AXIOM HEALTHCARE OF WEST FRANKFORT
For profit - Corporation
96 Beds
AXIOM HEALTHCARE
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
0/100
#460 of 665 in IL
Photo by Patrick Grubbs
Photo by Patrick Grubbs
Photo by Google Street View
1 / 5 photos
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Axiom Healthcare of West Frankfort has received a Trust Grade of F, indicating poor quality and significant concerns regarding its care. It ranks #460 out of 665 nursing homes in Illinois, placing it in the bottom half, and #3 out of 4 in Franklin County, meaning there is only one local option that is better. Unfortunately, the facility is worsening, with issues increasing from 17 in 2024 to 24 in 2025. Staffing is a significant concern here, with a low rating of 1 out of 5 stars and a high turnover rate of 65%, which is notably above the state average of 46%. Additionally, the facility has incurred $157,866 in fines, higher than 82% of Illinois facilities, suggesting repeated compliance issues. There are serious incidents reported, including a critical failure to provide appropriate treatment alternatives for a resident, which led to an emergency room visit due to possible allergic reactions. There was also an instance of mental and verbal abuse by a staff member towards a resident, resulting in significant emotional distress. Lastly, a resident fell while unsupervised in the smoking area, requiring emergency medical attention for lacerations, indicating ongoing safety and supervision problems. Overall, while there may be some strengths in the facility, the numerous deficiencies and critical incidents raise serious concerns for families considering this nursing home for their loved ones.
- Trust Score
- F
- In Illinois
- #460/665
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 65% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $157,866 in fines. Lower than most Illinois facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 23 minutes of Registered Nurse (RN) attention daily — below average for Illinois. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 59 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 31%
Review needed
17 → 24 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 17 issues
2025: 24 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Illinois average (2.5)
Significant quality concerns identified by CMS
Staff Turnover: 65%
19pts above Illinois avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $157,866
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: AXIOM HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (65%)
17 points above Illinois average of 48%
The Ugly 59 deficiencies on record
2 life-threatening 3 actual harm
Sept 2025
13 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, record review the facility failed to provide supervision during smoking to prevent an accident ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review the facility failed to provide supervision during smoking to prevent an accident and failed to provide an appropriate intervention to prevent future falls for 1 of 15 residents (R27) reviewed for accidents in a sample of 48. This failure resulted in R27 falling outside in the designated smoking area and then having to be sent out to the emergency room for laceration on her left and right arm and having to be seen by a wound care specialist. Findings include:
R27's admission Record dated 09/10/25 documents an admission date of 06/06/25 with diagnoses of history of falling, tobacco use, type 2 diabetes mellitus with diabetic neuropathy, unspecified sequelae of nontraumatic intracerebral hemorrhage.
R27's MDS (Minimum Data Set) dated 08/18/25 documents in Section C a BIMS (Brief Interview for Mental Status) score of 13 which indicates R27 is cognitively intact. Section GG documents walk 10 feet as supervision and touching assistance, walk 50 feet with two turns as supervision and touching assistance, and walk 150 feet as supervision and touching assistance.
R27's Care Plan with a revision date of 06/10/25 with a focus area of Risk for falls which has a goal of resident will be free of falls. Interventions for this focus include 08/04/25 Fall intervention updated to include maintenance supervisor to fix concrete in courtyard, 06/06/25 determine residents' ability to transfer, 06/06/25 ensure call light is available to resident, 06/06/25 evaluate fall risk on admission and PRN (as needed), 06/06/25 if fall occurs, alert provider, and 06/06/25 if fall occurs, initiate frequent neuro and bleeding evaluation per facility protocol.
R27's witnessed fall report dated 08/03/25 document's incident location: Outside, Nursing Description: Nurse visualized pt (Patient) laying on back outside on floor, skin tear to the left wrist, left forearm, right forearm with blood present applied pressure to the skin tear to stop bleeding. Pt voiced no pain in lower extremities, no inverting turn to feet. VS (Vital Signs) obtained other nurse called appropriate persons. Pt sent to (Local Hospital) with bed hold policy. Resident Description: Patient stated she was trying to get out of the way of another pt when she tripped and lost her balance. Pt stated she did not have pain in lower extremities, but her arms were a 10/10. Injuries observed at time of incident: laceration left forearm, skin tear left wrist, and skin tear right forearm.
A statement taken by V2 (Director of Nursing) from V24 (Certified Nurse Assistant/CNA) dated 08/03/25 documents under statement: “I was passing cigarettes to the residents and heard yelling. I saw (R27) on the concrete next to the railing holding her arm saying I was trying to get out of his way.”
R27's hospital discharge records from local hospital dated 08/03/25 documents her diagnosis as other skin changes- large skin tears bil (Bilateral) forearm left greater than right. Special notes document leaves covered, until you can get an appt (appointment) with pcp (Primary Care Physician) or wound care. R27's hospital records document that R27 was sent back to the facility with a prescription for Doxycyline Hyclate (antibiotic) every 12 hours and Hydrocodone-Acetaminophen (pain medication) every 6 hours for pain control.
R27's hospital records for a visit on 8/5/25 document, “Pt (patient) states, “I was trying to move away from somebody yesterday and I was kind of knocked over and I fell and I hit the concrete my body and scraped my arms real bad. They sent me to (Name of local ER). Today my arm just won't stop bleeding so they sent me back in.” These records document Final diagnoses as skin tear of left upper extremity and hand swelling.
R27's wound assessment and plan from the wound care doctor dated 08/05/25 documents right forearm wound measurement 4 cm (centimeter) length X 5 cm width X 0.1cm depth and left forearm wound measurement: 10 cm length X 6.5 cm width X 0.1cm depth.
On 09/09/25 at 9:40AM, R27 stated on 08/03/25 that she was walking outside down the ramp to go smoke with all the smokers. R27 said she had her rolling walker and was holding on to the rail to go down the ramp. R27 stated she was trying to go down that ramp when she saw R10 who had already gone down the ramp and was coming back her way, R27 said she was trying to get out of his way because he doesn't pay attention, and he will run you down. R27 said that she was trying to get out of his way and tried to back up, but his walker bumped into her walker, and she went back and fell. R27 said that R10 didn't stop he just kind of bumped her as he went past, and she was on the ground bleeding. R27 said that she had large skin tears to both of her arms from the fall and that there was blood all over. R27 said that she was yelling out in pain. R27 said that the staff had her sit up on her wheeled walker and was trying to get the bleeding to stop. R27 stated that she did not trip or fall over any cracks or broken concrete. R27 stated she heard that R10 bumped into another resident the next day she didn't know who it was. R27 said that her wounds on her arms were so bad she had to have a wound doctor take care of them and they talked about a wound graft to the left arm, but they didn't have to do a graft. R27 said that the wounds to her arms are just now starting to heal. R27 stated that she doesn't feel safe around R10 when they go out to smoke.
R10's admission Record dated 09/10/25, documents an admission date of 05/11/21 with diagnoses schizophrenia, need for assistance with personal care, anxiety, depression and nicotine dependence.
R10's MDS dated [DATE] documents in Section C a BIMS score of 11 which indicates R10 has moderately impaired cognition. Section GG documents walk 10 feet as supervision or touching assistance, walk 50 feet as supervision and touching assistance, and walk 150 feet as supervision and touching assistance.
R10's Care Plan has a focus area of Tobacco use with a revision date of 04/24/25 with a intervention in part of: The resident requires supervision while smoking with a date initiated of 05/10/25. Another focus is: The resident has a history of being impatient during smoke breaks when he is waiting in line to enter/exit building r/t (related to) poor impulse control with a revision date of 09/09/25 with interventions in part of: The resident's triggers for impatience are during smoke breaks when entering/exiting the building d/t (due to) becoming impatient with peers. Resident is educated on single file line with peers wanting to enter/exit also and that cutting in line is not allowed. Resident educated at each smoke break time to reduce aggression revision on 09/09/25, Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of resident posing danger to self and other with a date initiated of 08/20/24, and when the resident becomes agitated: Intervene before agitation escalates: Guide away from source of distress: Engage calmly in conversation: If response is aggressive, staff to walk calmly away, and approach later revision on 09/09/25.
On 09/09/25 at 10:58AM, R10 stated he has bumped into several residents before when going outside for his designated smoke break. R10 stated that it is his fault sometimes when he bumps into other residents and other times it is the other resident fault. R10 stated he remembers R27 falling outside on one of their designated smoke breaks. R10 said that the resident doesn't get out of his way. R10 said that when R27 fell she was yelling and bleeding all over. R10 said that he doesn't know who all he has bumped into at the facility. R10 said that when he goes out to smoke, they try to make him last in the line. R10 said that he doesn't know why he must be last that is just what they told him at the facility.
On 09/09/25 at 11:30AM observed R27 right and left arm. R27 had an area to her left forearm which appeared to be approximately 10cm long and around 7 cm wide with some redness noted, along with areas that appeared to be scar tissue and raised. R27's right forearm arm had an area which appeared to be scar tissue no open area noted areas appears to be approximately around 5cm in length.
On 09/08/25 at 3:00PM, R26 who was alert and oriented stated she is a smoker, and she was outside on the designated smoke break when R10 fell. R26 stated R10 was trying to hurry up and get his cigarette and R27 was coming down the ramp and that R27 was trying to get out of the way of R10 and R27 backed up and fell. R26 stated that R10 just went over and bumped R27 as she was laying on the ground. R26 stated that a nurse has her write a statement about what happened on 08/03/25 with R27's fall. R26 stated that R10 is always in a hurry and doesn't look where he is going and bumps into everyone. R26 said R10 has bumped into her before.
On 09/09/25 at 10:38AM, R3 who was alert and oriented stated that she is a smoker and that she was outside on 08/03/25 when R27 fell. R3 stated that R27 was coming down the ramp to go outside to smoke and that R10 was going to run over R27 with his rolling walker so R27 was trying to get out of the way and fell. R3 said after R27 fell that R10 plowed right over her. R3 stated that R10 has bumped into her with his rolling walker and caused a skin tear to her leg. R3 said that R10 is always in a hurry to be the first out to smoke and he wants to get his cigarettes first. R3 said that she thought he has bumped into another resident legs and caused a skin tear.
