9 removed his gown and gloves in the room and exited the room without changing his N95 face mask.
On February 13, 2024 during the initial tour, R1, R2, R3, R4, R5, R6, and R7 did not have contact isolation and droplet isolation signage posted outside of their room door to notify staff and visitors what kind of isolation the residents were on. R1-R7's rooms had the following signs: ISOLATION, Do Not Enter Please see the nurse, and Use PPE (Protective Personal Equipment) When Caring for Patients with Confirmed or Suspected COVID-19.
On February 13, 2024 at 12:07 PM, V7 (RN/Registered Nurse) said the residents on COVID-19 isolation had droplet and contact isolation implemented. V7 said the staff were supposed to wear gowns, N95's, goggles, and gloves while in the room. V7 said hand hygiene should be done before applying PPE and after removing PPE. V7 said the staff should wear PPE any time they enter the rooms under COVID-19 isolation. V7 said they could wear the same N95 face mask from a COVID-19 isolation room to another room because there are limited supply of N95s.
On February 13, 2024 at 12:13 PM, V8 (RN) said the staff should wear a gown, N95 face mask, goggles, and gloves before going into a COVID-19 isolation room. V8 said all PPE should be removed and all new PPE should be worn going into another resident's room.
On February 13, 2024 at 02:03 PM, V1 (DON/Director of Nursing) said the staff are supposed to perform hand hygiene and then apply an N95 mask, gloves, and the gown. V1 said the staff are not necessarily supposed to wear the face shields unless the resident has symptoms. V1 said she would request more information from the regional consultant.
On February 13, 2024 at 02:41 PM, V10 (Regional Director of Clinical Operations) said when the staff go into the room, they should be wearing N95's, gowns, gloves, and face shields, which was according to their policy. V10 then said the CDC (Centers of Disease Control) website states staff do not have to wear face shields, and when asked, said the facility should be following their policy for COVID-19 PPE guidelines.
The facility's COVID-19 Control Measures policy revised on November 7, 2022, showed All HCP [Health Care Professionals] must wear an N95 and eye protection when caring for all residents. HCP are to wear N95 and eye protection when facility is in outbreak, regardless of the Community Transmission Level. Additional PPE is to be utilized (gowns/gloves) when caring for residents with suspected or confirmed COVID-19. Contact Precautions- Post signage on door. Droplet Precautions- Post signage on door.
The facility's Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19 undated document showed Preferred PPE- Use N95 or Higher Respirator, face shield or googles, one pair of clean, non-sterile gloves, and isolation gown. Acceptable Alternative PPE- Face shield or googles, Facemask (N95 or higher respirators are preferred but facemasks are an acceptable alternative), One pair of clean, non-sterile gloves, and isolation gown.
Feb 2024
3 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Safe Environment
(Tag F0584)
Someone could have died · 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 maintain a safe, clean, comfortable homelike environmen...
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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 safe, clean, comfortable homelike environment following the disruption of water services due to broken pipes in the facility.
The failure resulted in a lack of available handwashing facilities and the accumulation of human feces/urine in the toilets. The lack of response caused a risk for psychosocial harm to residents as evidenced by their disgust for having to eliminate in toilets full of urine/feces and subsequently not have hand washing facilities available to wash hands.
This applies to 35 of 60 residents (R2, R4, R8, R10-R13, R15-R17, R19-R23, R25, R26, R30-R32, R35, R40, R41, R43-R51, R58, R59 R60) reviewed for homelike environment who could utilize facility bathrooms/toilets in a sample of 61.
The Immediate Jeopardy began on 1/17/24 at 9:30 PM when the initial water pipe break occurred. V1 (Acting Administrator), V2 (Director of Nursing), V3 (Regional Director of Operations), and V7 (Division Director of Operations) was notified of the Immediate Jeopardy on 1/25/24 at 3:00 PM. The surveyor confirmed by observations and interview that the Immediate Jeopardy was removed on 1/25/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the training and monitoring.
The findings include:
On 1/23/24 at 8:33 AM, the State Regional Office was informed by V13 (Maintenance Director) that the facility had frozen pipes from Wednesday, 1/17/24 through Monday, 1/22/24. V13 state during that period, the water was shut down periodically up to two hours at a time to replace twelve frozen pipes. V13 stated the facility had emergency water supplies on site during the water shut down period. V13 stated as of 1/23/24 at 8:33 AM, all running water was restored to the building and only dry wall repairs remained to be completed.
On 1/23/24 at 10:00 AM with V2 (Director of Nursing) and V3 (Regional Director of Operations), V1 (Acting Administrator), stated the facility water pipes recently broke but running water was restored to all parts of the facility. V1 stated the water was only off for short periods of times while repairing the pipes but was turned on immediately. V1 stated the only repairs remaining were dry wall installation to cover the holes in the ceilings where the pipes burst.
On 1/23/24 at 10:46 AM, R23 stated there was no running water in the community bathrooms for the past five to six days. R23 stated while the water was shut off, the toilets filled up with stool and urine. R23 stated earlier that morning he tried to use the 200 hall community bathroom but the toilets were full of urine and feces. R23 walked down to the 200 hall community bathroom but the toilet was emptied. There was no bucket in the 200 hall community bathroom for flushing toilets. The sink was turned on and only had cold water available from the sink. R23 stated he was being given bottled water for drinking and to brush his teeth. R23 stated the shower in the 200 hall community bathroom was the only shower in the facility with working hot water.
On 1/23/24 at 11:05 AM, V13 (Director of Maintenance) and V3 (Regional Director of Operations) both re-stated the running water was restored to all areas of the facility since the first water break on 1/17/24 after water being shut off intermittently to repair several pipe bursts. V13 and V3 stated when the facility fixed one broken pipe, they would turn the water back on and another pipe would burst and require repairs. V3 and V13 stated there were numerous pipe that burst since 1/17/24.
On 1/23/24 at 12:46 PM, V3 stated V6 told her he was expecting plumbers to arrive that day to restore water to the executive office area, but he was not aware any toilets/sinks/hot water was not in service to resident areas in the facility. V3 stated she was unaware of the lack of service to resident areas as well.
On 1/23/24 at 11:07 AM during tour of the facility with V1 (Acting Administrator) and V18 (Illinois Department of Public Health Certified/Licensed Plumbing Inspector), the following observations were made and resident interviews obtained:
- The shared bathroom between 111/113 (utilized by R12 and R13) had no running water to the toilet or the handwashing sink. R12 stated the water was shut off for approximately a week in his room and the staff flush down the toilets possibly once a day. R12 stated the toilets built up with feces and urine during the day. There was no bottled water or sanitizer in the bathroom or any bucket with water in the bathroom for flushing the toilet.
- The shared bathroom between rooms 112/114 (utilized by R8 and R10) had no running water to the toilet or handwashing sink. The toilet was full of stool and urine and the toilet was unable to be flushed. There were no water buckets in the bathroom for flushing or water bottles for washing hands near the sink. R8 stated her sink never had any hot water, but now she had no water flowing from her sink or to her toilet. R8 stated she shared a toilet with R10 in room [ROOM NUMBER] and she had to use the 200 hall community toilet because her toilet was full of waste. R8 stated he also found the 200 hall community toilet full of waste when she needed to use it.
- The shared bathroom between rooms 108/110 (utilized by R15) had no running water to the toilet or sink. R15 stated, I'm going in my pants! What else can I do!? R15 stated she had to urinate or defecate in her incontinence brief because she did not have a choice due to the toilets not working. R15 stated the pipes broke approximately a week ago and the toilets had not been working since the pipes broke. There were no buckets of water near the toilet for flushing and no bottled water or sanitizer for handwashing near the sink.
- rooms [ROOM NUMBERS] were both designated isolation rooms requiring contact precautions to enter the rooms. The room [ROOM NUMBER]/213 shared bathroom (utilized by R4 and R30) had no running water to the toilet and no hot water available from the handwashing sink. There was no bucket of water available near the toilet for flushing the toilet. R4 stated, I haven't been able to use the toilet on and off for about a week! R4 stated he recently moved to room [ROOM NUMBER] from room [ROOM NUMBER]. R4 stated he eliminated his stool/urine in the toilet of his old room which built up in the toilet because the toilet would not flush. R4 stated the staff were not flushing down the wastes in the toilet. R4 stated, I tried to use the toilet in my old room [ROOM NUMBER] or the one next to 106 when mine was full!
- Shared bathroom between rooms 207/209 had faucets falling off the sinks and no running water from the sink or to the toilet. There was no bucket of water near the toilet for flushing and no bottled water or sanitizer near the sink for handwashing.
- Shared bathroom of rooms 203/205 had no running water to the toilet and no hot water available in the handwashing sink. There was no bucket of water near the toilet for flushing. V5 (Family) stated, the water has been off a couple of days in room [ROOM NUMBER]. The toilet in room [ROOM NUMBER] had no water running to the toilet and no bucket of water near the toilet for flushing.
- The back nursing station handwashing sink had no running water
- Women's 300 hall community bathroom (utilized by R40, R41, R43-50) had no hot or cold water available from the shower and no hot water available at the only working handwashing sink. The second handwashing sink was covered in plastic wrap and not available for use.
- V4 (Director of Housekeeping) stated the housekeeping staff walked through the facility with a large container of water on a cart and flushed all of the toilets periodically.
- V3 called V6 (Regional Maintenance Director) and V6 stated he thought the toilets were shut off by the plumbers but was not sure how long they had no running water. V1 stated he did was not aware that the pipes were shut off to the toilets and sinks that were not functioning during tour of the facility.
- V8 (CNA- Certified Nursing Assistant) stated the facility had water leaks since 1/17/24 and the water was shut off in the building on and off. V8 stated there was another leak on 1/20/24 and V8 thought the water was shut off because the facility was still trying to repair it.
- V11 (Laundry) stated the facility had shut off water to residents since 1/17/24 and V10 (Housekeeping) stated she was aware the facility turned off water to residents since 1/20/24
- V12 (CNA) stated the toilets in resident rooms were being flushed on and off by housekeeping from a large water container pushed through the hall by housekeeping
On 1/23/24 at 1:50 PM with V1 (Acting Administrator) and V18 during tour of the facility the following observations were made and interviews were obtained:
- R16 stated he utilized the 100 hall community bathroom but the toilet and handwashing sink were not working, so he had to soil his brief since 1/20/24 if he needed to urinate/defecate because the toilet was not working in the community bathroom. R16 stated the staff were only changing his brief once a shift and was forced to sit in his soiled brief. R16 stated staff never gave him an alternative toilet to use when he was informed the toilet was not working in his community bathroom. On 1/24/24 at 1:57 PM with V3 (Regional Director of Operations), R16 again stated while the toilets were not working, he was forced to urinate/defecate in his incontinence brief instead of utilizing the toilet in the hall community toilet per his preference.
- R19 was in his room, sitting in his wheelchair, and had a urinal sitting on the floor in front of him. R19 stated since the water was shut off to the 100 hall community bathroom, he was filling a urinal with urine because the toilets were filled up with urine and feces for the last four or five days. R19 stated the toilet did not flush and there was no running water to the toilets. R19 stated, I have no alternative! [The toilets] are all the same! R19 stated all of the facility toilets were full of human waste for the last four to five days.
- The men's and women's 100 hall community bathrooms (utilized by R16, R17, R19, R23, R58, R59, and R60) had no water running to their toilets or their handwashing sinks. There were disconnected pipes in the women's bathroom visible through an exposed hole in the bathroom. There were no buckets of water near the toilet for flushing and no bottled water or sanitizer near the sink for handwashing.
- R17 stated he normally utilizes the 100 hall community bathroom but there was no running water to the toilet or handwashing sink. R17 stated he was using the 200 hall community bathroom but had difficulty finding a toilet that was not full of human feces/urine waste when he needed to use the bathroom.
On 1/23/24 at 2:05 PM during tour of the facility the following observations were made, and interviews obtained:
- R20 stated 1/23/24 was the first day in four to five days that their hall had a toilet that flushed. R20 stated, If you had to go, you held your nose and went in because the toilet was full of feces and urine. R20 stated the facility staff began flushing the toilet 1/22/24 but were not flushing the toilets over the weekend. R20 stated, It would get heavy enough to make itself flush but not all the way. R20 stated the handwashing sink had no running water and residents only had the sanitizers on the hallway wall to clean their hands.
- R21 stated he used the 400 hall community bathroom which had no running water to the toilet/handwashing sink for days. R21 stated the bathroom continued to not have hot water running to the handwashing sink. R21 stated, Oh God, we were filling them up! Piss and crap in there! They would get a bucket of water and flush it down maybe three or four times over a few days!
- The 400 hall community bathrooms had cold water only running from the handwashing sinks
On 1/23/24 at 2:55 PM, R22 stated he had previous bowel surgeries which caused him to have blood in his stools. R22 stated when the toilets were not working, he had a bowel movement with blood which remained in his toilet his bathroom (shared by R32) for two days before staff flushed it down. R22 stated he was urinating in mouth wash bottles and empty water gallon containers because there was no room in his toilet for additional waste. R22 stated he sealed up the bottles/containers of urine and then dumped them in the toilet when the water was turned back on. R22 stated he had no hot water in his handwashing sink and had not had hot water in the sink for two years.
On 1/23/24 at 2:55 PM, the shared bathrooms between rooms 304/306 (utilized by R35), between 300/302 (utilized by R22 and R32), and between 301/303 (utilized by R31) had no hot water available from the handwashing sink.
On 1/24/24 at 1:40 PM with V3, R35 stated he utilized a urinal when he needed to urinate while the toilets were not working and later flushed it down the toilet himself when the toilets were eventually flushed by staff. R35 stated he had a bowel movement during the day and someone later came and flushed the bowel movement during the night. R35 stated no staff gave any instructions on what to do when the toilets would not flush. R35 stated, It didn't feel comfortable!
On 1/24/24 at 1:57 PM with V3, R47 stated, We had to go on top of what was there! It was gross! R47 stated she had to use the toilet which was full of feces and urine all weekend. R47 stated the residents could not wash their hands and had to use the sanitizer in the hall.
On 1/24/24 at 1:10 PM with V3, R20 stated the lack of an available, clean/flushed toilet made her feel very gross, yucky, very gross! R20 stated, I am not used to that. We always had clean bathrooms. This has been disgusting!
On 1/24/24 at 1:50 PM with V3, R40 stated the facility had no water in the sink or toilets over the weekend and the human waste built up in the toilets. R40 stated having to urinate/defecate in a full toilet made her feel not good!
