REGENCY CARE
For profit - Limited Liability company
99 Beds
Independent
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
0/100
#615 of 665 in IL
Photo by Regency Care
Photo by Regency Care
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1 / 5 photos
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Regency Care in Springfield, Illinois, has received a Trust Grade of F, which indicates significant concerns about the quality of care. It ranks #615 out of 665 facilities in Illinois, placing it in the bottom half, and #8 out of 8 in Sangamon County, meaning there are no better local options. The facility is worsening, with issues increasing from 10 in 2024 to 18 in 2025. Staffing is a concern, with a rating of 2 out of 5 stars and a high turnover rate of 58%, which is above the state average. The facility has also faced significant fines totaling $210,065, higher than 88% of Illinois facilities, indicating repeated compliance issues. Specific incidents include a serious failure to protect residents from sexual abuse, where one resident was abused multiple times due to inadequate supervision, and another incident where a resident had to wait excessively for assistance, leading to humiliation and loss of dignity. While the facility does have average RN coverage, the overall picture shows serious weaknesses in care and safety, making it a concerning choice for families considering this nursing home.
- Trust Score
- F
- In Illinois
- #615/665
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 58% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $210,065 in fines. Higher than 89% of Illinois facilities, suggesting repeated compliance issues.
- Skilled Nurses ○ Average
- Each resident gets 32 minutes of Registered Nurse (RN) attention daily — about average for Illinois. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 40 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 8%
Review needed
10 → 18 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 10 issues
2025: 18 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: 58%
12pts above Illinois avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $210,065
Well above median ($33,413)
Significant penalties indicating serious issues
Staff turnover is elevated (58%)
10 points above Illinois average of 48%
The Ugly 40 deficiencies on record
1 life-threatening 4 actual harm
Mar 2025
17 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Resident Rights
(Tag F0550)
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 answer resident's call lights to address their needs and promote re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to answer resident's call lights to address their needs and promote resident dignity for 6 of 6 residents (R9, R16, R25, R30, R33 and R285) reviewed for dignity in the sample of 42. This failure resulted in R285 becoming incontinent and feeling humiliated.
Findings include:
1. R285 was admitted on [DATE] with diagnosis of, in part, fracture of left fibula, left tibial fracture, fracture around internal prosthetic left knee joint, and retention of urine.
R285's Care Plan dated has an ADL Self Care Performance Deficit requires substantial/maximal assistance from staff participation for toileting hygiene and transfers and requires substantial/maximal staff participation with personal hygiene and set up help from staff with oral care.
On 3/10/25 at 12:50 PM, R285 stated she will wait a minimum of 30 minutes or more to have her call light answered. R285 stated, I've had to wait so long and accidentally soiled myself because I couldn't wait any longer. It's humiliating.
The facility policy Call Light dated 8/1/05 documents it is the policy of this facility to maintain the highest quality of care for its residents. The policy documents to answer call light promptly. The policy documents if you are unable to meet resident request or need, leave call light on and obtain assistance from charge nurse.
2. During the resident council meeting held on 3/12/2025 at 2:30PM, R9, R16, R25, R30, and R33 all stated call lights are not answered timely. All stated could take up to 30 minutes to get light answered.
R9's Minimum Data Set (MDS) dated [DATE] documents R9 is cognitively intact.
R16's MDS dated [DATE] documents R16 is cognitively intact.
R25's MDS dated [DATE] documents R25 is cognitively intact.
R30's MDS dated [DATE] documents R30 is cognitively intact.
R33's MDS dated [DATE] documents R33 has moderate cognitive impairment.
The facility resident council minutes dated 2/27/2025 documents under old business any unresolved issues since last month residents state Certified Nursing Assistants (CNAS) still take awhile to answer call lights. Resident council minutes dated 1/31/2025 documents old business any unresolved issues last month CNAs are still taking a long time to answer call lights, new business residents state the CNAs come to find out the reason the light is on and leaves without fixing the issues, residents stated CNAs are very late answering call lights at night.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the resident with a written notice of why they were going 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 provide the resident with a written notice of why they were going to the hospital for 2 of 3 residents (R1, R185) reviewed for transfer/discharge notices in the sample of 42.
Findings include:
1. On 3/11/25 at 9:20 AM, R1 stated the staff tell me why I am going to the hospital, but they don't give me anything in writing. They always let my family know if I am sent out to the hospital.
On 3/11/25 at 10:31 AM, V28 Licensed Practical Nurse, stated the resident will get a bed hold policy. I tell the resident if they are alert and orientated why they are going out but nothing in writing.
On 3/11/25 at 11:14 AM, R1's Electronic Medical Record fails to document a written notice to R1 as to why he is being sent to the hospital.
R1's Nurses Note, dated 2/22/2025 14:05, documents, Note Text: EMS (Emergency Medical Services) arrived and left with resident at approximately 2:00 PM to (local hospital) ER (Emergency Room).
2. R185's Face Sheet, print date of 3/12/25, documents that R185 was admitted on [DATE].
R185's Health Status Note, dated 3/9/25, documents, Resident left with ambulance at this time. Will be taken to (local) hospital. Message was left for POA (power of attorney) upon initial time of incident. Writer will attempt to call POA again.
R185's Electronic Medical Record fails to document the written notice to R185 as to why she was sent to the hospital.
On 3/12/25 at 11:00 AM, V1, Administrator stated that R1 and R185 did not have a written notices as to why he was sent to the hospital.
On 3/12/25 at 8:40 AM, V1 stated, I am not sure if the nurses give the resident a written reason for transfer to the hospital. I don't think we have a policy on that.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide notice regarding the bed hold policy to residents when tran...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide notice regarding the bed hold policy to residents when transferred to the hospital for acute care for 2 of 3 residents (R1, R185) reviewed for notice of bed hold policy in the sample of 42.
Findings include:
1. On 3/11/25 at 9:20 AM, R1 stated the staff tell me why I am going to the hospital, but they don't give me anything in writing. They always let my family know if I am sent out to the hospital.
On 3/11/25 at 10:31 AM, V28 Licensed Practical Nurse, stated the resident will get a bed hold policy.
On 3/11/25 at 11:14 AM, R1's Electronic Medical Record fails to document a bed hold form for R1's hospitalization on 2/22/25.
R1's Nurses Note, dated 2/22/2025 14:05, documents, Note Text: EMS (Emergency Medical Services) arrived and left with resident at approximately 2:00 PM to (local hospital) ER (Emergency Room).
On 3/12/25 at 11:00 AM, V1, Administrator stated that R1 did not have a bed hold for the hospital visit on 2/22/25.
2. R185's Face Sheet, undated, documents that R185 was admitted on [DATE].
R185's Health Status Note, dated 3/9/25, documents, Resident left with ambulance at this time. Will be taken to (local) hospital. Message was left for POA (power of attorney) upon initial time of incident. Writer will attempt to call POA again.
R185's Electronic Medical Record fails to document a bed hold given for R185's hospital transfer.
On 3/12/25 at 8:40 AM, V1 stated, The nurses should be giving a copy of the bed hold to the resident when they are sent to the hospital. If the resident is admitted to the hospital the business office manager will notify the family of the bed hold and ask if they family wants a bed hold.
The IL (Illinois) Bed Hold Notification, undated, documents, 'When a resident is transferred to a hospital, or when the resident takes a therapeutic leave of absence, they have the right to request that their bed be held until their return. Such a request is a called a bed hold. It continues, The bed - hold notification will be issued at the time of transfer, and in cases of emergency transfer, notice will be given within 24 hours of leave.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for 1 of 16 residents (R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for 1 of 16 residents (R185) reviewed for baseline Care Plan in the sample of 42.
Findings include:
R185's Face Sheet, print date of 3/12/25, documents R185 was admitted on [DATE] with a diagnosis of History of Falling.
R185's Clinical Admission, dated 3/6/2025, documents, Mental Status: Resident is confused. Oriented to person. Confused: Chronic.
Level of cognitive impairment: Moderate impairment (memory loss). Resident is coherent. Speech is clear. Language barrier: No
Genitourinary: Ostomy (including urostomy, ileostomy, and colostomy).
Urinary catheter intact. Urine amber in color. Urine retention noted. Genitourinary Note: Hospital stated resident has urinary retention.
On 3/11/25 R185's Electronic Medical Record fails to document a Care Plan for R185 addressing her medical and safety needs.
On 3/11/25 at 11:00 AM, V1, Administrator, stated Normally when a person is admitted , and the nurse does the admission Assessment the computer program generates the interim Care Plan. The nurse that did (R185's) admission Assessment did not answer the Care Plan questions so an interim Care Plan was not created.
The policy Care Plan Process, dated 11/2017, documents, The Baseline Care Plan will be completed and implemented within 48 hours of admission. This Care Plan will include instructions needed to provide person centered care that meets professional standards of quality. At a minimum, the baseline care plan will address the resident's initial goals for stay, dietary, therapy and social services needs, as well as PASSAR (Preadmission Screening and Resident Review) recommendations if applicable. Necessary physician orders will be included as well.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
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 have an updated resident centered Care Plan to address...
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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 have an updated resident centered Care Plan to address the current needs of the residents for 2 of 16 resident (R21, R42) reviewed for Care Plan in the sample of 42.
Findings include:
R21's Face Sheet, print date of 3/12/25, documents R21 was admitted on [DATE] and has a diagnosis of Dependence on Renal Dialysis.
R21's Pre/ Post Dialysis Evaluation, dated 3/4/25, documents, Access site: Access site location: LUE (Left Upper Arm).
R21's Care Plan, dated 9/8/23, documents, (R21) has renal failure r/t (related to) End Stage disease. Receiving hemodialysis with (Dialysis Center) on Tuesday (Tuesday), Thur (Thursday), Sat (Saturday) mornings. Interventions: Assist resident with ADL's (Activities of Daily Living) and ambulation as needed. Fluid Restriction as ordered. (1500ml (milliliters) as ordered. Give good oral hygiene. Give medications as ordered by physician. Monitor changes in mental status; Lethargy, Somnolence, Fatigue, tremors, seizures. Monitor for s/sx (signs and symptoms) of hypovolemia or hypervolemia. Monitor vital signs as ordered. Plan rest periods as needed. weight monitoring 3 x weekly. To be done at dialysis. This Care Plan fails to document R21's Let Upper Arm fistula, do not use left arm for blood pressure or blood draws.
On 3/12/25 at 3:35 PM, V1, Administrator, stated R21's Dialysis Care Plan is not complete related to it does not document the fistula site and do not use left arm for blood pressures or blood draws.
2. R42's Face Sheet, print date of 3/12/25, documents R42 was admitted on [DATE] and has Hemiplegia and Hemiparesis following a stroke and Epilepsy.
R42's Bed Rail Evaluation, dated 11/22/24, documents R42 has bilateral 1/2 bed rails.
On 3/11/25 at 10:04 AM, R42 is in bed with 1/2 bed rails raised. V25 Certified Nurse Aide stated that R42 does try to use them when he is being turned.
R42's Care Plan, dated 12/7/23, documents, (R42) is at risk for limited physical mobility r/t hemiparesis / hemiplegia. Intervention: Side Rails: 1/4 side rails, x 2 bilaterally, to promote bed maneuverability due to hemiparesis / hemiplegia.
The policy Resident Assessment and Care Planning, dated 11/2017, documents, The facility must evaluate and modify, if necessary, the efficacy and appropriateness of each resident's care plan on at least a quarterly basis, and with a significant change in condition.
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 showers, and basic grooming assistance was pro...
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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 showers, and basic grooming assistance was provided for 1 of 24 residents (R2) reviewed Activities of Daily Living (ADLs) in the sample of 42.
Findings include:
R2's admission Record, undated, documents R2 was admitted to the facility on [DATE] with diagnosis of Congestive Heart Failure, Chronic Kidney Disease, and Osteoarthritis.
R2's Care Plan, dated 2/3/25, documents R2 scored an 11 on her BIMS (Basic Interview for Mental Status - 13-15= Intact cognitive response, 8-12= Moderate Cognitive Impairment, and 0-7= Severe Cognitive Impairment). R2 understands need for placement and can express her needs. Interventions: needs assistance with all decision making.
R2's Minimum Data Set (MDS), dated [DATE], documents R2 has a moderate cognitive impairment and requires partial/moderate assistance from staff for bathing and dressing.
On 3/10/25 at 10:05 AM, R2 was seen sitting on the side of her bed and appears to have greasy hair. R2 stated she has not had a shower or a bath in a long time.
On 3/11/25 at 8:45 AM, R2 stated she did not get a shower last evening and is unsure when she last had a shower or bed bath. R2's hair still appears very greasy, combed, and matted.
On 3/12/25 at 8:55 AM, R2 sitting in wheelchair next to her bed. R2's hair appears very greasy and combed back with flakes in her greasy hair. R2 stated the only time they wash me up is when they are cleaning me down there (pointed to groin area). R2 stated My hair needs washed, it really feels dirty, and I would feel a lot better after getting a shower. I'm not sure I can stand up to get a shower, I will probably drown.
On 3/12/25 at 8:58 AM, When asked about R2 getting showers, V13, Certified Nursing Assistant (CNA), stated (R2) gets a shower on Monday and Thursday Evenings, so I would not have anything to do with it.
On 3/12/25 at 9:05 AM, V12, Licensed Practical Nurse (LPN)/Wound Nurse, stated I collect the resident shower sheets from the staff and do weekly audits with them. When told that R2 has greasy hair and stated she has not had a shower in a long time, V12 stated There are no shower sheets in my binder for the month of February or March for (R2). When asked about her audits she completed, V12 stated Well, I don't want to tell you this, but it looks like (R2) has not had a shower since she's been here. I believe I even asked the CNAs for (R2's) shower sheets and they had none to give me.
On 3/13/25 at 9:15 AM, V12, stated I called every CNA who was working with (R2) on the shower days and asked them why (R2) didn't get a shower and they all said they filled out a shower sheet and/or (R2) refused a shower. I had each one of them come in last night to fill out a shower sheet from that day they worked. V12 provided handwritten notes indicating R2 refused, and some shower sheets that were completed last evening (3/12/25).
On 3/13/25 at 10:25 AM, V1, Administrator, stated I would expect the staff to ensure all residents are getting their showers as scheduled. I agree, if the shower sheets weren't done and (R2) has greasy hair, the showers probably weren't done.
On 3/13/25 at 12:00 PM, V1, stated We have looked and cannot find any policy for showers or ADL Care of Residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and record reviews the facility failed to clarify pre-operative instructions and document and notify the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and record reviews the facility failed to clarify pre-operative instructions and document and notify the physician a change in condition while providing medical treatment without an order for 1 of 2 residents, (R45) reviewed for quality of care in the sample of 42.
Findings include:
R45's Face Sheet, undated, documented R45 was admitted to the facility on [DATE] with diagnosis of, in part, atrial fibrillation, abnormalities of gait and mobility, hypertension, and malignant neoplasm of colon.
R45's Minimum Data Set (MDS) dated [DATE], documented she is cognitively intact and does not use oxygen therapy of any form.
R45's Care Plan dated 2/6/25, does not include any care plan regarding R45 requiring the use of oxygen or respiratory issues.
On 3/10/25 at 10:52 AM, R45 had an oxygen concentrator set up next to her bed with oxygen turned on to 3 Liters nasal cannula being administered to her as she was lying in bed. The oxygen concentrator had humidification attached and dated 2/27/25. R45 stated she was having back pain, and she gets pain medication for it. As R45 was speaking, she paused several times and closed her eyes as if she was falling asleep but did not have any complaint of shortness of breath.
On 3/10/25 at 12:42 PM, R45 had blue tinged lips, not wearing oxygen, sitting in her chair eating lunch at bedside table. R45 was speaking normal at this time and stated she was feeling fine.
R45's Progress notes dated 3/11/2025 at 12:21 AM, documented, Resident o2sat (oxygen saturation) at 60% o2 started immediately 2l (liters) resident sent to ER (emergency room) for eval (evaluation) and TX (treatment)- MD (medical director) - POA (power of attorney) and nurse manager notified.
R45's Progress notes dated 3/11/2025 at 6:15 AM, documented, Hospital - Admitting DX (diagnosis) - Acute Hypoxia.
R45's Progress Notes, dated 3/11/25 at 10:06 PM, documented, writer entered residents room to pass medications and observed resident asleep in bed. writer woke resident up asked her how she felt and responded with just a little tired. resident stated she wanted to get up out of bed and dressed. writer checked to verify shower chart and confirmed it was residents shower day. writer asked if she wanted to get in shower and she replied with yes. writer did not at that time notice anything out of the ordinary other than her still being in bed. after resident was out of shower and up in w/c writer entered room to check on resident then and did notice residents lips a light blue color. writer took vitals and found O2 to be a little low at 88. resident has standing orders to apply oxygen as needed. writer placed oxygen on resident monitored residents pulse-ox encouraging resident to take big breaths in nose and out mouth, residents oxygen did come back up to and floated from 92-93. resident did say this helped her feel better. writer made sure call light was in reach and to call if she needed anything.
On 3/11/25 at 9:18 AM, V1, Administrator, stated she didn't see any assessment or transfer documentation in R45's electronic medical record (EMR) chart from her being sent out to the hospital for hypoxia. V1 stated she did not see any orders for R45 to be on oxygen and no charting to say why she was even started on it.
On 3/11/25 at 9:30 AM R45's oxygen concentrator is at the side of her bed with humidification bottle dated 3/1/25 now. There is a sign posted outside R45's door stating, no smoking, oxygen in use, no open flames and enhanced barrier precautions.