On 09/09/25 at 10:46AM, R28 who was alert and orientated stated that she is a smoker and goes out for the designated smoke breaks. R28 stated she remembers when R27 had her fall outside on 08/03/25. R28 stated R27 was trying to get out of the way of R10 so he didn't run her over. R28 stated she is not sure if R10 bumped her or pushed her causing the fall. R28 said R10 is always in a hurry to get outside to smoke and will pass all the residents up on the ramp and try to get outside first. R28 stated that she knows that R10 has bumped into a couple of residents while trying to get outside to smoke. R28 could not remember who all R10 has bumped into.
On 09/09/25 at 2:25PM, R4 who was alert and oriented at that time stated that she does go outside to smoke. R4 stated that she thought a guy bumped into her when she was outside smoking but couldn't remember who it was. R4 stated that she didn't know if she got a skin tear or not from the guy bumping into her.
On 09/08/25 at 3:00PM, V16 (Licensed Practical Nurse/LPN) stated that R27 fell on [DATE]. V16 said that she wasn't outside when R27 fell but that she heard that R27 was trying to get out of the way of R10 and that R27 fell and received skin tears to both arms. V16 said that she was taking witness statements to help the agency nurse out because residents were saying R10 bumped into R27.
On 09/08/25 at 3:13PM, V1 (Administrator) stated that R27's accident on 08/03/25 when R27 fell outside on the designated smoking break was because R27 was trying to back up out of R10's way and then she fell.
On 09/08/25 at 3:31PM, V22 (Agency LPN) stated that R27 fell outside on her designated smoke break on 8/3/25. V22 stated that when R27 fell outside she caused skin tears to both arms that were bleeding bad and that she had to send R27 out to the local hospital.
On 09/09/25 at 11:55AM, V25 (Social Service Director) stated that she has only worked at the facility for around month. V25 said that R10 must go last in the line when they are going out on the designated smoke breaks. V25 stated that when she started working at the facility that is what they told her, she didn't remember who told her. V25 said she doesn't know why they didn't make him the first person to go out because he is always in a hurry to get outside and smoke. V25 said that R10 gets in hurry and tries to get down the ramp as fast as he can. V25 stated that when she takes the residents outside for their designated smoke breaks, she has heard several residents talking about how R10 has bumped into them, but she has never had any of those residents come to her complaining about it. V25 said she tries to wait to pass out the cigarettes to the residents until all the residents are outside so she can make sure all the residents get outside first safely.
On 09/09/25 at 2:33PM, V28 (MDS/Care Plan Nurse) stated that R10 use to have a focus area on the Care Plan about his impulse control of getting in a hurry to go outside and smoke. V28 stated that she resolved that focus area on the care plan because she went back and looked at the social service notes and nurses' notes and did not see any more concerns with R10 rushing to get outside to smoke. V28 stated the last incident that R10 had with getting into a hurry was back on 03/11/25 when R10 was in a hurry to get out and bumped someone with his rolling walker. V28 said that she was putting the focus area back on R10's care plan today about him having impulse control and getting in a hurry to smoke. V28 said that the reason she was putting the focus area back on his care plan is because she was told today that R10 was rushing and getting in front of people to get outside.
On 09/09/25 at 3:46PM, V21 (Maintenance Director) stated that he did repair some concrete out in the designated smoking area. V21 stated that he didn't know why he must repair the area. V21 said that the concrete around the smoking area did have a few cracks, and it had a dip in one of the areas and he filled it the best he could. V21 said that he didn't know if some of the wheels on the wheelchairs were getting stuck on the cracks or what. V21 said that the cracks and the dip are on the patio part not by the handrail. V21 said that he doesn't remember if he got a work order about it or if he was just told about the cracks.
On 09/09/25 at 3:51PM, V1 stated that when R27 fell outside in the designated smoking area they talked about her fall in their daily meeting. V1 said they were trying to figure out how R27 fell so they went outside to the designated smoking area and found some cracks in the concrete, and they thought those could be a fall hazard, so they had V21 repair the cracks. V1 said that she doesn't know why R10 is last coming when they take the residents out on their designated smoke breaks, but she is currently doing an in-service with staff about taking residents out to smoke and monitoring for behaviors when they are outside smoking along with being mindful about what is going on outside when the residents are smoking.
On 09/10/25 at 11:02AM, V2 (Director of Nursing) stated on 08/03/25 R27 was trying to get out of the way of R10 when she fell. V2 stated that the staff member who was outside supervising when R27 was R24. V2 said that R24 said in her statement that she was passing out cigarettes when R27 fell, and she heard her yelling. V2 said that R24 should not have passed out any cigarettes until she had made sure that all the residents made it out to the smoking area and was able to observe all resident when they smoked. V2 said that she thought fixing the cracks in the concrete was an appropriate intervention for R27's fall, because she thought it said somewhere that R27 fell because of the cracks.
On 09/09/25 at 3:45 PM there were six residents outside smoking with nine residents lined up making their way out the door to the smoking area. R10 was in line to go out to the smoking area. R10 would shuffle his feet pushing his walker forward coming within approximately an inch of hitting the resident in front of him and then would move backwards almost stepping into the resident behind him. This action continued until R10 was in the outside area.
The facility policy titled “Fall Prevention Program” with a revision date of 11-21-17 documents the purpose as: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Guidelines include in part: Methods to identify risk factors.
The facility policy titled ‘Safe Smoking and Vaping Policy/Procedure” with a last update date of 09/10/25 documents under policy: The facility works to provide appropriate care for residents, keeping safe and comfort in mind. Residents may have the desire to smoke/vape, and accommodations will be provided as the facility deems appropriate. The facility treats the use of vaping products the same as traditional smoking products. Procedure documents in part: 3. The rules are as followed # 3. Conduct while smoking must promote safety. #4. No negative behaviors related to smoking are permitted. B. The timeframes above are the only times smoking materials may be distributed. Continued disruption of resident care responsibilities over smoking break times constitutes a violation of the “No negative behaviors related to smoking are permitted.”
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 ensure residents were free from mental abuse for 1 of 15 residents (R34) reviewed for abuse in a sample of 48. Findings include:R34's admiss...
Read full inspector narrative →
Based on interview and record review the facility failed to ensure residents were free from mental abuse for 1 of 15 residents (R34) reviewed for abuse in a sample of 48. Findings include:R34's admission record documents an admission date of 08/27/25 with diagnoses including: chronic obstructive pulmonary disease with acute exacerbation, acute embolism and thrombosis of femoral vein, enlarged lymph nodes, diverticulitis, nicotine dependence, erythema intertrigo, depression, and anxiety disorder. R34's care plan documents a focus area of: I am at risk for abuse/neglect. Date initiated 8/27/25. Goal, I will be cared for in a safe manner and verbalize to staff any incidences of abuse. Date initiated 9/2/25. Interventions include, Assess resident for risk for risk of abuse, educate resident to speak to staff if feeling uncomfortable with a situation, ensure safety if feeling unsafe, observe resident in care situations, observe resident in company of peers, report any verbalization of abuse or neglect to administrator immediately. All initiated 8/27/25. A report sent to IDPH regarding an incident involving R34 dated 09/05/25 documents: Description of Occurrence: Alleged report of staff to resident verbal abuse. This alleged incident occurred on August 30, 2025 but was reported to the Administrator this morning, September 2, 2025 at approximately 9:00 am after a full investigation, it was determined that a staff member (V30, Certified Nursing Assistant/CNA) was showing other staff members a picture of a character from a TV show. This image was meant to make fun of the resident for his appearance and intelligence. The resident observed this staff member showing the image and pointing then laughing at him. The resident did not know what the image was but felt that the staff member was making fun of him and this humiliated him. Follow up/Report Summary: Investigation included interviews with the staff members that this staff member showed the image to on her cell phone. It was determined that no other residents were aware of this incident as it occurred. When interviewing the staff member, she acknowledged the incident but claimed she was not making fun of the resident. It was then determined that this was an incident of mental abuse and the staff member was terminated from her employment. In-services were conducted with all staff of residents' rights and dignity. On 09/08/25 at 1:48 PM, V43 (Family) stated that R34 was currently in the hospital. V43 stated that R34 told her the staff at the facility were making fun of him. V43 stated R34 was upset that he was being mocked. V43 stated, one of the workers also got onto him for sitting next to the dining room. V43 stated, R34 was mortified when they were making fun of him and he does not want to return to the facility.On 09/09/25 at 1:11 PM, V42 (Dietary) stated, V30 did show a picture on her phone in the dining room of the character named Bubbles from the show Trailer Park Boys stating the new guy R34 looked like Bubbles from the show. V30 did show the picture to several people. V42 admitted some would not take it as a compliment to be compared to Bubbles from that show. On 09/09/25 at 3:10 PM, V29 (Activities Director) stated she was in the dining room when V30 was showing the picture of Bubbles on her phone to others stating she thought R34 looked like the character. V29 stated, Bubbles is a character from the show Trailer Park Boys. V29 stated, she could see where some would not take that as a compliment to be compared to Bubbles from that show. V1's written statement dated 09/02/25 documents: Resident (R34) stated the female caregiver was showing other staff members her phone and pointed at him, then she laughed Resident (R34) stated he did not know what was on the phone but he felt humiliated. V45's (CNA) written statement dated 09/03/25 documents: (V30) walked up to me in the hallway to show me a picture of Bubbles from Trailer Park Boys and said, Doesn't he look like Bubbles talking about (R34).V30's written statement dated 09/02/25 documents: On Saturday (08/30/25) we were in dining serving breakfast and (R34) said something and I said it reminded me of Bubbles off of a TV show. (V36) asked who that was so I pulled up a picture. I was not making fun of him. Simply said it was funny and reminded me of that person on that show.The facility policy dated 12/17/21 titled, Abuse Prevention and Reporting - Illinois documents: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to report and allegation of staff to resident abuse to the state agency (Illinois Department of Public Health) and failed to report an allegati...