On 1/23/24 at 11:07 AM, the front nursing station, employee bathroom near the nursing station, and beauty shop all had no hot water available from the handwashing sinks.
On 1/24/24 at 11:58 AM, V6 (Regional Maintenance Director) stated on 1/22/24 he toured the facility to see what work the previous plumbers completed in the facility. V6 stated they left the facility assuming the toilets and sinks were still frozen. V6 stated he believed V1 was working in the facility at the time of his visit.
On 1/23/24 at 12:30 PM, V15 (Building Code Enforcement Superintendent - Village of South [NAME]) stated he was at the facility three times on 1/22/24 and was told the facility restored all the water to all of the facility areas other than the executive office.
On 1/24/24 at 1:15 PM during tour of the facility with V3 (Regional Director of Operations), the following residents were identified as utilizing facility toilets: R2, R4, R8, R10-R13, R15-R17, R19-R23, R25, R26, R30-R32, R35, R40, R41, R43-R51, R58, R59 R60.
On 1/24/24 at 2:25 PM, V2 (DON) stated the residents did not have access to hand sanitizer in their rooms but only that which was available from dispensers in the hallways.
Facility Timeline, dated 1/25/24, shows the facility had an initial water pipe break on 1/17/24 at 9:30 PM. The timeline shows the facility experienced multiple, daily, ongoing water pipe breaks from 1/17/24 to 1/23/24.
Emergency Water Plan, dated 9/25/12, shows, Water from the water heater tanks will be used as a primary source to flush toilets and resident bathing. This water will be placed in a bin with wheels that can be moved around the building. Cleaned, empty 5 gallon pails in which chemicals and detergents were received should be kept filled with non-potable water near each toilet stool for flushing toilets. Water basins will be available to be filled with non-potable water for resident bathing as necessary. The plan also shows, Use alcohol or other approved disinfectants for all hand washing.
Physician telephone order, dated 1/10/24, shows R30 was placed on contact isolation. Physician telephone order, dated 1/24/24, shows R30's isolation was discontinued.
Physician telephone order, dated 1/22/24, shows R4 was placed on contact isolation precautions.
Most recent MDS (Minimum Data Set) documentation for the following residents showed the residents were cognitively intact: R4 (!/3/24), R15 (1/8/24). R16 (12/2/23), R17 (12/13/23), R18 (12/2/23), R19 (10/23/23), R20 (12/1/23), R21 (11/16/23), R22 (12/8/23), R23 (1/18/24), R35 (12/28/23), R40 (11/1/23), and R47 (11/9/23). MDS, dated [DATE], showed R12's cognition was moderately impaired.
The Immediate Jeopardy that began on 1/17/24 was removed on 1/25/24 when the facility took the following actions to remove the immediacy:
- The affected 35/60 residents assessed/interviewed by members of the IDT (Interdisciplinary Team( team staff and no acute changes, s/s (signs/symptoms) of infection, or any distress noted.
- All plumbing was restored and back to normal operations as of 1/24/24
- The facility completed a QA (Quality Assurance) process review on 1/25/24 with the facility QA members.
- On 1/23/24 designated staff were assigned to check and flush all toilets in the facility every 15 minutes and documenting on a form, until certainty of entire system was fully functioning.
- All residents residing in the facility assessed by IDT team for acute changes, S/S of infection, or any distress and none noted on 1/24/24.
- The facility QA team reviewed facility water loss procedure, emergency water and hand hygiene during duration of the emergency and again on 1/25/24.
- As of 1/25/24, greater than 75% of staff inserviced on Hand Hygiene Policy, including Hand Hygiene when loss of water, as well as Emergency Water Policy, including handling of human waste. All other staff will be inserviced prior to the start of their next shift.
- All staff will be in serviced at the time of and through the duration of any declared emergency with loss of water on Hand Hygiene Policy, including Hand Hygiene when loss of water, as well as Emergency Water Policy, including flushing of toilets, communication to staff and residents on emergency situations with updates as needed, delegation of duties to departments during emergencies.
- Immediate QA meeting held with facility QA Committee and Regional Team on 1/25/24. Regional Team to monitor effectiveness of facility Emergency Preparedness through next Quarterly QA meeting.
- Administrator or designee will inservice staff on emergency water policies and procedures twice a month for the next three months. Administrator, DON or Designee will randomly question 3 staff members a week for 8 weeks on emergency water policies and procedures.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to to document assessment of wounds, treatments, and physician orders....
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to to document assessment of wounds, treatments, and physician orders.
This applies to 1 of 3 residents (R1) reviewed for wounds in a sample of 61.
The findings include:
Face sheet, undated, shows R1 was admitted to the facility on [DATE] and his admission diagnoses included stage 4 pressure ulcer of the sacral region, osteomyelitis of vertebra, sacral, and sacrococcygeal region, and hemiplegia following a cerebral infarction affecting his right dominate side. R1 was discharged from the facility June 1, 2022 when the family (V22) called 911 after a disagreement with the facility.
Review of R1's clinical record showed R1 was transferred to the hospital emergency room on 2/25/22, treated for osteomyelitis of the sacral pressure ulcer, bacteremia, urinary tract infection, and acute and chronic kidney disease. R1 was readmitted to the facility on [DATE]. Nursing admission Assessment, dated 3/3/22, shows R1 was assessed to have a stage 4 pressure ulcer and ankle wound. The nursing admission assessment failed to show any assessment of the ankle wound, show a physician was notified or treatment orders were obtained. The facility was unable to provide documentation or assessment of the ankle wound from March 2022. Review of wound physician notes, primary physician notes, nursing progress notes, and physician POS (Physician Order Sheet), dated 3/3/22 to 3/23/22 show no assessment or treatments of R1's ankle wound. The nursing progress notes show R1 was transferred to the hospital on 3/23/22.
Review of R1's clinical record showed R1 was readmitted to the facility on [DATE] from the hospital.
Nursing notes, dated 4/7/22, show R1 had an open sore on right outer ankle (2 cm x 2 cm). The note shows no assessment of the ankle wound, fails to show a physician was notified or treatment orders for the wound. Review of R1's POS and nurses notes, dated 4/7/22 to 4/13/22, show no assessment or treatments of R1's right lateral ankle wound. Again, the facility was unable to produce closed record documentation that the wound had been assessed and physician orders obtained.
Wound physician note, dated 4/13/22, show R1's ankle wound was assessed. The 4/13/22 assessment shows, unstageable (due to necrosis) of the right, lateral ankle full thickness, pressure, duration >3 days, 2.8 cm x 2.3 cm x 0.1 cm, moderate sero-sanguinous exudate, thick adherent devitalized necrotic tissue 30%, slough 30%, granulation tissue 40%. The dressing treatment plan shows, Primary dressings leptospermum honey apply once daily for 30 days. Secondary dressing foam silicone border apply once daily for 30 days Recommendations Off-load wound; Reposition per facility protocol; Sponge boot. The procedure note shows, The wound was cleansed with normal saline and anesthesia was achieved using benzocaine. Then with clean surgical technique, 15 blade was used to surgically excise 3.86 cm2 of devitalized tissue and necrotic subcutaneous fat and surrounding connective tissues along with slough and biofilm were removed at a depth of 0.1 cm and healthy bleeding tissue was observed
Review of R1's POS, dated 4/7/22 to 4/30/22, show no physician orders for treatment of R1's right ankle wound.
Review of R1's TAR (Treatment Administration Record), dated 4/1/22 to 4/30/22, shows a treatment order for R1's right ankle open area which includes cleanse [with] NSS (saline) and apply Xeroform cover with boarder form, change daily. The TAR shows the treatment was applied 4/7/22 to 4/30/22. Review of the TAR shows no treatments which included leptospermum honey or foam silicone border application of R1's right ankle. The TAR shows R1 was assessed to have a pressure wound of the right, lateral ankle measuring 2.8 cm x 2.3 cm x 0.2 cm.
On 1/30/24 at 3:49 PM, V20 (Wound Physician) stated the facility should notify the wound physician of any resident wounds for treatment orders. V20 also stated he expected the facility to follow his wound treatment recommendations as physician orders and implement the treatment recommendations for residents as provided.
On 1/30/24 at 3:48 PM, V21 (Former Wound Nurse) stated the wound physician treatment recommendations provided in the wound physician assessments were expected to be transcribed to the resident POS and TAR for implementation as treatment orders for resident wounds.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to employ a qualified, competent administration to manage...
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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 employ a qualified, competent administration to manage the facility during an emergency and implement the emergency plan for loss of water services.
This applies to all 60 residents residing in the facility.
The findings include:
Facility census, dated 1/23/24, showed there were 60 residents residing in the facility.
On 1/30/24 at 9:26 AM, V1(Acting Administrator) stated he applied for a temporary nursing home administrators license but had not received his temporary license yet. V1 stated he sent his application for the license three months ago and began working as the facility temporary administrator three months ago.
Long Term Care Facility Administrator Form, dated 11/16/23, shows V1 applied to begin as administrator at South [NAME] Rehab and Healthcare and attached a copy of the application for IL licensed administrator. Application for Licensure and/or Examination, dated 9/8/23, shows V1 applied for a temporary certificate (nonexamination) as a nursing home administrator. The application shows V1 attempted, and failed, the Illinois Nursing Home Administrator Examination in May 2022.
On 1/31/24 at 10:05 AM, V3 (Regional Director of Operations) stated V1 was a licensed temporary administrator.
On 1/23/24 at 10:00 AM with V2 (Director of Nursing) and V3 (Regional Director of Operations), V1 (Acting Administrator), stated the facility water pipes recently broke but running water was restored to all parts of the facility. V1 stated the only repairs remaining were dry wall installation to cover the holes in the ceilings where the pipes burst.
On 1/23/24 at 8:33 AM, the State Regional Office was informed by V13 (Maintenance Director) that the facility had frozen pipes from Wednesday, 1/17/24 through Monday, 1/22/24. V13 state during that period, the water was shut down periodically up to two hours at a time to replace twelve frozen pipes. V13 stated the facility had emergency water supplies on site during the water shut down period. V13 stated as of 1/23/24 at 8:33 AM, all running water was restored to the building and only dry wall repairs remained to be completed.
On 1/23/24 at 11:05 AM, V13 (Director of Maintenance) and V3 (Regional Director of Operations) both re-stated running water was restored to all areas of the facility since the first water break on 1/17/24. V3 and V13 stated there were numerous pipe that burst since 1/17/24.
However, on 1/23/24 during tour of the facility with V1 (Acting Administrator) and V18 (Illinois Department of Public Health Certified/Licensed Plumbing Inspector), the following observations were made, and resident interviews obtained:
-The shared resident room bathrooms in the 100 hall, as well as the 100 hall community bathroom, had no running water to the sinks or toilets. There were no buckets of water for flushing human waste down the toilets as they filled with feces/urine, and there were no water bottles or hand sanitizer available at the sinks for hand hygiene. The shared bathrooms in resident rooms were full of human waste.
- The men's and women's 100 hall community bathrooms (utilized by R16, R17, R19, R23, R58, R59, and R60) had no water running to their toilets or their handwashing sinks. There were disconnected pipes in the women's bathroom visible through an exposed hole in the bathroom. There were no buckets of water near the toilet for flushing and no bottled water or sanitizer near the sink for handwashing.
- All three shared resident bathrooms in the 400 hall had no water running to the bathroom toilets and no hot water running in three of the four resident bathroom sinks. The private bathroom in room [ROOM NUMBER] had no running water to the toilet. None of the bathrooms had buckets of water for flushing the toilets, hand sanitizer, or bottled water for washing hands near the sinks.
-The 200-hall nursing station handwashing sink had no running water
- Women's 300 hall community bathroom (utilized by R40, R41, R43-50) had no hot or cold water available from the shower and no hot water available at the only working handwashing sink. The second handwashing sink was covered in plastic wrap and not available for use.
-The front nursing station, employee bathroom near the nursing station, and beauty shop all had no hot water available from the handwashing sinks.
V3 called V6 (Regional Maintenance Director) and V6 stated he thought the toilets were shut off by the plumbers but was not sure how long they had no running water. V1 stated he was not aware that the pipes were shut off to the toilets and sinks that were not functioning during tour of the facility.
On 1/23/24 at 12:46 PM, V3 stated V6 told her he was expecting plumbers to arrive that day to restore water to the executive office area, but he was not aware any toilets/sinks/hot water was not in service to resident areas in the facility. V3 stated she was unaware of the lack of service to resident areas as well.
On 1/24/24 at 11:58 AM, V6 (Regional Maintenance Director) stated on 1/22/24 he toured the facility to see what work the previous plumbers completed in the facility. V6 stated they left the facility assuming the toilets and sinks were still frozen. V6 stated he believed V1 was working in the facility at the time of his visit.
On 1/23/24 at 12:30 PM, V15 (Building Code Enforcement Superintendent - Village of South [NAME]) stated he was at the facility three times on 1/22/24 and was told the facility restored all the water to all of the facility areas other than the executive office.
V8 (CNA) stated the facility had water leaks since 1/17/24 and the water was shut off in the building on and off. V8 stated there was another leak on 1/20/24 and V8 thought the water was shut off because the facility was still trying to repair it.
V11 (Laundry) stated the facility had shut off water to residents since 1/17/24 and V10 (Housekeeping) stated she was aware the facility turned off water to residents since 1/20/24
V12 (CNA) stated the toilets in resident rooms were being flushed on and off by housekeeping from a large water container pushed through the hall by housekeeping.
On 1/23/24 at 2:55 PM, the shared bathrooms between rooms 304/306 (utilized by R35), between 300/302 (utilized by R22 and R32), and between 301/303 (utilized by R31) had no hot water available from the handwashing sink.
On 1/24/24 with V3 (Regional Director of Operations) in the 400 hall, R47, R20 and R40 all stated the 400 hall toilet filled with human waste and was not being flushed by staff after use. The residents stated there was no hand sanitizer available other than the dispensers in the hallway.
Emergency Water Policy, revised 4/2014, shows, A. The Administrator/designee shall be responsible for making all major policy decisions concerning the declaration and activation of the facility's emergency water plan. The Dietary Manager, the Maintenance Manager, and the Director of Nursing shall direct the implementation of the plan during the emergency water situation. The policy shows, 3. Activation of the Plan - Department Duties / Responsibilities A. Administration 1. Receive and confirm all information relative to the overall emergency water situation within the Facility. 2. Initiate notification procedure for emergency supplies. 3. Notify VP of Operations about emergency situation. 4. Coordinate all activities between Nursing, Dietary and Engineering 6 Check and insure all units and departments have an adequate supply of emergency water
V1 was not aware of the continued water supply issues and lack of water to resident rooms, showers, and common bathrooms. V1 did not monitor or designate staff to monitor the water shut off process during pipe repair and V1 did not accurately keep local and state official apprised of the water status. V1 did not ensure the facility emergency policy was implemented and areas were promptly repaired when new damage was noted.
