Does ARCADIA CARE WATSEKA have any serious inspection findings?

Yes, ARCADIA CARE WATSEKA has 2 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 103 total deficiencies from recent inspections.

Where is ARCADIA CARE WATSEKA located?

ARCADIA CARE WATSEKA is located in WATSEKA, IL. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does ARCADIA CARE WATSEKA have?

ARCADIA CARE WATSEKA has 123 certified beds.

Who owns ARCADIA CARE WATSEKA?

ARCADIA CARE WATSEKA is a for profit - limited liability company facility and is part of the ARCADIA CARE chain.

Is ARCADIA CARE WATSEKA safe?

ARCADIA CARE WATSEKA has documented safety concerns including a substantiated abuse finding on record, 2 immediate jeopardy citations, placement on the CMS Special Focus Facility list. Families should ask about corrective actions taken.

Do nurses at ARCADIA CARE WATSEKA stick around?

ARCADIA CARE WATSEKA has high staff turnover at 62%. High turnover can mean less continuity of care as staff change frequently.

Was ARCADIA CARE WATSEKA ever fined?

Yes, ARCADIA CARE WATSEKA has been fined $574,310 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is ARCADIA CARE WATSEKA on any federal watch list?

Yes, ARCADIA CARE WATSEKA is on the CMS Special Focus Facility (SFF) list, which identifies nursing homes with a history of serious quality issues. Only about 1% of facilities are on this list.

What have inspectors found at ARCADIA CARE WATSEKA?

Medicare inspectors have found 103 deficiencies at ARCADIA CARE WATSEKA: 2 critical, 16 serious, 85 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting ARCADIA CARE WATSEKA?

Families visiting ARCADIA CARE WATSEKA should ask about staff retention and training programs, what corrective actions were taken after fines, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does ARCADIA CARE WATSEKA compare to other nursing homes?

ARCADIA CARE WATSEKA does not have enough inspection data for a CMS star rating yet. This may be a newer facility.

ARCADIA CARE WATSEKA | 0/100 (Grade F)

Mar 2025 9 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect the resident's right to be free from physical abuse and verb...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect the resident's right to be free from physical abuse and verbal abuse for three (R26, R24, R61) of four residents reviewed for abuse in a sample list of 35. Findings Include: The facility's Abuse Prevention and Reporting Policy dated September 2024 documents the facility affirms the right of the residents to be free from abuse. Physical Abuse is the infliction of injury on a resident that occurs other then by accidental means. Examples of physical abuse include hitting, slapping, and kicking. Verbal abuse may be considered a type of mental abuse and includes the use of oral communication to residents within hearing distance. Examples include harassing a resident, mocking, insulting, yelling at, and threatening residents. A resident to resident altercation should be reviewed as a potential situation of abuse. This policy also documents employees are required to report any incident, allegation or suspicion of potential abuse to the administrator immediately. 1. R26's Medical Diagnoses List dated March 2025 documents R26 is diagnosed with Bipolar Disorder, borderline Personality Disorder, and Dementia Moderate with Agitation. R26' Minimum Data Set, dated [DATE] documents R26 has a moderate cognitive impairment. R26's Aggressive Behavior assessment dated [DATE] documents R26 has a general awareness and capability of understanding his behavior, has been verbally and physically aggressive with other residents and has a trigger of loud noises. R26's Care Plan dated 2/19/25 documents R26 has a behavior problem of verbal and physical aggressions towards staff and peers. R26 also has the potential to be physically aggressive related to poor impulse control. 2. R61's Medical Diagnoses List dated March 2025 documents R61 is diagnosed with Major Depression Disorder and Chronic Ulcers of the Lower Extremities. R61's Minimum Data Set, dated [DATE] documents R61 is cognitively intact. R61's Care Plan dated 12/27/24 documents R61 is at a high risk for abuse/neglect. R61's Progress Note dated 12/20/24 documents R61 stated that she was yelled at and slapped in the face by R26 when he was trying to get by her coming from the dining room. V11 Certified Nurses Assistant (CNA) witnessed this altercation. The Final Abuse Investigation Report dated 12/30/24 documents on 12/20/24 R26 got in R61's face and started yelling and then hit her in her face. On 3/24/25 at 2:00 PM R61 stated R26 is often very moody and yells and curses at others. R61 stated in December 2024 R26 was sitting in the middle of the dining room path and there was a traffic jam when she asked R26 to move forward and out of the way. As she passed around his wheelchair she accidentally hit the wheel of his chair with her chair and he yelled and reached out tried to kick her and hit her. He ended up slapping her across her face. R61 stated she was stunned and it stung a bit. R61 stated staff stepped in-between them and took her to her room. R26 stated she avoids R26 at all costs. R26 stated she doesn't want to pass by R26 and he would knock her teeth down her throat. R61 stated, R26 is very aggressive towards others and just the other day R61 told R26 to chill out when he was going back and forth with another resident and he told R61 to shut the f*** up b**** (expletives). On 3/24/25 at 2:32 PM V11 (CNA) stated she observed the altercation between R26 and R61. There was a wheelchair jam trying to get out of the dining room. R26 was yelling at R61 to move and she said she was doing the best she could. As they passed each other R26 kept trying to kick R61 and R26 slapped R61 across the face. V11 stated she then got in between the residents and blocked his feet and hands from hitting her again. V11 stated she was concerned that R26 would kick R61's legs and she has fragile wounds on her legs. V11 stated she got R61 out of the dining room. V11 stated there have been many occasions that R26 gets into arguments or altercations with other residents- both verbally and physically. R26 also curses at residents and tries to hit others if he is agitated. 3. R24's Medical Diagnoses List dated March 2025 documents R24 is diagnosed with Generalized anxiety and Major Depressive Disorder. R24's Minimum Data Set, dated [DATE] documents R24 is cognitively intact. On 3/22/25 at 11:02 AM R24 stated a male resident (R26) punched her in the arm about a month ago as she passed him in the dining area. R24 stated R26 was stopped in his wheelchair and was in the way of others passing. R24 passed around R26 in her wheelchair and R26 reached out and punched her in the arm. R24 stated R26 punched her pretty hard and he then started yelling/cursing at her. R24 stated R26 is often verbally and physically abusive to other residents. R26 wheels around the facility and will tell other residents to shut the f*** (expletive) up and calls people b**** (expletive). The Final Abuse Investigation Report dated 2/13/25 documents on 2/6/25 R24 reported R26 hit her in her arm when she asked him to move out of the way. On 3/24/25 at 2:10 PM V21 Licensed Practical Nurse (LPN) stated she did not witness R24 getting slapped by R26 but she did come over when she heard the commotion and saw R24 was visibly upset and crying. R24 stated she was passing by R26 and he punched her in the arm. On 3/24/25 at 4:00 PM V1 Administrator confirmed R26 has behavior issues and gets agitated easily. V1 confirmed residents need to feel safe in their home and some interventions need to be put in place in order to keep residents safe from R26's verbal and physical outbursts. V1 confirmed these incidents of slapping, punching, and verbally attacking residents with foul aggressive language could be considered abusive.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to report an allegation of verbal abuse for one (R36) of four resident reviewed for abuse in the sample list of 35. Findings Include: On 3/23/...

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Based on interview and record review, the facility failed to report an allegation of verbal abuse for one (R36) of four resident reviewed for abuse in the sample list of 35. Findings Include: On 3/23/25 at 11:39 AM V2 Director of Nursing (DON) stated R36 told V2 last week that the agency nurse V13 Licensed Practical Nurse (LPN) was very rough in her approach with him, her tone was harsh to him and that the nurse was talking about other residents to R36. V2 stated V2 did not tell V1 Administrator about it but stated she thought R36 told V1 himself. V2 stated she did not recognize R36's allegation as potential abuse at the time. V2 (DON) stated all potential abuse is supposed to be reported immediately to V1 Administrator. On 3/2/25 at 9:10 AM V1 Administrator stated R36 had not reported any abuse to V1 and no staff member reported any abuse regarding R36. V1 was not aware of R36's potential abuse allegation. The facility's Abuse Prevention and Reporting-Illinois Policy dated October 2022 documents employees are required to report any incident, allegation or suspicion of potential abuse to the administrator immediately.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to coordinate a Pre-admission Screening and Resident Review (PASARR) le...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to coordinate a Pre-admission Screening and Resident Review (PASARR) level II evaluation for two (R21, R62) of three residents reviewed for PASARR II completion in the sample list of 35. Findings Include: 1. R21's Medical Diagnoses List dated March 2025 documents R21 was admitted to the facility on [DATE] and had a diagnoses of Schizoaffective Disorder: Bipolar Type and Anxiety Disorder. R21's Preadmission Screening and Resident Review (PASARR) Level I screening dated 10/9/23 documents a Level II screening is not indicated because there is no evidence of a serious behavioral health condition (Serious Mental Illness) however, if changes occur or new information refutes those findings a new screen must be submitted. On 3/23/25 at 9:25 AM V5 Business Office Manager confirmed the Preadmission Screening and Resident Review (PASARR) Level I was completed for R21 on 10/9/23 before he was transferred to the facility. V5 confirmed R21's PASARR Level I screening documents no Level II is required due to no Serious Mental Illness diagnoses. However, V5 confirmed R21 is diagnosed with Schizoaffective Disorder: Bipolar Type and Anxiety Disorder. V5 confirmed staff need to routinely review the PASARR screenings for accuracy. 2. R62's Medical Diagnoses List dated March 2025 documents R62 was admitted to the facility on [DATE] and had a diagnoses of Major Depressive Disorder, Brief Psychotic Disorder, and Generalized Anxiety. R62's Preadmission Screening and Resident Review (PASARR) Level I screening dated 12/11/24 documents a Level II screening is not indicated because there is no evidence of a serious behavioral health condition (Serious Mental Illness) however, if changes occur or new information refutes those findings a new screen must be submitted. On 3/23/25 at 9:25 AM V5 Business Office Manager confirmed the Preadmission Screening and Resident Review (PASARR) Level I was completed for R62 on 12/11/24 before she was transferred to the facility. V5 confirmed R62's PASARR Level I screening documents no Level II is required due to no Serious Mental Illness diagnoses. However, V5 confirmed R62 is diagnosed with Major Depressive Disorder, Brief Psychotic Disorder, and Generalized Anxiety. V5 confirmed staff need to routinely review the PASARR screenings for accuracy.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to provide an appropriate indwelling urinary catheter collection bag and failed to secure the bag in a safe and dignified manner...

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Based on observation, interview, and record review, the facility failed to provide an appropriate indwelling urinary catheter collection bag and failed to secure the bag in a safe and dignified manner for one of one resident (R63) reviewed for indwelling urinary catheters on the sample list of 35. Findings Include: R63's undated diagnoses list documents R63's diagnoses as: Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Chronic Kidney Disease Stage IV, Calculus of Ureter, and presence of Urogenital Implants. R63's Physician Order Sheet (POS) dated March 2025, documents an order for 16 (french)Fr/10 (cubic centimeters)cc related to other Obstructive and Reflux Uropathy. On 03/22/25 at 9:30 AM, R63's catheter bag was attached to R63's pants visible to all. R63's catheter tubing is looped down through his pant leg, exiting at the bottom then looped back up and secured on the outside of R63's pants. On 3/22/25 at 9:40 AM, V9 Licensed Practical Nurse (LPN) stated there are no leg bags available but confirmed R63 should have a leg bag on for safety and dignity. On 3/22/25 at 10:04 AM, V1 Administrator stated he was made aware they needed more leg bags and it is his responsibility to place the order. The facility's Urinary Catheter Care Policy dated last Revised September 2020, documents indwelling catheters may be secured to prevent trauma and tension and catheters shall be positioned to maintain a downhill flow of urine to prevent a back flow of urine into the bladder or tubing during transfer, ambulation, and body positioning.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R17's Face Sheet (3/24/24) documents R17 has the following diagnoses: Mild Neurocognitive Disorder, Morbid Obesity, Osteoarth...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R17's Face Sheet (3/24/24) documents R17 has the following diagnoses: Mild Neurocognitive Disorder, Morbid Obesity, Osteoarthritis, Spinal Stenosis, Urinary Incontinence, and Type 2 Diabetes. R17's Quarterly Assessment (12/24/24) documents R17 is cognitively intact, has bilateral lower limb impairments, and is dependent on staff for bathing. R17's Care Plan (current) documents R17 is dependent on staff with bathing/showering. R17's Shower schedule documents R17 is to receive showers on second shift on Wednesday and Saturday. R17's Shower Sheets documents R17 received showers and/or bed baths five times from 2/1/25 through 3/22/25. Further documents R17 only refused to be bathed twice during the same time period. On 3/22/25 at 9:39 AM, R17 stated R17 does not always receive showers. R17 stated R17 requires the use of a mechanical lift for transfers and staff are overworked causing staff to not be timely in providing cares. On 3/24/25 at 8:55 AM, V19 (CNA) stated shower sheets are to be filled out every time a shower and/or bed bath is given or refused. V19 confirmed the shower sheets that are in the binder are the showers/bed baths that were given and/or refused. Based on observation, interview, and record review, the facility repeatedly failed to provide showers to residents according to their plans of care, physician orders, and preferences. This failure affects three residents (R17, R45, R61) out of five reviewed for activities of daily living on the sample list of 35. Findings Include: Facilities Bathing - Shower and Tub Bath Policy dated October 2024 documents: Purpose: To ensure resident's cleanliness to maintain proper hygiene and dignity. Guidelines: A shower, tub bath or bed/sponge bath will be offered according to resident's preference, no less than once per week or according to the resident's preferred frequency and as needed or requested. 1. On 3/22/25 at 10:20 AM, R45 was seated in a tilt back wheelchair in R45's room. R45 was unshaven and had long nails. R45 Medical diagnoses; Encounter for Palliative Care, Dementia, Anxiety Disorder, Chronic Atrial Fibrillation and Schizoaffective Disorder. R45's Minimum Data Set (MDS) dated [DATE] documents R45's Shower/Bathe is Dependent on staff assistance. R45's Care Plan dated 1/30/25 documents R45 has an Activities of Daily Living (ADL) self-care performance deficit related to Activity Intolerance, Confusion, Dementia. Intervention: Bathing/Showering: R45 requires assist of (2) staff member with bathing/showering. Facilities Shower Schedule documents R45 is scheduled to receive showers on Monday and Thursdays. R45's Shower Sheets for February and March documents R45 received a shower on 2/6/25, 2/10/25, 3/7/25, 3/11/25 and 3/12/25, there are no other documented showers, bed bath or refusals in R45's medical records. On 3/23/25 at 11:00 AM V13 Licensed Practical Nurse (LPN) stated residents are assigned 2 showers a week. V13 stated that after the resident receives their shower by a Certified Nursing Assistant, they document it on a shower sheet, whether they get the shower, bed bath or refuse it. V13 stated all the shower sheets are in a book by halls, and whatever is in there is what was given. On 3/23/25 at 11:30 AM V8 Certified Nursing Assistant (CNA) stated that all residents are scheduled to receive two showers per week. V8 stated that after the shower is given, the CNA who provides the shower should complete a shower sheet. V8 stated if a resident continues to refuse a shower a bed bath is offered, and the bed bath or refusal will be documented on the resident's shower sheet. V8 confirmed that according to R45's shower sheets, R45 only received showers on 2/6/25, 2/10/25, 3/7/25, 3/11/25 and 3/12/25. 2. On 3/22/25 at 10:10 AM R61 stated that R61 does not get two showers a week. R61 stated R61 does need staff assistance to get a shower, and the staff always have an excuse why they are not able to give R61 a shower. R61's Medical Diagnoses; Heart Failure, Peripheral Vascular Disease, Pulmonary Hypertension, Personal History of Pulmonary Embolism, Left Ventricular Failure and History of Falls. R61's Care Plan dated 3/19/25 documents R61 has an Activities of Daily Living (ADL) self-care performance deficit related to Activity Intolerance, Fatigue, Psychotropic medications, Shortness of Breath. Intervention: Bathing and Showering: R61 requires assist of 1 staff member with bathing/showers. R61's Minimum Data Set (MDS) dated [DATE] documents R61 Shower/Bathe self: needs partial/moderate assistance. Facilities Shower Schedule documents that R61 is scheduled to receive showers on Wednesdays and Saturdays. R61's Facility Shower Sheets dated February and March documents R61 did not receive any showers, and refused showers on 2/1/25, 2/5/25 and 2/26/25, there are no other documented showers, bed bath or refusals in R61's medical records. On 3/23/25 at 11:00 AM V13 (LPN) stated residents are assigned 2 showers a week. V13 stated that after the resident receives their shower by a CNA, they document it on a shower sheet, whether they get the shower, bed bath or refuse it. V13 stated all the shower sheets are in a book by halls, and whatever is in there is what was given. On 3/23/25 at 11:30 AM V8 (CNA) stated that all residents are scheduled to receive 2 showers a week. V8 stated that after the shower is given, the CNA who administered the shower will complete a shower sheet. V8 stated if a resident continues to refuse a shower a bed bath is offered, and the bed or refusal will be documented on the resident's shower sheet. V8 confirmed that according to R61's showers sheets, R61 did not receive any showers in February or March, and refused showers on 2/1/25, 2/5/25 and 2/26/25.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to provide and implement activities to meet the interest and needs of the residents. This failure affects four residents (R8, R5...

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Based on observation, interview, and record review, the facility failed to provide and implement activities to meet the interest and needs of the residents. This failure affects four residents (R8, R55, R57, R63) of thirteen residents reviewed for activities in the sample list of 35. Findings Include: All four residents (R8, R55, R57, R63) reside on the facility's locked memory care unit/hallway. On 3/22/25 at 9:45 AM, 10:00 AM, 2:00 PM and 3/23/25 at 9:40 AM, and 11:00 AM. all four residents (R8, R55, R57, R63) were in their rooms asleep or sitting not engaged, with no structured activities. 1. R8's undated diagnoses list includes: Unspecified Dementia, unspecified severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. R8's Care Plan (current), documents R8's preferences for activities are horticulture based activities or crafts, allow resident to choose preferred craft activity; assist with arranging community activities; and ensure the activities the residents is attending is compatible with physical and mental capabilities, compatible with known interests and preferences, adapted as needed; and compatible with individual needs and abilities and age appropriate. 2. R55's undated diagnoses list includes: Alcohol Dependence with Alcohol-Induced Persisting Dementia. R55's Care Plan (current) documents ensure that the activities the resident is attending are compatible with physical and mental capabilities, compatible with known interests and preferences, adapted as needed; and compatible with individual needs and abilities and age appropriate, invite the resident to scheduled activities, modify daily schedule/treatment plan to accommodate activity participation as resident requests, and provide activity calendar. 3. R57's undated diagnosis list includes: Vascular Dementia, unspecified severity with other behavioral disturbances. R57's Care Plan (current) documents encourage participation in simple activities and provide structured activities such as toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes' 4. R63's undated diagnoses list includes: unspecified Dementia, unspecified severity with other Behavioral Disturbances, unspecified Dementia, unspecified severity without Behavioral Disturbance Psychotic Disturbance, Mood Disturbance, and Anxiety. R63's Care Plan (current) documents encourage participation in activities that promote exercise, physical activity, and the resident needs activities that minimize the potential for falls while providing diversion and distraction. On 3/23/25 at 11:52 AM V14 Activity Director stated she is short staffed right now and has not had anyone to organize or lead activities on the locked memory care unit/hall. V14 stated she has just hired an assistant who will be assigned to that unit on weekends however until she is trained, facility corporate has instructed that the memory care Certified Nursing Assistants should be doing the activities on that unit on the weekends. So far, V14 stated V14 has not been able to have staff engage residents. V14 confirmed residents on the memory care unit should not be sitting around all day or sleeping due to boredom and should be engaged and active as much as possible. The facility's Dementia Unit Admission/Discharge Criteria and Program dated September 2024 documents the goal of this program is to provide a safe environment for the individual, while offering attributives that support the best quality of life possible.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

Based upon interview and record review, the facility failed to have a Registered Nurse (RN) providing services at least eight consecutive hours a day, seven days a week. This failure has the potential...

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Based upon interview and record review, the facility failed to have a Registered Nurse (RN) providing services at least eight consecutive hours a day, seven days a week. This failure has the potential to affect all 62 residents currently residing in facility. Findings Include: The Facility Assessment Tool for Arcadia Care of Watseka dated November 2024 through November 2025 documents staffing should include one registered nurse (RN), two licensed practical nurses (LPN), and six certified nursing assistants (CNA's) for the 6:00 AM thru 6:00 PM shift and one registered nurse (RN), one licensed practical nurse (LPN), and five certified nursing assistants (CNA's) for the 6:00 PM thru 6:00 AM shift. The facility's March 2025 Nursing Schedule documents no Registered Nurses coverage on the following dates 3/8, 3/9, 3/13, 3/14, 3/17, and 3/18/25. The facility's daily assignments document indicates no RN coverage over a 24 hour period for the dates of 3/8, 3/9, 3/13, 3/14, 3/17 and 3/18/25. On 3/24/25 at 1:20 PM, V7 Regional Registered Nurse and V2 Director of Nursing confirmed there are days that the building lacks appropriate RN coverage but that they are currently working on correcting that. Facility Census dated 3/23/25 documents 62 residents currently residing in facility.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 62 reside...

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Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 62 residents in the facility. Findings Include: On 3/22/25, 3/23/25 and 3/24/25 V3 Dietary Manager was actively supervising dietary operations in the facility kitchen. On 3/11/25 at 11:04 AM V3 Dietary Manager stated that V3 was hired a couple of weeks ago as Dietary Manager. V3 stated that V3 is not currently a Certified Dietary Manger. V3 stated at this time V3 fails to meet the State of Illinois standards to be a food service manager/dietary manager. On 3/22/25 at 2:02 PM V1 Administrator confirmed that V3 Dietary Manager does not currently have a valid Food Safety/Dietary Manager Certificate as required. The Facility Assessment (not dated) documents a full-time dietician or other clinically qualified nutrition professional to serve as the director of food and nutrition services is needed to provide competent support and care for the facility's resident population every day and during emergencies. The facility Long-Term Care Facility Application for Medicare and Medicaid (3/23/25) documents 62 residents reside in the facility.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0882 (Tag F0882)

Could have caused harm · This affected most or all residents

Based upon observation, interview and record review the facility failed to employ an Infection Prevention Nurse that physically works onsite in the facility at least part time. This failure has the po...

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Based upon observation, interview and record review the facility failed to employ an Infection Prevention Nurse that physically works onsite in the facility at least part time. This failure has the potential to affect all 62 residents residing in the facility. Findings Include: Observations were made on 3/22/25, 3/23/25 and 3/24/25 between the hours of 8:30 AM and 4:00 PM. During these times, no certified Infection Preventionist nurse was in facility. On 3/24/25 at 2:00 PM, V7 Regional Registered Nurse stated the facility's Infection Preventionist is a Regional Infection Preventionist (V25) who works offsite. V7 stated V25 is responsible for all infection tracking and logs and that these are not kept/maintained in the facility. On 3/25/25 at 9:18 AM V2 Director Of Nursing (DON) stated she believes they are supposed to be tracking resident infections but that V25 Regional Infection Preventionist keeps track of resident infections. V2 stated she herself does not have access to the infection tracking log. On 3/25/25 at 9:32 AM V25 Regional Infection Preventionist stated she is at the facility every Tuesday. V25 stated she focuses on Infection Control in the building one day per week. The facility's clinical nurse schedule for month of March 2025 documents no Infection Prevention nurse on site. Resident Census dated 3/23/25 documents a total of 62 residents currently residing in facility.

Mar 2025 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 sufficient Registered Nursing (RN) hours on six of fifteen days reviewed for RN staffing. This failure has the potential to affect ...

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Based on interview and record review, the facility failed to provide sufficient Registered Nursing (RN) hours on six of fifteen days reviewed for RN staffing. This failure has the potential to affect all 66 residents in the facility. Findings include: The facility Nursing Daily Schedule (February 20, 2025 through March 6, 2025) documents on 2/22/25, 2/23/25, 2/27/25, 3/3/25, 3/4/25, and 3/5/25, the facility scheduled zero (0) hours of RN coverage for a 24 hour period. On 3/6/25 at 12:25pm, V3 Regional Director confirmed the hours listed on the facility nursing daily schedule were correct and the facility failed to have RN coverage on 2/22/25, 2/23/25, 2/27/25, 3/3/25, 3/4/25, and 3/5/25. The facility Resident Midnight Census dated 3/6/25 documents 66 residents reside in the facility.

Feb 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the residents (R1) right to be free from physical abuse by ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the residents (R1) right to be free from physical abuse by another resident (R2) for one of five residents (R1) reviewed for abuse in the sample list of 10. Findings include: R1's Facility Census documents R1 was admitted to the facility on [DATE] and has the following medical diagnoses: Sequelae of Cerebrovascular Disease, Hemiplegia and Hemiparesis following Infarction Affecting Right Dominant Side, Schizoaffective Disorder Bipolar type, Anxiety Disorder, Acute Kidney failure, Cerebral Infarction, muscle Weakness and Difficulty in Walking. R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview for Mental Status (BIMS) score 11, moderate cognitive impairment. R1's Abuse and Neglect Screening assessment dated [DATE] documents R1 is a high risk for abuse. R1's Social Service Note dated 1/31/25 at 12:04pm documents Psychosocial assessment reviewed for R1. Assessment completed due to Verbal Altercation - R1 to R2. Behavioral diagnosis includes A new onset or increase in behaviors include Increased agitation yelling out. R1 has a history of: Alcohol use. Triggers that alarm or distress resident are loud noises fighting or angry outbursts. Interventions in place include Activity Food/Snacks Redirect. R1's incident note dated 1/31/25, late note at 12:25 am documents V1 (Administrator) was notified of a physical altercation with R2. Medical Doctor, R1's Power of Attorney (POA), and Ombudsman notified. Investigation initiated. R2's Facility Census documents R2 was admitted to the facility on [DATE] and has the following medical diagnoses: Dementia with Agitation and Bipolar Disorder. R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview for Mental Status (BIMS) score 9, moderate cognitive impairment. R2's Incident Note date 1/31/25 at 12:21 pm documents V1 (Administrator) was notified of a physical altercation with R1. Medical Doctor, R2's Power of Attorney (POA), and ombudsman notified. Investigation initiated. On 2/19/25 at 10:50 am V7 (Cook) stated, on 1/31/25 at 10:30am V7 heard resident's arguing in the dining room. V7 stated, V7 went into the dining room and observed R1 and R2 arguing, both were in their wheelchairs. V7 stated, V7 grabbed the back handles of R2's wheelchair to remove R2 from R1 at which time R2 swung R2's left arm striking R1 in the right shoulder. On 2/19/25 at 10:55 am V6 (Cook) stated, on 1/31/25 at 10:30 am V6 was in the Dietary Mangers office and heard resident's arguing in the dining room. V6 stated, V6 looked out and observed V7 (Cook) behind R2 who was seated in R2's wheelchair, and R1 was to R2's left in R1's wheelchair. V6 stated, while V7 was attempting to separate R2 from the area, R2 swung R2's left arm hitting R1 in the right shoulder. On 2/19/25 at 11:04am V1 (Administrator) said, on 1/31/25 V1 was notified of an incident in the dining room between R1 and R2. V1 said, V1 responded and both residents were separated and being assessed by V2 (Director of Nursing). V1 said, V1 interviewed V6 (Cook) and V7 (Cook) who informed V1 that they heard arguing in the dining room, and upon entering the dining room they observed R1 and R2 arguing. V1 said, as V7 was attempting to remove R2, R2 swung R2's left arm and struck R1 in the right shoulder. The Facility's Abuse Prevention Policy dated 9/24 documents: Guidelines: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents.

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

Comprehensive Care Plan (Tag F0656)

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 person-centered comprehensive care plan wit...

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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 person-centered comprehensive care plan with intervention for behaviors. This failure affects one resident (R6) of four residents reviewed for behaviors in the sample list of ten. Findings include: R6's Facility Census documents R6 was admitted to the facility on [DATE] and has the following medical diagnoses: Dementia and Schizophrenia. R6's Minimum Data Set (MDS) dated [DATE] documents R6's Brief Interview for Mental Status (BIMS) score 10, moderate cognitive impairment. R6's Nursing Note dated 1/4/25 at 3:49am documents R6 was restless during night shift and declined to go to sleep. R6 also refused help with personal cares from Certified Nursing Aides and R6 also refused to wear brief. R6's Nursing Note dated 1/15/25 at 5:57am documents R6 came out of R6's room around 2:00am, with no pants/underwear or (brief) on. R6 did have on a hat, coat, gloves and appropriate footwear. When writer told R6, R6 didn't have any pants, R6 responded with 'I don't care' and 'so what'. Writer attempted to educate R6 on importance of pants, R6 started speaking loudly and reiterating 'I don't care' 'so what' 'it doesn't matter.' R6 went into dining room and sat in usual meal spot chair. Certified Nursing Assistant was able to redirect R6 back to R6's room and dress appropriately. V9 Certified Nursing Assistant (CNA) Witness Statement dated 2/18/25 documents on 2/18/25 V9 did note that R6 was up and down at the desk most of the night. R6 usually is up throughout the night, R6 routinely takes R6's clothes and brief off and walks the hallway and needs continuous redirection. The Facility's Comprehensive Care Plan policy dated 10/24/24 documents: Purpose: To develop a comprehensive care plan that directs the care team and incorporate the residents goals, preferences, and services that are to be furnished to attain or maintain the residents highest practicable physical, mental and psychosocial well-being. Guidelines: The facility will develop and implement a comprehensive care person-centered care plan for each resident, consistent with the residents rights, that includes measurable objectives and timeframe's to meet a residents medical, nursing, and mental psychosocial needs that are identified in the comprehensive assessment. On 2/19/25 at 11:45am V10 (CNA) said, V10 works the day shift. V10 said, R6 is independent with transfers and uses a walker to ambulate. V10 said, when R6 uses the restroom, R6 removes all R6's clothes and when R6 gets done, R6 sometimes forgets to get dressed and will come out of R6's room naked. V10 said, V10 or other staff will bring R6 back to R6's room to get dressed. On 2/19/25 at 2:35pm V4 Licensed Practical Nurse (LPN) said, R6 does walk around the halls all night and likes to sit in the TV area across from the nurse's station. V4 said, sometimes when R6 goes to the bathroom, R6 will come out and be naked, and is told to go get dressed, and will go back into R6's room and get dressed. On 2/19/25 at 2:50pm V8 (CNA) said, R6 sometimes does go to the bathroom and remove all R6's clothes and when R6's done will forget to get dressed and comes out naked. V8 said, staff will tell R6 to go get dressed and R6 will go get dressed. On 2/19/25 at 3:00pm V1 (Administrator) confirmed that R6 does not have a comprehensive care plan regarding R6's behavior of undressing and walking around naked, nor any intervention for this behavior.

Jan 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect a residents right (R3) to be free from Abuse by another res...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect a residents right (R3) to be free from Abuse by another resident (R1), for two (R1, R3) out of three residents reviewed for abuse in the sample list of nine residents. Findings include: The facility policy titled 'Abuse Prevention and Reporting', reviewed 9/2024, documents this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. The purpose of this policy is to assure that the facility is doing all that is within it's control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. Abuse: Abuse means any physical or mental abuse injury or sexual assault inflicted upon a resident other than by accidental means. R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview for Mental Status (BIMS) score 12, moderate cognitive impairment and is able to propel self in wheelchair without assistance. R1's Incident Note dated 12/11/24 at 8:39pm documents V1 Administrator was notified of a R1 to R3 altercation. Residents representatives, Medical Doctor, local police department, and ombudsman notified. Residents separated immediately. Investigation initiated. R1's Nursing Note dated 12/11/24 at 10:15pm documents R1 went down A hall, into R3 and R4's room and kicked R3 in his left shin unprovoked and then attempted to steal property from the R4. R3's Minimum Data Set (MDS) dated [DATE] documents R3's Brief Interview for Mental Status (BIMS) score 11, moderate cognitive impairment and is dependent of staff for transfers using a mechanical lift. R3's Incident Note dated 12/11/24 at 9:03pm documents V1 Administrator was notified of a resident-to-resident altercation. Residents representatives, Medical Doctor, local police department, and ombudsman notified. Residents separated immediately. Investigation initiated. R4's Minimum Data Set (MDS) date 12/10/24 documents R4's Brief Interview for Mental Status (BIMS) score 13, cognitively intact. On 12/31/24 at 10:00am R3 stated that a couple of weeks ago R3 was sitting in R3's wheelchair watching TV in R3's room. R3 stated that R4, R3's roommate came into the room and was in R4's bed. R3 stated R1 came into R3's room and R1 was told to get out of R3 and R4's room. R3 stated R1 got upset and grabbed R4's cane off of R4's bed and hit R3 in the left shin 3 times and also kicked R3 in the left shin. R3 stated V11 Agency Licensed Practical Nurse came into the room and removed R1 from the room. V3 stated that V11 assessed V3 for pain, and R3 had some pain in R3's shin and was given pain medication. On 12/31/24 at 10:45am R4 (R3's roommate) stated several weeks ago R1 came into R4 and R3's room and R4 told R1 to get out of the room. R4 stated that R1 got all upset and picked up R4's cane off the bed and hit R3 who was sitting in R3's wheelchair watching TV. R4 stated staff came into the room and removed R1 from the room. On 12/31/24 at 1:35pm V1 Administrator stated on 12/11/24 at around 8:39pm, V1 was informed of an alleged altercation between R1 and R3. V1 stated all residents were separated, notifications to residents family, Local Police, Ombudsman and Medical Doctor were made. V1 stated that V1 started an investigation and was informed by R3 that R1 came into R3's room and R4 (R3's roommate) asked R1 to leave, and R1 grabbed R4's cane and hit R3 in the shin. V1 stated that R3 informed V1 that staff responded to R3's room and removed R1. On 1/2/25 at 8:51am V11 Agency Licensed Practical Nurse stated on 12/11/24 V11 was working the 6:00pm - 6:00am shift and at around 8:00pm V11 heard yelling coming from R3 and R4's room. V11 stated that upon entering the room, R1 was yelling at R3 and R4, and R3 and R4 were telling R1 to leave the room. V11 stated that R1 had R4's cane in R1's hand, and V11 took it and gave it to R4, and removed R1 from R3 and R4's room. V11 stated V11 came back to R3's room, and R3 stated that R1 kicked R3 in the shin, and also took R4's cane off R4's bed and hit him 3 times in the shin. V11 stated that R4 confirmed that R1 had kicked and hit R3 in the shin.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

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 provide showers for four (R6, R7, R8 and R9) of four d...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide showers for four (R6, R7, R8 and R9) of four dependent residents reviewed for showers and failed to provide dental care for one (R9) of four residents reviewed for dental care from a total sample list of nine residents reviewed for dependent care. Findings include: The facility bathing policy dated October 2024 documents that a shower or bath will be offerred according to resident preference at a minimum of once per week. The facility morning and bedtime care policies dated October 2024 document that dental care will be provided both morning and night to promote comfort, cleanliness, and dignity. 1.) On 12/31/24 at 1:30PM, R6 was laying in bed with yellowed fingernails measuring over an inch past the nail, with particulates of unknown substances under them. R6 appeared disheveled and stale smelling. On 12/31/24 at 1:30PM, R6 stated, I haven't had a shower in a long time, I don't know how long, but its been more than a week. They trim my nails when they give me a shower and I need it done. I would like to have one. On 1/2/25 at 09:40AM, R6 was wearing the same shirt that he had on 12/31/24 and stated that he had not had a shower in a long time. R6's Minimum Data Set, dated [DATE] documents R6 as moderately cognitively intact. R6's Minimum Data Set, dated [DATE] documents R6 as a maximum assist for bathing. The facility provided shower sheets for the past two months documents R6 was given showers on 11/21/24, 11/27/24, and 12/26/24. 2.) On 12/31/24 at 1:40PM, R7 was laying in bed using an electronic device wearing a hospital gown with stains. On 12/31/24 at 1:40PM, R7 stated, I don't get showers very often, they just don't have the staff to do it. I'm a (mechanical lift) and I like showers in the evening, so they really don't have the staff then. I would like a shower sometime this week, for sure. On 1/2/25 at 9:45AM, R7 stated that she had not yet had a shower. R7's Minimum Data Set, dated [DATE] documents R7 as cognitively intact and dependent for all cares including showering. The facility provided shower sheets for R7 document one shower in the past 2 months dated 11/21/24. 3.) On 12/31/24 at 1:45PM, R8 was laying in bed wearing only a brief with a catheter bag in place. R8's beard and nails were moderately long (1/2) inch from the end of the finger. On 12/31/24 at 1:45PM, R8 stated that he could not remember the last time that he had a shower. On 1/2/25 at 9:46AM, R8's shirt had food debris on it and R8 stated that he had not had a shower in some time. R8's Minimum Data Set, dated [DATE] documents R8 as cognitively intact and dependent for all care including showers. The facility provided one shower sheet for R8 over the past two months dated 11/21/24. 4.) On 12/31/24 at 2:15PM, R9 was sitting in her wheelchair speaking to V1 Administrator in her room. R9 smelled stale. On 1/2/25 at 9:50AM. R9 stated, I can't tell you the last time that I had a bath. They just wash my (periarea) and call it good. I'm supposed to have a whirlpool bath twice a week but they just don't do it. I would love to get my hair washed and my teeth brushed. It has been four days since they brushed my teeth and that's just gross. R9's Minimum Data Set, dated [DATE] documents R9 as cognitively intact. R9's Minimum Data Set, dated [DATE] documents R9 as dependent for all care including showers. R9's facility provided shower sheets for the last 2 months include no shower sheets for R9. On 12/31/24 at 1:25PM, V12 Certified Nursing Assistant stated, We haven't done any showers yet today because we didn't have the staff. On 12/31/24 at 2:20PM, V13 Regional Nurse stated that at a minimum, residents should get a shower once a week.

Dec 2024 4 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to use proper equipment to transport a resident (R1) resu...

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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 use proper equipment to transport a resident (R1) resulting in R1 sustaining an impacted tibia fracture and associated proximal fibula fracture. The facility also failed to follow its incident/accident policy by failing to report a serious injury to the state survey agency and thoroughly investigate an injury to determine the root cause and develop interventions for one (R1) of three residents reviewed for accidents in the sample list of seven. Findings include: On 12/3/24 at 1:56 PM R1 stated on 10/20/24 R1 had a left leg tibia/fibula fracture caused while V9 Certified Nursing Assistant (CNA) was pushing R1 in a shower chair down the hallway, R1 started to slip and attempted to push herself back up and R1's left toe/foot caught on the rug in the hallway. R1 screamed ow and thought it was broken. R1 stated x-rays were not taken for two to three days. R1 stated R1 was seen by V15 Orthopedic Physician on 11/6/24, who told R1 that R1's leg could not be casted as it would worsen R1's foot drop and require amputation, so the bones were left to fuse. On 12/4/24 at 9:24 AM the shower chair was viewed with V7 CNA. The chair was made of plastic piping and had four small caster wheels, and it did not include foot pedals or foot/leg support. R1's Diagnosis List documents R1 has a diagnosis of Multiple Sclerosis and is wheelchair bound. R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact, has impaired range of motion to both legs, uses a wheelchair for mobility, and is dependent on staff for transfers. R1's Nursing Note dated 10/21/2024 at 12:35 AM documents R1 received a shower and complained of ankle and knee pain, physician notified and orders received for x-ray. The Incident Investigation Form dated 10/21/24 at 12:30 AM, recorded by V9 CNA, documents V9 was pushing R1 in a shower chair down the hallway after R1's shower when R1's left foot was low to the ground and struck the edge of the carpet rug in front of the patio door. This form documents R1 screamed ow and V9 backed up to assist in moving R1's foot, R1 was brought to her room and the nurse was notified. The Incident Investigation Form dated 10/21/24 at 12:30 AM, recorded by V17 CNA, documents V17 witnessed V9 pushing R1 in a shower chair, R1 yelled ow and R1's toe was stuck underneath the carpet. R1's left ankle x-ray dated 10/21/24 documents a questionable hairline fracture of the anterior aspect of the left distal tibial metaphysis and recommends additional radiographs for further evaluation. R1's left ankle x-ray dated 10/22/24 documents R1 has diffuse Osteopenia (decreased bone mineral density) and a subacute nondisplaced fracture of the distal end of the left tibia. R1's Progress Note dated 11/6/24, recorded by V15, documents R1's chief complaint as I (R1) slipped, caught the rug, and it rebroke my (R1's) ankle and hyperextended my (R1's) knee. This note documents based on x-rays completed on 11/6/24 R1 had an impacted left distal tibia fracture with an associated proximal fibula fracture; and R1 is nonambulatory/bed-bound and has contractures to both ankles. This note documents due to R1's significant contractures V15 did not recommend casting and recommended to repeat x-rays of the left leg to ensure that there are no changes in alignment. R1's Care Plan with revised date 12/3/24 does not document R1's injury. There is no documentation that the facility reported R1's incident and fracture to the state survey agency or conducted a thorough investigation to identify root cause and develop/implement interventions to address the incident. On 12/3/24 at 3:32 PM V17 CNA stated V17 witnessed V9 CNA pushing R1 in a shower chair down the hall, R1's toe stubbed against the rug in front of the patio door and R1 yelled Ow. V17 stated R1 was transferred to bed and complained of left shin and ankle pain which was reported to the nurse. V17 stated a lot of times residents' feet brush against the floor when staff use the shower chair to transport residents. V17 stated the staff use the shower chair to transport because there is not enough room in the shower room for the full mechanical lift and R1 uses the mechanical lift for transfers. On 12/4/24 at 9:35 AM V17 described the shower chair used for R1, and it was not a reclining back shower chair and did not have foot rest/support. V17 stated R1's incident happened on 10/20/24 around 10:00 PM. On 12/3/24 at 4:16 PM V1 Administrator stated V1 did not report R1's injury since she did not become aware of the fracture until about a week after the incident happened. V1 confirmed R1's injury should have been reported to the state survey agency and the facility should have investigated the injury/incident. V1 stated V1 obtained staff statements regarding the incident, and staff were educated to slow down when transporting residents in a shower chair and ensure the resident's feet are off of the floor. V1 stated V1 was told by staff that R1's toe got caught on the rug while staff were pushing R1 in the shower chair down the hallway. On 12/4/24 at 9:10 AM V2 Director or Nursing stated V2 updates the care plans and confirmed R1's care plan does not address R1's injury. V2 stated V2 did not investigate R1's injury/incident and stated V2 thought it was acceptable for staff to use shower chairs to transport residents. On 12/4/24 at 1:31 PM V16 (R1's Physician) stated V16 ordered R1's x-rays, V16 saw R1 on 10/31/24 and R1 reported R1's foot got caught and hyperextended her leg while coming back from the shower. V16 confirmed R1's fractures would be consistent with an injury caused from stubbing her toe/foot on the carpet while being transported in a shower chair. V16 stated it would have been safer to use a wheelchair to transfer between locations rather than a shower chair since there is no foot support or pedals, which a wheelchair has. The Owner's Manual for (shower chair), provided by the facility on 12/4/24, dated November 2018 documents This device is NOT intended to be used as a transfer bench or device. The facility's Incident and Accidents policy dated October 2024 documents an incident/accident report will be completed for all serious accidents/incidents of residents and unexpected events that cause actual or potential harm to a resident and will include the date/time of the incident/accident, written statements, possible cause of incident, physical assessment, injuries, vital signs, treatment, and notification of appropriate parties. This policy documents to report actual injuries to the state survey agency within 24 hours of the occurrence and submit a narrative summary of the incident within five working days.

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 F0697 (Tag F0697)

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 routinely assess for pain and develop a care plan to address pain fo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to routinely assess for pain and develop a care plan to address pain for one (R1) of five residents reviewed for accidents in the sample list of seven. Findings include: The facility's Pain Management Program dated October 2024 documents the pain assessment protocol will be initiated when: the pain assessment identifies pain on admission with changes in condition including incidents associated with potential for pain, identified on the Minimum Data Set (MDS), pain medication is given routinely or pain is not controlled, a change in condition occurs that requires pain control, a significant increase in use of PRN (as needed) pain medication, there is a change in pain related to behavior/cognition/mood, and when there is a diagnosis associated with pain/discomfort. This policy documents to use a pain rating scale to determine level of pain, develop and implement a care plan to address pain, assess for pain during routine medication administrations and document the pain assessment and the resident's response to pain management On 12/3/24 at 1:56 PM R1 stated on 10/20/24 R1 had a left leg tibia/fibula fracture caused while V9 Certified Nursing Assistant (CNA) was pushing R1 in a shower chair down the hallway, R1 started to slip and attempted to push herself back up and R1's left toe/foot caught on the rug in the hallway. R1 stated R1's pain at that time was a 20 on a zero to ten scale and R1's pain did not improve until Ultram was taken frequently. R1's Diagnosis List documents R1 diagnoses include Multiple Sclerosis, Type Two Diabetes Mellitus, Sacral Stage Four Pressure Ulcer, and Osteoarthritis of the hip. R1's MDS dated [DATE] documents R1 is cognitively intact and has impaired range of motion to both legs. This MDS documents R1 does not take scheduled pain medication, only as needed (PRN); within the last five days R1 experienced frequent pain, with the worse pain rated a five, that occasionally interfered with sleep and therapy sessions and frequently interfered with daily activities. R1's Care Plan with revised date 12/3/24 does not include problems, goals, and interventions to address R1's injury and pain. R1's left ankle x-ray dated 10/21/24 documents a questionable hairline fracture of the anterior aspect of the left distal tibial metaphysis and recommends additional radiographs for further evaluation. R1's left ankle x-ray dated 10/22/24 documents R1 has a subacute nondisplaced fracture of the distal end of the left tibia. R1's Progress Note dated 11/6/24, recorded by V15, documents based on x-rays R1 had an impacted left distal tibia fracture with an associated proximal fibula fracture, R1 is nonambulatory/bed-bound and has contractures to both ankles. This note documents due to R1's significant contractures V15 (Orthopedic Physician) did not recommend casting and recommended to repeat x-rays of the left leg to ensure that there are no changes in alignment. R1's Physical Therapy (PT) Note dated 10/21/24 documents R1 was unable to perform left leg active range of motion (AROM) due to left ankle/foot pain. R1's PT Note dated 10/22/24 at 10:03 AM documents R1 rated left leg pain a nine/ten on a zero to ten scale. R1's PT Notes dated 10/24/24, 10/25/24, and 10/28/24-10/31/24 document R1 had left leg pain that impacted treatment or participation in ROM and pain improved on 10/29/24 and 10/30/24. There are no orders to routinely assess R1's pain every shift. R1's October 2024 Medication Administration Record (MAR) documents an order to administer Ultram 25 milligrams every eight hours as needed and this medication was administered six times for pain rated between three and five, and once on 10/25/24 at 5:20 AM for pain rated an eight. This MAR documents following R1's injury, Ultram was only documented as given on the 22nd at 2:56 AM, 23rd at 1:30 AM, 25th at 5:20 AM, and 29th at 5:26 AM. R1's November 2024 MAR documents Ultram was given ten times for pain rated between zero and eight. R1's Ultram Controlled Substances Proof of Use dated 8/11/24-11/8/24 documents between 10/20/24 and 11/4/24 Ultram was additionally given (not recorded on R1's MAR) on 10/20/24 at 10:00 PM, 10/21/24 at 6:00 AM and 12:00 PM, 10/24/24 at 5:21 AM and 10/30/24 at 12:12 AM. There are no corresponding pain scales pre and post administration for these entries since they are not documented on R1's MAR. On 12/3/24 at 7:53 AM V18 CNA stated R1 would say to be careful with her leg, that it was broken, and R1 would complain of pain which was reported to the nurses. On 12/3/24 at 3:23 PM V10 CNA stated V10 worked night shift on 10/26/24 and 10/27/24 after R1's leg fracture, R1 complained of ankle pain which was reported to the nurse. On 12/3/24 at 3:32 PM V17 CNA stated V17 witnessed V9 CNA pushing R1 in a shower chair down the hall, R1's toe stubbed against the rug in front of the patio door and R1 yelled Ow. V17 stated R1 was transferred to bed and complained of left shin and ankle pain which was reported to the nurse. On 12/4/24 at 9:28 AM V19 Physical Therapy Assistant stated R1 was very stiff and weak so we tried to improve range of motion (ROM) to R1's legs. V19 stated on the morning of 10/21/24 R1 would not allow V19 to do any ROM to the left leg, R1 complained of excruciating pain and said R1's foot got caught on a rug causing R1's knee to hyperextend. V19 stated R1 complained of left leg pain during therapy sessions therefore ROM was not performed, and V19 reported this to the nurses and emphasized the need for pain medication. On 12/4/24 at 9:10 AM V2 Director of Nursing stated pain should be assessed every shift and with PRN medication administration, and documented on the MAR. V2 stated there should have been an order to assess R1's pain every shift. V2 confirmed R1's pain should have been routinely assessed after R1's injury/incident, V2 reviewed R1's MAR and confirmed pain was not assessed every shift. V2 stated V2 updates the care plans and confirmed R1's care plan does not address R1's fracture or pain. On 12/4/24 at 1:31 PM V16 (R1's Physician) stated R1 had chronic pain and an order for Ultram PRN prior to R1's injury. V16 confirmed nursing staff should have routinely assessed R1's pain following R1's injury. V16 stated the Ultram should have automatically been given if R1 was complaining of pain and R1's pain had improved when V16 evaluated R1 on 10/31/24.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review the facility failed to administer insulin and diabetic medications timely and as ordered for four (R1, R2, R4, R7) of four residents reviewed for ins...

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Based on observation, interview, and record review the facility failed to administer insulin and diabetic medications timely and as ordered for four (R1, R2, R4, R7) of four residents reviewed for insulin in the sample list of seven. Findings include: The facility's Medication Administration Policy dated October 2024 documents medication administration is documented on the Medication Administration Record (MAR), medications must be administered according to physician's orders including the right time, and to notify the physician of medication errors. The Resident Council Minutes dated 11/27/24 documents concerns with morning medications taking three hours to get and an insulin problem. 1.) R1's November 2024 MARs document to administer Humulin R (Regular insulin) U-500 (concentrated) units/milliliter give 40 units subcutaneously three times daily at 8:00 AM, 11:00 AM and 4:00 PM. There is no documentation that this medication was administered as ordered on 11/6/24 for all doses, 11/9/24 at 4:00 PM, 11/11/24 at 4:00 PM, 11/14/24 at 11:00 AM and 4:00 PM, and 11/25/24 at 4:00 PM. R1's Nursing Note dated 11/9/2024 at 5:47 PM documents only partial dose of insulin was administered per R1's request for blood sugar of 157 milligrams/deciliter (mg/dl). R1's Nursing Notes dated 11/24/24 at 6:43 PM and 9:50 PM document due from previous shift for R1's scheduled insulin administrations. There is no documentation in R1's medical record why insulin was not administered on 11/6/24, 11/11/24 and 11/25 or that V16 (R1's Physician) was notified of the missed doses of insulin or adjusted dose on 11/9/24. On 12/4/24 at 12:07 PM V2 Director of Nursing confirmed nurses should notify the physician when insulin/diabetic medications are not given or withheld without an order and this should be documented in a nursing note. V2 stated the agency nurses don't know to contact the physician when a medication is not available, but they should notify the physician and then contact the pharmacy. V2 confirmed nurses should document medication administration on the MAR indicated by a checkmark and it should not be left blank (incomplete). 2.) R2's November 2024 MAR documents to administer Insulin Lispro subcutaneously per sliding scale based on blood glucose results before meals and at bedtime. This MAR is blank (incomplete) for R2's insulin administration scheduled at 4:00 PM on the 17th, 25th, and 28th. This MAR documents NA (not applicable) on the 19th for R2's 5:30 AM blood glucose check and refers to the nursing notes for the insulin scheduled at 7:30 AM. There is no documentation in R2's medical record that R2's blood glucose was checked as ordered for these dates. R2's Nursing Note dated 11/19/2024 at 10:25 AM documents R2's Lispro sliding scale dose was not given and the physician was notified. There is no other documentation why R7's insulin was not administered for the other dates listed and that R7's physician was notified. 3.) On 12/3/24 at 1:30 PM R4 stated sometimes R4 waits four hours to get his medications and R4's morning medications and insulin have been given at 1:00 PM. R4's November 2024 MAR documents to administer Lantus (insulin) 90 units subcutaneously daily at 8:00 PM, Trulicity (diabetic medication)1.5 milligrams (mg)/0.5 milliliters (ml) inject 1.5 mg subcutaneously weekly on Saturdays, and Humalog insulin 35 units three times daily before meals at 7:00 AM, 11:00 AM, and 4:00 PM. This MAR is blank for Lantus administrations on 11/6/24 and 11/9/24 and Humalog administrations on 11/6/24 and at 4:00 PM on 11/25/24. This MAR documents NA for Humalog administration on 11/19/24 at 11:00 AM. R4's Humalog 7:00 AM dose was given at 10:31 AM on 11/8/24, 8:44 AM on 11/11/24, 2:46 PM on 11/14/24, 9:22 AM on 11/15/24, 10:47 AM on 11/16/24, 8:28 AM on 11/17/24, 9:18 AM on 11/18/24, 8:45 AM on 11/22/24, and 10:38 AM on 11/22/24. R4's Humalog 11:00 AM dose was given at 4:33 PM on 11/9/24, 12:51 PM on 11/13/24, 3:18 PM on 11/14/24, 12:29 PM on 11/16/24, 12:34 PM on 11/17/24, and 12:39 PM on 11/18/24. R4's Humalog 4:00 PM dose was given at 5:51 PM on 11/16/24, 5:46 PM on 11/16/24, and 5:41 PM on 11/19/24. This MAR does not document Trulicity was administered on 11/9/24 and defers to R4's nursing notes. R4's December 2024 MAR documents on 12/2/24 Lantus was held and defers to R4's nursing notes. R4's Nursing Note dated 11/9/2024 at 5:14 PM documents the facility did not have Trulicity to administer, the pharmacy was notified and the medication was to be delivered that evening. There is no follow up documentation that this medication was delivered and administered as ordered. R4's Nursing Note dated 12/2/24 at 8:43 PM R2's Lantus was held due to blood glucose of 88 mg/dl. There is no documentation that the physician was notified of the missed doses of Trulicity, Humalog, and Lantus. On 12/4/24 at 12:27 PM the medication cart for R4's hall was viewed with V24 Licensed Practical Nurse. V24 was unable to locate R4's Trulicity and Lantus. V24 then checked the medication room and was still unable to locate these medications. V24 stated V24 will have to contact the pharmacy to have the medications delivered. On 12/3/24 at 12:51 PM V13 Activity Director stated during the November 2024 Resident Council Meeting R4 voiced concerns with the timeliness of R4's insulin administration since the facility recently changed to a liberalized medication pass. On 12/4/24 at 12:07 PM V2 stated medications with specified times have to be administered within an hour window before/after the scheduled time and the nurses should record medication administration on the MAR at the time the medication was given. V2 stated the nurse should have given R4's Trulicity when it came in and documented this information in a nursing note or on the MAR. 4.) On 12/4/24 at 10:05 AM R7 stated when agency nurses work they don't always check R7's blood glucose, especially at supper time, and then R7 doesn't get R7's scheduled sliding scale insulin. R7 stated this has happened a couple of times. R7's November 2024 MAR documents to administer Ozempic (diabetic medication) 4 mg/3 ml give 1 mg subcutaneously once weekly on Mondays and this medication was not given on 11/25/24 and defers to R7's nursing notes. R7's November 2024 and December 2024 MARs document to administer Tresiba (diabetic medication) 100 units/ml give 38 units subcutaneously once daily, and this medication was not required on 11/17/24 and 11/23/24, left blank on 11/25/24, and not given with defer to nursing notes on 12/2/24 and 12/3/24. These MARs document to administer Lispro 10 units three times daily with meals and per blood glucose based sliding scale three times daily. These MARs document Lispro 10 units was not required on 11/7/24 at 12:00 PM and 5:00 PM and on 12/1/24 at noon. There is no documentation that R7's blood glucose was checked at noon on 11/23/24 and sliding scale insulin administered as ordered. There are no orders to hold R7's scheduled Tresiba or Lispro 10 units. R7's Nursing Notes document R7's Tresiba was on order on 11/30/24, was not in stock and ordered on 12/2/24, and was not given on 12/3/24 due to low blood glucose. There is no documentation that R7's physician was notified of missed doses of insulin. R7's Nursing Notes document Lispro 10 units was held on 11/23/24 at 4:31 PM due to low blood glucose of 81 mg/dl. There are no other notes to document why Ozempic, Lispro, or Tresiba weren't administered as ordered and that the physician was notified. On 12/4/24 at 12:07 PM V2 stated we were waiting on insurance approval for Tresiba and the physician should have been notified. V2 stated the agency nurses don't know to contact the physician when a medication is not available, but they should notify the physician and then contact the pharmacy.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

Based on observation, interview and record review the facility failed to staff a Registered Nurse (RN) for eight consecutive hours per day. This failure has the potential to affect all 68 residents re...