Read full inspector narrative →
Based on interview and record review the facility failed to report and allegation of staff to resident abuse to the state agency (Illinois Department of Public Health) and failed to report an allegation of staff to resident abuse to the Administrator for 1 of 15 residents (R4) reviewed for abuse and neglect in the sample of 48. The Findings include:1. R4's admission record dated 09/12/25 documents an admission date of 12/07/22 with diagnoses in part of major depressive disorder, overactive bladder, panic disorder, pelvic and perineal pain, personal history of malignant neoplasm of cervix, weakness, and need for assistance with personal care. R4's MDS (Minimum Data Set) dated 06/18/25 documents in Section C a BIMS (Brief Interview for Mental Status) score of 06 which indicates R4 has severely impaired cognition. Section GG documents toileting as dependent. R4's Care Plan a focus area with a date initiated of 03/06/25 of Behavior Management with an intervention in part of toilet resident routinely and upon request. If resident requests are continuous remind her of the last time she was toileted. Another focus area with a date initiated of 04/04/24 document, at risk for Abuse with intervention in part of investigate statements/allegations per facility protocol. Check resident for any physical marks, injury, interview personal assigned to provide care and notify abuse care coordinator of any abuse allegation immediately. R4's progress notes dated 07/22/25 at 8:20AM completed by V3 (Assistance Director of Nursing) documents, This nurse was alerted by V29 (Activity Director) that resident was accusing V34 (transportation) during breakfast of stating, I will take you to your bedroom and beat your ass. The resident then told other staff members that the person that made the statement was V33 (Certified Nurse Assistant/CNA). This nurse notified V1 (Administrator) and V2 (Director of Nursing) of accusation. This nurse spoke with V33 (CNA), V34 (Transportation), V35 (CNA), and V37 (CNA), and V36 (CNA). These staff members stated that the statements were never said, and they were simply trying to explain to the resident that they were in the middle of breakfast and would take her back to her bedroom after breakfast. The nurse gave V1 all the statements. On 09/04/25 at 11:02AM, R4 stated that she knows someone was mean to her in the dining room and that they told her that she couldn't go to the bathroom. R4 stated that she doesn't remember who it was that told her that or when it was. On 09/03/25 at 4:05 PM, V38 (Vice President of Operations) stated, (after reading the behavior note for R4 dated 07/22/25 at 8:20 AM) yes that incident should have been reported and investigated.On 09/04/25 at 9:27AM, V1 (Administrator) stated that she did not send in an investigation into IDPH regarding the allegations made by R4. V1 stated that she did not get any statement from resident on 07/22/25. 2. On 09/03/25 at 4:03 PM, R4 stated she did have a problem with a staff member who put shampoo on her head and then let the shampoo run into her eyes. R4 stated, at first, she thought it was a man, but it was a female staff member. R4 said she did not know the staff member's name. R4 said the female staff member let the shampoo run into her eyes and it was burning, and she wouldn't wash it out. R4 stated that she felt like the staff member did this on purpose, because she wouldn't wash the shampoo out of her eyes, she just left it there. R4 said she did tell one of the staff about it, but she couldn't remember who it was she told it to. R4 said that it upset her a lot and she said that this took place several weeks ago. On 09/09/25 at 1:05 PM, V18 (Certified Nurse Assistant/CNA) stated on 07/19/25 she heard R4 yelling out from the shower room. V18 stated, V32 was giving R4 a shower and she could hear R4 yelling from the break room. V18 stated, she walked into the shower room and could see V6 (CNA) standing in the corner while V32 (CNA) was giving R4 a shower. V18 stated, R4 had soap all over her face and she was yelling that her eyes were burning and V32 kept telling R4 that she was fine. V18 stated, V32 never offered to rinse the soap out of R4's eyes or give R4 a towel. V18 stated, V32 just kept telling R4 she was fine and to get over it. V18 said R4 just kept saying it burns and yelling out. V18 said she looked over at V6 who was just standing there rolling her eyes. V18 stated, she reported this to V27 (Agency Licensed Practical Nurse). V18 stated, R4 also told V27 what happened.On 09/03/25 at 4:41 PM, V27 (Agency Licensed Practical Nurse) stated, the first night she worked, R4 was screaming during the shower she was given, R4 was screaming to the point she walked down to check on them. The CNA's (V9 and V32) giving R4 the shower stated, oh, her (R4) screaming is just her behavior and waved her off. V27 stated, she did not report this to V1 because she did not know the resident's behaviors and the other nurse working V16 (LPN) knew about the situation. V27 stated, she did not hear R4 yelling at any other time unless she needed something and her call light was not in reach.On 09/09/25 at 3:51PM, V1 (Administrator) stated no one ever told her about the incident with V32 and R4 in the shower until it was reported to her by IDPH. V1 stated that V18, V27, nor V16 (Licensed Practical Nurse) ever said anything about this incident, and they all have her cell phone number. V1 stated V18 is a disgruntled employee and she never reported anything to her. V1 said she investigated the incident and that V32 did get soap in R4's eyes not on purpose and that they did wipe out her eyes right away. V1 said that R4 does have a behavior of yelling out often. V1 stated that she would not think of V32 to do anything like that to leave soap in R4's eyes.The facility policy titled Abuse Prevention and Reporting with a revision date of 10/24/22 documents in part, Internal Reporting Requirements and Identification of Allegations: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately. In the absence of the administrator, reporting can be made to an individual who has been designated to act as administrator in the administrator's absence. Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Department of Public Health immediately, but not more than two hours after the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to thoroughly and timely investigate an allegation of staff to resident abuse for 1 of 15 residents (R4) reviewed for abuse in a sample of 32 ...
Read full inspector narrative →
Based on interview and record review, the facility failed to thoroughly and timely investigate an allegation of staff to resident abuse for 1 of 15 residents (R4) reviewed for abuse in a sample of 32 Findings include:1. R4's admission record dated 09/12/25 documents an admission date of 12/07/22 with diagnoses in part of major depressive disorder, overactive bladder, panic disorder, pelvic and perineal pain, personal history of malignant neoplasm of cervix, weakness, and need for assistance with personal care. R4's MDS (Minimum Data Set) dated 06/18/25 documents in Section C a BIMS (Brief Interview for Mental Status) score of 06 which indicates severely impaired cognition. Section GG documents toileting as dependent. R4's Care Plan a focus area with a date initiated of 03/06/25 of Behavior Management with an intervention in part of toilet resident routinely and upon request. If resident requests are continuous remind her of the last time she was toileted. Another focus area with a date initiated of 04/04/24 document, at risk for Abuse with intervention in part of investigate statements/allegations per facility protocol. Check resident for any physical marks, injury, interview personal assigned to provide care and notify abuse care coordinator of any abuse allegation immediately. R4's progress notes dated 07/22/25 at 8:20AM completed by V3 (Assistance Director of Nursing) documents, This nurse was alerted by V29 (Activity Director) that resident was accusing V34 (transportation) during breakfast of stating, I will take you to your bedroom and beat your ass. The resident then told other staff members that the person that made the statement was V33 (Certified Nurse Assistant/CNA). This nurse notified V1 (Administrator) and V2 (Director of Nursing) of accusation. This nurse spoke with V33 (CNA), V34 (Transportation), V35 (CNA), and V37 (CNA), and V36 (CNA). These staff members stated that the statements were never said, and they were simply trying to explain to the resident that they were in the middle of breakfast and would take her back to her bedroom after breakfast. The nurse gave V1 all the statements. On 09/04/25 at 11:02AM, R4 stated that she knows someone was mean to her in the dining room and that they told her that she couldn't go to the bathroom. R4 stated that she doesn't remember who it was that told her that or when it was. On 09/03/25 at 4:05 PM, V38 (Vice President of Operations) stated, (after reading the behavior note for R4 dated 07/22/25 at 8:20 AM) yes that incident should have been reported and investigated.On 09/04/25 at 9:27AM, V1 (Administrator) stated that she did not send in an investigation into IDPH. V1 stated that she did not get any statement from resident on 07/22/25. V1 said that R4 has behaviors of yelling out often. V1 said that they did talk to a couple of the staff working that day and take statements from the them asking them if V34 told R4 that she was going to beat her ass. V1 said that V34 (Transportation) was just telling R4 that she was already in the bathroom before she went to the dining room for breakfast, because R4 was yelling out in the dining room that she had to go to the bathroom. V1 said that R4 has a behavior of saying she has to go to the bathroom and doesn't go. V1 said the facility has taken R4 to several doctor's appointments regarding her asking to go to the bathroom all the time. V1 stated that V33 (CNA) had taken R4 to the bathroom, before she came into the dining room. V1 stated that R4 did go to the bathroom with V33 (CNA). V1 stated on the witness statement it does say that V33 (CNA) stated don't argue with her she is always right meaning R4 and directed to R4. V1 said V33 (CNA) should not have said that to R4. V1 said that was V33's way of dealing with the situation. V1 stated that V33 (CNA) should have taken R4 to the bathroom again instead of telling her she already went even though it is a behavior. V1 said that yes it does say in the care plan when the resident request to go to the bathroom they should take her. V1 stated that R4 is not on a scheduled toileting program.On 09/09/25 at 3:51PM, V29 (Activity Director) she did report to the nurse on 07/22/25 that R4 was making allegations regarding V33 (CNA) and V34 (Transportation) saying that they were going to beat her ass. V29 stated that she did not hear V33 (CNA) or V34 (Transportation) make any statement about beating R4's ass. On 09/10/25 at 11:02AM, V2 (Director of Nursing/DON) stated that she wasn't working on 07/22/25 when the allegation was made regarding V33 (CNA) and V34 (Transportation) regarding making negative comments. V2 stated that she was not aware of the allegation until recently. V2 stated that V33 (CNA) should have taken R4 to the restroom when she requested. On 09/12/25 at 8:10AM, V34 (Transportation) stated that she worked on 07/22/25 and that she was passing trays in the dining room when R4 started yelling out that she had to piss. V34 said that R4 was getting really loud and disrupting the dining room. V34 stated that she told R4 that she had just got up and went to the bathroom. V34 stated she was trying to talk to R4, but she just kept yelling out that she had to piss and started to cuss at all the staff. V34 said she thought that R4 was on a toilet every two hours toileting schedule. V34 told R4 that she was on a every two-hour toileting schedule. V34 said that she told R4 that she has taken her to all her doctor appointment regarding her feeling like she has to go pee all the