On 3/11/25 at 10:01 AM, V8, Medical Director, MD, stated the facility did not call me or my office to tell me R45 was sent to the hospital last night. V8 stated she does not have any orders for R45 to be on oxygen from any of her notes but will look into details on what was going on. At 10:24 AM, V8 stated the hospital admitted R45 for hypoxia and ruled out multiple diagnosis to be the cause but still did not know what is causing it. V8 stated the facility has standing orders to be able to administer oxygen if a resident is short of breath but they are supposed to notify me if this is needed. V8 stated she was never notified that R45 had been using oxygen, that would be a change from her normal condition. V8 stated R45 did not require oxygen and did not know the facility had been administering it to her. V8 stated the facility should have notified me of any change in condition for R45, which was not done.
On 3/11/25 at 9:31 AM, V5, Licensed Practical Nurse, LPN, stated she has taken care of R45 many times. V5 stated R45 wears oxygen at night at 2L nasal cannula and has been on it for a long time now, it's not something new. V5 stated she could not find an order for oxygen in R45's chart.
On 3/12/25 at 8:40 AM, V1, Administrator, stated V8 said her office received a faxed notification of R45's condition from the night she went out but did not find it until today. V1 stated she expects her nurses to be notifying the provider via phone not by fax and she will have to do some education on that.
On 3/12/25 at 3:15 PM, V1 stated she expects the medical provider to be notified of any change in condition including is a resident is placed on oxygen.
The facility's Guidelines for Physician Notification of Change in Resident Condition with revision date of 4/2019, documented the standard is for staff to observe, document and communicate to the physician changes in resident condition promptly. The policy continued to document a change in condition may include abnormal or deviation from normal vital signs. The facility's policy included under notification of changes that a facility must immediately inform the resident; consult with the resident's physician when there is a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). The policy also documented that it is the responsibility of each nurse to notify the physician of a significant change in condition before the end of the shift.
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
Based on observation, interview, and record review the facility failed to provide dressing to pressure sore for 1 of 5 residents (R40) reviewed for pressure sores in the sample of 42.
Findings include...
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Based on observation, interview, and record review the facility failed to provide dressing to pressure sore for 1 of 5 residents (R40) reviewed for pressure sores in the sample of 42.
Findings include:
On 3/12/2025 at 8:40AM V14, Certified Nursing Assistant (CNA) removed R40's adult diaper. R40 did not have a dressing to pressure ulcer on coccyx. R40 was incontinent of stool. V14 CNA stated, they normally put a bandage on her sore. V14 placed another adult diaper on R40 and placed her in a wheelchair without a dressing on R40's pressure ulcer.
R40's physician orders (PO) dated 1/22/2025 documents control gel formula dressing; apply to coccyx topically, Monday, Wednesday, and Friday day shift for stage 2 pressure injury.
On 3/13/2025 at 9:51 AM, V12, Wound Nurse, stated dressings are to be in place as ordered for pressure sores. V12 stated I did her treatment right before I left yesterday, I would have forgot but the staff reminded me.
The facility policy entitled Wound and Ulcer policy and Procedure dated, revised dated 3/28/2024 documents it is the policy of this facility to provide nursing standards for assessment, prevention, treatment, and protocols to manage residents at any level of risk for skin breakdown and for wound management. The policy documents initiate the treatment protocol appropriate for the stage of the ulcer or the wound assessed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed, supervise a meal, to store an oxygen cylinder and trans...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed, supervise a meal, to store an oxygen cylinder and transfer residents with a full mechanical lift in a safe manner for 3 of 5 residents (R1, R42, R51) reviewed for accidents in the sample of 42.
Findings include:
1. R42's Face Sheet, print date of 3/12/25, documents R42 was admitted on [DATE] and has Hemiplegia and Hemiparesis following a stroke and Epilepsy.
R42's Minimum Data Set (MDS), dated [DATE], documents that R42 is moderately cognitively impaired and is dependent on staff for transfers.
R42's Event Note, dated 1/30/2025 at 5:15 PM, documents, Situation: writer was called into room by CNA (Certified Nurse Aide). Writer was told that while transferring resident with mechanical lift, one CNA maneuvering lift and one CNA with hands on resident directing into wheelchair, when sling shifted, and bottom right hook strap became unhooked, and resident fell onto buttocks and then fell back and hit his head on the floor. CNAs were unable to catch resident or assist fall with it happening so fast. Background: resident was being transferred via (full) mechanical lift Assessment (RN) (Registered Nurse)/Appearance (LPN) (Licensed Practical Nurse): VSS (vital signs stable) ROM WNL (range of motion within normal limits) for resident. Recommendations: (no documentation entered)
R42's Fall Management Review, dated 1/31/2025 11:43, documents, Situation: Resident fell onto buttock during a full mechanical lift transfer Background: Resident was being transferred using a full mechanical lift with the assist of 2 CNAs. During transfer, the strap became unhooked from the lift causing the resident to fall to the floor on his buttock. The CNAs were in correct position, one maneuvering the machine and the other with hands on the resident guiding him to the w/c (wheelchair). Assessment (RN)/Appearance (LPN): Resident was lying on back/buttock on the floor. Did his head on the floor. No visible injuries. ROM WNL.
On 3/11/25 at 9:40 AM V11 Certified Nurse's Aide (CNA) and V25 CNA entered R42's room to transfer R42 from the wheelchair to a shower chair using a full mechanical lift. V11 and V25 both attached the sling loops to the hoist. Neither pulled down on the sling loops. V25 began to raise the lift, V11 was holding the sling neither double checked the sling loops. R42 was transferred to the shower chair.
On 3/11/25 at 9:58 AM, V11 and V25 transferred R42 from the shower chair to the bed. V11 and V25 both attached the sling loops to the hoist. Neither pulled down on the sling loops. V25 began to raise the lift, V11 was holding the sling neither double checked the sling loops. R42 was transferred to the bed.
On 3/12/25 at 2:15 PM, V1, Administrator, stated the way I understand it the CNAs did not check the sling straps and the strap slid off of the hoist. The aides should be double checking the straps and aide should always have hands on the sling and steady the sling while using the full mechanical lift.
The manual Hoyer' Presence, undated, fails to document checking the sling and keeping the sling steady.
2. On 3/10/25 at 12:20 PM, R1 is sitting in his room eating his lunch unsupervised.
On 3/11/25 at 8:35 AM, R1 is in the dining room eating breakfast.
On 3/11/25 at 9:20 AM, R1 stated, A few days ago I started coughing while I was eating. They sent me to the hospital and since I have been back sometimes, they let me stay in my room and sometimes they make me go out to dining room. Yesterday they let me stay in my room for 2 meals but this morning they made me go out to the dining room.
R1's Physician Order, dated 2/24/25, documents, SUPERVISION AT ALL MEALS. MUST BE IN DINING ROOM AT MEALTIMES.
R1's Physician Order, dated 3/11/25, documents, 'Oxygen 3 lpm (liters per minute/ nasal cannula or face mask q (every) shift as needed for dyspnea.
R1's Nurses Note, dated 2/22/25, documents, At approximately 1315 writer had been called into resident's room by roommate's sister. She reported that resident was choking on his meal. Writer was able to make sure resident was able to breathe and resident stated he could. Writer looked into resident's mouth and found no food particles. Resident kept coughing and coughing up large pieces of food. Lungs sounds diminished but with some rubbing noises could be heard. Resident stated he could feel fullness in his chest. He kept coughing up multiple food particles. Resident also had emesis several times. Resident able to talk but talking causes him to cough again and in which food particles come up with each cough. Resident remains on 4L (liters) O2 (oxygen) via NC (nasal cannula). Writer has call out to V27 Physician (which he is on call this weekend). Awaiting call back at this time. Writer has call out to POA (Power of Attorney).
On 3/13/25 at 7:50 AM, V1, Administrator, stated R1 did not choke he was just having a swallowing issue. I will have to look into if he can eat in his room by himself.
On 3/13/25 at 9:40 AM, V2, Director of Nurses, stated after R1's coughing incident R1 was seen by Speech Therapy, and they are the ones that recommended R1 not to eat unsupervised which he should not be doing.
On 3/11/25 at 9:20 AM, R1 is sitting in his room. There is a single oxygen cylinder sitting on the floor. The oxygen cylinder is not in an oxygen stand or cart to prevent tipping or falling.
On 3/12/25 at 1:40 PM, V1, Administrator, stated, I had that hall checked for oxygen tanks Monday. I guess they didn't see it.
On 3/12/25 at 8:15 AM R1 is in his bed with bilateral side rails raised eating breakfast. There is a single oxygen cylinder sitting on the floor. The oxygen cylinder is not in an oxygen stand or cart to prevent tipping or falling.
R1's Face Sheet, print date of 3/12/25, documents R42 was admitted on [DATE] and has diagnoses of Pneumonia and Congestive Heart Failure.
R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact.
The policy for Walk About Oxygen Cylinders, dated 8/2009, documents, All cylinders must be kept secure: 1. Tanks must be in a cart, rack or chained to a wall.
3. On 3/11/25 at 11:35 AM, V9, CNA, and V7, CNA, brought in the full body mechanical lift device to get R51 out of bed and to her wheelchair. V9 controlled the lift device while V9 got R51's wheelchair ready. R51 was lifted off her bed and turned around while hanging freely in the air and no one holding onto her. R51's wheelchair was approximately 6 feet away from her bed and R51 was pulled over to her wheelchair while swinging freely in the air. Several attempts made to lower R51 to the wheelchair with R51's sling sideways, both CNAs turned R51's wheelchair sideways and R51 then lowered to wheelchair.
On 3/11/25 at 1145 AM, V9 stated to V7 I know we are supposed to keep a hold of the resident at all times when the state is watching us. I just noticed that we did not do that.
R51's Care Plan, dated 2/20/25, documents R51 is at risk for falls. Interventions: 2/19/25 may use (full body mechanical lift device) lift for transfers as needed. PT to eval for knee brace. It continues R51 Safety with interventions: Safety measures - including strategies to reduce the risk of infection, falls, injury initiated as appropriate.
R51's MDS, dated [DATE], documents R51 is cognitively intact and requires substantial/maximal assistance from staff for transfers.
On 3/13/25 at 10:25 AM, V1, Administrator, stated I would expect the staff to hold onto the resident at all times during a (full body mechanical lift) transfer.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
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 assess an dialysis access for 1 of 1 resident (R21) reviewed for di...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess an dialysis access for 1 of 1 resident (R21) reviewed for dialysis in the sample of 42.
Findings include:
R21's Face Sheet, print date of 3/12/25, documents R21 was admitted on [DATE] and has a diagnosis of Dependence on Renal Dialysis.
R21's Physician Order, dated 5/1/24, documents, Dialysis @ (DIALYSIS CENTER) TUES-THUR-SAT mornings.
R21's Pre/ Post Dialysis Evaluation, dated 3/4/25, documents Treatment Information: Post-Dialysis Evaluation.
Time back in facility: 03/04/2024 11:45 AM Treatment performed off-site. Transported by facility transport.
Access site: Access site location: LUE (Left Upper Arm) Skin: WNL (within normal limits). No prolonged bleeding. Catheter / port intact: Yes. Catheter / port intact: Yes. Warmth at Site: No. Decreased circulation distal from site: No. Bruit: positive. Thrill: Yes. Dressing dry / intact: Yes. Skin color is WNL. Skin warm / dry to touch. Normal skin turgor. Completed Clinical Suggestions: (no documentation entered)
R21's Pre/ Post Dialysis Evaluation, dated 1/25/25, documents, Treatment Information: Post-Dialysis Evaluation. Time back in facility: 01/25/2025 11:47 AM Treatment performed off-site. Transported by facility transport. Access site: Access site location: LUE Skin: WNL. No prolonged bleeding. Catheter / port intact: Yes. Catheter / port intact: Yes. Warmth at Site: No. Decreased circulation distal from site: No. Bruit: positive. Thrill: Yes. Dressing dry / intact: Yes. Skin color is WNL. Skin warm / dry to touch. Normal skin turgor.
Completed Clinical Suggestions: (no documentation entered)
R21's Electronic Medical Record fails to document any other assessments of R21's Left Upper Arm fistula between 1/25/25 and 3/4/25 and 3/4/25 and 3/12/25.
On 3/12/25 at 3:20 PM, V22, Licensed Practical Nurse, stated I do assess fistula sites. V22 was questioned where that is charted, V22 stated usually you chart that in the Medication or Treatment Record, but it is not on R21's.
On 3/12/25 at 3:40 PM, V1, Administrator, stated, dialysis fistulas should be assed at least every shift. The Pre and Post Dialysis evaluation should be done after every dialysis session.
The policy Care of a Resident Receiving Hemodialysis, undated, documents, Monitoring Procedures 1. Medications as ordered per physician - Notify Nephrologist of changes 2. Monitor Dialysis site q (every) shift and return from dialysis for bleeding and redness.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to do a complete assessment of bed rails, obtain a Physi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to do a complete assessment of bed rails, obtain a Physician Order and consent for bed rails for 3 of 3 residents (R1, R42, R185) reviewed for bed rails in the sample of 42.
Findings include:
1. R42's Face Sheet, print date of 3/12/25, documents R42 was admitted on [DATE] and has Hemiplegia and Hemiparesis following a stroke and Epilepsy.
R42's Minimum Data Set (MDS), dated [DATE], documents that R42 is moderately cognitively impaired, is dependent on staff for bed mobility, and does not have bed rails.
R42's Bed Rail Evaluation, dated 11/22/24, documents R42 has bilateral half bed rails and no other alternative attempted or considered. This Bed Rail Evaluation fails to document the medical reason related to the use of bed rails and the risks associated with the use of bed rails.
R42's Care Plan, dated 12/7/23, documents, (R42) is at risk for an ADL (Activities of Daily Living) Self Care Performance Deficit r/t (related to) hemiparesis / hemiplegia. Intervention: Bed Mobility: (R42) requires assistance of 1 with the use of side rails.
On 3/11/25 at 10:04 AM, R42 is in bed with half bed rails raised. V25, Certified Nurses Aide, stated that R42 does try to use them when he is being turned.
2. R1's Face Sheet, print date of 3/12/25, documents R1 was admitted on [DATE] and has diagnoses of pneumonia and Congestive Heart Failure.
R1's MDS, dated [DATE], documents R1 is cognitively intact, requires substantial assistance with bed mobility, and does not use bed rails.
R1's Bed Rail Evaluation, dated 2/17/25, documents R1 has bilateral quarter bed rails and no other alternative attempted or considered. This Bed Rail Evaluation fails to document the medical reason related to the use of bed rails and the risks associated with the use of bed rails.
R1's Electronic Medical Record fails to document a Physician Order for the use of bed rails.
On 3/12/25 at 8:15 AM, R1 is in his bed with bilateral side rails raised eating breakfast.
3. R185's Face Sheet, print date of 3/12/25, documents R185 was admitted on [DATE] with a diagnosis of History of Falling.
R185's Clinical Admission, dated 3/6/2025, documents, Mental Status: Resident is confused. Oriented to person. Confused: Chronic.
Level of cognitive impairment: Moderate impairment (memory loss). Resident is coherent. Speech is clear. Language barrier: No
Genitourinary: Ostomy (including urostomy, ileostomy, and colostomy).
Urinary catheter intact. Urine amber in color. Urine retention noted. Genitourinary Note: Hospital stated resident has urinary retention.
R185's Bed Rail Evaluation, dated 3/6/25, documents R185's medical diagnosis / reason for bed rails is confusion.
R185's Electronic Medical Record fails to document a consent or a Physician Order for the use of bed rails.
On 3/12/25 at 8:33 AM, R185 is lying in bed asleep with the bilateral side rails raised.
On 3/13/25 at 9:50 AM, V12 Restorative Licensed Practical Nurse, stated, there should be a medical diagnosis for the reason the side rails are being used documented. Confusion is not a proper diagnosis for side rails. Every side rail has a risk, and it should be documented on the evaluation.
The policy Resident Care Policy and Procedure, dated 1/10/18, documents, Prior to the use of be rails for a resident, the facility will document assessment of use, obtain physician order for use, and obtain consent from the responsible party or POAHC. (Power of Attorney for health Care).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a Physician prescribed antibiotic for 1 of 18 resident (R18...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a Physician prescribed antibiotic for 1 of 18 resident (R185) reviewed for medications in the sample of 42.
Findings include:
R185's Face Sheet, print date of documents that R185 was admitted on [DATE] and has a diagnosis of Pneumonia.
R185's Hospital Discharge Plan, dated 3/6/25, documents R185 was in the hospital for Pneumonia. R185's Hospital Medication discharge Report, dated 3/6/25, documents, New Medications: amoxicillin - clavulanate (Augmentin 875 mg (milligram) - 125 mg oral tablet) 1 tab (s) Oral every twelve hours for 3 days.
R185's Physician Orders, dated March 2025, fails to document amoxicillin - clavulanate (Augmentin 875 mg (milligram) - 125 mg oral tablet) 1 tab (s) Oral every twelve hours for 3 days.
On 3/11/25 at 11:30 AM, V2, Director of Nurses, stated that the hospital discharge orders for Augmentin did not get transferred over to the admitting orders that is why R185 did not receive the Augmentin.
On 3/13/25 at 8:02 AM, V8, Physician, stated (R185) was probably on IV (intravenous) antibiotics in the hospital. When they discharged her, they probably just wanted to finish her up on the oral antibiotics. It didn't hurt her to cut the antibiotics short. I do expect the facility to transcribe the hospital discharge orders as they are written so all the medications are continued.
The policy Physician Orders, dated 5/2022, documents, It is the policy of this facility to maintain current physician orders to provide treatment according to the attending physician for each resident in the facility. a) All medications and treatments shall be given only upon the written order of the physician. All such orders shall be written in the medical record and shall be given as prescribed by the physician at the designated times.