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Based on observation, interview and record review the facility failed to staff a Registered Nurse (RN) for eight consecutive hours per day. This failure has the potential to affect all 68 residents residing in the facility. Findings include: On 12/3/24 at 11:54 AM V3 RN was working on the memory care unit of the facility. V3 stated this is V3's third day working for the facility. The facility's Daily Assignment Sheets dated 11/21/24-11/24/24, 11/27/24, 11/28/24, 11/30/24, and 12/1/24 do not document the facility had an RN on duty for eight consecutive hours each day. The facility's Daily Assignment Sheets dated 11/20/24, 11/25/24, and 11/26/24 document V2 Director of Nursing worked between three and four hours on second shift on these dates and there were no other RNs listed. On 12/3/24 at 2:20 PM the Daily Assignment Sheets were reviewed with V2. V2 confirmed all of the nurses listed on the assignment sheets for 11/21/24-11/24/24, 11/27/24, 11/28/24, 11/30/24, and 12/1/24 are Licensed Practical Nurses (LPNS) and the facility did not have eight consecutive hours of RN coverage each of those days. V2 stated V2 worked the floor on 11/26/24 from 2:00-6:00 PM, 11/25/24 from 3:00-6:00 PM, and 11/20/24 from 2:00-6:00 PM, and confirmed there were no other RNs staffed those days provide eight consecutive hours of RN coverage. V2 stated we have been using a lot of agency nurses, but corporate will only allow us to use LPNs. V2 stated the facility has one full time RN and a part time RN who only works Mondays and Tuesdays. The facility's Midnight Census, provided by V1 Administrator on 12/3/24, documents 68 residents reside in the facility.

Aug 2024 20 deficiencies 2 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Deficiency F0697 (Tag F0697)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to effectively manage pain, routinely assess for pain, an...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to effectively manage pain, routinely assess for pain, and timely implement pain medication orders for one (R45) of two residents reviewed for Hospice in the sample list of 36. This failure resulted in R45 experiencing uncontrolled pain as evidenced by grimacing, moaning, and yelling out. Findings include: The facility's Pain Prevention & Treatment policy dated 12/7/17 documents: It is the facility policy to assess for, reduce the incidence of and the severity of pain in an effort to minimize further health problems, maximize ADL (Activities of Daily Living) functioning and enhance quality of life. Assessment of pain will be completed with changes in the resident's condition, self reporting of pain or evidence of behavioral cues indicative of the presence of pain and documented in the nurses notes or on the Pain Management Flow Sheet. This will include, but is not limited to, date, rating, treatment intervention and resident response. The Pain Management Flow Sheet will be initiated for those residents with but not limited to: routine pain medication, daily pain, diagnosis that may anticipate pain. Information collected on the Pain Assessment Form will be used to formulate and implement a resident specific Pain Treatment Plan documented in the resident's care plan. On 8/25/24 at 8:34 AM R45 was lying in bed moaning. V7, V9, and V10 Certified Nursing Assistants (CNA) entered R45's room. V9 stated R45 is on hospice and does that a lot, in regards to R45's moaning. V9 stated V9 will try to see what R45 needs. On 8/25/24 at 8:42 AM R45 had been repositioned. V4 Registered Nurse entered R45's room and R45 reported having back pain when V4 asked about R45's pain. On 8/25/24 at 4:15 PM V7, V9, V28 CNAs entered R45's room, provided urinary catheter care, and transferred R45 with a full mechanical lift from the bed into a reclining geriatric chair. During the catheter care R45 grabbed hold of the privacy curtain and moaned when staff turned and moved her. During the transfer R45 had facial grimacing and cried out ow, it hurts, hurry hurry. V7 and V9 were asked about R45's pain and moaning, and stated that was normal for R45. On 8/26/24 at 3:33 PM R45 was heard moaning from R45's room. V9 stated V9 will check on R45. R45's ongoing Diagnoses List documents R45 has Cirrhosis of the liver, Acute Kidney Injury, Hyperuricemia, and Esophageal Varices. R45's Minimum Data Set, dated [DATE] documents R45 has severe cognitive impairment, and during the last five days R45's pain was almost constant, frequently affected sleep, and almost constantly affected daily activities. R45 rated the worst intensity of pain as very severe, horrible during the last five days. There is no documentation that R45's pain is routinely assessed besides on admission and when PRN (as needed) pain medication is administered. R45's Care Plan dated 7/23/24 documents R45 is at risk for pain and documents interventions to anticipate need for pain relief and respond immediately to complaints of pain, monitor/document probably cause for pain episodes, remove/limit causes of pain when possible, monitor and report signs of pain to the nurse. This care plan does not document new interventions were developed/implemented to address R45's pain after 7/23/24. R45's July 2024 Medication Administration Record documents Percocet (narcotic pain medication) 5-325 milligrams (mg) one tablet twice daily for pain from 6/29-7/16/24, Fentanyl (narcotic) 12 micrograms (mcg) (incorrectly noted as 25 mcg) patch apply every 72 hours starting 7/17/24, Percocet 5-325 mg one tablet every 4 hours PRN from 6/29/24-8/15/24. 20 doses of PRN Percocet was given in July, and there were four times that R45's pain was rated 7-9 on a 1-10 scale between 7/10/24 and 7/16/24. R45's Hospice Physician Order Form dated 8/14/24 documents an order to discontinue Fentanyl 12 micrograms (mcg) and start Fentanyl 25 mcg patch apply every 72 hours. There is no documentation that this was implemented prior to 8/25/24 (11 days after the order). R45's August 2024 MAR documents Fentanyl 12 mcg patch was administered every 72 hours from 8/1-8/25/24, excluding 8/19/24 in which this entry documents to refer to R45's nursing notes. R45's nursing notes do not document why this medication was not administered. R45's August 2024 MAR documents Morphine Sulfate concentrate 20 mg/ml (milliliters) give 5 mg or 10 mg every hour PRN for pain initiated 8/15/24, Percocet 5-325 mg one tablet every 4 hours PRN discontinued 8/15/24. This MAR documents Tylenol 650 mg PRN was given on 8/20/24 at 10:20 AM for pain rated 9, and 15 doses of Morphine 10 mg and seven doses of Morphine 5 mg were given. R45's pain was rated 7-10 for 11 of the Morphine administrations, and 6 of these doses are documented as being ineffective in pain relief. There is no documentation that R45 refuses pain medication. R45's Controlled Substances Proof of Use dated 8/15/24-8/25/24 documents three Morphine Sulfate 0.5 ml (10 mg) administrations 8/24/24 at 8:00 PM, and 8/25/24 at 12:00 AM and 5:00 AM that are not documented on R45's MAR or nursing notes. There are no pre and post pain assessments documented for these administrations. On 8/25/24 at 10:48 AM V4 Registered Nurse (RN) stated R45 gets Fentanyl, Morphine, Tylenol and Ativan for pain, some of these medications are scheduled and some are given PRN. V4 stated we have been giving R45's PRN medications around the clock. V4 stated it was passed on in shift report today that R45 was uncomfortable and was up until 3:00 AM. At 11:36 AM V4 stated R45 had only one Fentanyl 12 mcg patch on this morning, which V4 removed and applied two patches. On 8/26/24 at 9:31 AM V14 Licensed Practical Nurse stated V14 was not sure why V14 did not administer R45's Fentanyl patch on 8/19/24, and possibly R45 refused the medication. On 8/26/24 at 12:00 PM V26 Hospice RN stated V26 consults with the nurses about R45's pain during each visit and the facility calls when R45 has increased pain. V26 confirmed the facility should call hospice if there are problems managing R45's pain. V26 stated V26 ordered Fentanyl 25 mcg from the hospice pharmacy on 8/18/24 and discovered during narcotic count on 8/20/24 that the facility still only had the 12 mcg patches. V26 confirmed not administering Fentanyl as ordered could contribute to R45 having increased pain. On 8/26/24 at 3:49 PM V21 LPN stated R45 was in a lot of pain on Saturday night (8/24/24), and R45 is usually in a lot of pain when R45 is laying down. V21 stated R45 rated R45's pain that night as a 10, we repositioned R45, V21 administered Haldol, Morphine, and Ativan and R45 slept for a few hours. V21 stated R45 woke up again moaning around 1:30-2:00 AM and then again at 6:00 AM. V21 stated Morphine does help relieve R45's pain and it helped that night. V21 stated if the medication administration is not documented on the MAR then it would be on the count sheets. V21 stated sometimes it doesn't show up on the MAR when V21 documents PRN medication administration. V21 stated R45 moans, yells out, and thrashes about when R45 has pain. On 8/25/24 at 3:42 PM V2 Director of Nursing (DON) stated pain should be documented in a progress note, pain should be assessed on an hourly basis for hospice residents, and hospice should be consulted for any uncontrolled pain. When asked about pain assessment documentation, V3 Assistant DON stated we chart by exception and pain scales are documented when PRN medications are given. V3 stated 12 mcg was ordered on 7/17/24 and V3 put an order in today to increase to 25 mcg and may apply two 12 mcg patches until the 25 mcg patches arrive. At 3:51 PM V2 reviewed R45's hospice binder and confirmed order to increase Fentanyl 25 mcg on 8/14/24. On 8/27/24 at 3:55 PM V2 stated hospice nurses give the facility their notes and order forms, and verbally tell the nurses of any new orders.

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Deficiency F0698 (Tag F0698)

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 provide dialysis services to one (R15) of two residents reviewed for...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide dialysis services to one (R15) of two residents reviewed for dialysis services from a total sample list of 36. This failure resulted in R15 being hospitalized for Hypervolemia. Findings include: On 8/27/24 at 1:10PM, R15 stated, I missed nearly two and a half months of dialysis because V11 Social Services Director didn't understand that I needed dialysis and didn't get a nurse involved. I ended up in the hospital really sick. I was doing dialysis three times a week before I came here. R15's undated census report documents that R15 was initially admitted to the facility on [DATE]. R15's undated diagnosis sheet documents that R15 was admitted with a diagnosis of kidney failure. R15's admission record dated 12/18/23 documents that R15 was admitted to the facility with a renal shunt for dialysis. R15's medical record documents that R15 was admitted to the hospital on [DATE] for Hypervolemia. R15's hospital discharge notes dated 2/6/24 document that R15 needs three times a week dialysis, to follow up with nephrology and to have a renal diet. On 8/27/24 at 2:30PM, V1 administrator stated , R15 was admitted urgently in December of 2023. The day of admission R15 was supposed to have dialysis; however the facility could not provide transportation on that date and after that I'm not sure what happened because (V11 Social Services Director) was handling it (dialysis appointments). On 8/27/24 at 2:45PM, V2 Director of Nursing said that nursing issues such as dialysis should be managed by nursing and that now they are being done so. On 8/27/24 at 1:50PM, V32 Dialysis Registered Nurse said that R15's first treatment at their facility was on 2/9/24 after she had been being dialyzed at the hospital. V32 said that R15 has kidney failure that requires dialysis three times a week and that the risks of not receiving dialysis three times a week could result in critical fluid overload including hospitalization.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure for the dignity of two (R5, R15) of 16 residents reviewed for...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure for the dignity of two (R5, R15) of 16 residents reviewed for dignity from a total sample list of 36 residents. Findings include: The facility Abuse Prevention Program Policy dated 11/28/16 documents that the facility prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. Additionally the facility seeks to establish an environment that promotes resident sensitivity, resident security, and prevention of mistreatment, exploitation, neglect, and abuse of resident misappropriation of resident property. 1.) R5's Minimum Data Set, dated [DATE] documents that R5 is cognitively intact. R5's Minimum Data Set, dated [DATE] documents that R5 is dependent for personal hygiene. On 8/25/26 at 12:26PM, R5 said that V12 Certified Nursing Assistant (CNA) wasn't always nice to her and could make her feel bad and hurt her feelings. R5 said that V12 CNA would get mad when R5 couldn't move her legs to help when she was being provided care. It isn't abuse, but she is very disrespectful. 2.) R15's Minimum Data Set, dated [DATE] documents that R15 is cognitively intact. R15's Minimum Data Set, dated [DATE] documents that R15 requires partial to moderate assistance with lower body cares. On 8/27/24 at 1:10PM, R15 stated, I don't like (V12 CNA) caring for me. She has a smart mouth and she is very disrespectful to me. On 8/26/24 at 1:28PM, V2 Director of Nursing (DON) confirmed she had complaints about (V12 CNA) and has addressed the issue.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review the facility failed to notify the Physician, Power of Attorney and Dietician of a significant weight loss of greater than 10 percent for one of one re...

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Based on observation, interview and record review the facility failed to notify the Physician, Power of Attorney and Dietician of a significant weight loss of greater than 10 percent for one of one resident (R43) reviewed for weight loss in the sample list of 36. Findings include: The facility's Notification for Change in Resident Condition or Status policy with a revised date of 12/7/17 documents, The facility and/or facility staff shall promptly notify appropriate individuals (i.e. {for example} Administrator, DON {Director of Nursing}, Physician, Guardian, HCPOA {Health Care Power of Attorney}, etc.{etcetera}) of changes in the resident's medical/mental condition and/or status. Procedure: 1 The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: n. 5% weight gain or loss in 30 days, 7.5% weight gain or loss in 90 days, 10% weight gain or loss in 180 days. 3 Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. R43's Order Summary Report dated 8/25/24 documents diagnoses including Age-Related Cognitive Decline, Depression and Anxiety. R43's Care Plan dated 3/8/24 documents R43 has a nutritional problem or a potential nutritional problem related to Depression with an intervention to provide and serve diet as ordered, monitor intake and record every meal dated 3/8/24. R43's weight log dated 8/25/24 documents R43's weight on 7/25/24 as 134.2 pounds and on 8/14/24 as 119.4 pounds which resulted in a 11.03% (percent) weight loss in one month. R43's Nurse's Notes dated 8/16/24 at 2:17 PM by V15 Dietary Manager documents R43 has lost 15 pound in a 20 day period. R43 had some edema which may be cause of some of the weight loss. R43 has not been eating very much lately. Staff will continue to monitor and help assist R43 during meal times. On 8/26/24 at 12:08 PM, R43 was feeding herself lunch. R43 had a pork fritter with gravy, scalloped potatoes, green beans, peaches, a cup of red drink, water and coffee. On 8/27/24 at 10:47 AM, V2 Director of Nursing confirmed R43's significant weight loss and confirmed there is no documentation that the POA, Physician or Dietician were notified of the significant weight loss. V11 Social Services Director also confirmed that she did not discuss the weight loss with the family.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

Based on interview and record review the facility failed to ensure one resident (R28) was free from physical abuse by another resident (R38) of seven residents reviewed for abuse in a sample list of 3...

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Based on interview and record review the facility failed to ensure one resident (R28) was free from physical abuse by another resident (R38) of seven residents reviewed for abuse in a sample list of 36 residents. Findings include: R28's Progress Note dated 8/15/24 at 6:29PM documents (R38) became agitated, as (R28) was yelling out 'daddy daddy', as staff was moving (R38) in dining room, (R38) picked up his glass of water and threw it on (R28) . Staff removed (R38) from dining room. (R28) had no injuries and no complaints of pain. R28's Physician's Order Summary printed 8/28/24 includes the following diagnoses: Dementia, Psychotic Disturbance, Anxiety, Bipolar Disease, Post-traumatic Stress Disorder. There is no documentation of specific resident centered interventions for R28 in relation to the diagnosis of Post-traumatic stress Disorder in R28's care plan. On 8/26/24 at 11:00AM V1, Administrator stated We were aware (R38) is physically aggressive at times. He was observed 8/15/24 to have thrown a glass of water on (R28). They were immediately separated. Looking back it was probably not the best choice to put (R28 and R38) at the same table for meals since (R28) does yell out at times. The facility Abuse Prevention Program dated 11/28/16 documents, this facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined. Abuse is the willful injection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. The Abuse Prevention Program also documents, Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. The Abuse Prevention Program also documents, Examples of verbal abuse include, but are not limited to, threats of harm, or saying things to frighten a resident, such as telling a resident that he/she will never be able to see family again. Mental Abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident(s), harassment, humiliation and threats of punishment or deprivation.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their abuse policy for two (R5, R45) of seven residents revi...

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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 their abuse policy for two (R5, R45) of seven residents reviewed for abuse from a total sample list of 36 residents. Findings include: The facility abuse policy dated 11/28/2016 documents that employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect and abuse of resident and misappropriation of resident property to a supervisor and administrator. This policy documents resident representatives will be notified of allegations of abuse, including misappropriation of resident property. 1.) On 8/25/24 at 1:00PM, R5 stated that she had a new cellular phone go missing and that she knew that it had been taken because the charger was left. R5 stated she notified V11 Social Services Director (SSD) that it was missing over a week ago and that she didn't know if they were going to replace it. On 8/25/24 at 1:15PM, V11 SSD stated she was still investigating the complaint. On 8/26/24 9:07AM V1 Administrator stated V11 SSD had not reported the allegation of potential misappropriation of personal property to her and that V1 Administrator did not know that R5's cellular phone was missing until yesterday (8/25/24) when the State Agency brought it to her attention. V1 stated, I am the abuse coordinator and the missing item should have been reported to me immediately so that a misappropriation of personal property investigation could have begun. The facility provided grievance dated 8/15/24 documents R5 notified V11 Social Services Director of the missing cellular phone. 2.) The facility's IDPH (Illinois Department of Public Health) Notification Form dated 8/23/24 documents on 8/23/24 at 12:00 PM V1 Administrator was notified of alleged missing Narcotics and an investigation was initiated. This form does not document that R45's (resident involved) family/representative were notified of the allegation. The facility's Final Report to IDPH documents the investigation determined pharmacy processed R45's Fentanyl (narcotic pain medication) patches and Lorazepam on 8/19/24, and a package containing only R45's Lorazepam was delivered on 8/20/24. This form documents the facility was unable to determine that R45's Fentanyl was delivered to the facility. R45's Hospice Physician Order Form dated 8/14/24 documents an order to discontinue Fentanyl 12 micrograms (mcg) patch apply every 72 hours and start Fentanyl 25 mcg patch apply every 72 hours. R45's Minimum Data Set, dated [DATE] documents R45 has severe cognitive impairment. There is no documentation in R45's medical record that R45's family was notified of R45's missing Fentanyl. On 8/25/24 at 8:43 AM V1 Administrator stated last Friday (8/23/24) V26 Hospice Registered Nurse reported that on 8/20/24 hospice sent by mail R45's Lorazepam tablets and one box of Fentanyl patches to the facility. V1 stated the facility received a package for R45 on 8/20/24, V1 signed the mail delivery receipt for the package and gave the package to V3 Assistant Director of Nursing. V1 stated the package only contained a card of Lorazepam tablets and was unable to locate the box of Fentanyl patches. On 8/25/24 at 4:45 PM V1 stated V1 did not report the missing Fentanyl to R45's family. V1 stated that notification should have been done right away, but V1 was busy conducting narcotic audits at that time.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to schedule a follow up cardiology appointment for one (R46) of two res...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to schedule a follow up cardiology appointment for one (R46) of two residents reviewed for dialysis in the sample list of 36. Findings include: R46's Diagnoses List documents R46's diagnoses include Type 2 Diabetes Mellitus, Hypertension, Chronic Obstructive Pulmonary Disease, Seizures, Stenosis of Carotid Artery, and Nonrheumatic Mitral Valve Prolapse. R46's Census documents R46 expired on [DATE]. R46's Hospital Discharge Instructions dated [DATE] documents R46's discharge problems were Acute Respiratory Failure and Hypertension, R46 has dialysis scheduled three times weekly, and to contact V27's office (Cardiologist) to schedule a follow up appointment. There is no documentation in R46's medical record that the facility contacted V27's office to schedule this appointment. On [DATE] at 11:02 AM V11 Social Services Director stated V11 is responsible for scheduling resident appointments. V11 reviewed the facility's appointment calendar and did not see that R46 had an appointment scheduled with V27. V11 stated V11 asks for copies of hospital discharge summaries and reviews appointments that are needed. V11 stated V11 was not sure if V11 received notification to schedule R46's appointment. V11 stated V3 Assistant Director of Nursing (ADON) is the only other employee who assists with scheduling appointments. On [DATE] at 11:07 AM V3 ADON stated the facility was probably in the process of scheduling R46's appointment, but then R46 died. V3 stated V11 does the appointment scheduling and keeps record of appointments. V3 stated V3 did not schedule R46's follow up appointment. On [DATE] at 11:13 AM V1 Administrator stated the facility does not have a policy for scheduling resident appointments, we expect physician's orders to be followed.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to obtain treatment orders and implement pressure relievin...

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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 obtain treatment orders and implement pressure relieving interventions for three (R5, R14 and R4) of three residents reviewed for pressure ulcer wounds from a total sample list of 36 residents. Findings include: The facility Preventative Skin Care Policy dated October 2006 documents that it is the policy of the facility to provide preventative skin care through repositioning and careful washing, rinsing, drying and observation of the residents skin condition to keep them clean, comfortable, well groomed and free from pressure ulcers. If reddened areas are noted, it will be reported to the Charge Nurse. Any resident identified as being at high risk for potential skin breakdown shall be turned and reposition a minimum of every two hours. The facility Decubitus Care/Pressure Areas Policy dated January 2018 documents that it is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer. 1.) R5's skin assessment dated [DATE] documents R5 is at high risk for skin breakdown. R5's physician orders dated 1/26/24 documents barrier cream to be applied to R5's buttocks for excoriation twice daily. R5's August 2024 treatment administration record documents that barrier cream was not applied as ordered on 8/5/24, 8/10/24, 8/14/24, 8/17/24 and 8/20/24. R5's Minimum Data Set, dated [DATE] documents that R5 is cognitively intact. On 8/25/24 at 11:00AM, R5 stated she had a wound on her buttocks and legs and that she didn't think that there was a treatment on it. On 8/26/24 at 8:36AM V2 Director of Nursing stated that she is unaware of R5 having any wounds. On 8/26/24 at 2:15PM, R5 was rolled to the side where two half dollar sized stage two wounds were visualized on R5's right buttock and upper thigh. No dressing or treatment was on the wounds. On 8/26/24 at 2:20PM, V16 Licensed Practical Nurse (LPN) stated she was not aware prior to now that R5 had any open areas to her skin and there were no current treatment orders for R5's open wounds. On 8/26/24 at 2:25PM, V23 Certified Nursing Assistant (CNA) stated she saw open wounds on R5's backside last week and that she told the nurse at that time. 2.) R14's skin assessment dated [DATE] documents that R14 is at high risk for skin breakdown. R14's orders dated 8/9/24 document to apply Nystatin External Cream 100,000 units per gram every 12 hours as needed for excoriation. On 8/25/24 at 10:18AM, R14 stated she has a wound on her bottom. R14 was sitting in the common room from 8:30AM to 11:30AM without a pressure relieving cushion in her wheelchair. On 8/27/24 at 10:45AM, R14 was sitting in her wheel chair in her resident room without a pressure relieving cushion in the chair. On 8/26/24 at 8:36AM, V2 Director of Nursing stated that she is unaware of R14 having any current wounds. On 8/26/24 at 4:15PM, R14 had open areas and irritation to inner thighs. R14's vaginal area, inner thighs and buttocks were red/raw/excoriated. A linear open wound was on the left inner thigh and a superficial open wound was on the left posterior thigh/gluteal fold. On 8/26/24 at 4:30PM, V16 LPN stated the posterior thigh wound was identified yesterday and reported to the nurse. V12 stated R14 was red like this when she last cared for her, but couldn't recall what day. On 8/27/24 at 1:30PM, V2 Director of Nursing stated physician orders should be followed including treatments and medications to prevent skin breakdown. 3.) R4's Order Summary Report dated 8/25/24 documents diagnoses including Dementia, Shizoaffective Disorder, Type 2 Diabetes Mellitus, Muscle Weakness and Unsteadiness on Feet. R4's Care Plan dated 2/28/24 documents R4 has a pressure ulcer or potential for pressure ulcer development with interventions to see the TAR (Treatment Administration Record) for current orders, administer treatments as ordered and monitor for effectiveness, follow the facility's policies and protocols for prevention/treatment of skin breakdown and monitor and document and report any changes in skin status all dated 2/28/24. R4's skin risk assessment dated [DATE] documents R4 is at a high risk for skin impairment. Interventions listed on the assessment are pressure reducing device for the bed and chair and a protective device (protective sleeves). R4's Minimum Data set (MDS) dated [DATE] documents R4 has a pressure reducing device for the bed and the chair. R4's shower sheet dated 8/4/24 documents discoloration on the left heel. R4's shower sheet dated 8/12/24 documents left heel under findings and does not document any other information regarding the left heel. R4's shower sheet dated 8/17/24 documents a pressure ulcer and has the left heel circled. R4's shower sheet dated 8/22/24 documents a blister on the left heel. R4's Treatment Administration Record (TAR) dated 7/1/24 through 7/31/24 documents an order for cushion protective boots when in bed every shift with a start date of 7/11/24. This order is not signed out as completed on 7/12/24, 7/14/24, 7/15/24, 7/20/24, 7/25/24 and 7/26/24 on the night shift and on 7/31/24 on the day shift. There is no treatment order for the left heel on the July TAR. R4's August (TAR) documents the order for the cushion protective boots and is not signed out as completed on 8/2/24 and 8/13/24 on the day shift and on 7/3/24, 7/5/24, 7/10/24 and 7/17/24 on the night shift. R4's TAR dated 8/1/24 through 8/31/24 does not document a treatment order for R4's left heel. On 8/25/24 at 9:10 AM, R4 was in her bed in her room with gripper socks on with her feet resting directly on the bed. There were no protective cushion boots on her feet or any boots visible in her room. On 8/26/24 at 1:46 PM and 3:25 PM, R4 was laying in bed with her feet directly on the mattress with no protective boots on her feet. On 8/25/24 at 11:27 AM, 12:14 PM and 2:45 PM, R4 was sitting in her wheel chair and there was no cushion underneath her, she was sitting directly on the sling bottom of the wheel chair and she had gripper socks on both feet. On 8/26/24 at 8:12 AM, 8:45 AM, 9:55 AM, 11:10 AM and 1:46 PM, R4 was in her wheel chair with gripper socks on both feet and no cushion in her wheel chair underneath her. On 8/27/24 at 1:05 PM, R4 was in bed and V23 Certified Nursing Assistant removed R4's left gripper sock. R4 had a large round sore on the left heel, approximately two inches in diameter. The bottom portion (approximately 1/4 inch) of the sore was black and necrotic. The rest of the sore was red. V23 then removed R4's right gripper sock and R4 had a red area on the right outer ankle with a white spot in the middle of the reddened area. At this time V23 confirmed that there was no cushion in R4's wheelchair that was sitting in her room. On 8/28/24 at 9:32 AM, R4 was in bed and she did not have any protective boots on her feet. On 8/27/24 at 11:44 AM, V2 Director of Nursing confirmed there was no treatment order for R4's left heel or right ankle. On 8/27/24 at 1:35 PM, V3 Assistant Director of Nursing stated R4 is supposed to have protective heel boots on when she is in bed. On 8/27/24 at 1:46 PM, V2 confirmed that R4 should have a pressure relieving device in her wheel chair and stated that they will contact the doctor to have R4's left heel looked at.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to properly maintain a urinary collection bag to prevent cross contamination and failed to change a urinary catheter as ordered f...

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Based on observation, interview, and record review the facility failed to properly maintain a urinary collection bag to prevent cross contamination and failed to change a urinary catheter as ordered for one of one resident (R45) reviewed for urinary catheters in the sample list of 36. Findings include: On 8/25/24 at 8:42 AM, 10:46 AM, and 2:33 PM R45 was lying in bed. R45's urinary collection bag was laying on the floor and contained dark urine. On 8/25/24 at 4:15 PM V7, V9 and V28 Certified Nursing Assistants entered R45's room and provided R45's urinary catheter care. V9 stated the facility has been out of privacy bags which are used to cover the urinary collection bags. V7 stated V7 placed a pillow case over R45's urinary collection bag this afternoon to keep it from contacting the floor. R45's Physician Order dated 7/1/24 documents urinary catheter size 16 French with 30 cc (cubic centimeter) bulb, change monthly and as needed. R45's July and August 2024 Treatment Administration Records document this order, but do not document that R45's urinary catheter has been changed. There is no documentation in R45's medical record that R45's urinary catheter has been changed monthly as ordered. R45's Urine Culture dated 7/24/24 documents Escherichia coli (bacteria) and Pseudomonas aeruginosa (bacteria) greater than 100,000 colony forming units, indicating a urinary tract infection. On 8/25/24 at 2:40 PM V3 Assistant Director of Nursing stated R45's catheter is changed routinely at the facility by hospice and should be documented in the hospice notes. At this time documentation of R45's catheter changes was requested. On 8/26/24 at 8:07 AM V2 Director of Nursing confirmed urinary collection bags should be kept off of the floor for infection control purposes. V2 stated there should be a barrier between the collection bag and the floor, and staff could use an incontinence pad on the floor as a barrier. At this time documentation was requested for R45's urinary catheter changes. On 8/26/24 at 12:00 PM V26 Hospice Registered Nurse stated hospice can assist with changing R45's catheter, but R45's catheter has not been changed by hospice. On 8/28/24 the facility had not provided any documentation that R45's catheter was changed. The facility's Urinary Drainage Collection Unit policy dated February 2018 documents to keep the urinary drainage bag covered with a dignity bag.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

2.) R5's undated diagnoses sheet documents the following diagnoses including: Congestive Obstructive Pulmonary Disease, Hypertension, Congestive Heart Failure, Right Heart Failure, Chronic Respiratory...

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2.) R5's undated diagnoses sheet documents the following diagnoses including: Congestive Obstructive Pulmonary Disease, Hypertension, Congestive Heart Failure, Right Heart Failure, Chronic Respiratory Failure with Hypercapnia, Acute Respiratory Failure with Hypoxia, Congenital Bronchomalacia, Pulmonary Heart Disease, Other Diseases of the Bronchus, and Morbid Obesity with Alveolar Hypoventilation. R5's physician order dated 8/16/24 documents an order for oxygen at two liters per nasal cannula when in bed. On 8/25/24 at 12:17PM, R5 was wearing oxygen per nasal cannula and the concentrator was delivering four liters per nasal cannula. There was no label with the date of change documented on the tubing or on the water bottle. On 8/25/24 at 12:20PM, R5 was not wearing oxygen and said that the staff always administer four liters of oxygen when she wears it at night. R5's oxygen tubing was laying on top of the concentrator, undated. On 8/26/24 at 10:52AM, R5 was not wearing oxygen and the oxygen tubing was laying on top of the concentrator, undated. Based on observation and record review the facility failed to store respiratory equipment in a clean and sanitary manner, failed to change respiratory equipment as ordered, failed to date respiratory equipment when changed and failed to administer oxygen as ordered for two of three (R22, R5) residents reviewed for respiratory care in the sample list of 36. Findings include: The facility's Oxygen Therapy policy with a revised date of August 2003 documents, Oxygen therapy may be used provided there is a written order by the physician. The order must state liter flow per minute, mask or cannula, time frame. Change oxygen tubing/mask/cannula/and/or tracheostomy mask on a weekly basis. Date tubing changes and document on the treatment sheet. If humidification is indicated, date prefilled bottles when changed. 1.) R22's Order Summary report dated 8/25/24 documents diagnoses including Essential Hypertension, Pneumonia, Chronic Obstructive Pulmonary Disease With Exacerbation, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris. On 8/25/24 at 11:26 AM, R22's nebulizer machine was sitting on the bedside table behind her with the nebulizer mask hanging on the side of it, uncovered and open to the air. On 8/26/24 at 8:40 AM, R22's nebulizer machine and mask with the tubing attached was still sitting out in the open with no cover on it. The nebulizer mask and the medication cup portion of the mask were dated 8/6/24. R22's Order Summary Report documents an order for Iprotropium-Albuterol Inhalation solution 0.5-2.5 mg (milligrams)/3 ml (milliliters) one vial, inhale orally every 6 hours as needed for wheezing related to Chronic Obstructive Pulmonary Disease with Exacerbation with a start date of 12/13/23. There is no order to change the nebulizer mask or tubing.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to administer medications in accordance with manufacturer's instructions and facility policy for two (R14, R34) of nine residents...

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Based on observation, interview, and record review the facility failed to administer medications in accordance with manufacturer's instructions and facility policy for two (R14, R34) of nine residents reviewed for medication administration in the sample list of 36. This failure resulted in four medication errors out of 25 opportunities, a medication error rate of 16%. Findings include: 1.) On 8/26/24 at 4:15 PM V16 Licensed Practical Nurse (LPN) administered crushed R14's Atorvastatin 20 milligrams (mg) tablet, Carvedilol 6.25 mg tablet, and Eliquis 5 mg tablet and placed into a medication cup. V16 did not dissolve these medications in water. V16 entered R14's room and checked R14's gastrostomy tube placement with a syringe. V16 poured approximately 40 ml (milliliters) of water into the syringe connected to R14's gastrostomy tube to administer via gravity flow. The water did not infuse and V16 checked R14's gastrostomy tube placement with air rush technique three times before water would infuse via gravity flow. V16 stated R14 gets a total of 300 ml of water flush for medication administration. V16 poured 10 ml water into the syringe connected to R14's gastrostomy tube, followed by 15 ml of Potassium 20 milliequivalents/15 ml, followed by the crushed medications, followed by the remainder of the 300 ml of water. On 8/27/24 at 8:45 AM V16 confirmed V16 did not dissolve R14's crushed medications in water prior to administration. V16 stated V16 usually dissolves the medication in warm water first, but forgot to do that. R14's Physician's Orders dated 6/28/24 document to administer Atorvastatin 20 mg daily, Eliquis 5 mg one twice daily, and Carvedilol 6.25 mg twice daily. There are no orders documenting the amount of water that should be mixed with R14's medications for administration. The facility's Administration of Medication Via a Feeding Tube policy dated 3/17/23 documents unless it is contraindicated, crush medications well and dissolve in water prior to administration, and flush with 5 cc (cubic centimeters) of water between crushed and liquid medications. 2.) On 8/27/24 at 7:53 AM V16 LPN gave R34 one puff of Albuterol Sulfate 90 mcg followed by another puff less than 30 seconds later and without shaking the inhaler between puffs. On 8/27/24 at 8:45 AM V16 stated I believe you have to wait 30 seconds before administering the second puff of Albuterol. R34's August 2024 Medication Administration Record documents R34 receives Albuterol 90 mcg two puffs inhaled four times daily. The Albuterol manufacturer's insert dated February 2019 documents to when administering more than one puff, wait one minute and shake the inhaler between puffs.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0847 (Tag F0847)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents and resident representatives understood the facilit...

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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 and resident representatives understood the facility's arbitration agreement. This failure affects two (R32, R35) of three residents reviewed for arbitration in the sample list of 36. Findings include: 1.) R35's Agreement to Resolve Disputes by Binding Arbitration dated 2/2/23 documents this is an agreement between the facility and R35 to utilize arbitration (an outside third party) to settle disputes between R35 and the facility, and the resident waives the right to a trial in court and a trial by a jury for future legal claims that the resident may have against the facility. This agreement is signed by R35 and V11 Social Services Director. R35's ongoing census documents R35 admitted to the facility on [DATE]. R35's Minimum Data Set (MDS) dated [DATE] documents R35 as cognitively intact. On 8/27/24 at 12:59 PM R35 stated the facility staff come to you with a stack of papers to sign on admission, they briefly explain things and then say sign here. R35 stated the arbitration agreement was not explained to her that it waives the right to a court trial for legal claims. R35 stated R35 would not have signed the arbitration agreement if she had known, because R35 wants the option of a court trial. 2.) R32's Agreement to Resolve Disputes by Binding Arbitration dated 6/14/22 documents this is an agreement between the facility and R32 to utilize arbitration to settle disputes between R32 and the facility, and the resident waives the right to a trial in court and a trial by jury for future legal claims that the resident may have against the facility. This agreement is signed by V30, R32's Guardian, and V11. R5's MDS dated [DATE] documents R32 has severe cognitive impairment. On 8/27/24 at 1:40 PM V30 stated V30 did not fully understand the arbitration agreement that was signed. V30 stated the agreement wasn't explained to V30 very well and V30 did not understand that V30 was waiving R32's right to a court trial by signing the arbitration agreement. V30 stated V30 would still want a court trial as an avenue if legal action would ever be needed. On 8/27/24 at 1:53 PM V11 stated V11 explains to residents and their representatives that arbitration is a third party that is brought in to resolve disputes without going through the court systems, and that the resident is not able to utilize the court system for legal claims if the arbitration agreement is in place. V11 confirmed the arbitration is voluntary and is reviewed with residents as part of their admission paperwork. V11 stated V11 will follow up with R32 and V30 and review the arbitration agreement with them.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review the facility failed to accurately account for controlled substance medications and repeatedly failed to ensure medications were provided as ordered f...

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Based on observation, interview, and record review the facility failed to accurately account for controlled substance medications and repeatedly failed to ensure medications were provided as ordered for four (R45, R14, R32, R22) of 16 residents reviewed for physician orders in the sample list of 36. Findings include: 1.) R45's Hospice Physician Order Form dated 8/14/24 documents an order to discontinue Fentanyl 12 micrograms (mcg) and start Fentanyl 25 mcg patch apply every 72 hours. The facility's IDPH (Illinois Department of Public Health) Notification Form dated 8/23/24 documents on 8/23/24 at 12:00 PM V1 Administrator was notified of alleged missing Narcotics and an investigation was initiated. The facility's Final Report to IDPH documents the investigation determined pharmacy processed R45's Fentanyl (narcotic pain medication) patches and Lorazepam on 8/19/24, and a package containing only R45's Lorazepam was delivered on 8/20/24. This form documents the facility was unable to determine that R45's Fentanyl was delivered to the facility. The facility's investigation file for this incident contained a proof of delivery receipt with the tracking number for R45's medication package and V1 signed for the delivery on 8/20/24. This file included written statements from V3 Assistant Director of Nursing (ADON), V14 Licensed Practical Nurse (LPN), and V2 DON dated 8/23/24-8/25/24 that document V1 received the package, gave the package to V3, V3 opened the package which only contained a card of R45's Lorazepam, V3 gave this package to V14 to put away, and V2 never received this package. On 8/25/24 at 8:43 AM V1 Administrator stated last Friday (8/23/24) V26 Hospice Registered Nurse reported that on 8/20/24 hospice sent R45's Lorazepam tablets and one box of Fentanyl patches to the facility. V1 stated the facility received a package for R45 on 8/20/24, V1 signed the mail delivery receipt for the package and gave the unopened package to V3 Assistant Director of Nursing (ADON). V1 stated per V3, the package only contained a card of Lorazepam tablets and did not contain a box of Fentanyl patches. On 8/25/24 at 4:45 PM V1 stated V1 spoke with staff at the hospice pharmacy and determined R45's Lorazepam and Fentanyl patches were in the same delivery package with the same tracking number. V1 stated from now on we aren't going to accept mail delivery of controlled medications. V1 confirmed the facility has not required a second signature to verify receipts of controlled medications delivered by mail. On 8/26/24 at 8:55 AM V1 stated V1 was unable to locate a packing slip for the package that contained R45's Lorazepam. On 8/25/24 at 8:59 AM V3 ADON stated V1 gave V3 the envelope which was unopened/not damaged, V3 opened it and it only contained R45's Lorazepam. V3 stated V3 then gave the envelope containing the medication to V14 Licensed Practical Nurse (LPN) to put in the medication cart. At 3:34 PM V3 confirmed there was no other staff present with V3 when the bag was opened, to verify receipt of the medications that were delivered. On 8/25/24 at 3:30 PM V5 LPN stated (mail carrier) delivers medications in a bag that contains no identifying information, and once opened if it contains controlled medications then the nurse is responsible for completing a controlled medication count sheet. V5 stated it's not required to have two signatures to verify receipt of these medications. On 8/26/24 at 9:31 AM V14 LPN stated on 8/20/24 V14 was given an unopened bag and was told it contained narcotic medications. V14 stated V14 was in the middle of doing wound treatments so she asked V2 DON if she could leave the bag with V2 in V2's office, and V2 agreed. V14 stated V14 never saw the bag again and V14 was unsure what medications were in the bag since it was unopened. On 8/25/24 at 3:34 PM V2 DON stated V2 was not aware that R45's Fentanyl 25 mcg patches were in the building and it was reported to V2 that during the investigation V14 reportedly placed a package of medications on V2's desk. V2 stated V2 didn't know anything about that, but on 8/16/24 R45's Morphine was delivered, V14 placed it on V2's desk and told V2 to hold onto it. V2 stated V2 then placed the Morphine at V3's working area to be put away as the medication is suppose to be locked in the medication cart. 2.) R45's August 2024 Medication Administration Record (MAR) documents to give Lorazepam 1 mg tablet every 2 hours as needed for anxiety/restlessness, and this medication was given one time on 8/15, two times on 8/17, once on 8/18, once on 8/20, none on 8/21, and once on 8/22. The Controlled Substances Proof of Use dated 8/14/24 for R45's Lorazepam 1 mg does not match the entries on R45's MAR, and documents Lorazepam was dispensed three times on 8/15/24 including two entries at 6:30 AM, three times on 8/17, six times on 8/18, three times on 8/20, once on 8/21, and five times on 8/22/24. R45's August 2024 MAR documents Morphine sulfate 20 milligrams/milliliter give 5 mg or 10 mg every hour as needed, and this medication was given four times on 8/16, twice on 8/17, once on 8/18, twice on 8/20, twice on 8/21, none on 8/24, and three times on 8/25. The Controlled Substance Proof of Use dated 8/15/24 for R45's Morphine does not match the entries on R45's MAR, and documents two entries on 8/16, four on 8/17, five on 8/18, four on 8/20, four on 8/21, five on 8/24, and four on 8/25/24. On 8/25/24 at 4:45 PM V1 stated V1 conducted a house wide audit of controlled medications and identified some discrepancies between the count sheets and the MARs. V1 stated the medications should be signed out on both the count sheet and the MAR. On 8/26/24 at 3:49 PM V21 LPN stated V21 gave R45 Haldol, Morphine, and Ativan on the evening shift of 8/24/24. V21 stated if the medication administrations are not documented on the MAR then it would be recorded on the medication count sheet. V21 stated sometimes when V21 signs out the medications on the MAR it doesn't show up. On 8/27/24 at 10:10 AM V2 Director of Nursing (DON) stated the controlled medication count sheets should match the MAR. 3.)On 8/27/24 at 10:33 AM the B Hall/C Hall medication cart was viewed with V22 LPN and all controlled medications were counted and verified with the controlled count sheets. There were 28 tablets of Lorazepam 1 mg remaining in R32's medication card and the Controlled Substance Proof of Use for this medication dated 8/17/24 documents 29 tablets as the remaining quantity. This was confirmed with V22. V22 stated V21 LPN must have forgot to sign out last night's dose. V22 stated I know that's no excuse, and confirmed controlled medications are to be signed out when given. R32's August 2024 MAR documents V21 LPN administered Lorazepam 1 mg tablet at 8:00 PM on 8/26/24 4.) R22's Controlled Substance Proof of Use dated 7/4/24 for Lorazepam 1 mg documents two doses were administered, one on 7/12 at 5:00 PM and the other on 8/16/24 at 6:00 AM. There is an entry dated 7/5/24 that a pill fell out of the card and the pill was wasted. There is only one nurse signature (V3 ADON) for the destruction of this pill. There is no order or documented administrations of this medication on R22's July and August 2024 MARs. On 8/26/24 at 4:55 PM V2 DON reviewed R22's Lorazepam count sheet and stated that is V3's signature (in reference to the wasted entry). V2 confirmed there is no second signature verifying destruction of this medication. V2 stated V3 should have had a second nurse witness the wasting of this controlled medication. On 8/26/24 at 5:00 PM V3 ADON stated R22's Lorazepam tablet fell out of the card and into the cart, so V3 had to waste the medication. V3 confirmed V3 did not have a second nurse verify that the medication was wasted. V3 stated I'm usually down the hall by myself. On 8/27/24 at 10:24 AM V16 LPN confirmed V16 administered R22's Lorazepam on 7/12/24 and stated there should have been an order and administration documented on the MAR. 5.) R14's Physician Order dated 6/30/24 documents to administer Omeprazole oral suspension give 20 ml once daily via gastrostomy tube. R14's Nursing Note dated 8/25/2024 at 10:47 AM documents spoke to pharmacy in regards to resident medication Omeprazole liquid for g-tube (gastrostomy) not being delivered. Pharmacy states medication is held up in insurance. R14's Nursing Notes dated 8/26/24 and 8/27/24 documents Omeprazole was not available for administration. There is no documentation that R14's physician was notified of missed doses of Omeprazole and that the medication was not covered by R14's insurance. On 8/28/24 at 8:42 AM V2 DON searched the medication cart for R14's Omeprazole and was unable to locate the medication. V2 stated V2 was not aware that R14 has been without Omeprazole. V2 stated this is an issue with medications not being covered by insurance. V2 stated the pharmacy notifies us and then we have to notify the physician to get it changed to another medication that is covered, resubmit to insurance, and then go through the process all over again. The facility's Controlled Substances policy dated 11/16/18 documents At the time a Controlled Substance is delivered, the Charge Nurse and the Delivery Person will count the controlled substance together to verify the count. The facility's Controlled Substances policy dated 11/6/18 documents Schedule II drugs must be kept under two locks that require two different keys and when controlled substances are delivered the charge nurse and delivery person will verify the count of the item delivered. This policy documents to record Schedule II drug administrations on a disposition sheet, and if a dose needs to be destroyed two nurses must be present and the destruction recorded on the disposition sheet. This policy documents reconciliation of controlled substances will occur between the oncoming nurse and the nurse going off duty. The facility's Medication Administration policy dated 11/18/17 documents to record the date, time, medication, dose and route on the resident's MAR, including PRN (as needed) medications. This policy documents notify the pharmacy and physician when a medication is unavailable.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

5.) R5's undated diagnosis sheet documents the following psychiatric diagnoses including: Post Traumatic Stress Disorder, Schizoaffective Disorder-Bipolar Type, and Personal History of Other Mental an...

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5.) R5's undated diagnosis sheet documents the following psychiatric diagnoses including: Post Traumatic Stress Disorder, Schizoaffective Disorder-Bipolar Type, and Personal History of Other Mental and Behavioral Disorders. R5's behavior tracking could not be located in the medical record during this survey. R5's Physician Orders dated 11/25/23 document Aripiprazole (Antipsychotic) 20 milligrams (mg) daily. R5's physician orders dated 11/25/23 document Topiramate (Anticonvulsant that can be used for Obsessive Compulsive Disorder) 200mg twice daily. R5's physician orders dated 3/22/24 document Ativan (sedative) 1.0mg / Benadryl (antihistamine) 25mg / Haldol (antipsychotic) gel 1.0mg every eight hours as needed. On 8/27/24 at 9:00AM, V2 Director of Nursing provided consents for the above medications (R5,R19, R33,R38, R39) that were not signed and were dated 8/27/24. This is all that I can do, we don't have them. Based on interview and record review the facility failed to obtain consent for psychotropic medications, identify resident specific targeted behaviors, and justify duplicative antipsychochic medication for five residents of five residents (R5,R19, R33,R38, R39) reviewed for psychotropic medications in a sample list of 36. Finding Include: The facility's policy Psychotropic Medication policy reviewed 6/17/22 states It is the policy of this facility that resident not be given unneccesary drugs. Unnecessary drugs is any drug that is used: 1. In an excessive dose. 2. For excessive duration 3. without adequate moinitoring. 4. without adequate indications for use 5. In the presence of adverse consequences that indicate the drugs should be reduced or discontinued. This policy documents to obtain consents for use of psychotropic medications. 1. R38's Physician's order summary printed 8/28/24 documents current physician's orders for the following psychotropic medications: Haldol (antipsychotic) Injection Solution 5 MG/ML (Haloperidol Lactate) Inject 5 mg intramuscularly every 24 hours as needed for elevated agitation Haloperidol Oral Tablet 5 MG (Haloperidol) Give 1 tablet orally at bedtime. Mirtazapine (antidepressant) Oral Tablet 15 MG (Mirtazapine) Give 15 mg by mouth at bedtime. Quetiapine Fumarate (antipsychotic) Oral Tablet 50 MG (Quetiapine Fumarate) Give 1 tablet orally one time a day. There was no documentation of resident specific behaviors justifying the use of antipsychotics observed for R38. There was no tracking of behaviors documented for R38. There was no physician's documentation to justify the concurrent duplicative orders for antipsychotic medications for R38. There was no consent documented for the use of Haldol for R38. 2. R19's Physician's order summary printed 8/28/24 documents current physician's orders for the following psychotropic medications: 1.Depakote Sprinkles Oral Capsule Delayed Release sprinkle (Neuroleptic) 125 MG (Divalproex Sodium) Give 2 capsule by mouth two times a day, Mirtazapine Oral Tablet 15 MG (antideppressant) Give 15 mg by mouth at bedtime, Seroquel (antipsychotic) Oral Tablet 25 MG (Quetiapine Fumarate) Give 1 tablet orally in the evening. There was no documentation of resident specific behaviors justifying the use of antipsychotics observed for R19. There was no tracking of behaviors documented for R19. 3. R33's Physician's order summary printed 8/28/24 documents current physician's orders for the following psychotropic medications: Depakote Sprinkles Oral Capsule Delayed Release Sprinkle (Neuroleptic)125 MG (Divalproex Sodium) Give 2 capsule orally in the morning Give 4 capsule orally in the evening, Melatonin (Sleep Aide) 10 MG sublingually Give 1 tablet orally at bedtime. Mirtazapine (antidepressant) Oral Tablet 7.5 MG (Mirtazapine) Give 1tablet orally at bedtime. Risperidone Oral Tablet (Antipsychotic) Give 0.25 mg orally at bedtime every other day. There was no documentation of resident specific behaviors justifying the use of antipsychotics observed for R33. There was no tracking of behaviors documented for R33. 4. R39's Physician's order summary printed 8/28/24 documents current physician's orders for the following psychotropic medications: Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Neuroleptic) Give 4 capsule by mouth two times a day. Lorazepam (antianxiety) Oral Tablet 0.5 MG (Lorazepam) Give 0.5 mg by mouth in the evening. Mirtazapine (antidepressant) Oral Tablet 30 MG (Mirtazapine) Give 30 mg by mouth at bedtime. Olanzapine Oral Tablet 10 MG (Olanzapine) Give 10 mg by mouth one time a day. There was no documentation of resident specific behaviors justifying the use of antipsychotics observed for R39. There was no tracking of behaviors documented for R39. On 7/.29/24 V2 Director of Nursing stated I see we don't have any specific behaviors identified or tracked for (R19, R33,R38, R39). I can also see (R38) is on two antipsychotics and there is no physician's documentation to justify the reason.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

Based on observation, interview and record review the facility failed to administer seizure medication, pain medication and nebulizer treatments as ordered resulting in multiple missed doses of medica...

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Based on observation, interview and record review the facility failed to administer seizure medication, pain medication and nebulizer treatments as ordered resulting in multiple missed doses of medications for three (R46, R45, R99) of 16 residents reviewed for physician orders in the sample of 36. Findings include: The facility's The facility's Medication Administration policy dated 11/18/17 documents to record the date and time of medication administration on the Medication Administration Record (MAR), document the reason for not administering a medication, and notify the pharmacy and physician when a medication is unavailable. 1.) R45's Hospice Physician Order Form dated 8/14/24 documents an order to discontinue Fentanyl 12 micrograms (mcg) and start Fentanyl 25 mcg patch apply every 72 hours. R45's August 2024 Medication Administration Record (MAR) documents R45's Fentanyl was not administered 8/19/24 and documents to refer to progress notes. There is no documentation in R45's progress notes as to why this medication was not administered as ordered and there is no documentation that R45 has refused Fentanyl administration. R45's Controlled Substance Proof of Use form dated 8/14/24 documents Fentanyl 12 mcg patch was not dispensed after 8/16/24 until 8/22/24, indicating the medication was not administered as ordered on 8/19/24. On 8/26/24 at 9:31 AM V14 Licensed Practical Nurse stated V14 was not sure why V14 did not administer R45's Fentanyl patch on 8/19/24 and possibly R45 refused the medication. On 8/26/24 at 12:00 PM V26 Hospice Registered Nurse confirmed R45 experiences pain and if Fentanyl not administered as ordered could contribute to R45 having increased pain. 2.) R46's March 2024 MAR documents Lacosamide 50 mg (milligrams) give one tablet by mouth twice daily for seizures starting on 1/12/24 and ending on 6/12/24. R46's Nursing Notes document between 2/19/24 and 4/24/24 R46's Lacosamide was unavailable, on order, and awaiting insurance approval. There is no documentation in R46's nursing notes that V25 Physician was notified of the Lacosamide being unavailable or of the missed doses. On 8/26/24 at 1:35 PM V3 Assistant Director of Nursing stated there was a pharmacy/insurance issue with getting R46's Lacosamide and confirmed this resulted in the medication being unavailable. On 8/26/24 at 1:41 PM V20 Regional Nurse and V1 Administrator both stated when medications are unavailable V1 should be notified to provide cost coverage of the medication for a certain amount of time until approval obtained from insurance for coverage or the physician is notified and gives an order for an alternative medication that is covered by the resident's insurance. On 8/26/24 at 2:26 PM V1 provided a pharmacy Proof of Delivery dated 4/26/24 that documents 60 tablets of Lacosamide 50 mg was delivered to the facility for R46. V1 stated that is the only documentation V1 could provide for deliveries of R46's Lacosamide between February 2024 and April 2024. On 8/27/24 at 12:00 PM V25 Physician confirmed missing doses of seizure medications placed R46 at risk for having seizures. V25 stated V25 was not aware that there was an issue with insurance coverage for R46's Lacosamide and that the medication was not administered as ordered. 3.) R99's Order Summary Report dated 8/27/24 documents an admission date of 8/21/24 and documents diagnoses including Pneumonia, Aphasia Following Cerebral Infarction, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. R99's hospital chest X-ray report dated 8/18/24 documents Right lower lung infiltrate or atelectasis changes were noted. R99's hospital discharge medication orders dated 8/21/24 document an order for Albuterol-Ipratropium nebulized 3 mg (milligrams)-0.5 mg/3 ml (milliliters) four times a day. R99's Nurse's Note dated 8/21/24 at 2:17 PM documents R99 was admitted to the facility from the hospital. R99's Nurse's Note dated 8/21/24 at 11:41 PM documents Albuterol Sulfate Inhalation Nebulizer Solution was not administered due to resident sleeping. R99's Nurse's Note dated 8/23/24 at 1:20 AM documents the Albuterol Sulfate Inhalation Nebulizer Solution was not administered with no reason documented. R99's Nurse's Note dated 8/23/24 at 5:47 AM and 8/24/24 at 5:08 AM document the Albuterol Sulfate Inhalation Nebulizer Solution was not administered due to not having a nebulizer machine. R99's Nurse's Note dated 8/24/24 at 12:17 PM documents the nebulizer was not administered with no reason documented. R99's Nurse's Note dated 8/24/24 at 3:14 PM and 8/25/24 at 1:19 AM document the nebulizer was not administered due to it being on order and not having a machine. R99's Nurse's Note dated 8/25/24 at 5:31 AM documents the nebulizer was not administered and does not document a reason. R99's Nurse's Note dated 8/26/24 at 1:06 PM documents the nebulizer was not administered due to waiting on the pharmacy to deliver. R99's Nurse's Note dated 8/27/24 at 12:19 AM and 8/27/24 at 5:06 AM document that the nebulizer was not administered and no reason was documented. On 8/26/24 at 1:36 PM, R99 does not have a nebulizer machine in his room. On 8/27/24 at 9:53 AM there was no nebulizer in R99's room. At this time, R99 was outside of his room and stated yes when asked if his lungs were hurting and ran his hand over his right side of his chest indicating where it was hurting. R99 confirmed that he does not have a nebulizer machine in his room and has not received any nebulizer treatments. On 8/26/24 at 11:42 AM, V16 Licensed Practical Nurse stated that she cannot give R99 his nebulizer treatment because she does not have the medication. On 8/27/24 at 10:07 AM, V3 Assisted Director of Nursing confirmed that R99 was ordered nebulizer treatments on admission from the hospital. V3 stated that it was originally ordered incorrectly as an inhaler not a nebulizer treatment and confirmed R99 does not have a machine due to insurance issues.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Laboratory Services (Tag F0770)

Could have caused harm · This affected multiple residents

2.) R25's Physician Order dated 6/5/25 documents Comprehensive Metabolic Panel (CMP), Complete Blood Count (CBC) and Hepatic Function Panel. There is no documentation in R25's medical record that a He...