Sept 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0712
(Tag F0712)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure residents were seen by their attending physician as shown in the facility's policy.
This applies to 11 of 12 residents (R2-R12) revi...
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Based on interview and record review, the facility failed to ensure residents were seen by their attending physician as shown in the facility's policy.
This applies to 11 of 12 residents (R2-R12) reviewed for physician services in the sample of 11.
The findings include:
On September 18, 2023, the facility provided a list of all residents and the primary care physician responsible for the resident's care at the facility. The facility identified R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, and R12 as residents under the care of V6 (Attending Physician). The facility does not have documentation to show the residents (R2-R12) have been seen by V6 (Attending Physician) since their admission to the facility.
On September 19, 2023 at 8:24 AM, V2 (DON-Director of Nursing) provided admission dates for the following residents:
R2 - January 24, 2023
R3 - April 17, 2023
R4 - March 22, 2023
R5 - May 4, 2023
R6 - January 30, 2023
R7 - June 8, 2023
R8 - December 29, 2022
R9 - April 10, 2023
R10 - January 25, 2023
R11 - October 28, 2022
R12 - December 26, 2022
On September 18, 2023 at 11:28 AM, V5 (NP-Nurse Practitioner) said, I see all of [V6's] residents at the facility. He has never seen them. He would never have seen R1 while she resided at the facility. He does not come to the facility to see residents.
On September 19, 2023 at 9:32 AM, V2 (DON-Director of Nursing) said, All new admission residents are assigned to [V6] (Attending Physician). [V6] does not come to the facility. He has never stepped into this facility and has not seen any of his residents. All of the people on the list that we identified as being assigned to [V6] have never been seen by him, since their admission date, because he does not come here.
The facility's policy entitled Physician Services, revised 1/8/18 shows: Physician Services are those services provided by a physician responsible for the care of individual residents. Such services include, but are not limited to: A. A written report of a physical examination conducted five (5) days prior to, or within seventy-two (72) hours after admission; .H. The resident must be seen by the attending physician at least once every thirty (30) days for the first ninety (90) days after admission and the resident's total plan of care must be reviewed and revised, if necessary at each visit; I. After the first ninety (90) days the resident must be seen by the physician at least every sixty (60) days; the physician may schedule alternate visits by a PA (Physician's Assistant) or NP; J. At each sixty-day visit the resident's total plan of care (including medications and treatments must be reviewed; Quality physician visits are considered timely if they occur no later than ten (10) days after the required date. Physician services shall be under the supervision of the Medical Director.
Jun 2023
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0559
(Tag F0559)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to allow two consenting adults the right to cohabitate. T...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to allow two consenting adults the right to cohabitate. This applies to 2 of 2 residents (R32 & R40) reviewed for roommates in the sample of 18.
The findings include:
R40's Face Sheet showed she is a [AGE] year old female with an original admission date of 4/21/21. The face sheet showed she has a history of brain cancer, seizures, and falling.
R40's 5/9/23 Minimum Data (MDS) Set showed she was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15. The MDS showed she required supervision and setup assistance for bed mobility; transfers; mobility on and off the unit; and eating.
R40's 2/1/23 Bimonthly Psychiatric care showed, she is stable from a psychiatric standpoint .
R40's 5/11/23 Social Service Note showed resident is alert and oriented .resident wants to share a room with a male resident. Both Residents are able to make decisions .
R32's Face Sheet showed he is [AGE] year old male with an original admission date of 12/14/2018. The face sheet showed he has a history stroke, kidney failure, and right sided paralysis.
R32's 6/8/23 Minimum Data Set showed he had moderate cognitive impairment with a Brief Interview for Mental Status score of 10 out of 15. The MDS showed he required extensive assistance of one person for bed mobility and two people for transfers. The MDS showed he required limited assistance of one person for locomotion on the unit.
R32's 6/5/23 Monthly Psychiatric care visit showed, .Per staff, the patient remains [NAME] (cooperative) with meds (medications) and care .Overall stable from a psychiatric standpoint with current medication regimen. There have been no behavioral problems/issues/concerns during today's visit .
R32's 3/6/23 Social Service note showed, .Resident is unable to speak clearly. Resident is socializing with female resident. They would like to share a room .
On 6/7/23 at 8:14 AM R32 was in R40's room. R32 was in his wheelchair and R40 was sitting at the edge of her bed eating her breakfast. The residents were having a conversation. R40 was clean; well groomed; and without visible signs of bruising, cuts, or other injuries. R32 was dressed in clean clothing and had a splint to his right hand. R32 had difficulty with speech; however, he answered questions appropriately. R40 was alert and oriented. R40 answered questions appropriately; however, her responses were delayed. R40 stated, We have been a couple since December and we have been trying to move in together since January. I talk to [V1] about moving in together once a week . R40 stated there are other unmarried couples who live together in the facility. R32 was alert and oriented. R32 was answering questions appropriatly and he stated he would like to move in with R40. (Initial documented request in R32's chart was made on 3/6/23; three months prior)
On 6/08/23 at 8:30 AM, R32 was in R40's room in nearly an identical condition as they were on 6/7/23 with R40 eating breakfast at the edge of her bed and R32 sitting in his wheelchair facing her. R40 and R32 said they would be willing to leave their current rooms and move to a new room if needed. R40 and R32 stated that option has not been offered. R40 said, I feel like I am being treated differently than other residents. There is another couple that is not married and they are allowed to live together and they didn't have to go through corporate. It is upsetting to me to be treated different because of my age. I'm an adult; I should be treated like one and be allowed to live with who I want to live with.
On 6/07/23 at 1:06 PM, V3 Registered Nurse (RN) stated [R40] is in relationship with [R32]. She is able to make her own decision and the POA (Power of Attorney) is aware of it as well. [R40] is a safe and decent person; he has no negative behaviors. He is able to make his own decisions. They have been together for 6 months .There is no reason that I know why they couldn't live together.
On 6/07/23 at 2:23 PM, V4 Social Service Director stated, R40 and R32 are in a relationship. V4 stated both residents are able to make their own decisions. V4 stated the residents have asked to live in the same room; however, V4 stated this request was made at least one month ago. V4 stated, The only reason they can't live together is because she is child bearing age and that scares me. I don't want to raise a baby. V4 stated there are other residents in the facility who are not married, opposite genders, in a realationship, and live together. V4 said, the situation is little bit scary.
On 6/07/23 at 2:50 PM, V1 stated the facility does not have a policy for intimate relationships.
On 6/08/23 at 8:36 AM, V1 stated, About a month ago they said they wanted to share a room but because she is child bearing we took it too corporate . V1 stated the facility was afraid of being liable for a resident becoming pregnant. V1 stated there are other residents in the facility, who are of different genders, who are in a relationship, and are allowed to cohabitate. V1 stated the residents were educated on safe sex and the potential consequences. V1 stated the facility has the ability to accommodate R32 and R40's room change and a room change can be done in less than a day's time.
The Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities (revision 11/18) stated, As an individual living in a long-term care facility, you retain the same rights as every citizen of Illinois and of the United States. The following regulations provide some clarity on specific rights granted to residents living in long-term care facilities .You have the right to choose your roommate when practicable.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to ensure a resident did not have a seat belt restraint unless medically necessary. The facility failed to have an order, consent,...
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Based on observation, interview and record review the facility failed to ensure a resident did not have a seat belt restraint unless medically necessary. The facility failed to have an order, consent, assessment, and care plan for a seat belt restraint for 1 of 1 residents (R19) reviewed for restraints in the sample of 18.
The findings include:
On 6/6/23 at 11:20 AM, R19 was sitting in a wheelchair in his room with a seat belt on. R19's left hand was contracted and he stated he was not able to remove the seat belt. R19 stated the seat belt was put on so he wouldn't fall out of his chair.
On 6/6/23 at 11:58 AM, R19 propelled his wheelchair to the dining room table. At 12:00 PM, V5 CNA (Certified Nursing Assistant) sat down next to R19 and started to feed him his sandwich from his tray. R19's seat belt was not released during his supervised lunch. At 12:07 PM, V5 continued to feed R19 with the seat belt intact.
On 6/7/23 at 2:55 PM, V2 DON (Director of Nursing) stated R19 was a chair bound resident that required assistance with activities of daily living and was in a restorative eating program. V2 stated R19 has not had any changes in condition and was stable with his medical condition. V2 stated she did not know R19 had a seat belt and she was surprised he had one. V2 stated the facility's restraint policy is if a resident cannot remove the seat belt themselves then it is a restraint. V2 stated the regulation stated the same thing. V2 stated V13 RN (Registered Nurse) was over Restorative Programs and she would have to ask her about R19's seat belt.
On 6/7/23 at 3:00 PM, R19's medical record was reviewed and there wasn't an order, consent, evaluation/assessment, or care plan in place for the use of a seat belt.
On 6/7/23 at 3:16 PM, V13 RN (Registered Nurse/Restorative Nurse/MDS & Care Plan Coordinator) stated R19 did not have a seat belt. V4 (Social Services Director) was present and stated R19 had a seat belt on and has had it on for at least two weeks because he was sliding out of his chair. V13 stated she did not know anything about the seat belt. V13 stated an order, consent, assessment and care plan was needed for the use of the seat belt.
The Physician Order Sheet dated 6/1/23 for R19 showed medical diagnoses including anoxic brain injury, hypertension, alcohol use, encephalopathy, depression, insomnia, and difficulty walking.
The MDS (Minimum Data Set) dated 4/4/23 showed no cognitive impairment; extensive assistance needed for bed mobility, transfers, dressing eating, toilet use, and personal hygiene.
The facility's Physical Restraint/Enabler Policy (7/24/18) showed , A physical restraint is any manual method or physical or mechanical device, equipment, or material attached or adjacent to the resident's body, which the individual cannot remove easily and which restricts freedom of movement or normal access to his or her body. Procedure: Complete Physical Enabler/Restraint Use/Reeducation Evaluation. Obtain verbal and/or written consent from resident/legally responsible party (may obtain verbal consent until able to receive written consent). Document in nurses notes the date, time, and which type of consent obtained prior to physical restraint being applied. Obtain a physician's order for restraint or adaptive device/enabler. The order must include: specific medical/physical reason, type of restraint/enabler, release and reposition at least every two hours and when to be used. Release the restraint at a minimum every two hours. Document in the nurses notes the type of restraint being used and the resident's response to the physical restraint. Place the physical restraint problem on the residents care plan. The care plan must address the duration, type, and circumstances under which the restraint can be used.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident received clean clothing daily for 1 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident received clean clothing daily for 1 of 2 residents (R34) reviewed for activities of daily living in the sample of 18.
The findings include:
R34's face sheet printed on 6/8/23 showed diagnoses including but not limited to history of transient ischemic attack, muscle weakness, and left sided hemiplegia (paralysis). R34's facility assessment dated [DATE] showed moderate cognitive impairment and staff assistance needed for bed mobility, transfers, walking, dressing, toilet use, and personal hygiene.
On 6/6/23 at 11:50 AM, R34 was lying in bed and dressed in a black, cartoon character tee shirt. R34 was covered with a light sheet up to his waist. R34 stated he had not had his clothing changed or been out of bed all morning. R34 pulled back the sheet and was wearing black sweatpants with a navy-blue stripe down the side. A white, incontinence brief was visible sticking out of the waist band and a package of incontinence briefs were on top of his nightstand. At 12:19 PM, R34's family member stated he visits R34 on a regular basis. R34 is wet and smells bad at many of the visits.
On 6/7/23 at 8:14 AM, R34 was lying in bed sleeping and wore the same shirt and pants observed on him the day before. At 8:31 AM, V5 (Certified Nurse Aide) said the night shift staff were the last to change R34's incontinence brief. He refuses care at times, so we reapproach later or try a different staff member to get him to let us change him. At 11:07 AM, R34 was outside smoking with staff present. R34 was wearing the same cartoon character tee shirt and black sweatpants. R34's clothing was wrinkled and disheveled. V7 (Activity Director) wheeled R34 into the building after smoking. R34 did not resist staff in anyway. V3 (Registered Nurse) stated R34 never resists staff assistance during smoking breaks. At 2:30 PM, R34 was seated in the group dining room, wearing the same clothing.
On 6/8/23 at 8:36 AM, V6 (Certified Nurse Aide) was wheeling R34 down the hallway. R34 did not show any signs of refusing staff assistance. R34 wore the same clothing as the last two days. At 9:53 AM, V6 transferred R34 from the wheelchair to a shower chair. R34 did not resist or refuse care. R34 said his last shower was Monday and that is when he was put into the current clothing. R34 said staff have not changed his clothes since that last shower (3 days ago). R34 said he sleeps in his clothes, and nobody changes them in the morning or at night. V6 confirmed R34's memory was intact. V6 said residents should be changed each night into pajamas or a gown, based on preference. V6 said all residents should be put into clean and fresh clothing daily.
On 6/8/23 at 10:23 AM, V2 (Director of Nurses) stated resident clothing should be changed every morning. Residents should be changed into sleeping attire each night. Residents are free to choose what they wish to wear, but it should be clean clothing. Dirty clothing is not good for resident dignity. Fresh clothing is very important for good hygiene and to prevent infections.
The facility A.M. Care policy reviewed dated 3/20/23 states: A.M. care will be given to all residents daily. 11. Dress or assist resident to dress in clean, comfortable clothing, including shoes, stockings, and underwear. The facility undated P.M. Care policy states: P.M. care is provided to the resident for personal hygiene and for the purpose of refreshing the resident every evening. 13. Apply hospital gown or resident's own sleepwear if requested.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place for a resident at high risk for pressure ulcers for one of six residents (R53) reviewed for pressure in the sample of 18.
The findings include:
R53's face sheet printed on 6/8/23 showed diagnoses including but not limited to pulmonary embolism, atrial fibrillation, anemia, bipolar disorder, and depression. R53's facility assessment dated [DATE] showed cognitively intact and requires staff assistance with bed mobility, transfers, locomotion, dressing, eating, toilet use, and personal hygiene. R53's facility assessment incorrectly showed no incontinence issues.