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** 2. R51's admission Record, undated, documents R51 was admitted to the facility on [DATE] with diagnosis of Morbid Obesity, Urina...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R51's admission Record, undated, documents R51 was admitted to the facility on [DATE] with diagnosis of Morbid Obesity, Urinary Tract Infections (UTI), Acute Cystitis, Hydronephrosis, Anxiety Disorder, and Extended Spectrum Beta Lactamase (ESBL).
R51's Care Plan, dated 1/10/25, documents R51 has a catheter related to Hydronephrosis with Renal and Ureteral Calculous Obstruction. Interventions: Position catheter bag and tubing below the level of the bladder and away from entrance room door. It continues R51 is at risk for an ADL Self Care Performance Deficit Generalized muscle weakness.
R51's MDS, dated [DATE], documents R51 is cognitively intact and is dependent on staff for toileting.
On 3/11/25 at 11:20 AM, V9, CNA, and V7, CNA, performed incontinent care on R51 with no Personal Protective Equipment (PPE), except gloves, while on Enhanced Barrier Precautions. Supplies brought to bedside, including a bucket of soapy water and washcloths. R51's incontinent brief was unfastened and V9 got a wet washcloth from the water and wiped R51's urinary catheter from urethra opening down the catheter, then got another wet washcloth out of the water and wiped R51's left groin, then with another wet washcloth and wiped down R51's vagina twice. R51 was rolled to her right side while V9 got wet cloth and wiped R51's left buttock and anal area. V9 placed a clean incontinence brief under R51 and rolled her to her back and the brief was fastened. There was no drying of R51, no cleaning of R51's right groin, buttock or hip, and no wiping under abdominal fold. Both CNAs used their soiled gloves to put R51's clean incontinence brief on, her pants put on, placed the full body mechanical lift device sling under her, then R51 requested to take her nightgown off and put a shirt on and both CNAs did this still with their soiled gloves on. Both CNAs doffed gloves and left the room with no hand hygiene seen done.
On 3/13/25 at 10:25 AM, V1, Administrator, stated I would expect the staff to provide timely and complete incontinent care, including proper hand hygiene and glove changes when soiled.
3. R60's admission Record, undated, documents R60 was admitted to the facility on [DATE] with diagnosis of Parkinson's Disease, Depression, Transient Ischemic Attack (TIA)/Cerebral Vascular Infarction without residual deficits, and Falls.
R60's Care Plan, dated 1/10/25, documents R60 is at risk for an Activities of Daily Living (ADL) Self Care Performance Deficit related to Parkinson's. It continues R60 has had actual falls with intervention of frequent toileting every two hours.
R60's MDS, dated [DATE], documents R60 had a moderate cognitive impairment and is dependent on staff for toileting, bathing, and transfers.
On 3/11/25 at 9:25 AM, V7, Certified Nursing Assistant (CNA), assisting R60 to get out of bed and dressed. R60 had a strong smell of a bowel movement (BM) noted. V7 assisted R60 to the restroom and pivoted R60 to the toilet. Upon removing R60's incontinence brief, a large BM was seen. While R60 was finishing on the toilet, V7 had the water running in the sink with half of a towel in the sink. After R60 finished, V7 took the towel out of sink, donned gloves, and took the wet part of the towel to the toilet and wiped R60's buttock and anal area, then used the same gloves to put on a clean incontinence brief on R60 and pulled up his pants, then assisted him back to his wheelchair. V7 did not do hand hygiene after doffing gloves or leaving the room.
The Facility's Hand Hygiene Protocol Policy, dated 7/26/21, documents Cleaning your hands reduces: The spread of potentially deadly germs to residents; The risk of healthcare provider colonization or infection caused by germs acquired from the resident. During routine resident-care: Use an Alcohol-Based Hand Sanitizer: Before resident contact, before moving from work on a soiled body site to a clean body site on the same resident, after touching a resident or the resident's immediate environment, after contact with blood body fluids or contaminated surfaces, immediately after glove removal, and prior to leaving resident's room. Wash with Soap and Water: When hands are visibly soiled, after assisting resident with toileting (e.g., bedpan, urinal, restroom).
Based on interview, observation, and record review, the facility failed to place residents on Enhanced Barrier Precautions, wear Personal Protective Equipment, perform hand hygiene and change gloves when needed for 3 of 16 residents (R74, R51, R60) reviewed for infection control in the sample of 42.
Findings Include:
1. R74 was admitted to the facility on [DATE] with diagnosis of, in part, sepsis due to enterococcus, hydronephrosis with ureteropelvic junction obstruction, and emphysema with a history of methicillin susceptible staphylococcus aureus infection.
On 3/11/25 at 12:55 PM, V5 LPN provided nephrostomy care to R74 and emptied her urine bag without a gown on. There was an enhanced barrier precautions (EBP) sign and supplies outside R74's door. V5 stated R74 is on EBP and she should have been wearing a gown while providing R74 care.
The Enhanced Barrier Precautions Protocol, undated, documents, Enhanced Barrier Precautions expands the use of Personal Protective Equipment (PPE) beyond situations in which exposure to blood and body fluids is anticipated, refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for the transfer of Multi-Drug Resistant Organism (MDROs) to staff hands and clothing. If Enhanced Barrier Precautions are required, a sign should be placed outside the resident's room to assist in education staff, residents, and visitors, on appropriate personal protection. When required, Enhanced Barrier Precautions apply to everyone caring for treatment. Personal Protective Equipment. Hand hygiene must be followed. PPE (gown and gloves) should be used during high contact resident care activities. Examples of high contact resident care activities requiring gown and glove use include: Dressing. Bathing / Showering. Transferring. Provide hygiene. Changing lines. Changing briefs or assisting with toileting. Device care of use: central line, urinary catheter, feeding tube, tracheostomy / ventilator. Wound care: any skin opening requiring a dressing.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 03/12/25 at 8:40AM during incontinent care V16, activities assisted V14 CNA to stand R40 with use of gait belt in R40's ba...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 03/12/25 at 8:40AM during incontinent care V16, activities assisted V14 CNA to stand R40 with use of gait belt in R40's bathroom. With R40 holding on to grab bar by stool V14 CNA removed R40's adult diaper. R40 incontinent of stool. V14, CNA with wet cloth with cleanser reached between R40's legs from the back and swiped from the front to the back. V14 did not cleanse bilateral groin or separate the labia. V14 cleansed rectal area and dried all areas. V14 did not cleanse buttocks.
R40's care plan dated 10/23/2024 documents R40 at risk for ADL (Activity Daily Living) related to disease process. R40's care plan documents the intervention dated 10/23/2024 toilet use requires staff participation to use the toilet.
R40's Minimum Data Set (MDS) dated [DATE] documents R40 requires supervision with toileting, and R40 is frequently incontinent of stool.
5. On 03/12/25 at 09:15 AM during incontinent care with R20 in bed on her back. V11, CNA removed adult diaper wet as verified by V11. V11 with wet wash cloths with shampoo body wash on washcloths. With soaped wet washcloth V11 wiped across R20's perineal area. V11 then cleansed bilateral groin. V11 did not separate or cleanse R20's labia. V20 did not rinse R20 prior to drying. V11, CNA then turned R2 to left side and cleaned and dried R20. R20 was not rinsed prior to drying.
R20's MDS dated [DATE] documents R20 is frequently incontinent of urine R20's MDS documents R20 is dependent on staff for toileting.
The facility policy Perineal Care Policy and Procedure dated, revised 11/2016 documents residents who require assistance from nursing staff to cleanse perineal area will be cleansed in a manner that decreases the risk of transmission of infection and promotes skin integrity. The policy documents perineal care includes care of the external genitalia and anal area and will be performed by a nurse or nurse's assistant. The policy documents for female genitalia- use gentle downward strokes from the front to the back of the perineum, using a clean section of the washcloth or premoistened wipe with each stroke. The policy documents if soap and water used, use clean, wet washcloth to rinse perineal area, using same motion as you did with cleansing, ensuring clean section of the washcloth or pre moistened wipe is used with each stroke. Pat dry resident's perineal area with a dry towel. Turn the resident on their side or in a position comfortable to resident to cleanse rectal area, cleanse rinse, and pat dry the anal area in the same manner you cleansed the perineal area, using strokes that work away from the urethra opening. If needed.
Based on interview, observation, and record review, the facility failed to provide complete incontinent care to prevent urinary tract infection for 5 of 5 residents (R20, R40, R51, R60, R185) reviewed for urinary incontinence in the sample of 42.
Findings include:
1. R185's Face Sheet, print date of 3/12/25, documents R185 was admitted on [DATE] with a diagnosis of History of Falling.
R185's Clinical Admission, dated 3/6/2025, documents, Mental Status: Resident is confused. Oriented to person. Confused: Chronic. Genitourinary: Ostomy (including urostomy, ileostomy, and colostomy).
Urinary catheter intact. Urine amber in color. Urine retention noted. Genitourinary Note: Hospital stated resident has urinary retention.
R185's Health Status Note, dated 3/9/2025 06:40, documents, Note Text: ER (Emergency Room) nurse called with report. Resident is being sent back on ABT (antibiotic) for UTI (Urinary Tract Infection).
On 3/10/25 at 12:09 PM, V11, Certified Nurse Aide (CNA), entered R185's room to provide care. R185 is lying in a low bed. R85 has an indwelling urinary catheter. R185's urinary drainage bag is hooked onto the bed side rail at a point that the bag is above the bladder. V11 removed R185's incontinent brief, the brief had stool smears, with a wash cloth that was moistened with peri-wash and water V11 wiped R185's pubic area and left groin, V11 rolled R185 onto her side, and with another wash cloth that was moistened with peri-wash and water, cleansed R185's rectal area and buttocks. V11 did not cleanse or spread the labia, cleanse the urethra opening, indwelling catheter tubing, or dry R185 after the care.
On 3/11/25 at 2:10 PM, V11 was questioned why she did not cleanse or spread the labia or dry R185 on 3/10/25, V11 stated, because I was by myself and she is a bigger lady.
On 3/13/25 at 9:18 AM, V2, Director of Nurses, stated, catheter care should be complete, spreading the labia, and cleansing the catheter tubing.
The policy Catheter Care / Incontinent Care, dated 8/1/05, documents, Procedure: 5. Turn or assist resident to back lying position. 6. Expose genitalia. 7. Put on clean gloves. 8. Cleanse peri area or if appropriate. Cleanse area of insertion of catheter into meatus using clean washcloth prepared with soap and water. Cleanse downward from top to bottom giving care to cleanse the catheter when applicable. Use a clean wash cloth for each swipe down. 9. Rinse well with clean cloth. 10. Dry with clean towel.
2. R51's admission Record, undated, documents R51 was admitted to the facility on [DATE] with diagnosis of Morbid Obesity, Urinary Tract Infections (UTI), Acute Cystitis, Hydronephrosis, Anxiety Disorder, and Extended Spectrum Beta Lactamase (ESBL).
R51's Care Plan, dated 1/10/25, documents R51 has a catheter related to Hydronephrosis with Renal and Ureteral Calculous Obstruction. Interventions: Position catheter bag and tubing below the level of the bladder and away from entrance room door. It continues R51 is at risk for an ADL Self Care Performance Deficit Generalized muscle weakness.
R51's MDS, dated [DATE], documents R51 is cognitively intact and is dependent on staff for toileting.
On 3/11/25 at 11:20 AM, V9, CNA, and V7, CNA, performed incontinent care on R51 with no Personal Protective Equipment (PPE), except gloves, while on Enhanced Barrier Precautions. Supplies brought to bedside, including a bucket of soapy water and washcloths. R51's incontinent brief was unfastened and V9 got a wet washcloth from the water and wiped R51's urinary catheter from urethra opening down the catheter, then got another wet washcloth out of the water and wiped R51's left groin, then with another wet washcloth and wiped down R51's vagina twice. R51 was rolled to her right side while V9 got wet cloth and wiped R51's left buttock and anal area. V9 placed a clean incontinence brief under R51 and rolled her to her back and the brief was fastened. There was no drying of R51, no cleaning of R51's right groin, buttock or hip, and no wiping under abdominal fold. Both CNAs used their soiled gloves to put R51's clean incontinence brief on, her pants put on, placed the full body mechanical lift device sling under her, then R51 requested to take her nightgown off and put a shirt on and both CNAs did this still with their soiled gloves on. Both CNAs doffed gloves and left the room with no hand hygiene seen done.
3. R60's admission Record, undated, documents R60 was admitted to the facility on [DATE] with diagnosis of Parkinson's Disease, Depression, Transient Ischemic Attack (TIA)/Cerebral Vascular Infarction without residual deficits, and Falls.
R60's Care Plan, dated 1/10/25, documents R60 is at risk for an Activities of Daily Living (ADL) Self Care Performance Deficit related to Parkinson's. It continues R60 has had actual falls with intervention of frequent toileting every two hours.
R60's Minimum Data Set (MDS), dated [DATE], documents R60 had a moderate cognitive impairment and is dependent on staff for toileting, bathing, and transfers.
On 3/11/25 at 9:25 AM, V7, Certified Nursing Assistant (CNA), assisting R60 to get out of bed and dressed. R60 had a strong smell of a bowel movement (BM) noted. V7 assisted R60 to the restroom and pivoted R60 to the toilet. Upon removing R60's incontinence brief, a large BM was seen. While R60 was finishing on the toilet, V7 had the water running in the sink with half of a towel in the sink. After R60 finished, V7 took the towel out of sink, donned gloves, and took the wet part of the towel to the toilet and wiped R60's buttock and anal area, then used the same gloves to put on a clean incontinence brief on R60 and pulled up his pants, then assisted him back to his wheelchair. V7 did not wipe the front or sides of R60 at all. V7 doffed her gloves and pulled R60 to the sink to wash his face. V7 did not do hand hygiene after doffing gloves or leaving the room.
On 3/13/25 at 10:25 AM, V1, Administrator, stated I would expect the staff to provide timely and complete incontinent care, including proper hand hygiene and glove changes when soiled.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview and Observation the facility failed to properly store medications for 4 of 11 residents (R27, R30, R48, R237)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview and Observation the facility failed to properly store medications for 4 of 11 residents (R27, R30, R48, R237) observed for proper medication storage in the sample of 42.
The Findings Include:
1. The 300-North Hall Medication Cart was Reviewed with V4, Registered Nurse (RN). Basaglar Insulin Pen was seen in the cart and was opened with no resident label, name, or the date it was opened.
On 3/10/25 at 12:15 PM, V4 stated There are only a few residents who are on that insulin, so I'm sure I can narrow it down to who's it is. The label must have fallen off.
2. On 3/10/25 at 11:00 AM, R27 was seen lying in bed with a medicine cup sitting on his bedside table with 7 pills in the cup.
R27's Medication Administration Record (MAR), dated March 2025, documents R27 received the following medications on 3/10/25 at 8:00 AM: ASA 81 MG (milligram), Atorvastatin 40 MG, Cetirizine 10 MG, Famotidine 20 MG, Iron 325 MG, Folic Acid 1 MG, Lisinopril 10 MG, Metoprolol 25 MG, Magnesium Oxide 400 MG.
R27's Minimum Data Set (MDS), dated [DATE], documents R27 is cognitively intact.
On 3/10/25 at 12:50 PM, V4, RN, stated I always make sure the resident takes all of their meds before leaving the room. There are very few people I trust here that would take their pills if not.
On 3/11/25 at 9:23 AM, V7, CNA, stated It's a common thing around here to find a cup of medications left in a resident's room for them to take.
3. On 3/11/25 at 9:20 AM, R237 had a bottle of Pepto-Bismol sitting on his dresser. R237 does not have an order for this.
R237's MDS, dated [DATE], documents R237 is cognitively intact.
4. R30 was admitted to the facility on [DATE] with diagnosis of, in part, Parkinson's disease, type two diabetes mellitus, and hypertension.
On 3/10/25 at 10:35 AM, R30 had a cup with medications in it sitting on his bedside table. R30 stated the medications were his morning doses, the nurse usually just leaves it there for me to eventually take.
5. R48 was admitted to the facility on [DATE] with diagnosis of, in part, femur fracture, type two diabetes mellitus, and hypertension.
On 3/10/25 at 10:11 AM, R48 had a cup of medications on her bedside table. R48 stated the medications were left there this morning by the nurse because she was running late.
The Facility's Medication Storage Policy, dated 5/23/24, documents Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. C. All medications dispensed by the pharmacy are stored in the container with the pharmacy label.
The Facility's Medication Administration Policy, dated 1/11/10, documents It is the policy of this facility to accurately administer medication following physician's orders. 13. Make sure the resident takes the medication. Generally, do not leave meds at bedside (may be exceptions after thorough assessment and care planning).
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
Based on interview, observation, and record review, the facility failed to serve palatable food. This failure has the potential to affect all 87 residents residing in the facility.
Findings include:
1...
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Based on interview, observation, and record review, the facility failed to serve palatable food. This failure has the potential to affect all 87 residents residing in the facility.
Findings include:
1.On 3/12/25 at 11:20 AM the kitchen was entered. The food thermometer was calibrated to 32 degrees. The noon meal was on the steam table. The garlic butter chicken was 151 degrees, the ground chicken was 186 degrees, the pureed chicken was 150 degrees, the whole sweet potato was 172.5 degrees, the cubed sweet potatoes was 168 degrees, the pureed sweet potato 175 degrees, the cauliflower was 176 degrees, the pureed cauliflower was 177 degrees, gravy 169 degrees, rice was 194 degrees. At 11:34 AM the kitchen service started. The first 300 hall cart went out to the hall at 11:47 AM. The second 300 hall cart went out to the hall at 11:58 AM. The 300 hall trays were all delivered at 12:20 PM. The 100 hall cart was delivered at 12:12 PM. The 100 hall trays were all delivered at 12:28 PM. The 200 hall cart was delivered at 12:14 PM. The 200 hall trays were all delivered at 12:36 PM. The dining room cart was delivered at 12:22 PM. The dining room trays were all delivered at 12:36 PM.