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2.) R25's Physician Order dated 6/5/25 documents Comprehensive Metabolic Panel (CMP), Complete Blood Count (CBC) and Hepatic Function Panel. There is no documentation in R25's medical record that a Hepatic Function Panel was completed as ordered. On 8/25/24 at 1:45 PM R25's laboratory results were viewed with V2 Director of Nursing (DON). V2 confirmed the order dated 6/5/24 included Hepatic Function Panel and confirmed there was no Hepatic Function Panel results in R25's medical record. V2 stated the Hepatic Function Panel is usually part of the CMP or Basic Metabolic Panel. On 8/26/24 at 8:14 AM V29 Phlebotomist at facility's contracted laboratory confirmed there are additional liver function tests that are conducted as part of a Hepatic Function Panel that are not covered by a CMP. V29 stated a bilirubin level is not captured on a CMP. V2 confirmed R25 had a CBC, CMP and Lipid Panel on 6/10/24, and R25 has not had a Hepatic Function Panel completed. 3.) R46's Care Plan dated 6/24/24 documents R46 has Diabetes Mellitus and includes an intervention for blood glucose monitoring and to refer to orders and Medication Administration Record (MAR). R46's April 2024, May 2024, and June 2024 MARs documents check blood glucose twice daily and to check blood glucose at noon four times weekly and notify the provider for blood sugar less than 60 and greater than 400. These MARs do not document R46's blood glucose results. These MARs document Lantus/Glargine insulin give 10 units daily as of 1/13/24, Jardiance 10 milligrams (mg) twice daily, and Lispro insulin 5 units subcutaneously three times daily as of 1/12/24. On 8/26/24 11:07 AM V3 Assistant DON stated blood glucose results should be documented on the MAR. V3 reviewed R46's electronic MAR and confirmed blood glucose results were not recorded. V3 stated it must have been a computer issue. Based on interview and record review the facility failed to obtain laboratory tests as ordered and repeatedly failed to document blood glucose results for three of three residents (R4, R25, R46) reviewed for laboratory services in the sample list of 36. Findings include: The facility's Glucose Monitoring policy with a revised date of August 2018 documents, Purpose: To monitor resident's blood glucose to assist in the development of an appropriate medication and treatment regime for resident's with a metabolic disorder caused by an imbalance between insulin supply and demand. Document results of blood glucose and insulin dosage on medication sheet. The facility's undated Laboratory Tests policy documents, Obtain laboratory orders upon admission, readmission and PRN (as needed) for medication and condition monitoring per the physician's order. 1.) R4's Order Summary Report documents a diagnosis of Type 2 Diabetes Mellitus with an admission date of 11/18/22. This Order Summary document an order for an A1C (glycated hemoglobin) every three months. R4's pharmacy consultation report dated 6/26/24 documents R4 has orders for labs, but at the time of this review they were not available in the medical record. The missing laboratory values include: A1C every 3 months. This report is signed and dated by a physician on 7/3/24 for the recommendation to have the labs obtained. R4's last A1C was obtained on 11/27/23, nine months ago. This laboratory report sheet was provided by V1 Administrator on 8/25/24 at 3:04 PM. The results of the A1C laboratory draw were high at 6.6% (percent) which normal range is 4.0 to 5.6. On 8/26/24 at 11:55 AM, V3 Assistant Director of Nursing provided a laboratory report dated 7/10/24 with an A1C result of 6.7%, high again. V3 confirmed there are not any A1C results between November 2023 and July 2024, every three months as they are ordered.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected multiple residents

Based on observation, interview and record review the facility failed to provide the correct consistency for a pureed diet for seven (R1, R4, R7, R19, R23, R29, R33) of seven residents reviewed for pu...

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Based on observation, interview and record review the facility failed to provide the correct consistency for a pureed diet for seven (R1, R4, R7, R19, R23, R29, R33) of seven residents reviewed for pureed diets in the sample list of 36. Findings include: The facility policy dated 10/2012 documents that the Method of Pureeing food includes blending mixture to a smooth, pudding-like consistency. The policy documents to never puree with water. 1.) R1's physician order dated 6/14/23 documents a pureed texture for meals. 2.) R4's physician order dated 3/26/24 documents a pureed texture for meals. 3.) R7's physician order dated 10/2/23 documents a pureed texture for meals. 4.) R19's physician order dated 5/3/24 documents a pureed texture for meals. 5.) R23's physician order dated 11/20/23 documents a pureed texture for meals. 6.) R29's physician order dated 5/1/23 documents a pureed texture for meals. 7.) R33's physician order dated 5/3/24 documents a pureed texture for meals. On 8/26/24 at 9:45AM, V17 [NAME] made pureed pork fritters. V17 [NAME] did not use a recipe and added unmeasured amounts of water and thickener three times before coming to the consistency that she stated was pureed. When taste tested, the pureed meat had lumps in it. V17 [NAME] stated that she does not test the pureed consistency, I just kind of go with how it looks and we don't get complaints. On 8/26/24 at 10:00AM, V15 Dietary Manager said that the cooks are supposed to follow the recipe for pureed food, use broth to blend and they should test the product to make sure that there are no lumps. If the pureeds aren't smooth, they could cause a resident to choke.

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

Failures at this level require more than one deficient practice statement. A. Based on record review and interview the facility failed to monitor potential exposure sites for Legionella. This failure...

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Failures at this level require more than one deficient practice statement. A. Based on record review and interview the facility failed to monitor potential exposure sites for Legionella. This failure has the potential to affect all 44 residents who reside in the facility. B.) Based on observation, interview and record review the facility failed to don PPE (Personal Protective Equipment) prior to entering a contact isolation room for one of one resident (R34) reviewed for transmission based precautions in the sample list of 36. Findings include: a.) The Long-Term Care Facility Application For Medicare and Medicaid dated 8/25/24 documents 44 residents reside in the facility. The facility's policy Legionella Policy and Procedures (not dated) states Legionella Bacteria thrive and multiply in hot or cold water systems and storage tanks and then spread through spray from showers and taps. Should concerns are identified the following measures may be initiated to minimize and control the risks: Have the water system inspected, maintained, and cleaned. (Annually). Ensure water cannot stagnate anywhere in the system remove redundant pipe work (As needed). No documentation was provided by the facility to indicate the plumbing has been inspected. Locations where redundant piping may exist have been and require regular flushing have not been assessed. No surveillance has been documented. On 8/29/24 at 10:00AM V1, Administrator stated We do not have documentation of an assessment for possible sources of stagnation or a plan to flush such sites if they exist. b.) The facility's Contact Precautions policy with a revised date of December 2009 documents, In addition to Standard Precautions, use Contact Precautions, or the equivalent for specified residents known or suspected to be infected or colonized with epidemiologicallly important microorganisms that can be transmitted by direct contact with the resident (hand or skin to skin contact that occurs when performing resident care activities that require touching the residents dry skin) or indirect contact (touching with environmental surfaces or resident care items in the residents environment.). Gloves: In addition to wearing gloves as outline under Standard Precautions, wear gloves (clean non sterile gloves are adequate) when entering the room. Remove gloves before leaving the residents environment and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. Gown: In addition to wearing a gown as outlined under Standard Precautions, wear a gown (a clean, nonsterile gown is adequate) when entering the room if you anticipate that your clothing will have substantial contact with the resident, environmental surfaces, or items in the residents room, or if the resident is incontinent or has diarrhea, an ileostomy, a colostomy, or wound drainage not contained by a dressing. On 8/25/24 at 8:48 AM, V4 Registered Nurse stated R34 is on contact isolation due to ESBL (extended-spectrum beta-lactamase, bacteria) in the urine. On 8/26/24 at 1:31 PM, V16 Licensed Practical Nurse entered R34's room to administered medication without donning any PPE. There was a sign on the door typed up and documents Contact Isolation and to see the nurse before entering. There is no instructions as to what PPE is required prior to entering the R34's room. R34 was lying in bed and does not have fine motor control of her hands so V16 administered her medication and drink to her. On 8/26/24 at 2:59 PM, V16 entered R34's room again without donning any PPE. On 8/28/24 at 9:32 AM, V6 Housekeeping/Laundry Supervisor was in R34's room next to the bed showing her pictures on her phone without any PPE on. R34's Laboratory Report dated 5/15/24 documents Urine Culture results of Klebsiella Pneumoniae ESBL and Proteus Mirabilis (bacteria). R34's Laboratory Report dated 7/19/24 documents Urine Culture results as Proteus Mirabilis and Escherichia Coli. On 8/26/24 at 1:50 PM, V3 Assistant Director of Nursing stated that R34 is on contact isolation due to ESBL in her urine and stated that they are trying to get three negative urine cultures for her.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0882 (Tag F0882)

Could have caused harm · This affected most or all residents

Based on interview and record review the facility failed to employ a certified Infection Preventionist. This failure has the potential to affect all 44 residents who reside at the facility. Findings ...

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Based on interview and record review the facility failed to employ a certified Infection Preventionist. This failure has the potential to affect all 44 residents who reside at the facility. Findings Include: The Long-Term Care Facility Application For Medicare and Medicaid dated 8/25/24 documents 44 residents reside in the facility. The facility's Infection Control Surveillance and Monitoring Policy reviewed 12/7/18 states It is the policy of the facility to do routine surveillance and and monitoring of the facility to determine if compliance with work practices and care of protective clothing and equipment is maintained. Procedure: Monitoring the effectiveness of the facility work practices and protective equipment will be conducted by the Administrator, Infection Control Preventionist (ICP) and the Director of nursing (DON). This includes but is not limited to: a. Surveillance of the facility to ensure that required work practices are observed and that protective equipment and clothing are provided and properly used; b. Investigation of known or suspected parenteral exposure to blood/body fluids to establish the conditions surrounding the exposures; and c. Improve in training, work practices, or protective equipment to prevent recurrence. d. Maintain a procedure of notification to physicians, and Illinois Department of Public Health (IDPH) as required by regulation, of any infectious cases. e. Review all policies, procedures, and programs related to infection control including any environmental control on a yearly basis. On 8/27/24 at 10:00AM V2, Director of Nursing stated I have (V3), Assistant Director of Nursing help me with Infection Prevention, tracking, and control. Neither (V3) or myself are certified Infection Preventionists. On 8/27/24 at 10:05AM V3 stated I haven't taken the infection Preventionist training, but I track the infections, cultures and antibiotics.

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

Safe Environment (Tag F0921)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review the facility failed to ensure a safe, comfortable, and functional environment by failing to maintain the building structure to prevent roof leaks. Th...

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Based on observation, interview, and record review the facility failed to ensure a safe, comfortable, and functional environment by failing to maintain the building structure to prevent roof leaks. This failure affects one (R12) of 16 residents reviewed for environment in the sample of 36. This failure has the potential to affect all 44 residents residing in the facility. Findings include: On 8/25/24 at 8:09 AM near the nurse's station, centralized area where all of the resident halls connect, and the beginning of the C Hall the ceiling tiles were sagging and had large brown stains. One tile had been removed and there were cords visible hanging down approximately a couple inches below the ceiling. On 8/25/24 at 8:20 AM R12 was lying in bed. R12's room had a brown stained ceiling tile near R12's doorway. R12 stated R12 admitted to the facility in October 2023 and the brown area on the ceiling tile has gotten larger since R12's admission. R12 stated the facility's roof leaks when it rains which is what causes the brown discoloration. On 8/28/24 at 8:40 AM the ceiling tiles near the nurse's station and at the beginning of the C Hall were sagging and had large brown stains. One tile has been removed and had visible cords hanging down. Directly below this area was a wet floor sign and a bath towel that contained a basin collecting water droplets leaking from the ceiling. On 8/27/24 at 3:35 PM V2 Director of Nursing stated the roof leaks and the ceiling tiles have been like that for a long time, even when V2 was working as a hospice nurse at the facility a year and a half ago. On 8/27/24 at 3:40 PM V1 confirmed the brown, sagging ceiling tiles near the nurse's station. V1 stated the facility's roof still leaks when it rains. V1 stated the facility has gotten roof repair quotes and the roof has been patched, but it still leaks. V1 stated the roof has not been repaired yet since V1 is awaiting corporate approval of the quotes for the repair. The Long-Term Care Facility Application For Medicare and Medicaid dated 8/25/24 documents 44 residents reside in the facility.

May 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect the residents' right to be free from verbal abuse by a staff...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect the residents' right to be free from verbal abuse by a staff member. This failure affected two of four residents (R2, R3) reviewed for abuse in the sample of four. Findings Include: The facility's Abuse Prevention Program dated 11/28/16 documents the facility affirms the right of it's residents to be free from abuse or mistreatment. Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, or saying things to frighten a resident, such as telling a resident that he/she will never to be able to see his/her family again. The Abuse Investigation Report dated 5/1/24 documents on 4/30/24 at 9:00 PM V5 Agency Nurse was taking residents outside to smoke. R2 reminded V5 that R3 needed a smoking apron. V5 then turned to R3 and told him that he better not f***ing (expletive) burn himself or V5 was going to get R2 to kick his ass. R2's Medical Diagnoses sheet dated May 2024 documents R2 is diagnosed with Diabetes and Abnormal Gait. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact. On 5/16/24 at 12:45 PM R2 stated they were going out to smoke and he told V5 Agency Nurse that R3 needs a smoking apron. V5 stated she doesn't have time to deal with all this sh*t. Then V5 turned to R3 and told him, he better not f***ing burn himself or she will have R2 kick his ass. R2 stated he thought that was uncalled for and V5 shouldn't be talking to residents in that way so he reported it the following day. R3's Medical Diagnoses sheet dated May 2024 documents R3 is diagnosed with Dementia, Schizoaffective Disorder Bipolar Type and Alcohol Dependence. R3's Minimum Data Set (MDS) dated [DATE] documents R3 has a moderate cognitive impairment. On 5/16/24 at 12:40 PM R3 stated he remembers when they were outside smoking, V5 Agency Nurse told him he better not burn himself or she would have R2 kick his ass. R3 stated this made him feel disgusting and made him feel bad. R3 stated she shouldn't be talking to him that way. He doesn't treat her that way and so she shouldn't be so mean. On 5/16/24 at 1:13 PM V1 Administrator confirmed on 5/1/24 R2 reported the incident to staff who reported it to her immediately. V5 was an agency nurse and she was told not to return to the facility anymore. V1 confirmed R2 and R3 are able to recall the incident and their statements have stayed consistent. V1 confirmed there's no reason to believe that this didn't happen the way they are saying and she would consider the incident to be verbally abusive. V1 confirmed V5 should not have spoken to residents that way and that is why she was told she could not return to the facility.

May 2024 4 deficiencies 2 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

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 interview and record review the facility failed to protect the residents' right to be free from physical abuse by anoth...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect the residents' right to be free from physical abuse by another resident. This failure affected three of five residents (R1, R2, R3) reviewed for abuse in the sample of nine. R1 pushed R2 who sustained skin tears to both elbows. R1 shoved R3 who fell into the wall, hit her head/back against the wall, then fell to the ground. R3 complained of back pain and was sent to the emergency room. Findings Include: The facility's Abuse Prevention Program dated 11/28/16 documents the facility affirms the right of it's residents to be free from abuse or mistreatment. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means. Physical abuse can include such things as hitting, slapping, pinching, and kicking. The Abuse Investigation Summary dated 4/24/24 documents on 4/24/24 at 6:15 PM R1 and R2 were involved in an incident of physical aggression. R1 and R2 were ambulating in the hallway. R1 stopped walking and as R2 walked past, R1 shoved R2 to the floor. R2 sustained skin tears to both elbows. The Abuse Investigation Summary dated 4/24/24 documents on 4/24/24 at 6:30 PM R1 and R3 were involved in an incident of physical aggression. R1 was standing in the hallway and R3 walked past him. As R3 walked past, R1 shoved R3. R3 stumbled but caught herself before falling to the ground. The Abuse Investigation Summary dated 4/26/24 documents on 4/26/24 at 1:30 PM R1 and R3 were involved in an incident of physical aggression. R1 was standing in the hallway and R3 walked past him and appeared to reach her hand out towards R1. As she did this, R1 shoved R3. R3 hit the wall behind her and fell to the ground. R1's Medical Diagnoses sheet dated May 2024 documents R1 is diagnosed with Alzheimer's Disease, Altered Mental Status, and Delusional Disorders. R1's Psychosocial Evaluation dated 3/9/24 documents R1 is uncooperative, wanders, paces, enters other resident's bedrooms uninvited, has delusions, is physically aggressive and abusive, violates the personal space of others and does not understand social limits. R1's Wandering/Elopement Evaluation dated 3/11/24 documents R1 is ambulatory and wanders. R1 also may become agitated when approaching others during wandering. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has severe cognitive impairment. R1 also has physical behavioral symptoms directed towards others (hitting, pushing, grabbing, kicking). R1's Care Plan dated 2/22/24 documents R1 is cognitively impaired and has the potential to be physically aggressive related to Dementia, Alzheimer's Disease, Pain, and Delusional Disorder. The same Care Plan documents R1 has a behavior problem with peers in his personal space related to Dementia. Staff are to intervene as necessary to protect the rights and safety of others. R2's Medical Diagnoses sheet dated May 2024 documents R2 is diagnosed with Dementia with Behaviors, Anxiety, and Insomnia. R2's Care Plan dated 3/11/24 documents R2 is cognitively impaired and wanders aimlessly with his head down. R2 has behaviors that others may find disruptive or socially inappropriate such as intruding into other's personal space. Other residents may seek reprisal against R2. R3's Medical Diagnoses sheet dated May 2024 documents R3 is diagnosed with Bipolar Disease, Alzheimer's Disease, Dementia, Hallucinations, Anxiety, Depression, and Wandering. R3's Care Plan dated 3/11/24 documents R3 is cognitively impaired and wanders. R3 has the potential to be verbally aggressive related to Depression and Cognitive Deficits. On 5/2/24 at 2:10 PM V1 Administrator confirmed R1 has a history of physical aggression towards staff and other residents. V1 confirmed R1 is ambulatory, wanders, and needs supervision. V1 confirmed R1, R2, and R3 are all cognitively impaired residents who reside on the facility's locked dementia unit. V1 stated during the abuse investigation for incidents on 4/24/24, R1 was visualized on video surveillance walking down the hall, stopping and then as R2 passed him in the hallway, R1 shoved him and R2 fell to the floor. V1 stated as staff were attending to R2, R1 was standing in the group of residents that started to congregate in the area. R3 then started to walk through the group of people surrounding R2 and R1 preceded to shove R3. R3 stumbled into the wall but did not fall to the ground. V1 confirmed facility staff should have removed R1 from the hallway after he shoved R2 and in not doing so they did nothing to protect other residents from becoming victims. V1 stated one staff should have attended to R2 and one staff should have removed R1 from the area and supervised him so he was not able to be aggressive with anyone else. V1 confirmed R2 sustained an abrasion to each elbow from the fall. After R2 was attended to, R1 was sent to the hospital for a psychiatric evaluation. The hospital performed diagnostic tests and found nothing acute. The hospital said R1 was not acting aggressive and sent R1 back to the facility the next morning on 4/25/24. V1 confirmed when R1 returned, the staff did not implement increased supervision or any other new intervention to ensure R1 would not be physically aggressive towards any other residents. R1 went about his business as usual. V1 Administrator confirmed the staff need to be able to keep residents safe from other resident's aggression. V1 also confirmed during the abuse investigation for the incident on 4/26/24, R1 was visualized on video surveillance again walking down the hallway. R1 stopped in the hallway and R3 passed R1 walking down the hallway. As R3 passed R1, she reached towards R1 and R1 shoved R3. R3 fell into the wall, hit her head/back against the wall, and fell to the ground. R3 complained of back pain and was sent to the emergency room but no acute injuries were found. R1 was again sent to the the hospital for a psychiatric evaluation and remains there at this time.

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to adequately supervise and maintain a safe environment fo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to adequately supervise and maintain a safe environment for residents, thoroughly investigate a fall, and failed to include a focus area, goal and interventions for a resident. These failures affect three residents (R2, R4, R6) out of three residents reviewed for falls in a sample list of nine residents. R6 sustained a dislocated Right Fourth finger and Left Foot Contusion as a result of an unwitnessed fall when the resident was found with dresser on top of him. Findings Include: 1. R6's Electronic Medical Record (EMR) documents R6's medical diagnoses as Dislocated Right Fourth Finger, Contusion to Left Foot, Moderate Dementia with Agitation, Delusional Disorder, Dysthymic Disorder and history of Embolism and Thrombosis of Deep Veins of Left Lower Extremity. R6's Minimum Data Set (MDS) dated [DATE] documents R6 was severely cognitively impaired. This same MDS documents R6 requires supervision with toileting, dressing, personal hygiene, transfers, ambulation and maximum assistance with bathing. R6's Care Plan intervention dated 2/29/24 documents staff are to assist with ambulation and transfers. This same careplan documents an intervention dated 3/11/24 that instructs staff to cue, orient and supervise as needed. R6's Fall Risk Evaluation dated 4/13/24 documents R6 as a risk for falling. R6's Nurse Progress Note dated: -4/23/24 at 8:30 PM documents (R6) was found on the floor by (V17) Certified Nurse Aide (CNA) when she heard a loud noise coming from (R6's) room. (R6) was on the floor laying on right side with dresser on top of him. (V17) CNA removed the dresser and came for help. On entering room (R6) is sitting on his bottom with legs bent. On assessment area found to top of Left Foot where skin had been sheared and on further assessment area found to his Right ring finger, which is bent not aligned as it should be. -4/24/2024 at 1:53 AM documents (R6's) Unwitnessed event was first noted on 04/23/2024 8:30 PM. Just prior to/at the time of the event (R6) appears to have been in his room going through his dresser drawers. (V17) Certified Nurse Aide (CNA) working on unit had just walked by (R6's) room taking another resident to his room and (V17) saw (R6) at his dresser in the top drawer. (V17) CNA heard a loud noise from next door, went immediately to the room and found (R6) on the floor with dresser on top of him. Review of (R6's) pain parameters reveals (R6) rates pain level as 7. Non-verbal sounds of pain or crying at the time of the event. Facial expressions (e.g grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw) at the time of the event. Protective body movements or grasping at body at the time of the event. New onset pain observed/reported. Pain location includes upper extremity limb pain. -4/24/2024 at 9:09 AM documents Interdisciplinary Team Meeting (IDT) Falls-Root Cause- (R6) fidgeting with dresser and fell. R6's Fall Investigation dated 4/23/24 documents R6 had an unwitnessed fall in his room at 8:30 PM on 4/23/24. This same fall investigation documents V17 Certified Nurse Aide (CNA) witnessed R6 in R6's room going through his dresser drawers prior to R6's fall. This investigation documents V17 did not assist R6 at that time. This same investigation documents V17 saw (R6) at his dresser in the top drawer. V17 heard R6 yelling out and found R6 on the floor with dresser on top of him. When moving dresser, a blanket was found under it which made in unbalanced. R6's Fall Investigation documents R6's Right Fourth finger and top of Left Foot were injured. V17's Fall Investigation statement dated 4/23/24 for R6's fall on 4/23/24 documents (V17) walked in (R6's) room and the lights were on and (R6) was between both beds with the large dresser on top of (R6). (V17) got the dresser off of him and notified the nurse immediately. R6's Hospital records dated 4/23/24 document (R6) was sent to the emergency department via ambulance service from facility for a report that (R6) had dresser fell on (R6's) Right Hand. (R6's) Right Hand is swollen and Right Fourth finger is angled over Right Fifth finger. Cold pack applied to Right Hand. Left Foot appears swollen as well. (R6's) Right Fourth Finger was reduced and placed finger in aluminum splint. (R6's) Right Fourth digit was anesthetized via digital block with subcutaneous injection of eight cc of 1% Lidocaine. This same hospital record documents R6's diagnosis for this hospital stay as Traumatic dislocation of joint of finger, Fall and Contusion of Left Foot. R6's X Ray results of Right Hand dated 4/23/24 documents Impression: Dislocation of the Fourth finger on Right Hand at the PIP (Proximal Interphalangeal) joint. R6's Final Incident Report to the State Agency dated 4/23/24 documents R6 was in his room 'fidgeting' with his dresser. Upon entering R6's room, R6 was noted to be on floor in between the bed with the dresser on top of him. Upon assessment of (R6), he was noted to have an abrasion to top of his Left Foot and Right Fourth finger was noted to be bent. R6 was sent to the emergency room where he was treated for an abrasion to top of Left Foot and dislocated Right Fourth finger. This same report documents Discharge Instructions from emergency room stated (R6's) Fourth Finger on Right Hand was dislocated, have reduced it back into place, wear splint on finger as needed for comfort and follow up with Orthopedic. R6's Final Report documents The facility believes that (R6) was rummaging through dresser, attempted to remove one of the drawers, causing dresser to tip over onto resident. On 5/2/24 at 3:32 PM R6 wandering in dining area tapping his fingers on dining room tables to music that was playing. No staff present in dining area. On 5/3/24 at 1:10 PM V4 Dementia Unit Director stated R6 has a history of rummaging in his dresser drawers. V4 stated R6 likes to remove the clothes from the drawers and refold them. V4 stated R6 'is very busy' and requires a lot of supervision. V4 stated R6 has no safety awareness and should be supervised more closely to help prevent falls. V4 stated If (V17) Certified Nurse Aide (CNA) had assisted R6 as she saw him rummaging in his drawers prior to his fall, then he probably would not have fallen that time. On 5/3/24 at 2:45 PM V1 Administrator stated R6's fall could have been prevented if the staff would have made sure R6's surroundings were safe. V1 Administrator stated she was unaware of R6's dresser having a blanket underneath it which caused it to be off balance. V1 stated If the staff would have just moved the blanket from out from under the dresser, (R6) probably would not have fallen and dislocated his finger. V1 stated the staff failed to make sure R6's dresser was stable which in turn caused R6 to fall and dislocate his finger. V1 Administrator stated R6 had advanced Dementia and cannot be expected to provide for his own safety. V1 stated The staff are supposed to do that and they did not. 2. R4's Electronic Medical Record (EMR) documents admitted to facility on 10/28/23 with medical diagnoses of Severe Dementia with Psychotic Disturbance, Thyrotoxicosis with Diffuse Goiter, Intestinal Obstruction, Intestinal Adhesions with Partial Obstruction, Alzheimer's Disease, Ascites, Repeated Falls, Weakness, Urinary Incontinence, Incontinence of Feces and Need for Assistance with Personal Care. R4's Minimum Data Set (MDS) dated [DATE] documents R4 was severely cognitively impaired. This same MDS documents R4 was dependent on staff for toileting, personal hygiene, bathing and maximum assistance for dressing. R4's Fall Risk assessment dated [DATE] documents R4 as a risk for falling. R4's Care Plan initiated on 10/31/23 does not include a focus area, goal nor interventions for R4's being at risk of falling until 11/7/23. R4's Electronic Medical Record (EMR) documents R4 was last observed at 1:41 AM on 11/5/23 prior to being found on floor at 7:05 AM on 11/5/23. R4's Nurse Progress Noted dated 11/5/23 at 7:50 AM documents At 7:05 AM (R4) was observed lying on the floor, noted with small amount of blood to her mouth/oral area and small amount of blood also noted on the floor next to her head. (R4's) Right bottom lip noted swollen, Right side of face noted red, bump to Right anterior scalp area, no visual laceration noted to head or anywhere else. (R4) was noted nonverbal, per attending (V7) Certified Nurse Aide (CNA) this is not her norm. R4's Fall Investigation dated 11/5/23 documents R4 had an unwitnessed fall in R4's room on 11/5/23. This same investigation documents time of R4's fall was 7:05 AM. This same investigation report documents R4 obtained an injury to the top of her scalp, level of consciousness was 'Stuporous' and mobility was 'ambulatory without assistance'. Root cause documented as self transfer. This same investigation documents (V3) (R4's) Power of Attorney (POA) stated (R4) fell a lot at home and that is one of the main reasons she was placed at facility. On 5/2/24 at 2:10 PM V7 Certified Nurse Aide (CNA) stated V7 was the CNA on duty assigned to R4 the morning (11/5/23) R4 had an unwitnessed fall in her room. V7 stated V7 was scheduled from 6:00 AM-6:00 PM. V7 stated V7 came in that day (11/5/23) and started at the opposite end of the hall getting people up. V7 stated I (V7) did not see (R4) that morning until I went in to get her up. The nurse was on another hall and the other CNA was with me. No one could have checked on (R4). The night shift had told us that (R4) had been up all night rummaging through drawers and being very busy. I thought (R4) was just sleeping since I hadn't seen her that morning. Once I got to (R4's) room, there was blood on the floor where she had a bloody lip. (R4) was wearing two pairs of pants and had put her head through the sleeve of her own shirt. I stayed with (R4) until the ambulance came and took her to the hospital. (R4) was trying to hold her head but I encouraged her not to do that since we (facility) didn't really know how bad she was hurt yet. (R4) moaned like she was in pain. On 5/3/24 at 1:15 PM V1 Administrator stated R4 fell on [DATE]. V1 stated the exact time of the fall unclear due to the last time R4 was checked on was 1:41 AM. V1 stated We (facility) have no way to show that (R4) was checked from 1:41 AM-7:05 AM when (R4) was found laying on the floor of her room. V1 confirmed there is no documentation of R4 being monitored or assisted with cares during that time frame. V1 stated (R4) could have been laying there for awhile. We (facility) know that (R4) was up and down all night. We (facility) know that (R4) was found at 7:05 AM. The staff should have been monitoring (R4) more closely, especially since she was up and about in the middle of the night already. (R4) ended up going to the hospital with a bloody fat lip that could have been prevented if our staff were watching her better. I am thankful (R4) wasn't hurt any worse. 3. R2's undated Medical Diagnosis List documents R2's medical diagnoses as Dementia, Insomnia and Anxiety. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 as requiring maximum assistance with toileting, dressing, personal hygiene and supervision with transfers and mobility. R2's Care Plan intervention dated 3/12/24 instructs staff to Assist (R2) with ambulation and transfers. This same care plan documents an intervention dated 3/11/24 for R2 to be supervised on a one to one continual basis when up and walking. R2's Nurse Progress Note dated 4/22/24 at 1:08 PM documents Staff was called to hall after being informed (R2) had a fall. (Facility was) Informed by (V18) visitor that (R2) walked into cart and fell to buttocks and did not hit his head. Assessed (R2) for injury and none noted. R2's Nurse Progress Note dated 4/22/4 at 1:11 PM documents Just prior to/at the time of the event (R2) appears to have been pacing. Location of the event: Hallway. Description of the environment: (R2) was walking up and down hall and housekeeping cart in the middle of the hall. Facility staff actions/interventions and response at the time of the event: Staff instructed to stay with (R2) at all times. R2's Fall investigation dated 4/22/24 documents (V18) Visitor saw (R2) walk into (housekeeping) cart, then fell to floor on buttocks. Root Cause: Clutter in hallway. On 5/2/24 at 3:35 PM R2 was walking in hall with V10 Unit Aide. V10 walking with R2 side by side or in front/back of R2 depending on space available. R2 walked into an unoccupied room with two beds, two dressers and an attached bathroom. R2 was walking in a narrow space about five feet long between a bed and wall up to bedside dresser in corner. There was not enough room for V10 to walk with R2 in that space, so V10 Unit Aide waited at the end of the bed and then when R2 walked out of the area, V10 would again walk with R2. V10 Unit Aide did not try to re-direct R2 out of that narrow space. R2 paced back and forth in that same space several times. R2 became unsteady twice during the time he was pacing back and forth in that same space. On 5/2/24 at 3:40 V10 Unit Aide stated V10 is assigned to 'constantly be with (R2)'. V10 stated R2 paces all day but at night will sleep through the night 'pretty well'. V10 stated V10 should stay directly with R2 at all times due to R2 falls frequently and has an unsteady gait. V10 Unit Aide stated V10 and R2 would not both 'fit' in the space between the bed and wall so V10 did not walk with R2 in that space. V10 Unit Aide stated I saw (R2) get a little wobbly and hoped he wouldn't fall again. I wouldn't have been able to help him. I should have tried to get (R2) to just walk somewhere else. On 5/3/24 at 1:05 PM V4 Dementia Unit Director stated R2 normally walks around the unit 'a lot' with his head down and eyes closed. V4 stated R2 was on a one to one continual observation when R2 fell on 4/22/24. V4 stated (V12, Activity Aide) should have redirected R2 away from the housekeeping cart instead of 'just allowing (R2) to run into the housekeeping cart and fall because he was trying to maneuver around it'. V4 stated (R2) has no safety awareness and doesn't know what he is doing. The staff need to be paying closer attention to (R2) so he doesn't fall so much. We (facility) all know that (R2) falls and needs a lot of guidance. On 5/3/24 at 1:55 PM V12 Activity Aide stated V12 directly witnessed R2 walk into the housekeeping cart causing him to fall on 4/22/24. V12 stated I don't remember seeing anyone else with (R2). I was not the 'one to one' assigned to (R2) that day. I was walking out of the dining room because it was right after lunch so I was helping other residents get back to their rooms or other areas. (R2) was pacing and he walked right into the housekeeping cart. There were no staff directly next to (R2). That big yellow housekeeping cart was right in the middle of the hall in everyone's way. (R2) keeps his head down and eyes closed when he walks so he would not have even seen it. This is a Dementia unit. We (staff) have to keep the aisles and all the areas clear of fall hazards. Many of the residents do not have any awareness of their surroundings and could get hurt on something like that. On 5/3/24 at 2:40 PM V1 Administrator stated R2 fell on 4/22/24 due to a housekeeping cart sitting in the middle of the hallway. V1 stated the housekeeping cart should not be left in the middle of a resident hallway. V1 stated staff should have re-directed R2 away from the cart which would have avoided the fall to begin with. V1 stated R2 is unsteady on his feet at times. V1 stated R2 has been on continual observations when R2 is up and walking since 3/11/24. V1 stated There is no reason for (R2) to have fallen like that. The staff should have been watching more closely and redirected him prior to getting that close to the housekeeping cart. V1 stated R2's fall on 4/22/24 could have been avoided if the staff were paying closer attention to R2. The facility policy titled 'Fall Prevention' revised 11/10/18 documents Appropriate interventions will be implemented for residents determined to be at high risk at the time of admission for up to 72 hours. The unit nurse will place documentation of the circumstances of a fall in the nurses notes or on an Assess/Intercommunicate/Manage (AIM) for Wellness form along with any new intervention deemed to be appropriate at the time. Report all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan. All staff must observe residents for safety. If residents with a high risk code are observed up or getting up. Help must be summoned or assistance must be provide to the resident.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect the residents' right to be free from physical abuse by anoth...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect the residents' right to be free from physical abuse by another resident by failing to follow the Abuse Prevention Program and remove an alleged perpetrator and implement interventions in order to keep others free from abuse. This failure affected three of five residents (R1, R2, R3) reviewed for abuse in the sample of nine. Findings Include: The facility's Abuse Prevention Program dated 11/28/16 documents the facility affirms the right of it's residents to be free from abuse or mistreatment. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means. Physical abuse can include such things as hitting, slapping, pinching, and kicking. The policy documents residents who allegedly mistreat or abuse another resident will be removed from contact with other residents during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable intervention considering their safety and the safety of other residents. The Abuse Investigation Summary documents the following: On 4/24/24 at 6:15 PM R1 shoved R2 to the floor. R2 sustained skin tears to both elbows. On 4/24/24 at 6:30 PM R1 shoved R3. R3 stumbled but caught herself before falling to the ground. On 4/26/24 at 1:30 PM R1 shoved R3. R3 hit the wall behind her and fell to the ground. R1's Medical Diagnoses sheet dated May 2024 documents R1 is diagnosed with Alzheimer's Disease, Altered Mental Status, and Delusional Disorders. R1's Psychosocial Evaluation dated 3/9/24 documents R1 is uncooperative, wanders, paces, enters other resident's bedrooms uninvited, has delusions, is physically aggressive and abusive, violates the personal space of others and does not understand social limits. R1's Wandering/Elopement Evaluation dated 3/11/24 documents R1 is ambulatory and wanders. R1 also may become agitated when approaching others during wandering. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has severe cognitive impairment. R1 also has physical behavioral symptoms directed towards others (hitting, pushing, grabbing, kicking). R1's Care Plan dated 2/22/24 documents R1 is cognitively impaired and has the potential to be physically aggressive related to Dementia, Alzheimer's Disease, Pain, and Delusional Disorder. The same Care Plan documents R1 has a behavior problem with peers in his personal space related to Dementia. Staff are to intervene as necessary to protect the rights and safety of others. R2's Medical Diagnoses sheet dated May 2024 documents R2 is diagnosed with Dementia with Behaviors, Anxiety, and Insomnia. R2's Care Plan dated 3/11/24 documents R2 is cognitively impaired and wanders aimlessly with his head down. R2 has behaviors that others may find disruptive or socially inappropriate such as intruding into other's personal space. Other residents may seek reprisal against R2. R3's Medical Diagnoses sheet dated May 2024 documents R3 is diagnosed with Bipolar Disease, Alzheimer's Disease, Dementia, Hallucinations, Anxiety, Depression, and Wandering. R3's Care Plan dated 3/11/24 documents R3 is cognitively impaired and wanders. R3 has the potential to be verbally aggressive related to Depression and Cognitive Deficits. On 5/2/24 at 2:10 PM V1 Administrator confirmed R1 has a history of physical aggression towards staff and other residents. V1 confirmed R1 is ambulatory, wanders, and needs supervision. V1 confirmed R1, R2, and R3 are all cognitively impaired residents who reside on the facility's locked dementia unit. V1 stated during the abuse investigation for incidents on 4/24/24, R1 was visualized on video surveillance walking down the hall, stopping and then as R2 passed him in the hallway, R1 shoved him and R2 fell to the floor. V1 stated as staff were attending to R2, R1 was standing in the group of residents that started to congregate in the area. R3 then started to walk through the group of people surrounding R2 and R1 preceded to shove R3. R3 stumbled into the wall but did not fall to the ground. V1 confirmed facility staff should have removed R1 from the hallway after he shoved R2 and in not doing so they did nothing to protect other residents from becoming victims. V1 stated one staff should have attended to R2 and one staff should have removed R1 from the area and supervised him so he was not able to be aggressive with anyone else. V1 confirmed R2 sustained an abrasion to each elbow from the fall. After R2 was attended to, R1 was sent to the hospital for a psychiatric evaluation. The hospital performed diagnostic tests and found nothing acute. The hospital said R1 was not acting aggressive and sent R1 back to the facility the next morning on 4/25/24. V1 confirmed when R1 returned, the staff did not implement increased supervision or any other new intervention to ensure R1 would not be physically aggressive towards any other residents. R1 went about his business as usual. V1 Administrator confirmed the staff need to be able to keep residents safe from other resident's aggression. V1 also confirmed during the abuse investigation for the incident on 4/26/24, R1 was visualized on video surveillance again walking down the hallway. R1 stopped in the hallway and R3 passed R1 walking down the hallway. As R3 passed R1, she reached towards R1 and R1 shoved R3. R3 fell into the wall, hit her head/back against the wall, and fell to the ground. R3 complained of back pain and was sent to the emergency room but no acute injuries were found. R1 was again sent to the the hospital for a psychiatric evaluation and remains there at this time. V1 confirmed the facility's Abuse Prevention Program requires staff to remove or separate a alleged perpetrator from other vulnerable residents in order to ensure everyone's safety.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to employ a Registered Nurse to serve as full time Direct...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to employ a Registered Nurse to serve as full time Director of Nurses (DON). This failure has the potential to affect all 47 residents in the facility. Findings Include: Upon survey entrance and throughout the survey (5/2/24- 5/3/24) there was no Director of Nurses present and employed by the facility. On 5/3/24 at 1:40 PM V1 Administrator confirmed the facility does not currently employ a full time Director of Nurses. There has not been a full time DON employed by the facility since March 2024. V1 confirmed the facility census is currently 47 residents. The facility's Facility assessment dated [DATE] documents a full time nursing supervisor (Director of Nurses) is required in order to meet the resident's needs and provide competent support and care for the facility's resident population.

Apr 2024 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 sufficient Registered Nursing (RN) hours on three of eight days reviewed for RN staffing. This failure has the potential to affect ...

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Based on interview and record review, the facility failed to provide sufficient Registered Nursing (RN) hours on three of eight days reviewed for RN staffing. This failure has the potential to affect all 48 residents in the facility. Findings include: The facility Nursing Schedule (April 19, 2024 through April 26, 2024) document on 4/19/24, 4/20/24, and 4/21/24, the facility scheduled zero (0) hours of RN coverage for a 24 hour period. On 4/26/24 at 10:22am, V1 Administrator in Training confirmed the hours listed on the facility nursing schedule were correct and the facility failed to have RN coverage on 4/19/24, 4/20/24, and 4/21/24. The facility Resident Midnight Census dated 4/26/24 documents 48 residents reside in the facility.

Apr 2024 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 sufficient Registered Nursing (RN) hours on two of 18 days reviewed for RN staffing. This failure has the potential to affect all 4...

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Based on interview and record review, the facility failed to provide sufficient Registered Nursing (RN) hours on two of 18 days reviewed for RN staffing. This failure has the potential to affect all 49 residents in the facility. Findings include: The facility Nursing Schedule (April 1, 2024 through April 18, 2024) document on Saturday 4/6/24 and Sunday 47/24, the facility scheduled zero (0) hours of RN coverage for a 24 hour period. On 4/18/24 at 9:55am, V1 Administrator in Training confirmed the hours listed on the facility nursing schedule were correct and the facility failed to have RN coverage on 4/6/24 and 4/7/24. The facility Resident Midnight Census dated 4/18/24 documents 49 residents reside in the facility.

Apr 2024 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

Safe Environment (Tag F0921)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe and homelike environment for nine of ni...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe and homelike environment for nine of nine (R1, R2, R3, R4, R5, R6, R7, R8, and R9) residents reviewed for their environment on the sample list of seven. This failure also has the potential to affect all 49 residents residing in the facility. Findings include: On 4/15/24 at 10:00 AM, the facility's drop ceiling had multiple water stained, missing, and bulging ceiling tiles in the hallways, common areas, and in the residents' bedrooms and bathrooms. The stains on these tiles were dark yellow to brown in color, circular, and ranged from saucer to dinner plate width in size. These observations included: two water stained ceiling tiles outside of room [ROOM NUMBER], three water stained ceiling tiles outside of the double doors entering the D hall, five water stained ceiling tiles in a common area where residents watch television, a missing ceiling tile and three water stained ceiling tiles by the double doors going into the entrance of B hall, three water stained ceiling tiles in R4's room, and multiple water stained tiles in the main dining room. At 10:05 AM, V5 Licensed Practical Nurse stated the common area where the residents sit to watch television was leaking onto the floor last week. V5 stated it was also leaking in the front lobby. At 10:15 AM, R5 was lying in bed in the room. Two water stained ceiling tiles were on the ceiling in the room. R5 stated the tiles started to show staining last week after it rained. At 10:17 AM, R8 and R9's ceiling had three water-stained ceiling tiles. On 4/15/24 at 10:19 AM, R6 was sitting in her room in a wheelchair. R6's ceiling above her head had four water stained ceiling tiles. R6 stated the tiles haven't started to leak but have been stained for awhile and they became worse after last week. On 4/15/24 at 10:20 AM, R10's room had two missing ceiling tiles. On 4/15/24 at 10:21 AM, R7 was sitting in a wheel chair in his room. R7's ceiling had a water stained ceiling tile and a bulging ceiling tile. R7 stated the tiles on his ceiling frequently gets water stained and the tiles will sometimes bulge. At 10:20 AM, R1 stated she was moved out of her room on the 400 wing because two of her ceiling tiles fell in and her ceiling was leaking water. At 10:21 AM, V8 Activity Director stated the facility has had roof issues for a year. At 10:22 AM, V9 Housekeeper stated they have had to use water buckets to catch water leaking from the ceiling. V9 stated they have had to move residents when the water leaked into their rooms. V9 stated the roof has been leaking for about a year. At 10:25 AM, R2 was sitting in a wheel chair in the room. R2 stated the ceiling tile fell in his bathroom last week. R2's bathroom ceiling was missing a tile. R2's ceiling in the room had two water stained tiles. One of those tiles was bulging. At 10:30 Am, two ceiling tiles were missing outside of R3's room. R3 stated the roof has been leaking for years and they haven't done anything about it. R3 stated when they put in the metal roof which sits under the flat roof and they removed some pipes when they did it and stuck wash clothes in the holes which actually causes the water to wick in onto the metal roof. R3 stated the gutters were full when it rained which caused water to pool on the roof and then soak into the ceiling tiles. At 10:22 AM, V10 Housekeeper stated last week it rained a lot so more of the building was affected. At 11:09 AM, V2 Administrator In Training stated it rained three times last week and that caused the roof to leak and the ceiling tiles to become wet. V2 stated there are areas on the roof that need patched. V2 stated the roof has been a problem for a year to two years. The facility's Facility assessment dated [DATE] documents that safety checks and routine maintenance will be conducted to ensure appropriate maintenance of the building. The facility's Census report dated 4/15/24 provided by V2 (Administrator in Training) documents there are 49 residents residing in the facility.

Mar 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to protect residents' right to be free from abuse perpetrated by another resident. This failure affects two residents (R1 and R3) out of five ...

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Based on interview and record review, the facility failed to protect residents' right to be free from abuse perpetrated by another resident. This failure affects two residents (R1 and R3) out of five reviewed for abuse allegations on the sample list of 24. Findings include: 1. The facility's Initial Report to the Illinois Department of Public Health dated 3/8/24 documents an alleged resident to resident altercation. This same report documents the aggressor (R2) was sent to the emergency room for evaluation. The facility's Final Report to IDPH dated 3/11/24 documents R1 had been wandering in and out of other resident's rooms including R2's room. R2 had grabbed hold of R1's wrist and jerked R1's arm. This report documents a staff member (V3, Activity Assistant) attempted to intervene but R2 also grabbed hold of V3's wrist. Another staff member (V14, Certified Nursing Assistant) intervened and was able to separate the involved residents and staff member. This Final Report documents R2 had been hospitalized at a geriatric psychiatric service clinic for evaluation and treatment. On 3/19/24 and 3/20/24, at various times, R1 was observed ambulating throughout the facility's locked dementia care unit utilizing a walker. R2 was observed ambulating in the same locked dementia care unit independently without an assistive device. R1 did have dark purple bruising on her right forearm and wrist area in a distinctive pattern resembling a thumb and three fingerprints. The larger bruise was approximately 3 centimeters (CM) by 2 cm, and the series of three smaller bruises were approximately 1 cm by 1 cm, each with a half moon shaped perimeter bruise resembling the shape of a fingernail. On 3/19/24 at 2:50 PM, V1, Administrator, stated, I reviewed the camera footage from this incident and I did see that (R2) did grab hold of (R1's) wrist and started jerking it when (R1) wandered into his room. (V3) attempted to intervene and (R2) grabbed hold of her arm too, then (V14) came and was able to get everybody separated. On 3/20/24 at 1:05 PM, V3, Activity Assistant, stated, I was working and present when the incident between (R1) and (R2) happened. (R1) was coming out of the dining room walking with her walker and she approached (R2's) doorway and had her hand on the doorknob. V3 continued, I said to (R1) no that isn't your room so lets go over here, and I put my hand on (R1's) walker to steady it because (R1) had one hand on the doorknob. V3 then stated, (R2) came into the hallway and grabbed (R1) by the arm by her wrist and could not get him to let go of it, then (R2) grabbed hold of my wrist and his grip was so tight I became concerned he could break a bone of (R1). V3 further stated, I could not get (R2) to let go of either one of us so I called for a CNA (Certified Nursing Assitant, V14) who came and got (R2) to let go. V3 concluded by stating, There is no way (R2's) actions were accidental, he didn't slip on a banana peel and reach out to grab us to catch his balance, (R2) was upset and yelling something about the walker that didn't make sense to me while he was holding on to us. On 3/20/24 at 1:24 PM, V14, CNA, stated, What I remember is seeing (R2) have a hold of (R1's) wrist and was jerking it, and (R2) had (V3's) arm in a hold too. I was able to come and get my fingers wiggled between (R2's) fingers and (R1's) arm. I got (R2) to let go and started talking to him about going to get some snacks. V14 concluded by stating, There were some red marks on (R1's) wrist at that time after the incident. 2. On 3/19/24 and 3/20/24, R3 was observed independently ambulatory throughout the facility's locked dementia unit. R3 was wearing a padded head gear and walked with his face looking straight down at the ground. R4 was observed mostly in his own room and in the resident lounge area. The facility's Initial Report to IDPH dated 3/11/24 documents an incident of a resident to resident altercation. The facility's Final Report to IDPH dated 3/12/24 documents (R3) had stood up to ambulate and bumped into (R4), (R4) then pushed (R3). (R3) contacted the wall and experienced a skin tear approximately 3 cm long on the elbow. On 3/19/24 at 2:50 PM, V1, Administrator, stated, I investigated this incident and I looked at the camera footage. I saw (R1) stand up in the resident lounge area and start walking. (R1) always walks with his head straight down and bumps into things and people at times. V1 continued, (R1) bumped into (R4) and (R4) retaliated by pushing (R3) causing (R3) to bump into the wall. V1 concluded by stating, The other staff present at this incident were (V15, Licensed Practical Nurse) and (V16, Certified Nursing Assistant). On 3/20/24 at 3:07 PM, V15, Licensed Practical Nurse, stated, I wasn't present at the actual incident when (R4) pushed (R3) but the incident was reported to me by (V16). I did go to assess (R3) and (R4) directly after the incident and (R3) had a skin tear on his elbow approximately 3 cm long, nothing serious. V15 concluding by stating, I do know (R4) doesn't like it when other people come into his personal space.

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 F0825 (Tag F0825)

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 therapy services as ordered by the physician for three of 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 therapy services as ordered by the physician for three of three residents (R17, R18, R19) out of seven reviewed for therapy on the sample list of 24. Findings Include: The Facility assessment dated [DATE] documents the facility provides therapy services through a contract agency. On 3/20/24 at 1:32 pm, V1 AIT (Administrator in Training) stated the facility currently does not have a therapy service and hasn't since 2/20/24. V1 stated the prior contracted therapy company walked out and stopped providing [NAME] due to non-payment by the facility's corporate ownership entity. V1 further stated a new company had been scheduled to begin providing services at the facility on 3/4/24 but had not yet come to the facility. V1 concluded by stating there were three residents who did not complete their prescribed course of therapy, R17, R18, and R19. 1. R18's MDS (Minimum Data Set) dated 2/13/24 documents R18 is alert and oriented. On 3/20/24 at 10:39 am, R18 stated R18 was admitted to the facility back in December and started therapy. R18 explained R18 only worked with therapy for a month before they stopped coming to the facility. I (R18) was doing well and they (therapy) were going to try and get me (R18) walking again so I (R18) could go home but that didn't happen. R18 further stated, R18 is going home on 4/5/24 but R18 not getting therapy could be detrimental for R18 because R18 still can't walk but can stand and pivot with the use of a walker. R18 exclaimed, R18 has to try to go home though because there is no reason to keep giving the facility money for services that R18 needs when R18 isn't getting those services {therapy}. R18's February 2024 Physician Orders contained the following orders: PT (Physical Therapy) CLARIFICATION ORDER: Effective 2/8/2024, patient to receive PT services 2-3 times a week for 4 weeks to address therapeutic exercises, therapeutic activities, neuromuscular re-education, gait training, and group therapy. OT (Occupational Therapy) CLARIFICATION ORDER: Effective 2/7/2024, patient to be seen for OT services 3-5 times a week for 4 weeks to address therapeutic exercises, therapeutic activities, neuromuscular re-education, self care training, wheelchair management, and group therapy. R18's medical record contained Therapy Notes from both OT and PT from the time of the Clarification Orders through 2/18/24. OT and PT Notes both dated 2/18/24 document that effective 2/19/24, the therapy company will no longer be providing services at the facility effective 2/19/24 {1.5 weeks after therapy was ordered for 4 weeks}. 2. R19's January 2024 Physician Orders contained the following orders: PT (Physical Therapy) CLARIFICATION ORDER: Effective 1/29/2024, patient to receive PT services 2-3 times a week for 4 weeks to address therapeutic exercises, neuromuscular reeducation, gait training, group therapy, and therapeutic activities OT (Occupational Therapy) CLARIFICATION ORDER: Effective 1/30/2024, patient to receive OT services 3-5 times a week for 4 weeks to address therapeutic exercises, neuromuscular reeducation, group therapy, therapeutic activities, self care management, and wheelchair management R19's medical record contained Therapy Notes from both OT and PT from the time of the Clarification Orders through 2/18/24. OT and PT Notes both dated 2/18/24 document that effective 2/19/24, the therapy company will no longer be providing services at the facility effective 2/19/24 {2.5 weeks after therapy was ordered for 4 weeks}. 3. R17's February 2024 Physician Orders documents an OT (Occupational Therapy) CLARIFICATION ORDER dated 2/13/24 for R17 to be seen 3-5 times a week for 4 weeks to address therapeutic exercises, therapeutic activities, neuromuscular re-education, group therapy, self care training, and wheelchair management. R17's OT Therapy Note dated 2/18/24 documents the therapy company will no longer be providing services at the facility effective 2/19/24 {less than one week after therapy was ordered for 4 weeks}.