R53's pressure ulcer risk assessment dated [DATE] showed a high risk.
R53's June 2023 physician orders showed: Prevalom boots (heel protectors) on while in bed. Turn and reposition per facility protocol.
On 6/6/23 at 10:14 AM, R53 was lying on his back in bed with his head elevated. R53's feet were resting directly on the mattress. There were no heel protectors on his feet or pillow under his calves. At 11:56 AM and 2:05 PM, R53 was in the same position.
On 6/7/23 at 8:22 AM, R53 was lying in bed with his head elevated and no heel protectors on his feet. At 10:25 AM, V5 and V6 (Certified Nurse Aides) performed incontinence care for R53. After care, R53 remained on his back and his heels directly on the mattress. R53 was not lying on any type of specialized mattress. At 12:48 PM, R53 was in the same position.
On 6/8/23 at 9:16 AM, R53 was in bed on his back and his heels were directly on the mattress.
On 6/8/23 at 11:18 AM, V3 (Registered Nurse) and this surveyor located R53's heel protectors on the floor in the closet. R53 confirmed the boots are never put on his feet. V3 said the heel protectors are not used unless there is an actual opening to the skin. V3 stated there is no need for the boots because R53's heels are okay. V3 said R53 can reposition himself in bed, so there is no need for staff to help him. (Facility assessment showed staff assistance is required). V3 said residents need to be repositioned every two hours to prevent pressure ulcers and breathing problems. V3 said R53 only gets out of bed a few times per week.
On 6/8/23 at 11:47 AM, V2 (Director of Nurses) stated staff should always be implementing pressure relieving interventions. Residents with a high risk for skin break down need to be on a specialized air mattress. V2 said interventions are important to reduce pressure on high pressure sites. Heel boots are especially important to reduce it on the heels. Interventions should be in place before skin changes or openings happened. It is important to prevent ulcers so there is no need to treat them. Physician orders need to be followed and be charted on the TAR (Treatment Administration Record). If there is nothing documented on the TAR, it means the order has not been carried out. V2 and this surveyor observed R53's mattress together. V2 stated this is not a specialized air mattress. He needs to be on one due to his high risk of skin break down.
R53's June 2023 TAR was reviewed and showed an order start dated 3/17/23 for Prevalom boots on while in bed. The TAR showed a second order start dated 4/19/23 for turn and reposition per facility protocol. The TAR sections were blank for the entire month.
The facility Decubitus Care/Pressure Areas policy revision dated 1/18 states under the policy section: It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to ensure splints were applied for residents with contractures, restorative programs were implemented, reviewed, and revised as ne...
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Based on observation, interview and record review the facility failed to ensure splints were applied for residents with contractures, restorative programs were implemented, reviewed, and revised as needed for 2 of 3 residents (R15 & R19) reviewed for contractures in the sample of 18.
The findings include:
1. On 6/7/23 at 8:50 AM, R15 was laying on his back in his bed. R15's left hand and fingers on his left hand were contracted. R15 did not have a splint on his left hand. No hand splint was visible in his room. R15 stated that no one does any ROM (range of motion) to his left hand so he tries to do what he can himself. R15 stated he gets pain to his left hand. R15 stated he used to have a splint for his left hand but it disappeared a long time ago. R15 stated he would wear the splint if he still had it. contracted left hand and fingers.
On 6/7/23 at 9:03 AM, V9 CNA (Certified Nursing Assistant) came into R15's room and stated she has only been at the facility a week and has never seen a splint for R15's hand and has never put one on him. V9 stated she doesn't do any ROM to R15's hand because he has pain in that hand when his fingers are moved. R15 stated he would be okay with staff doing ROM for him.
The Physician Order Sheet dated 6/1/23 for R15 showed medical diagnoses including cerebral vascular accident, left sided hemiparesis, left upper extremity and left lower extremity contracture, osteoarthritis, hypertension, neurogenic bladder, deep venous thrombosis, acute renal failure, neoplasm of scrotum, suprapubic catheter, hematuria, and seizures.
The Restorative Nursing Program Documentation dated April 2023 showed R15 should have a left hand corrective orthosis/soft splint with grip. The wearing - schedule per resident preference; may wear as tolerated up to 8 hours. Resident specific interventions: observe skin before and after splint application, inspect device for safety before use and clean device as needed, train resident in placement/use/skin breakdown and abnormal circulation signs and symptoms. Report abnormalities in skin or pain to the nurse. The Restorative Nursing Program Documentation dated April 2023 showed R15 did not refuse and no splint was applied to his hand on 4/8, 4/9, 4/12, 4/14, 4/22, 4/23, 4/27, 4/28, 4/30, & 4/31. The Restorative Nursing Program Documentation form for May 2023 for R15 showed no splint was applied on 5/12, 5/14, 5/15, 5/17, 5/18, & 5/22. The Restorative Nursing Program Documentation for R15 for June 2023 for showed a check mark on 6/1 - 6/6/23 that he had the splint on to his left arm/hand. R15 did not have a splint in his room and had stated (6/7/23 at at 9:03 AM) he hasn't had one for a long time.
The Restorative Nursing Program Documentation for R15 for PROM (passive range of motion) to the left upper extremity and left lower extremity showed he was to have 5-10 reps done for 15 minutes per day on the May 2023 and June 2023 forms. The forms were initialed that ROM had been done. In the interview with R15 on on 6/7/23 at 8:50 AM he stated it was not being done.
On 6/7/23 at 1:00 PM, V1 (Administrator) stated V13 RN (Registered Nurse) and V2 DON (Director of Nursing) were responsible for the restorative program and that there is a person that comes in some afternoons to walk people; they try to walk as many people as they can.
On 6/7/23 at 1:34 PM, V13 RN (Registered Nurse) stated that her and V2 DON were over the restorative programs. V13 stated she checks every resident that comes into the building, does an assessment and places the resident on restorative programs based on the assessment. V13 stated every quarter she was to look at the restorative program in place and see if there were any significant changes. V13 stated she reviews the restorative documentation once in awhile when she has time. V13 stated she thought R15 had a splint a couple of years ago but doesn't have anything because of a massive contraction to his hand. V13 stated if a splint was refused to be worn then it should have been documented as a refusal on the restorative nursing program documentation. V13 stated she probably missed reviewing R15's restorative program and wasn't sure what was in place for the resident.
On 6/7/23 at 2:20 PM, V1 (Administrator) stated she thought R15 had a splint for his left hand but could be wrong. V1 stated she has never seen a splint on R15's left arm or hand.
R15's Care Plan dated 5/5/23 showed, Restorative Nursing Program - range of motion both passive and active. Contracted left upper extremity and left lower extremity. Assess and document restorative participation and response to the program quarterly and as needed for change in abilities. Review goals and approaches with interdisciplinary team quarterly and as needed with changes in his condition. Revise goal and approaches as needed to maximize participation and independence levels. Note and share successful strategies for participation and goal achievement. R15's care plan showed the splint was discontinued 2/1/23. The Restorative Nursing Program Documentation showed for May 2023 and June 2023 that the splint was applied some days and not applied on others.
The Physician Order Sheet dated 6/1/23 for R15 showed medical diagnoses including cerebral vascular accident, left sided hemiparesis, left upper and lower extremity contractures.
The MDS (Minimum Data Set) dated 5/5/23 for R15 showed no cognitive impairment; total dependence on staff for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing.
The facility's Restorative Nursing Programs policy (9/27/17) showed, Perform a comprehensive assessment of each resident to establish needs and strengths to determine the resident's readiness/capacity to learn and physical ability to participate. Develop goals and objectives per individual resident needs. Writing the program once the need is identified. Steps implemented to reach the goal (approaches). Implementing the program Evaluating the program: Determine if the goal has been archived by measuring and comparing objectives. 1. Through observations of the resident's performance. 2. Interview with the residents if appropriate. Documentation of the program: B. Reassessment every 90 days or sooner if determined appropriate for level of care/needs established by IDT ( interdisciplinary team). F. Progress note will be written by licensed nurse addressing resident progress, participation, and response/tolerance of program every 90 days or sooner if determined appropriate for level of care/needs established by IDT.
2. On 6/6/23 at 11:20 AM, R19 was sitting in a wheelchair in his room with a seat belt on. R19's left hand was contracted, his index (first) finger stayed pointed out straight and the other fingers were relaxed into his palm area. R19 was able to move his fingers away from his palm to a hallway point with the fingers facing downward. R19 had to used his right hand with much effort to use that hand and try an open the other hand. R19 stated he didn't have a splint for his right hand but would wear one if he had one. R19 had black velcro shoe on his left foot and regular tennis shoe on his right foot. R19 stated he has the black shoe because his toes curled under. There wasn't a hand splint in R19's room.
On 6/7/23 at 1:34 PM, V13 RN (Registered Nurse) stated that her and V2 DON were over the restorative programs. V13 stated she checks every resident that comes into the building, does an assessment and places the resident on restorative programs based on the assessment. V13 stated every quarter she was to look at the restorative program in place and see if there were any significant changes. V13 stated she reviews the restorative documentation once in awhile when she has time. V13 stated if a splint was refused to be worn then it should have been documented as a refusal on the restorative nursing program documentation. V13 stated she probably missed reviewing R19's restorative program and wasn't sure what was in place for the resident.
On 6/8/23 at 9:05 AM, V14 CNA (Certified Nursing Assistant) stated she was R19's CNA for the day. V14 stated R19 had a splint to his foot that he wears every day. stated she does ROM to his arms and hands but not really his legs. V14 stated she likes to works with R19's hands because he gets frustrated at not being able to use his hands like he wants to. V14 went to R19's room and showed what appeared to be a new hand splint next to his bedside.
On 6/8/23 at 9:19 AM, R19 was sitting in his wheelchair in the common area without a splint to his left hand. R19 stated he received a splint for his hand yesterday.
The Restorative Nursing Program Documentation form for R19 for May 2023 showed he was to have a splint to his right and left hand; on for 4 hours and off for 4 hours. No refusals were documented. Check marks were to be done if the splint was worn per schedule. An R was to be documented if he refused to wear the hand splint. The time in minutes for the length of time he wore the splint were to be documented on the form. were to be documented. The third shift on 5/3, 5/4, 5/6, 5/10, 5/12, 5/14, 5/15, 5/17, 5/18 and 5/22 did not show any documentation of the splint being applied for 4 hours. The Restorative Nursing Program form for R19 for June 2023 showed the splint was not applied on the day shift for 4 hours on 6/1-6/3, 6/5 & 6/6/23.
The Range of Motion Assessment for R19 was dated 4/3/23 and showed he was a candidate for restorative programming and had contracted fingers on the left hand.
The May 2023 and June 2023 notes for R19 were reviewed and did not show a monthly note written or co-signed by a licensed nurse regarding the resident's response and tolerance to the splint for his left hand.
The facility's Restorative Nursing Programs policy (9/27/17) showed, Perform a comprehensive assessment of each resident to establish needs and strengths to determine the resident's readiness/capacity to learn and physical ability to participate. Develop goals and objectives per individual resident needs. Writing the program once the need is identified. Steps implemented to reach the goal (approaches). Implementing the program Evaluating the program: Determine if the goal has been archived by measuring and comparing objectives. 1. Through observations of the resident's performance. 2. Interview with the residents if appropriate. Documentation of the program: B. Reassessment every 90 days or sooner if determined appropriate for level of care/needs established by IDT ( interdisciplinary team). F. Progress note will be written by licensed nurse addressing resident progress, participation, and response/tolerance of program every 90 days or sooner if determined appropriate for level of care/needs established by IDT.
The facility's Splints/Appliances (4/06) policy showed, The program will be identified on the residents care plan including the problem, approaches, and goals. A monthly note written or co-signed by a licensed nurse regarding the resident's response and tolerance to the splint will be documented in the clinical record. The licensed nurse of occupational therapist will reassess the resident's response to the splint as needed minimally every 90 days.
The Physician Order Sheet dated 6/1/23 for R19 showed medical diagnoses including anoxic brain injury, hypertension, alcohol use, encephalopathy, depression, insomnia, and difficulty walking.
The MDS (Minimum Data Set) dated 4/4/23 showed no cognitive impairment; extensive assistance needed for bed mobility, transfers, dressing eating, toilet use, and personal hygiene.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to provide a safe transfer for 1 of 2 residents (R159) reviewed for safety in the sample of 18.
The findings include:
On 6/6/23 at...
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Based on observation, interview and record review the facility failed to provide a safe transfer for 1 of 2 residents (R159) reviewed for safety in the sample of 18.
The findings include:
On 6/6/23 at 12:19 PM, R159 was leaning to the side in his padded reclining wheelchair. V9 CNA (Certified Nursing Assistant) was in his room and stated she could just transfer R159 to bed; a mechanical lift was not needed. At 12:21 PM, V11 CNA came into R159's room to help V9 transfer R159 to bed. V9 put the gait belt around R159. V11 had his arm under R159's arm pit and V9 was holding onto the gait belt. They tried to stand R159 up and V11 grabbed the back of R159's pants to stand while V11 grabbed the side of the residents pants. R159 couldn't bear weight with his transfer. V9 stated R159 was not able to bear weight.
On 6/8/23 at 11:39 AM, V2 DON (Director of Nursing) stated a resident's transfer ability is based on V13's RN (Registered Nurse/MDS Care Plan Coordinator) assessment. V2 stated she thought R159 was a mechanical lift transfer. V13 stated R159's care plan stated he could be transferred with two people and they may use a mechanical lift. V13 stated R159 was not able to assist with his transfers and could not stand. V2 was notified of the transfer observation for R159 on 6/6/23 at 12:19 PM and she stated that transfer was not okay and the safest way for R159 to be transferred would be by using a mechanical lift.
The MDS (Minimum Data Set) dated 4/6/23 for R159 showed total dependence for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing.
The most recent Care Plan in R159's medical record was dated 1/5/23 and showed transfer resident using two assist. Use a gait belt for all hands on transfers from one surface to another. The only part of the resident's care plan that was updated with a date of 5/8/23 was for droplet precautions.
The Physician Order Sheet dated 6/1/23 showed diagnoses including sepsis, hypertension, dementia, depression, gastroesophageal reflux disease, thoracic aortic aneurysm, encephalopathy, urinary tract infection, benign prostatic hypertrophy, cerebral vascular accident, hypothyroidism, and cerebral atherosclerosis.