On 3/12/25 at 12:36 PM a test tray was sampled. The chicken was 106 degrees. The chicken was dry, tough, and bland. It tasted cold. The cauliflower was 124 degrees. It tastes lukewarm. The cubed sweet potatoes were 117 degrees and they tasted warm and bland.
On 3/13/25 at 9:35 AM, V1, Administrator, stated it seems like it is a staffing delivery issue of the trays and that is why the food is cold. We do not have policy on palatable food.
The Resident Council Meeting Minutes, dated 9/26/24, documents, Food continue to be overcooked.
The Resident Council Meeting Minutes, dated 11/27/24, documents, Residents state the food is cold.
The Resident Council Meeting Minutes, dated 1/31/25, documents, Residents state the vegetables are overcooked. Residents state the noodles are overcooked. Residents state the food temperature is not consistent and is often lukewarm when they receive it.
The Long Term Care Facility Application for Medicare and Medicaid, dated 3/10/25, documents the facility has 87 residents residing in the facility.
2. On 3/10/25 at 10:10 AM, R51 stated the food is Shi**y here and is usually cold.
3.On 3/11/25 at 9:10 AM, V7, Certified Nursing Assistant (CNA), stated We get a lot of the residents complaining that their food is cold, and we just heat it up for them. It's hard to keep the food warm until they get it. We don't have enough people to hand the trays out fast enough.
4. On 3/11/25 at 12:05 PM, R51's lunch tray was delivered to her room and placed on her bedside table. R51 was not in her room and was in therapy. When R51 returned, she stated her food was already cold and V7 heated it up for her.
5. On 3/11/25 at 12:08 PM, V7, CNA, was seen warming up R27's lunch plate.
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 interview, observation, and record review, the facility failed to dry dishware before use. This failure has the potential to affect all 87 residents residing in the facility.
Findings include...
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Based on interview, observation, and record review, the facility failed to dry dishware before use. This failure has the potential to affect all 87 residents residing in the facility.
Findings include:
On 3/12/25 at 11:34 AM the kitchen service began. At 11:51 AM, the trays and the dish covers were noted to be wet. The napkin was getting wet and water drops from the dish covers were potentially dropping onto the food. V21, Dietary Aide, confirmed the trays were wet. V19, Cook, stated they probably did not get shook out enough to dry.
On 3/12/25 at 1:40 PM, V1, Administrator, stated Now that I am overseeing the kitchen I have realized that I need to order more supplies because there just isn't enough time in between the meals for things to dry.
On 3/13/25 at 9:35 AM, V1, stated We do not have policy on palatable food or drying dishes.
The Long Term Care Facility Application for Medicare and Medicaid, dated 3/10/25, documents the facility has 87 residents residing in the facility.
Jan 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
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 follow Physician orders for 1 of 4 (R4) reviewed for indwelling cat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow Physician orders for 1 of 4 (R4) reviewed for indwelling catheter care in the sample of 8.
Findings include:
On 1/8/25 at 4:03 PM, R4 stated her catheter bag is always emptied so it never gets to full. R4 stated she is not sure how often they actually change the actual urinary catheter. R4 stated that she has a leg bag on right now and that there is barely any urine in it. R4 requested that the indwelling urinary catheter is not observed.
On 1/8/25 at 4:09 PM, V5, Registered Nurse, stated that (indwelling urinary) catheters are changed every 30 days and as needed.
On 1/13/25 at 1:20 PM, V2, Director of Nurses, stated that indwelling urinary catheters are changed every thirty days or as needed.
On 1/13/25 at 4:35 PM, V2 stated, On November 18 is when it (R4's indwelling urinary catheter) was supposed to be changed. The nurse that night discontinued the order and then told a night nurse on the 21st to change it which it was done. For some reason, the order was changed to have the indwelling urinary catheter changed the next time on 12/31/24. Which made it 10 days late.
R4's Face Sheet, print date of 1/13/25, documents that R4 was admitted on [DATE] and has a diagnosis of Hydronephrosis with renal and ureteral calculous obstruction.
R4's Minimum Data Set, dated [DATE], documents that R4 is cognitively intact and has an indwelling urinary catheter.
R4's Physician Orders, dated 12/1/2024, documents, Change (indwelling urinary) catheter monthly and as needed every night shift every 30 day(s.)
R4's Nurses Note, dated 11/21/2024 01:33, documents, New (indwelling urinary) catheter Fr (french) 18 inserted aseptically. Clear yellow urine in return. Procedure well tolerated.
R4's December 2024 Treatment Record documents that R4's indwelling urinary catheter was changed on 12/31/24.
The policy Catheter Protocol, dated 2/10, documents, Catheters shall be changed per MD (Medical Doctor) order. Change of catheter is recorded on the Treatment Sheets and may also be placed in the Nurse's Notes if needed.
Dec 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews the facility failed to follow R4's care plan and provide appropriate footw...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews the facility failed to follow R4's care plan and provide appropriate footwear during a transfer for 1 of 3 residents, (R4), reviewed for accidents in a sample of 6.
Findings include:
1.R4 was admitted to the facility on [DATE] with diagnosis of, in part, heart failure, Alzheimer's disease, and dementia.
R4's Minimum Data Set (MDS) dated [DATE] documented R4 is severely cognitively impaired and requires partial/moderate staff assistance with transfers.
R4's Care Plan dated 8/22/24, documented she is at risk for falls related to gait/balance problems for a history of falls with an intervention to ensure that R4 is wearing appropriate footwear (properly fitting shoes, brown leather shoes, tartan bedroom slippers, black non-skid socks) when ambulating or mobilizing in wheelchair.
On 12/23/24 at 12:00 PM, R4 was transferred by V3, Certified Nursing Assistant (CNA), from the bed to her wheelchair via gait belt with regular socks that were not non skid. R4 was left in her recliner without proper footwear on.
On 12/23/24 at 3:36 PM, V1, Administrator, stated fluffy socks are not what R4 is supposed to be wearing and she expects the staff to be following the resident's care plan.
Oct 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent physical abuse for 1 of 4 (R2) residents, reviewed for abus...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent physical abuse for 1 of 4 (R2) residents, reviewed for abuse in a sample of 4.
Findings include:
R2's Minimum Data Set (MDS), dated [DATE] documented that R2's cognition was moderately impaired, that she uses a wheelchair to be mobile and that she requires set up help on some Activities of Daily Living (ADL's) and maximum assistance for mobility and dressing ADL's.
R2's Care Plan, dated 7/8/2024, documented, Physical Assault: (R2) was in an abusive relationship in the past. She has dealt with this and declines services and intervention at this time.Resident will verbalize understanding of available services if needed. Reevaluate as needed.
R2's Physicians order sheet, dated 10/2024, documented diagnoses of other postprocedural complications and disorders of digestive system, peritoneal abscess, infection following a procedure, superficial incisional surgical site, subsequent encounter, and urinary tract infection, site not specified.
On 10/28/2024 at 11:00 AM, R2 stated that V3, Certified Nurse Assistant, (CNA), was in and out of her room, doing things for her, the evening before and that she was also on her cell phone talking to some girl about being her girlfriend or something while in her room. R2 stated that she left her room and was out in the hallway being loud on her phone. R2 continued to state that the next day, when (V5), Business Office Manager, came down to see her, she let her know what was going on with V3 being on her phone instead of assisting the residents. R2 continued to state that around 1:30 pm that day, (V3), CNA, came back into her room took the bowl of soup and threw it at her. She continued to state that she was not hurt. R2 continued to state that she (V3) was yelling at her telling her that she wasn't getting fired and that they were only moving her to a new hall and that she wasn't talking about a girlfriend. R2 stated that (V3), CNA, was trying to intimidate her because she told on her about being on her phone. R2 was asked if she felt safe at the facility and she stated that some people are very caring and some she is [NAME] of but she does not feel threatened and she feels safe living at the facility. She also stated that she spoke with the police and pressed charges against (V3), CNA. R2 stated that she does not fear (V3), CNA, coming back because it was taken care of as it should have been.
On 10/28/2024 at 1:45 PM, V5, Business Office Manager (BOM), stated that she went in to see R2 when she 1st got to work on 10/15/24. She stated that (R2) was her daughter's grandmother. She continued to state that (R2) told her that (V3) was on her phone being loud in her room and in the hallway, the day or night before. V5 stated that once (R2) told her this she went to the (V2), Director of Nurses, immediately with this information. She then stated that around 11:30 am she took (R2) some soup and then she went and covered the front desk for another girl. V5 continued to state that at 1:39 pm she received a text message from (R2) telling her to get down to her room and see what the CNA had done to her. She stated that she immediately asked if she was hurt and if she was ok, V5 stated that was the soup that she brought into her at 11:30 am so it wasn't hot any longer. V5 continued to state that she ran and got (V1), Administrator and (V2), Director of Nurses to come and check out (R2). V5 also stated that around 1:00 pm, they had the girl (V3), CNA in (V1's) office and the voices were getting really loud.
On 10/29/2024 at 10:00 AM, V2, Director of Nurses, stated that she was told by (V5), BOM, about (V3), CNA being on the phone while taking care of residents and that she also had a complaint by another staff member about her being on her phone and that she went and looked for her. V2 stated that she found her in the sun room, talking on her phone. V2 stated that her and (V3) had a talk about not being on her phone while taking care of residents and that she could use her phone on her break time and away from care areas. V2 stated that (V3) apologized and went back to work. Later that morning, therapy staff came to her and stated that a resident had complained that (V3) was on her phone while she was doing incontinent care. V2 stated that she went down to that residents room to talk to him and (V3) walked by and saw her sitting there talking to the resident and that was when she went to (V1's) office and was upset. V2 continued to state that (V3) did raise her voice trying to talk over her but (V3) acted more upset and was defending herself and did not seem to be agitated. V2 then stated that she did not see (V3) leave the facility, but was told that soup was thrown on (R2) by (V3), so her, (V1), Administrator,(V5), BOM, and another nurse went immediately to go check on (R2) and assess her. V2 stated that when (V3) left the building at 1:05 pm and then returned around 1:39 pm to throw soup on (R2), no one would of even wondered why she was coming possible through the employee entrance because she was working that day.
On 10/29/2024 at 8:45 AM, V1, Administrator, stated when asked about when (V3), CNA, was pulled into the office and spoken with about her being on her phone how was her demeanor. V1 stated that they didn't pull (V3) into her office, and that she came in there upset and not agitated as she could tell, stating that she could not lose her job because she was homeless and that she was on her phone because someone was calling her about a place to live. V1 continued to state that she was concerned that this person needed assistance because she was homeless. V1 continued to state that (V3) left the building at or around 1:05 pm, but then at 1:15pm or so, (V5), BOM, got a text message from (R2) to come down to her room immediately to see what (V3) had done to her. V1 continued to state that no one saw (V3) come back into the building through the front door and that every door code was the same so she may have come in through the employee entrance. V1 continued to state that she had maintenance change all the door codes the same day.
On 10/17/2024, an Interview was done by V1, Administrator. V7, CNA was interviewed regarding the event that took place on 10/15/2024. It documented, Tuesday October 15, 2024. Delivered lunch tray to (R2). Did anything occur when you delivered her lunch tray (V7, CNA): The girl that had that group was standing in the room. I assumed she was doing something with (R2). Did you hear or see anything occur when you delivered the tray? (V7, CNA)- No. Did you speak to the CNA that was in the room? (V7) when she came out of the room, yeah. What was said during that conversation? (V7) She was asking me who she needed to talk to because she was fed up with having that group. I told her go talk to (Staffing). What time was that? (V7) Around lunch time maybe 12:30. Did you see this aid after that? (V7) No. Do you know the aides name? (V7, CNA) I believe it was ( V3, CNA). It continued to document, Did you see or hear that CNA, (V3) speak inappropriately to any resident while you were working? (V7, CNA) No. Did you see (V3) enter (R2's) room around 1:30 PM? (V7) No. Did you see (V3) throw soup at (R2), (V7)- No. It continues, Did (V3,CNA) have any interaction with you around 1:30 PM? (V7) No.
Report to State Agency, dated 10/18/2024, documented, (R2) reported to the Business Office Manager (V5) that an Agency CNA, (V3) entered her room at approximately 1:35 pm and stated I didn't say I had some girlfriend. They are not going to fire me; they are going to just move me. (R2) then stated, That girl with the pink bonnet picked up my bowl of soup and threw it at me and said that's what you get. (R2) had soup on her gown, her bed, the wall and the soup bowl was upside down on the right side of (R2's) bed. Head to toe assessment completed, no injuries. (R2) state, The soup was not hot. It continues, (V3, CNA) left the facility prior to her scheduled shift ending after being upset about being told she was not to be on her phone by the DON (V2). (V1) Administrator attempted to call (V3, CNA) per phone number on file (XXX-XXX-XXXX), a female aswered and said, wrong number. It continues, (V3) was immediately put on the do not return list with (Staffing Agency), (V6, Staffing Agency Supervisor) was notified via phone that (V3, CNA) is to not return to our facility or facility property related to occurrence and provided allegation information.
The facility's policy, Resident care policy and procedure regarding abuse and neglect, involuntary seclusion, exploitation, Misappropriation of Resident Property, Injuries of Unknown Origin, and social Media, dated 03/15/2018, documented, 1. All residents have the right to be free from verbal, sexual, physical, mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation
Sept 2024
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free from sexual abuse for 1 of 6 (R5), review...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free from sexual abuse for 1 of 6 (R5), reviewed for abuse in the sample of 6. This failure resulted in R5 experiencing two episodes of being sexually abused by R1 on 9/8/24, in which R5 was verbally heard yelling for help, stating that it hurt. The reasonable person concept can also be utilized, a reasonable person would experience fear, trauma, humiliation, should sexual abuse occur to them.
The Immediate Jeopardy began on 9/8/2024 when R5 was sexually abused by R1. The abuse was witnessed by V5 (Certified Nurse Assistant, CNA). After removing R1 from the room, leaving R1 unsupervised, R1 again re-entered the room and sexually abused R5 for a second time. V1 (Administrator) was notified of the immediate jeopardy on 9/23/2024 at 2:27 PM. The surveyors confirmed by observations, interview, and record review that the Immediate Jeopardy was removed on 9/24/24 but noncompliance remains at Level Two due to additional time needed to evaluate the implementation and effectiveness of in-service training.
Findings include:
On 9/20/2024 at 10:22 AM, V6 (Licensed Practical Nurse, LPN) stated she was the manager on duty and was physically in the facility on 9/8/2024 when the incident between R1 and R5 occurred. V6 stated a Certified Nursing Assistant (CNA) reported the incident to her. V6 stated it was witnessed by the CNA and reported to her that R1 was holding R5's penis. V6 stated she reported the incident to the administrator immediately. V6 stated she had not observed R1 have any inappropriate behavior recently. V6 stated there was an incident with R1 involving sexual abuse in February 2024, which was founded. V6 stated R1 was started on Provera at that time. V6 stated R1's Provera had been discontinued, but agreed R1 was started back on Provera after the recent incident with R5.
On 9/20/2024 at 10:50 AM, V1 stated that based on her investigation she did substantiate the allegation of abuse involving R1 and R5 based on witnessing of actual incident and witness statements. V1 did agree that R1 did have a previous incident of abuse.
On 9/20/2024 at 11:00 AM, V5 stated she was on break on 9/8/2024 and upon return she heard R5 yelling help, it hurts. V5 stated R1 had his hand under R5's sheet. V5 stated when she pulled the sheet back R1 had his hands around R5's penis. V5 stated R1 dropped R5's penis at that time. V5 stated she removed R1 from the room into the hall. V5 stated she left R1, going to report the incident to V6, who was the manager on duty. V5 stated when she returned from reporting the incident R1 was back in the room holding R5's penis a second time.
R1's care plan dated 2/26/2024 documents R1 has a hyper-sexual and flirtatious behavior. R1's care plan documents the following interventions: 2/26/2024 anticipate and meet R1's needs, caregivers to provide opportunity for positive interaction, attention, stop and talk with him as passing by, if reasonable discuss behavior, explain/reinforce why behavior is inappropriate and/or unacceptable, intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternative location as needed, md to review chart, medications, recent changes in status, diagnosis, recent labs.
R5's electronic medical record documents R5 has diagnosis in part of encounter for closed fracture, with routine healing, unspecified fall, and urinary tract infection. R5's Minimum Data Set (MDS) dated [DATE] documents that R5 has severe cognitive impairment. R5's care plan dated 9/12/2024 documents R5 has impaired physical mobility. R5's care plan documents R5 is at risk for Activities of Daily Living (ADL) self-care deficit related to disease process. R5's care plan documents R5 requires mechanical lift with 2 staff for transfers.
On 9/20/2024 at 10:31AM V2 Director of Nursing (DON) stated if incident involving sexual abuse would separate residents and have a visual on them.
On 9/19/24 at 11:22 AM, R1 was noted to be cognitively impaired, expressing no concerns regarding abuse or memories of events that had occurred.
R5 was unable to be interviewed, as he did not reside in the facility during the time of this survey. R5's Clinical Record documented his discharge from the facility on 9/12/24.