Feb 2024 2 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to identify a resident's fall risk by inaccurately comple...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to identify a resident's fall risk by inaccurately completing the admission fall risk assessment, develop an at risk for falls care plan and implement fall prevention interventions, provide appropriate supervision and assistance to prevent falls, investigate falls and implement appropriate post fall interventions for two of three residents (R1, R2) reviewed for falls on the sample list of three. This failure resulted in a newly admitted resident (R2) not being identified as a fall risk therefore not having any fall prevention interventions implemented. R2 experienced daily falls, including a fall on 1/26/24 in which R2 sustained a facial laceration requiring closure with adhesive glue and strips at the Emergency Room. Findings Include: 1. On 2/6/24 at 9:20 am, R2 was walking down hallway on the Dementia Unit, bent forward and leaning to the right, while holding onto the hand rail. R2 was repeatedly asking for help stating, I need help, I don't know where my kids are. R2 had a scabbed laceration above the left eye brow but was not able to state what happened. On 2/6/24 at 10:48 am, V2 AIT (Administrator in Training) stated R2 had a fall that was witness over the surveillance cameras by V16 BOM (Business Office Manager), which caused R2's eye laceration. V2 explained R2 was a fairly new admission at that point, coming from another facility with a history of falls. V2 also stated R2 had experienced multiple falls since being admitted to the facility. R2's ongoing Census documents R2 was admitted to the facility on [DATE]. R2's ongoing Diagnoses Listing documents the following diagnoses: Alzheimer's Disease, Vascular Dementia with Behavioral Disturbances, and Anxiety. R2's admission assessment dated [DATE] documents R2 requires substantial/maximal assistance with moving from sitting to lying position and lying to sitting, partial/moderate assistance with moving from sitting to standing and for transfers, and has poor trunk control. R2's Fall Risk assessment dated 1/24//24 and 1/25/24 documents R2 is not a fall risk however the one dated 1/30/24 documents R2 is a fall risk. R2's Progress Notes document the following: 1/24/24 at 3:42 pm - experienced a witnessed fall. R2 has a small bump on the head. 1/25/24 - experienced fall at approximately 6:40am. R2 was walking down the hallway, using the siderail with CNA (Certified Nursing Assistant) close by. R2's gait was unsteady and R2 was unable to keep balance and fell to floor. 1/26/24 - Staff reported witnessing R2 falling to the floor via video surveillance. Nurse and staff responded and noted R2 to be lying on the floor on R2's back with complaints of head pain and was noted to have a laceration with bleeding to above the left eye. 1/30/24 - observed R2 getting out of the recliner in the tv room, and when R2 stood up, R2 fell back on the foot rest and fell forward hitting R2's head on the left side above the eyebrow, where R2 had previously had steri-strips applied. The area had a small amount of blood, and pressure was applied with cold cloth, more steri-strips applied. R2's Risk Management Notes for the above falls document the following: 1/24/24 - CNA called nurse to hallway due to witnessing R2 fall on the floor. R2 bumped R2's head and also received a small skin tear to the left forearm. CNA stated R2 had an unsteady gait and was unable to keep R2's balance. R2 was not able to explain what happened. Education provided to R2 and CNA's to try and prevent falls. There is no post fall intervention documented as being implemented. 1/25/24 - R2 was walking down hallway with a CNA close by. R2's gait was unsteady and R2 was unable to keep balance and fell to the floor. There is no post fall intervention documented as being implemented. 1/26/24 - nurse called to hallway for a witnessed fall of R2. R2 was lying on R2's back on the inlet of the doorway in the hallway. Staff had witnessed R2 ambulating and became unsteady falling in the hallway/doorway via camera observations. R2 noted to have a laceration above the left eye, actively bleeding with open exposure of epithelial tissue. R2 was only able to state area of pain, not what had happened. R2 was sent to the hospital and the laceration to the left eye was repaired with glue and steri-strips. There is no post fall interventions documented as being implemented. 1/30/24 - R2 observed getting out of the recliner in TV room, when R2 stood up, R2 fell back on the foot rest and fell forward hitting R2's head on the left side above the eyebrow, where R2 had previously had steri-strips applied. The area had a small amount of blood, and pressure was applied with cold cloth, and more steri strips were applied. R2's medical record does not contain an at risk care plan for R2's fall risk upon admission. R2's Care Plan dated 1/29/24 {4 days after admission and after the first fall} documents R2 has had an actual fall with minor injury due to cognitive impairment. R2 does not understand limits, is unaware of safety needs, and has poor balance. This care plan includes interventions of: 15 minute checks for two weeks, pharmacy consult to evaluate medications, provide activities that promote exercise and strength building where possible, provide wheelchair when unsteady gait and PT (Physical Therapy) for strength and mobility. On 2/6/24 at 10:28 am, V2 stated that the fall care plan and interventions were completed on 1/29/24 explaining, after R2's first fall (1/24/24) therapy screened R2, after the second fall, V2 instructed staff to place R2 in a wheelchair due to weakness, after the third fall, pharmacy completed a medication review and after the 4th fall, R2 was placed on 15 minute checks. R2's PT Plan of Care dated 1/29/24 documents R2 presents to skilled PT after suffering 1-2 falls per day since R2 arrived at the facility {5 days prior}. R2 resides on the locked Alzheimer's unit and is currently using a wheelchair for mobility due to multiple falls. R2's PT notes dated 2/1/24 documents R2 requires support on the right side due to increased right side lean and wanting to reach out for wall rails. Fatigues quickly. On 2/6/24 from 9:20 am - 9:32 am, and 1:15 pm - 1:31 pm, R2 was wandering/walking the hall's unassisted, bent over forward and leaning to the right. R2's gait was unsteady. On 2/6/24 at 2:45 pm, V10 Agency LPN (Licensed Practical Nurse) stated R2 is suppose to have staff with R2 when ambulating, R2 is not to be ambulating independently. On 2/7/24 from 5:10 am - 5:45 am, R2 was wandering/walking the halls unassisted, bent over leaning forward and leaning to the right. R2's gait was unsteady. On two seperate occasions during this time, V12 CNA and V13 CNA walked past R2 and did not assist R2 with ambulation or redirect R2 to sit down and not ambulate independently. On 2/7/24 at 7:10 am, V15 CNA stated V15 was working on 1/25/24 when R2 fell. V15 explained R2 was not walking at the time, as the Risk Management Report documents but instead had been sitting in wheelchair and when R2 stood up, R2's foot hit the wheelchair wheel causing R2 to loose balance and fall. V15 stated V15 reported how the fall occurred to the nurse on duty. On 2/7/24 at 7:25 am, V10 confirmed V10 filled out the Risk Management Report for R2's fall on 1/2/524 and explained V15 had reported that R2 lost R2's balance and fell. V10 stated V10 does not recall V15 saying R2 had lost balance due to hitting R2's foot on the wheelchair wheel but V15 might have. V10 just assumed R2 had been walking and then lost balance due to R2's gait being unsteady. On 2/7/24 at 7:35 am, V2 stated no investigations for root cause R2's falls were completed and that V2 came up with the interventions based off what the nurses wrote on the Risk Management Reports. On 2/7/24 at 9:20 am, V2 confirmed R2's fall risk assessments dated 1/24/24 and 1/25/24 were not accurate as the medications that R2 takes, along with R2's known fall history would have made R2 a fall risk. V2 also confirmed R2 did not have a fall risk care plan implemented with fall prevention intervention implemented at the time of admission but should have. 2. On 2/6/24 at 9:40 am, R1 had a scabbed laceration over the right eyebrow, which was open to air. The entire right eye is surrounded with a purple bruise with a greenish colored bruise to the right cheek bone. R1's IDPH (Illinois Department of Public Health) Notification Form dated 1/27/24 documents R1 was found on the floor next to R1's bed, bleeding from R1's head. R1 had a facial laceration that was closed with adhesives while at the hospital. R1's MDS (Minimum Data Set) dated 11/1/23 documents R1 has severe cognitive impairments and requires set up assistance only for mobility. R1's Care Plan dated 1/29/23 documents R1 had a fall with minor injury with an intervention for pharmacy to conduct a medication review. On 2/6/24 at 1:44 pm, V2 AIT (Administrator in Training) stated V2 did not conduct an investigation into R1's fall. Stated the new intervention of pharmacy doing a medication audit was V2's idea as V2 is the one that decides what interventions to put into place since the facility does not have a DON (Director of Nursing). V2 confirmed the intervention was not an appropriate intervention due to R1 rolling out of bed and that a medication review would not assist in preventing R1 from rolling out of bed again or keep R1 safe if it did happened again. The facility Fall Prevention Policy dated 11/10/18 documents the facility will provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. Upon admission, the resident's fall risk will be identified and appropriate interventions will be implemented for residents determined to be at high risk for falls. If resident's are high risk for falls and observed up or getting up, help must be summoned or assistance must be provided to the resident. If a fall occurs, immediately after the fall, a huddle will be conducted to help identify circumstances of the fall and the unit nurse will place new interventions and new interventions will be written on the care plan.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to employ a full time Director of Nursing. This failure h...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to employ a full time Director of Nursing. This failure has the potential to affect all 48 residents who reside at the facility. Findings Include: On 2/6/24 at 8:45 am, V2 AIT (Administrator in Training) stated the facility does not have a DON (Director of Nursing) or anyone serving as a DON full time explaining that the former DON quit on 1/19/24. The Facility assessment dated [DATE] documents the facility will have an RN with administrative duties 8-12 hours a day. The facility Nurses Midnight Census dated 2/5/24 documents 48 residents reside at the facility.

Oct 2023 12 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Deficiency F0697 (Tag F0697)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to effectively manage and treat ongoing pain for two of three residents...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to effectively manage and treat ongoing pain for two of three residents (R11, R35) reviewed for pain on the sample list of 25. These failures resulted in R11, on hospice, screaming out in severe pain throughout the night. Findings include: The Pain Prevention and Treatment policy dated 12/7/14 documents it is the facility's policy to assess for and reduce the incidence and severity of pain in order to enhance resident's quality of life. Pain is subjective and should be documented as perceived by the resident. R11's Medical Diagnoses list dated 10/12/23 documents Dementia with Agitation, Bipolar Disorder, Schizoaffective Disorder, Osteoarthritis, and Osteoporosis. R11's Physician Order Sheet dated October 2023 documents R11 is on Hospice and is prescribed Morphine Sulfate (narcotic analgesic) scheduled and as needed for discomfort. R11's Minimum Data Set, dated [DATE] documents R11 is severely cognitively impaired. R11's Care Plan dated 7/26/23 documents R11 suffers from chronic pain. Staff are to anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Staff are to notify the physician if interventions are unsuccessful. R11's Care Plan also documents R11 is receiving Hospice Services and the goal is to remain as comfortable as possible. R11's Medication Administration Record dated October 2023 documents on the night of 10/7/23 through the morning of 10/8/23, R11 did not receive any of the 'as needed' doses of Morphine Sulfate. R11 received her last scheduled dose of Morphine Sulfate around 8:00 PM on 10/7/23. R35's Medical Diagnoses list dated 10/12/23 documents difficulty Walking, Muscle Weakness, and Bipolar Disorder. R35's Physician Order Sheet dated October 2023 documents R35 is prescribed Acetaminophen every eight hours as needed or Percocet (opioid analgesic) every four hours as needed for pain. R35's Care Plan dated 6/8/23 documents R35 suffers from chronic pain. Staff are to anticipate the resident's need for pain relief and respond immediately to any complaint of pain. R35's Medication Administration Record dated October 2023 documents on the night of 10/7/23 through the morning of 10/8/23 R35 was given two doses of Percocet pain medication. On 10/11/23 at 2:00 PM R35 stated she had issues with the V10 LPN on the night of 10/7/23. R35 stated she is in almost constant pain and V10 was refusing to give her pain medication timely. R35 stated V10 was rude and told her she was not giving her pain medication and slammed the door when she left the room. R35 rated her pain as a 10/10 and stated the staff do not do enough to help her relieve her pain. R35 stated V10 LPN also just let R11 who was R35's roommate scream and yell in pain all night long. R35 stated R11 sounded so uncomfortable and was crying and it was horrible to listen to. On 10/12/23 at 1:00 PM V12 Certified Nurses Assistant (CNA) stated on the night shift of 10/7/23 both R11 and R35's pain was ignored by their assigned nurse V10 Licensed Practical Nurse (LPN). V12 stated R11 is on hospice, has impaired cognition, and will yell out when she is agitated or in pain. V12 stated on the night of 10/7/23, R11 was yelling out and when asked what was wrong, R11 stated she hurt and kept repeating that over and over. V12 stated R11 was crying and appeared to be in pain. V12 stated she reported this to V10 LPN and V10 snapped at V12 and said she was not going to give R11 anything for pain. V12 stated more than one staff member reported R11 being in pain to V10 but V10 would not administer R11's pain medication. V12 stated R11 was crying and yelling out in pain all throughout the night shift. V12 also stated R35 began to complain about severe pain in the early morning hours of 10/8/23. V12 stated she reported this to V10 LPN and V10 told her to mind her own business. V12 stated R35 repeatedly had on her call light complaining of pain. V12 stated R35 told her V10 LPN had entered her room to answer the call light and told her she was not getting anything for pain, shut off the light, and slammed the door. V12 stated R35 was visibly upset and in pain. On 10/12/23 at 1:46 PM V20 Certified Nurses Assistant (CNA) stated on the night shift of 10/7/23 V10 Licensed Practical Nurse (LPN) ignored R11 and R35's pain. V20 stated R11 was screaming in pain all throughout the night shift from about 9:00 PM through the end of the shift. V20 stated she told V10 LPN and other staff told her as well about R11's pain and R35's pain. V10 LPN did not address R11's pain and did not give her any pain medication. R11 cried and yelled out it hurts all throughout the night shift on 10/7/23. V20 stated R11 normally does not yell out and cry all night long and normally sleeps through the night. V20 stated R35 complained of pain in the early hours of 10/8/23 and V10 ignored her requests for something for pain. On 10/12/23 at 2:30 PM V13 Certified Nurses Assistant (CNA) stated on the night shift of 10/7/23, R11 cried in pain and yelled out for hours and V10 Licensed Practical Nurse did nothing for her (R11). V13 CNA stated R11 was yelling out and saying she hurt. V10 LPN was told by multiple staff and did nothing to help R11. V13 CNA stated R35 also stated she needed something for pain multiple times and V10 LPN was told and did nothing. V13 stated R35 told her V10 LPN had entered her room to answer the call light, R35 told her she needed pain medication, and V10 told her she was not getting anything for pain, shut off the light, and slammed the door. On 10/12/23 at 5:08 PM V11 Licensed Practical Nurse (LPN) stated she worked the night shift on 10/7/23. V11 stated R11 was in a lot of pain that night and was screaming out and crying and stating she hurt all throughout the night. V11 LPN stated she told V10 LPN about R11's pain. V11 stated V10 refused to give R11 any pain medication. V11 stated she told V10 if she didn't want to care for her residents properly then she could leave the facility. V10 refused to leave and refused to give R11 any pain medication. V11 LPN stated R35 was also complaining of pain and needs her prescribed pain medication every four hours. R35 was complaining of pain and rating it a 10/10. V11 stated R35 told her that V10 LPN was refusing to bring her pain medication and R35 was visibly upset and in pain. On 10/13/23 at 9:44 AM V10 Licensed Practical Nurse confirmed worked the night shift on 10/7/23 and was the assigned nurse for both R11 and R35. V10 confirmed she administered R11's scheduled Morphine Sulfate but did not give her any 'as needed' doses. V10 LPN confirmed staff members came to her concerning R11's pain but V10 did not feel like R11 was in that much pain. V10 LPN confirmed she did spend most of the shift on the dementia unit where the doors were shut and did not hear R11 yelling out or crying in pain. V10 LPN confirmed R11 and R35's room is not on the dementia unit. V10 LPN confirmed she was late a little late giving R35 her pain medication because she passed medications to the dementia unit first. V10 LPN confirmed if a resident is having pain, request pain medication, and/or has pain medication available to be given, the pain medication should be administered. On 10/13/23 at V30 Hospice Nurse stated R11 is alert to person, she's very confused and can express pain but can't say the location of her pain if asked. V30 stated R11 does have scheduled Morphine Sulfate for pain and 'as needed' Morphine Sulfate if needed for further discomfort. V30 stated if R11 or any patient for that matter is in pain and crying out, seems agitated, is crying or stating they are hurting, the nurse should give the prescribed pain medication that is available. V30 confirmed if R11 was exhibiting pain by yelling, crying, and stating she was hurting, V10 LPN should have administered the 'as needed' Morphine Sulfate. On 10/13/23 at 1:00 PM V2 Director of Nurses and V3 Director of Clinical Operations confirmed nurses should always address a resident's pain and discomfort by either giving pain medications or trying an alternative method of pain control. Both V2 and V3 both confirmed if those things are tried and the resident's pain is still not relieved, nursing staff should address uncontrolled pain with the resident's physician. Both V2 and V3 confirmed V10 LPN should have administered R11's 'as needed' pain medication when she was crying out in pain. Both V2 and V3 confirmed R35 is always complaining of pain and asks for her 'as needed' Percocet frequently.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide incontinence care in a dignified and private ma...

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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 incontinence care in a dignified and private manner for one resident (R39) and failed to provide dignity when staff inappropriately yelled about a residents unusual eating manner for one resident (R93). These failures have the potential to affect two of two residents reviewed for dignity on the sample list of 25. Findings include: The undated Resident's Rights for People in Long-term Care Facilities documents residents have the right to privacy. A resident's medical and personal care are private. The facility may not give resident's information to any unauthorized persons without the resident's permission 1. R39's Medical Diagnoses sheet dated 10/13/23 documents R39 is diagnosed with Delusional Disorder, Alcohol-Induced Persisting Amnestic Disorder and Insomnia. R39's Minimum Data Set, dated [DATE] documents R39 is severely cognitively impaired and requires extensive assist of one person for transfers and toileting. On 10/12/23 at 1:00 PM V12 Certified Nurses Assistant (CNA) stated about a week ago, staff were trying to change R39 while he was having some behaviors. V10 LPN (Licensed Practical Nurse) told everyone to leave R39 alone and when R39 was in the hallway, V10 LPN ripped his incontinence brief in the back and it fell off of him to the floor. On 10/12/23 at 1:46 PM V20 Certified Nurses Assistant (CNA) stated R39 was in his room and needed his incontinence brief changed. R39 was attempting to use the bathroom on the floor of the room. V20 stated she tried to redirect R39 and calm him down but it wasn't helping. V20 stated at that time V10 Licensed Practical Nurse came into the room and told her to leave R39 alone. V20 stated she left the room and R39 followed her into the hallway. V20 stated R39's incontinence brief was sagging with the weight of the urine collected in it. V10 LPN went behind R39 and ripped the back of R39's incontinence brief and it fell to the ground and the inside material went all over the floor. V20 CNA confirmed R39 was exposed in the hallway. V20 stated R39 seemed livid and turned to V10 and called her (expletive) and tried to hit her. V20 CNA stated she took R39 to his room and got him cleaned up. On 10/12/23 at 2:30 PM V13 Certified Nurses Assistant (CNA) stated she and V20 CNA were attempting to take R39 to the bathroom before he urinated on the floor in his room. V13 stated R39's incontinence brief was very wet and needed to be changed. R39 was having behaviors and cursing but it was nothing out of the ordinary when R39 was upset. V13 CNA stated V10 LPN told the CNA staff to leave R39 alone and get out of his room. V13 stated the staff left and R39 followed them into the hallway. V13 stated V10 LPN went behind R39 and ripped his incontinence brief and it fell to the floor in the hallway. V13 confirmed R39 was exposed in the hallway. On 10/12/23 at 4:30 PM V1 Administrator stated she was notified that R39's incontinence brief had been ripped off by V10 LPN in the hallway. V1 stated she viewed camera footage of the incident and did see R39 in the hallway with a very saturated incontinence brief. V1 confirmed R39's brief was removed in the hallway. On 10/13/23 at 9:44 AM V10 LPN stated three CNAs were attempting to assist R39 with going to the bathroom and changing his incontinence brief which was heavily saturated. V10 LPN stated she told the CNA staff to leave R39 alone and give him some space. R39 followed them into the hallway. V10 LPN stated she stepped behind R39 and noticed how saturated his incontinence brief was. V10 stated she tore the back of the brief and it fell to the ground. V10 stated R39 got very angry with her and yelled and cursed at her. V10 confirmed R39's brief fell to the ground after she tore it and R39 was in the hallway exposed before CNA staff took him to get him cleaned up and put on a new incontinence brief. On 10/13/23 at 12:04 PM V1 Administrator stated the incident with R39 happened around 1:30 AM on 9/29/23. On 10/13/23 at 1:00 PM V2 Director of Nurses and V3 Director of Clinical Operations confirmed V10 LPN should not have torn R39's incontinence brief while in the hallway, causing it to fall to the ground and exposing R39 in a public place. V2 and V3 confirmed incontinence care should be done in a private place. 2.) R93's Physician Order Summary Report sheet (POS) dated 10/13/23 documents R93's diagnoses include the following: Unspecified Dementia, Moderate With Agitation. The same POS documents R93 was admitted to the facility 10/09/23 (one day prior to the following observation). On 10/10/23 at 12:07 pm through 12:30 pm, R93 sat in a full resident (unidentified) memory care unit dining room. The dining room included unidentified residents and a visitor, V18, R40's Family Member. R93 was eating his lunch. R93 consumed Salisbury steak, mashed potatoes and mixed vegetables using a butter knife. R93 sorted and picked at his food. R93 dropped several bites during his meal and resumed eating without verbal or physical assistants. R93 ate 100 percent of his meal with the butter knife. V6, Certified Nursing Assistant (CNA) was seated at one end of the dining room. R93 was seated approximately ten feet away. V6, CNA drew attention to R93 when V6, gestured with a nod of V6's head towards R93. V6, CNA stated loudly across the full dining room, to V7, CNA, He (R93) ate with a butter knife the whole time. At 12:48 pm V6, CNA stated I think that is HIPPA (Health Insurance Portability and Accountability Act) violation or something like that. The dining room was full. Nobody should have heard me say that. If they (residents on memory care unit) didn't all have Dementia, I would not have said that. It would have been embarrassing to him (R93). On 10/10/23 at 3:45 pm V1, Administrator was given the above information and confirmed R93 has the right to dignity while dining. V1 stated her expectation is that staff treat all residents with dignity.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect the residents right to be free from physical and mental 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 protect the residents right to be free from physical and mental abuse by another resident. This failure affects one of five residents (R19) reviewed for abuse on the sample list of 25. Findings include: R14's Diagnoses Sheet dated 10/12/23 documents the following diagnoses: Alzheimer's Disease With Late Onset Delusional Disorder. R14's Minimum Data Set, dated [DATE] documents R14 has severe cognitive impairment. The same MDS documents R14 has had no physical or verbal behaviors directed towards self or others. R14's Care Plan dated 8/03/23 documents the following: (R14) is/has potential to be physically aggressive by being combative with staff during cares r/t (related to) poor impulse control, anxiety, delusional d/o (disorder), (and) Alzheimer's. R19's Diagnoses Sheet dated 10/12/23 documents the following diagnoses: Vascular Dementia Severe With Other Behavioral Disturbances, Major Depressive Disorder, Recurrent, and Anxiety Disorder. R19's Minimum Data Set, dated [DATE] documents R19's Brief Interview of Mental Status score of four out of a possible 15, indicating severe cognitive impairment. The same MDS documents R19 has had no physical or verbal behaviors directed towards self or others. On 10/12/23 at 2:08 PM V21, Certified Nursing Assistant (CNA) stated V21, CNA worked B- hall with V10, Licensed Practical Nurse (LPN) on 10/7/23. V21, stated R14 had a rough night. R14 was screaming overnight on 10/7/23. V10 LPN and V21, CNA did rounds after V10, LPN finished passing medications on C-hall. V21, CNA stated V10, LPN helped V21, CNA change R14 and helped with R19. V21, CNA then stated I told (V10, LPN) I saw (R14) get up and hit (R19). (R14) went over to (R19's) bed pulled (R19's) covers off and started smacking (R19) on the arm. (R19) was screaming and crying. V21 also stated (V21) did not report this to the (V2, Director of Nursing) or (V1, Administrator). I guess I should have. I know we are supposed to tell our supervisor and the Administrator anytime there is abuse. (R14) was deliberately targeting (R19), because she (R19) started screaming when (R14) pulled (R19) blankets off. On 10/13/23 at 10:35 am V10, LPN stated when V10, LPN went into R14 and R19's room to help V21, CNA with R14 and R19's care, V10 remembered V21 CNA saying R14 hit R19. V10 stated both residents were in their beds. V10 thought V21 was giving V10 history about the residents since V10 had only worked in the facility a couple of weeks. V10 stated I did not know it (R14 hit R19) had just happened. It would have been reported immediately to the Administrator. I misunderstood; I thought the situation had happen, sometime previous. Not that night (10/7/23). The facility policy Abuse Prevention Program dated as revised 11/28/16 documents the following: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. The same policy also states that Abuse is the willful injection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Mental abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident(s), harassment, humiliation and threats of punishment or deprivation.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow a physician ordered intervention to remove a re...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow a physician ordered intervention to remove a residents helmet while in bed. This failure resulted in an alteration in R18's skin integrity. R18 is one of one resident reviewed for skin impairment on the sample list of 25. Findings include: R18's Physician Order Summary Report sheet (POS) dated 10/12/23 documents the following: Soft helmet to be worn while up out of bed. May take off for meals. R18's Minimum Data Set, dated [DATE] documents R18 has severe cognitive impairment. On 10/10/23 at 12:23 PM, R18 had a helmet on while dining. After lunch, V7, Certified Nursing Assistant (CNA) walked with R18 to his room. R18 was grabbing the fastened, chin strap of his helmet as he was walked to his room. V7, CNA assisted R18 to lay down in R18's low bed. V7,CNA left R18's helmet on and fastened as R18 went to sleep. On 10/10/23 at 1:20 pm R18 continued in low bed asleep with the fastened helmet on. R18 was restless and tugging at the fastened chin strap of the helmet while R18 slept. On 10/10/23 at 1:23 pm V7, CNA stated We always leave his (R18's) helmet on when he is in bed. He sometimes wakes up and gets out of bed on his own. I didn't know it was supposed to be taken off at anytime, meals or sleeping. On 10/10/23 at 1:25 pm V6, CNA added to V7's statements. V6, CNA stated Nights (night shift staff) leave it on every night too. He (R18) is a high fall risk. This is his intervention. On 10/10/23 at 3:45 pm R18 remained in bed, asleep since lunch according to V6,CNA. R18 was laying in bed, in a right side lying position. R18 woke up with R18's fastened helmet still on. R18 was fidgeting with the fastened helmet, chin strap. V8, Licensed Practical Nurse (LPN) assisted V6, CNA to perform R18's incontinence care. V8, LPN completed a brief head to toe, skin assessment. R18 became more restless in bed. V8, LPN removed R18's helmet. R18 had two, deep indentations surrounded by red, irritated skin. The two red-irritated indentations were located on R18's right forehead, above the eyebrow and extended back into R18's scalp. R18's red, deeply indented, irritated skin was clearly visible through R18's thinning hair. The two red, irritated, deep indentations were approximately one inch a part. One skin indentation with surrounding irritated skin, measured approximately six inches. The second indentation on R18's forehead and scalp measured approximately five inches. The indentations were directly under where R18's had been laying on his right side with the helmet on. R18 also had a silver dollar sized, red irritated indentation under his right ear. V8, LPN confirmed the helmet aligned with the red- irritated indentation, from R18's helmet being left on while R18 slept.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement a physician ordered scoop mattress interventi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement a physician ordered scoop mattress intervention for a resident (R18) with a history of falls and a seizure disorder. This failure affected one of two residents (R18) reviewed for accident/falls on the sample list of 25. Findings include: R18's Diagnoses Report dated 10/12/23 documents the following diagnoses: Other Frontotemporal Neurocognitive Disorder, Alzheimer's Disease, Unspecified, Epileptic Seizures Related to External Causes, Not Intractable, Without Status Epileptics, Anxiety Disorder, Muscle Weakness Generalized, Unspecified Lack of Coordination, Difficulty Walking Not Elsewhere Classified, and Insomnia. R18's Physician Order Summary Report sheet (POS) dated 10/12/23 documents Safety Devices: Scoop mattress to promote safety with bed mobility. R18's Minimum Data Set, dated [DATE] documents R18 has severe cognitive impairment. R18's Fall Risk assessment dated [DATE] documents R18 is at high risk for falls with a score of 12, and has had 1-2 falls in the past three months. The facility Fall Log dated May 2023 through September documents R18 has had 11 (eleven) falls in the facility. On 10/10/23 at 12:23 PM, R18 was in dining room and fell asleep. R18 woke up and was walked to R18's room by V7, Certified Nursing Assistant (CNA). V7, CNA assisted R18 to lay down in R18's low bed. There was no scoop mattress on R18's bed. On 10/10/23 at 1:20 PM R18 continued to sleep in R18's low bed without the scoop mattress. R18 was restless while he slept. On 10/10/23 at 3:45 PM R18 had remained in bed, asleep since lunch according to V6,CNA. V8, Licensed Practical Nurse (LPN) confirmed there was no scoop mattress on R18's bed. On 10/13/23 at 1:34 PM V3, Regional Director of Operations stated R18's scoop mattress should have been on R18's bed to keep R18 safe.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to change the oxygen tubing and humidifier bottle for one of two residents (R6) reviewed for respiratory care on the sample list ...

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Based on observation, interview, and record review the facility failed to change the oxygen tubing and humidifier bottle for one of two residents (R6) reviewed for respiratory care on the sample list of 25. Findings include: The Oxygen Therapy policy dated March 2019 documents oxygen tubing should be changed on a weekly basis and the tubing changes should be dated and documented on the residents Treatment Administration Record (TAR). When using humidification, changes need to be dated and documented on the TAR. R6's Medical Diagnoses List dated 10/12/23 documents R6 is diagnosed with Chronic Obstructive Pulmonary Disease, Heart Failure, and Chronic Respiratory Failure. R6's Physician Order Sheet (POS) dated October 2023 documents an order for oxygen via nasal cannula every shift for Chronic Obstructive Pulmonary Disease. The same POS documents an order to change the oxygen tubing and humidifier bottle weekly on night shift on Saturdays. On 10/10/23 at 2:32 PM R6's oxygen was being administered via nasal cannula at four liters per hour. The oxygen tubing was not dated, the humidifier bottle was not dated, and the humidifier bottle was totally dry and empty. On 10/13/23 at 1:00 PM V2 Director of Nurses and V3 Director of Clinical Operations confirmed nurses need to change oxygen tubing and humidifier bottle at least weekly, date the tubing and humidifier bottle when changed, and not let the humidifier bottle become empty.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

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 education and offer Pneumococcal vaccines for three of five ...

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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 education and offer Pneumococcal vaccines for three of five residents (R9, R19, R34) reviewed for vaccinations on the sample list of 25. Findings Include: The Immunization of Residents policy revised 5/19/23 documents facility will offer immunizations and vaccinations that aid in the prevention of infectious diseases unless medically contraindicated or otherwise ordered by the residents attending physician or the facility's medical director. Procedure: 1. Explain to the resident, residents guardian or the residents Durable Power of Attorney for Health Care, at the time of admission and start of the recognized mass immunization period, the importance of vaccination against common illness such as pneumonia and influenza. 2. Obtain a written order for the vaccination, unless otherwise ordered by the residents attending physician or the resident or authorized representative refuses. 3. Obtain permission/consent from the resident, residents guardian or the residents Durable Power of Attorney for Health Care to administer the ordered vaccine, unless contraindicated. 4. Verify the date of last vaccination. Obtain proof of previous Pneumococcal and Influenza vaccination for residents when able. Assess all newly admitted residents Pneumococcal and influenza vaccination status upon admission and record the last known immunization on the residents Immunization Record. 5. Offer the PCV13, PCV15, PCV20 or PPSV 23 as indicated utilizing the pneumonia Vaccine Timing Guidelines, unless contraindicated. 1. R9's Medical Diagnoses List dated October 2023 documents R9 was admitted on [DATE] and is diagnosed with Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Hypertensive Heart Disease with Heart Failure, Generalized Anxiety Disorder, Mild Intellectual Disabilities, Dissociative and Conversion Disorders, Dissociative Fugue, and Need For Assistance with Personal Care. There is no documentation in R9's medical record of Pneumococcal vaccination history or that the facility provided education regarding the Pneumococcal vaccine, offered the vaccine, or that the vaccine was given or declined. 2. R19's Medical Diagnoses List dated October documents R19 was admitted on [DATE] and is diagnosed with Major Depressive Disorder, Vascular Dementia, Hypothyroidism, Psychotic Disorder with Delusions, Arthritis Multiple Sites, Dietary Vitamin B12 Deficiency Anemia, Insomnia Due to other Mental Disorder, Psychosis and Protein-Calorie Malnutrition. There is no documentation in R19's medical record of Pneumococcal vaccination history or that the facility provided education regarding the Pneumococcal vaccine, offered the vaccine, or that the vaccine was given or declined. 3. R34's Medical Diagnoses List dated October 2023 documents R34 was admitted on [DATE] and is diagnosed with Alzheimer's Disease, HTN, Hyperlipidemia, Hypothyroidism, Anxiety Disorder, Depression, GERD, Atherosclerotic Heart Disease, Type 2 Diabetes, Delusional Disorders, Psychophysiologic Insomnia, Nutritional Deficiency and Bipolar Disorder. There is no documentation in R34's medical record of Pneumococcal vaccination history or that the facility provided education regarding the Pneumococcal vaccine, offered the vaccine, or that the vaccine was given or declined. On 10/13/23 at 11:23am V1 Administrator in Training said residents vaccination status should be assessed upon admission and documented in the residents medical record. V1 confirmed R9, R19, and R34 or their representatives should have been educated regarding the Pneumococcal vaccine and offered the vaccine. If the vaccination was given or declined, it should be documented in the resident's medical record.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

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 recognize and report allegations of abuse/neglect/injur...

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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 recognize and report allegations of abuse/neglect/injuries of unknown origin to the administrator and the state survey agency for five of five residents (R11, R35, R14, R18, R19) reviewed for abuse on the sample list of 25. Findings include: 1. On 10/12/23 at 1:00 PM V12 Certified Nurses Assistant (CNA) stated on the night shift of 10/7/23 both R11 and R35's were neglected by their assigned nurse V10 Licensed Practical Nurse (LPN). V12 stated R11 is on hospice, has impaired cognition, and will yell out when she is agitated or in pain. V12 stated on the night of 10/7/23, R11 was yelling out and when asked what was wrong, R11 stated she hurt and kept repeating that over and over. V12 stated R11 was crying and appeared to be in pain. V12 stated she reported this to V10 LPN and V10 snapped at V12 and said she was not going to give R11 anything for pain. V12 stated more than one staff member reported R11 being in pain to V10 but V10 would not administer R11's pain medication. V12 stated R11 was crying and yelling out in pain all throughout the night shift. V12 also stated R35 began to complain about severe pain in the early morning hours of 10/8/23. V12 stated she reported this to V10 LPN and V10 told her to mind her own business. V12 stated R35 repeatedly had on her call light complaining of pain. V12 stated R35 told her V10 LPN had entered her room to answer the call light and told her she was not getting anything for pain, shut off the light, and slammed the door. V12 stated R35 was visibly upset and in pain. V12 CNA stated she called V1 Administrator about her concerns about the neglect of R11 and R35. V12 stated V1 Administrator told her she would look into it but V12 never heard anything else about it. On 10/12/23 at 1:46 PM V20 Certified Nurses Assistant (CNA) stated on the night shift of 10/7/23 V10 Licensed Practical Nurse (LPN) was neglectful and ignored R11 and R35's pain. V20 stated R11 was screaming in pain all throughout the night shift from about 9:00 PM through the end of the shift. V20 stated she told V10 LPN and other staff told her as well about R11's pain and R35's pain. V10 LPN did not address R11's pain and did not give her any pain medication. R11 cried and yelled out it hurts all throughout the night shift on 10/7/23. V20 stated R11 normally does not yell out and cry all night long and normally sleeps through the night. V20 stated R35 complained of pain in the early hours of 10/8/23 and V10 ignored her requests for something for pain. V20 stated V1 Administrator was notified that night of V10 LPN neglecting R11 and R35. On 10/12/23 at 2:30 PM V13 Certified Nurses Assistant (CNA) stated on the night shift of 10/7/23, R11 cried in pain and yelled out for hours and V10 Licensed Practical Nurse did nothing for her (R11). V13 CNA stated R11 was yelling out and saying she hurt. V10 LPN was told by multiple staff and did nothing to help R11. V13 CNA stated R35 also stated she needed something for pain multiple times and V10 LPN was told and did nothing. V13 stated R35 told her V10 LPN had entered her room to answer the call light, R35 told her she needed pain medication, and V10 told her she was not getting anything for pain, shut off the light, and slammed the door. V13 stated V1 Administrator was called and notified of the concerns that night by more than one staff member. On 10/12/23 at 5:08 PM V11 Licensed Practical Nurse (LPN) stated she worked the night shift on 10/7/23. V11 stated R11 was in a lot of pain that night and was screaming out and crying and stating she hurt all throughout the night. V11 LPN stated she told V10 LPN about R11's pain. V11 stated V10 refused to give R11 any pain medication. V11 stated she told V10 if she didn't want to care for her residents properly then she could leave the facility. V10 refused to leave and refused to give R11 any pain medication. V11 stated she called V1 Administrator to notify her that V10 LPN was neglecting R11's pain and V1 said she would look into it but I had not heard anything else. V11 LPN stated R35 was also complaining of pain and needs her prescribed pain medication every four hours. R35 was complaining of pain and rating it a 10/10. V11 stated R35 told her that V10 LPN was refusing to bring her pain medication and R35 was visibly upset and in pain. On 10/11/23 at 12:25 PM V1 Administrator confirmed staff called her on the night of 10/7/23 beginning around 12:14 PM. Staff reported to her that V10 Licensed Practical Nurse was not addressing R11 and R35's pain. The staff told V1 R11 and R35 were yelling out in pain and V10 was refusing to give them medication. V1 confirmed no report was ever made to the state survey agency about the alleged neglect. R11's Medical Diagnoses list dated 10/12/23 documents Dementia with Agitation, Bipolar Disorder, Schizoaffective Disorder, Osteoarthritis, and Osteoporosis. R11's Physician Order Sheet dated October 2023 documents R11 is on Hospice and is prescribed Morphine Sulfate (narcotic analgesic) scheduled and as needed for discomfort. R11's Minimum Data Set, dated [DATE] documents R11 is severely cognitively impaired. R11's Medication Administration Record dated October 2023 documents on the night of 10/7/23 through the morning of 10/8/23, R11 did not receive any of the 'as needed' doses of Morphine Sulfate. R11 received her last scheduled dose of Morphine Sulfate around 8:00 PM on 10/7/23. R35's Medical Diagnoses list dated 10/12/23 documents difficulty Walking, Muscle Weakness, and Bipolar Disorder. R35's Physician Order Sheet dated October 2023 documents R35 is prescribed Acetaminophen every eight hours as needed or Percocet (opioid analgesic) every four hours as needed for pain. On 10/11/23 at 2:00 PM R35 stated she had issues with the V10 LPN on the night of 10/7/23. R35 stated she is in almost constant pain and V10 was refusing to give her pain medication timely. R35 stated V10 was rude and told her she was not giving her pain medication and slammed the door when she left the room. R35 rated her pain as a 10/10 and stated the staff do not do enough to help her relieve her pain. R35 stated V10 LPN also just let R11 who was R35's roommate scream and yell in pain all night long. R35 stated R11 sounded so uncomfortable and was crying and it was horrible to listen to. 2. R18's Minimum Data Sheet documents R18 has severe cognitive impairment. R18's Progress note dated 10/9/2023 at 01:59 documents the following: A.I.M. (Assessment/Evaluation, Intercommunicate, Management/Intervention) For Wellness- Event Record Note Text: Event Details: (R18) appears to have sustained an injury that was unwitnessed- or is of unknown origin. Event was first noted on 10/09/2023 (at) 1:45 AM. Evaluation of the resident (R18) and event occurred on or about 10/09/2023 (at) 1:47 AM. Just prior to/at the time of the event (R18) appears to have been sleeping. (R18's) account of the event is unable to relate. Witness to the event includes: N/A (not applicable) Location of the event is: unknown description of the environment at the time of the event includes: patient was sleeping and CNA's (Certified Nursing Assistants) doing care and found areas on patient. Staff's immediate response is noted as (sic) called nurse to evaluate and treat. Unable to determine if this type of event is known to have occurred previously. On 10/11/23 at 11:08 am V1, Abuse Prevention Coordinator/ Administrator in Training provided an undated skin grid that documented R18 had a seven centimeter bruise on R18's right scapula and a second bruise on R18's right lower abdomen. V1 acknowledged the documentation of R18's abdomen bruise was documented on the skin grid V1 had provided. V1 also provided shower sheets 9/18, 9/20, 9/23, 9/27, 9/29, 10/4/23 and 10/7/23. Each of the shower sheets documents a red area on R18's right scapula. There was no documentation on any of the above shower sheets regarding R18's abdomen bruise. On 10/10/23 at 3:45 PM V8, Licensed Practical Nurse (LPN) assisted V6, Certified Nursing Assistant (CNA) with R18's incontinence care. V8, LPN completed a brief head to toe skin assessment as R18 laid in bed. R18 had a one-inch long by three-inch wide scar-like pink colored area present, off centered aspect of R18's right abdomen. R18 did not allow V8 to raise R18's shirt above his abdomen to assess R18's shoulders. On 10/12/23 at 1:00 PM V12, Certified Nursing Assistant (CNA) stated she worked overnight 10/08/23. V12 stated V12 provided care for R18 and saw R18's stomach had a purple- red area next to his umbilicus and what looked like a rug burn on his shoulder. V12 stated both areas were close to the same size. Approximately three or four inches wide. V12 stated V12 told V11 Licensed Practical Nurse, and V11 assessed and reported to V2, Director of Nursing and V1, Administrator/Abuse Prevention Coordinator. On 10/12/23 at 5:25 PM V11, Licensed Practical Nurse stated V12 and V13 Certified Nursing Assistants called V11 down to R18's room to see areas on R18's skin they had not seen before. V11 stated R18 had a seven centimeter line that was bluish-red on the right side of his umbilicus. He also had a red area on his right scapula. V11 stated V11 measured and documented the areas. V11 then stated V11 reported the injuries of unknown origin to V1 Abuse Prevention Coordinator, V2 Director of Nursing, V5, Physician and R18's Family Member V32. On 10/11/23 at 11:00 am V1, Abuse Prevention Coordinator/ Administrator in Training stated R18 was found to have a bruise near his clavicle. V1 stated this clavicle bruise is documented on his previous shower sheets and skin assessments. V1 also stated she did not consider the area on R18's shoulder unknown because it is documented several weeks as a previous area. V1 also stated she had not heard anything about R18's abdomen bruise. V1 acknowledge she had not thoroughly investigated nor reported the abdomen bruise as it was not noted on R18's previous shower sheets. V1 acknowledged R18's abdominal bruise is an injury of unknown origin that should have been reported and thoroughly investigated. 3. R14's Minimum Data Set, dated [DATE] documents R14's has severe cognitive impairment. R14's A.I.M. For Wellness-Event Record dated 10/9/2023 at 02:28 am documents the following: Note Text: Event Details: (R14) appears to have sustained an injury that was unwitnessed-or is of unknown origin. Event was first noted on 10/09/2023 1:30 AM. Evaluation of the resident and event occurred on or about 10/09/2023 1:35 AM. Just prior to/at the time of the event (R14) appears to have been sleeping. (R14) account of the event is unable to relate details. Witness to the event includes: N/A. Location of the event is: unknown. Description of the environment at the time of the event includes: patient (R14) was in her bed CNA's (unidentified) went to check on patient due to yelling out. R14's Health Status Progress Note dated 10/9/2023 at 01:53 am signed by V11, Licensed Practical Nurse (LPN) documents the following: On resident care CNA's (unidentified Certified Nursing Assistants) observed numerous bruises to resident (R14) left side of body from her face to her lower leg, also on assessment residents mouth has abrasions to lip and upper gum area. Resident is unable to communicate how this happened but on assessing resident has pain when touching her, but is easily calmed. Patients (R14) temperature taken at this time but unable to get anything else due to (resident R14) becoming extremely agitated. DON (V2, Director of Nursing) made aware. On 10/11/23 at 4:00 PM V1, Administrator in Training/Abuse Prevention Coordinator stated V1 assumed R14's extensive bruises occurred from a fall 10/2/23. V1 confirmed she did not recognize R14's bruises as injury of unknown origin, did not complete a thorough abuse investigation to conclude the origin and did not report R14's bruises to the State Agency. On 10/12/23 at 1:00 PM V12, Certified Nursing Assistant (CNA) stated she worked overnight 10/08/23. V12 stated V12 was provided incontinence care for R14 and saw bruises all up and down R14's hip, lower lower leg, left upper arm and shoulder. V12 also stated R14 had some redness to her left cheek and it looked like R14 bit her lip. V12, CNA told V11, Licensed Practical Nurse (LPN). V11, LPN evaluated R14's skin and reported the bruises to V2, Director of Nursing and V1, Administrator In Training/Abuse Prevention Coordinator. On 10/12/23 at 5:25 PM V11, LPN stated V12 CNA and V13 CNA called V11, LPN down to R14's room due to bruising that they had not seen before. V11 stated neither had she seen the bruises. V11 stated R14 had discoloration on her face that was pale yellow- green, three small red spots on her left upper arm, petechia light purple on her left abdomen, light green bruising on her left hip and lower calf. V11 stated the yellow and green areas may have been old bruises but V11 had not seen them. V11 stated staff have to report injuries of unknown origin if we don't know what happened. The red areas on left upper arm look fresh. V11 stated I (V11) left messages at the time, then (V11) told (V1, Abuse Prevention Coordinator) and (V2), DON by phone at 6:30 am that morning (10/9/23). They said they would investigate and find out what is going on. I documented everything and left a message for the (V27) Guardian and notified the provider (V28, Physician). On 10/13/23 at 11:30 am V8, Licensed Practical Nurse (LPN) assessed R14 skin. Multiple fading bruises all along the left side of R14's upper arm, left hip and left calf, a birth mark like spotted light brown patch on her left abdomen. There was no bruising on R14's face. 4. R19's Minimum Data Set, dated [DATE] documents R19's Brief Interview of Mental Status score of four out of a possible 15, which indicates severe cognitive impairment. On 10/11/23 at 11:08 am V1, Abuse Prevention Coordinator/ Administrator in Training provided a group of witness statements regarding events that occurred on night shift 10/7/23. The witness statements document an allegation that V10, Licensed Practical Nurse held down (R19). On 10/12/23 at 1:00 PM V12, CNA stated On 10/7/23 shift, I did not actually lay eyes on (R14) and (R19) I was in the break room with (V13, CNA). The break room shares a wall with (R14) and (R19) room. I heard (V10, LPN) laughing. I heard what sounded like something hitting the wall. Maybe the headboard of the bed. It was loud and (V13, CNA) heard it too. I know (R14) did not take her meds several times that week. I heard she hadn't taken her meds that night either. I knew she (R14) gets agitated easy when she does not get the medications. I listened at the wall, and I heard something like a thud. I thought maybe (R14) had a fall. We (V12 and V13) ran through the B-hall door. (V10, LPN) told us get the (expletive) off this hall, it is not your hall. We did not get close to (R14's) doorway, couldn't actually see in (the room). (V10, LPN was standing in the door way. We left B-Hall. (V21, CNA) was (R14's) CNA. She (V21, CNA) was in the room with (V10, LPN). (V11, LPN) was outside the break room door and saw through the window. (V11, LPN) said she saw (V10, LPN) laughing up in (R19's) face. (V11, LPN) thought (V10, LPN) may be restraining (R19) while (V21, CNA) did (R19's) incontinence care. On 10/12/23 at 2:50 PM V13, Certified Nursing Assistant (CNA) stated V13, CNA worked 10/7/23 overnight shift. V13, CNA stated V13, CNA had gone on break at 1:30 am. V13 was in the break room. V13, CNA could hear R19 in her room, next to the break room. R19 was crying loud and yelling 'mama, mama'. V13 stated, V13 then heard laughing and banging and a loud boom sound. V13 stated about that time, V11, Licensed Practical Nurse (LPN) came inside through the break room door. V13 stated she was told by V11, LPN that V11, LPN could see into R19 and R14 shared room, while V11, LPN was outside. V13, CNA stated V11, LPN said V11, LPN saw V10, LPN and V21, CNA holding (R19) down to change R19's incontinence brief. V13, CNA stated V13, CNA went down to B-[NAME] Memory Care Unit with V12, CNA and heard R19's 'crying get louder'. V13 stated V10, LPN came to the doorway, right by R19's bed. V10, LPN told V12 and V13 to get off and stay off the B-unit Memory Care Unit because they were not working the B-unit. V13 also stated I left at 5:00 am. By then I think between all of us, we called (V1, Administrator) five or six times to report everything. On 10/12/23 at 5:25 PM V11, Licensed Practical Nurse (LPN) stated on 10/07/23 V11, LPN had been working A-Hall. V11, LPN stated she had heard a lot of loud noises coming from R14 and R19's shared room. V11, LPN stated she had been outside on break and came back into the facility through the break room door. The break room shares a wall with R14 and R19's shared room. V11, LPN stated while V11, LPN was outside, V11, LPN could see into R14 and R19's room. V11 stated she could see V21, Certified Nursing Assistant was on one side of R19's bed and V10, LPN was on the other side of R19's bed. V21, CNA was changing R19 incontinence brief. V10 was leaning over R19 and laughing close to R19's face. V11, LPN stated it was a horrible night. V11 stated V11 had already called or maybe text V1, Administrator about a conflict between V10, LPN and V11, LPN about medications and another resident. V11 stated (V1, Administrator) called back and was notified of everything. I also called (V2, Director of Nursing, DON) around 4:10 am. (V2, DON) called back at 6:19 am and told me to make a statement. So we all made statements. On 10/11/23 at 11:35 am V1 Abuse Prevention Coordinator/ Administrator in Training stated Saturday night 10/7/23, V1 got a call regarding staff bickering amongst themselves. V1 stated she had not heard anything about V10, Licensed Practical Nurse (LPN) supposedly holding a resident down, or refusing any resident medications, until V1 got the witness statements. V1 stated the following: I did not feel this was an abuse allegation because (V10, LPN) had not held anybody down, and I checked PCC (electronic medical record) and all residents meds (medications) were given. The allegation that two residents didn't get there meds was not true. I am still investigating this (10/7/23 incident). I did not report to IDPH (Illinois Department of Public Health) because it was about staff bickering and attitudes towards each other. I did not consider this abuse. 5. On 10/12/13 at 2:08 PM V21, Certified Nursing Assistant (CNA) stated V21, CNA worked B- hall with V10, Licensed Practical Nurse (LPN) on 10/7/23. V21, stated R14 had a rough night. R14 was screaming overnight on 10/7/23. V10 LPN and V21, CNA did rounds after V10, LPN finished passing medications on C-hall. V21, CNA stated V10, LPN helped V21, CNA change R14 and helped with R19. V21, CNA then stated I told (V10, LPN) I saw (R14) get up and hit (R19). (R14) went over to (R19's) bed pulled (R19's) covers off and started smacking (R19) on the arm. (R19) was screaming and crying. V21 also stated (V21) did not report this to the (V2, Director of Nursing or the V1, Administrator). I guess I should have. I know we are supposed to tell our supervisor and the Administrator anytime there is abuse. (R14) was deliberately targeting (R19) because she started screaming when (R14) pulled (R19's) blankets off. On 10/12/23 at 4:25 PM V1, Administrator, Abuse Prevention Coordinator stated V1 should have been told of the allegation of physical abuse regarding R14 smacked R19 on the arm 10/7/23. V1 stated she would have initiated an investigation and reported to the state agency. The facility policy Abuse Prevention Program dated as revised 11/28/16 documents the following: IV. Internal Reporting Requirements and Identification of Allegations Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the administrator. All residents, visitors, volunteers, family members or others are encouraged to report their concerns or suspected incidents of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property to a supervisor and administrator. Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated. Supervisors shall immediately inform the administrator or his/her designated representative (specified by the administrator in the case of a planned absence) of all reports of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property. Upon learning of the report, the administrator or designee shall initiate an investigation.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected multiple residents

Based on observation, interview and record review the facility failed to protect residents by failing thoroughly investigate injuries of unknown origin (R14, R18), alleged staff to resident abuse (R19...