time and they haven't found anything. V34 said when she was talking to R4 that she just kept yelling and getting louder. V34 was just trying to talk to her so she would calm down. V34 stated she was not aware of what R4 alleged she said. V34 stated they did take a statement from her on 07/22/25. V34 stated that she was not suspended on 07/22/25 when the allegation was made.A statement dated 07/22/25 no time by V34 documents, To whom it concerns, I V34 was in the dining room serving breakfast as resident R4 was repeatedly asking to go to the bathroom when V33 (CNA) said to res (Resident), you just got up and would have to wait until after breakfast. R4 kept asking and started arguing and that's when I stated to res R4 that I've taken her to all her medical appts (appointments) for her bladder and they have found nothing medically wrong so you will have to wait as everyone is on a 2-hour bathroom schedule. R4 proceeded to say how everyone here is a bitch and it isn't fair- that's when I walked away.On 09/12/25 at 8:21AM, V33 (CNA) stated on 07/22/25 when she was in the dining room passing out trays that R4 was yelling out saying that she had to piss. V33 said that R4 was getting really loud and yelling out in the dining room. V33 stated she told R4 that she had just got up and just got into the dining room and had already gone to the bathroom. V33 said she was trying to talk to R4, but she just continued to yell and getting louder and then R4 stated calling us names. V4 said that that no matter what we did that R4 wasn't listening to us. V33 stated that she did tell R4 that she is right that she is always right. V33 said that she was told the resident is always right. V33 said that it was probably not the most appropriate thing to say to R4. V33 stated that she didn't know who toileted R4 before they brought her into the dining room, she stated that she was not the one who toileted her that day. V33 said that it was 2 other staff she didn't remember who and they told her that R4 just went to the restroom before they brought her in the dining room. V33 stated that she was not suspend on 07/22/25 when the allegation was made. A statement dated 07/22/25 at 7:00AM by V33 documents, I (V33) was in dining room passing trays R4 was asking to go to bathroom. I told her she just got up and would have to wait until after breakfast. She started arguing and I said don't argue with her she's always right and walked away. A report to IDPH Regional Office completed by V1 on 9/6/25 documented, an incident date of 07/22/25 under Description of Occurrence: It was reported to this Administrator this afternoon that there was alleged abuse incident between two staff members and R4. Follow up /Final Summary documents: After a full investigation with interview with staff and residents. There were no findings that any verbal abuse had taken place. There was a documented incident that occurred on 07/22/25. The administrator had spoken to the resident that morning about the interaction between the resident and both of the staff members. Both staff members were also in-serviced by the administrator and the DON on interaction and redirection with residents. All other staff members were also in-service on redirection and interaction with residents. On going in-services will continue with all staff members. The Administrator also was in-serviced by the VP (Vice President) of operations regarding reporting any type of allegation made to the Department of Public health. The Administrator was also in-serviced on the process and procedure of reporting incidents. The two staff members were able to return to work after the full investigation was completed. The facility policy titled Abuse Prevention and Reporting with a revision date of 10/24/22 documents, Internal Investigation, All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation. Investigation Procedures: the appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents. Residents to who the accused had regularly provided care, and employees with who the accused has regularly worked, will be interviewed to determine whether any one has witnessed any prior abuse, neglect, exploitation, mistreatment or misappropriation of resident property by the accused individual.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to respect the resident rights to have an environment that promotes maintenance and enhancement of his or her quality of life for 40 of 40 resi...
Read full inspector narrative →
Based on interview and record review the facility failed to respect the resident rights to have an environment that promotes maintenance and enhancement of his or her quality of life for 40 of 40 residents (R1, R2, R3, R4, R5, R6, R7, R8, R10, R11, R12, R13, R15, R16, R17, R18, R19, R21, R23, R24, R25, R26, R27, R29, R30, R31, R32, R33, R35, R38, R39, R40, R41, R42, R43, R44, R45, R46, R47, R48) that live on the north and south halls reviewed for resident rights in a sample of 48. The findings include: R3's Transfer/Discharge report dated 08/28/25 documents an admission date of 06/12/24 with diagnoses in part of bipolar disorder, delusional disorder, major depressive disorder, schizophrenia, borderline personality disorder, anxiety, and need for assistance with personal care. R3's MDS (Minimum Data Set) dated 06/30/25 documents in Section C a BIMS (Brief Interview Mental Status) score of 15 which indicates cognitively intact. R3's Care Plan documents a focus area of I have increased agitation; restlessness with a date initiated 06/10/25 with an intervention in part of offer resident quiet, calming environment in which to voice cause of agitation to staff.
On 08/28/25 at 11:35AM, R3 stated that staff gets loud and fights a lot on evening shift and yells and screams at each other in front of the residents.
On 09/09/25 at 1:15 PM, V18 (Certified Nurse Assistant/CNA) stated that on 07/20/25 she was working on evening shift with V32 (CNA) who got upset over the staffing assignment. V18 said that V32 came down the hall cussing and yelling at her about the staffing assignment. V18 said she told V32 that she didn't make the staffing assignment up and to take it up with the nurse who was working. V18 stated that she tried to walk down the hallway and V32 was blocking the hallway and wouldn't let her get passed. V18 said that she finally did get passed V32 then V32 came running down the hallway after her yelling and cussing. V18 said that it was getting so bad that V32 was yelling at her around the nurses' station as well. V18 said that V39 (CNA) another staff member came into work. V18 said she went to get food and went to shut the door to the break room and that V39 came in asking V18 what her problem was. V18 said she went to shut another door and that V39 came in and asked her why she was slamming doors and V18 said that she told V39 she wasn't and that V39 told her she was weird. V18 said they have their own group on evening shift, and she wasn't in their group. V18 said that V27 (Agency Licensed Practical Nurse/LPN) told V18 to just stay on her hall and try to stay away from V32 and V39. V18 said that V32 and V39 just kept harassing her and that V27 called V1 (Administrator) and V2 (Director of Nursing/DON) about how V32 and V39 was acting towards V18. V18 said V32 came up to the nurses' station yelling at her and that V27 had to tell her to stop. V18 stated that it just continued and that she finally didn't feel safe at work and that the nurse called someone and asked if she could go home. V18 said she was given approval to go home, and she was waiting for her ride outside and that V32 and V39 both leaned outside of the facility and told her to leave and don't fu**ing come back b***h.
On 09/09/25 at 2:50 PM, V29 (Activity Director) stated that she was working as weekend manager one weekend she said she usually works around 4 hours. V29 said that she could hear staff yelling and screaming at each other. V29 said that she went to see who it was she said that it was V32 (CNA) and V18 (CNA). V29 said V18 told her that she was in a resident's room and that V32 came down to that resident room and was jumping all over her about the staff assignment. V29 said V18 told her that V32 was blaming her for upsetting other staff V24 (CNA) and V9. V29 said that she went and talked to V24 and V9 asking them if V18 had done anything to upset them and they stated no. V29 said that V24 was a little upset not at V18 but overall, the drama at the facility. V29 said that V24 left and that is when V39 came into work. V29 said V18 told her that she was going into a room and that she shut the door with her foot because she has just put gloves on and that V39 opened the door and asked her why she slammed the door and V18 told V39 that she did not slam the door and then V39 told V18 she is just weird. V29 said that V1 did know about V18, V32, and V39 yelling at each other and of the way they were acting in the facility.
On 09/03/25 at 4:41 PM, V27 (Agency Licensed Practical Nurse) stated, the second night she worked, the CNAs were yelling and screaming at each other down the halls. V32 (CNA) was following V18 (CNA) down the hall yelling at her. V32 was starting arguments with V18 because of the things that took place the night before. The CNA (V18) that was getting followed down the hall went home early because she didn't feel comfortable with the situation. V27 stated, she could hear them on the two main halls (the north and south halls). V27 stated, the place had all kinds of drama going, it was crazy.
The timecard reports document on 07/20/25 the CNAs working the 2:00 PM - 10:00 PM shift were V9, V32, V24, and V18 and the only CNA to leave early was V18.
The room roster provided on 08/28/25 documents R2, R23, R4, R18, R11, R33, R24, R29, R10, R6, R13, R38, R39, R35, R32, R1, R19, R15, R40, R41, R25, R8, R30, R26, R42, R27, R43, R5, R44, R45, R21, R12, R16, R17, R7, R31, R46, R47, and R48 live on the north and south halls.
On 09/08/25 at 10:44 AM, V40 (Agency LPN) stated, the time he worked at the facility, he remembers CNA's yelling at each other, you could hear them from the nurse's station on the north and south hall. Residents wanted to go to the bathroom and they couldn't. V40 stated it was chaos at the facility.
The facility's undated Resident Rights policy documents in part, “Our most important goal is to provide the highest standard of care to our residents in an environment safe, secure, and free of clutter. All employees of (Name of Facility) are expected to treat all residents, their family members, co-workers, and visitors with the utmost respect, kindness, and professionalism at all times… Employees that fail to provide superior care will be subject to corrective action, up to and including termination of employment.”
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 F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a method for altering staff when resident's nee...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a method for altering staff when resident's need assistance for 5 (R4, R7, R15, R17, R30) of 15 residents reviewed for call lights in reach in a sample of 48. Findings include: 1. R15's transfer/discharge report documents an admission date with diagnoses including: chronic respiratory failure, chronic obstructive pulmonary disease, anxiety disorder, depression, shortness of breath, cachexia, chronic viral hepatitis C, peripheral vascular disease, and muscle wasting and atrophy.
R15's Minimum data set (MDS) dated [DATE] documents a brief interview of mental status of 12 indicating R15 is moderately impaired. Section GG documents sit to stand, chair/bed to chair transfer and toilet transfer as partial/moderate assistance with walk ten feet documented as not attempted due to medical condition or safety concerns.
On 08/28/25 at 1:35 PM, R15's oxygen tubing was not in place, it was around her face but it was approximately an inch away from her nose. R15 was laying in bed sleeping and her call light was on the far side of her bedside table approximately three feet from her.