The facility's ADL Task Analysis Sitting Transfer Bed to Chair policy (1/02) showed the resident is supposed to be able to place their feet on the floor during the transfer.
The facility's ADL Task Analysis Sit to Stand policy (1/02) showed the resident was to be able to push on feet and hands on the wheelchair to stand. Neither policy showed what would be a safe transfer with a gait belt; or the procedure for the transfer. No other policy was available.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0825
(Tag F0825)
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 assess a resident for therapy services to upgrade thei...
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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 assess a resident for therapy services to upgrade their diet for 1 of 1 (R38) reviewed for specialized rehabilitation services in the sample of 18.
The findings include:
R38's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include alcohol dependence, dementia without behavioral disturbance, essential hypertension, insomnia, and weakness.
On 6/06/23 at 12:05 PM, R38 was in his room feeding himself a pureed diet. R38's facility assessment dated [DATE] showed he is severely cognitive impaired and has no symptoms of a swallowing disorder. R38's last nutritional assessment dated [DATE] completed by the facility's Registered Dietitian showed, . Pureed, Nectar thick liquids . Diagnosis: Liver cirrhosis, hypertension, dementia, Alzheimer's disease, insomnia, depression, right leg swelling, and psychotic disorder . Annual Assessment: Resident receiving pureed/NTL (nectar thick liquids) . No concerns with chewing or swallowing .
R38's physician progress note dated 7/12/2020 showed, C/O (Complains of) COVID 19, dysphagia, cough status post ER (Emergency Room) visit recently . A/P (Assessment and Plan) 1. COVID 19 positive viral infection; 2. viral pneumonia secondary to COVID 19; 3. Oropharyngeal dysphagia likely secondary to COVID 19 . 5. Cough secondary to COVID 19 .
R38's care plan initiated 11/14/22 showed, Nutrition; Resident specific information - has diagnosis of alcoholic liver cirrhosis, hypertension, dementia, Alzheimer's disease, insomnia, depression . is on a puree diet due to episodes of difficulty swallowing while in the hospital .
On 6/06/23 at 1:20 PM, V3 RN (Registered Nurse) said, I'm not sure why [R38] is on a pureed diet, he was just on it when he got here.
On 6/08/23 at 9:45 AM, V2 DON (Director of Nursing) said, I think [R38] has been on a pureed diet since he has been here. He came with that. We have been educating his wife because she brings in food for him that is not pureed. I'm not sure why he is on that diet, must be dysphagia. I'm not sure if he has seen speech therapy.
On 6/08/23 at 9:50 AM, V8 (Director of Therapy) said, [R38] was on physical therapy and occupational therapy services but he was never on speech therapy.
On 6/8/23 at 1:25 PM, V2 DON said she looked into R38's record further and found that he came in to the facility on his initial admission date with a regular diet and thin liquids. V2 said R38 was downgraded to a pureed diet during the time when he was diagnosed with COVID 19. V2 said R38 should have been referred to speech therapy as soon as his COVID 19 symptoms were resolving so they could consider upgrading his diet. V2 said, [R38] having a pureed diet if he does not require one could affect his quality of life because a lot of people don't like pureed food.
The facility's policy and procedure titled Restorative ADL (Activities of Daily Living) Programs with revision date of 01/02, Policy: Restorative programs shall be planned for any resident with a reasonable likelihood for improvement in their functioning levels or to prevent a loss of function. Responsibility: All nursing personnel, Therapy personnel. Procedure: . 3. Every resident will be re-evaluated at least every ninety (90) days, more frequently if there is a significant change in their condition . 5. Programs will be designed and directed toward the resident becoming as independent as capabilities will allow, thus promoting self esteem and enhancing quality of life .
The Illinois Long-Term Care Ombudsman Program Resident's Rights for People in Long -Term Care Facilities with revision date of 11/2018 showed, . Your facility must provide services to keep your physical and mental health, at their highest practicable levels .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to prevent cross contamination of resident contact surface...
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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 of resident contact surfaces by not removing gloves after incontinence care and a dressing change prior to touching anything else for 2 of 2 residents (R54 & R15) reviewed for infection control in the sample of 18.
The findings include:
1. On 6/7/23 at 1:12 PM, V12 RN (Registered Nurse/Wound Care Nurse) was in R15's room for a dressing change to a wound on his left outer ankle. V12 had gloves on and stated she was going to clean the peri wound, then the wound because the periwound was cleaner. V12 took saline and gauze and wiped the peri wound. V12 cleaned the red wound bed on R15's ankle with saline and gauze. V12 did not remove her gloves, picked up the scissors and cut open the calcium alginate package. V12 removed the calcium alginate and cut it to the size of the wound and applied it to the wound. V12 applied a border foam dressing on top of the wound and stated it was for protection and drainage. V12 discarded the empty calcium alginate package in garbage, put his grip sock and heel boot. V12 took the indwelling urinary catheter drainage bag that was in a plastic bag, removed the bag and attached it to the side of the bed. V12 removed her gloves.
On 6/7/23 at 1:30, V12 stated she thought she changed her gloves after cleaning R15's wound but couldn't wash her hands in the sink because there isn't a sink. V12 stated gloves should be changed after removing old dressing and cleaning the wound and before the application of the new dressing.
On 6/7/23 at 2:20 PM, V1 (Administrator)was notified of the observation on 6/7/23 at 1:12 PM when V12 provided wound care for R15's ankle. V1 stated V12 should have changed her gloves after cleaning the wound and putting a new dressing on for infection control/cross contamination reasons.
The Wound Care Physician's Note dated 5/31/23 for R15 showed he had a stage 4 left lateral ankle wound that measured 2.4 x 3.6 x 0.2 cm that had been present for greater than 537 days. The treatment plan was calcium alginate to the wound with a foam border dressing over top of it.
The Physician Order Sheet dated 6/1/23 for R15 showed medical diagnoses including seizures, suprapubic catheter, cerebral vascular accident, left hemiparesis, left upper extremity and left lower extremity contractures, and osteoarthritis.
The MDS (Minimum Data Set) dated 5/5/23 for R15 showed no cognitive impairment; total dependence on staff for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing.
The facility's Aseptic Wound and Skin Treatment Procedure (3/16/23) showed, Put on gloves and removed soiled dressings and place in plastic bag at the end of the bed. Remove gloves and place in plastic bag. Wash your hands. Put on clean gloves. Clean the wound as ordered. Place soiled sponges used for cleaning wound in a plastic bag. Remove gloves and place in plastic bag. Wash your hands. Put on clean gloves. Apply clean dressing as ordered, using gloves or no touch technique. Remove gloves and discard in plastic bag.
2. On 6/6/23 at 10:31 AM, there was a strong odor of urine in R54's room. V9 CNA (Certified Nursing Assistant) was asked to check R54 and his bed and incontinence brief were saturated with urine. V9 and V10 CNA put gloves on and and V9 undid the sides of R54's incontinence brief and squirted a foam cleanser on the front of his groin. V9 took a wash cloth and wiped one side of his groin, turned the washcloth and wiped the other side of his groin. V9 discarded the washcloth in a bag. V9 grabbed another wash cloth and wiped off the area above R54's penis but did not clean his penis. V9 laid the washcloth on his bed. Some of the spray cleanser was still visible on his skin. V9 removed and disposed of her gloves. V9 sprayed her hands with sanitizer and put new gloves on. V9 and V10 turned R54 onto his right side. V10 was on the opposite side of the bed helping hold R54 in place. V9 squirted the foam cleanser on R54's buttocks, picked up the wash cloth from the bed and cleaned his buttocks in a circular motion. V9 did not change her gloves, grabbed the clean sheet and incontinence brief and placed it under R54 after she has rolled up the soiled brief and linen under him as far as she could go over to V10's side. V9 and V10 rolled R54 onto his left side towards V9 who grabbed a package of disposable wipes and laid them on the bed. V9 told V10 she had the wipes in case V10 needed to use them. V10 shook her head no. V10 finished pulling R54's soiled sheet and brief out from under him and laid it on his top sheet at the end of his bed. V10 pulled the clean sheet and clean brief through and laid R54 onto his back. V9 picked up the soiled sheet and incontinence brief and threw it in the plastic bag. V9 and V10 removed R54's gown and put a clean gown on him. V9 and V10 boosted R54 up in bed by pulling on the bottom sheet. V9 and V10 took the top sheet that the soiled linen and brief had laid on and placed it over R54. V10 removed her gloves, stated she was going to wash her hands and left the room. V9 bagged up the linen and removed her gloves. V9 was asked when hands were supposed to be washed and/or gloves changed and she stated that she used hand sanitizer because there is no sink in the room. V9 stated she should change her gloves said after she washed R54's his front side and before washing his back side. V9 stated she is supposed to change her gloves after cleaning one area and going to another for infection control. V9 stated gloves are to be changed before touching anything else for infection control.
On 6/8/23 at 11:45 AM, V1 (Administrator) was notified of the incontinence care observation on 6/7/23 at 10:31 AM for R54. V1 stated that the care provided was not appropriate and staff needed to be re-educated on changing gloves and washing hands when providing incontinence care. V1 stated it was an infection control problem.
The Physician Order Sheet dated 6/1/23 for R54 showed diagnoses including cerebral vascular accident, dysphagia, hypertension, hyperlipidemia, severe morbid obesity, hand contractures, and right sided hemiplegia.
The MDS dated [DATE] for R54 showed dependence on staff for all activities of daily living.
The facilities Perineal Cleansing policy (12/17) showed, Wash pubic area, including upper inner aspect of both thighs as well as the penis and scrotum. Place soiled items in plastic bag. Dry area thoroughly. Remove gloves and wash hands with soap & water, cleansing gel or other product. Apply clean incontinence product, clothes or position resident comfortably. The basic infection control concept for pericare is to wash from the cleanest to the dirtiest area and remember to change or remove gloves and wash hands when going from working with contaminated items to clean items.
Apr 2022
15 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 4/28/22 at 11:19 AM, R9 was in the dining room sitting in her wheelchair. The spokes of R9's wheelchair were covered in de...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 4/28/22 at 11:19 AM, R9 was in the dining room sitting in her wheelchair. The spokes of R9's wheelchair were covered in debris; the sides of the wheelchair were dirty; the wheels were cracked and appeared dry rotted with pieces of the wheels missing; and the arm rests had foam taped to them with the tape being dirty and frayed. The arm rests were partially visible under the foam and they were torn with the padding missing. The locking mechanism for R9's wheel chair had pieces of tubing that had been placed over the metal bar that comes in contact with the wheel. The tubing looked similar to garden hose.
On 4/28/22 at 11:19 AM, R9 stated the duct tape and foam is dirty and frayed. R9 stated the tape and foam is there as a repair for the arm rests. R9 said she is dependent upon her wheelchair for her independence and to move about the facility. R9 said the tubing on the locks has fallen off and she has to push it back on so she is able to lock the wheels. R9 said she has had the wheelchair for several years and there has never been any maintenance on it. R9 stated she has attempted to trade her wheelchair with other residents; however, there were no takers.
On 4/28/22 at 8:35 AM, V12 Maintenance Director stated, he doesn't do regular checks on wheelchairs and he will put tubing on the brakes to give them more grip.
On 4/28/22 at 10:25 AM, V1 Administrator in Training stated if staff see issues with wheelchairs they should put in a work order. V1 said duct tape should probably not be used to repair wheelchairs.
Based on observation, interview, and record review the facility failed to maintain residents' wheelchairs in a manner to meet their needs for 2 of 2 residents (R17, R9) reviewed for accommodation of needs in the sample of 17.
The findings include:
1. On 4/26/22 at 10:34 AM, R17 was sitting in his wheelchair. The arm rests of R17's wheelchair were wrapped with fraying, black duct tape. R17 pointed to the right arm rest and stated, The screws came out a long time ago, so he duct taped the arm rests. If the duct tape gets gross or loose, then the maintenance guy will come change it. He's got more things to fix than my wheelchair. I just don't lean on the right side. R17's wheelchair had foam padding, held in place with duct tape near the 90 degree bar attaching the wheelchair seat to the front wheels. The brake pad of R17's wheelchair was wrapped in duct tape.
R17's undated Cumulative Diagnosis Form showed diagnoses to include, but not limited to: morbid obesity, diabetes, depression, coronary artery disease, congestive heart failure, hypertension, sleep apnea, depressive disorder, anxiety disorder, chronic neck and back pain, and neuropathy.
R17's facility assessment dated [DATE] showed he was cognitively intact and had a wheelchair.
R17's care plan dated 4/20/22 showed he had bilateral lower extremity weakness, morbid obesity, and fragile skin. R17's fragile skin care plan showed he is prone to bruising and skin tears.
On 4/28/22 at 8:25 AM, V9 (Registered Nurse - RN) said V12 (Maintenance Manager) fixes the wheelchairs. V9 stated, I'm not sure why there would be duct tape on a wheelchair. I would think the wheelchair would need to be fixed. V9 said R17 is careless when he uses his wheelchair. V9 stated, he needs to be bubble wrapped.
On 4/28/22 at 8:35 AM, V12 (Maintenance Manager) said he does not perform regular wheelchair checks. V12 said he will check resident wheelchairs if someone says something to him or he sees something wrong with the chair. V12 said he does use duct tape on resident wheelchairs. V12 and this surveyor went into R17's room. R17 was sitting in his wheelchair, the pad to the right arm rest had slipped to the side. R17's arm was resting on the metal bar, covered with duct tape. R17 stated, Yea, sometimes that pad will slide around because the screws are missing. I just try not to lean on it. V12 said the screws had fallen out of R17's arm rest a while ago and he had put in a request to order long arm pads for R17's wheelchair. V12 said he submits an equipment request for approval, then corporate orders the equipment. V12 stated, The request must have been denied. It's been a few months. I thought those (long arm rests) would be more comfortable for him and they would come with new screws. R17's right arm rest wobbled when he shifted in his wheelchair.
V12's equipment request dated 7/23/21 (9 months ago) showed a request for Universal Full Length Padded Armrests, which included attachment hardware (screws).
On 4/28/22 at 10:25 AM, V1 (Administrator in Training) said staff should be notifying V12 (Maintenance Manager) of any issues with resident wheelchairs. V1 stated, He probably shouldn't be using duct tape to repair wheelchairs. It's not a normal practice. If the screws were missing from the arm rest, then duct tape should not be used to hold the arm rest in place. Aesthetically it looks horrible and it's probably not very comfortable. There are probably infection control issues there. I wouldn't want my arm resting on a piece of duct tape. V1 said to replace or repair a wheelchair V12 must submit a work order into the regional office, then the request goes to corporate for approval. V1 said if the request is put in by Sunday, then the request will be reviewed that week. V1 said the delivery may take 7 to 10 days. V1 said she would not expect 9 months to pass without V12 (Maintenance Manger) following up. V1 said V12 should be doing scheduled checks of the resident wheelchairs.