The facility policy abuse prohibition dated 3/15/2018 documents all residents have the right to be free from sexual abuse. The policy documents sexual abuse is non-consensual sexual contact of any type which includes, but is not limited to sexual coercion, or sexual assault. The policy documents sexual coercion shall include any intentional or knowingly touching or fondling a non-consenting resident's sex organs, anus, or breast either directly or through clothing for the purpose of sexual gratification or arousal of the accused. The policy documents if the incident involves suspected abuse, the charge nurse shall assure that the suspected abuser has no further contact with the resident involved or with any other resident.
The immediate jeopardy that began on 9/8/2024 was removed on 9/24/24, when the facility took the following actions to remove the immediacy:
Nurse managers and Administrator interviewed all residents for abuse on 09/23/24 and 09/24/2024. No abuse was determined or reported at this time.
Facility completed head to toe assessment on all residents by Nurse managers on 09/24/2024. No signs or symptoms of abuse were noted at this time.
All resident charts have been reviewed on 09/24/2024 by the facility Administrator, DON, Nurse Managers and Social Service Director, including progress notes and tasks, to identify any additional resident behaviors and incidents if applicable; no residents were identified.
The resident identified for exhibiting inappropriate behaviors related to the citation is in a private room directly across from the nurse's station for supervision and 1:1 when choosing to exit his private room - interventions will remain in place as long as resident is residing in facility. Assignments of 1-1 will alternate between staff directly assigned per Administrator.
Primary Care Physician reviewed chart and medications, ordered 5mg tablet of Provera daily and was initiated. Primary Care Physician requested a psychiatry consult. V16, Psychiatrist, contacted and recommended in-patient psychiatry evaluation. Facility has made several attempts to place for psychiatry evaluation without acceptance. V16 will continue to follow the resident in the facility. Facility Pharmacy consultant completed Medication Regimen Review and Chart Review.
Facility sent referrals with resident's approval to multiple facilities for the resident to reside, all referrals have been declined.
The facility Social Service Director reassessed the resident's PTSD Screen for DSM-5/Trauma Informed Care, PHQ-2 to 9 Evaluation, Brief Interview for Mental Status (BIMS) Evaluation; no significant changes were identified.
Residents Identified:
There was 1 male resident identified to have been directly affected by the inappropriate behavior of the male resident. The identification was reported to Administrator on 09/08/2024; full investigation was initiated including staff and resident interviews conducted by the facility Administrator. Administrator completed full body assessment of both male residents on 09/08/2024, no harm identified. All residents are at risk for being affected by this male resident's behavior; he will reside in a private room directly across from the nurse's station for supervision and 1:1 when choosing to exit his private room; resident will remain in the private room across from the nurse's station while residing in the facility.
The male resident identified to have been directly affected by the inappropriate behavior on 09/08/2024 was immediately provided a room reassignment. Resident was interviewed and assessed on 09/08/2024 immediately following occurrence by the Administrator, resident was unable to recall occurrence, he denied pain. The resident did not display any s/s of negative effects. Administrator reviewed resident's chart on 09/08/2024 and implemented monitoring resident every shift to ensure any changes in mood, activities, or ADL status would be identified and reviewed every shift by the Administrator. No changes in psychosocial well-being were identified. Resident's care plan was updated on 09/08/2024 by Administrator. Resident was reassessed on 09/11/2024 by the Social Service Director, PHQ-2 to 9 Evaluation, Brief Interview for Mental Status (BIMS) Evaluation completed; no significant changes were identified. Upon admission from hospital, resident had a discharge plan to return to previous facility he resided, once facility was able to accept based on bed availability, discharged from facility on 09/11/2024.
Immediate Education:
Regency Care - [NAME] has policy, procedures, and protocols based on current standards of practice.
*
V1,Administrator provided education to each department manager on 09/23/24 and 09/24/2024 regarding the facility Abuse and Neglect Policy; disciplinary action that will result if failure to follow facility policy.
*
Department managers V2 (Director of Nursing), V7 (Assistant Director of Nursing), V9 (Infection Preventionist), V6 (MDS Coordinator), V10 (Restorative), V11 (Social Services), V12/V13 (Environmental Services), V14 (Dietary Manager), V8 (Business Office Manager) provided education to all staff regarding the facility Abuse and Neglect Policy; disciplinary action that will result if failure to follow facility policy on 09/23/2024 and 09/24/2024.
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The Director of Nursing or designee will review behavior notes and progress notes (on the clinical dashboard and 24-hour summary) of all residents to identify inappropriate behaviors and notify Administrator and reviewed at daily IDT meetings.
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The Administrator updated care plan on 09/08/2024 of the resident identified for exhibiting inappropriate behaviors and staff were educated on 09/08/2024 - 09/13/2024. Care plan was reviewed and updated again on 09/23/2024.
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Administrator provided education regarding the 09/23/2024 updated care plan for resident identified for exhibiting inappropriate behaviors to each department manager on 09/23/24 and 09/24/2024.
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Administrator and department managers provided education to all staff of the 09/23/2024 Care Plan revisions and updates on 09/23/2024 and 09/24/2024.
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Administrator provided education to all department managers on 09/09/2024 regarding resident's care plan: resident will reside in a private room directly across from the nurse's station for supervision and 1:1 when choosing to exit his private room; resident will remain in the private room across from the nurse's station while residing in the facility. Administrator educated department managers again on 09/23/24 and 09/24/24.
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09/24/2024 The Interdisciplinary Team (IDT) has reviewed, discussed and approved the Immediate Jeopardy Removal Plan. The IDT included staff members: V1 Administrator, V2 Director of Nursing, V7 Assistant Director of Nursing, V9 Infection Preventionist, V6 MDS Coordinator, V10 Restorative, V11 Social Services, V12/V13 Environmental Services, V14 Dietary Manager, V8 Business Office Manager, V15 Medicaid Specialist/Admissions coordinator.
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Administrator will monitor to ensure compliance of interventions put in place by auditing 3 X week for 4 weeks. Audits will be reviewed at nest QA meeting in October 2024.
Mar 2024
6 deficiencies
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 complete incontinent care for 1 of 4 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 provide complete incontinent care for 1 of 4 residents (R4) reviewed for incontinence, in the sample of 33.
Findings include:
On 3/27/2024 at 1:09 PM, during incontinent care, V15, Certified Nursing Assistant (CNA) washed hands with soap and water prior to donning gloves. V15, CNA, unfastened R4's incontinent brief. R4's incontinent brief wet as verified by both V15, CNA and V14, CNA. V15, CNA with washcloth sprayed no rinse peri wash and wiped down right groin, then gets a clean washcloth and swipes down R4's peri area , V15 then gets a clean wash cloth and cleaned R4's left groin. V14 only dried R4's right groin, prior to turning R4 to her right side facing the window. V15 cleansed R4's right buttock with clean washcloth with no rinse peri wash, then with clean washcloth cleansed left buttocks. V15, CNA cleansed R4's rectal area from front to back. V15 did dry R4's buttocks or rectal area prior to applying a clean incontinent brief.
R4's Care plan, dated 2/23/2024, documened, (R4) has bladder incontinence related to history of Urinary tract infection (UTI) and bladder re-sectioning. R4's care plan documents
INCONTINENT: Check R4 every 2 hours and as required for incontinence. Wash, rinse and dry perineum.
R4's Minimum Data Set (MDS), dated [DATE], documented that R4 was dependent on staff for toileting and is frequently incontinent of urine.
On 3/28/2024 V17, CNA, stated that when providing incontinent care to a female resident it is expected that the labia is separated and go from front to back . V17 also stated that all areas are to be dried after care is provided.
The facility policy, Perineal policy and procedure dated 2015, documented, Female genitalia use gentle downward strokes from the front to the back of the perineum. It continues, Pat dry resident's perineal area with a dry towel.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the Facility failed to ensure residents on a pureed diet were served their me...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the Facility failed to ensure residents on a pureed diet were served their meal consistent with the requirements of a pureed diet consistency for 1 of 4 residents, (R62) reviewed for Diet Orders, in the sample of 33.
Findings include:
R62's Minimum Data Set (MDS), dated [DATE], documented that R62's cognition was severely compromised.
R62's Physician's Orders, dated 3/27/2024, documented that R62's was on a pureed diet.
On 3/25/24 at 12:15 PM, V10, R62's Caregiver, stated that R62's ham and peas were not pureed enough. At this time, R62's plate was observed with whole chunks of peas that had not been completely pureed, as well as a dime sized chunk of ham mixed in the rest of the pureed ham mixture. V10 took R62's tray out of her room and returned with three bowls of pureed food. V10 stated, This is much better, more smooth. She (R62) has difficulty swallowing.
On 3/27 at 10:00 AM, V10 stated, I frequently have to send her food back because because it isn't pureed enough and not the right consistency. Yesterday the peas had whole chunks and there was a piece of meat that was about the size of a dime. I told her other caretaker about it and she said, Oh, like always.
On 3/28/2024 at 9:51 AM, V8, Dietary Manager, stated that the pureed food should be smooth and not have chunks.
The Facility's Policy titled Pureed-Level 4-PU4, undated, documented, All foods will be a smooth pudding like consistency and should not have any lumps.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on interview, observation and record review the facility failed to store food in accordance with professional standards for food service safety. This failure has the potential to affect 78 of 79...
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Based on interview, observation and record review the facility failed to store food in accordance with professional standards for food service safety. This failure has the potential to affect 78 of 79 residents living at the facility.
Findings include:
On 3/25/24 at 8:50 AM, the kitchen was toured. V8, Dietary Manager, was present for the tour. There was a 25 pound bag of flour. The flour bag had a measuring cup with the handle in the flour. There was a large bag of undated thawed chicken thighs and two undated thawed pork chops in the large refrigerator. The refrigerator, in the dry storage room, contained one large plastic bag of chopped lettuce with no expiration date nor received date. This refrigerator also contained six small bags of shredded carrots. The shredded carrots did not have an expiration date nor a received date.
On 3/25/24 at 9:15 AM V8, Dietary Manager, stated, The thawed meat should have been stored in a plastic tote and dated. I will throw it away.
On 3/27/24 at 1:40 PM V8, Dietary Manager, stated, The measuring cup is used to scoop the flour out of the bag and it should not be stored in the bag of flour. V8 removed the measuring cup from the bag of flour. V8 also stated that she would expect the bagged lettuce and bagged carrots to be dated.
The facility Food Labeling and Dating policy, dated 2/22, documented, Labeling and dating food is important to assure foods are used in a timely manner. The following procedures are to be used for proper food labeling. 1. Proper food labeling included: name of product, date stored and in some cases, the time. 2. The food must be labeled and dated if it is removed from its original container. 3. Leftover foods placed in a container must be cooled down properly, labeled and dated. 4. Once refrigerated or frozen items are properly labeled, they need to be used or disposed of according to the Refrigerator and Freezer Storage Chart. 5. When taking food items out of the freezer to thaw, make sure they are labeled with the date when placed in the refrigerator.
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 observations, interview and record review, the facility failed to change gloves during indwelling catheter care for one...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to change gloves during indwelling catheter care for one of three (R11) residents, reviewed for infection control in a sample of 33.
Findings include:
R11's face sheet, dated 03/27/24, documented that R11's diagnoses include Aphasia, cerebral infarction, hypertension and type 2 diabetes.
R11's Minimum Data Set, dated [DATE], documented that R11 had a catheter.
R11's physicians orders, dated 3/2024, documented, Foley cath care every shift and (as needed).
On 3/27/2024 at 10:30 am, V11, Certified Nursing Assistant (CNA) and V12, CNA, performed indwelling catheter care on R11. V12 touched R11's labia and then assisted with applying a clean incontinent brief, touched R11's clean gown and touched R11's shoulder and hand before removing her gloves and washing her hands. V11 performed peri care on R11's buttocks with visible bowel movement present on R11's anal area, wiping from buttocks toward perineum. R11 then proceeded to apply clean incontinent brief and bed pad without changing gloves.
On 3/27/2024 at 11:00 am, V12, CNA, stated she should have changed her gloves during peri care after she had touched R11's labia.
On 3/27/2024 at 12:2 V11, CNA, stated that she should have wiped form perineum towards buttocks and that she should have changed her gloves before touching the clean incontinent brief.
The facility's policy titled, Perineal care policy and procedure, dated 11/2016, documented, Cleanse perineal area from front to back and to change gloves between peri care and applying clean incontinent brief.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to refrigerate 4 insulin flex pens prior to opening on 1 of 2 medication carts reviewed for medication storage.
Findings include:...
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Based on observation, interview and record review the facility failed to refrigerate 4 insulin flex pens prior to opening on 1 of 2 medication carts reviewed for medication storage.
Findings include:
On 03/27/24 at 12:50 PM, the medication cart on the 300 hall was reviewed with V4, Licensed Practical Nurse (LPN) and it revealed the following, several unopened and not refrigerated insulin pens; Levemir injectable flex pen, Aspartate flex pen, Humalog, and Basaglar insulin pens . Stickers on all four insulin pens documented, Refrigerate until opened.
On 3/27/2024 at 12:50 PM, V4, LPN, stated that the insulin should be refrigerated prior to opening.
The facility policy Storage of medication, undated, documented Medications requiring refrigeration are to be kept in the locked refrigerator or in a refrigerator in a lockable area.
The facility insulin administration policy, dated 10/2009, documented, Reserved insulin will be kept in the refrigerator.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the Facility failed to ensure meals were served at acceptable temperature and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the Facility failed to ensure meals were served at acceptable temperature and a palatable texture for 4 of 4 residents (R29, R41, R52, R179) reviewed for Dietary Services, in the sample of 33.
Findings include:
1.
On 3/25/2024 at 12:25 PM, R52 was observed poking at a grilled cheese sandwich which was visibly soggy. At this time, R52 stated, Look, it's like they spilled milk on it.
On 3/26/2024 at 9:50 AM, R52 stated, They did it again. Messed up the meal yesterday. I ordered a grilled cheese. It was so soggy you could ring it out.
On 3/26/2024 at 12:50 PM, R52 stated, The pork chop was cold and stiff. It took a long time for me to eat it.
On 3/26/2024 at 12:30 PM, a test tray was delivered. The hashbrown casserole appeared to be a blob of yellow substance and the broccoli was watery and mushy.
The Facility's Week at a Glance menu dated 3/24/2024 documents the noon meal on Monday March 25, 2024 to be served as pineapple glazed ham, baked sweet potato, pea, bread and apple spice cake. It further documents the noon meal on Tuesday March 26th, 2024 documents the meal served was lemon garlic pork loin, hashbrown casserole, broccoli florets, bread and cherry crunch.
2.
On 3/25/2024 at 10:37 AM, V13, R179's daughter in law, stated, The only issue I have is that by the time the food gets here, it's cold. Some things (food) get hard when you warm them up.
R179's Minimum Data Set (MDS), dated [DATE], documented that R179 was cognitively intact.
On 3/26/2024 at 12:30 PM, R179 stated, Sometimes it's hot, sometimes it's not (referring to her meals).
On 3/28/2024 at 9:51 AM, V8, Dietary Manager, stated, The grilled cheese should be crispy.
The Facility's Resident Council Meeting Minutes, dated 12/22/2023, documented, Old Business: Any unresolved issues last month: Residents state meal temperature was improved but could still use improvement at dinnertime and breakfast. It continues to document, Dietary: Residents state dinner and breakfast trays have not been as hot as they would like sometimes.
The Facility's Resident Council Meeting Minutes, dated 1/25/2024, documented, Dietary: Residents state food has been warmer, but some resident would like it to be hotter. Residents state they would like dietary staff to pay closer attention to their preferences on their meal tickets. Residents state they would like their food to match the food on the menu provided and if not to be alerted if there is a change in menu. Sometimes the bread is overcooked and feels too hard. Residents state vegetables are often too soft and overcooked.
The Facility's Resident Council Meeting Minutes, dated 2/23/2024, documented, Old Business: Residents state vegetables are often too soft and overcooked. It continues, Nursing: Residents state they would like CNAs (Certified Nursing Assistant) to pass trays as soon as they arrive and close the metal door between passing each tray to maintain food temperature. It further documents, Residents state food has been warmer, but some residents would like it to be hotter. It continues, Residents state vegetables are still overcooked sometimes. Residents state bread is still overcooked sometimes and arrives hardened.
3. On 03/27/24 at 11:30 AM, R29 stated that she eats in her room. R29 stated that the hot food is never hot. R29 stated that the food does not taste good.
R29's MDS, dated [DATE], documented that R29 was cognitively intact.
4. 0n 3/26/24 at 09:30am, R41 stated that she eats in her room and the food is always cold. R41 stated that she likes eggs over easy and the facility is to put the to put the food on hot plate.
R41's MDS, dated [DATE], documented that R41 was cognitively intact.
The facility was unable to provide a policy.
Feb 2024
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to protect a resident from sexual abuse for 2 of 3 reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to protect a resident from sexual abuse for 2 of 3 residents (R1 and R2) reviewed for sexual abuse in the sample of 6. Based upon a reasonable person's concept, R2 would not have wanted sexual contact without her consent and would have experienced psychosocial harm (e.g., fear, anger, depression, anxiety and humiliation) as a result of the sexual abuse since there is an expectation that R2 would not be sexually abused in the facility.
Findings include:
The facility's report, Report to Illinois Department of Public Health dated [DATE] documents, Initial Report: (R1), 90 y/o (year old) male with a BIMS (Brief Interview for Mental Status) of 7 and (R2), 70 y/o female, with a BIMS of 3 observed in a sexual act in room [ROOM NUMBER]-1 by staff. Staff intervened immediately and residents were separated. Upon initial interview, both parties were consenting. (R2) was assessed for injuries and none noted. After separation and assessment, (R2) attempted to seek out (R1) again. MD (Medical Doctor) and POA (Power of Attorney) for both parties and police have been notified.(R2) was sent to (local hospital) for examination. Investigation initiated. Final report to follow.