On 09/03/25 at 10:10 AM, R15 was laying in her bed sleeping, R15's call light was on the bedside table approximately three feet from her.
2. R17's admission record documents an admission date of 05/04/20 with diagnoses including: cerebral infarction, vascular dementia, obsessive compulsive personality disorder, anxiety disorder, major depressive disorder, depression spondylolysis, need for assistance with personal care, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, repeated falls, and bradycardia.
R17's Minimum Data Set, dated [DATE] documents a BIMS score of 15 indicating R17 is cognitively intact. Section GG documents lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, and toilet transfer as partial to moderate assistance needed with walk 10 feet as not applicable.
R17's care plan documents a focus area of: risk for falls dated 04/11/24 with an intervention listed as: fall intervention to include resident education on fall prevention, encourage resident to ask for assistance when needing something dated 04/29/25.
On 08/28/25 at 1:34 PM, R17's call light was not in reach, R17 was laying in bed and his call light was on his bedside table, approximately three feet from him.
3. R7's transfer/discharge report documents an admission date of 06/25/25 with diagnoses including: acute and chronic respiratory failure with hypoxia, chronic kidney disease, dependence on supplemental oxygen, essential hypertension, human immunodeficiency virus, muscle weakness, atherosclerotic heart disease, chronic obstructive pulmonary disease with acute exacerbation, encounter for palliative care, anxiety disorder, and need for assistance with personal care.
R7's MDS dated [DATE] documents a BIMS score of 15 indicating R7 is cognitively intact. Section GG documents R7's ability to: sit to stand, chair/bed to chair transfer as dependent. Toilet transfer is dependent. R7's ability to walk 10 feet is not applicable.
R7's care plan documents a focus area of at risk for falls dated 06/25/25 with an intervention dated 07/11/25 of ensure call light is available to resident. R7's care plan documents a focus area of: I have an ADL (activities of daily living) self-care performance deficit dated 07/11/25 with an intervention of encourage the resident to use bell to call for assistance dated 07/11/25. R7's Care plan documents a focus of risk for falls with a revision date of 09/09/25 with intervention of ensure call light is available to resident. Another focus area of I have an ADL (Activities of Daily Living) self-care with a revision date of 09/09/25 with an intervention of encourage the resident to use bell to call for assistance.
On 08/28/25 at 1:58 PM, R7's call light was not in reach. R7 was sitting in her recliner in front of her TV. The call light was on the floor over by the bedside table approximately five feet away. When R7 was asked if she knew where her call light was and if she could reach it, R7 started trying to get out of her recliner to find and get her call light. Surveyor stopped her and stated the call light was found. When trying to put the call light in R7's reach, the call light would not reach to where R7 was sitting.
On 08/28/25 at 11:16 AM, R7 stated that staff has taken her call light away from her and placed it out of her reach and hide it. R7 said they take it away from me and put it out of my reach on days and evenings.
4. R30's admission record documents an admission date of 02/28/25 with diagnoses including: panlobular emphysema, chronic obstructive pulmonary disease, supraventricular tachycardia, Alzheimer's disease, severe protein calorie malnutrition, cervical disc degeneration, bilateral primary osteoarthritis of knee, age related osteoporosis, lack of coordination, depression, major depressive disorder, wandering, spondylosis, muscle wasting and atrophy, cognitive communication deficit, and need for assistance with personal care.
R30's MDS dated [DATE] documents a BIMS score of 04 indicating R3 has severe cognitive impairment. Section GG documents R30 requires partial to moderate assistance for: sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, and toilet transfer.
R30's care plan documents a focus area of: risk for falls dated 03/04/25 with an intervention listed as; ensure call light is available to resident dated 03/01/25.
On 09/09/25 at 2:34 PM, R30 was laying in bed, R30's call light was on the floor with the cord under the legs of the bedside table with the button under her roommates bed, R30 did not provide a relevant response to the question asked about the call light.
5. R4's admission record dated 09/12/25 documents an admission date of 12/07/22 with diagnoses in part of major depressive disorder, overactive bladder, panic disorder, pelvic and perineal pain, personal history of malignant neoplasm of cervix, weakness, and need for assistance with personal care.
R4's MDS (Minimum Data Set) dated 06/18/25 documents in Section C a BIMS (Brief Interview for Mental Status) score of 06 which indicates R4 has severely impaired cognition. Section GG documents toileting. Functional abilities dependent with sit to stand, chair to bed transfers, lying to sitting.
R4's Care Plan documents a focus area of Alteration in bed mobility with a revision date of 09/03/24 interventions include in part, Keep frequently used items in reach while in bed. Position at side of bed for optimal reach. Keep Call Light in reach and answer promptly.
On 08/28/25 at 10:00AM, R4 who was alert and oriented at the time stated that she has a problem with staff taking away her call light all the time. R4 stated that they will put the call light on top of her bed light so she can't reach it. R4 stated that staff has told her that she uses the light too much and that she really doesn't need anything all the time, so they take away the call light and put it on top of the bed light or out of reach of her.
On 08/28/25 at 10:03AM, observed R4's who was laying in bed in her room with her call light wrapped around R4's bed light and out of reach of R4.
On 09/04/25 at 1:40PM observed R4 sitting in the dining room in her reclining chair no other resident observed in dining room wet floor signs up on dining room entrance along with plastic chains. R4 yelling out that she wants to go to her room and lay down. Observed staff sitting up at the nurse's station not acknowledging R4.
On 09/04/25 at 1:50PM observed R4 still in the dining room yelling out she wanted to lay down.
On 09/04/25 at 1:52PM observed staff coming to get R4 to take to her room.
On 09/09/25 at 2:25PM, observed R4 who was sitting in her reclining wheelchair next to her bed with her call light sitting on the floor out of the reach of R4 who was in her room at the time. Observed R4 holding up her cup yelling out saying that she doesn't want to drop her cup asking for help.
On 09/08/25 at 2:24 PM observed R4 who was in bed and R4's call light was on her bedside table approximately four feet from her, not where she could reach the light.
On 09/09/25 at 2:30PM, V26 (Family Member) stated when she comes in to visit R4 that her call light is on the floor often out of reach of R4.
On 09/09/25 at 1:12 PM, R29 who is alert and oriented, stated, she used to be R4's roommate and she used to turn her call light on for R4 when R4's light was not in reach for R4.
On 09/03/25 at 4:41 PM, V27 (Licensed Practical Nurse) stated, she specifically remembers R4 did not have her call light in reach every time she entered her room and she would keep putting it back in place for R4. V27 stated, she remembers this because she heard R4 yelling out once and she went into her room to see why she was yelling and R4 stated, because she did not have her call light, so she yelled for help. V27 stated one time she went into R4's room and she saw her call light and it was not in reach again. V27 stated, she even asked the CNAs who put her to bed because her call light was not in R4's reach again. V27 stated, there were other times the CNA's would say, R4 couldn't get up this time.
On 09/03/25 at 11:06AM, R20 stated that she has heard residents complain about not having their call lights in reach. R20 said that call lights are left on the floor often. R20 said that she will have to make sure she has her own call light and sometimes other residents as well. R20 said that residents will tell her that staff don't care if their call lights are in reach or on the floor. R20's MDS dated [DATE] documents in Section C a BIMS score of 14 which indicates R20 is cognitively intact.
On 09/03/25 at 3:19PM, V18 (Certified Nurse Assistant/CNA) stated that it was a common thing for staff to take away some of the resident call lights. V18 stated they would take away R4, and R7's call lights often they wouldn't really hide them they would just make it to where the resident couldn't reach them.
On 09/04/25 at 9:54AM, V5 (CNA) stated that they do have a resident who says that her call light is out of reach often it is R4. V5 said that she doesn't know how, but it is at the end of the bed or on the floor sometimes. V5 said that when she works, she tries to connect it to the bed rail or to the resident bed with the clip. V5 said she knows there are a couple of other residents who complain that their call light is not in reach as well, but she couldn't remember who all it was.
The Facility policy titled “Call Light” with a revision date of 02/02/2018 which documents the purpose as: to respond to resident' request and needs in a timely and courteous manner. 1. All residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside to other reasonable accessible location. Note: In the event the bed is positioned in a manner that is not within the resident' reach notify maintenance for a call light cord extension.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to provide a smoke/vape free building for 5 of 5 residents (R2, R5, R6, R18, R23) reviewed for environment in a sample of 48. Findings Include:...
Read full inspector narrative →
Based on interview and record review the facility failed to provide a smoke/vape free building for 5 of 5 residents (R2, R5, R6, R18, R23) reviewed for environment in a sample of 48. Findings Include:On 08/28/25 at 10:06AM, R2 who was alert and orientated stated that she has observed a staff member who was vaping in the hallway of the building. R2 stated that she doesn't know the staff name, but she is the one who looks like a boy.
On 08/28/25 at 10:08AM, R6 who was alert and orientated stated that he has witnessed staff vaping in the hallway. R6 said that they vape in the hallway on day and evening shift. R6 said that it has been several staff and didn't want to name any names.
On 08/28/25 at 11:23AM, R5 who was alert and orientated stated that she has witnessed staff vaping in the hallways and in some resident rooms. R5 said that they pull out their vapes often.
On 09/03/25 9:38AM, R18 who was alert and orientated stated that she has witnessed staff in the building vaping in the hallway.
On 09/03/25 at 9:42AM, R23 who was alert and orientated stated that she has witnessed staff vaping in the building. R23 said that she has witnessed V5 (Certified Nurse Assistant/CNA) take a hit off her vape in the hallways as she is pushing a resident down the hall in a wheelchair.
On 09/03/25 at 12:54PM, V13 (CNA) stated that she has observed several staff vaping in the break room on several occasions on 2-10 shift. V13 stated that they were in-serviced a while back about vaping in the building when she first started.
On 09/03/25 at 3:19 PM, V18 (CNA) stated that she has seen staff vaping in the building around the break room.
On 09/09/25 at 2:50PM, V29 (Activities Director) stated that she has witnessed staff vaping in the building. V29 said that she has witnessed V24 (CNA) do it often. V29 stated that V24 doesn't work at the facility now she quit to go back to Florida.