The facility's undated Maintenance Services policy showed, It is the policy of [the facility] that maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation: 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a resident dependent upon cares with privacy d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a resident dependent upon cares with privacy during wound care for 1 of 1 resident (R36) reviewed for privacy in the sample of 17.
The findings include:
R36's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include stage 4 pressure ulcer of sacral region, urinary tract infection, hemiplegia following a cerebral infarction, aphasia, major depressive disorder, and osteomyelitis of the vertebra and sacrum. R36's facility assessment dated [DATE] showed he is cognitively impaired and requires extensive assistance for all cares except eating.
On 4/27/22 at 12:41 PM, V10 CNA (Certified Nursing Assistant) and V9 RN (Registered Nurse) were assisting the wound care physician with a dressing change for R36. R36's roommate was laying in his bed with the head of bed elevated and the privacy curtain was only pulled to cover R36's lower legs from his roommate's view. R36 was exposed from the middle of his back down to his feet and was rolled away from the roommate exposing his bare buttocks and his stage 4 pressure ulcers to his roommate during wound care. At 1:10 PM while wound care continued V10 motioned to V9 to pull the curtain shut. V9 grabbed the curtain and gave it a quick pull but it did not close and R36 remained exposed to his roommate as care continued. R36's roommate was looking over at R36 watching wound care. At 1:17 PM, after care was completed and as V9 and V10 were exiting the room, the privacy curtain was pulled to provide privacy.
On 4/28/22 at 1:58 PM, V2 (Regional Clinical Director) said the privacy curtain should be pulled during personal cares so the roommate cannot see the care being provided. V2 said not providing privacy for a resident during personal care is a dignity issue.
On 4/28/22 at 11:56 AM, V1 (Administer in Training) said the facility does not have a specific policy regarding providing privacy during care but uses the Resident's Rights booklet for Long Term Care facilities.
The Illinois Long Term care Residents' Rights for People in Long Term Care Facilities with revision date of 11/2018 showed, . Your rights to dignity and respect . Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to provide oral care for a resident dependent upon staff for assistance. This applies to 1 of 1 resident (R32) reviewed for activ...
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Based on observation, interview, and record review the facility failed to provide oral care for a resident dependent upon staff for assistance. This applies to 1 of 1 resident (R32) reviewed for activities of daily living in the sample of 17.
The findings include:
R32's Face Sheet, provided on 4/28/22, showed an original admission date of 1/24/2018 with diagnoses to include: Multiple Sclerosis, lack of coordination, muscle wasting, and age related physical debility.
R32's 3/8/22 Minimum Data Set (MDS) showed he was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The MDS showed R32 required extensive assistance for personal hygiene (brushing teeth.)
On 4/26/22 at 9:59 AM and 4/27/22 at 12:37 PM, R32's teeth showed food buildup between his teeth and his gum line was inflamed. R32's right hand was contracted and he minimal use with his left hand.
On 4/27/22 at 12:37 PM, R32 stated I do need help to brush my teeth because of my MS (multiple sclerosis.) It's been a couple months since my teeth have been brushed. R32 said staff do not offer to assist with his oral care and it feels good to have his teeth brushed.
On 4/27/22 at 1:05 PM, V11 Certified Nursing Assistant (CNA) stated R32 does not need assistance with brushing his teeth, only setup assistance.
On 4/27/22 at 12:59 PM, V5 CNA said R32 does need assistance with oral care. V5 said R32 is almost total care. (R32 is dependent upon staff for nearly all of his care.) V5 said R32 can sometimes floss his teeth but he needs help brushing his teeth. V5 said all CNA's can brush resident's teeth and he had not been told by R32 he needed his teeth brushed.
On 4/28/22 at 11:10 AM, R32 stated, They brushed my teeth yesterday, after I talked to you. It did feel good to have them brushed. The CNA that brushed them was a little rough, but it did feel good.
On 4/28/22 at 11:03 AM, V4 Registered Nurse stated oral cares helps to prevent infections, stimulates appetite, and helps the residents to feel clean.
R32's Care Plan showed interventions to Provide oral care with am and PM cares .
The facility A.M. Care policy (Reviewed 1/2018) showed morning care will be provided to all resident daily to include oral care. The policy showed, Give oral hygiene per resident's ability for self-care .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure preventative measures for pressure ulcer preven...
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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 preventative measures for pressure ulcer prevention and healing were implemented for 3 of 6 residents (R36, R25, and R50) reviewed for pressure ulcers in the sample of 17.
The findings include:
1. R36's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include stage 4 pressure ulcer of sacral region, urinary tract infection, hemiplegia following a cerebral infarction, aphasia, major depressive disorder, and osteomyelitis of the vertebra and sacrum. R36's facility assessment dated [DATE] showed he is cognitively impaired and requires extensive assistance for all cares except eating. R36's March 2022 monthly weight showed he weighed 254 pounds.
R36's complete care plan was provided and showed only one care plan which mentioned R36's pressure ulcer. This care plan initiated on 2/21/22 only addressed a wound vac that was no longer in place at the time of this survey.
On 4/26/22 at 9:49 AM, R36 had a low air mattress on his bed. The mattress was set on the comfort level 9. There was a guide to comfort levels which corresponded to resident weight printed on the top of his mattress which was only visible up to level 8 and showed level 8 was for residents who weighed 300 pounds. On 4/27/22 at 12:01 PM, R36's low air loss mattress remained on level 9. On 4/28/22 at 12:31 PM, R36's mattress remained on level 9.
On 4/28/22 at 9:41 AM, V9 RN (Registered Nurse) said R36 has a low air loss mattress on his bed to promote wound healing and to prevent further deterioration. R36 said, The air mattress is placed on the bed by the maintenance director and he does not touch it. V9 said he does not know what setting it should be on because all of that is handled by maintenance.
On 4/28/22 at 11:20 AM, V12 (Maintenance Director) said he puts the air mattresses on the beds. V12 said he does not know what setting the air mattresses are supposed to be on for the resident. V12 said he turns the mattress on the high to mid level to ensure it is working and then lets the CNA (Certified Nursing Assistant) set it on whatever they want.
On 4/28/22 at 12:31 PM, V9 CNA said she does not set anything on the air mattresses. V9 said the one who sets the level of the air mattress is V12 (Maintenance Director).
On 4/28/22 at 1:58 PM, V2 (Regional Clinical Director) said the purpose of the low air loss mattresses is to prevent any further deterioration of wounds. The mattresses should be set to the individual resident specifications.
The air mattress user's manual was requested. V1 (Administrator in Training) provided a brochure for an air mattress but not the one that R36 had on his bed. On 4/28/22 at approximately 12:00 PM, V1 said the only air mattresses used in the facility were the one that this brochure showed. V1 said she was not aware that there were other air mattresses being used. On 4/28/22 at 2:25 PM, V1 said the company they rent the air mattresses from said they do not have any of the user manuals for the mattresses.
The facility's policy and procedure titled Pressure Sore Prevention Guidelines with revision date of 1/18 showed, . Policy: It is the facility's policy to provide adequate interventions for the prevention of pressure ulcers . Special Mattress . Specify type of mattress on the Care Plan .
2. R25's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include diabetes, acquired absence of unspecified leg above knee, stage 3 pressure ulcer of sacral region, and other sequel of cerebral infarction. R25's facility assessment dated [DATE] showed he has moderate cognitive impairment, requires extensive assistance for all cares except eating, and is at risk for developing pressure ulcers.
R25's April 2022 Physician Order Sheet showed, May use low air loss mattress. R25's 4/19/22 RD (Registered Dietitian) monthly note showed R25 to weigh 245 pounds. R25's care plan provided on 4/28/22 showed R25 to be at risk for pressure ulcers . on and off pressure ulcer in sacral area. The same care plan showed an intervention added 11/1/21 for pressure relief mattress in bed - air loss. R25's wound evaluation and management summary dated 1/12/22 showed, . He has a stage 3 pressure wound sacrum for at least 8 days duration . preventative recommendations to prevent recurrence .
On 4/26/22 at 9:46 AM, R25 was laying in bed. There was a low air loss mattress on the bed set at level 8. There was a guide to comfort levels which corresponded to resident weight printed on the top of the plastic air mattress control box which was only visible up to level 8 and showed level 8 was for residents who weighed 300 pounds (55 lbs more than R25 weighed). On 4/28/22 at 9:59 AM, R25's air mattress remained on level 8.
3. R50's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include urinary tract infection, abnormal posture, sepsis, and lack of coordination. R50's facility assessment dated [DATE] showed he has moderate cognitive impairment, requires extensive assistance from staff for all cares except eating, and is at risk for developing pressure ulcers. R50's care plan was provided on 4/28/22 and showed, [R50] at risk for Pressure Ulcer per Braden Risk Assessment . Risk factors include has lymphademic wounds, redness to buttocks and perineal area 1/6/22 intervention Pressure relief mattress in bed foam . R50's April 2022 weight recorded on his Report of Monthly Weight showed R50 to weigh 224 pounds.
On 4/26/22 at 9:45 AM, R50 was laying in his bed with a low air loss mattress on the bed. The air mattress showed it was set to 300 pounds (76 pounds more than R50 weighs). On 4/27/22 at 12:42 PM, R50's air mattress remained set on 300 pounds.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to provide range of motion exercises for a resident with contractures. This applies to 1 of 2 residents (R32) reviewed for range ...
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Based on observation, interview, and record review the facility failed to provide range of motion exercises for a resident with contractures. This applies to 1 of 2 residents (R32) reviewed for range of motion in the sample of 17.
The findings include:
R32's Face Sheet, provided on 4/28/22, showed an original admission date of 1/24/2018 with diagnoses to include: multiple sclerosis, lack of coordination, muscle wasting, and age related physical debility.
R32's 3/8/22 Minimum Data Set (MDS) showed he was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The MDS showed R32 was totally dependent upon staff for bed mobility, transfers, dressing, eating, and toileting. The MDS showed he had limited range of motion to all four extremities.
On 4/26/22 at 9:59 AM, R32 stated, I'm getting worse at being able to stretch that right hand. R32 stated he used to be able to open the right hand further. R32 was able to open his right hand about 50 percent. R32 had no splint to the right hand. R32 stated, The staff never work with that right hand they never stretch it open. R32's knees and hips were contracted to approximately 90 degrees. R32 stated he would not refuse any range of motion exercises to his body.
On 4/27/22 at 12:59 PM, V5 Certified Nursing Assistant (CNA) stated, R32 is totally dependent upon staff for nearly all of his care. V5 said, I don't know what range of motion exercises he (R32) needs but we move his arms and legs when we go in there and from time to time he may refuse it. V5 stated range of motion (ROM) are documented in the activities of daily (ADL) binder.
R32's ADL binder showed two pages related to range of motion. One sheet showed perform active ROM of BUE (bilateral/both upper extremities), BLE (bilateral lower extremities) 5 to 10 reps (repetitions) 15 minutes daily with the goal to maintain and increase function. (Active range of motion is range of motion the resident completes themselves. R32 was totally dependent upon staff for most of his care.) The ROM sheet showed V6 CNA documented the ROM as being done on the first shift from April 3, 2022 through April 21, 2022 and on the third shift from April 7, 2022 through April 21, 2022.
R32's ADL binder showed a second ROM sheet with interventions to include .encourage to perform ROM 5-10 reps 15 minutes daily, complete ROM to joint when resident is unable . V6 documented this intervention as being done the same as the previous ROM sheet.
V1 Administrator in Training provided V6's working schedule as a hand written note. From 4/3/2022 through 4/21/22 (19 days), V6 only worked 6 days.
On 4/28/22 at 11:03 AM, V4 Registered Nurse stated range of motion exercises are use to maintain and prevent decline in a residents range of motion.
The facility's Range of Motion Protocol showed it is the facility's policy to provide Range of Motion exercises for residents who through assessment demonstrate the need for exercise to prevent functional decline in range of motion.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate supervision to a wandering, confused ...
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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 adequate supervision to a wandering, confused resident to prevent a fall for 1 of 1 resident (R49) reviewed for a falls in the sample of 17.
The findings include:
On 4/27/22 at 12:26 PM, R49 was observed ambulating, independently throughout the facility.
The facility's Quality Care Reporting Form dated 2/20/22 showed R49 had an alleged fall on the patio at 8:05 PM. This document showed the fall was reported by a resident to the nurse. This document showed R21 sustained a 1 centimeter (cm) cut on his left eyebrow, 1.5 cm x 0.5 cm skin tear to his right cheek, and a 1 cm cut to his right nostril. This document showed, Summary of event and any actions taken: Resident with confusion ran outside the patio and lost his balance; medication review .
The facility's undated Post Fall Root Cause Worksheet showed, . 8. What was going on, on the unit 5 minutes before the fall? Everybody was busy at work. 9. Where were staff? Nurse: passing medications. CNAs: attending to other residents.
R22's (resident that witnessed R49's fall) Witness Statement dated 2/20/22 showed he and another resident came inside from the patio and the door was still open. This statement showed R49 ran out the door, to the patio, and went down on the ground, face first. This statement showed R22 called for help.
R49's Nurses Notes dated 2/20/22 at 8:05 PM, showed, Heard a loud call from a resident on front dining room, attended at once and saw the resident (R49) . outside, on the patio, sitting on the floor, bleeding from his face and trying to get up, called for assistance . This note showed R49 was very confused and unable to tell the nurse what happened. This note showed R49 sustained cuts to his left eyebrow, right cheek, and the top of his nose. R49 was sent to the emergency room due to the possibility he hit his head on the concrete patio.
R49's undated Diagnoses form showed diagnoses to include, but not limited to seizure disorder, depression, history of TBI (traumatic brain injury), and cognitive impairment.
R49's IDT Progress Notes showed he had previous falls on 2/14/22 and 2/18/22.
R49's Fall Risk Care Plan revised 2/20/21 showed, Resident has risk factors that require monitoring. Walks independently with supervision, his gait is generally steady, but he walks fast and [NAME]. (Resident) takes psychotropic medications for behaviors related to TBI . (A) Observe for unsteady/unsafe transfer or ambulation and provide stand by or balance support as needed.