On [DATE] at 9:00 AM, R2 was up in her bathroom washing her hands with stand-by assistance verbal cues from V5, Certified Nursing Assistant (CNA). After finishing, she asked, What do I do now? Where do I go? V5 continued to give her verbal cues and R2 walked back to her bed and laid down. She was able to answer short, direct questions during conversation, but was unable to recall going out to the hospital.
R2's Face Sheet, printed [DATE] documents her diagnoses to include: Cirrhosis of Liver, Portal Hypertension, Esophageal Varicies without Bleeding, Type 2 Diabetes Mellitus, Gastrointestinal Hemorrhage, Muscle Weakness, Unspecified Dementia, Unsteadiness on Feet, Unspecified Abnormalities of Gait and Balance, Arteriosclerotic Heart Disease (ASHD), Gastroesophageal Reflux Disease (GERD), Major Depressive Disorder, and Acute Duodenal Ulcer with Hemorrhage.
R2's Minimum Data Set (MDS) dated [DATE] documents R2 is severely cognitively impaired, she is independent with bed mobility and ambulation, and frequently incontinent of urine. This assessment documents R2 did not have any behaviors at time of assessment.
R2's Care Plan, initiated [DATE] documents: (R2) has a dementia diagnoses. Scored a 3 on her BIMS. Goal: (R2) will maintain current level of cognition by review date of [DATE]. Intervention for this care plan documents: (R2) required approaches that maximize involvement in daily decision making and activity.
After the sexual encounter between R1 and R2 occurred, R2's Care Plan was updated with the new focus dated [DATE]:
(R2) has a hyper-sexual and flirtatious behavior towards residents and staff.
Goal: (R2) will have fewer episodes of hyper-sexual and/or flirtatious behaviors by review date
Interventions: Assist (R2) to develop more appropriate methods of coping
and interacting with staff and residents. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with her as passing by.
If reasonable, discuss with (R2) her behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable.
Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed.
(R2) is to have no male caregivers.
Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes.
R2's Progress Note dated [DATE] at 11:30 PM documents, When responding to a call light pressed by 110-2, Staff observed (R1) on his knees at the bedside performing oral sex on Resident. She was holding her left leg up and laughing. Staff immediately separated them and (R1) was escorted from the room. Writer was called to the room. Resident nor (R1) was unable to tell Writer what had just happened. She only continued to laugh and run her fingers through her hair. From the hallway (R1) was yelling for cookies. Earlier today, Resident and (R1) was observed by staff attempting to kiss and hold hands in his room. They were redirected and separated at that time. (R3) (110-2) advised Writer that at 2320, (R1) had wheeled himself into the room, began to talk to Resident and soon started to kiss her leg and private area.
On [DATE] at 8:45 AM R1 was sitting in the w/c in his room. He stated, I feel good. Just keep an eye on me. I don't want anything to happen to me. R1 stated he gets along with his roommate and other residents just fine. He stated, Just keep an eye on me and make sure I do ok. R1 was unable to recall that he had a different roommate a couple days ago or any interaction between him and any female residents.
R1's Face Sheet, printed [DATE], documents his diagnoses as : Type 2 Diabetes Mellitus, Peripheral Vascular Disease, Transient Ishemic Attacks and Cerebral Infarction without Residual Deficits, Abnormalities of Gait and Mobility, Unsteadiness on Feet, Vascular Dementia, ASHD, Insomnia, Cardiac Pacemaker, Anemia, and Hyperlipidemia.
R1's MDS dated [DATE] documents he is severely cognitively impaired (BIMS 7), he is independent with bed mobility, transfers and mobility, uses both a wheel chair (w/c) and a walker, able to walk up to 50 feet.
Care Plan: initiated on [DATE], after sexual encounter with R2, documents :
(R1) has a hyper-sexual and flirtatious behavior.
Goal: (R1) will have no evidence of behavior problems by review date.
Interventions for this behavior care plan initiated [DATE]:
Anticipate and meet (R1) needs.
·
Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him as passing by.
·
If reasonable, discuss behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable.
·
Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed.
R1's Care Plan was reviewed and he had no other Care Plan regarding inappropriate behaviors prior to [DATE].
R1's Progress Note dated [DATE] at 8:14 AM documents, Behavior Note:
Behaviors: Very sexually aggressive to staff. Made several comments to female and male staff that he wanted to kiss it and that they would like it. Non-pharm interventions: Redirected. Writer told Resident that his comments were inappropriate and that he should not say things like that. Writer offered him cookies. Pharm interventions: Summary: Cookie distraction only effective for a short time. Sexual comments resumed. Unable to redirect at this time.
R1's Progress Note dated [DATE] at 11:20 PM documents, Resident found in room [ROOM NUMBER]. He was engaged in inappropriate sexual behavior with a female Resident of that room. They were immediately separated and he was placed in 1:1 supervision at the nurse's station.
On [DATE] at 8:15 AM, V3, Assistant Director of Nursing (ADON) stated they currently have an investigation going on regarding sexually inappropriate behavior between a male and female resident who were caught during a sexual act. She identified the residents as (R1) and (R2). V3 stated both of these residents have dementia and neither are alert and oriented . V3 stated according to the staff who witnessed it, neither of the residents were resisting and both were enjoying it, and R2 was giggling. V3 stated the staff who initially witnessed the incident, V9, CNA, observed (R1) in (R2's) room and he was performing oral sex on her and she was holding one of her legs up in the air. V3 stated the two residents were separated immediately and the administrator, police, MD and families were notified. V3 stated (R2) was sent to the emergency room for evaluation and she returned with no new findings. V3 stated (R2) was seeking (R1) out before she even left for the hospital. V3 stated (R2) ambulates independently and (R1) mostly uses his w/c but is able to ambulate also. V3 stated 1:1 were started immediately. V3 stated when (R2's) son was notified, he stated he is not surprised that she is the instigator. She stated (R1) does not have a POA, just an emergency contact and she just said ok when she was notified. V3 stated since the incident the residents have been kept separated. She stated a few days before the incident, (R2) was started on Trazadone due to not sleeping well . V3 stated a side effect of Trazadone in women can be increased sexual drive and they think this might be why (R2) was sexually inappropriate. V3 stated (R2) has been on 1:1, because she is ambulatory. V3 stated yesterday (R2) was very flirtatious and (R1) was not paying attention to her. V3 stated they are looking into a memory care unit for (R2) to go to.
On [DATE] at 10:07 AM , V14, R2's son, during phone interview, stated he received a call Sunday night from the facility to inform him his mother (R2) and a male resident were doing something sexual in her room and she was sent to the hospital to get checked out. He stated he received a call from a nurse at the hospital who stated they didn't find anything, and then the nurse from (the facility) called and let him know she was back in the facility and they had settled her in. V14 stated (V3), ADON followed up with him by phone later and let him know a man had entered (R2's) room and his mother was participating in a sexual act and was not resistant to what was going on. V14 stated his mother has no clue what is going on and if she was in her normal state of mind she would never had participated in sexual activity with that man. He stated his father just passed away in November and (R2) does not even remember him or that he died. V14 stated his mother did not recognize him the last time he visited. He stated the facility is keeping the two of them separated. V14 stated he has not seen any sexually inappropriate behaviors from his mother before. He stated she is happy go lucky, always laughing and giggling. He stated this person is not the mother he knew. He stated it is heartbreaking because his mother would never have done this when she was in her right mind.
On [DATE] at 9:40 AM V10, Licensed Practical Nurse (LPN) stated she worked the 200 hall from 7:00 PM until 11:00 PM and then picked up both 100 and 200 Halls for rest of night shift from [DATE] to [DATE]. V10 stated the CNAs on the 100 Hall, (V8) and (V9), called her to (R2's) room. She stated by the time she arrived to the room, (R1) was sitting in his w/c in the hall, and the CNAs were in (R2's) room trying to get her settled down back into bed because (R2) was trying to get up and come out into the hall. V10 stated she asked (R1) what happened and he just asked for cookies and was unable to tell her what happened. She stated the CNAs reported when they went into (R2's) room to answer the call light, (R1) was on his knees next to (R2's) bed. V10 stated up until that morning ([DATE]) the most she heard (R1) say was ,Nurse, give me some cookies. She stated on that morning, prior to this incident, around 5:00 AM, he was saying to her, Just let me lick it and you'll like it repetitively. V10 stated she tried to redirect him and he finally went to his room and went to sleep. V10 stated she returned to work at 7:00 PM and received report from the day shift nurse that (R2) was in (R1's) room and had to be redirected out of his room. She stated (V12), the day shift nurse said (R2) was leaning over (R1) at the time and close to his face, either whispering or trying to kiss him. V10 stated (R1) usually only comes out of his room occasionally to go to the nurses station or the day room, but she had never seen him go into other resident's rooms. V10 stated on the night of the incident between (R1) and (R2), (R2's) roommate, (R3) had put on the light and V10 went back in to talk to her after (R1) and (R2) were separated and (R1) removed from (R2's) room. V10 stated (R3) told her she saw (R1) come into their room, and he kissed (R2) on the leg and then started having oral sex with her. She stated she asked (R3) if she was alright and (R3) stated yes and that she thought maybe (R2) was just lonely. She stated (V3), ADON, asked her if the sexual contact between (R1) and (R2) was forced and V10 stated she informed her, No (R2) was holding her leg up during the incident. V10 stated it appeared consensual but neither (R1) or (R2) have the cognitive ability to give consent as they are both confused.
On [DATE] at 10:15 AM V3, ADON, stated she was first notified of the incident between (R1) and (R2) from (V1), Administrator around 11:30 PM on Sunday night. She stated later the nurse called and told her . V3 stated she was the wound nurse prior to being ADON and had never heard (R1) make sexual comments to anyone. She stated the incident between (R1) and (R2) was consensual, but neither (R1) nor (R2) have the cognitive capacity to consent. She stated the facility does not have an assessment to determine if a resident has the ability to consent, but both (R1) and (R2) are severely cognitively impaired.
The facility's policy, Resident Care Policy and Procedure Regarding Abuse and Neglect, Involuntary Seclusion, Exploitation, Misappropriation of Resident Property, Injuries of Unknown Origin, and Social Media, revised [DATE] documents, This facility, for the protection of the residents, utilizes the seven stages of the CMS STRIIPP abuse prevention protocol. These stages include: S, screening potential hires, T, training new and existing employees; R, reporting of incidents, investigations, and facility response to the result of the investigations; I, identification of possible incidents or allegations which need investigation; I, investigation of incidents and allegations; P, protection of residents during investigations; and P, Prevention policies and procedures. 1. All residents have the right to be free from verbal, sexual, physical, mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation. 2. All residents have the right to personal privacy of not only their own physical body; but also of their personal space, including personal care, and living accommodations. 14. Sexual abuse is non-consensual sexual contact of any type which includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Sexual coercion shall include any intentional or knowingly touching or fondling a non-consenting resident's sex organs, anus or breast either directly or through clothing for the purpose of sexual gratification or arousal of the accused. 3. All staff are trained that a facility will treat all residents with respect and dignity, promote and protect the rights of all residents and recognized their individuality. 4. All staff will have training on dementia management and abuse prevention.
Nov 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to provide supervision for 1 of 5 residents (R2) reviewed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to provide supervision for 1 of 5 residents (R2) reviewed for dining assistance in the sample of 9.
Findings include:
On 11/14/23 at 8:05 AM, R2 is in her bed with the head of bed up at 45 degrees. R2 has her breakfast tray in front of her. She has scrambled eggs in between her biscuit halves for a sandwich. She has eaten only a small amount. She has spilled her coffee cup onto the tray. She has a small glass of orange juice and a bowl of oatmeal which she has not touched. Her silverware was still wrapped in the paper napkin which is soaked with coffee which she spilled. R2 has no staff with her in the room.
On 11/14/23 at 10:50 AM, V5, Certified Nurse Aide, stated that R2 has a very poor appetite. R2 needs a little assistance with meals because she has poor eyesight. Sometimes she is alert and other times confused.
On 11/14/23 at 1:35 PM, V3, Assistant Director of Nurses, stated that R2 should be supervised while she is eating.
On 11/14/23 at 2:00 PM, V3, stated that the facility does not have a policy on dining assistance.
R2's admission Profile, print date of 11/14/23, documents that R2 was admitted on [DATE] and has a diagnosis of Palliative Care.
R2's November 2023 Physician Orders documents, Admit to Hospice dx, (diagnosis), aspiration pneumonia. Regular diet, regular texture, thin liquids.
R2's Minimum Data Set, (MDS), dated [DATE], documents, that R2 is cognitively intact and requires limited assist of 1-person physical assist with dining.
R2's Significant Change MDS, dated [DATE], documents that R2 is mildly cognitively impaired.
R2's current Care Plan documents, I (R2) am at risk for an ADL, (Activity of Daily Living), Self-Care Performance Deficit r/t, (related to), Activity Intolerance, Confusion, Fatigue, Impaired balance Date Initiated: 07/20/2023. Intervention: EATING: I require SUPERVISION/SETUP assistance of one staff participation to eat. Date Initiated: 07/20/2023 Revision on: 07/20/2023.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a palatable meal for 3 of 9 residents (R1, R5, R9) reviewed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a palatable meal for 3 of 9 residents (R1, R5, R9) reviewed for dining services in the sample of 9.
Findings include:
1. On 11/14/23 at 8:10 AM, R5 stated, The food sometimes is cold by the time we get it.
R5's admission Profile, print date of 11/14/23, documents R5 was admitted on [DATE] and has Type 2 Diabetes and Hypertension.
R5's Minimum Data Set (MDS), dated [DATE], documents R5 is cognitively intact.
2. On 11/14/23 at 8:30 AM, R9 stated that her tray was cold when it was served to her, but they did heat it up in the microwave this morning. R9 stated the food is ok.
R9's admission Profile, print date of 11/14/23, documents that R9 was admitted on [DATE] and has diagnosis of Parkinson's Disease.
R9's MDS, dated [DATE], documents that R9 is cognitively intact.
3. On 11/14/23 at on 11/14/23 at 8:07 AM, R1 is sitting in her recliner. R1's breakfast tray is still covered. R1 stated that she is not hungry this morning. R1 stated, I eat in my room mainly for breakfast and yes the food is cold sometimes.
R1's admission Profile, print date of 11/14/23, documents that R1 was admitted on [DATE] and has diagnoses of Parkinson's Disease, Dementia, and encounter for Palliative Care.
R1's admission MDS, dated [DATE], documents that R1 is severely cognitively impaired and requires set up assistance for meals.
On 11/14/23 at 11:45 PM, V4, Dietary Manager, stated she does do a Resident Council for food. She stated that she talks to the residents to see how the food is tasting and she has some pretty vocal ones so she usually knows how it is tasting. V4 stated, We have been working on food temperatures because it has been a problem. I have been here for 3 months, and it is getting better.
The Food Committee Minutes, dated 10/26/23, documents, Residents state meals continue to come to them cool or lukewarm, mornings and evenings specifically. *Much better but still room for improvement.
Aug 2023
1 deficiency
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to provide the services of a Registered Nurse (RN) for 8 consecutive hours a day seven days a week. This had the potential to affect all 81 res...
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Based on interview and record review the facility failed to provide the services of a Registered Nurse (RN) for 8 consecutive hours a day seven days a week. This had the potential to affect all 81 residents residing in the facility.
Findings include:
On 8/1/2023 at 11:00 AM V2, Director of Nursing (DON), states she does not have an RN for 8 consecutive hours 7 days a week. V2 states she tries to work extra hours to provide the RN coverage, but she can only do so much.
On 8/1/2023 at 11:00 AM V4, Licensed Practical Nurse (LPN) states that the facility does not have 8 consecutive hours of an RN 7 days a week.
On 8/1/2023 at 2:30 PM V1, Administrator states they have been working on RN hours and they thought they had the RN hours required. V1 reviewed the nursing schedules and agreed that the facility did not have 8 consecutive hours of RN coverage on the dates of 6/2/2023, 6/7/2023, 6/8/2023, 6/12/2023, 6/13/2023, 6/16/2023, 6/22/2023, 7/11/2023, 7/12/2023 and 7/13/2023.
Staffing schedules reviewed and noted no Registered Nurse scheduled on the dates of 6/2/2023, 6/7/2023, 6/8/2023, 6/12/2023, 6/13/2023, 6/16/2023, 6/22/2023, 7/11/2023, 7/12/2023 and 7/13/2023.
The facility's Resident Census and Conditions of Residents form, CMS 672, dated 8/3/2023 documents that the facility has 81 residents living in the facility.
.
Apr 2023
6 deficiencies
2 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to implement intervention to prevent, timely identify, an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to implement intervention to prevent, timely identify, and monitor pressure ulcers for 2 of 5 residents (R3, R113) reviewed for pressure ulcers in the sample of 31. This failure resulted in R113 developing an unstageable pressure ulcer to her right buttocks five days after admission.
Findings include:
1. R113's Order Summary Report, dated 4/18/23, documents that R113 was admitted on [DATE] with diagnoses of a fracture of left femur, Type 2 Diabetes Mellitus and Peripheral Vascular Disease.
R113's Nurse (N) Advance (Adv) -Clinical admission Form, dated 4/13/23, documents, R113 arrived at the facility via transport another facility. The Form documented R113 used a wheelchair. It continues, Resident is alert & (and) oriented x (times) 3. Oriented to place. Oriented to time. Oriented to person. The Form documented that R113 had a pressure ulcer/injury to R113's left buttock measuring 3.2 centimeters (cm) length by 2.8 cm width.