On 09/03/25 at 4:41 PM, V27 (Agency Licensed Practical Nurse) stated, the couple days she worked at the facility, there were CNA's (Certified Nurse Aides) that were vaping in the facility.
The facility document titled, Inservice Form dated 04/15/25 documents: in service title- vaping, with the summary of the in service listed as there is to be no vaping within the building.
The facility Employee Standards of Conduct documents “(The Facility) expects that each employee's conduct and performance will conform with the highest standards of professionalism with respect to treatment of all residents, visitors and their families and our ethical practices; the requirement of their job; published and common-sense health and safety rules; and applicable federal, state, and local laws, rules and regulations. While it is impossible to provide an exhaustive list of conduct that is not appropriate in the work setting, the following list provides some examples of conduct that is not permitted. This list is not intended to, nor does it alter the “at-will” nature of your employment, which means that you or “The Facility” may end the employment relationship at any time, for any reason that is not legally protected, with or without advance notice. Violation of “The Facility” standards of conduct may lead to corrective action, up to and including immediate termination. Violations of conduct standards that constitute ground for immediate dismissal include in part Violating “The facility” drug/alcohol-free workplace policy and violating “The Facility” non-smoking 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
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow the menu provided to the facility and correct portion sizes d...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow the menu provided to the facility and correct portion sizes directed by the menu for 7 (R2, R3, R6, R9, R11, R13 and R27) of 15 residents reviewed for following the menu in a sample of 48. Findings include:1. R2's admission record dated 09/10/25 documents an admission date of 09/01/20 with diagnoses in part of need for assistance with personal care and unspecified protein-calorie malnutrition.
R2's MDS (Minimum Data Set) dated 08/13/25 documents in Section C a BIMS score of 15 indicating R2 is cognitively intact. Section GG eating as supervision or touching assistance.
R2's Care Plan documents a focus area of Resident hoards food with a date initiated of 04/03/24. Another focus area of Risk for Malnutrition with a date initiated of 04/03/24 with an intervention in part of provide supervision during meals.
On 08/28/25 at 10:06AM, R2 stated that the facility does run out of food often. R2 said they won't have enough food for everyone and then they give the residents smaller serving sizes. R2 said that recently they had a taco bake and that staff was eating it along with the residents and they ran out of the taco bake. R2 said that one of the nursing staff V11 (Licensed Practical Nurse/LPN) knew they kept running out of food and that she went to V1 (Administrator/ADM) about it. R2 said that they did go buy a big ham for the facility for the residents, but the kitchen staff left it out and it went bad. R2 said they also run out of supplies like, sugar, salt, and Catsup often.
2. R3's Transfer/Discharge Report dated 08/28/25 documents an admission date of 06/12/24 with diagnoses in part of acquired absence of other specified part of digestive tract, gastro-esophageal reflux disease, need for assistance with personal care and other vitamin b12 deficiency anemias.
R3's MDS dated [DATE] documents in Section C a BIMS score of 15 which indicates R3 is cognitively intact. Section GG documents eating as independent.
R3's Care Plan documents a focus area of at risk for impaired nutrition with a revision date of 06/13/24 with intervention in part of monitor eating environment.
On 08/28/25 at 11:35AM, R3 stated the kitchen runs out of food all the time. R3 said the kitchen will give some of the staff food at times or sometimes the staff will just go in the kitchen and get some of the main meal. R3 said when that happens, they don't have enough food to be able to feed all the residents. R3 said if they are close to running out of the meal that they will cut the resident portions into smaller portions. R3 said that she doesn't think the kitchen has enough of the meal to be able to serve all the residents already and if the staff eats any of the food, then they don't have enough.
3. R6‘s admission record dated 09/10/25 documents an admission date of 04/04/25 with diagnoses in part of gastro-esophageal reflux disease, muscle wasting and atrophy, and need for assistance with personal care.
R6's MDS dated [DATE] documents in Section C a BIMS score of 15 which indicates R6 is cognitively intact. Section GG documents eating as supervision and touching assistance.
R6's Care Plan documents a focus of, “I have a potential nutritional problem” with a revision date of 07/11/25 with interventions in part of provide, serve diet as ordered. Monitor intake and record every meal.
On 08/28/25 at 10:08AM, R6 stated that the facility has ran out of food many of times. R6 said that last week they ran out of food, and they didn't have anything to give him except for 2 Jello cups.
4. R9's Transfer/discharge Report dated 08/28/25 documents an admission date of 03/14/25 with diagnosis in part of Vitamin d deficiency and need for assistance with personal care.
R9's MDS dated [DATE] documents in Section C a BIMS score of 07 which indicates severely impaired cognition. Section GG eating as supervision and touching assistance.
R9's Care Plan documents a focus area, “I have a potential nutritional problem” with a revision date of 05/28/25 with interventions in part of provide, serve diet as ordered.
On 08/28/25 at 11:15 AM, R9 who was alert and oriented stated that the facility has a big problem with running out of food consistently she said that they sometime let the staff eat as well and then they don't have enough food and other times they just run out of food. R9 said when they are close to running out of food they cut their portions into smaller sizes.
5. R27's admission record dated 09/10/25 documents an admission date of 06/06/25 with diagnosis in part of unspecified protein-calorie malnutrition, type 2 diabetes mellitus, deficiency of other specified B group vitamins, and vitamin D deficiency.
R27's MDS dated [DATE] documents in Section C a BIMS score of 13 which indicates R27 is cognitively intact. Section GG documents eating as set-up and supervision.
R27's Care Plan a focus area of, “I have Diabetes Mellitus” with a date initiated of 06/23/25. Another focus area of, “I have a potential nutritional problem” with a revision date of 06/23/25 and an intervention in part of provide, serve diet as ordered. Monitor intake and record q (Every) meal.
R27's Order Summary Report documents an order on 06/06/25 and no end date for CCD (Controlled Carb Diet) regular texture, regular/thin consistency.
On 09/09/25 at 11:30AM, R27 stated she is a diabetic and one morning recently they didn't have any breakfast meats and no eggs so for breakfast she got two cinnamon rolls and a bowl of cereal. R27 stated that she shouldn't get anything like that for breakfast with her being a diabetic. R27 said that staff told her that they didn't have anything else to give her. R27 said that she is glad her diabetes is under control well or it could have been bad with her eating that stuff. R27 said that she didn't have any choice, but to eat the cinnamon rolls and cereal or she wouldn't have gotten anything. R27 said that on the main meal if she wants seconds, she will ask that Certified Nurse Assistant, and they will ask the kitchen, and kitchen will tell staff they don't have anymore. R27 said that some residents might get seconds, but not all residents if they want it. R27 said that they won't even offer her anything else. R27 said other days she will notice her portion size or meat if much smaller than other residents.
On 09/03/25 at 10:53AM, V6 (Certified Nurse Assistant/CNA) stated the facility does have enough food to serve all the residents, but sometimes they do not have enough food to give the residents seconds.
On 09/03/25 at 11:41AM, V8 (CNA) stated that they do run out of food she said that usually they have enough to serve residents the main meal and then kitchen will get rid of the food that is left over and then residents will request some more food and they won't have any to give them, so they get nothing else.
On 09/03/25 at 11:43AM, V9 (CNA) stated yes, the facility does run short on food, and they cut the portions down for the residents when they are getting low on food when serving.
On 09/03/25 at 12:15PM, V10 (CNA) stated the kitchen was running short on food for the meals at times. V10 stated that they maybe have enough food to get all the residents the main meal. V10 said if a resident wants seconds, they don't usually have enough for that.
On 09/03/25 at 12:23PM, V11 (Licensed Practical Nurse/LPN) stated that they have ran out of stuff in the kitchen like they ran out of breakfast meats to be able to serve the residents. V11 said that facility did not have any protein to be able to serve the residents at breakfast. V11 said that she had a resident who was a diabetic receive two cinnamon rolls and a bowl of fruit loops for breakfast. V11 said that she did ask the kitchen why a diabetic was getting two cinnamon rolls and a bowl of fruit loops, and they told her they didn't have no breakfast meats to be able to serve her.
On 09/03/25 at 3:19PM, V18 (CNA) stated the kitchen would run out of food often in the evening and wouldn't have anything to replace it. V18 said that is they did have enough to be able to serve all the resident the main meal, the kitchen staff would throw the rest away and residents would ask for seconds, and they wouldn't have anything to be able to give the residents.
On 09/04/25 at 2:11PM, V19 (CNA) stated that they usually have enough food to serve residents the main meal, but if a resident wants seconds, they usually don't have enough to be able to serve them seconds.
On 09/04/25 at 2:32PM V20 (CNA) stated they don't have enough food for the residents he said that several of the residents will request seconds, and they don't have anything to give them or anything else.
On 09/09/25 at 2:50PM, V29 (Activity Director) stated that yes some of the staff eat out of the kitchen after all the residents receive a meal if there is anything left over. V29 stated that the kitchen did have a problem with running out of food. V29 said that the spreadsheets didn't match the menu. V29 stated that she used to work in the kitchen. V29 said they use to run out of food for the residents because they didn't make enough. V29 said the facility did run out of breakfast meats and eggs one morning a couple of weeks ago. V29 said they did serve diabetics two cinnamon rolls and a bowl of cereal.
On 09/09/25 at 3:51PM, V1 (Administrator) stated that the facility does have enough food for the residents. V1 said that she is having the kitchen work with their dietary service on making sure they follow the menus.
On 09/08/25 at 10:44 AM, V40 (Agency LPN) stated the time he worked at the facility, they ran out of food for the residents.
On 09/08/25 at 1:11 PM, V42 (Dietary) stated she has been serving dinner before and it will be getting close to the end so she will put a smaller portion of food on the plate to make sure she has enough food for all the residents, she will then try to go back and put some more food on the plates after she has put food on all the plates to make sure all the residents get food.
On 09/10/25 at 11:02AM, V2 (Director of Nursing) stated that she was aware of residents complaining they weren't getting seconds, but not of them not getting any food.