The facility's Staffing Schedule for 2/20/22 showed V14 (Registered Nurse - RN), and V5, V16, V17 (Certified Nursing Assistants - CNAs) worked PM evening shift.
On 4/28/22 at 10:34 AM, V1 (Administrator in Training) said R49 has had some falls and had one nasty fall, on the patio. V1 said she was not in the building when R49 fell on the patio. V1 said R49's fall was witnessed by a staff member. V1 said another resident notified the nurse that R49 had fall. V1 said R49 was not allowed to smoke anymore and he had gone out to the patio when another resident was returning inside.
On 4/28/22 V14, RN, was not available for interview.
On 4/28/22 at 11:11 AM, V5 (CNA) said he was working on 2/20/22. V5 said he was providing resident care on 100 hall. V5 said he did not see R49 fall. V5 said her head nurse said R49 fell, but by the time I finished care, R49 was already in the dining room.
On 4/28/222 at 12:05 PM, V17 (CNA) said she was working the night R49 fell, but she did not see him fall. V17 said she was coming back from break, with V16, when she heard the nursing calling over the intercom. V17 said the nurse was on the intercom saying she needed assistance by the dining room. V17 stated, By the time I got up front, R49 was in the dining room with the nurse and he had blood coming from his head. V17 stated, I don't know what he was doing out there.
On 4/28/22 at 12:46 PM, V16 (CNA) said she was working the night R49 fell on the patio, but she did not see him fall. V16 said the nurse was calling over the intercom for help. V16 stated, When I got up there, the nurse was outside on the patio ground and R49 was bleeding from his face. I don't know if any staff saw him fall. V16 said R49 should not have been outside, he was really confused.
The facility's Fall Prevention Policy revised 11/10/18 showed, To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility . All staff must observe residents for safety .
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 provide catheter care in a manner to prevent cross con...
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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 catheter care in a manner to prevent cross contamination for a resident with a history of urinary tract infections for 1 of 3 residents (R36) reviewed for catheters in the sample of 17.
The findings include:
R36's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include stage 4 pressure ulcer of sacral region, urinary tract infection, hemiplegia following a cerebral infarction, aphasia, major depressive disorder, and osteomyelitis of the vertebra and sacrum area. R36's facility assessment dated [DATE] showed he is cognitively impaired and requires extensive assistance for all cares except eating.
R36's acute care hospital discharge instructions from his hospital stay from 2/25/22 through 3/3/22 showed, . Reason for visit: Sepsis, UTI .
On 4/27/22 at 12:01 PM, R36's catheter bag was not in a privacy bag and was laying directly on floor next to his bed. V10 CNA (Certified Nursing Assistant) and V11 CNA were replacing R36's bed pad. V11 picked the catheter bag up off the floor and placed it in the blue privacy bag hanging from the bed frame. V11 went and got a urinal and then took the catheter bag back out of the privacy bad, opened the drainage tube, drained the urine into the urinal, and then replaced the drainage tube without cleaning it.
On 4/27/22 at 12:41 PM, V9 RN (Registered Nurse) and V10 CNA were assisting the wound care physician with a dressing change. R36's head of the bed had been lowered but the foot of the bed remained elevated. As V9 was cleaning the wound, V10 placed the catheter bag on the foot of the bed causing the catheter drainage bag to be above the level of R36's bladder. There was urine in the tube of the catheter which was observed flowing back toward R36's bladder.
On 4/27/22 at 12:01 PM, V11 CNA said, The catheter bag shouldn't be on the floor, it was supposed to be in the blue bag but I wasn't finished with taking care of him . I was going to come back in and put it back in the blue bag. V11 said the catheter bag should not be directly on the floor because of privacy it should be in the blue bag.
On 4/28/22 at 9:41 AM, V9 RN said the CNAs empty the catheter bags and report the output to him. V9 said the CNAs would just empty the bag and they don't have to clean the tip of the tubing before placing it back into the bag. V9 said the catheter bag should not ever be on the floor for infection control. V9 said the catheter drainage bag should stay below the level of the bladder because gravity won't flow the normal way. V9 said if you put it higher than the bladder the urine will flow back toward the resident and can cause UTIs (urinary tract infections).
On 4/28/22 at 1:58 PM, V2 (Regional Clinical Director) said when draining the urine from a catheter bag they should clean the tip of the urinary drainage tube with alcohol before closing it. V2 said the catheter bags should be maintained below the level of the bladder. V2 said cleaning the tip of the catheter drainage tube and keeping the urinary drainage bag below the level of the bladder is important to prevent urinary tract infections.
The facility's policy titled Catheter Care with review date of 2/18 showed, Purpose: Catheter care is provided daily and as needed to all residents who have an indwelling catheter to reduce the incidence of infection . The catheter care policy only addresses the procedure for providing perineal and catheter care at the entrance to the body. The facility's policy and procedure for catheters and for emptying the catheter drainage bag was requested and not received.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assess the integrity of a resident's gastrostomy tube ...
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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 assess the integrity of a resident's gastrostomy tube (G-tube) and identify changes to the integrity of the G-tube for 1 of 2 residents (R37) reviewed for feeding tubes in the sample of 17.
The findings include:
On 4/26/22 at 10:54 AM, R37 was lying in bed, on his back, with the head of the bed elevated. R37 said he doesn't get his feedings through his G-tube anymore and has been eating. (A G-tube is a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications.) R37 used his left hand to pull his blankets away from his upper body. R37's G-tube was wraped with multiple areas of black/brown discoloration noted along the inside of the tube. The G-tube was contoured and had a bubbling appearance. (A G-tube is usually smooth).
On 4/27/22 at 2:11 PM, V9 (Registered Nurse - RN) said R37 started eating recently and his tube feedings were on hold. V9 administered liquid medications and flushes through R37's G-tube. R37 said he saw the warped G-tube with dark discolorations. V9 stated, I haven't seen a tube look like that. It works though. I'm not sure if we have a policy on changing the G-tubes. I think it (the G-tube) will just stay in as long as it can stay. We don't change the G-tubes here. V9 said the resident would need to see a gastrointestinal (GI) doctor for the tube to be changed. V9 said he was not aware of R37's G-tube being changed.
R1's undated Facesheet showed he was admitted to the facility on [DATE].
R37's undated Diagnosis form showed diagnoses to include, but not limited to: stroke, right side weakness, peripheral vascular disease, diabetes, seizure disorder, aphasia, chronic kidney disease, gastrostomy status (11/29/18), and history of small bowel obstruction. A hand written note showed, R37 had surgery for the small bowel obstruction and a G-tube was put in after surgery (1/9/19).
R37's facility assessment dated [DATE] showed R37 had severe cognitive impairment; required extensive assistance for bed mobility; was totally dependent for eating; and had a feeding tube.
R37's April 2022 Physician's Order Sheet showed R37's medications were ordered to be administered through the G-tube.
R37's Enteral Nutrition Support Care Plan reviewed 3/7/22 showed R37 had a silicone type G-tube. The interventions showed, .Assess/record complications including irritation, self extubation (removal of the tube), tube dysfunction, and/or tube dislodgement .
R37 did not have any notes from the GI doctor regarding R37's G-tube.
On 4/27/22 at 3:24 PM, V2 (Regional Director of Clinical Operations) said she is a nurse that consults and looks over nursing care for the facility. V2 said the nurse should assess the G-tube color, patency, and integrity. V2 said if R37's G-tube was warped and had discoloration, then she expects the nurses to call the doctor and update him on the tube integrity. V2 said a G-tube should not appear warped or have black/brown discolorations inside the tube. V2 said if a G-tube is not working correctly, then there is a risk for the medications or flushes being put into the tube to go into the wrong place. V2 said R37 should have records from the hospital or a note from the GI doctor regarding his G-tube, if it was changed. V2 stated, In my experience I am not aware of a G-tube being in for years at a time. We would have to talk to the ordering physician.
On 4/28/22 at 8:08 AM, V1 (Administrator in Training) said she did not have any notes from the GI doctor and was unable to find any documentation that R37's G-tube had been changed.
The facility's Daily Cleansing of G/J/PEG Tube Site Policy showed, It is the policy of [the facility] to provide care and services to the resident with a gastrostomy or jejunostomy tube to maintain the site in clean and safe manner as to minimize the risk of infections.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0742
(Tag F0742)
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 track and document changes/escalations in residents' 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 track and document changes/escalations in residents' behaviors. This applies to 2 of 5 residents (R29, R49) reviewed for behavioral services in the sample of 17.
The findings include:
1. R29's Face Sheet showed an original admission date of 5/14/2021.
R29's 2/9/22 Minimum Data Set (MDS) showed moderate cognitive impairment.
On 4/26/22 at 1:59 PM, R29 had many scratches to his right forearm and right upper arm. The scratches appeared recent; they were bright red and many of the scratches had tiny scabs. The scratches were numerous (greater than 20) and the average length was approximately 4 to six inches.
On 4/28/22 at 9:06 AM, V4 Registered Nurse, stated R29's scratches were self-inflicted. V4 said, (R29) gets easily upset, like if his charger is not working he will start screaming and scratching. He will also reach into his brief and scratch himself when he is upset.
R29's psychiatric provider from 3/8/22 showed, he has a history of developmental delay and he is being seen for a follow up visit for mood, behavior and medication management due to his increasing sexually inappropriate behavior. The note continued, During my initial visit with him on 11/2/21, I started him on lexapro 10 mg (milligrams) daily to help with sexually inappropriate behavior by decreasing libido . The note showed, under physical exam; Behavior .Sexually inappropriate behavior towards staff . The note showed Continue to monitor mood/behavior/sleep as you are.
R29's Nurse's Notes (provided on 4/28/22) were reviewed for the year 2022. Last nurses note was 3/18/22. Nursing notes for 2022 did not discuss any negative behaviors to include sexually inappropriate behaviors or scratching.
On 4/28/22 at 9:39 AM, V4 Registered Nurse (RN) V4 provided an example of resident behavior tracking, which is maintained in a binder near the nursing station. V4 showed that behavior tracking log is where nursing staff document resident behaviors. V4 said the purpose of behavior tracking is to monitor for trends or changes in a resident's behaviors. V4 said, I think the sexual behavior is when he scratches his private area. V4 said R29 does not have a behavior tracking log.
On 4/28/22 at 9:42 AM, V3 Social Services Director said R29's scratching behavior is new and it should be tracked and documented. V3 said, R29 should have behavior tracking. V3 said she would interpret the Mental Health providers note stating continue to monitor mood/behavior/sleep as you are to mean behavior tracking. V3 said the purpose of behavior tracking is to aide in monitoring a resident's behaviors and to track trends or changes in those behaviors. V3 said the tracking is also important for the mental health providers as it provides them with a snap-shot of their behaviors during the time when the provider is not in the facility. V3 would also expect R29's care plan to reflect his behaviors, such as the scratching and inappropriate sexual behavior, and to have appropriate interventions for those behaviors.
On 4/28/22, R29's care plan did not show any sexually inappropriate or scratching behaviors.
The facility's Behavior Record Guide (Behavior Tracking policy, undated) showed .Each shift should code for the date and shift for the target behavior, the frequency of the behavior .the behavior record is to be completed when the caregiver completes ADL (Activities of Daily Living) sheets for the day .
2. On 4/26/22 at 10:17 AM, R49 was not in his room. V18 (Licensed Practical Nurse - LPN) stated, He's wandering around. He walks around most of the day. He'll go in and out of rooms and eat other residents' food.
On 4/27/22 at 12:26 PM, R49 was observed ambulating, independently throughout the facility.
R49's undated Diagnoses form showed diagnoses to include, but not limited to: seizure disorder, depression, history of TBI (traumatic brain injury), and cognitive impairment.
R49's Psychiatric Visit dated 3/29/22 showed R49 had a psychiatric history of depression and mild cognitive impairment. This document showed R49 was being seen today for facility and patient request due to his increasing anxiety and agitation. This documented showed, This patient was recently hospitalized from [DATE] -3/27/22 due to psychiatric instability and agitation. This document showed R49 displays inappropriate behaviors of increasing anxiety and agitation, curses at staff, and stealing food. This document showed staff report his mood fluctuates. This document showed, Assessment: .4. Continue to monitor/mood/behavior/sleep as you are .
R49's Neurology Progress Notes dated 3/18/22 showed he has a history of schizoaffective disorder, TBI (traumatic brain injury), craniotomy, and recent fall 2/2022. This document showed he was sent to hospital for neurology evaluation due to increasing confusion and worsening mental status. This document showed he is impulse here, requiring wrist restraints and a sitter.
R49's Smoking Care Plan dated 12/14/21 showed R49 does not follow the smoking policy. One of the interventions for this care plan was behavior tracking daily.
R49's Care Plan revised 4/4/22 showed R49 has a history of physical aggression when at past skilled facility. One of the interventions for this care plan was behavior tracking daily.
R49's Care Plan revised 4/4/22 showed R49 has ineffective individual coping with being easily annoyed. One of the interventions for this care plan was behavior tracking daily.
R49's Care plan revised 4/4/22 showed, Resident is known to display/has history of paranoid thoughts/behaviors and/or open conflict/criticism with others including false accusations . Interventions: Initiated Behavior Monitoring program to attempt to identify patterns, precursors, and causes of behavior and to attempt to understand the meaning of the behavior . A hand written note on the bottom of this care plan dated 3/10/22 showed, Resident has behaviors of wandering around building, not knowing where he is going. Resident is an elopement risk .
In 4/28/22 at 9:15 AM, V4 (Registered Nurse - RN) said R49 wanders around the building and he's very confused. V4 said that R49 was more aggressive and having more behaviors, so he was sent to the hospital for psychiatric evaluation. V4 said the Behavior Tracking Sheets are not done for everyone. V4 said V3 (Social Services) and the MDS Coordinator decide who gets Behavior Tracking. V4 said R49 should have behavior tracking sheets. V4 searched the entire Medication Administration binder on R49's unit and R49's chart. V4 stated, I don't see any behavior tracking for R49; I will have to check on that. V4 said the behavior tracking sheets showed what behaviors the resident is having and what intervention was done. V4 said there is a code with number used to complete the documentation. V4 said the purpose of behavior tracking is to observe for patterns of behavior, monitor improvement or decline in resident behaviors, and to provide information for the nurse to call the physician if patterns or declines are noticed.