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Based on observation, interview and record review the facility failed to protect residents by failing thoroughly investigate injuries of unknown origin (R14, R18), alleged staff to resident abuse (R19), and alleged resident to resident physical abuse (R14, R19). These failures affects three of five residents (R14, R18, R19) reviewed for abuse on the sample list of 25. Findings include: 1. R18's Progress note dated 10/9/2023 at 01:59 documents the following: A.I.M. For Wellness- Event Record Note Text: Event Details: (R18) appears to have sustained an injury that was unwitnessed- or is of unknown origin. Event was first noted on 10/09/2023 (at) 1:45 AM. Evaluation of the resident (R18) and event occurred on or about 10/09/2023 (at) 1:47 AM. The same Progress note documents the following: Review of (R18's) skin integrity reveals: Change in skin color integrity/condition noted. Right shoulder (rear) - Other (specify): abrasion: Length = 6cm, Width = 1.7cm, - Stage I, Right iliac crest (front) - Bruising: Length = 7cm, Width = 0.5 cm, - Stage Unstageable. Review of (R18) pain parameters reveals resident rates pain level as 1. Vocal complaints of pain at the time of the event. Facial expressions (eg. grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw) at the time of the event. New onset pain observed/reported. Pain location includes Abdominal pain / tenderness. Pain noted in alternate location, see A.I.M. For Wellness Event Record for additional information. area to abdomen is tender to touch. On 10/11/23 at 11:00 am V1, Abuse Prevention Coordinator/ Administrator in Training acknowledge the facility did not thoroughly investigate R18's bruises of unknown origin and should have reported R18's injuries of unknown origin to the State Agency. 2. R14's Health Status Progress Note dated 10/9/2023 at 01:53 am signed by V11, Licensed Practical Nurse (LPN) documents the following: On resident care CNA's (unidentified Certified Nursing Assistants) observed numerous bruises to resident (R14) left side of body from her face to her lower leg, also on assessment residents mouth has abrasions to lip and upper gum area. Resident is unable to communicate how this happened but on assessing resident has pain when touching her, but is easily calmed. patients (R14) temperature taken at this time but unable to get anything else due to president (resident R14) becoming extremely agitated. DON (V2, Director of Nursing) made aware. On 10/11/23 at 4:00 pm V1, Administrator in Training/Abuse Prevention Coordinator stated V1 assumed R14's extensive bruises occurred from a fall 10/2/23. V1 confirmed she did not recognize R14's bruises as injury of unknown origin, did not complete a thorough abuse investigation to conclude the origin and did not report R14's bruises to the State Agency. 3. On 10/11/23 at 11:08 am V1, Abuse Prevention Coordinator/ Administrator in Training provided a group of witness statements regarding events between staff members arguing amongst themselves, that occurred on night shift 10/7/23. The witness statements contained additional information. The witness statements document an allegation of physical abuse. The allegation documents of R19 was held down by V10, Licensed Practical Nurse. On 10/12/23 at 2:50 pm V13, Certified Nursing Assistant (CNA) stated V13, CNA worked 10/7/23 overnight shift. V13, CNA stated V13, CNA had gone on break at 1:30 am. V13 was in the break room. V13, CNA could hear R19 in her room, next to the break room. R19 was crying loud and yelling 'mama, mama'. V13, CNA then heard laughing. V13, CNA heard banging and a loud boom sound. V13 stated about that time, V11, Licensed Practical Nurse (LPN) came inside through the break room door. V13 stated V13 was told by V11, LPN that V11, LPN could see into R19 and R14 shared room, while V11, LPN was outside. V13, CNA stated V11, LPN said V11, LPN saw V10, LPN and V21, CNA holding (R19) down to change R19's incontinence brief. On 10/13/23 at 10:35 am V10, Licensed Practical Nurse (LPN) stated V10, LPN worked V10, LPN's entire shift. V2, Director of Nursing (DON) text V10, LPN the morning after the allegation, at 8:00 am. V10, LPN called V2, DON back at about 10:00 am. V2, DON did not mention anything about an abuse allegations. V2, DON said V10, LPN was being suspended because of an incident with V11, LPN the other nurse working that night. V11, wanted V10's narcotic keys and V10, LPN would not give them to V11, LPN. On 10/11/23 at 11:35 am V1 Abuse Prevention Coordinator/ Administrator in Training stated Saturday night 10/7/23, V1 got a call regarding staff bickering amongst themselves. V1 stated she had not heard anything about V10, Licensed Practical Nurse (LPN) supposedly holding a resident down, or refusing any resident meds, until V1 got the witness statements. V1 acknowledged she had not completed an investigation and did not report the allegation of physical abuse of R19 by V10, LPN to the State agency. 4. On 10/12/13 at 2:08 pm V21, Certified Nursing Assistant (CNA) stated V21, CNA worked B- hall with V10, Licensed Practical Nurse (LPN) on 10/7/23. V21, stated R14 had a rough night. R14 was screaming overnight on 10/7/23. V10 LPN and V21, CNA did rounds after V10, LPN finished passing medications on C-hall. V21, CNA stated V10, LPN helped V21, CNA change R14 and helped with R19. V21, CNA then stated I told (V10, LPN) I saw (R14) get up and hit (R19). (R14) went over to (R19's) bed pulled (R19's) covers off and started smacking (R19) on the arm. (R19) was screaming and crying. V21 also stated (V21) did not report this to the (V2, Director of Nursing or the V1, Administrator). I guess I should have. I know we are supposed to tell our supervisor and the Administrator anytime there is abuse. (R14) was deliberately targeting (R19) because she started screaming when (R14) pulled (R19) blankets off. On 10/12/23 at 4:25 pm V1, Administrator, Abuse Prevention Coordinator stated V1 should have been told of the allegation of physical abuse regarding R14 smacking R19 on the arm 10/7/23. V1 stated she would have initiated an investigation and reported to the state agency. The facility policy Abuse Prevention Program dated as revised 11/28/16 documents the following: The following definitions are based on federal and state laws, regulations and interpretive guidelines. *Abuse: Abuse is the willful injection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy further documents *Physical Abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment, *Mistreatment means inappropriate treatment or exploitation of a resident, and *Serious Bodily Injury: an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization, or physical rehabilitation. The abuse policy also documents: The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruises, lacerations, other abnormalities, or injuries of unknown origin as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation and reporting to the administrator or designee. If the resident complains of physical injuries or if resident harm is suspected, the resident physician will be contacted for further instructions. V. Protection of Residents The facility will take steps to prevent mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property while the investigation is underway. * Residents who allegedly mistreat or abuse another resident or misappropriate resident property will be removed from contact with that resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement considering his or her safety, as well as the safety of other residents and employees of the facility. * Accused individuals not employed by the facility will be denied unsupervised access to the resident during the course of the investigation. * Employees of this facility who have been accused of mistreatment, exploitation, neglect, abuse or misappropriation of resident property will be immediately removed from resident contact until the results of the investigation have been reviewed by the administrator or designee. Employees accused of alleged mistreatment, exploitation, neglect, abuse or misappropriation of resident property shall not complete their shift as a direct care provider to residents.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nu...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. These failures have the potential to affect all 44 residents residing in the facility. Findings include: On 10/11/23 at 9:40AM, V14 Dietary Manager was actively supervising dietary operations in the facility kitchen during resident meal preparations. V14 reported being the full-time manager of the facility food service and reported not being a clinically qualified Certified Dietary Manager or having the equivalent training. On 1012/23 at 8:32am V1 Administrator in Training (AIT) said, V14 Dietary Manager currently is not a Certified Dietary Manager, and the facility is working to get V14 into class to get the proper education and certificate. Facility assessment dated [DATE] documents facility staff needs (hours per day), dietician or other clinically qualified nutrition professional to serve as the director of food and nutrition services (8 hours). The Facility's Centers for Medicare and Medicaid Services Form 802 Matrix, dated 10/11/23, documents 44 residents reside in the facility.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review, the facility failed to prevent the potential for cross-contamination and foodborne illness by failing to protect stored food from paint debris and d...

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Based on observation, interview, and record review, the facility failed to prevent the potential for cross-contamination and foodborne illness by failing to protect stored food from paint debris and dust also failing to maintain a can opener in a sanitary condition. These failures have the potential to affect all 44 residents residing in the facility. Findings include: 1. On 10/11/23 at 9:40AM, paint was flaking and peeling from the entire wall surface located behind the food preparation table. Paint dust and paint chips were dispersed across the shelving and refrigerator. V14 (Dietary Director) was present and acknowledged the paint contaminating the stored preparation area was a concern. V14 said, V14 was employed since 6/1/23 and this had been a concern since V14 was employed. V14 said, V14 informed the previous Administrator who came and looked at it, but never did anything to fix it. V14 was unaware if the paint was lead-based. 2. On 10/11/23 at 9:45AM, the kitchen can opener at the food preparation area was soiled with accumulations of food. The cutting surfaces (food contact surfaces) of the opener were covered in black greasy food debris. V14 was present and said, we clean the removable can opener parts in the dish washer but haven't clean the portion that is secured to the table and it needs to be cleaned. The Facility's Centers for Medicare and Medicaid Services Form 802 Matrix, dated 10/11/23, documents 44 residents reside in the facility, all of whom consume food prepared by cooking in the kitchen.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0839 (Tag F0839)

Could have caused harm · This affected most or all residents

Based on observation, interview and record review, the facility failed to ensure there is a Licensed Administrator managing the facility. This failure has the potential to affect all 44 residents resi...

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Based on observation, interview and record review, the facility failed to ensure there is a Licensed Administrator managing the facility. This failure has the potential to affect all 44 residents residing in the facility. Findings include: On 10/10/23 at 9:30am, V1 Administrator in Training (AIT) was in the building. On 10/10/23, 10/11/23, 10/12/23, and 10/13/23, V1 was in the building as the acting Administrator. V4 (Regional Director) was not present in the facility during the survey period (10/10/23 through 10/13/23). On 10/10/23, V1 stated that V1 does not have an Administrator license nor does V1 have a temporary Administrator license. V1 stated V4 is the Administrator over the facility and is in the facility around 30 hours a week. V1 stated unable to obtain a temporary Administrator license due to still taking the required Administrator classes. The Resident Census and Conditions of Residents report dated 10/11/23 documents 44 residents reside in facility.

Oct 2023 4 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide showers as scheduled for one (R3) of three residents reviewe...

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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 showers as scheduled for one (R3) of three residents reviewed for showers in the sample list of four. Findings include: R3's Minimum Data Set, dated [DATE] documents R3 has severe cognitive impairment and bathing did not occur during the 7 day lookback period. R3's shower documentation for September-October 2023 provided by V1 Administrator in Training and V2 Director of Nursing, documents NA Not Applicable for R3's showers that were scheduled on 9/9/23, 9/15/23, and 9/19/23 and R3 is scheduled to receive showers twice weekly. There was no documentation that R3 received showers scheduled on 9/9/23, 9/15/23, and 9/19/23. On 10/4/23 at 1:27 PM V2 stated R3 is scheduled for showers twice weekly. V2 confirmed staff should document the shower as given or refused, and not NA. At 4:40 PM V2 stated V2 had no additional shower documentation to provide for R3. .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to monitor a rash, document weekly skin assessments, and report a newly identified rash to the physician to obtain treatment orde...

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Based on observation, interview, and record review the facility failed to monitor a rash, document weekly skin assessments, and report a newly identified rash to the physician to obtain treatment orders. These failures affect two (R1, R3) of four residents reviewed for rashes in the sample list of four. Findings include: 1.) R1's Physician Progress Note dated 8/17/23 documents R1 has a dermatological rash that is resolving. R1's Shower Sheet dated 8/15/23 and 9/13/23 documents redness to R1's groin. R1's September 2023 Medication/Treatment Administration Record (MAR/TAR) documents to apply Hydrocortisone 0.5 % cream to the right ankle daily as of 4/4/23, apply Clotrimazole External Ointment 1 % topically to perineum twice daily as of 7/31/23, and apply Triamcinolone Acetonide 0.1 % Cream topically to trunk, abdomen, back twice daily for allergic dermatitis. These treatments are documented as administered between 9/1/23 and 9/30/23. This MAR/TAR documents to complete a skin assessment weekly and indicate C=Clear; R=Rash, O=Other, P=Pressure, S= Skin Tear. R1's skin assessments are recorded on this TAR with a checkmark, and do not document the status of R1's skin using the identifications instructed. There are no other skin assessments or monitoring of R1's rash recorded in R1's medical record during September 2023. R1's Nursing Note dated 9/25/2023 at 8:17 PM documents R1's rash continues to arms and has a dermatology appointment scheduled at the end of the month. R1's Nursing Note dated 9/27/2023 at 4:39 PM documents R1 continues to receive creams for rash, and the rash is worsening to axillary, back, and chest. R1's Dermatology Progress Note dated 10/2/23 documents R1 had a rash that began a few months ago, there was a rash with pustules noted throughout R1's entire body, and R1 tested positive for Scabies (a highly contagious skin condition cause by a mite) on 10/2/23. On 10/4/23 at 10:51 AM R1 had a raised red rash on R1's arms. At 10:59 AM R1 raised R1's shirt and pant leg. R1 had a red, raised rash to chest, shoulder blades, back, and legs. R1 stated the rash is everywhere on R1's body and it itches terrible. On 10/4/23 at 3:12 PM V2 Director of Nursing stated skin assessments should be documented weekly under the assessments tab or in a progress note. V2 confirmed R1's medical record does not document weekly skin assessments in September 2023. 2.) R3's Shower Sheet dated 9/22/23 documents small red open areas noted to shoulders, chest, inner thighs, and buttock. R3's Shower Sheet dated 9/30/23 documents R3 had small red, round, bumps to upper torso, hands, lower legs, and hips, and R3 stated the areas are itchy. There is no documentation in R3's medical record that R3's rash was reported to R3's physician or that treatment was initiated prior to 10/2/23. R3's Nursing Note dated 10/3/2023 at 3:52 AM documents on 10/2/23 at 11:30 PM R3 was treated with Ivermectin and Elimite cream for Scabies. On 10/4/23 at 2:46 PM V11 Certified Nursing Assistant stated R3's areas (referring to 9/22/23 shower sheet) looked to be areas that R3 had picked, the areas were red and similar to a mosquito bite. V11 stated they were on R3's inner thighs, chest, and buttock. V11 stated V11 reported the areas to V5 Licensed Practical Nurse and V11 applied what appeared to be Vitamin A & D ointment. On 10/4/23 at 3:12 PM V2 stated changes in skin should be reported to V2, the resident's family and the physician. V2 stated this should be documented in a progress note. V2 reviewed R3's medical record and confirmed there was no documentation or treatment orders for R3's skin condition noted on 9/22/23. V2 stated the nurse should have notified R3's physician to obtain treatment orders. On 10/4/23 at 4:20 PM V12 Physician stated the facility notified V12 of R3's rash after the fact, when R3 was treated for Scabies on 10/2/23. The facility's Notification for Change in Resident Condition or Status policy dated as revised 12/7/17 documents the resident's physician will be notified of changes in the resident's condition, including physical condition, and when there is a need to alter treatment. This policy documents the nurse will record information related to a resident's change in condition in the medical record. The facility's Skin Condition Monitoring policy dated as revised 3/16/23 documents the nurse will assess and document skin abnormalities in the nurses notes and a skin evaluation will be completed. This policy documents the physician will be notified to obtain a treatment order, this treatment will be implemented until the area is healed/resolved and then the treatment may be changed to PRN (as needed). This policy documents that skin evaluations must be completed at least weekly until the area is healed, and the evaluations must include characteristics/descriptions of the area.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain updated infection control logs, report a comm...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain updated infection control logs, report a communicable disease to the local health department, label isolation linen containers, handle linens appropriately, and implement isolation for a resident (R2) with suspected Scabies (a highly contagious skin condition caused by a mite). These failures affect four (R1, R2, R3, R4) of four residents reviewed for infection control in the sample list of four. Findings include: 1.) The facility's Infection Control Logs dated 3/23/23-10/3/23 do not document R1 was diagnosed with Scabies on 10/2/23 or that R2 and R3 were treated for Scabies. R1's Dermatology Progress Note dated 10/2/23 documents R1 had a rash with pustules noted throughout entire body, and R1 tested positive for Scabies on 10/2/23. This note documents orders to administer Elimite 5% cream apply from neck to toes and administer Ivermectin 3 milligrams five tablets once on 10/2/23 and then repeat in 7 days. R2's Nursing Note dated 9/29/23 at 9:06 PM documents R2 admitted to the facility with a rash covering R2's entire body. R2's Nursing Note dated 10/3/2023 at 4:10 AM documents on 10/2/23 at 11:50 PM R2 was treated with Ivermectin and Elimite cream for Scabies. R3's Shower Sheet dated 9/22/23 documents R3 has small red open areas noted to shoulders, chest, inner thighs, and buttock. R3's Shower Sheet dated 9/30/23 documents R3 small red, round, bumps to upper torso, hands, lower legs, and hips, and R3 stated the areas are itchy. R3's Nursing Note dated 10/3/2023 at 3:52 AM documents on 10/2/23 at 11:30 PM R3 was treated with Ivermectin and Elimite cream for Scabies. There is no documentation that the facility contacted the Local Health Department to report R1's Scabies diagnosis and R2's/R3's suspected Scabies. On 10/4/23 at 10:51 AM R1 had a raised red rash on R1's arms. R1 stated R1 is friends with R2, and R2 has a rash similar to R1's. At 10:59 AM R1 raised R1's shirt and pant leg. R1 had red raised rash to chest, shoulder blades, back, and legs. R1 stated the rash is everywhere on R1's body and it itches terrible. On 10/4/23 at 8:10 AM R2 had faded dry/red rash areas on R2's arms. R2 stated R2 admitted with the rash from another facility and that the rash had covered R2's entire body. On 10/4/23 at 7:53 AM V1 Administrator in Training (AIT) stated the facility has a few Scabies cases, one confirmed, and two suspected. V1 stated R1, R2, and R3 have been on isolation and were treated for Scabies. V1 stated V2 is the Director of Nursing (DON) and is also the Infection Preventionist. At 9:27 AM V1 stated R1, R2, and R3 were moved to private rooms and placed on isolation on 10/2/23. On 10/4/23 at 11:43 AM V1 stated the facility has not involved the Local Health Department regarding Scabies. On 10/4/23 at 9:27 AM V2 DON stated R1, R2, and R3 were on contact isolation from 10/2/23 until last evening (10/3/23). On 10/4/23 at 11:24 AM V2 stated I (V2) think the Local Health Department should be informed of the Scabies, I (V2) have not notified them. (V1) would be able to tell you if they were notified. V2 confirmed the facility's Infection Control Logs are not up to date to include R1's Scabies, and R2's/R3's suspected Scabies. At 3:12 PM V2 confirmed the facility's Scabies Treatment policy does not document to place on Contact Isolation or the duration for isolation. On 10/4/23 at 1:03 PM V14 Local Health Department DON stated facilities should report if there are more than one case of Scabies and the facility has not reported any Scabies cases. V14 stated it would not hurt to treat any room mates prophylactically, but that is up to the physician. V14 stated residents with suspected/confirmed Scabies should be placed on contact isolation and continue for 24 hours after treatment. 2.) R2's Nursing Note dated 9/29/23 at 9:06 PM documents R2 admitted to the facility with a rash covering R2's entire body. R2's Nursing Note dated 10/3/2023 at 4:10 AM documents on 10/2/23 at 11:50 PM R2 was treated with Ivermectin and Elimite cream for Scabies. On 10/4/23 at 8:10 AM V13 Unit Aide removed R2's soiled bed linens and was not wearing gloves. V13 carried the linens out of R2's room and down the hallway. On 10/4/23 at 9:41 AM V13 stated residents' soiled linens are placed in a laundry bin in the shower room. V13 confirmed V13 carried R2's linens to the shower room and the linens were not double bagged or placed in a designated container for isolation linens. At 11:39 AM V13 confirmed V13 was not wearing gloves while handling R2's bed linens. V13 stated staff are suppose to wear gloves when handling dirty bed linens and clothing. On 10/4/23 at 9:29 AM V6 Housekeeping/Laundry Supervisor stated R1, R2, and R3 have containers in their bathrooms for linens and the linens should be placed in the container. V6 stated when their laundry is removed from their room it is double bagged using clear garbage bags, and brought to the laundry room. At this time there was a linen container in R2's bathroom. At 9:35 Am the laundry room was viewed with V6. V6 identified the linen container used for isolation, and this container did not contain a label to indicate isolation. V6 stated R1's, R2's, and R3's laundry is treated as isolation laundry for a week after Scabies treatment, and their laundry is washed separately from other resident laundry. At 10:02 AM V6 confirmed the laundry isolation bin located in the laundry room is not labeled to identify isolation use. V6 stated staff should wear gloves to remove dirty bed linens. 3.) R2's Nursing Note dated 9/29/23 at 9:06 PM documents R2 admitted to the facility with a rash covering R2's entire body. R2's Nursing Note dated 10/3/2023 at 4:10 AM documents on 10/2/23 at 11:50 PM R2 was treated with Ivermectin and Elimite cream for Scabies. There is no documentation that R2 was suspected to have Scabies or on contact isolation prior to 10/2/23. R2's Physician Progress Note dated 9/29/23 recorded by V12 Physician documents 9/29/23 documents R2 readmitted to the facility from (sister facility) with scattered rashes all over R2's body. R2 was referred to a dermatologist while residing at the other facility. V12 did not think R2 had been seen by a dermatologist so V12 told the nurse to refer R2 to a dermatologist. This note documents under Assessment/Plan R2 has a pruritic rash, was referred to dermatologist, and needs to rule out Scabies. This note documents that on 8/1/23 R2 had a rash, was given Keflex (antibiotic), and if R2's rash persisted R2 needed to see a dermatologist. This note documents on 9/11/23 R2 was referred to dermatology for maculopapular rashes with pruritis and V12 wanted to rule out Scabies. On 9/29/23 at 4:17 PM V3 Registered Nurse stated V12 assessed R2's rash on admission [DATE]), and V12 said V12 was unsure what the rash was. V3 stated V12 ordered a dermatology consult and Clobetasol cream. V3 stated nothing was mentioned at that time that R2 might have Scabies. V3 stated V3 would have implemented isolation at that time if it was suspected that R2 had Scabies. On 10/4/23 at 11:43 AM V1 AIT stated R4 was R2's room mate prior to R2 being placed on isolation and treated for Scabies. On 10/4/23 at 4:03 PM V1 confirmed R2's Progress Note dated 9/29/23 was not part of R2's medical record and had to be obtained from V12's office today. V1 and V2 confirmed there was no communication from (sister facility) regarding R2's rash prior to admission. V1 and V2 stated V12 did not inform the facility that V12 suspected R2 had Scabies. V2 stated if that had been communicated to the facility, then R2 would have been placed on contact isolation right away. On 10/4/23 at 4:20 PM V12 stated R2 had a persistent rash while at (sister facility), and V12 had referred R2 to dermatology. V12 stated V12 did not think that R2 had seen a dermatologist yet and questioned whether R2 had Scabies. V12 stated V12 defers to dermatology to make that determination. V12 stated V12 did not mention to any facility staff that V12 suspected R2 had Scabies and V12 did not order contact isolation. The facility's Illinois Department of Public Health Reportable Diseases policy dated as reviewed 4/11/22 documents facilities must report suspected or confirmed cases of diseases to the local health department and scabies must be reported. The facility's Scabies Treatment policy dated as reviewed 4/3/23 documents process for laundering linens and clothing, cleaning the resident room, administering treatment, and bathing the resident after 12-24 hours. This policy does not document the use or duration of contact precautions. The facility's Infection Control Surveillance and Monitoring policy revised 4/11/22 documents the DON/Infection Preventionist will update the Infection Control Log daily to analyze the information to identify trends and need for additional measures to prevent further spread of infection. The facility's [NAME]/Linen Handling policy reviewed 4/3/23 documents laundry personnel should wear gloves when sorting soiled linen. The facility's Contact Precautions policy reviewed 4/3/23 documents Contact Precautions are used for residents known or suspected to be infected with microorganisms that can be spread by direct contact with the resident or indirect contact with the resident's environmental surfaces. This policy documents to wear gloves when entering the resident's room and after removing gloves ensure hands do not touch potentially contaminated environmental surfaces to avoid transferring microorganisms.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0882 (Tag F0882)

Could have caused harm · This affected most or all residents

Based on interview and record review the facility failed to ensure the Infection Preventionist had completed required training on infection prevention and control. This failure has the potential to af...

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Based on interview and record review the facility failed to ensure the Infection Preventionist had completed required training on infection prevention and control. This failure has the potential to affect all 44 residents residing in the facility. Findings include: The facility's Infection Control Surveillance and Monitoring policy dated as revised 4/11/22 documents the facility will have routine surveillance and monitoring to determine compliance with infection control practices and the Director of Nursing (DON) may perform these duties if the DON has an approved Infection Control Certification. On 10/4/23 at 7:53 AM V1 Administrator in Training (AIT) stated the facility has a few Scabies cases, one confirmed, and two suspected. V1 stated V2 is the DON and is also the facility's Infection Preventionist. On 10/4/23 at 1:27 PM V2 DON stated V2 does not have Infection Preventionist training, and V2 wasn't aware until today that V2 was also responsible for the Infection Preventionist duties. V2 stated V2's employment began on 9/27/23. The facility's Nurses Midnight Census dated 10/3/23 documents 44 residents reside in the facility.

Jun 2023 4 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Failures at this level required more than one deficient practice statement. A. Based on observation, interview and record review...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Failures at this level required more than one deficient practice statement. A. Based on observation, interview and record review the facility failed to ensure staff were supervising residents, failed to ensure qualified staff were transferring residents, and failed to ensure bed wheels were locked to prevent accidents. The facility also failed to conduct fall investigations, develop and implement fall interventions, and complete neurological assessments after falls/accidents for three of five residents (R1, R3 and R4) reviewed for accidents in the sample list of ten residents. Failing to ensure trained/qualified staff were transferring R3 resulted in R3 falling from the wheelchair and suffering a head wound requiring seven staples. B. Based on interview and record review the facility failed to provide supervision to prevent a resident elopement for one of five residents (R10) reviewed for accidents in the sample of ten residents. Findings include: a. 1.) R3's undated medical diagnosis list documents medical diagnoses of Intellectual Disabilities, Muscle Weakness, Need for Assistance for Personal Care, Unsteadiness of Feet, Abnormalities of Gait and Mobility, Anxiety, Delusional Disorders and history of Right Femur Fracture. R3's Minimum Data Set (MDS) dated [DATE] documents R3 as severely cognitively impaired. This same MDS documents R3 as requiring limited assistance of one person for bed mobility and walking in room, and extensive assistance of two people for transfers, locomotion on and off unit, toileting and personal hygiene. R3's Physician Order Sheet (POS) dated June 1-30, 2023 documents a physician order dated 4/3/23 for Aspirin Enteric Coated (EC) 81 milligrams (mg) daily. R3's Fall Risk Evaluation dated 6/14/23 documents R3 as a high fall risk. R3's Medical Record documents R3 is on continual monitoring for history of falls. R3's Nurse Progress Note dated 6/14/23 at 8:06 PM documents (R3) was returning from bathroom in wheelchair when began to move impulsively and threw self out of wheelchair. Noted to have approximately two inch laceration over Right Eye. Area cleansed et dressing applied. R3's Hospital Discharge summary dated [DATE] documents R3's chief complaint as 'fall, laceration' and discharge diagnosis as 'Laceration of Forehead'. This same report documents R3's scalp laceration was repaired. This same report documents [AGE] year old fell from (R3's) wheelchair at facility and hit his forehead sustaining laceration. (R3's) bleeding was stopped with pressure dressing. This same hospital report documents R3 received seven staples to Right Forehead just above Right Eye due to fall. R3's Final Incident Report to Illinois Department of Public Health dated 6/20/23 documents R3 fell in R3's room while being transferred from wheelchair to bed by (V24) Unit Aid on 6/14/23. (V24's) Unit Aid written witness statement documents I was assisting (R3) back into his room from the bathroom in his wheelchair. I put the wheelchair facing the chair I sit in and proceeded to walk from behind the wheelchair towards my chair. As I started to walk around (R3) used his feet to move the wheelchair forward, got his feet caught up and slid out of the chair and fell into his side dresser. I called for a Certified Nurse Aide (CNA) and a CNA and a Nurse assisted (R3) up onto (R3's) bed. R3's Nurse Progress Note dated 6/24/23 at 4:00 AM documents (R3) was found on floor of hallway. Emergency services called and (R3) transferred to emergency room. R3's Electronic Medical Record (EMR) does not document Neurological assessments completed for 72 hours or fall investigations after R3's 6/14/23 fall nor 6/24/23 fall. R3's Care Plan does not document new fall interventions after R3's 6/14/23 nor 6/24/23 falls. On 6/28/23 at 2:05 PM Observed R3 laying on covers in bed. Observed R3's Left Elbow to have a dark purple bruise approximately small orange sized, R3's Left mid Forearm to have a dark purple baseball sized bruise on outer side, and R3's top of Left Hand to have a baseball sized fading purple and gray bruise. Observed R3's Right Forehead just above Right Eyebrow to be bruised with marks where staples had been removed earlier in day. On 6/29/23 at 11:50 AM (V9) Regional Director of Operations stated (R3) had a fall early morning of 6/24. The staff called me and said (V16) Unit Aide was supposed to be continuously monitoring (R3), (V16) fell asleep, (R3) got up and walked out into the hallway and fell. On 6/29/23 at 2:15 PM V1 Administrator stated R3 fell on 6/14/23 while being transferred by V24 Unit Aid. V1 stated Unit Aids are not trained to transfer, toilet or assist with feeding of residents. V1 stated (V24) Unit Aid should never have assisted (R3) with transferring. This led to (R3's) fall with a major injury. (R3) ended up with staples in his forehead. V1 stated V24 should have asked for help transferring R3. V1 Administrator stated Maybe this wouldn't have happened if (V24) would have asked for help. (V24) Unit Aid has already been educated on this. 2.) R4's undated Face Sheet documents medical diagnoses of Seizure Disorder, Schizoaffective Disorder and Depression. R4's Minimum Data Set (MDS) dated [DATE] documents R4 is severely cognitively impaired. This same MDS documents R4 requires extensive assistance of one person for bed mobility, transfers, dressing, eating and personal hygiene, and extensive assistance of two people for toileting. R4's Nurse Progress Note dated 6/7/23 at 12:25 AM documents Facility staff actions/interventions and response at time of the event: (R4) was assessed area found to Right Forehead with a approximately one inch laceration and a half dollar sized bump. Follow up recommendations to manage the resident's condition and needs: to keep area to Forehead dry and clean, watch for any signs and/or symptoms of seizure due to head trauma R4's Nurse Progress Note dated 6/7/23 at 1:54 AM documents (R4) was pushing a chair and stumbled and hit head causing a small laceration to Right side of Forehead and a half dollar size bump. (R4) wound was cleansed and bandaged. Ambulance was called to transport to emergency room for treatment. Around 8:15 PM emergency room called to inform that (R4) was set to discharge. emergency room glued the laceration and are monitoring (R4). Update called for (R4) is sleeping at this time, wound to head has been glued, (R4) getting Intravenous fluids for hydration and (R4) had been given Haldol and Ativan due to increased anxiety. R4's Nurse Progress Note dated 6/18/23 at 8:07 AM documents (R4) was in dining area and staff stated (R4) fell on another resident's arm. (R4) balance is always unstable. R4's Nurse Progress Note dated 6/20/23 at 3:46 PM documents (R4) walked into wall per staff and observed blood to wall by bed. (R4) has open area to Right side of Forehead. First-aid rendered. Tylenol given for pain management. Ambulance called. R4's Nurse Progress Note dated 6/20/23 at 4:20 PM documents (R4) observed standing by wall in bedroom by staff . Observed blood coming from (R4's) head and noted blood stain on wall. First aid rendered. Ambulance called. Physician aware to send to emergency room for further evaluation. R4's Nurse Progress Note dated 6/21/23 at 7:30 AM documents At approximately 7:10 AM this morning (V12) Licensed Practical Nurse (LPN) was in hallway speaking with staff when (V12) saw staff run towards (R4's) room. (R4) was trying to get on floor (normal behavior). (R4's) head slid down the wall as (R4) was getting on the floor. Noted to have reopened wound on top of (R4's) head. Minimal bleeding noted. R4's Nurse Progress Note dated 6/21/23 at 2:21 PM documents (V12) LPN was informed by staff that (R4) hit the floor; witnessed; it was explained to (V12) that (R4) tripped over the wheelchair wheel of the chair (R4) was sitting in and hit (R4's) head; noted that (R4) reopened wound that had the steri strips; steri strips removed. R4's Electronic Medical Record (EMR) does not document a fall investigation nor neurological assessments after R4's 6/7/23 fall with head injury. This same EMR does not document Neurological Assessments after R4's head injuries on 6/20/23 and twice on 6/21/23. R4's Care Plan does not document any new fall interventions after 6/6/23. This same care plan documents an intervention to encourage R4 to not crawl on the floor. On 6/27/23 at 11:15 AM Observed R4 to bend down to a crawling position on hands and knees on the floor in the Dementia Unit hallway On 6/27/23 at 11:16 AM Observed V7 Certified Nurse Aide (CNA) observe R4 crawl on the floor of the Dementia Unit. V7 CNA did not encourage R4 to not crawl on the floor. On 6/28/23 at 12:00 PM Observed R4 bend down to a crawling position on hands and knees on the floor. V18 Dementia Unit Coordinator was standing by watching R4. V18 did not encourage R4 to not crawl on floor. On 6/29/23 at 9:00 AM Observed R4 bed down to a crawling position on hands and knees on the hallway floor with other residents within reach of R4. V19 and V20 Certified Nurse Aides (CNA) walked by R4 two times each without offering R4 assistance to stand up or not crawl on floor. On 6/27/23 at 11:20 AM V7 Certified Nurse Aide (CNA) stated (R4) likes to crawl around on the floor. (R4) used to be a carpenter so he thinks he is nailing boards to the floor. (R4) is careplanned for crawling on the floor. On 6/28/23 at 12:05 PM V18 Dementia Unit Coordinator stated R4 is careplanned to crawl on the floor. V18 stated (R4) crawls on the floor all the time. (R4) is always bumping his head all the time down there. On 6/29/23 at 9:03 AM V19 Certified Nurse Aide (CNA) stated as she was walking by R4 crawling on the floor (R4) does that all the time. (R4) bumps his head a lot. I don't know why they (facility) doesn't do something about that. On 6/29/23 at 9:05 AM V20 Certified Nurse Aide (CNA) stated I am agency. I don't know these residents at all. I don't know how to see their careplan. I just do what the other staff do. On 6/29/23 at 2:45 PM V1 Administrator stated (R4) crawls on the floor all the time. Every time I go back to the Dementia Unit, it seems like (R4) is crawling around on the floor. I thought (R4) was careplanned for that. I do know (R4) bumps his head a lot and also falls. The staff should add fall interventions with each new fall and implement the fall interventions to prevent a resident from falling the same way again. It is obvious that this isn't happening. I don't know if (R4's) major injury (head wound) could have been prevented but we can certainly reduce the risk of him falling or having these accidents that cause him head injuries. On 6/29/23 at 1:00 PM V3 Interim Director of Nurses (DON) stated I have been working with our staff to try to use the careplan. The staff can't use the careplan if there isn't one or if the resident careplan is not updated. (R4) should not be crawling on the floor. We (staff) know that (R4) has had multiple head injuries from crawling on the floor. This needs to stop. (R4) is really going to get hurt one of these times. (R4) already had sutures from a fall. We (facility) had two Certified Nurse Aides (CNA) that day (R4) fell and busted his head open. Both CNA's were agency and did not know the residents well. This facility does have a lot of agency staff. I think that is part of the problem. With every head injury or unwitnessed fall the staff should complete three days of Neurological Assessments. Staff did not do that in any of these times (R4) had falls or accidents. We (facility) also did not do a fall investigation. We (facility) really do have a lot of work to do. 3.) R1's Electronic Medical Record (EMR) documents R1 as severely cognitively impaired. R1's Fall Risk Assessment documents R1 as a fall risk. R1's Care Plan does not document a focus area, goal nor interventions for R1 being at risk of falls. R1's EMR documents R1 as requiring supervision with transfers, toileting and locomotion. R1's Nurse Progress Note dated 6/25/23 at 5:40 AM documents R1 was found sitting on floor next to R1's bed in R1's room early morning of 6/25/23. R1's EMR does not document a fall investigation initiated until 6/29/23. R1's Hospital Record dated 6/25/23 documents R1's discharge diagnosis as Contusion of Head. R1's Final Incident Report to Illinois Department of Public Health (IDPH) dated 6/29/23 documents R1 had a large Hematoma to Right Forehead noted at time of fall. This same report documents root cause (R1) attempted to get out of bed and bed was not locked and moved away from (R1) as she attempted to get up. On 6/27/23 at 11:10 AM Observed R1 with dark purple and black circular bruising all the way around both eyes. This same bruising also extended above (R1's) Right Eye to mid forehead. Observed R1 walking independently in the hall of the dementia unit. On 6/27/23 at 11:12 AM R1 stated You should see the other guy! As R1 making a fist with Right hand and punching palm of R1's Left hand. R1 stated R1 did not know how R1's face got bruised. R1 stated (expletive) like this doesn't happen every day. I don't know how it happened but it sure does hurt!. On 6/27/23 at 9:20 AM V18 Dementia Unit Coordinator stated They (staff) told me (R1) fell over the weekend and got those bruises on her face. I don't know how (R1) fell. No one told me that. I don't see any thing about falls on (R1's) careplan. The staff would not know what interventions were put into place if it is not listed on the careplan. We (facility) have a lot of agency staff so those staff especially need to be able to see the resident careplan. I haven't done any training's on this unit for fall preventions or reporting of injuries. They (facility) never told me to do that. On 6/29/23 at 10:20 AM V3 Interim Director of Nurses (DON) stated the facility did not do a fall investigation for R1's fall until 6/29/23. V3 stated We (facility) have been so busy with so many other things. I got it done today but truthfully I didn't start it until today either. The facility policy titled Fall Prevention revised 11/10/18 documents Appropriate interventions will be implemented for residents determined to be at high risk at the time of admission for up to 72 hours. The unit nurse will place documentation of the circumstances of a fall in the nurses notes or on an Assess/Intercommunicate/Manage (AIM) for Wellness form along with any new intervention deemed to be appropriate at the time. Report all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan. All staff must observe residents for safety. If residents with a high risk code are observed up or getting up. Help must be summoned or assistance must be provide to the resident. The facility policy titled Emergency Care Head Injury reviewed 12/22/17 documents residents should be evaluated for head injuries for a minimum period of 72 hours to determine any negative effects, and to allow for immediate treatment to minimize permanent damage. The following procedure focuses on proper assessment of residents who have sustained a head trauma. Secure the resident from further danger, assess the resident including vital signs, consciousness and neurological (neuro) status, immobilize resident's head and neck, assign staff to remain with resident, notify physician immediately. Ongoing assessment (vital signs and neurological checks) should take place as follows: initially and every 15 minutes for one hour, every 30 minutes for one hour, every hour for four hours, every four hours for eight hours, every shift for the remainder of 72 hours. Assessments for the first 24 hours after injury shall be recorded on the Neurological/Head Trauma Assessment Form (Neuro Assessment Sheet). Additional documentation shall be recorded in the clinical record. Complete a Quality Care Tracking form and document all observations and occurrences. b. 1) R10's Undated Face Sheet documents medical diagnoses of Psychotic Disorder with Hallucinations due to known Physiological Conditions, Cerebral Vascular Accident (CVA), Flaccid Hemiplegia Affecting Unspecified Side, Hypertension, Diabetes Mellitus, Muscle Weakness, Difficulty in Walking and Major Depressive Disorder. R10's Minimum Data Set (MDS) dated [DATE] documents R10 as moderately cognitively impaired. This same MDS documents R10 as requiring supervision for bed mobility, transfers, locomotion off unit, and eating, and assistance of one person for locomotion on unit, dressing, toileting and personal hygiene. R10's Careplan does not include an elopement focus area, goal nor interventions. R10's Electronic Medical Record (EMR) does not include an elopement risk after R10's elopement on 5/27/23. R10's Nurse Progress Note dated 5/27/23 at 10:12 AM documents Received a phone call that (R10) was leaving the facility and was going towards baseball park by self and that he got combative with staff and had verbal aggression. (R10) has been spoke to about leaving facility supervised with family. This writer called non-emergency police to help with (R10). Non-emergency police arrived and spoke to (R10) and staff helped (R10) go back into facility. R10's Nurse Progress Note dated 6/10/23 at 12:51 PM documents Received a call from facility that (R10) left without supervision, called the family and they had said (R10) will be coming to their house which is a few blocks away from facility and (R10) is having a home visit. R10's Nurse Progress Note dated 6/10/23 at 11:01 PM documents (R10) returned from family visit at (9:45 PM). (V27) (R10's) family member told staff that he fell in their driveway. (R10) stated he had A lot of beer and some fireball. (R10) has multiple wounds: two on Right Upper Forearm both skin tears. First 1.0 centimeters (cm) x.01cm, second 1.0 cm x .01cm cleansed and approximated steri-strips applied, (R10) has an open area to Right knee 2cm x 1.5cm cleansed and dry dressing applied, has open blister to both great toes on the Right .5cm x .2cm at the knuckle, on the Left great toe just below the nail .3cm x .2cm sure prep applied to both. R10's Nurse Progress Note dated 6/22/23 at 6:22 PM documents (R10) went outside this morning and was seen in both the front and back of the building. One on one was provide to ensure (R10) did not leave building. On 6/27/23 at 3:00 PM observed R10 using R10's Left hand and arm to propel self slowly in the wheelchair in the hallway. Observed R10's Right Foot on foot pedal and R10's Urinary Catheter tubing dragging floor underneath R10's wheelchair. On 6/29/23 at 10:45 AM V25 (R10's) Power of Attorney (POA) for Healthcare stated No one let me know (R10) was leaving without permission. (R10) needs to be supervised. (R10's) thinking was changed after he had his stroke. (R10) definitely should not be wheeling himself around town. That is so dangerous. (R10) could get hit by a car or something. I am just picturing (R10) wheeling himself down the road. How awful. I don't have any problem if (R10) wants to go visit his family in town but that place needs to keep a better eye on him and make sure he gets there and back safely. On 6/29/23 at 1:45 PM R10 stated I left two times (5/27,6/10). They (facility) didn't even know where I was. (V27) (R10's) family member had to call them (facility) and say I was at (V27's) house. It is easy to get out of here. I just roll out the front door. I just wait until the staff are busy and roll right on out. (V27) knew I was coming over. (V27) lives just down the road a couple of miles. I made it to (V27's) house ok both times before so I thought I could do it again. But, that last time they (facility) caught me. R10 stated If I can't get a ride to (V27's) house then I will just take myself there again. On 6/29/23 at 11:25 AM V26 Social Service Director (SSD) stated R10 has a diagnosis of a Psychotic Disorder and has been seeing behavioral health services through the facility. V26 stated R10 has had multiple angry outbursts due to his previous Cerebral Vascular Accident (CVA). V26 stated On 5/27/23 (R10) wheeled himself out of the facility and left the property. (V28) (R10's) family member called the facility to report that (V28) saw (R10) wheeling himself down by the ball park a few blocks away. I called the non-emergency police. We (staff) and the police all went out looking for (R10). (R10) ended up at (V27) (R10's) family member's house. This is a couple of miles away from the facility. (R10) was intoxicated when he returned to facility later that night. Then again on 6/10/23 (R10) pretty much did the same thing. (R10) wheeled himself out of facility. (R10) wheeled himself across town again to (V27's) (R10's) family member's house. (V27) called the facility to let us (staff) know that (V27) would bring (R10) back after a family barbecue. (R10) was later returned to facility by (V27's) friend. When (R10) returned to facility he was intoxicated again. V26 SSD stated From what I understand the police found (R10) between a major retailer and the cemetery which is a little over two miles away. The police escorted (R10) the rest of the way to (V27's) house. When we (facility) went looking for (R10) we never did find him. The police found him. (R10) is not able to make sound decisions and should have been supervised more closely. On 6/29/23 at V29 Physician stated (R10) may belong in a different type of facility where they can manage his behaviors. (R10) should be more closely supervised due to (R10) eloping from facility twice before and attempted a third time. (R10) could get ran over by a car if he is wheeling himself down the center of the highway. It sounds to me like (R10) has an alcohol addiction and uses very poor judgement. V29 stated the facility is responsible for R10's safety. V29 stated the facility should supervise R10 more closely. On 6/29/23 at 3:20 PM V1 Administrator stated After (R10) eloped from this facility on 5/27/23, we (facility) made a new rule that every resident regardless of their cognitive status had to be supervised when outside of the facility and on the property by staff or family. We (facility) did not put anything specifically in place for (R10). (R10) sits up in the dining room a lot which is by the front door. The exit doors are alarmed but (R10) is strong enough to push himself through the front doors. This should not have happened once, much less twice. The second time (R10) eloped on 6/10/23 our staff just simply weren't paying attention. (R10) could have gotten hurt so badly. A car could have not seen (R10) and ran into him. I don't even want to think about what all the bad consequences would be if (R10) was struck by a car as he was wheeling himself down the middle of the highway. The facility policy titled Elopement Prevention Policy revised 10/06 documents the staff will assess all residents for the potential for elopement. Determination of risk will be assigned for each individual resident and intervention for prevention will be established in the plan of care to minimize the risk for elopement. A licensed nurse will complete the Elopement Risk Assessment upon and/or within eight hours of admission to the facility. An interim plan of care for minimizing the risk for elopement will be initiated upon high risk determination. A facility staff member will take a photograph of the resident upon or within eight hours of admission. The photograph will be placed in the Medication Administration Record (MAR). Any resident assessed to be at high risk for elopement will have their photograph and basic identifying information placed in a special folder or binder to be maintained at the nurses station. The Interdisciplinary Team (IDT) will initiate a plan of care for any resident determined high risk for elopement. Facility specific measures as well as resident specific measures will be included in each high risk resident's plan of care to minimize risk factors. Interventions of person door alarm devices and monitoring will be initiated as deemed necessary by the IDT and documented in the individual resident's plan of care. Any high risk resident will be promptly and courteously escorted back to the appropriate nursing unit, activity room, dining area or resident room when noted to be near an exit door. Revision of the Elopement Risk Assessment will be completed quarterly, after an isolated elopement attempt, monthly for resident who attempt elopement more than five times per week, upon a resident significant change in condition and as needed, determined by the IDT. The plan of care for minimizing elopement risks will be reviewed each time the Risk Assessment is completed with initials and dating of the care plan by any member of the IDT present for review. All employees will be educated within a reasonable timeframe of hire and throughout the year with elopement education on the location of the elopement file/binder and Elopement Prevention Policy.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the Physician, Hospice Nurse and Representative/Power of Atto...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the Physician, Hospice Nurse and Representative/Power of Attorney of changes in resident condition for one (R7) of three residents reviewed for changes in condition in the sample list of ten. Findings include: The facility's Notification for Change in Resident Condition or Status Policy with a revision date of [DATE] documents: The facility and/or facility staff shall promptly notify appropriate individuals (i.e., Administrator, Director of Nursing, Physician, Guardian, Healthcare Power of Attorney, etc) of changes in the resident's medical/mental condition and/or status. The resident's physician will be notified when a resident has a change in physical/emotional/mental condition. R7's Face Sheet dated [DATE] documents R7 was on Hospice and had the following diagnoses including: Alzheimer's Disease and Dementia. Further documents R7 expired at the facility on [DATE]. R7's Progress Note dated [DATE] at 12:51am, documents R7 had not eaten for two days, elevated temperature of 102.6 degrees Fahrenheit, bruising noted to bilateral feet, reddened groin area with penile discharge. This same note does not document V17 R7's Representative/Power of Attorney (POA), V22 Hospice Registered Nurse (RN) or V29 Physician of being notified of R7's change in condition. R7's Progress Note dated [DATE] at 3:19pm, documents R7 responding to tactile stimuli only, temperature of 99 degrees Fahrenheit, diminished lung sounds, and unable to take medication. Further documents R7's provider notified and a stat chest x-ray ordered at this time. This same note does not document V17 R7's Representative/POA or V22 Hospice RN of being notified of R7's change in condition or chest x-ray order. R7's Progress Note dated [DATE] at 6:54pm, documents R7 responding to tactile stimuli only, poor appetite, and slept most of the day. This same note does not document V17 R7's Representative/POA, V22 Hospice RN or V29 Physician of being notified of R7's change in condition. R7's Progress Note dated [DATE] at 4:55pm, documents R7 unable to take medication later in the day and more unresponsive as the day went on. This same note does not document V17 R7's Representative/POA, V22 Hospice RN or V29 Physician of being notified of R7's change in condition. R7's Progress Note dated [DATE] at 3:18am, documents R7 using accessory muscles while breathing, diminished lung sounds with low oxygen saturation, vital signs not within normal limits, and elevated temperature. Further documents R7's vital signs as follows: pulse of 48 beats per minute, blood pressure 86/60, respiratory rate of 50 breaths per minute, and temperature of 102.2 degrees Fahrenheit. R7 placed on 2L (liters) oxygen via nasal cannula and medication administered at this time. This same note does not document V17 R7's Representative/POA, V22 Hospice RN or V29 Physician of being notified of R7's change in condition. On [DATE] at 8:53am, V17 R7's Representative/POA stated V17 was notified on [DATE] around 8:00am of R7's change in condition by V12 LPN and V12 advised V17 that R7 started to decline around 3:00am. V17 stated V17 was not notified by the overnight nurse of R7's decline/change in condition. V17 stated when V17 arrived at the facility around 9-9:30am, R7 was actively dying and R7 passed away around 10:10am. V17 stated, if I was notified when he [R7] first started declining in the middle of the night, we could have been here sooner to be with him [R7]. V17 stated V17 was not aware that R7 had been declining over the past few days. On [DATE] at 11:15am, V22 Hospice RN stated R7 was on Hospice. V22 stated V22 was not notified at all of R7's change in condition on [DATE], [DATE], and [DATE]. V22 stated V22 was notified the morning of [DATE] by V12 LPN (when V12 came on shift) of R7's decline/change in condition. V22 stated V12 LPN advised V22 that R7 had started to deteriorate around 1:00am. V22 stated the nurse [V23 LPN] working overnight on [DATE] did not notify us [Hospice] or the family [V17] of R7's decline/change in condition when it occurred. V22 stated the expectation is for the facility to notify Hospice of any changes in condition for our Hospice residents. On [DATE] at 12:05pm, V12 LPN stated, I came in that morning ([DATE]) and the night shift nurse [V23 LPN] told me he [R7] was declining with rapid breathing and a temperature but [V23] 'didn't want to bother people at 3:00am' so I said that I would call. V12 stated family and Hospice were notified at that time around 8:00am. V12 stated Hospice and R7's family should have been notified when R7 began to decline. On [DATE] at 2:39pm, V23 LPN confirmed V23 worked the overnight shift/morning of [DATE]. V23 stated R7 was being rounded on frequently due to being told in report earlier that R7 wasn't doing well. V23 stated on the morning of [DATE] around 3:00am, R7 had diminished lung sounds with low oxygen saturation and an elevated temperature. V23 stated R7 was placed on 2L (liters) of oxygen and medication was administered at that time. V23 stated, I called Hospice but they did not answer. They are usually really good about answering and have an answering service. I may have had the wrong number and should have tried harder. I did not call POA/Family but should have. I did not want to bother them. On [DATE] at 3:06pm, V3 Interim Director of Nursing (DON) stated the nurses are to notify the family and Physician of any changes in resident condition. V3 stated Hospice is to be notified also if the resident is on Hospice.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow their abuse policy by not reporting an injury of...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow their abuse policy by not reporting an injury of unknown origin to Illinois Department of Public Health (IDPH) for one of three residents (R4) reviewed for injuries of unknown origin in a sample list of 10 residents. Findings include: The facility policy titled 'Abuse Prevention Program' revised 11/28/2016 documents nursing staff is responsible for reporting on a facility incident report the appearance of bruises, lacerations, other abnormalities or injuries of unknown origin as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation and reporting to the Administrator or designee. Upon learning of the report, the Administrator or designee shall initiate an investigation. The investigator will report the conclusions of the investigation within five days to the Administrator. The Administrator or designee is then responsible for forwarding a final written report of the results of the investigation and any corrective action taken place to the Illinois Department of Public Health (IDPH) within five working days of the reported incident. R4's undated Face Sheet documents medical diagnoses of Seizure Disorder, Schizoaffective Disorder and Depression. R4's Minimum Data Set (MDS) dated [DATE] documents R4 is severely cognitively impaired. This same MDS documents R4 requires extensive assistance of one person for bed mobility, transfers, dressing, eating, personal hygiene and extensive assistance of two people for toileting. R4's Medical Record does not document assessment, monitoring nor treatment of R4's top of scalp wound. On 6/27/23 at 11:15 AM Observed R4's top of scalp to have a nickel sized dark red, dry wound with no bandage covering in place. Observed R4 also had a smaller 1.0 centimeter (cm) by 1.0 cm dark red, dry wound with no bandage in place on top of scalp about a finger width apart from the larger area on the Right side of R1's top of head. Observed a third area on R4's Right Forehead with no bandage on it that was dark red, dry wound that was 1.0 cm by 1.0 cm. On 6/27/23 at 11:26 AM V8 Licensed Practical Nurse (LPN) stated I am not really sure what happened to the top of (R4's) head but he does fall sometimes and he crawls around on the floor. So who knows what happened. On 6/28/23 at 9:15 AM V18 Dementia Unit Coordinator stated (R4) walks by himself a lot. (R4) bends down and crawls around on the floor and then gets himself back up. The wound on the top of (R4's) head could have been caused by one of the times he hits his head. (R4) bumps his head a lot. I really don't know how that one happened though. I don't do the investigations for those type of things, the nurses do. They (facility) hasn't told me how that happened. On 6/29/23 at 2:00 PM V1 Administrator stated there was no report made to IDPH regarding R4's injury of unknown origin. V1 stated To be honest, I was never even told about it. So I of course wouldn't have reported it. Injuries should be investigated and reported if they are suspicious. We (facility) obviously did not follow our abuse policy.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

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 assess, monitor and treat skin injuries for four (R1, R...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assess, monitor and treat skin injuries for four (R1, R2, R3, R4) residents out of four residents reviewed for injuries of unknown origin in a sample list of 10 residents. Findings include: 1.) On 6/27/23 at 11:15 AM Observed R4 bend down to a crawling position on hands and knees on floor. Observed R4's top of scalp to have a nickel sized dark red, dry wound with no bandage covering in place. Observed R4 also had a smaller 1.0 centimeter (cm) by 1.0 cm dark red, dry wound with no bandage in place on top of scalp about a finger width apart from the larger area on the Right side of R4's top of head. Observed a third area on R4's Right Forehead with no bandage on it that was dark red, dry wound that was 1.0 cm by 1.0 cm. R4's undated Face Sheet documents medical diagnoses of Seizure Disorder, Schizoaffective Disorder and Depression. R4's Minimum Data Set (MDS) dated [DATE] documents R4 is severely cognitively impaired. This same MDS documents R4 requires extensive assistance of one person for bed mobility, transfers, dressing, eating, personal hygiene and extensive assistance of two people for toileting. R4's Physician Order Sheet (POS) dated June 1-30, 2023 does not document assessment, monitoring or treatment for R4's top of scalp wound. R4's Treatment Administration Record (TAR) dated May 1-31, 2023 does not document assessment, monitoring or treatment of R4's Forehead injury or top of head injury. R4's Treatment Administration Record (TAR) dated June 1-30, 2023 does not document assessment, monitoring or treatment of R4's Forehead injury or top of head injury. R4's Electronic Medical Record (EMR) does not document physical assessment, monitoring or treatment of top of scalp head injury. R4's Care Plan does not document a focus area, goal nor interventions for R4's skin alterations. 2.) On 6/27/23 at 2:05 PM Observed R3 laying on covers in bed. Observed R3's Left Elbow to have a dark purple bruise approximately small orange sized, R3's Left mid Forearm to have a dark purple baseball sized bruise on outer side and R3's top of Left Hand to have a baseball sized fading purple and gray bruise. On 6/27/23 at 2:10 PM V15 Unit Aide sitting with R3 stated (R3) is not aware enough to say how all of those bruises happened but I know (R3) fell one time recently because (V16) unit aide was supposed to be sitting with him and (V16) fell asleep, (R3) got up and walked into the hallway and fell. I don't think the bruises were there that bad before that. (R3) should not have all of these bruises. (R3) does not deserve that. (R3) is on continual monitoring every shift, every day due to previous behaviors and falling. So, there is no reason for (R3) to get all banged up like this. On 6/29/23 at 11:50 AM (V9) Regional Director of Operations stated (R3) had a fall early morning of 6/24. (R3) got up and walked out into the hallway and fell. That is more than likely how (R3's) arms got bruised. R3's Minimum Data Set (MDS) dated [DATE] documents R3 as severely cognitively impaired. This same MDS documents R3 as requiring limited assistance of one person for bed mobility and walking in room, and extensive assistance of two people for transfers, locomotion on and off unit, toileting and personal hygiene. R3's Physician Order Sheet (POS) dated June 1-30, 2023 does not document a physician order to assess, monitor and/or treat extensive bruising on R3's Left and Right Forearms. R3's Treatment Administration Record (TAR) dated June 1-30, 2023 does not document assessment, monitoring or treatment of R3's Right Forearm bruising nor Left Forearm bruising. R3's Care plan does not include focus area, goal nor interventions for R3's skin alterations. 3.) On 6/27/23 at 11:10 AM Observed R1 with dark purple and black bruising all the way around both eyes and over bridge of nose. This same bruising also extended above (R1's) Right Eye to mid forehead. Observed R1 walking in hall of dementia unit. On 6/27/23 at 11:12 AM R1 stated You should see the other guy! As R1 making a fist with Right hand and punching palm of R1's Left hand. R1 stated R1 did not know how R1's face got bruised. R1 stated (expletive) like this doesn't happen every day. I don't know how it happened but it sure does hurt!. R1's Electronic Medical Record (EMR) documents R1 as severely cognitively impaired. R1's EMR does not document assessment of R1's bilateral Peri-orbital bruising from R1's 6/25/23 fall. R1's Care plan does not include focus area, goal nor interventions for R1's skin alterations. 4.) On 6/28/23 at 11:35 AM Observed R2 laying in bed covered by a flat linen sheet. Observed R2's Left Forearm skin tear closed with no dressing covering area. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 as requiring extensive assistance of one person for bed mobility, dressing, toileting, personal hygiene and limited assistance of one person for transfers. R2's Nurse Progress Note dated 6/19/23 at 12:15 AM documents (R2) was found with blood to face and right arm by Certified Nurse Aides (CNA's). All areas cleansed and steri strips applied. Steri-strips applied to Right Eyebrow, Left Forearm and back of arm 2 areas found. (R2) was sent to emergency room for evaluation. R2's Physician Order Sheet (POS) dated June 1-30, 2023 does not document a physician order to assess, monitor or treat R2's skin alterations obtained 6/19/23. R2's Treatment Administration Record (TAR) dated June 1-30, 2023 does not document a physician order to assess, monitor or treat R2's skin alterations obtained on 6/19/23. R2's Care Plan does not document a focus area, goal nor interventions for R2's skin alterations. On 6/28/23 at 1:45 PM V10 Regional Clinical Nurse consultant stated We (facility) have tried to find the weekly wound tracking logs for all of the residents but weren't able to locate any of them. (V13) previous DON was let go and we (facility) believe (V13) took them with her or destroyed them. All I know is we (facility) don't have any documentation of the wounds for any of the residents. On 6/28/23 at 1:50 PM V3 Interim Director of Nurses (DON) stated Since we (facility ) do not have any wound tracking sheets for any of the residents I am doing whole house skin assessments tonight. We (facility) have not had an outside wound physician since March 2023 so we (facility) do not even have any notes to provide. We (facility) called a wound program and (V14) wound Advanced Practice Registered Nurse (APRN) is supposed to be starting this week. This whole house assessment will also help so we (facility) know which residents need to be seen. Any time a resident gets a new skin tear, abrasion, bruise, etc the nurse should asses the wound. The nurse should notify the Physician and Power of Attorney (POA). The nurse should obtain physician orders to monitor the wound and also get treatment orders if necessary. If the wound does not require a treatment, then the nurse should document that so we (facility) all know that has been addressed. None of that is being done. This has been a real mess. We (facility) are working on it but it is obvious that things are not like they should be. We (facility) have missed a lot.