The Concern/Compliment Form dated 08/07/25 by R11 documents nature of concern/compliment: not enough snacks at night. Dinner meal time at 5 PM then breakfast at 7 AM is a long time without meals and snacks. Bigger portions would be nice.
The Concern/Compliment Form dated 08/07/25 by R13 documents nature of concern/compliment: bigger portions of food.
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 F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to provide enough evening snacks so every resident may ha...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to provide enough evening snacks so every resident may have a snack in the evening for 8 residents of 17 residents (R2, R3, R7, R11, R20, R27, R29, and R35) reviewed for evening snacks in a sample of 48. Findings include:R2's admission record dated 09/10/25 documents an admission date of 09/01/20 with diagnoses in part of need for assistance with personal care and unspecified protein-calorie malnutrition.
R2's MDS (Minimum Data Set) dated 08/13/25 documents in Section C a BIMS score of 15 indicating R2 is cognitively intact. Section GG eating as supervision or touching assistance.
R2's Care Plan documents a focus area of Resident hoards food with a date initiated of 04/03/24. Another focus area of Risk for Malnutrition with a date initiated of 04/03/24 with an intervention in part of provide supervision during meals.
On 09/03/25 at 1:45PM, R2 stated that the facility had crappy snacks in the evening or they don't have enough snacks for all of the residents at the facility. R2 said that they maybe will get two saltine crackers as a snack. R2 said how is that a snack, she said why couldn't they put peanut butter on them for the diabetics.
On 09/03/25 at 10:53AM, V6 (Certified Nurse Assistant/CNA) stated she isn't sure if they have enough snacks in the evening, she thinks they do, but she knows that some of the resident will come and pick out the better snacks and then the other residents don't want what is left.
On 09/03/25 at 11:41AM, V8 (CNA) stated they don't have a lot of snacks. She stated they have a few items on the cart and the ambulatory resident will get the snacks that they want and then there isn't really anything left for the other residents.
On 09/03/25 at 12:15PM, V10 (CNA) stated they don't have enough snacks at night a lot of the time. V10 said they maybe have enough snacks to pass one hall snacks.
On 09/03/25 at 12:23PM, V11 (Licensed Practical Nurse/LPN) stated that sometimes they don't have the best snacks in the evening. V11 said they might have two saltine crackers or some graham crackers.
On 09/03/25 at 1:47PM, V14 (CNA) stated the facility does run out of snacks to give the residents. V14 said it is a hit and miss sometimes they have enough snacks to give all the residents other times they do not have enough snacks to give all the residents a snack. V14 said last week they did not have enough snacks to be able to give all the residents a snack.
On 09/03/25 at 2:30PM, V16 (LPN) stated that residents do get snacks, but that she feels like they don't get enough snacks for all the residents in the building to be able to get a snack. V16 said the kitchen will leave some saltine crackers or graham crackers out for the residents.
On 09/03/25 at 3:19PM, V18 (CNA) stated that the facility did not have enough snacks for all of the residents. V18 said that none of the mechanically altered diets would get any snacks in the evening because they didn't send anything for them to be able to eat.
On 09/04/25 at 2:11PM, V19 (CNA) stated that they do have snacks but sometimes they don't have enough snacks for all the residents.
09/04/25 at 2:28PM, V5 (CNA) stated the facility is short on snacks all the time. V5 said that they only have dry snacks and only a few. V5 said they can usually only get one hall pass with snacks. V5 said that they only have a few snacks to be able to offer those residents. V5 said that they can't even get any extra snacks because they lock up the refrigerator.
On 09/04/25 at 2:32PM, V20 (CNA) stated the facility runs out of snacks all the time and they don't have enough to be able to give all the residents a snack in the evening.
On 09/09/25 at 2:50PM, V29 (Activity Director) stated she does know that the facility was having a problem with not having enough snacks. V29 said that she thought it had gotten better. V29 said that the snacks are just sitting on the table and not passed till later and the smokers will go out for their 8pm smoke break and they will take what snacks they want and then they don't have enough snacks left over for all the residents.
On 09/09/25 at 3:51PM, V1 (Administrator) stated that she knew that they having enough snacks was a problem and she makes kitchen staff send a picture of the snacks that they leave out for the staff to pass, and she said that she knows they have enough snacks because she gets pictures of the snack basket.
On 09/04/25 at 3:10 PM, during a Resident Council meeting R2 stated, they had not been received evening snacks or fresh drinks in the evening until the last two days, R20, R29, R27, R35 agreed.
On 09/04/25 at 8:45 AM, R7 who was alert to person, place and time stated, she does not always get snacks in the evening.
On 09/08/25 at 1:11 PM, V42 (Dietary) stated, the afternoon dietary aide or sometimes the afternoon cook will get the evening snack basket together for the evening snacks. They will put some saltine crackers, oatmeal cream pies, cookies, puddings and some half peanut butter and jelly sandwiches. She is guessing all together there could be 35 to 40 snacks in the basket, maybe 50 at most. V42 stated, they have approximately ten to twelve diabetics at the facility currently. V37 stated, they take a picture of the snack basket every night and send it to V1 (Administrator) to show her snacks were put together. V42 stated, she does not know if the certified nurse aides (CNA's) pass them out every evening. V42 stated, the packages of saltines have two saltine crackers in each package and residents probably would take more than one package of saltines with a fourteen-hour time frame between meals.
On 08/28/25 at 11:35 AM, R3 who was alert to person, place and time stated they don't have hardly any snacks in the evening.
The facility document titled, Inservice Form dated 07/18/25 documents: inservice title snacks & water with the summary of the inservice stating: pass ice water and snacks (pureed or cooled snacks will be in the milk cooler).
The Concern/Compliment Form dated 08/07/25 by R11 documents: not enough snacks at night. Dinner mealtime at 5 PM then breakfast at 7 AM is a long time without meals and snacks.
The Concern/Compliment Form dated 08/30/25 by R2 documents: they don't have enough snacks in the evenings, only thing offered to her is saltine crackers. If they would add peanut butter, that would make them feasible to eat.
Resident council minutes dated 07/07/25 document under the section titled, Nursing ice water not being passed, snacks only offered to smokers at 8:00 PM.
On 09/08/25 at 1:03 PM the picture of the snack basket, which was a plastic tote container, approximately 16 inches by approximately 13 inches. This container appeared to hold approximately: 7 packages of saltines, 7 oatmeal cream pies, 4 packages of cookies, 7 pudding containers, 8 peanut butter and jelly half sandwiches.
On 09/08/25 at 1:03 PM, V41 (Dietary) stated, sometimes she makes the snack basket for the evening snacks. V41 stated, she will put a handful of crackers, a handful of oatmeal cream pies, some fruit cups, and some gelatin cups in the basket. V41 stated, she does not count the snacks in the basket.
On 09/08/25 at 10:44 AM, V40 (Agency LPN) stated, residents did not drinks passed to them, they did not have enough snacks. V40 stated, he felt they did not have enough staff.
The policy dated, 2025 titled, (company name) dietary policies and procedures documents: snacks: the food and nutrition department may provide snacks as requested by residents and HS ([NAME] somni (before bed)) snacks daily, per facility protocol.
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 F0583
(Tag F0583)
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 privacy was maintained for residents. This deficient practi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure privacy was maintained for residents. This deficient practice has the potential to affect all 52 resident that reside in the facility. The findings include: 1. On 08/28/25 at 1:30 PM, R13 stated he has heard staff talking about other residents' health issues and conditions where other residents could overhear. R13's Minimum data set (MDS) dated [DATE] documents a brief interview of mental status (BIMS) of 15, indicating R13 is cognitively intact.
2. On 09/08/25 at 2:55 PM, R33 stated he has heard staff talk about other residents and their health issues and backgrounds. R33's Minimum data set (MDS) dated [DATE] documents a brief interview of mental status (BIMS) of 10, indicating moderately cognitively impaired.
3. On 08/28/25 at 11:35AM, R3 who was alert and orientated stated that a lot of the staff talk about other resident's care and stuff in the dining room and in common areas in front of families and other residents that the care isn't about. R3 said that they talk about all kinds of things about other resident and staff will even make fun of some of the residents. R3 could not give names of any specific residents.
4. On 08/28/25 at 1:37PM, R12 who was alert and orientated stated that he has overheard staff talking about resident care in common areas, in the dining room and in his room. R12 could not remember the residents' names that staff were talking about.
5. On 08/28/25 at 1:40PM, R27 who was alert and orientated stated that she has heard staff talking about other residents' care in common areas and outside when they are smoking. R27 could not remember who all staff has talked about in those areas.
6. On 08/28/25 at 1:43PM, R28 who was alert and orientated stated that she has heard staff talking about other residents' care in common she couldn't remember who all the staff talked about.
7. On 09/03/25 9:42AM, R23 who was alert and orientated stated that she has heard V5 (Certified Nurse Assistant/CNA) sit outside when they are smoking and talk about other resident's care and how some of the other residents at the facility are nuts or crazy. R23 doesn't remember who all V5 talked about when she was outside talking about resident care and saying the resident was nuts.
8. On 09/02/25 at 11:06AM, R20 who was alert and oriented stated that she has heard staff talk about residents and their care in the dining room, in front of another resident. R20 stated that staff talks about other residents all the time all over the building in front of other residents. R20 said that staff will even make fun of the residents they are talking about. R20 did not give the names of the staff that was talking about resident care, and she did not give the names of the resident that staff was talking about.
On 09/03/25 at 11:43AM, V9 (Certified Nurse Assistant/CNA) stated that she has heard staff talk about resident care in common areas such as the dining room, but most of the time when they talk about resident care it's in the break room.
On 09/03/25 at 3:19PM, V18 (CNA) stated that she no longer works at the facility, but that she would hear staff talking about other resident's care in the dining room and in common areas where families and other resident were. V18 stated that some of the staff would also make fun of some of the residents. V18 said that some staff didn't care where they were, they would talk about the residents and say their names when they were talking about the resident care.
On 09/09/25 at 2:50PM, V29 (Activities Director) stated that she has heard staff talking about resident care in common areas such as in the dining room where families and other resident could hear and say names.