R113's N Adv - Braden Scale for Predicting Pressure Ulcer Risk Evaluation, dated 4/13/23, documents, Braden Evaluation: Sensory Perception: No impairment. Moisture: Occasionally moist. Activity: Chairfast. Resident is Slightly Limited: Makes frequent though slight changes in body or extremity position independently. Nutrition: Adequate. Friction and shear: Potential problem. N Adv - BRADEN Score: 17.0.
R113's Health status Note, dated 4/17/23, documents, Resident seen today in facility by (V18 Nurse Practitioner) with New orders for: Facility wound doctor to evaluate and treat for left buttocks wound - (pressure relieving) cushion on wheelchair and bed -Patient requesting bariatric bed.
On 4/17/23 at 10:05 AM, R113 was lying in bed with a knee immobilizer on. R113 was on a regular mattress and has no side rails for turning and repositioning. R113 stated that she was recently admitted because she broke her femur above her below the knee amputation, she is a diabetic and goes to renal dialysis 3 times a week. R113's stated that she believes she has a wound on her buttocks. R113 stated, I think I got it here. I have been asking for a better mattress and side rails, but I haven't gotten either yet. I really want the side rails so I can turn and reposition myself. It is hard to move with this knee immobilizer on.
On 4/18/23 at 8:10 AM, R113 was lying in bed. R113 has the same mattress as 4/17/23 and no side rails on her bed. R113 stated, The nurse last night found a new area on my buttocks. She called the doctor, and he wants me to have a CT (Computerized Tomography) scan.
On 04/18/23 at 12:56 PM, V11, Licensed Practical Nurse (LPN), Wound Nurse, stated, She (R113) developed an in-house pressure ulcer to her right buttock., The night nurse called (V16, Physician), and he said send her to ER (Emergency Room) and get a CT. I think he was half asleep because it was in the middle of the night the wound is 2 (centimeters) x (by) 2. (R113) did not want to do that. This morning I called him, and he wants an Xray to rule out osteomyelitis. I contacted our wound doctor, (V17 Wound Doctor), and got orders for a sheet of thera honey and cover with a dry dressing bid (twice a day). I looked into her history because she has been here before and last time, she had a pressure ulcer in the same spot.
R113's Health Status Note, dated 4/18/23 at 06:34 AM, documents, Resident has open area to right buttocks, 3cm x 3cm, heavy dark serosanguinous drainage with foul odor noted, resident c/o (complaint of) pain 7 out of 10, notified PCP (Primary Care Provider), rcvd (received) an order to send resident to ER for CT scan and rcvd a referral order to see Wound MD for eval (evaluation) and tx (treatment), resident made aware of n.o. (new order)
R113's Health Status Note, dated 4/18/23 at 09:05 AM, documents, Wound MD gave order to cleanse right upper buttock with wound wash and pat dry and then apply thera honey sheet to right upper buttock and cover with dry dressing twice daily.
R113's Health Status Note, dated 4/18/23 at 2:05 PM, documents, Received call from (V18) who states no need for CT or x-ray since wound isn't open and just continue with her orders for pressure relief equipment, resident currently has air loss mattress on bed with bariatric bed and side rails.
R113's Ulcer / Wound documentation, dated 4/18/23, documents that R113 has an unstageable pressure ulcer on her right buttock that measures 2 centimeters x 2 centimeters that has moderate serous drainage.
On 4/18/23 at 9:00 AM, V11 Wound Nurse, entered R113's room to change R113's right buttock pressure ulcer dressing. R113 was rolled onto her left side. V11 removed the old dressing that was on the right buttock. R113 stated that removing the dressing hurt the pressure ulcer. The dressing had a moderate amount of black, brown drainage on it. The wound was the approximate size of a quarter. The peri wound was red. The wound bed was black.
2. R3's admission Profile, print date of 4/19/23, documents that R3 was admitted on [DATE] and has diagnoses of Metabolic Encephalopathy and Epilepsy.
R3's Hospice Admitting Orders, dated 4/4/23, documents admitted to hospice on 4/4/23 with severe protein malnutrition. Activity: bedrest turn every 2 hours. Skin Care Orders: Clean open areas twice daily.
R3's Minimum Data Set, dated [DATE], documents that R3 is severely cognitively impaired and requires extensive assistance of 1 staff member for bed mobility.
R3's Braden Scale for predicting pressure ulcers, dated 4/4/23, documents that R3 is at high risk of developing a pressure ulcer.
R3's Hospice Nursing Initial Comprehensive admission Assessment, dated 4/4/23, documents that R3 has a coccyx Stage 2 pressure ulcer measuring 1 cm x 1 cm x 0.1 cm with a pink bloody wound bed and a right heel pressure ulcer that is unstageable that measures 2 cm x 3 cm.
R3's Ulcer / Wound documentation, dated 4/12/23, documents that R3 has an unstageable pressure ulcer to the sacrum that measures 2 cm x 2 cm.
R3 Medical Record fails to document on R3's right heel pressure ulcer on 4/12/23.
R3's Ulcer / Wound documentation, dated 4/19/23, documents that R3 has a Stage 2 pressure ulcer to the sacrum that measures 3 cm x 2.5 cm.
R3's Ulcer / Wound documentation, dated 4/19/23, documents that R3 has an unstageable Pressure ulcer of the right heel measuring 3.5 cm x 4 cm, the wound bed is Necrotic tissue and that the pressure ulcer was first identified on 4/19/23.
R3's Ulcer / Wound documentation, dated 4/19/23, documents that R3 has a deep tissue injury on the right lateral foot measuring 0.5 cm x 0.5 cm that was first identified on 4/19/23.
R3's Physician Orders, print date 4/11/23, documents, Monitor black area of right heel start date of 4/11/23, Cleanse open area to coccyx with soap and h2o (water) or saline apply optifoam drsg (dressing) change every 5 days and PRN (as needed) when soiled or dislodge start date of 4/4/23, Resident may stay in bed and turn and reposition q (every) 2hrs (hours) start date of 4/4/23.
On 4/18/23 at 3:10 PM, V11, Wound Nurse, stated, (R3) has not had her right heel measured. She got that wound while she was in the hospital, but I cannot find any documentation of that. She came back from the hospital on hospice, and they ordered just to monitor the wound. (R3's) son is a doctor and he does not want any treatment done to her pressure ulcers.
On 4/19/23 at 2:10 PM, V11, stated that R3's right heel was never measured because the pressure ulcer was not put onto the 24-hour report, so I didn't know about it. Pressure ulcers should be measured every week at least.
On 4/19/23 at 8:25 AM, R3 is lying on her back with the head of the bed elevated 20 degrees. R3 is wearing bilateral heel boots. The right foot is in the middle of the boot not in the heel pocket of the boot.
On 4/19/23 from 8:25 AM to 11:20 AM, based on 15 minute or less interval observations R3 was not given the benefit of turning or repositioning to relieve pressure.
On 4/19/23 at 11:20 AM, V21, Certified Nurse's Aide, entered R3's room to provide incontinent care. R3's incontinent brief was removed. R3's buttocks were red with crease marks on it. R3's back was red with crease marks on it also. At that time, R3 was wearing bilateral heel boots. R3's right foot was in the middle of the boot not in the heel pocket. At 11:30 AM, V11 and V12 both LPNs entered the room to change R3's sacrum pressure ulcer dressing and to exam R3's right heel. The sacrum pressure ulcer measured 3 cm x 2.5 cm. The wound bed is covered in 50% slough and the other 50% is red tissue. The pressure ulcer was cleansed with wound cleanser and a border foam dressing was applied. R3's bilateral heel boots were removed. R3's right heel has a dark black necrotic pressure ulcer measuring 3.5 cm x 4 cm. R3's right lateral foot has a pressure ulcer measuring 0.5 cm x 0.5 cm that is black and necrotic. R3's left heel has an area that is dark pink the approximate size of a quarter. R3's heel boots were reapplied.
On 4/19/23 at 11:30 AM, V12, LPN, stated, I have not been here in 4 days the last time I saw her heel it was just red. It was about the same size. V12 further stated that R3's left heel is soft.
On 4/19/23 at 11:30 AM, V11, LPN, stated, I have not seen her heel until now. I am going to call hospice and see about getting her a pressure relief mattress. The interventions (to prevent pressure ulcers) for her are her boots and turning and repositioning. V11 was questioned if he knew about the area on the outside of R3's right foot before it was noticed it by the surveyor, V11 stated that he did not know about it until it was pointed out.
On 4/19/23 at 4:10 PM, V2, Director of Nurses and V20, Regional Nurse, both stated that they expect pressure relieving devices to be put into place for a resident at risk for pressure ulcers and used correctly, turning and repositioning should be done, measuring of the pressure ulcer should be done weekly or if there is a worsening of the pressure ulcer and no one should sustain a pressure ulcer while they are at the facility. V20 further stated that since it was known that R113 had previous pressure ulcers R113 should have had a preventative mattress and side rails to aide in repositioning as soon as possible.
The policy Wound & Ulcer Policy and Procedure, dated 1/10/2018, documents, Wound & Ulcer Policy and Procedure. It is the policy of this facility to provide nursing standards for assessment, prevention, treatment, and protocols to manage residents at any level of risk for skin breakdown and for wound management. Procedure: All residents will be assessed to determine the degree of risk of developing a pressure ulcer using the Braden Scale - Ulcer risk Assessment. the resident will be assessed upon admission, once a week for four weeks, and monthly thereafter. Protocols may include any or all of the following based upon the needs and condition of the resident. Additional measures may be added at the discretion of the facility. High Risk Protocol: Residents with existing ulcers will be deemed as high risk for impaired skin integrity despite the Braden Risk Assessment Score. Daily skin checks completed by direct care staff. The Skin Observation Report may be used to communicate skin observation or changes to the nurse. Specialty mattress (low air loss, alternating pressure, etc.) with enhanced pressure reducing / relieving properties may be placed on the resident's bed and chair as indicated. Skin contact surfaces may be padded to protect boney prominences. Range of motion may be provided if clinically indicated. The resident may be placed on a turn and position schedule if clinically indicated. It continues, When a resident is found to have a wound our licensed nurse will complete ulcer, either on admission or during their stay, the following: Document assessment of the wound / ulcer in the medical record. Initiate the treatment protocol appropriate for the stage of ulcer or for the wound assessed. The classification and treatment of wounds, including ulcers, will follow the wound management program protocols for the wound type / ulcer stage assessed unless otherwise specified by the physician. Document wound / ulcer treatment provisions on the treatment administrations record. It continues, Assessment of progress toward healing in completed at least weekly and the physician is notified at least monthly of progress toward healing. If there is regression, the physician is notified of the condition change.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to monitor, provide progressive intervention, implement 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 monitor, provide progressive intervention, implement dietician recommendations, and encourage the resident to eat or offer substation for 1 of 6 residents (R40) reviewed for weight loss. This failure resulted in R40 having a19% weight loss in 3 months and a 23.8% weight loss in 6 months.
Finding includes:
R40's Care Plan, dated 09/20/2021, documented, Eating: supervision with set up/clean up assistance.
R40's Minimum Data Set, dated [DATE], documented that R40 required supervision with 1-person physical assistance for eating.
On 04/17/2023 at 12:31 PM, R40 was in bed with the head of her bed elevated and her meal tray sitting in front of her, with the lid off. On her tray was a piece of ham, not cut up, a baked sweet potato, without any butter nor was it cut up, a biscuit, not buttered or cut up and green beans. R40 had not eaten any food on the tray. R40 had some broken front teeth and 1 tooth totally intact. From 12:30 PM to 1:30 PM R40's room was under continuous observation. No staff member entered nor was any eating encouragement given.
On 04/17/2023 at 01:30 PM, V13, Certified Nurse's Assistant picked up R40s tray and placed it on the hall cart. When asked how much R40 consumed of her meal, V13 stated that she only took a couple of drinks but didn't touch her food. R40's meal tray was covered with a dome and under dome was a piece of ham, not cut up, a baked sweet potato, not cut up, biscuit and green beans.
On 04/19/2023 at 12:05 PM, a staff member served R40 her lunch tray. The staff member cut up R40's meat, pepper steak, buttered her biscuit and made sure all of her lids to her drinks were off. At 12:10 PM, R40 was sitting at the table and had not even took a bite of her food or a drink of any of her fluids. No staff members approached her to give her verbal cues to remind her to eat. Then at 12:15 PM, R40 was still sitting at the dining room table and had not even attempted to feed herself nor did any of the staff members assist or cue her to eat. At 12:20 PM, V13 asked R40 if she wanted to drink her milk and she told him she wanted chocolate milk. V13 went and retrieved a carton of milk for her, opened it and poured it in a cup with a handle. He then handed it to her, and she started to drink it. At 12:30 PM, R40 drank most of her chocolate milk but no staff gave her any verbal cues to eat or offer any other substations for her meal.
On 04/19/2023 at 02:00 PM, R40 stated that she did not care for the lunch today when she was asked.
R40's weight log documented weights on 05/12/2022 as 161.7 and on 08/08/2022 at 143.6 pounds as this was a 11.19% weight loss in three months.
R40's weight log documented weights on 10/01/2022 as 158.4 and on 03/31/2023 as 120.7 pounds as this was a 23.8% weight loss in six months.
R40's Dietician's Note, dated 05/23/2022 at 2:11 PM, documented, Nutrition Note Text: RD monthly weight note: Current weight is 161.7# (5/12/22). Weight is stable over the past month from 162#(4/5/22). She continues to trigger for significant wt. (weight) loss. Weight is down 11.6%(21.3#) over the past 5 months from 183#(12/8/21). BMI (Body Mass Index) is 27.8 (overweight but acceptable per age). Diet is LCS (low concentrated sweets) with thin liquids. She feeds herself. Intake has been variable lately due to AMS/confusion/hallucinations. often poor <25%. increased behaviors noted. Variable intake meal to meal with some refusals. Weight loss likely r/t (related to) confusion and hospitalization. Supplements include 60 ml (milliliters) med (medication) pass TID (three times daily) which were recently increased. Blood glucose levels have ranged 88-184mg(milligrams)/dL(deciliter) the past month. Skin: No edema noted. meds reviewed Continue to encourage adequate intake. increase supplements. liberalize diet. Monitor nutritional parameters. RD (registered dietician) f/up (follow-up) PRN (as needed).
R40's Dietary note, dated 05/31/2022 at 10:27 AM, documented, Note Text: 5 day completed. (R40) is currently on a LCS (low concentrated sweets) diet with thin liquids and is receiving 60cc (cubic centimeters) med (medication) pass TID (three times daily). She consumes varies amounts of her meals but lately 0-25% with an average fluid intake of 360ml per meal sometimes more. Her current weight is 161.7 pounds with BMI of 27.8. Dietary will continue to provide ordered diet, monitor her weight, monitor her for her changing needs, and refer her to the dietitian PRN (as needed).
R40's Dietician's Note, dated 08/10/2022 at 1:33 PM, documented, Nutrition Note Text: RD monthly weight note: Current weight is 143.6#(8/8/22). 146.5#(7/6/22) Weight is down 16.7% over the past month 6 months from 172.4#(2/11/22). wt. hx (weight history): 153.9#(6/9/22); 169.5#(1/20/22). Weight has continued to decline. BMI is 24.6(WNL). Intake is poor and she has been refusing to eat. Diet remains LCS with thin liquids. She feeds herself. Intake has been variable lately due to AMS/confusion/hallucinations. often poor <25%. increased behaviors noted. Variable intake meal to meal with many refusals. Weight loss likely r/t confusion and poor appetite. Supplements include 90ml med pass TID. Blood glucose levels have been acceptable most often this past month.
Rec adding high protein ice cream with meals and liberalize diet to regular.
Skin: No edema noted. meds reviewed Continue to encourage adequate intake. continued increased supplements. offer between meal snacks. Monitor nutritional parameters. RD f/up PRN.
R40's Dietary Note, dated 10/10/2022 at 11:23 AM, documented, Dietary Note Text: readmission completed. (R40) is currently on a cardiac diet with thin liquids. She is consuming 51-75% of her meals with an average fluid intake of 241ml-480ml per meal. Her current weight is 158.4 pounds with a BMI of 27.2. Dietary will continue to provide order diet, monitor her weight, monitor her intakes, and refer her to dietitian PRN.
R40's Dieticians Note, dated 02/28/2023 at 08:30 AM, documented, Nutrition Note Text: RD Wt. (weight)/Skin Note: Stage 3 pressure injury to sacrum. Previously healed in August but has reopened per DON. Tx (Treatment) in place. Current Ht-64, Current Wt-122.2#, BMI-21.0 Noted higher wts on 1/3 and 2/1 likely scale errors. Nursing to review wt. and reweigh to confirm loss. CBW is a 12.6% loss x 5 mo. Also noted a 17.9% loss x 2 mo (months) (12/6 wt.=148.8#). Poor PO noted at many meals. Fluid changes w/ CHF (Congestive Heart Failure) and diuretic rx (medication) could also influence wt. BMI is healthy and wt within IBW range. Further wt loss not desirable for resident. Diet Rx: NAS (no added salt)/reg/thin, 60ml med pass TID. Many intakes <25%, but a few meals in 26-75% range. No chew/swallow concerns noted. 2/10 Hgb A1c 5.3. Recent D/C of DM meds and accuchecks per MD. Will cont. to monitor A1c. Recommend 30ml liquid protein AWC d/t stage 3 wound. Due to wt. loss and poor PO, suggest MD consider addition of appetite stimulant. Diet/supplements adequate to meet/exceed needs and support healing. RD prn.
R40's Progress notes were reviewed and there was not documentation that R40's physician was notified of weight loss, nor was it documented about asking for an appetite stimulant.