Jun 2023 14 deficiencies 2 IJ (1 facility-wide)

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

Quality of Care (Tag F0684)

Someone could have died · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: develop and implement a care plan for a resident at h...

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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: develop and implement a care plan for a resident at high risk for skin breakdown, ensure proper nutrition and hydration via a jejunostomy feeding tube, ensure patency of the jejunostomy tube to prevent dehydration and promote wound healing, implement pressure relieving interventions, and completed pressure ulcer treatments as ordered for a resident. These failures affect one (R1) of three residents reviewed for pressure ulcers on the sample list of ten. These failures resulted in R1 becoming dehydrated and developing an infected stage III pressure ulcer requiring hospitalization for treatment. R1 also required surgery to replace a nonpatent enteral feeding tube. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 4/29/23 when the facility failed to develop and implement a care plan for a resident at high risk for skin breakdown, ensure proper nutrition and hydration via a jejunostomy feeding tube, ensure patency of the jejunostomy tube to prevent dehydration and promote wound healing, and implement pressure relieving interventions. On 6/7/23 at 2:00 pm, V2 AIT (Administrator in Training), V10 and V21 Corporate Nurses were notified of the Immediate Jeopardy situation. The surveyor confirmed by observation, record review, and interview that the Immediate Jeopardy was removed on 6/13/23 but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include: The facility Decubitus Care/Pressure Areas Policy dated January 2018 documents it is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer. A stage III pressure ulcer is described as broken skin, affecting full thickness and presents as a deep crater. Upon notification of skin breakdown, 4) notify the physician for treatment orders. 7) Nursing personnel are to notify dietary personnel of any pressure areas to seek nutritional support. 8) When a pressure ulcer is identified, additional interventions must be established and noted on the care plan in an effort to prevent worsening or re-occurring pressure ulcers. The facility Enteral Feedings Policy dated April 2016 documents 3. each tube feeding order may contain the following information: formula name, method of administration, route (site of entry), rate of feeding, time of feeding, flush volume and times, and additives. 5. The dietitian shall be notified of each new admission or re-admission of tube-fed residents. The dietitian will provide a tube feeding assessment and any applicable recommendations to nursing staff at the facility within 72 hours of admission. Nursing staff will relay the dietitian's recommendations to the physician. 10. Physician order for pre-med and formula administration flushes will be sought. 11. A record of daily intake of the tube feeding and the flushes for the resident will be kept by the nursing department. 12. Placement of the tube will be confirmed via aspiration of residual. If unable to confirm placement via aspiration, air instillation method may be used. 23. Residents receiving a tube feeding shall have an appropriate care plan developed. R1's MDS (Minimum Data Set) dated 5/6/23 documents R1 was admitted to the facility on [DATE] with severe cognitive impairments, has slurred speech and is rarely able to make R1's self understood, has no skin impairments but is at risk for skin breakdown, requires extensive assist of two staff for bed mobility, has not transferred in the past seven days {out of bed}, and receives enteral tube feedings. R1 does not have a care plan for R1's risk of skin breakdown or for any pressure relieving interventions. On 6/6/23 at 10:32, V29 MDS/Care Plan Coordinator stated residents with feeding tubes and pressure ulcers should have that care planned. V29 confirmed R1 does not have a care plan for his enteral feedings, risk of skin breakdown or actual pressure ulcer explaining, with switching to computerized charts, I'm a little behind. R1's ongoing medical record Diagnosis List documents the following diagnoses: Traumatic Hemorrhage of the Right Cerebrum, Encephalopathy, Dysphagia, and Autism. R1's Hospital Discharge Orders/Facility admission Orders dated 4/29/23 documents an order for an enteral tube feeding of Jevity 1.5 70 ml (milliliters) per hour for 14 hours. There were no free water flushes included on the hospital discharge orders, however there was a handwritten note that documents 350 ml QID (four times a day) next to the enteral feeding order. On 6/6/23 at 10:15 am, V10 Corporate Nurse stated V10 assumes that 350 ml QID is the flush order, but the nurses should have called to clarify that with V12 (R1's Physician). At this time, V10 also stated that R1 should have been assessed by V14 RD (Registered Dietitian) within 72 hours of admission. R1's medical record does not document V12 Physician was contacted to clarity R1's enteral feeding order or to obtain an order for free water flushes. The only nutritional assessment in R1's medical record is dated 6/4/23 {36 days after admission}. R1's Nutritional Assessment by V14 RD documents R1 has MASD (Moisture Associated Skin Damage) to the right and left inner buttocks and left lower buttock. Estimated nutritional needs are 1980 calories, 86 gm protein, and 1980 ml fluids. R1's increased needs estimated to maintain weights and promote wound healing. At this time, V14 suggests to increase tube feeding to Jevity 1.5 at 70 ml per hour for 16 hours. If tolerating after 48 hours, increase it to 18 hours. Again if tolerating after 48 hours, increase it to 20 hours feeding time and to decrease water flush to 350 ml water QID. On 6/6/23 at 10:46 am, V14 RD confirmed the 6/4/23 nutritional assessment for R1 was the first time V14 had assessed R1's nutritional needs. V14 explained, V14 comes to the facility once a month and when V14 was in the facility on 5/30/23, R1 was in the hospital, so R1 was not able to be assessed at that time. V14 stated, when a resident with a feeding tube is admitted to the facility, the facility should obtain a correct height and weight on the resident and notify V14 so an assessment can be completed to ensure the resident is receiving the required nutrition and hydration. V14 stated nobody at the facility reached out to V14 with that information or to alert V14 of having a resident (R1) with a feeding tube until V14 was in the facility on 5/30/23. V14 stated when R1 developed the pressure ulcers on 5/19/23, the facility should have alerted V14 of the change in condition so that additional recommendations could be made, but that didn't happen either. R1's Order Summary Report dated 6/5/23 documents an order dated 4/30/23 for an enteral feeding of 70 ml (milliliters) per hour one time a day for a diagnosis of Dysphagia, to start on 5/1/23 {2 days after admission}. There is no free water flush orders until 5/31/23 {32 days after admission}. The free water flushes are for 380 ml water QID (four times a day). This Order Summary documents a treatment order dated 5/19/23 to cleanse all wounds, apply Medihoney to the wound bed and apply hydrocolloid dressing and change three times a week on Monday, Wednesday and Friday and PRN (as needed) if the dressing is soiled or loose. R1's medical record does not document any intake monitoring for R1's enteral tube feeding or free water flushes to show how much nutrition and hydration R1 was receiving. R1's Progress Notes dated 5/19/23 documents R1 has a current skin issue including MASD (Moisture Associated Skin Damage) to three areas. R1's ongoing medical record Wound Measurements document R1 developed MASD to the Right inner buttock measuring 6.8 cm (centimeters) by 1.6 cm by 0.1 cm, left inner buttocks (lower) 2.3 cm by 1.0 cm by 0.1 cm, and left inner buttocks 5.3 cm by 0.9 cm by 0.1 cm. There is no documentation in R1's medical record including R1's May 2023 TAR (Treatment Administration Record) and Progress Notes that R1's wound treatment was completed as ordered. R1's Progress Notes dated 5/25/23 by V28 Agency LPN (Licensed Practical Nurse) documents {on 5/24/23} R1 appeared confused and drowsy and upon further assessment was found to be in delirious state with both hands raise to grab imaginary object, (R1) appear(s) drowsy but still respond to verbal command. (R1's) eyes are red with discharge. R1 was sent to the hospital for evaluation. R1's Hospital History and Physical dated 5/25/23 by V11 Hospital NP (Nurse Practitioner) documents R1 has resided at the nursing facility for one month and during this time has become dehydrated and developed a stage III pressure injury that was not present upon admission. Upon physical exam, R1 appears chronically ill and poorly nourished with a stage III pressure ulcer to the buttocks and coccyx with green drainage. R1 was noted to be septic and was admitted to the hospital with the following Diagnoses: Acute Sepsis related to Pressure Injury, Dehydration, Critical Hypernatremia, Electrolyte Imbalance, Lethargy, and Raised Serum Creatinine. R1's abnormal laboratory tests on 5/24/23, upon arrival to the hospital, were as follows: Sodium = 175 (normal is 135-145), BUN (Blood Urea Nitrogen) = 98 (normal is 8-25), Creatinine = 2.09 (normal is 0.7 - 1.5), BN/CR ( BUN/Creatinine ) = 46.89 (normal is 10-27), and WBC (White Blood Cell) Count = 13.5 (normal is 4.3 - 11). R1's Hospital Physician Notes dated 5/31/23 by V11 documents R1 was brought into the hospital from a local nursing home due to being severely dehydrated with a critical sodium level of 175. R1 has a J-tube (jejunostomy tube) for enteral tube feeding of Jevity 1.5 to run at a rate of 70 ml per hour from 2:00 pm - 4:00 am with a 380 ml water bolus along with water flushes between medications. J-tube was replaced while at the hospital. R1 was septic upon arrival mostly likely due to the sacral pressure ulcer. Acute Kidney Injury was due to pre-renal and dehydration. After fluids were given, R1's Creatinine levels returned to normal. R1's Hospital Discharge Instructions dated 5/31/23 document to ensure adequate water is given during flushing of tube and in between medications, R1 to have an air mattress, and Barrier Cream to bottom with foam dressing to open stage 3 pressure ulcer. On 6/6/23 at 11:05 am, V11 Hospital NP stated V11 is assuming R1 was not getting R1's feeding and/or water flushes explaining, there is no way that (R1) could have gotten so dehydrated if they (facility) were giving (R1) the ordered fluids. V1 stated R1's J-Tube was totally blocked off so and wondered how long it was blocked off, explaining that could have been why they were not giving fluids and/or feedings. V11 stated V11 had to have a surgeon come in and replace R1's J-tube. V11 also stated R1 had a nasty sacral pressure ulcer, that (R1) hadn't had the month prior. R1's eyes were sunken in and (R1) was very lethargic. I felt they had neglected (R1) by not giving (R1) these ordered fluids/feedings. V11 also stated, R1 not getting the proper nutrition, hydration, turned, cleaned up and bathed is what caused R1's pressure ulcer to develop and then become infected. R1 should not have developed that pressure ulcer. R1 probably had MRSA (Methicillin Resistant Staphylococcus Aureus) in the wound, based on the appearance of the wound with green drainage, that's why R1 was given IV (intravenous) Zosyn {Antibiotic}. V11 explained upon discharge, V11 ordered R1 to continue using the foam dressing to the pressure ulcers, as it will adhere to the wound and has a soft cushion to it. As of 6/5/23, R1's Physician Orders still document a treatment order of Medihoney and hydrocolloid to R1's pressure ulcers, not the foam dressing that was ordered at the time of hospital discharge on [DATE], or the order for an air mattress. These order now clarify the type of enteral tube feedings to be Jevity 1.5 but continues to order it at 70 ml per hour but does not document for how long, and also does not document flush orders or the recommendations of V14 from 6/4/23. On 6/5/23 at 11:30 am, R1 was lying on R1's back in bed, on a regular mattress. At 11:45 am, V3 DON (Director of Nursing), V9 RN (Registered Nurse) and V8 Agency CNA (Certified Nursing Assistant) entered R1's room to complete the ordered dressing changes. R1 was rolled to right side to reveal a foam dressing taped to left buttocks, which was not dated. V9 removed the dressing to reveal a 7.3 cm by 2.0 cm beefy red open area to the left buttocks with a full thickness,deeper area, in the middle of it measuring 1.5 cm by 1.7 by 0.2 cm. V9 cleansed the wound, applied Medihoney to the wound bed and then covered the wound with a hydrocolloid dressing. V3 confirmed the wound treatment that was originally on the wound was not what was showing as the active order on the physician order sheets but wasn't aware of the order for a foam dressing from the hospital. R1 was positioned on R1's back with a wedge slightly under R1's left hip. At 1:40 pm and 2:20 pm, R1 remained in the same position. At both times, R1 had dried BM (Bowel Movement) smeared down R1's legs and across the top of R1's right leg. On 6/5/23 at 2:25 pm, V10 stated there was no monitoring of R1's enteral nutritional and fluid intake because nobody put the order in to do so. V10 also stated R1 should have been getting feeding/flushes per the admission orders. On 6/6/23 at 8:58 am, 10:27 am, and 12:20 pm, R1 was sitting in a wheeled chair, reclined approximately 45 degrees, in the lounge across from the nurses station watching television. At 12:26 pm, V13 CNA stated V13 is assigned to R1 and that R1 was gotten up around 6:30 am {almost six hours prior} and placed in the chair. V13 stated V13 has not repositioned or toileted R1 since getting R1 up due to R1 being asleep every time V13 has checked on R1. The Immediate Jeopardy that began on 4/29/23 was removed on 6/13/23 when the facility took the following actions to remove the immediacy: 1. Changes made immediately following the reported incident, effective date 6/13/2023: 2. R1s order was changed and corrected as of 6/13/23 at 3:00PM to include enternal feeding type, how long the feeding is to run, and separate flush orders - completed on by V21, Regional Nurse 3. These orders are put in correctly and nurses will now have to sign off the flushes and feeding order - completed on 6/13/2023 - V21 Regional Nurse 4. Dietician updated notes are in assessments dated 6/4/2023 - Completed on 6/4/2023 by V14, Registered Dietitian 5. Intake tracking has been added to each shift for the nurses to fill in for both feedings and flushes - Completed and verified by V10 Regional Nurse 6/13/23 6. R1s care care plan has been updated to include skin break down on 6/13/2023 by V21 Regional Nurse and pressure relieving measures on 6/13/23 by V21. Care Plan is updated to include resident centered pressure relieving measures on 6/13/23 by V21, Regional Nurse. 7. R1s J tube now has orders now include for nurses to check J tube placement, J tube residual, and proper flushing completed by V21 Regional Nurse on 6/13/2023 8. R1 is on a pressure relieving mattress, is in a broda chair so he can be reclined and repositioned often, is frequent repositioning by staff Verified by S [NAME] Regional Nurse on 6/13/2023 9. R1s hospital discharge orders were double checked by 2 regional nurses to verify they are correct. Any incorrect orders were discontinued and entered correctly completed by V10 Regional Nurse and V21Regional Nurse on 6/13/2023 10. R1 will be assessed daily by nursing for skin assessments to assess for new wounds and monitor current wounds - completed by staff nurses daily, supplementary documentation added by V10 Regional Nurse on 6/13/2023 11. All residents have been assessed to check the braden scales and assure that daily or weekly skin checks are placed in the computer correctly - audit started by V21 Regional Nurse on 6/13/2023 and will be audited on an on going basis by V10, and V21, and eventually by the Director of Nursing once one is hired. 12. There are currently no other residents with a G tube or Jtube in the building 13. V10, and V21, and eventually by the Director of Nursing once one is hired will be monitoring all admissions and re admissions for G/J tubes to ensure proper orders are placed for 30 days starting 6/13/2023 14. Care policies for feeding tubes, skin breakdown have been reviewed do not show issues with identification, assessment, documentation, and process for notifications completed by V21, Regional Nurse on 6/13/2023 15. Clinical staff is being educated and trained on how to obtain accurate heights and weights with a return demonstration being performed starting on 6/7/2023 by V21 Regional Nurse to be completed by 6/13/2023 16. Nursing staff is being in serviced and educated on how transcribe physician orders for enternal feedings, flushes, wound care, and all physician orders in general by V21 Regional Nurse starting on 6/7/2023 to be completed by 6/13/2023 17. Nursing staff is being in serviced on how to monitor intakes for residents who are NPO and receive enternal feedings by V21 Regional Nurse starting on 6/7/2023 and completed by 6/13/2023 18. Nursing staff is being educated on how to care for G/J tubes for patency by V21, Regional Nurse starting on 6/7/2023 and completed by 6/13/2023 19. All mattresses in use at Watseka are pressure relieving mattresses unless the resident has a stage 2 or higher wound then they are placed on an air mattress. R1 was placed on a low air loss mattress as of 6/13/23 20. V10, V21 or the DON when one is hired will audit three times a week that all pressure ulcer treatments are completed as ordered starting 6/13/2023 for 3 weeks 21. V10 and V21, the regional team will ensure compliance by overseeing QA for the next 3 weeks then quarterly thereafter.

CRITICAL (L) 📢 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 most or all residents

⚠️ Facility-wide issue

Failures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review the facility failed to protect a resident's (R9) right to be free from...

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Failures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review the facility failed to protect a resident's (R9) right to be free from physical and mental abuse by V24 Certified Nurse's Assistant (CNA) and V25 CNA. This failure resulted in V24 and V25 taking away R9's walker, hiding it from R9, pushing R9, striking R9 on the arm, and then hitting R9 forcefully in the face with a clothing protector, resulting in R9 having a catastrophic reaction in which R9 became combative with V24 and V25 and R9 being removed from the facility by emergency services and taken to the emergency room. B. Based on observation, interview, and record review the facility failed to protect resident's rights to be free of physical and verbal abuse by other residents by failing to supervise and implement behavioral interventions for wandering and physically aggressive behaviors for seven of seven residents (R2, R3, R6, R7, R8, R9 and R10) reviewed for abuse on the sample list of ten. These failures resulted in the repetitive physical abuse of R3 by R8, R9, and R10, and R3 being hit, punched, and pushed down. These failures also resulted in R6 physically attacking R7 by punching R7 in the head and pulling R7's hair, and then striking R2 on the arm. This failure has the potential to affect all 77 residents residing in the facility. These failures resulted in R3 being pushed to the ground by R8 and R3 sustaining a laceration to the back of the head which required emergency medical services and four staples to close the laceration. These failures also resulted in multiple occurrences of resident-to-resident physical abuse in which residents were hit, punched, and pushed down to the ground by other residents. These altercations could result in serious bodily injury and harm. These failures resulted in an immediate jeopardy. The Immediate Jeopardy began on 4/4/23 when the facility failed to supervise and implement behavioral interventions for wandering and physically aggressive behaviors after R3 was physically abused by R9. V2 Administrator in Training was notified of the Immediate Jeopardy on 6/9/23 at 3:42 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 6/12/23, but noncompliance remains at Level Two because the facility requires more time to evaluate the effectiveness of in service training and the Plan of Correction. Findings include: a. The facility's video footage dated 6/3/23 at 5:07 PM, shows R9 sitting at a table eating dinner. R9's back is to the camera and there is no sound to this video footage. R9 is moving her hand across the table and is appearing to clean up something off of the table. V24 Certified Nurse's Assistant (CNA) walks over to R9's table and starts to wipe off the table with a clothing protector. R9 starts to grab at the clothing protector and knocks it off onto the floor. V24 then grabs R9's right hand squeezing it and walks away to the other side of the room. R9 continues to clean up the table when V24 walks over with towels. R9 tries to grab at the towels and V24 starts grabbing and squeezing R9's hands. V25 (CNA) then walks up to table and R9 begins hitting V24 on V24's backside. V24 then grabs R9's hand again and took something out of R9's hands. V25 removes dishes that are in front of R9 and when walking away pushes R9's walker away from the side of R9's table. R9 then stands up and grabs the walker. R9 walks with the walker over to V24 and V24 pushes R9 back with both hands and walks away from R9. R9 then grabs some paper towels and walks back to table to sit down. V24 then approaches R9 and attempts to grab something away from R9 and walks away. V25 then removes a roll of toilet paper off of R9's walker. V25 then folds R9's walker up and puts it in a room attached to the dining room and stands directly in front of the door obstructing R9's ability to get into the room to the walker. R9 then stands up to find the walker. V25 is noted to be saying something to R9 and begins moving both hands in a swatting motion at R9 while blocking R9's ability to get to the walker. R9 then hits V25 on the shoulder. V25 then swings her arm and hit R9's left shoulder with her fist. A un-identified nurse attempts to intervene and V25 drops her cell phone on the floor and R9 hits V25's back with a clothing protector. V25 then takes the clothing protector off her back and with a very forceful motion swings the clothing protector into the air and strikes R9 in the face and chest with the clothing protector. R9 is then taken out of the room by the unknown nurse and V24. On 6/8/23 at 12:15 PM, V24 stated there was an incident with R9 on 6/3/23 in the dining room. V24 stated R9 was upset that other residents in the dining room had been given soda pop but not her. V24 stated that caused R9 to squeeze a cup of soda for another resident and spill it onto the table. V24 confirmed that V24 grabbed R9's hands and put up her hands to push R9 away from her. V24 stated after R9 hit V25 with the clothing protector. V24 and the un-identified nurse then helped R9 to her room. V24 stated she is new to the facility and was not trained for the Dementia unit and did not know R9's behavior plan of care. On 6/8/23 at 12:35 PM, V25 stated on 6/3/23 there was an incident with R9 in the dining room. V25 stated V24 was attempting to clean the dining room when R9 became combative. V25 stated she attempted to intervene and to get R9 to come out of the dining room. V25 stated after R9 hit her, V25 reached her arm out but didn't mean to hit R9 and then after R9 hit her with the clothing protector and she grabbed it and swung it and it hit R9 in the face. V25 stated V24 and an un-identified nurse had to make R9 go to her room and R9 continued to be physically aggressive and fighting the staff until the police showed up. V25 stated she is new to the facility and was not trained for the Dementia unit and did not know R9's behavior plan of care. R9's Discharge Instructions for emergency room visit on 6/3/23 provided by V21 Corporate Nurse document R9 was seen in the emergency room for agitation and aggressive behaviors related to Dementia. V24 and V25's employee file provided by V2 Administrator did not include training for Abuse Prevention. The facility's fax to the state agency written by V2 Administrator dated 6/3/23 at 8:01 PM documents, alleged physical altercation between staff and resident. On 6/7/23 at 11:16 AM, V2 Administrator in Training stated the incident on 6/3/23 happened around dinner time. V2 stated someone at the facility called and reported that a CNA had swung at a resident. V2 stated she went into the building and had V24 and V25 go home. V2 stated the police were already at the building. V2 stated the next day V2 reviewed the video footage and V2 confirmed that V25 hit R9. R9's careplan with a revision date of 5/4/23 documents R9 has the potential to be verbally aggressive due to Dementia. This care plan includes an intervention to walk away from R9 if R9's response to staff is aggressive. b. 1.) R3's care plan with a revision date of 10/7/22 documents R3 has a diagnosis of Dementia, wanders, and has a disregard for personal spaces. This care plan documents R3 as having severe cognitive impairment. On 6/7/23 at 10:54 AM, R3 was walking up and down the hallways and going up to staff, other residents, and visitors touching their arms, jewelry, and shirts. R3 was noted to have staples to the back of her head. R3's Incident note dated 4/4/2023 at 10:37 AM, written by V17 Licensed Practical Nurse documents, Writer made aware by staff resident was struck with a walker by (R9). Upon assessment, (R9) stated (R3) was in my room and (R9) wanted (R3) out. (R3) escorted from (R9's) room. R9's care plan dated 4/11/23 documents R9 has a diagnosis of Dementia and has the potential for verbal and physical behaviors. This care plan did not include a revision or update after the incident on 4/4/23. R3's Incident note dated 5/7/2023 at 7:30 PM written by V16 Licensed Practical Nurse (LPN) documents, (R3) was hit in the chest by (R10) and fell onto floor hitting her head. R10's careplan dated 4/11/23 documents R10 has a diagnosis of Dementia and has the potential to become physically aggressive with staff due to Anger, Depression, Dementia, and poor impulse control. This careplan does not include a revision after the 5/7/23 incident with R3 until 6/3/23. R8's Behavior Note dated 5/24/2023 at 6:06 PM, written by V19 LPN documents, (V19) was informed by staff that (R8) throat-punched one of the (R3) on the unit; (V3, Director of Nursing) notified. R8's Behavior Note dated 5/28/2023 at 1:17 PM written by V18 LPN documents, (R8) observed by staff to have pushed another (R3), (R8) is agitated and redirected to his room for monitoring. Hospital Records dated 5/28/23 document R3 received four staples to a head wound after R3 fell (was pushed down by R8) on 5/28/23. R8's care plan dated 5/3/23 documents R8 has a diagnosis of Dementia and poor impulse control and can become verbally aggressive to staff. This care plan does not include a revision after R8 throat punched R3 on 5/24/23 or after R8 pushed R3 to the ground on 5/28/23 until 6/8/23. On 6/7/23 at 10:48 AM, V19 Licensed Practical Nurse stated R8 doesn't like R3 because she walks around and is in other peoples' personal space and is touching others. V19 stated I don't remember who but on 5/24/23 a staff member told me that (R8) had throat punched (R3). V19 stated I text (V3 Director of Nursing) but she never responded back. No one told us of any new behavioral interventions for (R8) or what to do to prevent (R3) from getting into people's space. (R8) is aggressive to staff and his family also. I know there were medication changes after he pushed her down on 5/28/23 but I don't know anything else besides that. On 6/7/23 at 10:23 AM, V2 Administrator in Training stated the facility's interdisciplinary team meets in the morning to go over incidents. V2 stated V2 did not know about the incidents occurring on 4/4/23, 4/11/23, or 5/24/23 until the incident occurring on 5/28/23 between R8 and R3. V2 stated the facility did not put in new behavioral intervention or increase supervision of R3. 2.) On 6/5/23 at 1:45 pm, V8 Agency CNA (Certified Nursing Assistant) stated R6 has shown behaviors towards female residents and explained, R6 had physical contact and verbal outburst towards R7 and R2 both, just a few days apart from one another. V8 stated V8 was at the facility on both occasions. V8 stated, the first time was a week or two ago while V8 was sitting at the nurses station and R6 was sitting in R6's wheelchair in the hall across from the nurses station. V8 explained that R2 was trying to get by R6 but R6's foot was sticking out. R2 said excuse me, can you please move your foot {talking to R6} and the next thing V8 heard was R2 say Ouch, you didn't have to do that, V8 stated then V8 heard R6 say, you (expletive)! V8 stated V8 stood up and asked what happened and R2 reported that R6 had hit R2 on the hand. V8 stated R2 had no bruising or even redness but V8 immediately separated R2 and R6 and reported it to V9 RN (Registered Nurse), and gave a written statement. V8 explained a couple of days later, (V8) was across the hall from (R6's) room and (R7) was sitting outside of (R6's) room with (R7's) back to (R6's) door. Next thing (V8) knew, (V8) heard (R6) yelling I (R6) told you to stay the (expletive) away from me and then started hitting R7 in the back of the head and by R7's ear. V8 stated V8 immediately separated them both and reported the abuse. V8 explained in the past, R6 and R7 use to live next to each other and would constantly go after each other so the facility had to move them to separate halls. The facility provided an initial abuse investigation dated 5/26/23 documenting a resident to resident altercation that included witness statements for the abuse between R6 and R7 but the facility did not provide an initial abuse investigation involving R6 and R2. On 6/5/23 at 2:05 pm, R6 was outside smoking, then propelled R6's self back into the facility and sat across from nurses station. On 6/5/23 at 2:05 pm, AIT (Administrator in Training) stated V2 was the Abuse Coordinator and explained R6 and R7 have a history between them and situations like this have happened previously, before V2 started working at the facility in March 2023. V2 stated there was no abuse allegation between R6 and R2 that V2 is aware of. At this time, V3 DON (Director of Nursing) was present and stated that V3 was aware of R6 hitting R2 on the arm and getting verbally aggressive with R2 because it was reported to V3 but that the unidentified staff that reported it said they had already made V2 aware of it. On 6/6/23 at 9:05 am, V2 AIT stated V2 does indeed remember hearing about a physical abuse allegation between R6 and R2 but got the allegation confused and didn't realize that R6 had been involved in two separate abuse allegations, V2 thought the staff was talking about the abuse between R6 and R7. V2 stated the physical abuse between R6 and R2 happened on 5/27/23. R6's MDS (Minimum Data Set) dated 4/10/23 documents R6 is non-ambulatory but requires supervision only with locomotion. On 6/7/23 at 9:00 am, R6 was propelling R6's self throughout the facility in R6's wheelchair without supervision. R6's Progress Notes dated 5/31/23 by V26 Behavioral NP (Nurse Practitioner) document R6 has a diagnosis of Vascular Dementia secondary to multiple CVA's (Cerebrovascular Accident's) with Right Sided Hemiparesis, Neurogenic Bladder, Aphasia. History of Schizoaffective Bipolar with ongoing issues with verbal outbursts and making false allegations and threats towards his peers and staff. He will curse people out or threaten to kill them. or call state. R6 had required medications adjustments due to R6's behaviors and upon follow up, it was reported that R6 had another violent incident with a female peer (R7). R6 was not happy that R7 was near R6's doorway and grabbed R7 by the hair. R6 admitted to the incident but stated (R6) didn't care because (R6) didn't want (R7) near (R6). On 6/5/23 at 10:45 am, R7 was lying in bed. When asked questions regarding the abuse allegation between R6 and R7, R7 responded with LaLaLa. R7's Care Plan dated 2/20/23 documents R7 has impaired expressive communication related to CVA and can only speak a few words. R7's Progress Notes dated 5/31/23 by V26 document R7 has a diagnosis of Vascular Dementia secondary to CVA with Right sided Hemiparesis and new onset behaviors of agitating R7's peers. The Notes state that R7 likes pushing R7's self into peers' rooms and got R7's hair pulled for refusing to leave, over the weekend. The Notes state that R7 has been impulsive and will touch peer's or go up to them and chat la-la-la. On 6/7/23 at 9:10 am, R2 was lying in bed and stated a week or so ago, R2 was trying to propel R2's self down the hall to get R2's laundry from the laundry room and a overbearing man (R6) was sitting by the nurses station with (R6's) foot sticking out. R2 explained R2 asked R6 several times to please move R6's leg but R6 didn't so R2 tried to go by R6 and R6 hit R2 on the wrist. R2 stated It hurt bad but didn't leave a bruise. R2 stated staff was at the nurses desk and immediately came around to check what was going on and separated us. R2 stated R2 doesn't remember the exact date explaining, I'm 96 and my memory isn't what it use to be. The facility Abuse Prevention Program dated 11/28/16 documents this facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined. Abuse is the willful injection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to resident or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, or saying things to frighten a resident, such as telling a resident that he/she will never be able to see family again. Mental Abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident(s), harassment, humiliation and threats of punishment or deprivation. The Nurse's Midnight Census dated 6/4/23 documents there are 77 residents residing in the facility. The Immediate Jeopardy that began on 4/4/23 was removed on 6/12/23 when the facility took the following actions to remove the Immediacy. On 6/14/23 between 9:00AM and 3:00PM the surveyor confirmed through observation, interview, and record review that the facility took the following action to remove the immediate jeopardy: 1. V2 Administrator in Training and V6 Dementia Unit Coordinator were in-serviced on the Abuse prevention policy and procedures and behavioral health policy, by V10 Regional Director of Operations on 6/09/23. Verified by surveyor 6/14/23. 2. Staff were in-serviced on the Abuse prevention policy and procedures on 6/10/23 by V3 Director of Nurses. The surveyor confirmed staff providing resident care in the facility on 6/14/23 had received training and training will continue until all staff have been trained. 3. V3 and V29 Care Plan Coordinator implemented behavioral interventions for physically aggressive residents R6, R8, R9, and R10 on 6/10/23. Verified by surveyor 6/14/23. 4. R6 will be provided more 1:1 activities throughout the day by activity staff and V6 Dementia Unit Coordinator. Verified by surveyor 6/14/23. 5. R8's medication review was completed by pharmacy staff on 6/12/23. Social Service staff will continue to follow up with R8 weekly to encourage one to one activities. Verified by surveyor 6/14/23. 6. R9's behavioral healthcare will increase to once weekly and promote more 1:1 activities provided. Verified by surveyor 6/14/23. 7. R10's medication review, increase 1:1 music therapy with hospice continuing by Hospice. Verified by surveyor 6/14/23. 8. R3's care plan was reviewed and revised with updated interventions for wandering behaviors by V3 and V29 on 6/10/23. R3 will receive 1:1 care for 7 days and then the Interdisciplinary Team (IDT) will reevaluate trends and patterns and the need for 1:1 on 6/19/23. Verified by surveyor 6/14/23. 9. V2 and V3 in-serviced staff on interventions for physically aggressive behaviors, supervision of wandering residents, updating care plans, and behavior tracking on 6/12/23. Verified by surveyor 6/14/23. 10. R3, R6, R8, R9, and R10's care plans were reviewed and revised to meet the resident's care needs by V3 and V29. Completed on 6/12/23. Verified by surveyor 6/14/23 11. All residents at risk for abuse were assessed and care plan interventions put in place. Checked by V3 and V29 on 6/12/23. Verified by surveyor 6/14/23. 12. Behavior tracking with targeted behaviors for R3, R6, R8, R9, and R10 was reviewed and revised by V3 and V29 on 6/12/23. Verified by surveyor 6/14/23. 13. Training for current staff, agency staff and new staff will continue and remain ongoing to educate staff on how to handle challenging individuals and calming the agitated. All new staff will also be educated on abuse prevention policy and procedures. Started on 6/12/23 and continuing. An outside training company will provide additional training at the facility for all employees and agency staff the week of June 19, 2023. Verified by surveyor 6/14/23. Quality Assurance Activities to assure the alleged deficient practice will not recur include: 14. QAT (Quality Assurance Team) to review implementation and effectiveness of interventions put into place to prevent further abuse through the daily QA meeting every weekday morning for the next 2 weeks Verified by surveyor 6/14/23. 15. QAT to conduct random rounds/interviews to ensure staff are aware of how to handle physically aggressive behaviors and wandering residents twice a week for the next 2 weeks. Verified by surveyor 6/14/23. 16. In-service training by V2 on Abuse prevention policy and Behavioral health policy will continue monthly for the next 3 months and then annually after. Verified by surveyor 6/14/23. 17. All new employees/agency staff will be in-serviced on the abuse prevention policy and behavioral health policy by the V2, continuing for new employees/agency. Verified by surveyor 6/14/23.

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

Abuse Prevention Policies (Tag F0607)

A resident was harmed · This affected 1 resident

Based on observation, interview, and record review the facility failed to follow it's Abuse Prevention policy to prevent the physical, verbal, and mental abuse of residents by failing to orientate new...

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Based on observation, interview, and record review the facility failed to follow it's Abuse Prevention policy to prevent the physical, verbal, and mental abuse of residents by failing to orientate new employees regarding Dementia management and resident abuse, and by failing to investigate allegations of abuse and report allegations of abuse to the facility's Administrator, the State Agency, Adult Protective Services, and local law enforcement to prevent subsequent abuse. These failures affected seven of seven residents (R2, R3, R6, R7, R8, R9 and R10) reviewed for abuse on the sample list of ten and have the potential to affect all 77 residents residing in the facility. These failures resulted in multiple incidents of physical abuse to R3 and R3 sustaining a laceration to the back of the head requiring emergency medical services and staples to close the laceration. Findings include: The facility's Abuse Prevention Program policy with a revision date of 11/28/16 documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This policy documents that during orientation of new staff the facility will cover, Dementia management and resident abuse preventions; Including, How to assess, prevent and manage aggressive, violent and/or catastrophic reactions of residents in a way that protects both residents and staff. This policy documents, Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the administrator. This policy documents, Supervisors shall immediately inform the administrator or his/her designated representative (specified by the administrator in the case of a planned absence) of all reports of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property. Upon learning of the report, the administrator or designee shall initiate an investigation. This policy also documents, The facility must ensure that all alleged violations involving mistreatment, exploitation, neglect or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures. If the events that cause the reasonable suspicion result in serious bodily injury or suspected criminal sexual abuse, the report shall be made to at least one law enforcement agency of jurisdiction and IDPH immediately after forming the suspicion (but not later than two hours after forming the suspicion), Otherwise, the report must be made not later than 24 hours after forming the suspicion. The Nurse's Midnight Census dated 6/4/23 documents there are 77 residents residing in the facility. 1. The facility's video footage dated 6/3/23 at 5:07 PM, shows V24 Certified Nurse's Assistant (CNA) grabbing and squeezing R9's hands and pushing R9 with both hands. This video also shows V25 CNA taking R9's walker and hiding it from R9, V25 striking R9 on the shoulder, and V25 grabbing a clothing protector and forcefully hitting R9 in the face and chest. On 6/8/23 at 12:15 PM, V24 stated she was hired at the facility about a month before the incident on 6/3/23. V24 stated she was not trained on Dementia management and resident abuse. On 6/8/23 at 12:35 PM, V25 stated she was hired at the facility about a month before the incident on 6/3/23. V25 stated she was not trained on Dementia management and resident abuse. V24 and V25's employee files provided by V2 Administrator in Training did not contain documentation that V24 and V25 were trained on Dementia management and resident abuse. 2. On 6/7/23 at 10:54 AM, R3 was noted to have staples to the back of her head. R3's Incident note dated 4/4/2023 at 10:37 AM, documents R9 struck R3 with her walker. R3's Incident note dated 5/7/2023 at 7:30 PM documents, R3 was hit in the chest by R10 and R3 fell onto floor hitting her head. R8's Behavior Note dated 5/24/2023 at 6:06 PM, documents R8 throat punched R3. R8's Behavior Note dated 5/28/2023 at 1:17 PM, documents R8 pushed R3 down. Hospital Records dated 5/28/23 document R3 received four staples to a head wound after R3 fell (was pushed down by R8) on 5/28/23. On 6/7/23 at 10:23 AM, V2 Administrator in Training stated no one reported the physical abuse of R3 by R8, R9, and R10 that occurred on 4/4/23, 4/11/23, or 5/24/23 to her so the incidents were not investigated and the state agency, adult protective services, or local law enforcement were notified. V2 stated that after the incidents no new interventions were put into place to prevent further abuse. 3.) On 6/7/23 at 9:00 am, R6 was propelling R6's self throughout the facility in R6's wheelchair without supervision. On 6/5/23 at 1:45 pm, V8 Agency CNA (Certified Nursing Assistant) stated R6 had physical contact and verbal outburst towards R7 and R2 both, just a few days apart from one another. V8 stated R6 had hit R2 on the hand and called R2 a (expletive) when R2 was trying to get past R6 in the hallway. V8 also stated that R6 physically attacked R7 outside of R6's room and was hitting R7 in the back and side of R7's head and pulling R7's hair. The facility provided an initial abuse investigation dated 5/26/23 documenting a resident to resident altercation that included a few witness statements for the abuse between R6 and R7 but the facility did not provide any information regarding the abuse allegation involving R6 and R2. On 6/5/23 at 2:05 pm, V2 AIT (Administrator in Training) stated V2 was the Abuse Coordinator. V2 confirmed V2 only received a few witness statements regarding the abuse allegation between R6 and R7 and did not complete a thorough investigation. V2 stated R6 was educated on not hitting other residents then stated, R6 isn't with it though so education really isn't going to help that but it's something we {facility} still had to do. On 6/6/23 at 9:05 am, V2 AIT stated V2 remembers hearing about a physical abuse allegation between R6 and R2 but got the allegation confused and didn't realize that R6 had been involved in two separate abuse allegations, therefore V2 did not complete an investigation into the abuse allegation, implement any interventions to prevent further abuse, or report the incident to IDPH (Illinois Department of Public Health).

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

Investigate Abuse (Tag F0610)

A resident was harmed · This affected 1 resident

Based on observation, interview, and record review the facility failed to investigate allegations of physical abuse and prevent further abuse for seven of seven residents (R2, R3, R6, R7, R8, R9 and R...

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Based on observation, interview, and record review the facility failed to investigate allegations of physical abuse and prevent further abuse for seven of seven residents (R2, R3, R6, R7, R8, R9 and R10) reviewed for abuse on the sample list of ten. This failure resulted in multiple occurrences of physical abuse to R3 in which R3 sustained a laceration to the back of the head requiring emergency services and staples to close the laceration. This failure also has the potential to affect all 77 residents residing in the facility. Findings include: 1. On 6/7/23 at 10:54 AM, R3 was noted to have staples to the back of her head. R3's Incident note dated 4/4/23 at 10:37 AM, documents R9 struck R3 with a walker. R3's Incident note dated 5/7/23 at 7:30 PM, documents R10 hit R3 in the chest and R3 fell onto to floor hitting R3's head. R8's Behavior note dated 5/24/23 at 6:06 PM, documents R8 throat-punched R3 in the throat. R8's Behavior Note dated 5/28/23 at 1:17 PM, documents R8 pushed R3 down causing R3 to have a laceration to the back of the head. Hospital Records dated 5/28/23 document R3 received four staples to a head wound after R3 fell (was pushed down by R8) on 5/28/23. R3's care plan dated 12/14/22 does not document and changes to R3's plan of care. R8's care plan dated 5/3/23 does not document any changes to R8's plan of care. On 6/7/23 at 10:23 AM, V2 Administrator in Training stated she did not know about the incidents involving R3 occurring on 4/4/23, 5/723, or 5/24/23. V2 stated these incidents were not investigated. V2 stated no changes were made to R3's plan of care after the incidents on 4/4/23, 5/7/23, 5/24/23, or 5/28/23. V2 stated no changes were made to R8's plan of care after the incident on 5/24/23. 2.) On 6/7/23 at 9:00 am, R6 was propelling R6's self throughout the facility in R6's wheelchair without supervision. On 6/5/23 at 1:45 pm, V8 Agency CNA (Certified Nursing Assistant) stated R6 has shown behaviors towards female residents and explained, R6 had physical contact and verbal outburst towards R7 and R2 both, just a few days apart from one another. V8 stated V8 was at the facility on both occasions. V8 stated, the first time was a week or two ago while V8 was sitting at the nurses station and R6 was sitting in R6's wheelchair in the hall across from the nurses station. V8 explained that R2 was trying to get by R6 but R6's foot was sticking out. R2 said excuse me, can you please move your foot {talking to R6} and the next thing V8 heard was R2 say Ouch, you didn't have to do that, then V8 heard R6 say, you (expletive)! V8 stated V8 stood up and asked what happened and R2 reported that R6 had hit R2 on the hand. V8 stated R2 had no bruising or even redness but V8 immediately separated R2 and R6 and reported it to V9 RN (Registered Nurse), and gave a written statement. V8 explained a couple of days later, (V8) was across the hall from (R6's) room and (R7) was sitting outside of (R6's) room with (R7's) back to (R6's) door. Next thing (V8) knew, (V8) heard (R6) yelling I (R6) told you to stay the (expletive) away from me and then started hitting R7 in the back of the head and by R7's ear. V8 stated V8 immediately separated them both and reported the abuse. V8 explained in the past, R6 and R7 use to live next to each other and would constantly go after each other so the facility had to move them to separate halls. The facility provided an initial abuse investigation dated 5/26/23 documenting a resident to resident altercation that included a few witness statements for the abuse between R6 and R7 but the facility did not provide any information regarding the abuse allegation involving R6 and R2. On 6/5/23 at 2:05 pm, AIT (Administrator in Training) stated V2 was the Abuse Coordinator. V2 confirmed V2 only received a few witness statements regarding the abuse allegation between R6 and R7 and did not complete a thorough investigation. V2 stated R6 was educated on not hitting other residents then stated, R6 isn't with it though so education really isn't going to help that but it's something we {facility} still had to do. On 6/6/23 at 9:05 am, V2 AIT stated V2 remembers hearing about a physical abuse allegation between R6 and R2 but got the allegation confused and didn't realize that R6 had been involved in two separate abuse allegations, therefore V2 did not complete an investigation into the abuse allegation nor implement any interventions to prevent further abuse. The Nurse's Midnight Census dated 6/4/23 documents there are 77 residents residing in the facility.

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

Administration (Tag F0835)

A resident was harmed · This affected 1 resident

Based on observation, interview, and record review the facility failed to ensure the Administrator in Training, Director of Nursing, and the Unit Coordinator of the Dementia Unit received sufficient t...

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Based on observation, interview, and record review the facility failed to ensure the Administrator in Training, Director of Nursing, and the Unit Coordinator of the Dementia Unit received sufficient training to adequately manage the facility in a manner that maintained the physical and mental well-being of it's residents. These failures contributed to ongoing incidents of physical and mental abuse to residents diagnosed with Dementia. These failures affected seven of seven residents (R2, R3, R6, R7, R8, R9, and R10) reviewed for abuse on the sample list of ten and has the potential to affect all 77 residents residing in the facility. As a result of these failures, R3 was repetitively physically abused ultimately sustaining a laceration to the back of the head requiring emergency medical services and four staples to close the laceration. These failures also resulted in R9 having a catastrophic reaction after being subjected to physical and mental abuse by untrained staff. Findings include: 1. On 6/7/23 at 10:54 AM, R3 was walking up and down the hallways and going up to staff, other residents, and visitors touching their arms, jewelry, and shirts. R3 was noted to have staples to the back of her head. R3's nurse's notes dated 4/4/2023 at 10:37 AM, documents R9 struck R3 with her walker due to R3 wandering into R9's room. This note documents V3 Director of Nursing was notified. R3's Incident note dated 5/7/2023 at 7:30 PM documents, (R3) was hit in the chest by (R10) and fell onto floor hitting her head. R8's Behavior Note dated 5/24/2023 at 6:06 PM documents, R8 throat-punched R3 and V3 was notified. R8's Behavior Note dated 5/28/2023 at 1:17 PM documents, R8 pushed R3. On 6/7/23 at 10:23 AM, V2 Administrator in Training stated she doesn't know much about R8's admission into the facility. V1 stated V23 Former Dementia Care Coordinator left on 4/29/23. V2 stated the Interdisciplinary team were covering incidents and changes on the Dementia unit since then. V2 stated they have morning meetings in which they discuss what was going on in the facility. V2 stated V2 did not know about the incidents involving R3 occurring on 4/4/23, 4/11/23, or 5/24/23 until the incident occurring on 5/28/23 between R8 and R3. V2 stated the unit coordinator is responsible for the behavior programs. V2 stated no behavioral interventions were put into place after these incidents. On 6/7/23 at 10:37 AM, V3 stated she remembers getting a text about the incident on 5/24/23 and she told V19 to call V2 Administrator. V3 stated V3 doesn't remember talking about it in the morning meeting the next day. On 6/7/23 at 10:15 AM, V6 Dementia Unit Coordinator stated she took over five days ago. V6 stated she is not sure about the behavior tracking or behavior programs for the residents yet. On 6/7/23 at 10:48 AM, V19 Licensed Practical Nurse stated on 5/24/23 a staff member told me that R8 had throat punched R3. I text V3, Director of Nursing but she never responded back. V19 stated no one told us of any new behavioral interventions for R8 or what to do to prevent R3 from getting into people's personal space. On 6/7/23 at 10:54 AM, V20 Certified Nurse's Assistant stated R8 is physically aggressive and no one has told him about a behavioral plan for R8. The facility's video footage dated 6/3/23 at 5:07 PM, showed V24 Certified Nurse's Assistant (CNA) grabbing and squeezing R9's hands and pushing R9 with both hands. This video also showed V25 CNA taking R9's walker and hiding it from R9, V25 striking R9 on the shoulder, and the V25 grabbing a clothing protector and forcefully hitting R9 in the face and chest. On 6/8/23 at 12:15 PM, V24 Certified Nurse's Assistant stated the residents on the Dementia unit all wander and go into each others rooms and we go and tell and they ignore us and won't do anything about it. We don't want residents hurt. They never tell us new interventions and when we asked a corporate nurse what the protocol was when residents are combative and they said we don't have one. V24 stated they didn't train me at all and if you want me to be honest one day we (V24 and V25 CNA) showed up and V2 Director of Nursing just threw us back there with no training at all. V24 stated they usually only had one of us CNAs back there. V24 statede V24 also worked back there by herself for 16 hours with 16 to 17 Dementia residents. V24 stated there are 5 or 6 residents who walk and they wander into each others' rooms. There at least 8 residents who are aggressive back there. V24 stated when V24 reported it to the nurse (unknown nurse) there was nothing done and no new interventions were put into place. On 6/8/23 at 12:35 PM, V25 CNA stated she started at the facility on April 17th, 2023. V25 stated she ended up working on the Dementia unit and didn't get any abuse or Dementia training at the facility. V25 stated she wasn't aware of any behavior health programs or interventions for the residents. V25 stated the facility threw us (V24 and V25) to the wolves. V25 stated after they (V24 an V25) complained about other staff, the facility retaliated by scheduling them to work back there with no training or direction. V25 stated we didn't know anything about the residents. V25 stated another employee from an agency told them who was combative and other then that V25 had to create her own cheat sheet that would remind her who was incontinent and who needed assistance. V25 stated in regards to the incident with V9, everything was happening so fast and I didn't know what to do. V25 stated the nurse (unknown) was with agency and she didn't know what to do, I think that was her first day. On 6/5/23 at 9:00 AM, V2 Administrator in Training stated she applied for a temporary Administrator license but hasn't received it yet. V2 stated V1 Administrator is the actual Administrator but isn't in the facility. V2 stated he's(V1) only here once a week due to having a lot of buildings and being in the buildings that have a lot of concerns. V10 Corporate Nurse(Acting Administrator at another facility) who was present at this time, stated she was here doing training with V3 Director of Nursing even though she's(V3) been here awhile, there are a lot of nursing concerns here. 2.) On 6/5/23 at 1:45 pm, V8 Agency CNA (Certified Nursing Assistant) stated R6 had physically attacked two separate residents R2 and R7, just a few days apart from each other. V8 explained R6 hit R2 on the arm when R2 was trying to pass R6 in the hallway and then hit R7 in the back and side of the head and pulled R7's hair. V8 stated V8 had reported both incidents to the nurse and Administration and gave a written witness statement. On 6/5/23 at 2:05 pm, V2 AIT (Administrator in Training) stated V2 was the Abuse Coordinator. V2 stated V2 only sent in an initial report to IDPH (Illinois Department of Public Health) on the incident between R6 and R7 and did not thoroughly investigate the incidents of abuse or really do anything other than gather a few witness statements regarding the incident between R6 and R7 because V2 didn't know what needed to be done. V2 explained V2 wasn't taught the right way how to handle doing reports and investigations. V2 stated V1 Administrator is the Regional Administrator, so V1 is over several facilities and has not been to this facility in a little over two weeks and the V2 did not call V1 for guidance of what to do.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide bathing assistance to one of three dependent residents (R1)...

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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 bathing assistance to one of three dependent residents (R1) reviewed for assistance in daily living. Findings Include: R1's MDS dated [DATE] documents R1 was admitted to the facility on [DATE], requires extensive assistance of two staff for personal hygiene and that bathing has not occurred. R1's Progress Notes dated 5/19/23 documents R1 has developed three MASD (Moisture Associated Skin Damage) areas: Right inner buttock measuring 6.8 cm (centimeters) by 1.6 cm by 0.1 cm, left inner buttocks (lower) measuring 2.3 cm by 1.0 cm by 0.1 cm, and left inner buttocks measuring 5.3 cm by 0.9 cm by 0.1 cm. These notes dated 5/24/23 documents R1 was admitted to the hospital. R1's Hospital History and Physical dated 5/25/23 documents R1 has a diagnosis of Acute Sepsis related to Pressure Injury. On 6/6/23 at 11:05 am, V11 Hospital Nurse Practitioner stated R1 not getting the proper nutrition, hydration, turned, cleaned up and bathed is what caused R1's pressure ulcer to develop and then become infected. R1's medical record as of 6/6/23 does not document that R1 has received a bath/shower since R1's admission on [DATE]. On 6/6/23 at 12:30 pm, V10 Corporate Nurse confirmed there is no documentation of R1 getting a bath/shower since R1's admission and stated, it doesn't look like it {bathing} was put into the computer as a task for the CNA's (Certified Nursing Assistant) to do.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to transcribe physician orders, implement physician orders and provide medications as ordered for residents. This failure affects two of seven...