On 4/28/22 at 9:41 AM, V3 (Social Services) said she works with the MDS coordinator to determine what residents need behavior tracking. V3 said she gets information from the nurses to make this determination. V3 said residents with schizophrenia or schizoaffective disorder with medications to treat those illnesses should have behavior tracking. V3 said the nurses are responsible for completing the behavior tracking. V3 said if the psychiatric provider documents to continue tracking behaviors as you are, then the resident behaviors should be tracked. V3 said the behavior tracking is done to see if we can find trends and determine the potential cause of the resident's behaviors. V3 said R49 has always been a little difficult, but he's more difficult lately. V3 said R49 is having more behaviors lately. V3 said she is seeking more appropriate placement for R49. V3 stated, I don't know why R49 doesn't have behavior tracking sheets.
On 4/28/22 at 10:34 AM, V1 (Administrator in training) said R49 can be difficult to redirect. V1 said R49 roams around the building. V1 said R49 became aggressive with a CNA and V1 felt the situation was out of control, so she had R49 sent to the hospital for evaluation.
R49's behavior tracking sheets were requested and not received from the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure behaviors were tracked for a resident with deme...
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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 behaviors were tracked for a resident with dementia and receiving an antipsychotic medication for 1 of 5 residents (R13) reviewed for behaviors.
The findings include:
R13's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include gastrointestinal mucositis, abdominal aortic aneurysm, without rupture, vascular dementia without behavioral disturbance, and unspecified dementia with behavioral disturbance. R13's facility assessment dated [DATE] showed he has moderate cognitive impairment and requires extensive assistance from staff for most cares.
R13's physician order sheet showed an order on 11/16/21 for the antipsychotic medication, Seroquel, for diagnosis of Schizoaffective disorder.
R13's complete care plan was provided and showed a care plan with start date of 4/14/22 which showed, . Resident is known to have/has a history of hallucinations and/or delusions .has behaviors of self isolating himself, verbally abusive to staff, sleeplessness related to diagnosis/condition - psychosis . Initiate behavior monitoring program to attempt to identify patterns, precursors, and causes of delusions/hallucinations to attempt to understand the meaning of the falsehood . R13 had another care plan with start date of 4/14/22 which showed, Resident is known/has history of displaying inappropriate behavior and/or resisting care/services. Specific behavior exhibited - upset during shower days, continues to change/stays in his soiled clothes and refuses assistance with changing, resident is offensive to other people. Related diagnosis/condition - dx of dementia, psychosis . Initiate behavior monitoring program . R13 had another care plan with start date of 4/14/22 which showed, Resident is known to display behaviors and/or open conflict/criticism with others including false accusations. Specific behavior exhibited - tendency to claim staff hurting him. Related diagnosis/condition - history of psychosis, dementia, paranoia . Initiate behavior monitoring program . R13 had another care plan with start date of 4/14/22 which showed, Psychotropic Med (Medication) Use, Class of drug, Antipsychotic, Related diagnosis - vascular dementia with behavioral disturbance. Behaviors exhibited . hallucinations, delusion, self isolates in his room, verbally abusive to staff, sleeplessness . Note changes in behavior, agitation, aggression, pacing, self abuse, hallucinations, delusions .
On 4/28/22 at 12:49 PM, V9 RN (Registered Nurse) said, We track the behaviors in the MAR/TAR, [V3] (Social Services) gives us the tracking sheets and we put them in the front of their MAR (Medication Administration Record). If we don't have tracking sheets we don't know what we are supposed to be tracking. [V3] already came here looking for [R13's] behavior tracking sheets. There isn't any.
On 4/28/22 at 9:42 AM, V3 (Social Services Director) said behavior tracking is determined by the MDS (Minimum Data Set) nurse and herself. V3 said a lot of the behavior tracking is based on their diagnosis and their behaviors. V3 said residents with diagnoses of schizophrenia, psychosis, and bipolar and residents on medications to treat those conditions are monitored for behaviors. to them. V3 said the purpose of behavior tracking is to monitor for trends and changing behaviors so the provider can see what behaviors the resident has been having in between their visits. V3 said behavior tracking will give providers a snapshot of the residents behaviors in between their visits to the facility.
On 4/28/22 at 1:45 PM, V1 (Administrator in Training) said there is no behavior tracking for R13.
On 4/28/22 at 1:58 PM, V2 (Regional Clinical Director) said it is important to track behaviors to identify trends and to identify any escalation of behaviors, to help to determine if new interventions are needed, and to determine if medications need adjustments.
On 4/28/22 the facility provided an undated policy titled Behavior Record Guide which showed, The Behavior Record form should be completed to include the resident's name, diagnosis, pertinent to the stated behavior (if known), any psychotropic medication pertinent to the stated behavior (if known), and target behavior . Some interventions are standard/common for many residents and some interventions are resident specific; again those most effective for the individual resident should be included on the form each shift should code for the date and shift for the target behavior, the frequency of the behavior, the corresponding number to the intervention used to assist the resident in managing the behavior and the outcome
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
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 remove a resident's expired insulin vial for 1 of 1 re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to remove a resident's expired insulin vial for 1 of 1 resident (R21) reviewed for medication storage and labeling in the sample of 17.
The findings include:
On [DATE] at 2:11 PM, V13 (Licensed Practical Nurse - LPN) reviewed the back medication cart with this surveyor. R21's opened, Lantus (long-acting insulin) vial had a label that showed it expired on [DATE] (8 days ago). The manufacturer's label on R21's insulin vial showed, Use within 28 days after initial use. V13 said insulin is only good for 28 days after we open it. V13 said R21's insulin was expired and should have been removed. V13 said the nurses should not be administering expired insulin because the medication may not be effective.
R21's undated Diagnosis form showed diagnoses to include, but not limited to: stroke, seizures, and diabetes.
R21's Diabetes Care Plan dated [DATE] showed, .(A) Insulin Dependent: Administer insulin as ordered.
R21's [DATE] Physician's Order Sheet showed, Lantus vial 100 Units/ml (long-acting insulin). Inject 32 Units SQ (Subcutaneous) every morning and evening - Hold if less below 100.
R21's [DATE] Medication Administration Record (MAR) showed R21 received the expired insulin 4/19, 4/20, 4/21, 4/22, 4/23, and [DATE].
On [DATE] at 9:11 AM, V4 (Registered Nurse - RN) reviewed R21's April MAR and said the only day R21 did not receive his long-acting insulin was [DATE]. V4 said there was a circle with a line through it and that is how the nurse showed the medication was not given.
On [DATE] at 1:58 PM, V2 (Regional Director of Clinical Operations) said expired insulin should be discarded and not in use.
The pharmacy's Insulin Storage Recommendations revised [DATE] showed opened Lantus expires in 28 days. This document showed, .Products with an expiration date sooner than other guidance will be considered expired after that date .
The facility's Procurement and Storage of Medications Policy reviewed [DATE] showed, . 14. All discontinued/expired non-controlled medications are to be removed from the active medication storage area, and the quantity should be noted on the medication sheet. All medications should then be returned to pharmacy or destroyed per facility policy as soon as practical.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on Observation, Interview and Record review the facility failed to ensure the lunch menu was followed for 3 residents (R25, R36, & R203) reviewed for resident's menu in the sample of 17 and 6 re...
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Based on Observation, Interview and Record review the facility failed to ensure the lunch menu was followed for 3 residents (R25, R36, & R203) reviewed for resident's menu in the sample of 17 and 6 residents (R2. R3, R18, R30, R39 & R152) outside of the sample.
The findings include:
On 4/26/22 at 10:11 AM, V8 (Dietary Manager) stated the facility has 9 residents (R2, R3, R18, R25, R30, R36, R39, R152 & R203) on a mechanical soft diet.
On 4/26/22 at 11:33 AM, V7 (Cook) plated up trays of food for all 55 residents in the facility. V7 used a gray handled scoop to serve the pureed chicken. V7 used a green handled scoop to serve the mechanical chicken.
On 4/26/22 at 12:04 PM, V7 went through the scoops in the food on the steam table and stated the green scoop was a number 12 and the gray scoop was a number 8. V7 went over to the scoop conversion chart on the refrigerator and stated the green number 12 scoop in the mechanical soft chicken provided 2.5 - 3 ounces. V7 stated the gray handled number 8 scoop in the pureed chicken provided 4 -5 ounces.
The facility's Dietary Spreadsheet Week 1 (10/21) showed for the noon meal on 4/26/22, 4 ounces of pureed chicken was to be served for the pureed diets. Three pieces of boneless chicken was to be served for mechanical soft diets.
On 4/26/22 at 1:46 PM, V8 (Dietary Manager) stated, On the spreadsheet it says how many ounces of each item is needed. They would then go to the chart (scoop size conversion chart) and if the meat is 4 ounces, they would grab a number 8 scoop and use that. We usually use the number 12 scoop for vegetables because it is 2.5 - 3 ounces. They should be following the menu/dietary spreadsheet.
On 4/26/22 at 2:12 PM, V8 reviewed the Dietary Spreadsheet - Week 1 (10/21) and stated, We use the same scoop size that is written down for the pureed food for the portion size for the mechanical soft. The menu says 3 pieces of chicken for mechanical soft, so we have gone over this, and we use the #8 scoop which is 4 ounces. Anytime this comes up we follow the scoop size for pureed for the mechanical soft.
On 4/27/22 at 9:30 AM, V1 (Administrator) stated the facility did not have a policy for following the menu and/or for ensuring the correct portion sizes were given.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to provide a full time DON (Director of Nursing) for their facility. This applies to all residents residing in the facility.
The ...
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Based on observation, interview, and record review the facility failed to provide a full time DON (Director of Nursing) for their facility. This applies to all residents residing in the facility.
The findings include:
The facility Census and Condition of Residents form #672 dated 4/26/22 documents there are 55 residents residing in the facility.
During this investigation from 4/26/22 through 4/28/22 there was no Director of Nursing in the facility.
On 4/28/22 at 1:39 PM, V1 (Administrator in Training) said they consider the DON (Director of Nursing) to be V2 (Regional Director of Clinical Operations). V1 said V2 is at another facility for their annual survey right now. V1 said the last time there was a full time DON for their building was approximately one year ago when they had a DON who lasted 4 days.
On 4/27/22 at 3:24 PM, V2 (Regional Clinical Director) said, I'm not the DON, I consult for them and I'am there looking over stuff 1-2 times every 2 weeks.
The facility provided the job description for a DON on 4/28/22 which showed, . Job Summary: To plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility and as may be directed by the Administrator and the Medical Director to ensure that the highest degree of quality care is maintained at all time .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review the facility failed to ensure dishes and divided plates were stored in a manner to prevent cross contamination.
This applies to all 55 facility reside...
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Based on observation, interview and record review the facility failed to ensure dishes and divided plates were stored in a manner to prevent cross contamination.
This applies to all 55 facility residents.
The findings include:
The facility's CMS (Centers for Medicare & Medicaid Services) form 672 Resident Census and Condition of Residents dated April 26, 2022, showed 55 residents reside in the facility.
On 4/26/22 at 10:05 AM the dishes and divided plates were sitting on a cart next to the dishwasher and steam table. The dishes and divided plates were stored face up and not covered.
On 4/26/22 at 10:07 AM, V8 (Dietary Manager) stated they always store the dishes face up because that's how they grab them to use them. V8 stated the dishes should be covered to prevent them from getting dirty and contaminated.
The facility's Kitchen Sanitation policy (10/14) showed, The food service manager will monitor sanitation of the dietary department on a daily basis.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to conduct Quality Assurance (QA) meetings at least quarterly. This failure has the potential to affect all residents in the facility.
The fin...
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Based on interview and record review the facility failed to conduct Quality Assurance (QA) meetings at least quarterly. This failure has the potential to affect all residents in the facility.
The finding include:
The facility's Resident Census and Conditions of Residents, form CMS-672, dated 4/26/22 documents there are 55 residents residing in the facility.
On 4/28/22 at 1:49 PM, V1 Administrator in Training stated there was a QA meeting in April 12, 2022; however, the QA meeting prior to April had been probably six months prior. V1 said the meetings were not done because the required members refused to come to the facility due to COVID concerns. V1 said the meetings should be held at least quarterly. V1 said the purpose of quarterly meetings is to .keep track of things; keep track of issues . (A copy of the last QA meeting sign in sheet was requested.)
The QA Sign In Sheet for the meeting prior to April 2022 is dated 9/18/22. (Nearly 7 months without a QA meeting)
The facility's Quality Assurance and Performance Improvement Plan (QAPI) dated 3/2/22 showed, The facility-wide performance improvement process includes identifying and implementing opportunities to improve the quality of resident care and quality of life, as well as other measures of organizational performance. The policy also showed, Objectives of the QAPI plan: Improve the quality of care thereby enhancing the quality of life for residents .
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 2 harm violation(s), $148,321 in fines, Payment denial on record. Review inspection reports carefully.
- • 54 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $148,321 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
- • Grade F (3/100). Below average facility with significant concerns.
Bottom line: Trust Score of 3/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is South Elgin Living & Rehab Center's CMS Rating?
CMS assigns SOUTH ELGIN LIVING & REHAB CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Illinois, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is South Elgin Living & Rehab Center Staffed?
CMS rates SOUTH ELGIN LIVING & REHAB CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 46%, compared to the Illinois average of 46%. This relatively stable workforce can support continuity of care. RN turnover specifically is 75%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at South Elgin Living & Rehab Center?
State health inspectors documented 54 deficiencies at SOUTH ELGIN LIVING & REHAB CENTER during 2022 to 2024. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, and 51 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates South Elgin Living & Rehab Center?
SOUTH ELGIN LIVING & REHAB CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 90 certified beds and approximately 57 residents (about 63% occupancy), it is a smaller facility located in SOUTH ELGIN, Illinois.
How Does South Elgin Living & Rehab Center Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, SOUTH ELGIN LIVING & REHAB CENTER's overall rating (1 stars) is below the state average of 2.5, staff turnover (46%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting South Elgin Living & Rehab Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is South Elgin Living & Rehab Center Safe?
Based on CMS inspection data, SOUTH ELGIN LIVING & REHAB CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Illinois. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at South Elgin Living & Rehab Center Stick Around?
SOUTH ELGIN LIVING & REHAB CENTER has a staff turnover rate of 46%, which is about average for Illinois nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was South Elgin Living & Rehab Center Ever Fined?
SOUTH ELGIN LIVING & REHAB CENTER has been fined $148,321 across 1 penalty action. This is 4.3x the Illinois average of $34,562. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is South Elgin Living & Rehab Center on Any Federal Watch List?
SOUTH ELGIN LIVING & REHAB CENTER 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.