R40's Dietician Notes, dated 03/22/2023 at 12:07 PM, documented, Nutrition Note Text: RD Wt/Skin Note: Stage 3 pressure injury to sacrum. Previously healed in August but has reopened per DON. Tx in place, improving per most recent Wound MD review. Current Ht-64, Current Wt-122.8#, BMI-21.1. Per Wt Exception Summary wt loss of 22.5% from wt on 10-1-22. Wt stable x 1 mos. Poor PO noted at many meals. Fluid changes w/ CHF and diuretic rx could also influence wt. BMI is healthy and wt within IBW range. Further wt loss not desirable for resident. Diet Rx: NAS/reg/thin, 60ml med pass TID. Many intakes <25%, but a few meals in 26-75% range. No chew/swallow concerns noted. Recently began receiving 30mL Liquid PRO daily. Meds reviewed, no nutrition-related med changes since last RD review. No recent labs available to review. Diet and supplements exceed estimated needs and are appropriate to support skin healing. RD will continue to monitor and f/u PRN.
On 04/19/2023 at 02:20 PM, V10, Dietary Manager stated that R40 was placed on Med Pass 3 times a day on 12/22/22 they have been trying to stabilize her weight since then. She also stated that R40's meal intake has been decreased. V10 continued to state that R40 is not one of the residents that the normally watch or assist. V10 continued to state that she reviews weights weekly looking for a 5% to 10% weight gain or weight loss and then sends a report to the nurse management team and the dietician.
On 04/20/2023 at 10:00 AM, V24, Dietician, stated that nursing should have assisted R40 with her meals and that R40's weight loss has slowed down and has been minimized.
On 04/20/2023 at 11:10 AM, V26, Certified Nurse Assistant (CNA) stated that it depends on R40's mood if she wants to eat or not but she likes to drink. V26 continued to state that R40 does require verbal cueing to eat her meals.
On 04/20/2023 at 11:15 AM, V27, CNA, stated that R40 requires assistance with eating her meals.
On 04/20/2023 at 10:05 AM V2, Director of Nurses stated that the staff should assist R40 if she is not eating or offer substitutes. V2, stated that she did not know that the Dietician recommend that R40 be on an appetite stimulant because she was not here at the facility at that time, but she will look into it.
The Facility's policy, Weight Management Policy and Procedure, dated 2/2016, documented, Any resident with a significant or insidious weight change will be referred to the dietitian for assessment of condition. The dietitian will implement any necessary clinical interventions or make recommendations regarding diet and supplementation to the physician. The physician will be notified of any significant weight change and be made aware of any recommendations made by the dietitian.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to answer call lights timely to address residents needs for 6 of 18 re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to answer call lights timely to address residents needs for 6 of 18 residents (R15, R23, R35, R59, R27 and R162) reviewed for dignity in a sample of 31.
Findings include:
1. On 04/18/2023 at 10:00 AM, R15 stated that call lights aren't answered within 20 minutes, and it isn't just one certain shift, it is all the time.
R15's Minimum Data Set (MDS), dated [DATE], documented that her cognition was intact.
2. On 04/18/2023 at10:00 AM, R23 stated that call lights aren't answered within 20 minutes, and it isn't just one certain shift, it is all the time.
R23's MDS, dated [DATE], documented that her cognition was intact.
3. On 04/18/2023 at 10:00 AM, R35 stated that call lights aren't answered within 20 minutes, and it isn't just one certain shift, it is all the time.
R35's MDS, dated [DATE], documented that her cognition was moderately impaired.
4. On 04/18/2023 at 10:00 AM, R162 stated that call lights aren't answered within 20 minutes, and it isn't just one certain shift, it is all the time.
R162's MDS, dated [DATE], documented that her cognition was intact.
5. On 04/17/2023 at 01:36 PM R27 stated that it takes a long time, over 45 minutes sometimes, for them to answer her call light.
R27's MDS, dated [DATE] documented that her cognition was intact.
6. R59's admission Record, print date of 4/19/23, documents that R59 was admitted on [DATE] and has diagnoses of a fracture of upper and lower end of left fibula and a fracture of left talus.
R59's MDS, dated [DATE], documents that R59 is cognitively intact.
On 04/17/23 at 10:45 AM, R59 stated that The night crew usually takes 60 minutes sometimes it can take up to 2 hours. I have even had to call up to the desk to have someone come and help me because I just got tired of waiting.
On 04/20/2023 at 11:10 AM, V26, Certified Nurse Assistant (CNA) stated that call lights should be answered immediately.
On 04/20/2023 at 11:20 AM, V27, CNA stated that they answer call lights as quick as they can.
On 04/20/2023 at 10:05 AM, V2, Director of Nurses, stated that she expected the staff to answer call lights timely.
Resident Council Meeting minutes, dated 01/26/2023, documented, Nursing/CNAs- CNAs are slow to answer calls, need more staff.
Resident Council Memorandum, dated 01/26/2023, documented, Issue Slow answering calls- need more staff. There was no response documented as to what the facility would do about these issues.
The Facility's Policy, Call Light, dated 08/01/2005, documented, 1. Answer call light promptly.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on interview and observation, the facility failed to serve food in a manner which prevents potential food borne illness for 4 of 72 residents (R13, R18, R53, R59) reviewed for food sanitation in...
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Based on interview and observation, the facility failed to serve food in a manner which prevents potential food borne illness for 4 of 72 residents (R13, R18, R53, R59) reviewed for food sanitation in the sample of 31.
Findings include:
On 4/18/23 at 12:25 PM, V9, Dietary Aide, was observed serving lunch from the 300-hall service kitchen. The lunch was a taco salad and Spanish rice. V9 was observed wearing a pair of gloves. V9 reached into a tortilla chip bag and got a handful of chips and placed them on a plate, then got a scoopful of taco meat and placed the meat on the chips. With the same gloves, V9 reached into a small pan of shredded lettuce and placed it on the meat, then reached into a bag of shredded cheese and placed the cheese on the lettuce and then reached into a pan of chopped up tomatoes and placed that on top. V9 then placed a ladle of Spanish rice onto the plate. V9 repeated the process serving the regular diet, the mechanical diets using her hands without changing gloves. She served R13, R18, R52, and R59.
On 4/18/23 at 1:00 PM, V9 was questioned about what type of training she had received for kitchen sanitation, V9 stated, I haven't had any training.
On 4/19/23 at 1:30 PM, V10, Dietary Manager, stated that the facility does not have a policy on food service and that she expects staff to use serving utensils with all foods and not using the same gloves between foods.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected most or all residents
Based on interview, observation and record review, the facility failed to date an opened vial of insulin and dispose of expired medication. This failure has the potential to affect all 72 residents re...
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Based on interview, observation and record review, the facility failed to date an opened vial of insulin and dispose of expired medication. This failure has the potential to affect all 72 residents residing in the facility.
Findings include:
1. On 4/18/23 at 1:58 PM, V7, Licensed Practical Nurse (LPN), medication cart was observed. R114's Lispro 3 milliliter (ml) vial was open and undated.
2. On 4/18/23 at 3:10 PM, 300-Hall Medication Room was observed. In the mini refrigerator there were expired stock Acetaminophen suppositories. There were 12 Acetaminophen 650 milligrams (mg) suppositories dated 3/23 and 2 Acetaminophen 650 mg suppositories dated 9/22 which could be used for all residents in the facility.
The facility's Physician Protocol, undated, documents, Mild Discomfort or fever greater that 101.0 Fahrenheit: Acetaminophen 325 mg 2 tablets by mouth every 4 hours prn (as needed). May use suppositories if unable to take orally. (House Stock).
On 4/18/23 at 3:15 PM, V2, Director of Nurses, DON, stated, All expired medications should be thrown away, open vials should be dated the day that they were opened and a Lispro (Humalog) insulin vial is only good for 30 days after opening.
The facility's policy, Storage of Medication, undated, documents, All discontinued / expired medications are to be removed from the active storage / medication area.
The facility's policy, Insulin Expiration Dates, dated 12/2016, documents that Humalog 3 ml or 10 ml vial expires after 28 days refrigerated or until expiration date.
The Resident Census and Conditions of Residents, CMS 672, dated 4/17/23, documents that the facility has 72 residents living in the facility.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0804
(Tag F0804)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide favorable and warm food for 5 of 27 residents (R15, R23, R2...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide favorable and warm food for 5 of 27 residents (R15, R23, R27, R35 and R162) reviewed for food palatability in a sample of 31.
Findings include:
1.On 04/18/2023 at 10:00 AM, R15 stated that the food has no flavor and was cold all the time. R15 also stated that they don't always get the menus for breakfast.
R15's Minimum Data Set (MDS), dated [DATE], documented that her cognition was intact.
2. On 04/18/2023 at 10:00 AM, R23 stated that the food has no flavor and was cold all the time. She continued to state that they don't always get the menus for breakfast.
On 04/19/2023 at 02:15 PM, R23 stated that she was unable to chew the taco salad yesterday and didn't even know what the meat was today.
R23's MDS, dated [DATE], documented that her cognition was intact.
3. On 04/18/2023 at 10:00 AM, R35 stated that the food had no flavor and was cold all the time. She stated that she doesn't always get the menu for breakfast.
R35's MDS, dated [DATE], documented that her cognition was moderately impaired.
4. On 04/18/2023 at 10:00 AM, R162 all stated that the food has no flavor and is cold all the time. All stated that they don't always get the menus for breakfast.
R162's MDS, dated [DATE], documented that her cognition was intact.
5. On 04/17/2023 at 01:36 PM, R27 stated that the lunch was crappy today. She continued to state that it was cold, and it was too salty. R27 continued to state that she was out for an appointment and wasn't able to fill out her menu.
On 04/19/2023 at 02:15 PM, R27 stated that she was unable to chew the taco salad yesterday and didn't even know what the meat was today.
R27's Minimum Data Set, dated [DATE] documented that her cognition was intact.
On 04/17/2023 at 8:45 AM, V10, Dietary Manager stated that they just started a new menu this past Sunday and a new cook starting and that this should help with the food complaints.
The Resident Council Meeting Minutes, dated 01/26/2023. documented, Food sometimes hot, sometimes cool. Resident Council Memorandum, dated 01/26/2023, documented, Response: Some foods are supposed to be cold. Will remind staff to keep food on steam table and hot cart till service time. Plates warmed.
Resident Council Meeting minutes, dated 03/31/2023, documented, Dietary- Some of the vegetables do not have flavor. Resident Council Memorandum, dated 03/31/2023, documented, Dietary- (V10, Dietary Manager) talked to (resident) and educated staff to send salt and pepper.
The facility was unable to provide a food palatability policy for review.
Feb 2023
3 deficiencies
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to use the services of a Registered Nurse, (RN), for at least eight hours daily. This has the potential to affect all 74 residents living in t...
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Based on interview and record review, the facility failed to use the services of a Registered Nurse, (RN), for at least eight hours daily. This has the potential to affect all 74 residents living in the Facility.
Findings Include:
The Facility's Daily Assignment sheet documented that the Facility did not have a RN for eight hours on 12/02/2022, 12/03/2022, 12/04/2022, 12/07/2022, 12/12/2022, 12/13/2022, 12/16/2022, 12/17/2022, 12/18/2022, 12/21/2022, 12/22/2022, 12/27/2022, 12/30/2022, 12/31/2022, 01/04/2023, 01/05/2023, 01/09/2023, 01/10/2023, 01/14/2023, 01/15/2023, 01/19/2023, 01/23/2023, 01/24/2023, 01/27/2023, 01/29/2023, 02/01/2023, 02/07/2023, 02/10/2023, and 02/12/2023.
On 02/14/2023 at 8:25 AM, V1, Administrator stated that V2, Director of Nurses, was working on the floor today passing pills.
On 02/15/2023 at 8:40 AM, V2, Director of Nurses stated, that she would have scheduled RN's 8 hours a day 7 days a week if she would have them. V2 continued to state that No one has been applying and she has been working the floor.
The facility's policy, Direct Care Staffing Requirements, dated 01/16/2018, documented, 1. There shall be at least one registered nurse on duty seven days per week, 8 consecutive hours, in a skilled nursing facility.
The Facility's Resident Matrix Form (CMS 802) dated 02/14/2023 documents there are 74 residents living in the Facility.
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
Based on observation, interview and record review, the facility failed to change gloves and perform hand hygiene appropriately for 12 of 12 (R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12 and R13) resi...
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Based on observation, interview and record review, the facility failed to change gloves and perform hand hygiene appropriately for 12 of 12 (R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12 and R13) residents reviewed for infection control in the sample of 28.
Findings include:
1. On 02/14/ 2023 at 12:00 PM, V4, Certified Nurse Assistant, (CNA), did not perform hand hygiene and took meal trays into R4's and R5's room. He then exited that room without benefit of hand hygiene and took meal trays off the food cart and entered R6's and R7's room. V4 then exited that room, without benefit of hand hygiene, and taking meal trays off the food cart and entered R8's and R9's room, then exited the room without benefit of hand hygiene, and then entered R10's room. V4 set up R10's meal tray, then exited the room without benefit of hand hygiene. He then took meal trays off the food cart and entered R11's and R12's room and exited the room without benefit of hand hygiene. He then took R13's meal tray off the cart and took it to him, set his meal tray up and exited R13's room without benefit of hand hygiene.
On 02/15/2023 at 1:45 PM, V13, CNA and V14, CNA both stated that they would perform hand hygiene before and after they go into a resident's room with a meal tray.
On 02/16/2023 at 9:45 AM, V2, Director of Nurses stated that she would expect the staff to wash their hands or use alcohol-based hand rub in between residents after care.
2. On 2/14/23 at 11:50 AM, V5 Licensed Practical Nurse (LPN) administered R2's Insulin with gloves. She then assisted R3 to the bathroom with the same gloves. V5 then assisted R2 back to his bed and gave R2's oral medication without performing hand hygiene.
The facility's policy, Hand Hygiene Protocol, dated 06/26/2021, documented, Use an Alcohol-Base Hand Sanitizer. It continues, After touching a resident or the resident's immediate environment (e.g., belongings or equipment.)
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 F0886
(Tag F0886)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to test residents and staff members appropriately during a COVID-19 Outbreak. This failure has the potential to affect all 74 residents residin...
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Based on interview and record review the facility failed to test residents and staff members appropriately during a COVID-19 Outbreak. This failure has the potential to affect all 74 residents residing in the facility.
Findings include:
On 02/14/2023 at 8:25 AM, V1, Administrator stated that the facility did not have any COVID-19 residents positive and that 1 staff member, V8, Social Services Director, has tested positive for COVID-19.
On 02/15/2023 at 8:40 AM, V2, Director of Nurses stated that when V8, Social Services Director, tested positive on 02/09/2023, the facility did contact tracing. They tested the residents who had contact with V8 in the past 48 hours and the Department Heads who had prolong contact with V8. V2 continued to state that the Department Heads are being tested twice a week and the residents, who had contact with V8 were only tested on e time because that was all they had to do.
The facility document, BD Veritor Plus Analyzer Machine Testing Log, dated 02/09/2023, documented that R2, R3, R16, R17, R18, R19, R20, R21, and R22 were tested and was negative for COVID-19. No further testing was completed.
The facility document, BD Veritor Plus Analyzer Machine Testing Log, dated 02/09/2023, documented that V1, Administrator, V2, Director of Nurses, V3, Dietary Manager, V19, Community Relations Coordinator, V20, Medicaid Specialist, V21, Environmental Services Director, V22, Activity Director, V23, Care Plan/ Minimum Data Set Coordinator, V24, Human Resources Generalist were all tested for COVID-19 and were negative. V8, Social Service Director was tested and was positive for COVID-19.
The facility document, BD Veritor Plus Analyzer Machine Testing Log, dated 02/14/2023, documented that V1, Administrator, V2, Director of Nurses, V3, Dietary Manager, V19, Community Relations Coordinator, V20, Medicaid Specialist, V21, Environmental Service Director, V22, Activity Director, V23, Care Plan/Minimum Data Set Coordinator and V25, Therapy Coordinator were all for COVID-19 and were negative. V24, Human Resources Generalist was not retested.
No further testing documentation was presented during this investigation.
The facility's COVID-19 Testing and Response Plan, dated 11/21/2022, documented, If contact tracing was completed, test all residents and (Health Care Provider) identified as close contact or who had a higher risk exposure . It continues, Test at day 1, day 3 and day 5.
The Facility's Resident Matrix Form (CMS 802) dated 02/14/2023 documents there are 74 residents living in the Facility.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 4 harm violation(s), $210,065 in fines, Payment denial on record. Review inspection reports carefully.
- • 40 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $210,065 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: Trust Score of 0/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Regency Care's CMS Rating?
CMS assigns REGENCY CARE 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 Regency Care Staffed?
CMS rates REGENCY CARE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 58%, which is 12 percentage points above the Illinois average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 62%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Regency Care?
State health inspectors documented 40 deficiencies at REGENCY CARE during 2023 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 4 that caused actual resident harm, 34 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Regency Care?
REGENCY CARE 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 99 certified beds and approximately 85 residents (about 86% occupancy), it is a smaller facility located in SPRINGFIELD, Illinois.
How Does Regency Care Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, REGENCY CARE's overall rating (1 stars) is below the state average of 2.5, staff turnover (58%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Regency Care?
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?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.
Is Regency Care Safe?
Based on CMS inspection data, REGENCY CARE 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 Regency Care Stick Around?
Staff turnover at REGENCY CARE is high. At 58%, the facility is 12 percentage points above the Illinois average of 46%. Registered Nurse turnover is particularly concerning at 62%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Regency Care Ever Fined?
REGENCY CARE has been fined $210,065 across 5 penalty actions. This is 6.0x the Illinois average of $35,180. 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 Regency Care on Any Federal Watch List?
REGENCY CARE 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.