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Based on interview and record review, the facility failed to transcribe physician orders, implement physician orders and provide medications as ordered for residents. This failure affects two of seven resident (R6, R7) reviewed for abuse on the sample list of 10. Findings Include: 1.) R6's Progress Notes dated 5/31/23 by V26 Behavioral NP (Nurse Practitioner) documents R6 has Vascular Dementia secondary to multiple CVA (Cerebrovascular Accident) with Right Side Hemiparesis, Neurogenic Bladder, Aphasia. History of Schizoaffective Bipolar with ongoing issues with verbal outbursts and making false allegations and threats towards R6's peers and staff. R6 will curse people out or threaten to kill them, or call state. R6 has required titration up of R6's behavioral medications for ongoing behaviors in January 2023 and again in April 2023. Upon follow up, R6 had another violent incident with a peer (R7). R6 was not happy R7 was near R6's doorway and grabbed R7 by the hair. R6 admitted to the incident but stated R6 didn't care because (R6) didn't want (R7) near (R6). V26 spoke with R6 about how his medications are not helping reduce R6's anger spells and informed R6 the next course of action is to start Haldol Decanoate {Antipsychotic} injection monthly. Will also titrate up R6's Topamax {Anticonvulsant} to the maximum dose of 200 mg (milligrams) daily for R6's rash mood swings and impulsive actions. R6's June 2023 Physician Orders document the new order of Haldol Decanoate 100 mg per ml (milliliter) and Topamax 200 mg BID (twice a day) but both orders document orders are pending confirmation. R6's June 2023 MAR (Medication Administration Record) documents the new order of Haldol Decanoate and Topamax 200 mg BID have not been administered. On 6/7/23 at 2:50 pm, V3 DON (Director of Nursing) stated pending confirmation is because those medications required family authorization and once that is obtained, then the nurse has to go into the computer and either activate it to show it's an active order and able to be administered. V3 stated V3 is unaware if R6's family has been notified of the new orders or if permission has been granted yet. 2.) R7's Progress Notes dated 5/31/23 by V26 Behavioral NP (Nurse Practitioner) documents R7 has diagnoses of Vascular Dementia secondary to CVA (Cerebrovascular Accident) with Right Sided Hemiparesis and a new onset behaviors of agitating R7's peers. R7 likes pushing R7's self into peers' rooms and got R7's hair pulled for refusing to leave the peer's room over the weekend. R7 has been impulsive and will touch peer's or go up to them and chat la-la-la. R7 is already on Gabapentin {Anticonvulsant} and Dilantin {Anticonvulsant} for seizures and is still impulsive. R7's cognitive impairment impedes R7's ability to take redirection correctly. Will titrate up R7's Gabapentin to 200 mg (milligrams) every eight hours for these behaviors. R7's June 2023 Physician Orders do not document the newly increased order for Gabapentin was ever transcribed or implemented. R7's June 2023 MAR (Medication Administration Record) documents R7 has continued to received the originally ordered dose of 100 mg TID (three times a day). On 6/6/23 at 2:50 pm, V3 DON (Director of Nursing) stated V27 SSD (Social Service Director) goes on rounds with V26 and then reports back to the nurses when a new medication order has been written so they can transcribe and implement it and stated, R7's new order should have been transcribed and implemented. On 6/6/23 at 3:00 pm, V27 stated on 5/31/23, V22 Agency LPN (Licensed Practical Nurse) and V27 both rounded with V26 so V22 was aware that R7 had a change in medication orders but is unsure why V22 did not transcribe and implement them.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected multiple residents

Based on interview and record review the facility failed to report allegations of abuse to the facility's administrator, the state survey agency, adult protective services, and to local law enforcemen...

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Based on interview and record review the facility failed to report allegations of abuse to the facility's administrator, the state survey agency, adult protective services, and to local law enforcement for seven (R2, R3, R6, R7, R8, R9 and R10) of seven residents reviewed for abuse on the sample list of ten. Findings include: 1. R3's Incident note dated 4/4/2023 at 10:37 AM, documents R9 struck R3 with a walker. R3's Incident note dated 5/7/2023 at 7:30 PM, documents R10 hit R3 in the chest and R3 fell onto to floor hitting R3's head. R8's Behavior note dated 5/24/2023 at 6:06 PM, documents R8 throat-punched R3 in the throat. On 6/7/23 at 10:23 AM, V2 Administrator in Training stated she did not know about the incidents involving R3 occurring on 4/4/23, 5/723, or 5/24/23. V2 stated these incidents were not reported to her, the state survey agency, adult protective services, or to local law enforcement. 2.) On 6/5/23 at 1:45 pm, V8 Agency CNA (Certified Nursing Assistant) stated R6 has shown behaviors towards female residents and explained, R6 had physical contact and verbal outburst towards R7 and R2 both, just a few days apart from one another. V8 stated V8 was at the facility on both occasions. V8 stated, the first time was a week or two ago while V8 was sitting at the nurses station and R6 was sitting in R6's wheelchair in the hall across from the nurses station. V8 explained that R2 was trying to get by R6 but R6's foot was sticking out. V8 stated R2 said excuse me, can you please move your foot {talking to R6} and the next thing V8 heard was R2 say Ouch, you didn't have to do that, then V8 heard R6 say, you (expletive)! V8 stated V8 stood up and asked what happened and R2 reported that R6 had hit R2 on the hand. V8 stated R2 had no bruising or even redness but V8 immediately separated R2 and R6 and reported it to V9 RN (Registered Nurse), and gave a written statement. V8 explained a couple of days later, (V8) was across the hall from (R6's) room and (R7) was sitting outside of (R6's) room with (R7's) back to (R6's) door. Next thing (V8) knew, (V8) heard (R6) yelling I (R6) told you to stay the (expletive) away from me and then started hitting (R7) in the back of the head and by (R7's) ear. V8 stated V8 immediately separated them both and reported the abuse. V8 explained in the past, R6 and R7 use to live next to each other and would constantly go after each other so the facility had to move them to separate halls. On 6/5/23, V2 AIT (Administrator in Training) provided an initial abuse investigation dated 5/26/23 documenting a resident to resident altercation that included a few witness statements for the abuse between R6 and R7 but did not provide the final abuse report and did not provide any evidence that the alleged abuse between R6 and R2 was reported to IDPH (Illinois Department of Public Health). On 6/5/23 at 2:05 pm, AIT stated V2 was the Abuse Coordinator. V2 stated for R6 and R7's abuse investigation, V2 only completed an initial report to IDPH (Illinois Department of Public Health) and obtained a few witness statements. V2 stated V2 did not send in a final report to IDPH. V2 then stated V2 was not taught the right way how to handle doing reports of abuse. On 6/6/23 at 9:05 am, V2 confirmed hearing about a physical abuse allegation between R6 and R2, but got them confused and didn't realize that R6 had been involved in two separate abuse allegations, therefore the alleged abuse was not reported to IDPH, the physician or R6 and R2's families.

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 eight consecutive hours in each 24 hour period for four days. This failure has the poten...

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Based on interview and record review the facility failed to provide the services of a Registered Nurse (RN) for eight consecutive hours in each 24 hour period for four days. This failure has the potential to affect all 79 residents residing at the facility. Findings include: The facility's Nurse's Midnight Census dated 6/4/23 documents 79 residents reside at the facility. The Facility Assessment updated 11/15/22 documents the facility houses residents with clinically complex physical, behavioral, and psychological diagnoses. The facility's June 2023 schedule and the staffing worksheets for 6/3/23, 6/4/23, 6/8/23, and 6/12/23 document there was no RN present in the facility on 6/3/23, 6/4/23, 6/8/23 or 6/12/23. On 6/12/23 at 2:00PM V10, Corporate Nurse stated We are aware we do not always have RN coverage for every shift.

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 F0837 (Tag F0837)

Could have caused harm · This affected most or all residents

Based on observation, interview and record review the facility failed to have a governing body in which the facility failed to have a licensed Administrator managing the facility or a governing body t...

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Based on observation, interview and record review the facility failed to have a governing body in which the facility failed to have a licensed Administrator managing the facility or a governing body that the Administrator in Training reports to concerning the management and operation of the facility. This failure has the potential to affect all 79 residents residing in the facility. Findings include: On 6/5/23 at 9:00 am, V2 AIT (Administrator in Training) stated V2 has applied for V2's temporary Administrator's license but has not received it yet. V2 stated that V1 Administrator is the actual Administrator of the facility but not currently at the facility due to having a lot of buildings. On 6/5/23 at 2:05 pm, V2 AIT stated V1 hasn't been to this facility in over two weeks, and that V2 has not called V1 to discuss and recieve guidance on how to handle the ongoing issues at the facility. On 6/6/23 and 6/7/23 from 8:30 am - 3:30 pm, and 6/8/23 from 9:30 am - 3:00 pm, V1 was not in the facility, which makes three weeks since V1 has been in the facility. The Facility Assessment last reviewed on 11/15/22 documents having a licensed Administrator managing the facility or a governing body that the Administrator in Training reports to concerning the management and operation of the facility. The facility's Nurses Midnight Census dated 6/4/23 documents 79 residents reside at 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

Deficiency F0865 (Tag F0865)

Could have caused harm · This affected most or all residents

Based on interview and record review the facility failed to maintain documentation of and demonstrate evidence of an ongoing Quality Assurance (QA) /Quality assurance and performance improvement (QAPI...

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Based on interview and record review the facility failed to maintain documentation of and demonstrate evidence of an ongoing Quality Assurance (QA) /Quality assurance and performance improvement (QAPI) program. This deficiency has the potential to affect all 79 residents who reside at the facility. Findings Include: The facility's Nurse's Midnight Census dated 6/4/23 documents 79 residents reside at the facility. The facility's policy Quality Assurance Plan (Not dated) states: (The facility) works to continually improve the way residents are cared for, and safety and operations within the facility through the Quality Assurance Process. Quality Assurance activities are to be completed continuouslyand objectively to provide a comprehensive review of the facility's Activities. The purpose of the Quality Assurance plan is: To help identify problems or potential problems, To provide information upon which corrective action can be planned, To help analyze the need for policy or procedural changes or in-service training. To act as a record that, when analyzed, will prevent similar mishaps or injuries, To provide quality of resident care and overall safety in the facility. On 6/13/23 at 2:00PM ,When asked what documentation or credible information the surveyor could review to show proof of an ongoing QA/QAPI program in the facility V21, Corporate Nurse stated We do not have documentation of a QA/QAPI progran because we have an Administrator in training who was not aware of the need for a formal QA/QAPI program. We are working with the facility to correct that going forward.

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 F0868 (Tag F0868)

Could have caused harm · This affected most or all residents

Based on interview and record review the facility failed to convene Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) meeting at least Quarterly including the requires facili...

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Based on interview and record review the facility failed to convene Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) meeting at least Quarterly including the requires facility staff. This deficiency has the potential to affect all 79 residents who reside at the facility. Findings Include: The facility's Nurse's Midnight Census dated 6/4/23 documents 79 residents reside at the facility. The facility's policy Quality Assurance Plan (Not dated) states: The Quality Assurance Comittee will conduct: Daily Meetings, Quarterly Meetings (at a minimum), and Other Quality Assurance meeting as required. On 6/12/23 the surveyor requested sign-in documentation from the last three QA/QAPI meetings. On 6/13/23 at 2:15PM V10 stated this quarter is April May June, so we can still have a June Meeting. However, I do not have sign-in sheets for the three quarters prior to that.

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 F0943 (Tag F0943)

Could have caused harm · This affected most or all residents

Based on interview and record review the facility failed to provide employees with required abuse, neglect, and exploitation training upon hire. This failure has the potential to affect all 79 residen...

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Based on interview and record review the facility failed to provide employees with required abuse, neglect, and exploitation training upon hire. This failure has the potential to affect all 79 residents who reside at the facility. Findings include: The facility's Nurse's Midnight Census dated 6/4/23 documents 79 residents reside at the facility. The facility's policy Abuse Prevention Program revised 11/28/16 states During orientation of new employees the facility will cover at least the following topics: Sensitivity yo residents rights and needs, staff obligation to prevent and immediately report abuse, neglect, exploitation, and theft (Misappropriation of resident property) to supervisory personnel and Administrator; and how to distinguish theft from lost items, and willful abuse from insensitive staff actions that should be corrected through counseling and additional training, Dementia Management and resident abuse prevention including how to assess, prevent, and manage aggressive, violent and or catastrophic, reaction of residents in a way that protects both residents and staff, and How recognize how to deal with burnout, frustration, and stress that may lead to inappropriate responses or abusive reactions to resident. V33, Certified Nurse's Aide's (CNA) personnel file documents V33 was hired 5/23/23. There is no documentation in V33's file to indicate V33 received the required Abuse/Neglect training. V34, Certified Nurse's Aide's (CNA) personnel file documents V34 was hired 5/19/23. There is no documentation in V34's file to indicate V34 received the required Abuse/Neglect training. V35, Certified Nurse's Aide's (CNA) personnel file documents V35 was hired 6/8/23. There is no documentation in V35's file to indicate V35 received the required Abuse/Neglect training. V36, Certified Nurse's Aide's (CNA) personnel file documents V36 was hired 2/22/23. There is no documentation in V36's file to indicate V36 received the required Abuse/Neglect training. V37, Certified Nurse's Aide's (CNA) personnel file documents V37 was hired 6/15/23. There is no documentation in V37's file to indicate V37 received the required Abuse/Neglect training. On 6/14/23 at 10:00AM V10, Corporate Nurse verified V33, V34, V35, V36, and V37 did not receive the required abuse/Neglect training upon hire.

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 F0947 (Tag F0947)

Could have caused harm · This affected most or all residents

Based on interview and record review the facility failed to ensure all CNA's receive the required 12 hours of annual training upon hire and at least annually thereafter. This failure has the potential...

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Based on interview and record review the facility failed to ensure all CNA's receive the required 12 hours of annual training upon hire and at least annually thereafter. This failure has the potential to affect all 79 residents who reside at the facility. Findings Include: The facility's Nurse's Midnight Census dated 6/4/23 documents 79 residents reside at the facility. V33, Certified Nurse's Aide's (CNA) personnel file documents V33 was hired 5/23/23. There is no documentation in V33's file to indicate V33 received the required Abuse/Neglect training. V34, Certified Nurse's Aide's (CNA) personnel file documents V34 was hired 5/19/23. There is no documentation in V34's file to indicate V34 received the required Abuse/Neglect training. V35, Certified Nurse's Aide's (CNA) personnel file documents V35 was hired 6/8/23. There is no documentation in V35's file to indicate V35 received 12 documented hours of training to be repeated annually V36, Certified Nurse's Aide's (CNA) personnel file documents V36 was hired 2/22/23. There is no documentation in V36's file to indicate V36 received received 12 documented hours of training to be repeated annually V37, Certified Nurse's Aide's (CNA) personnel file documents V37 was hired 6/15/23. There is no documentation in V37's file to indicate V37 received received 12 documented hours of training to be repeated annually On 6/14/23 at 10:00AM V10, Corporate Nurse verified V33, V34, V35, V36, and V37 did not receive received 12 documented hours of training to be repeated annually. The facility document Annually Mandated In-services revised 7/22/23 documents 41 areas of staff competency. On 6/14/23 at 2:15PM V10, Corporate Nurse stated It would be my expectation every staff would be competencied on all items on the Annually Mandated In-services upon hire before working on the floor and annually after that,

May 2023 4 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Quality of Care (Tag F0684)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to promptly notify the physician of an acute change in condition, docum...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to promptly notify the physician of an acute change in condition, document changes in condition, and monitor/assess for changes in condition for two (R1, R7) of three residents reviewed for hospitalization in the sample list of 12. This failure resulted in R1's multiple hospital readmissions for fluid volume overload, pleural effusions, pulmonary edema, acute hypoxic respiratory failure and congestive heart failure. The facility also failed to monitor anticoagulant use for one (R7) of three residents reviewed for hospitalizations in the sample list of 12. Findings include: 1.) R1's Diagnoses List dated 5/24/23 documents R1 has type II Diabetes Mellitus with Chronic Kidney Disease. R1's Physician Order dated 3/22/23 documents R1 receives hemodialysis at a dialysis center three times weekly on Mondays, Wednesdays, and Fridays. R1's Brief Interview for Mental Status score dated 5/5/23 documents R1 is cognitively intact. R1's Care Plan dated 11/14/22 documents R1 has End Stage Renal Disease, is noncompliant with diet, and includes an intervention to weigh monthly and report weight changes to the physician and dietitian. This care plan documents R1 receives dialysis three times weekly and includes interventions to monitor for changes in condition including fluid status, cognition and activities of daily living needs, and report these changes to the dialysis center. This care plan documents R1 uses oxygen as needed for shortness of breath and includes interventions to monitor R1's oxygen saturation every shift and as needed, and notify the physician of concerns. R1's Nursing Note dated 4/16/2023 at 6:51 PM documents R1 refused all medications, had not ate all day, and stated R1 did not feel well. There is no documentation that V16 (R1's Physician) was notified. There are no documented monitoring/assessments of R1 between 4/16/23 and 4/17/23. There is no documentation that R1 was transferred to the hospital on 4/17/23 or the reason for the hospital transfer. R1's emergency room assessment dated [DATE] at 10:31 AM documents R1 complained of nausea, vomiting, shortness of breath for the past two days, and R1 has no cardiac history. R1's last dialysis was on 4/14/23, with dialysis scheduled for 4/17/23. This assessment documents R1 had similar symptoms and hospitalization with dialysis about a month ago. R1's lungs were diminished with wet crackles, oxygen saturation was 50% (normal is 95% or higher), blood pressure was 188/118, and pulse was 92. R1 weighed 165 pounds (lbs). R1's chest x-ray dated 4/17/23 documents R1 had changes that were suspicious for congestive heart failure with developing pulmonary edema and pleural effusions (fluid in the lungs). R1's emergency room Note dated 4/17/23 documents R1 was given intravenous Lasix (diuretic), placed on high flow oxygen, then placed on Bilevel positive airway pressure (BIPAP), and transferred to a higher level hospital. R1's Hospital Progress Note dated 4/21/23 documents R1 was transferred from an outside hospital for acute hypoxic respiratory failure, and nephrology was consulted for dialysis for fluid volume overload and hyperkalemia. R1's weight on 4/21/23 was 145 lbs and 6.4 ounces. There are no routine monitoring of R1's weights, blood pressure, and oxygen saturation in R1's medical record. R1's weight on 2/1/23 was 167 lbs, on 4/19/23 and 4/23/23 R1 weighed 159 lbs. There are no other documented weights in April and May 2023 or documented assessments/monitoring of R1 after 4/22/23 until 4/30/23. R1's Nursing Notes document the following: On 4/30/2023 at 6:03 PM oxygen was administered at 2 liters per minute due to R1's complaints of shortness of breath and coughing up phlegm. On 4/30/2023 at 6:37 PM R1 was R1's usual self earlier in the day, and now complained of shortness of breath. R1's blood pressure was 180/76, respirations were 26, and oxygen saturation was 94%. R1 had a cough with a clear amount of phlegm and a nebulizer treatment was administered. On 4/30/2023 at 7:41 PM R1 was sitting on the side of the bed and complained of feeling much worse. R1's blood pressure was 180/104, pulse was 98, Oxygen saturation was 94%. The physician was notified and R1 was transferred to the local hospital. R1's Hospital Discharge summary dated [DATE] at 11:41 AM documents the following: R1 admitted to the hospital on [DATE] for complaints of shortness of breath. R1 reported having hemodialysis the day prior with 3.5 liters of fluid removed, and later that day R1 had sudden onset of shortness of breath and productive cough. R1's dialysis is scheduled three times weekly on Mondays, Wednesdays, and Fridays (indicating R1's last dialysis day was on 4/28/23.) R1's oxygen saturation was 65% on room air and R1 was placed on BIPAP. R1's chest x-ray showed volume overload with mild to moderate pleural effusions, pulmonary infiltrates, pulmonary edema, and congestive heart failure with mild cardiomegaly. R1 readmitted to the facility on [DATE] and there are no documented assessments/monitoring, or changes in condition between 5/5/23 and 5/15/23. R1's Nursing Note dated 5/15/23 at 3:17 PM documents R1's family member called and inquired how R1's condition was earlier in the day and if R1 went to dialysis. This family member reported that R1 had not felt good during the night. The nurse informed R1's family that R1's vital signs were obtained (these vital signs are not recorded in R1's medical record) and R1 was transferred to dialysis. R1 was transferred from dialysis to the local hospital and intensive care unit with diagnoses of hyperkalemia, shortness of breath, dialysis, and pulmonary edema. There are no documented assessments or monitoring of R1 after R1 returned to the facility on 5/19/23. On 5/23/23 at 8:41 AM R1 stated R1 went from dialysis to the hospital on 5/15/23 for shortness of breath, nausea, coughing, dizziness and sweating. R1 stated the facility had sent R1 to dialysis with R1's symptoms to see if dialysis would improve R1's symptoms, but the dialysis center told R1 there was nothing they could do for R1 and sent R1 to the hospital. R1 stated R1 was in a wheelchair and was on oxygen when R1 was transferred to dialysis, and R1's symptoms began on the night before around 6:00 PM. R1 kept waking up during the night and reporting R1's symptoms to the nurses, and R1 was not sure if the nurses reported R1's symptoms to V16 Physician. R1 stated R1 was hospitalized for pneumonia. R1 stated R1's symptoms are always the same and usually begin about 1-2 days prior to R1 being transferred to the hospital. R12 (R1's room mate) stated about 3-4 weeks ago R12 had to contact emergency services to request R1 be transported to the emergency room. R1 stated R1 had kept asking the nurses to send R1 to the hospital, and they refused saying R1 only needed dialysis. On 5/24/23 at 8:24 AM R1 stated R1 went to the local hospital in April and had to be transported to a higher level hospital for treatment. R1's symptoms had started the night before, and R1 had requested to go to the emergency room. R1 stated V2 Director of Nursing told R1 that R1 needed dialysis and did not contact 911 as R1 had requested. On 5/24/23 at 8:14 AM V31 Dialysis Nurse stated on 5/15/23 R1 arrived at dialysis in a wheelchair and on oxygen, normally R1 is ambulatory and does not use oxygen. R1 complained of being short of breath, sweating, and abdominal pain that had started the night before and the facility nurses had not addressed R1's symptoms. V31 stated R1's health changes quickly and has a history of respiratory illness. V31 stated R1 was immediately transferred to the local hospital and admitted to the intensive care unit. V31 stated V31 spoke to V25 Licensed Practical Nurse on 5/15/23 who told V31 that R1 did not look good that morning. V31 stated R1 also reported that a few weeks prior R1 was experiencing similar symptoms and requested to go to the hospital, but R1 had to call 911 because the nurses would not. On 5/24/23 at 8:29 AM V33 Certified Nursing Assistant stated there was a day that R1 went to dialysis in a wheelchair and on oxygen, and R1 did not return to the facility that day. V33 stated normally R1 is able to walk and take care of R1's self, and only uses oxygen as needed typically at night. On 5/24/23 at 11:07 AM V2 Director of Nursing stated residents on dialysis should be weighed weekly and recorded in the electronic medical record. Vital signs, swelling in extremities, puffiness of the face, and assessing lung sounds are all part of monitoring/assessing for fluid overload. V2 stated we chart by exception and only when there are changes noted in the resident. V2 stated V2 would expect an assessment to be done and documented when a resident complains of not feeling well, and the physician should be notified. V2 stated vital signs are not always getting done. V2 stated R1 went in a wheelchair to dialysis on the morning of 5/15/23, and normally R1 is ambulatory and only uses oxygen after dialysis treatments when needed. V2 stated R1 does not always feel well on dialysis mornings. On an unidentified date V2 told R1 it was a scheduled dialysis day when R1 requested to go to the hospital for vomiting. V2 stated V2 had to assist with another resident, and R1 called 911. On 5/24/23 at 2:57 PM V16 Physician stated R1 is noncompliant with R1's orders and medications which contributes to R1's fluid volume overload, and R1 receives dialysis three times weekly. V16 stated the facility should be monitoring R1's weights at least weekly, and blood pressure daily. V16 expects the nurses to complete an assessment including vital signs and oxygen saturation when R1 has a change in condition including of shortness of breath, dizziness, or nausea/vomiting. V16 stated R1 can have a rapid increase in blood pressure, and the nurses should notify V16 of their assessment and R1's change in condition/symptoms. V16 stated V16 is unable to manage R1's fluid volume overload in the facility, and R1 requires hospitalization and additional dialysis to treat R1's fluid volume overload. V16 stated if the facility is not monitoring R1 for signs/symptoms of fluid volume overload, then R1 could go downhill fast or possibly die. V16 stated V16 should have been notified of R1's change in condition and symptoms and R1 should have been sent to the emergency room on 5/14/23. R1 should not have been sent to dialysis in that condition. 2.) R7's Diagnoses List dated 5/24/23 documents R7 has End Stage Renal Disease, Kidney Failure, Atherosclerotic Heart Disease, Heart Failure, Type 2 Diabetes Mellitus, and history of myocardial infarction. R7's Care Plan revised 2/1/23 documents R7 receives dialysis three times weekly on Tuesdays, Thursdays, and Saturdays and includes interventions to monitor for changes and response to treatment, notify the dialysis center of changes in condition including fluid status, cognition, and activities of daily living needs. There are no routine assessments or monitoring of R7 and R7's vitals signs and weight documented in R7's medical record. R7's Nursing Notes document the following: On 5/14/2023 at 1:37 AM R7 had 3+ pitting edema to bilateral lower extremities, complaint of numbness/tingling to bilateral upper/lower extremities, blood pressure was 137/100, pulse was 104, oxygen saturation was 93%, respirations were 18, and blood glucose results were high. The physician was notified and R7 was transferred to the hospital. On 5/17/2023 at 4:06 PM R7 readmitted to the facility and reported that R7 had dialysis with 3 liters of fluid removed. There are no documented assessments after 5/17/23. On 5/22/23 at 1:13 PM R7 refused all morning medications and insulin. R7 complained of vomiting and diarrhea and requested to go to the emergency room. R7's face was puffy and abdomen was distended. R7 was transferred to the hospital by ambulance. There are no documented assessments/monitoring of R7 on 5/21/23 and prior to 5/22/23 at 1:13 PM or that R7's physician was notified of any change in condition prior to 5/22/23. R7's Hospital Note dated 5/14/23 at 8:33 AM documents R7 presented with weakness and abdominal pain that began over the last week with some nausea/vomiting, decreased urine output, fluid retention, weight gain, and abdominal distention. R7's pelvis computed Tomography showed anasarca (accumulation of fluid/swelling of the whole body), pleural effusion, abdominal ascites (fluid). On 5/23/23 at 1:11 PM V27 Certified Nursing Assistant stated on 5/21/23 R7 was overly tired and not out and about per R7's usual. V27 stated V27 served R7's supper tray then later that evening R7 went outside to smoke and V27 noticed R7's eyelids were swollen/puffy. V27 stated R7's ankles are always swollen, but R7 had no facial swelling prior. V27 stated V27 reported R7 feeling tired and R7's eyelid swelling to V30 Licensed Practical Nurse who said that V30 would assess R7. On 5/24/23 at 9:20 AM V26 Licensed Practical Nurse stated V26 reported to work on 5/22/23 at 10:00 AM and R7's face was puffy and abdomen was distended. V26 stated V26 last cared for R7 on 5/19/23 and R7 did not have facial swelling at that time. R7 complained of vomiting and diarrhea and was requesting to go to the hospital. It was passed on in report that R7 refused R7's morning medications. V26 stated R7 was transferred to the hospital around 11:00 AM. On 5/24/23 at 11:07 AM V2 Director of Nursing stated residents on dialysis are to be weighed weekly and recorded in the electronic medical record. Vital signs, swelling in extremities, puffiness of the face, and assessing lung sounds are all part of monitoring/assessing for fluid overload. V2 stated we chart by exception and only when there are changes noted in the resident. V2 stated V2 would expect an assessment to be done and documented when a resident complains of not feeling well, and the physician should be notified. V2 stated vital signs are not always getting done. V2 stated R7 was admitted to the hospital with fluid volume overload on 5/22/23. 3.) R7's Diagnoses List dated 5/24/23 documents R7 has a history of Transient Ischemic Attacks and Cerebrovascular Infarction. R7's April and May 2023 Medication Administration Records documents R7's Coumadin (anticoagulant) was increased from 5 milligrams (mg) daily to 7.5 mg daily on 4/6/23 and then decreased to 3.5 mg daily on 5/1/23. The order dated 5/1/23 indicates to monitor R7's Protime (PT)/International normalized ratio (INR) daily with a therapeutic goal of 2.5-3 and to adjust the dose accordingly as recommended by the physician. There is no documentation that R7's PT/INR was monitored routinely after 3/29/23, and there are no orders for routine PT/INR. There is no documentation in R7's medical record that attempts were made to obtain R7's PT/INR, that R7 refused laboratory draws, or that R7's physician was notified of refusals. R7's PT/INR on 3/29/23 was 25.6 and 2.42. R7's Laboratory Requisitions dated 4/5/23 and 4/12/23 documents R7 refused blood draw for PT/INR. R7's Laboratory Requisitions 4/19/23 and 5/10/23 documents R7 refused laboratory draw, but does not document what laboratory test was ordered. R7's Nursing Notes R7 went on a leave of absence from the facility on 4/23/23. R7's Physician Progress Note dated 5/10/2023 at 1:54 PM documents R7 readmitted to the facility and had been hospitalized for an elevated INR and R7's brain computed Tomography indicated an increase in R7's brain bleed. On 5/24/23 at 11:07 AM V2 Director of Nursing stated PT/INR should be done at least monthly or per physician's orders after an increase in dosage of Coumadin. At 3:33 PM V2 stated stated there were no orders to monitor PT/INR routinely and confirmed there were no PT/INR results after 3/29/23. V2 stated no one followed up on monitoring PT/INR after R7 readmitted to the facility. V2 stated R7 refused to have PT/INR drawn and the nurses should have notified the physician and documented in R7's medical record. V2 stated the facility does not have a policy on anticoagulant use/monitoring. The facility's Notification for Change in Resident Condition or Status revised 12/7/17 documents the physician will be notified of changes in resident's physical/emotional/mental conditions, refusal of treatment/medications, and transfer to hospital. Information related to the change in condition will be documented in the resident's medical record.

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Based on interview and record review the facility failed to develop a comprehensive care plan for a seizure disorder for one (R11) of three residents reviewed for seizures in the sample list of 12. F...

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Based on interview and record review the facility failed to develop a comprehensive care plan for a seizure disorder for one (R11) of three residents reviewed for seizures in the sample list of 12. Findings include: R11's Diagnoses List dated 5/24/23 documents a diagnosis of epileptic seizures related to external causes, not intractable, and without status epilepticus. R11's Physician's Order dated 4/4/23 documents to administer Phenytoin (seizure medication) Sodium Extended Release 100 milligram capsule by mouth three times daily. R11's Nursing Note dated 4/24/2023 at 1:13 PM documents R11 had a seizure. R11's Care Plan with a review date of 4/23/23 does not document a problem area, goals, and interventions for R11's seizures. On 5/24/23 at 11:07 AM V2 Director of Nursing reviewed R11's Care Plan and confirmed it does not include R11's seizures and interventions. V2 stated R11's seizures should be included in R11's care plan.

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

Based on observation, interview, and record review the facility failed to provide timely incontinence care for one (R4) resident. R3 and R4 are two of seven residents reviewed for activities of daily ...

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Based on observation, interview, and record review the facility failed to provide timely incontinence care for one (R4) resident. R3 and R4 are two of seven residents reviewed for activities of daily living in the sample of 12. Findings include: On 5/23/23 at 8:09 AM R3 stated sometimes R4 is left in urine/feces for 4 to 6 hours during the night. R3 stated staff provided R4's incontinence care earlier this morning and gave R4 another blanket because R4's was wet with urine. R4's Care Plan dated as reviewed 10/17/22 documents R4 requires extensive assistance or dependence on staff for assistance with activities of daily living and is incontinent with interventions to assist with incontinence care as needed. On 5/23/23 at 12:18 PM V10 Licensed Practical Nurse was in R3's/R4's room. R3 told V10 that R4 needs incontinence care. V10 told R3 that the Certified Nursing Assistants were in the dining room feeding residents. R3 stated R4 has not been changed in quite awhile. On 5/23/23 at 12:40 PM V7 and V9 CNAs provided R4's incontinence care. R4's brief was saturated with urine. R4's bed linens were wet and required a complete bed change. At 12:55 PM V7 and V9 both stated they had not provided incontinence care for R4 earlier in the shift. V9 stated V9 came on shift at 11:00 AM. On 5/23/23 at 12:58 PM V8 CNA stated the CNAs are primarily assigned halls for charting, but work together to provide care. V8 stated R4 was last toileted around 9:30 AM by V15 CNA. On 5/24/23 at 11:07 AM V2 Director of Nursing stated residents should be checked for incontinence and incontinence care provided at least every 2 hours. The facility's Perineal Cleansing policy dated as reviewed December 2017 documents the purpose is to eliminate odor, prevent irritation, prevent infection, and improve self-esteem.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

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 administer multiple doses of seizure medications for th...

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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 administer multiple doses of seizure medications for three of three residents (R9, R10, R11) reviewed for seizures in the sample list of 12. Findings include: 1.) R9's Care Plan dated 5/24/23 documents R9 has a seizure disorder and includes an intervention to administer seizure medications as ordered. R9's Physician's Orders dated 4/30/23 document to administer Vimpat (seizure medication) Oral Solution 10 milligrams (mg)/Milliliters (ml) give 200 mg via enteral feeding tube twice daily and Topiramate 300 mg enterally twice daily for diagnosis of epilepsy, unspecified, not intractable, with status epilepticus. R9's April and May 2023 Medication Administration Records (MARs) documents R9 did not receive 15 doses of Vimpat between 4/30/23 and 5/22/23 and refers to R9's progress notes. These MARs document Topiramate was not administered for 4 scheduled doses between 4/30/23 and 5/22/23. R9's Progress Notes document the following: R9 admitted to the facility on [DATE]. On 5/1/23 evening doses of Vimpat and Topiramate were not available. On 5/11/23 at 2:22 PM Topiramate on order. On 5/15/2023 at 2:56 PM the pharmacy was notified to request medication refill and the nursing department was aware. On 5/12/2023 at 1:37 PM Vimpat and Topiramate were not available and the pharmacy was notified. Vimpat was not available on 5/2/23, 5/3/23, 5/8/23-5/10/23, 5/13/23, and 5/15/23-5/18/23. 5/22/2023 at 10:52 PM Medication (Vimpat) still not available. There is no documentation in R9's medical record that V24 Physician was notified of R9's missed doses of seizure medications. R9's Seizure Note dated 5/10/2023 at 11:33 AM documents at 11:00 AM R9 was pale, eyes rolled back in head and moving back and forth, respirations shallow, unable to obtain blood pressure, pulse was 40 beats per minute, and oxygen saturation was 96 %. R9 aroused briefly and then became unresponsive. R9 was transferred to the local emergency room. On 5/24/23 at 5:59 AM V18 Licensed Practical Nurse stated R9 did not have Vimpat when R9 first admitted to the facility and it took awhile for the medication to be delivered from pharmacy. V18 stated V18 notified the pharmacy to order the medication, but never notified R9's physician. The medication cart containing R9's medications was reviewed with V18. R9's Vimpat bottle label documented a dispensed date of 5/22/23. V18 stated R9 did not have a bottle of Vimpat prior to 5/22/23. On 5/24/23 at 6:19 AM V2 Director of Nursing confirmed nurses should document medication administration with a check mark on the MAR, indicating the medication was administered. V2 stated if a medication is not given then it should be documented in the progress notes, and the nurses should notify the pharmacy to obtain the medications. V2 stated the nurses should notify the physician of missed doses of medications and record in a progress note. At 11:07 AM V2 confirmed there was no documentation that R9's missed doses of seizure medications were reported to V24 (R9's Physician). At 3:33 PM V2 confirmed there were no pharmacy delivery receipts for R9's Vimpat prior to 5/22/23. 2.) R10's Physician Order dated 4/4/23 documents to administer Depakote (seizure medication) Delayed Release 125 mg give three tablets by mouth twice daily, and R10 has a diagnosis of epilepsy, unspecified, not intractable, without status epilepticus. R10's April 2023 MAR does not document R10's evening dose of Depakote was administered on 4/27/23 and 4/28/23 and refers to the nursing notes. R10's Nursing Notes document R10's Depakote was reordered from pharmacy on 4/27 and 4/28/23. There is no documentation that V23 Physician was notified of R10's missed doses. On 5/24/23 at 11:07 AM V2 confirmed there was no documentation that R10's missed doses of Depakote were reported to V23 Physician. 3.) R11's Diagnoses List dated 5/24/23 documents a diagnosis of epileptic seizures related to external causes, not intractable, and without status epilepticus. R11's Physician's Order dated 4/4/23 documents to administer Phenytoin (seizure medication) Sodium Extended Release 100 mg capsule by mouth three times daily. R11's May 2023 MAR does not document Phenytoin scheduled at 4:00 PM was administered for 7 doses between 5/1/23 and 5/23/23. There is no documentation in R11's nursing notes why the medication was not administered or that R11's physician was notified of missed doses of the medication. R11's Nursing Note dated 4/24/2023 at 1:13 PM documents R11 had a seizure. On 5/24/23 at 3:33 PM V2 stated V2 was unable to locate documentation regarding R11's Phenytoin doses that were not signed out as administered, or documentation that R11's physician was notified. The facility's Medication Administration policy with a revision date of 11/18/17 documents medications should be verified and administered in accordance with the physician's order and the administration should be recorded on the MAR. This policy documents when medications are not administered record the omission and the reason on the MAR, and notify the pharmacy and physician when medications are not available or administered as scheduled.

May 2023 5 deficiencies 2 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Quality of Care (Tag F0684)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide treatment and services to promote wound healing for a resid...

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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 treatment and services to promote wound healing for a resident. R1 was admitted to the facility with multiple burn wounds to R1's right front thigh, left front thigh, left rear knee, left rear lower leg, and back in which the facility failed to assess, monitor, obtain orders and provide treatments for R1's wounds. This failure affects one of three residents (R1) reviewed for wounds on the sample of five. These failures resulted in R1's open wounds on R1's back to deteriorate and become infected requiring hospitalization. Findings include: The facility's Skin Condition and Monitoring policy dated 3/16/23 documents it is the policy of the facility to provide proper monitoring, treatment, and documentation of any resident with skin abnormalities. This policy documents the nurse will assess and document the findings in the nurses notes and complete a skin evaluation. The nurse will then notify the physician and obtain a treatment order including type of treatment, location of area to be treated, frequency of treatment and cleansing of the wound. Any skin abnormality will have a specific treatment order until area is resolved. Documentation of the skin abnormality must occur upon identification and at least weekly thereafter until the area is healed. Documentation of the area must include size, shape, depth, odor, color and presence of granulation tissue or necrotic tissue, treatment and response to treatment and prevention techniques in place for the resident. R1's Hospital Discharge Skin/Wound Assessments dated 4/7/23 at 8:00am document the R1's burn wounds including burn wounds to the Left posterior thigh and Back. These wound assessments document R1's dressing changes to each of these wounds as being changed on 4/6/23 and were dry and intact. R1's Admission/readmission Nursing Evaluation dated 4/7/23 at 3:46pm documents R1 admitted to the facility with reason for admission as Tracheostomy care, wound care and an indwelling urinary catheter. This evaluation documents R1 has burn wounds to the right front thigh, left front thigh, left rear knee and left rear lower leg with measurements. There is no documentation of R1's multiple back wounds on admission to the facility. This evaluation documents R1 is alert and oriented to person, place, time and situation and communicates via communication board. R1's Electronic Clinical Physician Orders dated 5/18/23 at 6:10pm do not document orders for wound care/dressing changes for April 2023 and May 2023. R1's Electronic Treatment Administration Records (TAR) dated April 2023 and May 2023 do not document R1 received dressing changes to R1's multiple burn/skin graft wounds on R1's back or any other of R1's burn/skin graft wounds, including R1's lower extremities. There is no documentation of attempts by the facility to clarify/review post hospital visit needs for R1's wound treatments. R1's Hospital records document R1's wound counsult note for multiple wounds present on admission 4/11/23 and wound details as follows: 4/11/23 at 11:42pm, R1's lower thoracic spine wound was midline lower thoracic spine with partial thickness. The wound bed was clean, moist, pink. Periwound was scar tissue with a scant amount of serosanguineous drainage. 4/12/23 at 12:00am, R1's left scapula multiple wound beds were clean, moist, and pink. The periwound was scar tissue and A scant amount of serosanguineous drainage. 4/12/23 at 12:00am, R1's right scapula multiple wound beds were clean, moist, and pink. The periwound was scar tissue With a scant amount of serosanguineous drainage. 4/12/23 at 12:00am, R1's multiple Left posterior leg wounds extending up to the posterior knee learned about was clean moist and pink with periwound of scar tissue. This wound contained a scant amount of serosanguineous drainage. 4/12/23 at 12:00am, R1's Right abdomen wound bed was clean with red hypergranulation and sutures, multiple areas. Red granulation was 76 to 100%. peri-wound is documented as scar tissue and that these wounds had small amount of serosanguineous drainage. This was cleansed with sterile normal saline and a border dressing applied. 4/12/23 at 12:00am, left lateral hip multiple wound beds were clean, dry, pink. peri-wound is documented as scar tissue with no drainage. 4/12/23 at 10:05am, left second toe dorsal pressure injury deep tissue and present on admission. The wound bed is dry and maroon and purple and color. peri-wound is intact with no drainage. 4/12/23 Left dorsal thigh multiple wound beds are clean, moist, and pink with no drainage and peri-wound as scar tissue. 4/12/23 at 10:09am, right thigh medial multiple wound beds clean, moist, pink with peri-wound documented as scar tissue and contained a scant amount of serosanguineous drainage. 4/12/23 at 10:10am, left lower back wound had full thickness with wound bed moist, pink, with slough. Red/granulation tissue 1-26%, yellow slough 51-75% with the peri-wound documented as scar tissue with a small amount of serosanguineous drainage. R1's Hospital Discharge Summary documents R1 discharged from the hospital on 4/25/23. This summary does not document wound care orders for R1's multiple wounds. R1's Hospital Discharge Instructions dated 4/25/23 do not document wound care/dressing change orders for R1' multiple wounds on R1's body. There is no documentation in R1's electronic medical record that the facility requested or obtained wound care orders upon readmission to the facility for R1's multiple wounds on multiple areas of R1's body. R1's admission assessment dated [DATE] at 11:58am documents R1 re-admitted to the facility on [DATE]. This assessment documents R1's admitting diagnosis as Respiratory Failure with reason for admission, tracheostomy. This assessment does not document R1's multiple skin wounds to R1's body. On 5/10/23 at 2:35pm, V5, emergency room Physician stated R1 admitted to the hospital on [DATE] with non-healing wounds and required a lot of cares/frequent wound care. V5 stated R1 is at an increased risk for skin breakdown as well as infection/decline to R1's wounds due to R1's history of burn wounds with skin grafts and current open wounds. R1's Hospital Nursing notes dated 5/3/23 at 9:55pm document R1 has poor skin turgor with breakdown, wounds with wound odor. These notes documents R1 has multiple open wounds to R1's back and legs bilaterally in area of previous burned skin. This note documents R1's dressings on R1's wounds were dated 4/27/2023 with purulent drainage noted. This note documents R1 has multiple dressings on legs, back and abdomen that were dated 4/27/2023. R1's wound dressings to R1's left hip, back, left thigh were draining yellow thick sanguineous and purulent drainage and had a foul odor. This note documents these dressings were soaked off with normal saline soaks, R1's wound dressings were removed and R1's wound beds were denuded with sanguineous, yellow thick green drainage noted in wound beds with a foul odor to R1's wounds. This note documents V12, R1's family stated R1's wounds were not that severe prior to admission to the facility. This note also documents 90% of R1's back is covered in full thickness open wounds with sanguineous drainage. R1's Hospital Therapy Notes dated 5/4/23 at 3:44pm document R1 has several open wounds from his previous burn injuries that have not been properly cared for and are infected. these notes document R1 would be appropriate to return to a skilled nursing facility, however it does not appear that (R1's) current facility has been able to provide the quality of care needed by (R1.) R1's Wound Consult note signed by V9, Wound Physician/General Surgeon dated 5/8/23 documents R1 has multiple raw areas on the back and behind the thigh that are still bleeding and that R1 needs to have operation on R1's wounds with potential skin grafts to wounds. On 5/10/23 at 1:00pm, V8, Licensed Practical Nurse (LPN)/Case Manager stated V9, Wound Physician/General Surgeon had recommended R1 go to surgery for skin grafting to R1's wounds. V8 was unsure if wound cultures were obtained but that V8 observed R1's wounds and they had slough and appeared infected. V8 stated when R1 came back to the hospital on 5/3/23, R1's wounds smelled awful and the worst V8 has ever seen. On 5/18/23 at 3:25pm, V2, Director of Nursing (DON) stated when R1 initially admitted to the facility on [DATE], R1 had fine mesh gauze impregnated with a blend of 3% Bismuth Tribromophenate and petrolatum to R1's wounds to R1's legs including R1's front left thigh, left posterior knee, left lower posterior leg and R1's right thigh. V2 stated those dressings were removed and replaced. V2 stated R1 could not tolerate facility staff holding R1's leg up to wrap, so V2 tried to do (internet search engine) search to find a dressing that would not stick to R1's wounds. V2 stated R1's leg wounds had some serosanguinous drainage but no odor and R1's wounds did not appear infected on 4/7/23. V2 stated, normally don't change (wound dressings) for 3-5 days but R1 did not have orders when R1 admitted to the facility and R1 did not have wound dressings to R1's back or any open areas. V2 stated V2 completed the assessment of R1's skin and R1 had wounds to the thigh, back of knee, but not R1's back. V2 stated V2 and an additional staff member who V2 was unable to identify slightly turned R1 over to get to R1's leg but that V2 did not complete a full skin assessment to R1's back. V2 stated R1 had orders for fine mesh gauze impregnated with a blend of 3% Bismuth Tribromophenate and petrolatum and that these orders were on R1's paperwork. V2 stated R1's electronic Clinical Physician Orders should document the wound care orders but do not. V2 stated V2 thought V2 put in R1's orders related to wound care/dressing changes, but (V2) working pretty late. V2 confirmed R1's wound care/dressing change orders were not entered in to R1's electronic medical record. V2 stated, looks like a partial skin assessment was completed when R1 readmitted to the facility on [DATE], but no detailed wound assessment. V2 stated V2 documented R1 had open burn wounds and asked staff (unsure of names of staff) to go back and document what staff found because V2 had other things to get done. V2 stated, Apparently I did not do a thorough (skin) assessment (on 4/7/23) if (V2) didn't see the wounds on (R1's) back.V2 stated V2 does not see documentation nor is V2 aware of any wound dressing changes being completed to R1's back while R1 was a resident at the facility.

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

Respiratory Care (Tag F0695)

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 ensure a resident received proper tracheostomy care to prevent the ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident received proper tracheostomy care to prevent the tracheostomy from becoming occluded and assist in respiratory infection prevention. This failure affects one of two residents (R1) reviewed for tracheostomy care on the sample of five. These failures resulted in R1 becoming hypoxic and requiring hospitalization. Findings include: R1's Hospital records document an Assessment and Plan dated 3/30/23 at 2:08pm, including R1 has a history of Heart Failure, Chronic Hypoxemic Respiratory Failure status post Tracheostomy in March 2020. This plan documents R1 requires continuous trach collar at 26%, titrate supplemental Oxygen to maintain Oxygen Saturations of 90-96%. R1's Progress Notes dated as follows document: 4/7/23 at 2:00pm document R1 admitted to the facility and that R1 has a tracheostomy (trach.) 4/10/23 at 11:15am - Noted to have frequent cough with return of thick mucous. Holds on to hard suction catheter device and R1 will self suction. R1's Hospital records document on 4/11/23 at 2:00pm, R1 just left a LTAC (Long Term Acute Care facility) after a year long admission. These records document R1 admitted to the facility 4 days ago (4/7/23) and has now been in the Emergency Department twice. This note documents R1 is hypoxic on trach collar to 89%-91% with copious trach secretions. R1's emergency room physician note dated 4/11/23 at 8:00pm documents R1 presents with excessive trach secretions, cough. This note documents R1's labs are concerning with an elevated [NAME] Blood Cell count, and a Chest X-ray consistent with Pneumonia. This note also documents R1 required 1 hour worth of suctioning and trach care upon arrival to the hospital and that R1 is critically ill. The Hospitalist Admit Note dated 4/12/23 documents R1 admitted to the hospital on [DATE] with a chief complaint of Respiratory Failure. This note documents R1 arrived to the emergency room hypoxic on 8L (liters). Tracheostomy noted to produce copious sputum. The chest X-ray was concerning for left basilar pneumonia. R1 reported R1's symptoms began about 8 days ago, last Monday. This note documents R1 has a tracheostomy XLT (Extra Length Tracheostomy) tube, 6.0mm (millimeter) ID (Inner diameter)/11.0mm OD (Outer Diameter) tracheostomy in place. R1 is coughing, producing purulent-appearing yellow mucus through tracheostomy. R1's lungs had mild diffuse adventitious lung sounds. This note documents R1 has Bilateral Pneumonia (likely bacterial) in a patient with significant risk for Aspiration Pneumonia, Acute on Chronic Hypoxic Respiratory Failure (increased work of breathing and Oxygen Saturation under 90% prior to arrival to the hospital) secondary to Pneumonia and Lactic Acidosis secondary to above. R1's Hospital Medical Records document a Pulmonary Tracheostomy Tube change procedure note dated 4/24/23 documents R1 had a size #6 XLT cuffed tracheostomy tube in place with the cuff deflated. R1 had a size #6 Cuffless XLT Tracheostomy tube placed on this date. These hospital records document problems with tracheostomy care and suctioning at the facility. These notes document to consider standing tracheostomy suction and care order at the time of discharge. R1's Treatment Administration Record (TAR) dated April 2023 documents R1 is to receive: Oxygen - Oxygen at 8 L (liters) per trach collar every shift with a Start Date of 04/07/2023 6:00pm. There is no documentation of humidification administration with the Oxygen. Trach: Site care - Remove dressing from under flange, cleanse outer cannula and skin daily with Normal Saline (NS) and gauze. Cleanse under cannula with cotton applicator and replace dressing under the flange, every shift with a start date of 4/8/23 at 6:00am. There is no documentation of the care of R1's inner cannula or if the inner cannula was disposable. Trach: May Suction Tracheostomy to maintain O2 (Oxygen) saturations, when coughing or excess secretions noted as needed for secretions with a start date of 4/7/23 at 3:12pm. R1's TAR dated May 2023 documents R1 is to receive: Oxygen - Oxygen at 8 L per trach collar every shift with a Start Date of 04/07/2023 6:00pm. There is no documentation of humidification administration with the Oxygen. Trach: Site care - Remove dressing from under flange, cleanse outer cannula and skin daily with NS and gauze. Cleanse under cannula with cotton applicator and replace dressing under the flange, every shift with a start date of 4/8/23 at 6:00am. There is no documentation R1 received this trach site care on this TAR. There is no documentation of the care of the inner cannula or if the inner cannula was disposable. Trach: May Suction Tracheostomy to maintain O2 sats, when coughing or excess secretions noted as needed for secretions with a start date of 4/7/23 at 3:12pm. There is no documentation of respiratory therapy evaluation/care by the facility's respiratory company. There is no documentation of emergency equipment located at R1's bedside, including ambu bag or replacement tracheostomy tube. On 5/10/23 at 7:50am, V12, R1's Family stated V12 spent hours at the facility every day. V12 stated one unidentified nurse (per V12, unable to know most names due to no name tags) used the flexible suction catheter and attempted to place it in R1's mouth and suction down R1's throat. V12 stated R1 put R1's hands up and panicked. V12 stated V12 told the nurse R1 could not be suctioned that way and told the unidentified nurse how to suction R1 but the nurse wound not deep suction R1. On 5/10/23 at 1:48pm, V11, Respiratory Therapy Supervisor stated V11 received report from V10, Respiratory Therapist on R1. V11 stated R1's tracheostomy was completely occluded upon arrival to the emergency room and that R1's rigged up tubing with blue cap contained hard, crusted build-up inside the tube. V11 stated due to the condition of the tracheostomy and dressing around the tracheostomy, the facility had not been providing tracheostomy care for R1 as R1 required. V11 stated R1's thick copious secretions were signs R1 was not receiving humidification for R1's tracheostomy and should have been. V11 stated R1's tracheostomy dressing was so stuck to R1's skin that it had to be soaked multiple times to be able to remove it from around R1's tracheostomy and R1's skin under the tracheostomy dressing was red/irritated. V11 stated R1's tracheostomy showed signs it was severely neglected by the facility. The facility's Tracheostomy Care policy dated 3/29/2019 documents tracheostomy care should be performed once per shift or as often as required to maintain patency of airway and minimize risk of infection. This policy documents to remove old tracheostomy dressing, and to change a disposable inner cannula daily. This policy also documents to replace the drain sponge behind the tracheostomy plate if being used.

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

Based on interview and record review, the facility failed to ensure urinary catheter care was completed for three of three residents (R1, R3, R4) reviewed for urinary catheters on the sample of five. ...

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Based on interview and record review, the facility failed to ensure urinary catheter care was completed for three of three residents (R1, R3, R4) reviewed for urinary catheters on the sample of five. Findings include: The facility's Catheter Care policy dated 3/15/23 documents catheter care is provided daily and as needed to all residents who have an indwelling catheter to reduce the incidence of infection. This policy documents staff are to wash their hands and apply clean gloves and wash the perineal area and if a male, retract the foreskin to wash around the urinary meatus. The facility's Intake and Output Measurement policy dated 3/20/23 documents the policy is to provide an accurate account of the resident's fluid intake and output. This policy documents to measure and record all intake and output including urine and drainage from catheter tubes. 1. R1's Physician's Orders dated 5/18/23 do not document orders for R1's urinary catheter or orders for urinary catheter care. R1's Care Plan Screen Admission/Baseline dated 4/7/23 documents R1 has a urinary catheter but does not document a plan of care related to R1's urinary catheter use. R1's Treatment Administration Records (TAR) dated April 2023 and May 2023 do not document R1 received urinary catheter care while at the facility. There is no documentation the facility was measuring and recording R1's urinary catheter output. On 5/18/23 at 3:25pm, V2, Director of Nursing stated urinary catheter care is to be completed every shift and as needed including emptying the urinary catheter bag once a shift and as needed. V2 stated the urinary catheter care completion is documented on the residents TAR and Certified Nursing Assistants (CNA's) have access to chart the amount of output from the urinary catheters. V2 stated V2 was unable to find documentation of amount of output from R1's urinary catheter or that R1 received urinary catheter care while at the facility. 2. R3's Care Plans dated 11/21/22 document R1 requires an indwelling urinary catheter for Urinary Retention. These care plans document R1's Urinary Catheter size as 18 french with a 30cc (cubic centimeters) balloon. These care plans document to complete urinary catheter care twice daily with soap and water, monitor/record changes in urinary output and empty urinary collection bag every shift and as needed. R3's Electronic Treatment Administration Records (TAR) dated April 2023 and May 2023 document R3 is to receive urinary catheter care every shift. These TAR's do not document R3 received urinary catheter care as follows: April 2023 TAR: Day shift: 4/6/23, 4/17/23, 4/18/23, 4/27/23, 4/28/23. Night shift: 4/6/23, 4/7/23, 4/13/23, 4/16/23, 4/20/23, 4/21/23, 4/27/23, 4/29/23, 4/30/23. May 2023 TAR: Day shift: 5/1/23, 5/6/23, 5/7/23, 5/10/23, 5/12/23. Night shift: 5/4/23, 5/12/23, 5/13/23, 5/14/23. There is no documentation the facility was measuring and recording R3's urinary catheter output. On 5/18/23 at 3:25pm, V2, Director of Nursing stated urinary catheter care is to be completed every shift and as needed including emptying the urinary catheter bag once a shift and as needed. V2 stated the urinary catheter care completion is documented on the residents TAR and Certified Nursing Assistants (CNA's) have access to chart the amount of output from the urinary catheters. V2 stated V2 was unable to find documentation of amount of output from R3's urinary catheter. 3. R4's Physician's Orders dated 4/4/23 document R4 is to receive urinary catheter care every shift. R4's Care Plans dated 4/4/23 document R4 requires an indwelling urinary catheter for a diagnosis of Multiple Sclerosis, Neurogenic Bladder and Pressure Ulcers. These care plans document staff are to complete urinary catheter care twice daily with cares with soap and water. These care plans also document to monitor intake and output every shift and to empty urinary catheter collection bag every shift and as needed. There is no documentation R4's urinary catheter collection bag is being emptied or that output from the urinary catheter is being monitored/documented. R4's Electronic Treatment Administration Records (TAR) dated April 2023 and May 2023 document R4 is to receive urinary catheter care every shift. These TAR's do not document R4 received urinary catheter care as follows: April 2023: Day shift: 4/10/23, 4/11/23, 4/13/23, 4/14/23, 4/18/23, 4/20/23, 4/21/23, 4/23/23, 4/25/23, 4/26/23. Night shift: 4/4/23, 4/6/23, 4/22/23, 4/26/23, 4/29/23. May 2023: Day shift: 5/1/23, 5/2/23, 5/3/23, 5/6/23, 5/8/23, 5/9/23, 5/10/23, 5/11/23, 5/12/23. Night shift: 5/6/23, 5/10/23, 5/13/23, 5/14/23. On 5/18/23 at 3:25pm, V2, Director of Nursing stated urinary catheter care is to be completed every shift and as needed including emptying the urinary catheter bag once a shift and as needed. V2 stated the urinary catheter care completion is documented on the residents TAR and Certified Nursing Assistants (CNA's) have access to chart the amount of output from the urinary catheters. V2 stated V2 was unable to find documentation of amount of output from R4's urinary catheter.

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 F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure residents admitted to the facility with orders for enteral tube feeding via gastrostomy tube received a comprehensive nutritional as...

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Based on interview and record review, the facility failed to ensure residents admitted to the facility with orders for enteral tube feeding via gastrostomy tube received a comprehensive nutritional assessment to ensure the type and amount of tube feeding formula and free water needs are appropriate for those residents. These failures affect two of two residents (R1, R5) reviewed for gastrostomy tube feeding on the sample of five. Findings include: 1. R1's Electronic Medical Record does not document the facility completed a comprehensive nutritional assessment for R1's nutritional requirements/needs for R1's enteral tube feeding and free water flush/administration while R1 was a resident at the facility. R1's Dietary Admission/Quarterly Evaluation dated 4/26/23 is incomplete. On 5/18/23 at 3:25pm, V2, Director of Nursing (DON) stated V13, Registered Dietician (RD) comes monthly for one or two days. V2 stated V13 was here last month, always at the end of the month. V2 stated V14, Dietary Manager (DM) reaches out to the V13, is my (V2's) understanding. V2 stated there is a form to fill out and sent to V14 who gives the information to V13. V2 stated V2 was unsure if that was completed and would check with V14 but did not provide documentation of the form for R1. V2 stated residents admitting to the facility who require gastrostomy tube feeding should be assessed by V13, RD within 24 - 48 hours of admission to the facility. V2 stated, I (V2) do not recall (V13) being notified for R1. 2. R5's Admission/readmission Nursing Evaluation dated 4/29/23 documents R5 has a gastrostomy tube to R5's abdomen. This evaluation documents R5 requires enteral feedings and that R5's enteral feeding formula as Jevity 1.5. R5's Electronic Medical Records do not document a comprehensive nutritional assessment/assessment for R5's enteral feeding/free water flushing needs. On 5/18/23 at 3:25pm, V2, Director of Nursing stated V2 didn't think V13, Registered Dietician (RD) had seen/completed an assessment for R5 and R5's enteral tube feeding requirements and free water flushes yet. The facility's Enteral Feedings policy dated February 2008 documents the facility is to provide commercially prepared product for enteral feedings when it has been determined oral feedings are not sufficient to meet physical requirements and enteral nutrition support is deemed appropriate. This policy documents the Dietician will monitor all diet orders for tube feedings and will recommend as appropriate, changes in product according to resident need. Tube feeding nutritional infromation when ordered continuous will be calculated by the RD on a 23 hour basis to allow for non-administration time required for daily cares. The fluid intake for the resident receiving tube feeding should be equivalent to the fluid needs as assessed by the Dietician. Fluid needs may not be met by product alone in which case water flus ordered my be recommended to meet the needs of the resident. A record of daily intake of the tube feeding and the flushes for the resident will be kept by the nursing department. A physician's order will be obtained for all infusion orders prior to initiation of feeding. Physician order for pre-medication and formula administration flushes will be sought.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents admitted to the facility with orders for enteral 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 ensure residents admitted to the facility with orders for enteral tube feeding via gastrostomy tube received orders specifying formula type and amount of feeding and free water flushes to be adminsitered. The facility failed to ensure residents were monitored for intake of enteral feeding formula and free water flushes. These failures affect two of two residents (R1, R5) reviewed for gastrostomy tube feeding on the sample of five. Findings include: 1. R1's Electronic Medical Record does not document the facility completed a comprehensive assessment for R1's nutritional requirements/needs for R1's enteral tube feeding and free water flush/administration while R1 was a resident at the facility. R1's Dietary Admission/Quarterly Evaluation dated 4/26/23 is incomplete. R1's electronic Clinical Physician Orders dated 5/18/23 document R1's orders including to flush R1's gastrostomy (g-tube) tube with 30mL (milliliters) of water before and after medications. These orders document R1's diet as NPO (nothing by mouth) and an order dated 4/26/23 for enteral feeding five times daily. These orders do not document orders for free water flush/administration. R1's Medication Administration Record (MAR) dated April 2023 documents R1 is to receive enteral tube feeding of Jevity 1.5 at 70mL per hour via g-tube with 600 (no unit of measurement documented) free water flush daily. There is no documentation of how many hours the Jevity feeding was to run/be administered, or total amount of Jevity that R1 was to receive or R1 actually received daily. There is no documentation for total amount of R1's free water flushes R1 received. R1's hospital medical records dated 4/11/23 document R1 was sent to the local emergency room for g-tube replacement. These hospital records document R1 is critically ill. R1's blood was drawn on 4/11/23 at 2:45pm with results as follows: Blood Urea Nitrogen (BUN) level 61 (Reference Range 8-26mg (milligrams)/dL (deciliter) Creatinine 1.76 (Reference Range 0.70-1.30mg/dL) and Sodium 159 Critical High (Reference Range 136-145). R1's laboratory report dated 4/11/23 at 5:25pm with results as follows: Blood Urea Nitrogen (BUN) level 62 (Reference Range 8-26mg (milligrams)/dL (deciliter) Creatinine 1.75 (Reference Range 0.70-1.30mg/dL) and Sodium 161 Critical High (Reference Range 136-145). R1's hospital medical records document R1 was transferred to an advanced level of care on 4/11/23. R1's hospital medical records document laboratory results dated [DATE] at 5:07am of BUN 17, Creatinine 0.75 and Sodium 140. R1's MAR dated May 2023 documents, Enteral Feed Order, five times a day for nutritional supplement bolus 290mL. This MAR does not identify type of tube feeding formula R1 was to receive. There is no documentation of how much free water R1 was to receive nor that R1 received free water per g-tube, only 30mL water flush before and after medication administration. R1's hospital emergency room physician notes dated 5/3/23 at 8:45pm document R1 looks dehydrated. This note documents R1's [NAME] Blood Cells and Sodium levels are elevated and R1's urine is positive for infection. This note documents R1's admitting diagnoses including Hypernatremia and Urinary Tract Infection. R1's Hospital Nursing Notes dated 5/3/23 9:55pm document R1's skin turgor poor. R1's Hospital report dated 5/4/23 documents R1's medical history including Type 2 Diabetes Mellitus, Chronic Combined Systolic and Diastolic Heart Failure, 3rd & 4th degree burns of multiple sites, Percutaneous Endoscopic Gastrostomy, Chronic Anemia and Surgical Skin Grafting. This report documents R1 presented to the emergency room by emergency medical services from the facility with complaint of weakness with V12, R1's family stating R1 had increased weakness for several days and R1 was having difficulty sitting upright in bed and using his arms. This report documents R1 receives tube feeding boluses five times daily, but that V12 is unsure if R1 has been receiving supplemental water flushes. This report documents R1 had Hypernatremia with a sodium level of 153 (no unit of measurement identified). This report documents R1's sodium level results were 150 (no unit of measurement identified) this morning after initiation of IV fluids and resuming tube feedings. This report documents to start free water flushes. On 5/18/23 at 3:25pm, V2, Director of Nursing (DON) stated V13, Registered Dietician (RD) comes monthly for one or two days. V2 stated V13 was here last month, always at the end of the month. V2 stated V14, Dietary Manager (DM) reaches out to the V13, is my (V2's) understanding. V2 stated there is a form to fill out and sent to V14 who gives the information to V13. V2 stated V2 was unsure if that was completed and would check with V14 but did not provide documentation of the form for R1. V2 stated residents admitting to the facility who require gastrostomy tube feeding should be assessed by V13, RD within 24 - 48 hours of admission to the facility. V2 stated, I (V2) do not recall (V13) being notified for R1. V2 stated it is the responsibility of the nurse caring for the resident who should be following up to make sure tube feeding orders are followed up on and accurate. V2 stated the residents medical records should document the total amount of tube feeding and free water administration each resident who receives enteral feeding and should be documented each shift. V2 stated V2 was unable to find documentation for R1's enteral tube feeding and free water administration amounts. 2. R5's Admission/readmission Nursing Evaluation dated 4/29/23 documents R5 has a gastrostomy tube to R5's abdomen. This evaluation documents R5 requires enteral feedings and that R5's enteral feeding formula is to Jevity 1.5. R5's Hydration Risk Screener assessment dated [DATE] documents hydration management planning is indicated with interventions to be implemented for hydration management including to refer R5 to V13, Registered Dietician for review/recommendations and for tube feeding review. R5's Electronic Medical Records do not document a nutritional assessment/assessment for R5's enteral feeding/free water flushing needs. R5's Clinical Physicians Orders dated 5/18/23 at 6:19pm document R5's orders including Enteral Feed one time a day, but the order does not identify what tube feeding formula R5 is to receive. There is no documentation of free water flush orders for R5 or that R5 is receiving any free water flushes. R5's Medication Administration Record (MAR) dated May 2023 documents R5 is to receive enteral feeding one time a day for Dysphagia 70cc (cubic centimeters) per hour. This MAR does not document what tube feeding formula R5 is receiving. There is no documentation R5 is receiving free water flushes. On 5/18/23 at 3:25pm, V2, Director of Nursing stated V2 didn't think V13, Registered Dietician (RD) had seen/completed an assessment for R5 and R5's enteral tube feeding requirements and free water flushes yet. V2 stated V2 thinks R5 is to have Jevity 1.5 enteral feeding formula. V2 stated, usually tube feeding administrations run over 22 hours a day with 2 hours where the tube feeding pump is shut off/not administering the tube feeding formula. V2 stated V2 is unaware of the amount of tube feeding formula R5 is to receive in a 24 hour period and that all that information should all be documented on each residents Medication Administration Record and Physicians Orders. V2 stated each resident receiving enteral tube feedings, should have an order specifying what tube feeding formula and total amount to be infused over a certain/prescribed time span. V2 stated free water flushes should be documented on the MAR too with documentation of actual amount administered. V2 stated V2 is unable to find documentation for R5's enteral tube feeding and free water administration amounts/totals. The facility's Enteral Feedings policy dated February 2008 documents the facility is to provide commercially prepared product for enteral feedings when it has been determined oral feedings are not sufficient to meet physical requirements and enteral nutrition support is deemed appropriate. The fluid intake for the resident receiving tube feeding should be equivalent to the fluid needs as assessed by the Dietician. Fluid needs may not be met by product alone in which case water flus ordered my be recommended to meet the needs of the resident. A record of daily intake of the tube feeding and the flushes for the resident will be kept by the nursing department. A physician's order will be obtained for all infusion orders prior to initiation of feeding. Physician order for pre-medication and formula administration flushes will be sought. The facility's Enteral Feeding Closed System Ready to Hang Product policy dated February 2008 documents the facility is to document information related to feeding on the flow record and/or Treatment Administration (TAR) or Medication Administration Records (MAR). The facility's Enteral Tube Feeding Bolus Procedure policy dated April 2007 documents the facility is to provide nutrition via gastrostomy tubes when ordered by a physician. This policy documents after the tube feeding formula is administered, the facility is to flush the tube with 30cc of water or per physician order. This policy documents the facility is to document information related to feeding on the flow record and/or TAR/MAR.

Apr 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 F0839 (Tag F0839)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a licensed health professional maintained an active nursing ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a licensed health professional maintained an active nursing license while working at the facility. This failure has the potential to affect all 81 residents in the facility. Findings include: The facility's Client Contract agreement between the facility and V3's (Agency Licensed Practical Nurse) Agency dated [DATE] documents: 2.2 Qualified Agency Employee(s). The required work experience, licensure and/or professional certification, and results of a background/criminal record check shall be confirmed by the Agency upon completing the necessary Pre-Assignment Screening. 3.2 Agency Employee Qualifications. All individuals providing services to Facility pursuant to this Agreement shall meet the following qualifications: 3.2.1 Licensure and Experience. All individuals providing services pursuant to this Agreement shall be licensed or certified, as appropriate, pursuant to the laws of the state of employment. 4.3. Documentation. a. Proof of current original license and appropriate certification in the state of temporary employment. On [DATE] V3's Licensed Practical Nurse (LPN) License lookup detail view on the Illinois Department of Financial and Professional Regulation website documents the following in regard to V3's LPN license: Status: Not renewed with last effective date [DATE] and an expiration date of [DATE]. V3's Time Sheets dated [DATE] through [DATE] documents V3 worked at the facility on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] through [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] for a total of 32 days after V3's LPN expired on [DATE]. On [DATE] at 10:00am, V2 Director of Nursing (DON) stated V3 worked at the facility as a LPN until the beginning of April. V2 stated they [facility] found out about V3 not having an active LPN license when the facility did not renew their contract with V3's agency. V2 stated V5 (Agency Client Manager) stated V3's inactive LPN license was discovered when V3 was going through the compliance process at the agency for job placement at another facility and V5 advised V2 of said finding. V2 stated the agency is responsible for checking agency staff licensing and certifications. On [DATE] at 10:55am, V6 Agency Corporate Compliance Officer stated V3 began V3's contract at the facility on [DATE] and V3's contract was extended twice. V6 stated the compliance process was started prior to V3 starting contract at the facility and V3's LPN license was active at that time. V6 stated V3 was going to take a contract at another facility to begin on [DATE], and V3 started the compliance process again at the beginning of April. V6 stated during that process, V3 was found to not have an active LPN license and when V3 was questioned about it, [V3] told us 'had thought she had renewed it.' We terminated [V3] at that time which was on [DATE]. The facility Midnight Census Report ([DATE]) documents 81 residents reside in the facility.

Apr 2023 4 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Quality of Care (Tag F0684)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to monitor and assess residents, timely identify and report changes in ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to monitor and assess residents, timely identify and report changes in condition, and follow physician's orders for two of four residents (R2, R3) reviewed for change in condition in the sample list of six residents. This failure resulted in R2 having multiple hospitalizations for dehydration and acute kidney injury, and R3 being hospitalized for six days with pneumonia. Findings include: 1.) R2's March 2023 Physician's Orders Summary documents: R2 admitted to the facility on [DATE]. R2's diagnoses include Dehydration, Acute Kidney Injury, Hypertension, Coronary Artery Disease with stable Angina Pectoris, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease Stage III, and systolic/diastolic Congestive Heart Failure. R2's Minimum Data Set (MDS) dated [DATE] documents R2 has moderate cognitive impairment, requires limited assistance of two staff for eating, and has not had complaints of difficulty or pain with swallowing. R2's Care Plan dated 2/1/23 documents R2 is at risk for altered nutritional status with an intervention to record meal intakes and report changes in R2's usual patterns. R2's laboratory results dated [DATE] at 12:47 PM documents R2's potassium was 3.4 and Creatinine (kidney function laboratory test) was 1.3. R2's January 2023 Food and Fluid Intake Sheet documents R2's meal intake varied between 50 % and 100 %, and two entries of 25 %. R2's fluid intake varied between 240 and 480 cc (cubic centimeters) per meal. R2's February 2023 Food and Fluid Intake sheet documents R2's meal intakes averaged between 0 and 50 %. R2 refused 24 meals and fluid intake for 7 meals between 2/1/23 and 2/22/23. R3's March 2023 Food and Fluid Intake Sheet documents R2 refused 14 meals between 3/1/23 and 3/8/23. R2's fluid intake recorded on 3/1/23 was 480 cc, on 3/3/23 was 240 cc, on 3/4/23 was 360 cc, on 3/5/23 was 240 cc, on 3/6/23 was 0, and 3/7/23 was 120 cc. There is no documentation in R2's medical record that V19 was notified of R2's poor fluid/meal intakes in February prior to being hospitalized on [DATE] and in March 2023 prior to being hospitalized on [DATE]. R2's February 2023 Medication Administration Record (MAR) documents R2 received the following: Bumetanide (Bumex) (diuretic) 2 mg (milligrams) by mouth twice daily from 2/1-2/21/23, on 2/24/23, and 2/26/23-2/27/23. Acetazolamide (diuretic) 500 mg by mouth twice daily, and Eplerenone (diuretic) 25 mg by mouth daily. R2's Nursing Notes document the following: On 2/22/23 at 11:00 AM R2's potassium level was 2.4 (low). V19 Physician evaluated R2 and ordered for R2 to be transferred to the local emergency room. On 3/1/23 at 12:05 AM R2 complained of chest pain, vomited, and was transferred to the emergency room. R2 returned at 7:50 AM with diagnosis of gastroenteritis, low potassium and elevated Troponin level. R2 was given intravenous potassium at the hospital. On 3/5/23 during 6:00 PM - 6:00 AM shift, R2 had poor intake, complained of chest pain, vomited a small amount and Nitroglycerine was administered. This note does not document that V19 was notified. On 3/8/2 during 6:00 AM - 6:00 PM shift, R2 complained of chest pain, V19 was notified, and R2 was transferred to the local hospital. R2's Progress Note by V19 dated 2/23/23 documents R2 had mental status change, loss of appetite, hypokalemia (low potassium), and dehydration. V19 advised to send R2 to the hospital. R2's Hospital Discharge summary dated [DATE] documents: R2 was admitted to the hospital on [DATE] and rehydrated by intravenous therapy, diuretics were held, and potassium was administered. This corrected R2's acute on chronic renal failure. R2 had acute dehydration that contributed to acute on chronic kidney failure with Creatinine (kidney function laboratory test) of 2.01 (high). R2's potassium was 2.6 (critically low). Discharge instructions include assessing diuretic therapy for acute hypokalemia cause, as R2's potassium has been corrected to 3.5 or higher (normal range), and orders for Bumetanide 2 mg by mouth once daily - hold if not eating/drinking. R2's After Visit Hospital Summary dated 3/2/23 documents: R2 was diagnosed with gastroenteritis and instructions to stay hydrated, take Zofran for nausea, and to follow up with R2's physician. Administer Zofran 4 mg (milligrams) by mouth as needed every 8 hours for nausea/vomiting for up to 15 doses. R2's March 2023 MAR does not document that Zofran was administered. This MAR documents Bumetanide was given daily from 3/2/23-3/8/23 and not held as ordered when R2's intake was poor and refusing meals between 3/1/23 and 3/8/23. There is no documentation in R2's medical record that R2's blood pressure was routinely monitored twice daily in February and March 2023. R2's Hospital History & Physical dated 3/8/23 documents: R2 presented with hypotension (low blood pressure) and Acute Kidney Injury likely secondary to dehydration. R2 received intravenous fluids for hydration and R2's diuretics were held. R2 reported having chest pain for the last week, nausea and vomiting, and pain with swallowing food. R2 reported avoiding drinking water due to the pain. R2 had previously admitted to the hospital for dehydration on 1/17/23. R2's blood pressure in the emergency room was 90/60. On 4/4/23 at 11:38 AM V10 Certified Nursing Assistant (CNA) stated in the beginning of March 2023, R2 was not eating/drinking very much, and the nurses and V2 Director of Nursing were aware. On 4/5/23 at 9:06 AM V16 CNA stated R2 had a poor appetite and fluid intake was poor in February and March 2023. R2 transferred R2's self when R2 first admitted , and then started sleeping a lot more and requiring a full mechanical lift to transfer. R2 had vomited last month on an unknown date. V16 reported R2's poor intakes and vomiting to an unidentified nurse. On 4/4/23 at 2:13 PM V2 Director of Nursing (DON) reviewed R2's February and March 2023 fluid/meal intakes and confirmed R2's refusals and poor intakes. V2 sated the nurses should have notified the physician of R2's poor appetite/fluid intakes. V2 stated R2 was transferred to the hospital on 3/2/23 for nausea/vomiting/diarrhea. V2 confirmed R2's 3/2/23 discharge instructions recommended to administer Zofran as needed for nausea/vomiting, and confirmed Zofran was not administered prior to V2's hospitalization on 3/8/23. At 4:52 PM V2 stated changes in condition and physician notification should be documented on an Assess Intervene Monitor for Wellness form or nursing note in the resident's medical record. V2 stated vital signs should be done twice daily and documented on a log kept in a binder at the nurse's station. On 4/5/23 at 8:11 AM V2 stated V2 was unable to locate documentation that V19 was notified of R2's poor fluid/meal intakes or vomiting on 3/5/23. On 4/5/23 at 10:47 AM V2 stated V2 was unable to locate any vital sign logs for R2 in February and March 2023. At 11:55 AM V2 stated the nurses should have followed the physician's order to hold Bumex when R2 had poor intakes. On 4/5/12 at 10:13 AM V19 Physician stated R2's potassium was 2.4 on 2/22/23. The facility notified V19 of R2's behaviors, but V2 does not recall being notified of R2's poor appetite and fluid intake. V2 would have ordered labs and intravenous fluids if needed if V19 was notified. R2 was seen in the emergency room on 3/2/23 for gastroenteritis. If R2 was not eating and had nausea/vomiting, the facility should not have given R2's diuretics which would make R2 dry as a bone. The facility should have held R2's diuretic and notified V19. Diuretics make a person even drier, especially if they are not drinking. V19 evaluated R2 on 2/23/23 and R2 did not look good. R2 looked dehydrated and had altered mental status. V19 instructed the facility to transfer R2 to the hospital. Lack of appetite with poor food/fluid intake and vomiting causes decreased potassium levels and affects kidney function. R2's hospitalizations definitely could have been prevented if the facility had notified V19 of R2's decreased intakes and vomiting. The nursing home staff should have followed the Bumex order to hold when R2's intakes were poor. The facility also should have been monitoring R2's blood pressures closes, as low blood pressure indicates dehydration. They should have been obtaining R2's vitals more frequently once R2's intakes were poor. 2.) R3's Hospital Discharge Summary documents R3 admitted to the hospital on [DATE] with Pneumonia and discharged on 3/13/23. R3 received aggressive antibiotic therapy, pulmonary toileting, and chest physiotherapy to help clear secretions. R3's Hospital Progress Note dated 3/6/23 documents R3's chief complaint was cough and increased difficulty breathing over the last 2-3 days. R3 had a loose sounding cough that R3 reported having for an unknown period of time. R3's Nursing Note dated 3/5/23 at 1:45 PM documents R3 was short of breath and lungs were coarse. The last recorded nursing note prior to 3/5/23 is dated 1/17/23. There is no documentation in R3's medical record that R3's lungs were assessed and vital signs obtained between 3/1/23 and 3/5/23. On 4/4/23 at 4:42 PM R3 stated R3 went to the hospital in March 2023 for pneumonia. R3 had a cough that started a few days prior to that, and then the nurses decided R3 needed to go to the hospital. On 4/4/23 at 12:01 PM V7 CNA stated a few days prior to R3 being hospitalized , R3 had a cough as if R3 was trying to clear phlegm. On 4/5/23 at 8:44 AM V13 CNA stated R3 had a cough, was short of breath, requested R3's oxygen be applied, and R3 was using a wheelchair instead of walking with a walker a few days prior to R3 going to the hospital on 3/5/23. V13 reported this to an unidentified nurse. On 4/5/23 at 11:33 AM V18 Medical Director/Physician stated: If a resident develops a cough, the nurse should examine the resident for fever, shortness of breath, assess lung sounds, and notify the physician so a Completed Blood Count and Complete Metabolic Profile (laboratory values) and chest x-ray can be ordered. On 4/4/23 at 4:52 PM V2 DON stated changes in condition and physician notification should be documented on an Assess Intervene Monitor for Wellness form or nursing note in the resident's medical record. V2 stated vital signs should be done twice daily and are documented on a log kept in a binder at the nurses' station. Vital signs are not documented in the resident's medical record routinely. On 4/5/23 at 11:55 AM V2 DON stated when a resident has a cough the nurses should assess lung sounds and pulse oximetry, and notify the physician. The facility's Notification for Change in Resident Condition or Status dated as revised 12/7/17 documents: The resident's physician will be notified when a resident has a change in physical/emotional/mental condition, a need to alter medical treatment and symptoms of infection. Information related to a resident's change in condition will be recorded in the resident's medical record.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to notify the physician of changes in resident condition ...

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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 notify the physician of changes in resident condition for three (R1, R2, R3) of four residents reviewed for changes in condition in the sample list of six residents. Findings include: 1.) On 4/4/23 at 8:20 AM V17 (R1's Power of Attorney) stated: V21 (R1's Family Member) visited R1 in late December 2022, assisted with dressing/incontinence care, and was concerned about R1's vaginal area. V21 reported this concern to V17 and V21 came in the next day to see R1. R1 had a grapefruit sized uterine/bladder/rectal prolapse and V17 transported R1 to the hospital. On 4/4/23 at 11:28 AM V9 CNA stated V9 noticed a golf ball sized, skin colored, cyst to the side of R1's inner labia. V9 reported this to unidentified nurses. At 1:37 PM V9 stated V9 noticed R1's cyst in the fall around August 2022. On 4/5/23 at 3:19 PM V15 CNA stated V15 assisted R1 with a shower in December 2022, and noticed what looked like a large, baseball sized hemorrhoid coming from R1's rectum. V15 reported this to an unidentified nurse. V15 had not noticed this previously during R1's showers. R1's December 2022 Physician's Orders document R1 has a diagnosis of Dementia with Behavioral Disturbances. R1's Shower/Abnormal Skin Report dated 12/29/22 signed by V15 Certified Nursing Assistant (CNA) documents R1 had redness to R1's bottom. The word hernia was written, and struck out with a line through it. There is no documentation in R1's medical record that R1's physician (V18) was notified of R1's perineal abnormalities noted in August and December 2022. R1's emergency room note dated 12/29/22 at 4:08 PM documents R1 presented with a bulge in the groin that has been present for an unclear amount of time. V17 (R1's Power of Attorney) reported that R1 has complained of pain down there for months. R1's Hospital History & Physical dated 12/31/22 at 7:18 AM documents gynecology was consulted to reduce R1's vaginal prolapse and a urinary catheter was inserted with a return of 1100 cc (cubic centimeters) of urine. On 12/29/22 at 5:14 PM R1's Creatinine (kidney function laboratory test) was 2.2 (high) and R1's Blood Urea Nitrogen (BUN) (kidney function laboratory test) was 26 (high). R1 needed arrangement for pessary placement (a vaginal device that supports the uterus/bladder/rectum). R1's Abdomen/Pelvis Computed Tomography dated 12/30/22 documents R1's bladder was distended and there was a 7.8 cm (centimeter) by 8.6 cm perineal mass that was suspicious for prolapse. The impression of these results are described as, Tricompartment severe pelvic organ prolapse inferior to pubococcygeal line, causing severe bilateral right greater than left hydronephrosis (excess fluid in kidney due to urine backup) and hydroureter (enlargement of ureter caused by blockage that prevents urine from d. R1's Hospital Physician Progress Note dated 1/3/23 at 5:14 PM documents R1 was admitted with severe tricompartment pelvic organ prolapse that resulted in bilateral nephrosis causing acute kidney injury (AKI) and urinary tract infection. R1's AKI had somewhat improved, and R1's BUN was 22 and Creatinine was 1.95 on 1/3/23 at 8:24 AM. R1 was discharged on 1/3/23. On 4/4/23 at 4:52 PM V2 Director of Nursing (DON) stated changes in condition and physician notification should be documented on an Assess Intervene Monitor for Wellness form or nursing note in the resident's medical record. V2 stated R1's family transported R1 to the gynecologist on 12/29/22. R1 admitted to the hospital and did not return to the facility. On 4/5/23 at 11:55 AM V2 stated V2 unable to locate any documentation regarding physician notification of R1's perineal abnormalities noted in August and December 2022. V2 was unable to locate any nursing notes for R1 between August and December 2022. On 4/5/23 at 1133 AM V18 Physician stated R1 had a history of vaginal bleeding, but does not recall that any recent vaginal problems were reported to V18 prior to R1's discharge from the facility in December 2022. R1 did not return to the facility. V18 was unsure of the reason for R1's discharge, but was told R1 admitted to another facility. 2.) On 4/4/23 at 9:02 AM 9:02 AM V7 and V8 CNAs entered R2's room and provided R2's incontinence care. R2 had a small/superficial open area on each buttock and one in the crease between R2's buttocks. V7 stated the wounds had developed within the last couple weeks. R2's Progress Note dated 3/27/23 recorded by V20 Cardiologist documents R2 reports that R2 has a sore on R2's buttocks. R2's April 2023 Physician's Orders and R2's Medication Review Report dated 4/5/23 do not document treatment orders for R2's buttock wound. There is no documentation that R2's buttock wound was reported to V19, R2's primary physician prior to 4/5/23. R2's January 2023 Food and Fluid Intake Sheet documents R2's meal intake varied between 50 % and 100 %, and two entries of 25 %. R2's fluid intake varied between 240 and 480 cc (cubic centimeters) per meal. R2's February 2023 Food and Fluid Intake sheet documents R2's meal intakes averaged between 0 and 50 %. R2 refused 24 meals and fluid intake for 7 meals between 2/1/23 and 2/22/23. R3's March 2023 Food and Fluid Intake Sheet documents R2 refused 14 meals between 3/1/23 and 3/8/23. R2's fluid intake recorded on 3/1/23 was 480 cc, on 3/3/23 was 240 cc, on 3/4/23 was 360 cc, on 3/5/23 was 240 cc, on 3/6/23 was 0, and 3/7/23 was 120 cc. There is no documentation in R2's medical record that V19 Physician was notified of R2's poor fluid/meal intakes in February prior to being hospitalized on [DATE] and in March 2023 prior to being hospitalized on [DATE]. R2's Nursing Note dated 3/5/23 during 6:00 PM - 6:00 AM shift, documents R2 had poor intake, complained of chest pain, vomited a small amount and Nitroglycerine was administered. This note does not document that V19 was notified. On 4/4/23 at 11:38 AM V10 Certified Nursing Assistant (CNA) stated in the beginning of March 2023, R2 was not eating/drinking very much, and the nurses and V2 Director of Nursing were aware. On 4/4/23 at 2:13 PM V2 DON reviewed R2's February and March 2023 fluid/meal intakes and confirmed R2's refusals and poor intakes. V2 sated the nurses should have notified the physician of R2's poor appetite/fluid intakes. At 4:52 PM V2 stated changes in condition and physician notification should be documented on an Assess Intervene Monitor for Wellness form or nursing note in the resident's medical record. On 4/5/23 at 8:11 AM V2 stated V2 was unable to locate documentation that V19 was notified of R2's poor fluid/meal intakes and vomiting on 3/5/23. At 9:00 AM V2 stated V2 was not aware that R2 had open wounds to R2's buttocks, and R2 had a buttock wound that healed in March. V2 confirmed when wounds are identified the physician should be notified to obtain a treatment order. On 4/5/12 at 10:13 AM V19 Physician stated R2's potassium was 2.4 on 2/22/23. The facility notified V19 of R2's behaviors, but V19 does not recall being notified of R2's poor appetite and fluid intake. R2's hospitalizations (2/22/23 and 3/8/23) definitely could have been prevented if the facility had notified V19 of R2's decreased intakes and vomiting. 3.) On 4/4/23 at 4:42 PM R3 stated R3 went to the hospital in March 2023 for pneumonia. R3 had a cough that started a few days prior to that, and then the nurses decided R3 needed to go to the hospital. On 4/4/23 at 12:01 PM V7 CNA stated a few days prior to R3 being hospitalized , R3 had a cough as if R3 was trying to clear phlegm. On 4/5/23 at 8:44 AM V13 CNA stated R3 had a cough, was short of breath, requested R3's oxygen be applied, and was using a wheelchair instead of walking with a walker a few days prior to R3 going to the hospital on 3/5/23. V13 reported this to an unidentified nurse. R3's Nursing Note dated 3/5/23 at 1:45 PM documents R3 was short of breath and lungs were coarse. The last recorded nursing note prior to 3/5/23 is dated 1/17/23. Thre is no documentation in R3's medical record that R3's physician was notified of any respiratory changes until 3/5/23. On 4/5/23 at 11:33 AM V18 Medical Director/Physician stated If a resident develops a cough, the nurse should examine the resident for fever, shortness of breath, assess lung sounds, and notify the physician so a Completed Blood Count and Complete Metabolic Profile (laboratory values) and chest x-ray can be ordered. On 4/4/23 at 4:52 PM V2 DON stated changes in condition and physician notification should be documented on an Assess Intervene Monitor for Wellness form or nursing note in the resident's medical record. On 4/5/23 at 8:11 AM V2 stated V2 was unable to locate documentation that R3's physician was notified of R3's cough prior to 3/5/23. The facility's Notification for Change in Resident Condition or Status dated as revised 12/7/17 documents: The resident's physician will be notified when a resident has a change in physical/emotional/mental condition, a need to alter medical treatment and symptoms of infection. Information related to a resident's change in condition will be recorded in the resident's medical record.

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 observation, interview, and record review the facility failed to provide incontinence care during toileting assistance ...

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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 incontinence care during toileting assistance for one resident (R3) of three reviewed for incontinence care in the sample list of 6. Findings include: R3's Minimum Data Set, dated [DATE] documents R3 has severe cognitive impairment, requires limited assistance of one staff person for toileting, and is frequently incontinent of urine and occasionally of bowel. R3's Hospital Discharge summary dated [DATE] documents R3 was admitted to the hospital on [DATE] and diagnosed with an acute urinary tract infection with Escherichia coli (bacteria commonly found in colon.) On 4/4/23 at 4:33 PM V14 Certified Nursing Assistant entered R3's room and offered to assist R3 with toileting. R3 walked to the bathroom and transferred onto the toilet. R3's incontinence brief was wet with a large amount of urine. V14 removed the brief and removed V14's gloves. V14 left the room to obtain a clean brief, and instructed R3 to pull the call light. V14 returned and applied a clean brief. R3 stood from the toilet and V14 instructed R3 to pull up R3's brief/pants. V14 did not cleanse R3's perineal area/buttocks. R3 had a small pea sized open area to R3's right inner buttocks. On 4/4/24 at 4:45 PM V14 confirmed V14 did not cleanse R3's perineal area. V14 stated V14 usually uses rags for cleansing during incontinence care. On 4/4/23 at 4:52 PM V2 Director of Nursing stated if the resident is incontinent, staff should cleanse the resident's perineal area during toileting. The facility's Perineal Cleansing policy with a reviewed date of December 2017 documents: Perineal cleansing is done to eliminate odor, prevent irritation/infection, and for the resident's self-esteem. Wash, rinse, and dry the pubic area, inner thighs, and frontal perineum followed by the peri-anal area after incontinence and prior to applying a clean brief.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

Based on interview and record review the facility failed to maintain complete and accurate medical records for four of six residents (R1, R2, R3, R6) reviewed for change in condition in the sample lis...

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Based on interview and record review the facility failed to maintain complete and accurate medical records for four of six residents (R1, R2, R3, R6) reviewed for change in condition in the sample list of six. Findings include: 1.) On 4/4/23 at 11:28 AM V9 CNA stated R1 noticed a skin colored golf ball sized cyst to the side of R1's inner labia, and V9 reported this to an unidentified nurse. At 1:37 PM V9 stated V9 noticed R1's labia cyst in the fall around August 2022. On 4/4/23 at 3:19 PM V15 CNA stated: V15 noticed what appeared to be a large, baseball sized, hemorrhoid coming out of R1's rectum while bathing R1 in December 2022. V15 had not noticed the hemorrhoid prior to that day and notified an unidentified nurse. R1's closed medical record was reviewed and did not contain any documentation of the labial cyst noted in August 2022 or nursing notes between August 2022 and December 2022. R1's Shower Sheet dated 12/29/22 and signed by V15 Certified Nursing Assistant (CNA) documents R1 had redness to R1's bottom. There is no follow up documentation regarding this, that R1's family transported R1 to the hospital, or the reason for the hospital transfer in R1's medical record. On 4/4/23 at 1:48 PM V2 Director of Nursing (DON) stated the nurses should be documenting when there are changes in resident's condition. V2 would like to see a nursing note charted at least monthly. At 2:13 PM V2 stated the nurses are not always good about documenting when they notify the physicians. On 4/5/23 at 8:11 AM V2 stated: R1 had vaginal bleeding in 2021 and V20 Social Services transported R1 to the gynecologist. R1 refused to get out of the vehicle to go inside to be evaluated. We involved the family about R1's gynecologist appointment. R1's family took R1 to the gynecologist in December 2022 and then R1 was transferred to the hospital. R1's family was not willing to take R1 to the gynecologist prior to December 2022. V2 has not been able to locate any documentation in R1's medical record of this information or any nursing notes between August 2022 and December 2022. At 11:55 AM V2 stated the facility has been having problems with locating medical records after corporate staff have thinned charts and when records are sent to storage. 2.) R2's Nursing Note dated 2/22/23 at 11:00 AM documents V19 Physician was in the facility, evaluated R2, and ordered for R2 to be sent to the hospital. R2's Nursing Note dated 2/23/23 6:00 PM-6:00 AM shift (no specific time) documents: R2 readmitted to the facility from the hospital. R2's Nursing Note dated 3/5/233 6:00 PM-6:00 AM shift (no specific time) documents R2 complained of chest pain and had vomited. Nitroglycerine was administered. R2's Nursing Note dated 3/7/23 6:00 AM-6:00 PM (no specific time) documents R2 complained of chest pain, R2's vitals were assessed, and V19 Physician was notified. R2's Nursing Note dated 3/8/23 6:00 AM-6:00 PM (no specific time) documents R2 was transferred to the hospital per V19's orders for complaints of chest pain. R2's medical record does not contain progress notes for V19's visits on 2/23/23 and 1/26/23, and V20 Cardiologist consult on 3/27/23. The facsimile cover sheets dated 4/5/23 documents these physician visit notes were sent to the facility on 4/5/23. R2's Cardiology Progress Note dated 3/27/23 documents: R2 was hypotensive (low blood pressure) due to decreased oral intake and diuretic use, monitor R2's blood pressure closely and monitor for signs of hypervolemia (fluid retention). R2's medical record does not document vital signs were routinely monitored twice daily in February, March, and April 2023. On 4/4/23 at 1:48 PM V2 DON stated the nurses should be documenting a time on their nursing notes, and agency nurses think they can enter a shift for their nursing note entry time. On 4/4/23 at 4:52 PM V2 DON stated vital signs should be documented twice daily, but they aren't always completed. Vitals are recorded on a log kept in a binder at the nurse's station and not in the resident's medical record. On 4/5/23 at 11:55 AM V2 confirmed R2's physician visit notes from 1/26/23, 2/23/23, and 3/27/23 were not in R2's medical record prior to 4/5/23 when the facility contacted the physicians' offices to request copies of these records. 3.) R3's March 2023 Physician's Orders and April 2023 Medication Review Report lists R3's physician as V18. R3's Nursing Note dated 3/5/23 at 1:45 PM documents R3 was short of breath and lungs were coarse. The last recorded nursing note prior to 3/5/23 is dated 1/17/23, and there is no documentation that R3 had a cough noted prior to 3/5/23. R3's Nursing Note dated 4/3/23 6:00 AM-6:00 PM (no specific time) documents R3 had a change in skin to left buttocks that measured 0.2 centimeters by 0.5 centimeters, the physician was notified and order was received to apply barrier cream twice daily and as needed. This order was not transcribed to R3's Treatment Administration Record or Physician's Orders. On 4/4/23 at 4:42 PM R3 stated R3 went to the hospital in March 2023 for pneumonia, and R3 had a cough that started a few days prior to that. R3 stated R3's bottom started hurting a few days ago, a nurse and CNA assessed R3 and found an open sore. R3 stated staff have been applying cream to the area, but none was applied today. On 4/4/23 at 12:01 PM V7 CNA stated a few days prior to R3 being hospitalized , R3 had a cough as if R3 was trying to clear phlegm. On 4/5/23 at 11:33 AM V18 Physician stated: R3 is not V18's patient. Sometimes the facility has V18 listed incorrectly in the medical record as a resident's physician and V18 has to tell the facility to correct it. On 4/5/23 at 10:47 AM V2 DON confirmed there are no documented treatment orders and treatment administrations for R3's buttock wound on April 2023 Treatment Administration Records and Physician's Order Summaries. At 11:55 AM V2 stated R3's physician is V19. 4.) R6's Nursing Note dated 3/14/23 6:00 AM-6:00 PM (no specific time) documents R6 was lethargic and hard to arouse during morning medication administration, and had some facial asymmetry noted. R6's physician and family were notified and R6 was transferred to the local hospital. On 4/4/23 at 1:48 PM V2 DON stated the nurses should be documenting a time on their nursing notes, and agency nurses think they can enter a shift for their nursing note entry time. The facility's General Rules of Charting/Documentation dated as revised January 2005 documents: Every entry must have the date (month, day and year), time, and your signature following the entry. Chart all pertinent changes in the resident's condition. Frequency of progress note charting: a. New Admission/re-admission: progress noted per facility policy (minimum of 72 hours). b. Change in resident's status: mental/physical, every shift until stabilized, 24 hour minimum. c. New problem identified: every shift until resolved or stabilized. d. Routine notes: per facility policy regarding Medicare, etc. (etcetera) However, every resident must have a note by a licensed nurse at least monthly. Any vital signs other than monthly are to be documented in the nurse's notes.

Mar 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report and notify the Administrator and Director of Nursing about i...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report and notify the Administrator and Director of Nursing about injuries of unknown origin for two resident (R2, R3) of three residents reviewed for Injury of Unknown Origin in the sample of three. Findings include: 1.) R3's Physician Order Sheet (POS) dated 3/1/23 through 3/31/23, documents R3's diagnoses as Dementia with Behavioral Disturbances, Depression, Behavioral Disturbances with Aggression, and Alzheimer's Dementia with Behavioral Disturbances. R3's Minimum Data Set (MDS) dated [DATE], documents R3 is severely cognitively impaired. R3's Care Plan dated 10/2/2022, documents R3's behaviors include combative with care, aggression and disregard for personal space. R3's Shower/Abnormal Skin Report dated 3/1/23, documents scratches on right arm. There is no documentation in R3's medical record of the scratches being reported to V1 Administrator or V2 Director or Nursing. R3's Nurse's Notes dated 1/19/23 at 11:00 PM, documents R3 was walking down the hallway and R3's right arm was bleeding, nurse asked R3 what happened and R3 was unable to answer. There is no documentation in R3's medical record of this being reported to V1 Administrator or V2 Director of Nursing. R3's Nurse's Notes dated 3/6/23 at 3:30 PM, document V16 Alzheimer's Unit Director told V17 Licensed Practical Nurse (LPN) that R3 was noted to have a bruise to the forehead. V17 LPN documented V17 asked R3 what happened but R3 was unable to recall. There is no documentation in R3's medical record of this being reported. On 3/29/23 at 3:20 PM, V2 Director of Nursing (DON), stated, the nurses did not fill out the correct paperwork for injuries of unknown origin as per policy so therefore V2 was not aware of resident injuries. V2 stated the nurses are supposed to complete a skin occurrence form when an injury is found on a resident that is of unknown origin. 2.) R2's Physician's Order Sheets dated 3/1/23 through 3/31/23 documents diagnoses including Hypertensive Disorder, Coronary Arteriosclerosis, Carotid Artery Stenosis, Osteoporosis, Dyspnea on Exertion, Acute Congestive Heart Failure, Chronic Kidney Disease Stage 3, Hypothyroidism and Diabetes Mellitus Type 2. R2's Minimum Data Set, dated [DATE] documents R2 has severely impaired cognition. R2's Care Plan dated 9/6/22 documents R2 has fragile skin and is prone to bruising and/or skin tears with interventions for weekly skin checks, assess new areas for size and injury, report findings to the Physician and family as indicated and to investigate the causes of injury/bruise/skin tear. R2's Shower/Abnormal Skin Report dated 3/16/23 by V11 Certified Nursing Assistant documents a bruise with a circle around the drawing of the entire upper right arm. This report is signed by V12 Registered Nurse. R2's Shower/Abnormal Skin Report dated 3/19/23 by V10 Certified Nursing Assistant documents two bruises to the upper right arm with two separate circles on the drawing of the upper right upper arm. This report is signed by V3 Registered Nurse. R2's Nurse's Progress Notes do not document any progress notes after 3/14/23. There is no documentation regarding the 3/16/23 or 3/19/23 bruises. On 3/29/23 at 3:00 PM, V3 confirmed that V3 signed R2's Shower/Abnormal Skin Report dated 3/19/23. V3 stated that V3 assumed the bruises on R2's right upper arm were from blood draws. V3 stated V3 did not report the bruises. On 3/29/23 at 3:46 PM, V10 confirmed that V10 documented a new bruise on the shower sheet dated 3/19/23 and confirmed that V10 reported the bruise to V3. On 3/30/23 at 10:45 AM, V2 Director or Nursing confirmed that R2's bruises on the right upper arm were never reported to V2 therefore they were never investigated. The facility's Abuse Prevention Program Policy dated Revised 11/28/2016, documents the nursing staff is responsible for reporting on a facility incident report the appearances of bruises, lacerations, other abnormalities, or injuries of unknown origin as they occur; upon report of such occurrences the nursing supervisor is responsible for assessing the resident, reviewing the documentation and reporting to the administrator or designee.

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) eight hours a day, seven days a week. This failure has the potential to affect all 84 reside...

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Based on interview and record review the facility failed to provide the services of a Registered Nurse (RN) eight hours a day, seven days a week. This failure has the potential to affect all 84 residents in the facility. The findings include: On 3/30/23 at 10:00 AM, V1 Administrator in Training provided the Nursing Daily Assignment Sheet for 3/25/23. This assignment sheet does not document a Registered Nurse working on 3/25/23. On 3/30/23 at 11:20 AM, V1 provided daily time punches for 3/25/23 which do not document any Registered Nursing hours. On 3/30/23 at 11:31 AM, V2 Director of Nursing confirmed there was no Registered Nurses working on 3/25/23. The facility's Matrix for Providers printed on 3/29/23 documents the facility has one resident on a ventilator that is currently in the hospital, two residents with Intravenous therapy and one resident with parenteral tube feeding. On 3/30/23 at 12:00 PM, V2 confirmed the facility has two residents that receive dialysis. The Facility Assessment with a review date of May, 2022 documents the facility has 123 Licensed beds with 35-55 skilled care residents and 12-20 Dementia Unit residents. This Assessment documents Facility Staff Needs (hours per day) of Licensed Nurses providing direct care should be 44-57 hours. This Assessment also documents, The Facility will be staff(ed) according to residents needs and required staffing guidelines and considerations of continuity of care. The facility's Resident Roster (Nurse Midnight Census) dated 3/28/23 documents 84 residents reside in the building.

Feb 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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide bathing as per plan of care for one of three r...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide bathing as per plan of care for one of three residents (R1) reviewed for bathing on the sample of four. Findings include: R1's Care Plans dated 9/9/22 document R1's diagnoses including Acute Respiratory Failure, Heart Failure, Diabetes Mellitus, Anemia, Acute Kidney Failure and Obesity. These Care Plans document R1 requires assist with Activities of Daily Living (ADL's) of one to two staff members. R1's Minimum Data Set (MDS) dated [DATE] documents R1 requires extensive assistance of one staff member for bathing. This MDS documents R1 is cognitively intact and rejection of care as not exhibited for R1. The facility's shower schedule documents R1 is to receive a shower on day shift 6:00am-2:00pm on Tuesday and Fridays. This schedule documents if showers are not completed on the shift as scheduled, the next shift is responsible to complete the left over showers. R1's Shower/Abnormal Skin Report sheets do not document R1 received a bath/shower on 1/10/23, 1/13/23, 1/20/23 or 1/27/23. There is no documentation R1 was offered or received a bath on 2/7/23 as scheduled. On 2/9/23 at 10:00am, R1 noted to have scattered red areas of skin to R1's upper chest area. R1 stated R1 is supposed to receive showers/bed baths on Tuesdays and Fridays but R1 only receives one about once a week. R1 stated when R1 does not have a bed bath, R1's skin gets itchy and red. R1 stated there have been times in the past when R1 had not received a bed bath/shower and staff had documented R1 had. R1 stated R1 was to receive a bed bath on 2/7/23 but did not, even after mentioning to the facility it was bath day. R1 stated R1 has not received a bath in a week. On 2/9/23 at 12:20pm, R1 stated 2/2/23 was the last time R1 received a bath. The facility's Shower Book contains an undated sheet titled Showers. This sheet documents to fill out shower sheets. This sheet documents instructions that three aides with three different attempts and one nurse signature are required for resident refusals. This sheet documents residents who are cognitive must sign the refusal.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

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 a residents respiratory equipment was kept off ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a residents respiratory equipment was kept off the floor, and failed to ensure respiratory suction tubing was stored to prevent cross contamination. The facility also failed to provide tracheostomy site care as ordered. These failures affect one of three residents (R1) reviewed for respiratory care needs on the sample of four. Findings include: R1's Physician's Orders dated February 2023 document R1's diagnoses including Respiratory Failure with Hypoxia or Hypercapnia, Morbid Obesity, Diabetes, Chronic Kidney Disease, Obstructive Sleep Apnea and Chronic Diastolic Heart Failure. These orders document R1's treatment orders for R1's tracheostomy (trach) including to change R1's trach monthly and as needed and that R1's trach is sutured in place. These orders document the facility is to provide tracheostomy site care every shift. R1's Care Plans dated 10/4/22 document R1 has a tracheostomy and requires Oxygen. These care plans document the facility is to perform trach care every shift and change R1's trach monthly with aseptic technique. R1's Treatment Administration Record (TAR) dated January 2023 does not document R1's trach was changed as ordered. This TAR does not document R1 received tracheostomy care each shift as ordered the following dates/shift: 6:00am-6:00pm shift - 1/13/23, 1/14/23, 1/15/23, 1/16/23, 1/19/23, 1/20/23, 1/21/23, 1/22/23, 1/23/23, 1/24/24, 1/26/23, 1/27/23, 1/28/23, 1/29/23 R1's TAR dated February 2023 does not document R1 received tracheostomy care each shift as ordered on the following dates/shifts: 6:00am-6:00pm shift - 2/1/23, 2/2/23, 2/3/23, 2/4/23, 2/5/23, 2/7/23. 6:00pm-6:00am shift - 2/1/23, 2/2/23, 2/3/23, 2/4/23, 2/5/23, 2/6/23, 2/7/23. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact. On 2/9/23 at 10:00am, R1 stated the facility does not provide trach care every shift like they are supposed to. R1 stated R1 has not had R1's trach changed out since coming to the facility in September 2022. R1 stated sometimes R1's condensation collection bag attached to R1's humidifier tubing ends up resting/in the garbage can and sometimes on the floor. At this time, R1's condensation collection bag attached to R1's humidifier tubing was laying on the floor. R1's suction tubing attached to R1's suction canister was laying uncovered on R1's nightstand. ON 2/9/23 at 1:40pm, V2, Director of Nursing stated R1 has not had R1's tracheostomy changed since admitting to the facility. V2 stated the respiratory care company is to do that although it has not yet been changed per R1's Physician's Orders. V2 stated the facility should be ensuring R1's humidifier tubing is kept off the floor and R1's suction tubing is to be kept in a plastic bag when not in use. V2 stated the facility is to document on the treatment record that treatments have been completed. The facility's Tracheostomy Care policy dated 3/29/2019 documents tracheostomy care should be performed once per shift or as often as required to maintain patency of the airway and minimize the risk of infection.

Jan 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify residents open dates of insulin bottles 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 identify residents open dates of insulin bottles and failed to identify expiration dates of insulin bottles. This failure affects two(R1,R2) of six residents reviewed for insulin administration in the sample list of six. Findings include: R1's Physician Order Sheet (POS) dated [DATE] through [DATE], documents R1's diagnoses as: Diabetes Mellitus, Diabetic Retinopathy, and Diabetic Neuropathy. These same orders document Novolog insulin 100 units/milliliter (ml) 10 ml inject 8 units subcutaneous (sub-Q) twice a day with lunch and dinner at 12:00 PM and 6:00 PM for diagnosis of Diabetes Mellitus. These orders also document Levemir Flextouch 100 units/ml inject 18 units sub-Q every bedtime for diagnosis of diabetes mellitus. R1's Care Plan dated [DATE], documents R1 has an alteration in metabolic function related to Diabetes Mellitus. R1's Minimum Data Set (MDS) dated [DATE], documents R1 as moderately cognitively impaired. R2's POS dated [DATE] through [DATE], documents Novolog 100 units/ml 10 ml inject 9 units sub-Q with breakfast, 8 units sub-Q with lunch, and 7 units sub-Q with supper all for a Diabetes diagnosis. This same POS documents Lantus pen 100 units/ml 3 ml inject 25 units sub-Q at bedtime for a diagnosis of Diabetes. R2's Care Plan dated [DATE], documents R2 has an alteration in metabolic function related to Diabetes Mellitus diagnosis. R1's MDS dated [DATE], documents R2 as moderately cognitively impaired. On [DATE] at 11:52 AM,V5 RN was going to give R2 insulin,V5 pulled out the insulin for R2 and when asked V5 the open date for the insulin, V5 stated [DATE]. V5 stated V5 was not sure if it was 30 days (for expiration), so V5 asked V4 RN who stated 28 days. V5 stated this bottle is not good let me get another bottle. V5 was asked if V5 was going to use the expired insulin and V5 stated yes, I would have used it if we hadn't checked the dates. On [DATE] at 1:00 PM, V4 was going to give R1 Novolog insulin and when asked what the expiration date was on the Novolog insulin bottle, V4 stated [DATE]. V4 stated the Novolog insulin was expired and that V4 was going to give the insulin if not asked what the expiration date was. On [DATE] at 1:18 PM, V2 Director of Nursing (DON) stated the insulin should either be marked as given on the MAR(medication administration record) or signed off on the back of the MAR to indicate why it was not given, initials and signatures from the nurses on the MAR indicate the insulin was given. V2 DON stated V2 goes by 28 days to use insulin once opened for pens and vials. Regarding R1, V2 stated R1 refused R1's insulin 50/50 of the time, when R1 refused, it should be circled on the MAR and written refused on the back of the MAR sheet and fax the back of the sheet to the doctor and make a note it was faxed to the doctor. On [DATE] at 10:15 AM, V7 pharmacy consultant stated Novolog insulin pen or vial is good for 28 days after being opened. V7 stated if Novolog is used after the expiration date of 28 days after being opened, it could start to loose it's potency if used. V7 stated Lispro insulin is also good for 28 days after it is opened and the same applies to Lispro as Novolog that is could start loosing it's potency if used. The facility's Subcutaneous Injections (Insulin/Heparin) dated Reviewed [DATE], documents the policies and procedures of the facility are not intended to replace sound clinical judgement of health care or to replace prevailing standards of care.

ARCADIA CARE WATSEKA

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ARCADIA CARE WATSEKA

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