The Facility room roster undated presented on 08/28/25 documents the facility total census is 52.
The facility document titled “Confidentiality Agreement” undated documents in part Under HIPPA policies, employees are prohibited from directly or indirectly divulging, using or permitting the use of any patient confidential information, including medical information, records and invoices, except as required in the course of employment with the facility. Employees work closely with residents, their doctors, and other staff all information concerning residents, their medical conditions or treatment, their finances, and their families or friends, is to be kept strictly confidential. This confidential information should not be given to other residents, persons outside of this facility, or even other employees unless 1.) withholding the information would hinder the resident's care, health, or safety. 2.) your supervisor or Department Director, or the Administrator, request the information, or 3.) disclosure properly is sought by an investigator/inspector from a government agency. Any employee violation this policy is subject to discharge.
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
Grievances
(Tag F0585)
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 address a concern area discussed and documented in resident council....
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to address a concern area discussed and documented in resident council. This failure has the potential to affect all 52 residents residing at the facility. Findings include:Resident council minutes dated 08/07/25 documents under the section titled, Nursing: some CNAs have hateful attitudes.
On 09/05/25 at 3:10 PM (during resident council) R27, stated, the previous concern of CNAs having hateful attitudes has not been resolved. Resident council stated, they have not been given any resolution for that concern. The CNAs act like they do not want to come help you. The staff are always on their phones and some staff still have hateful attitudes.
On 09/03/25 at 11:10 AM, V3 (Assistant Director of Nursing) stated the concern of CNAs having hateful attitudes should have been brought up at the morning meeting but she does not remember discussing it. V3 stated, there probably should have been a concern or grievance form documenting a resolution. V3 stated, there is no in-service addressing that concern.
On 09/03/25 at 4:14 PM, V29 (Activities Director) stated there is no concern form for the concern of CNAs with hateful attitudes from the resident council meeting on 08/07/25. V29 is not aware of any in-service or any other method of addressing that concern.
On 09/09/25 at 11:55AM, V25 (Social Service Director/SSD) stated that usually she is the one to fill out a grievance or concern form when the residents have them. V25 stated that she did not know that residents had a concern in resident council about staff being rude to them. V25 stated she doesn't know if V29 might have filled one out since she did resident council.
On 09/04/25 at 10:50AM, R1 stated that she used to have a problem with a bigger girl who worked at the facility. R1 said that she would be so rude to her when caring for her. R1 stated that she doesn't see the girl at the facility much anymore. R1 was alert to person and place.
On 09/04/25 at 11:04AM, R2 stated that she has had a problem with staff being rude with her. R2 stated they talked about staff being rude in resident council. R2's MDS (Minimum Data Set) dated 08/13/25 documents in Section C a BIMS score of 15 indicating R2 is cognitively intact.
On 08/28/25 at 11:16AM, R7 stated that staff is just downright rude at times when they talk to you or answer you. R7's MDS dated [DATE] documents in Section C a BIMS score of 15 which indicates R7 is cognitively intact.
On 09/09/25 at 11:30AM, R27 stated that staff are just rude to them at times. R27 said she will ask the staff for help with something and they will say with an attitude, “We are busy what do you want” or they will just say, “We are Busy” with a slight aggressive tone. R27 said that she couldn't provide us with the staff names, because none of them ever wear a name tag. R27's MDS dated [DATE] documents in Section C a BIMS score of 13 which indicates R27 is cognitively intact.
On 09/03/25 at 12:54PM, V13 (Certified Nurse Assistant/CNA) stated that they did have staff that were rude to the residents and it was V18 (CNA) and V24 (CNA). V13 stated that neither of them work at the facility anymore.
On 09/03/25 at 3:19PM, V18 (CNA) stated that she has observed V32 (CNA) be rude to several residents. V18 said V32 would say terrible things to residents. V18 could not remember what all V32 said or to whom she said it just that she would always have an attitude.
On 09/09/25 at 2:50PM, V29 (Activity Director) stated that she has heard staff be rude to residents. V29 said that V35 (CNA) she has heard be rude with resident when talking to them. V29 said when she had resident council that some of the residents were complaining about staff being rude. V29 stated that she is sure she wrote up a grievance/concern form about it. V29 stated that she does not know what happened to the grievance/concern form about staff being rude.
On 09/09/25 at 3:51PM, V1 (Administrator) stated that she was not aware of any complaints about staff being rude to residents.
On 09/10/25 at 11:02AM, V2 (Director of Nursing) stated that she was not aware of residents complaining in resident council about staff being rude. V2 stated she was not aware of any staff being rude to any residents at all.
The undated room roster presented on 08/28/25 documents 52 residents residing at the facility.
The facility policy dated 09/25/17 titled, Grievances documents: All alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, will be immediately reported to the administrator and as required by State law. All written grievances shall include: the date the grievance was received, a summary statement of the grievance, department assigned to investigate, steps taken to investigate the grievance, summary of the pertinent findings or conclusions regarding the concern(s) 2 statement as to whether the grievance was confirmed or not confirmed, corrective action taken or to be taken by the facility as a result of the grievance, including measures taken to prevent further potential violations of any resident right while the alleged violation is being investigated, the date the written decision was issued to the resident or the complainant. Every effort shall be made to resolve grievances in a timely manner, usually within 5 business days (excludes weekends and holidays). Under certain circumstances, additional time may be needed to complete an investigation and implement measures to resolve the grievance. In such cases, the resident or complainant should be notified of the extension.
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 F0726
(Tag F0726)
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 all staff maintained the appropriate licenses while working a...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure all staff maintained the appropriate licenses while working at the facility. This failure has the potential to affect all 52 residents residing at the facility. Findings include:On [DATE] at 1:11 PM, V2 (Director of Nursing/ DON) stated V4's (Licensed Practical Nurse/ LPN) license must have expired on [DATE]. V2 stated, V4 worked without a license from [DATE] to [DATE]. V2 stated they did not notice her license expired until [DATE], after that V4 worked as a certified nurse aide.On [DATE] at 11:35 AM, 1.R3 who was alert to person, place and time stated V4 was working as a nurse and now she is working as a CNA (Certified Nursing Assistant) because she didn't renew her nursing license.On [DATE] at 11:43 AM, V9 (CNA), stated V4 was working as a nurse she thought up until June and now she works as a CNA.On [DATE] at 12:23 PM, V11 (LPN) stated, she has worked with V4 as a nurse she said V4 was working as a nurse up till a couple of months ago V11 stated, they found out she let her license expire and she has been working as a CNA lately.On [DATE] at 12:33 PM, V12 (LPN) stated she has worked with V4 as a nurse around July or June. V12 stated, V4 now is working as a CNA because V4 let her nursing license expire, and they had to take her off the floor as a nurse because she didn't have a current nursing license.On [DATE] at 12:50 PM, V4 (LPN) stated, she did work as a nurse on the floor in June when her license was expired. V4 stated, she didn't know her license was expired until the DON and ADON (Assistant Director of Nursing) told her. V4 stated she is in the process of renewing it but she has to take some extra steps because it did expire.On [DATE] at 2:30PM, V16 (LPN) stated, V4 was working the floor as a nurse, but it has been two months since she worked as a nurse on the floor V4 has been working as a CNA lately.On [DATE] at 2:45PM, V17 (LPN) stated, the last time she could remember working with V4 as a nurse was in June.On [DATE] at 11:02 AM, V2 (DON) stated, V4 did work as a nurse at the facility and she did not have a current nursing license. V2 stated, V4 was a transfer from another sister facility and that she didn't think to check her nursing license, and she knows that she should of. She (V2) said that they found out at the end of June the beginning of July that V4 did not have an active license, and they took her off the schedule as a nurse and she has been working as a CNA until she can get her nursing license back.1. R9's transfer/discharge report documents an admission date of [DATE] with diagnoses including: Alzheimer's disease, Bipolar disorder, essential hypertension, anxiety disorder, major depressive disorder, morbid obesity, neutropenia, restless legs syndrome, and vitamin D deficiency.R9's medication administration record (MAR) documents: on [DATE] V4 (Licensed Practical Nurse) administered cholecalciferol, colace, miralax, and sertraline. On [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] V4 administered donepezil.2. R5's transfer/discharge report documents an admission date of [DATE] with diagnoses including: alcohol dependence with alcohol induced persisting dementia, altered mental status, bipolar disorder, chronic kidney disease, delusional disorders, depression, gastroesophageal reflux disease, insomnia, anxiety disorders, PICA in adults, macular degeneration, venous insufficiency, and Wernicke's Encephalopathy. R5's MAR documents: on [DATE] V4 administered daily-vite, folic acid, vitamin B-12, vitamin D3, and folic acid. On [DATE] R5's MAR documents V4 administered: divalproex, estradiol cream, hydroxyzine, melatonin, olanzapine.3. R4's MAR documents: on [DATE] V4 administered: aspirin 81, magnesium oxide, oyster shell calcium, solifenacin, vitamin B-1, vitamin C, divalproex sodium, docusate sodium, hydroxyzine HCL, polyethylene glycol, and risperidone.4. R3's transfer/discharge record documents an admission of [DATE] with diagnoses including: acquired absence of other specified parts of digestive tract, bipolar disorder, chronic obstructive pulmonary disease, delusional disorders, gastro-esophageal reflux disease without esophagitis, hyperlipidemia, insomnia due to other mental disorder, major depressive disorder, mental disorder, moderate intellectual disabilities, malignant neuroendocrine tumors, schizophrenia, and macular degeneration.R3's MAR documents on [DATE] V4 administered cyclobenzaprine HCL (hydrochloride) to R3. On [DATE] V4 administered quetiapine fumarate and divalproex sodium to R3. On [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] V4 administered atorvastatin calcium, quetiapine fumarate, divalproex sodium to R3. On [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] V4 administered clonazepam to R3. On [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] V4 administered lamotrigine to R3. On [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] V4 administered divalproex sodium to R3. On [DATE] V4 administered cyclobenzaprine HCL to R3. On [DATE], [DATE], and [DATE] administered olanzapine to R3.The room roster provided on [DATE] documents 52 residents residing at the facility. The job description listing a position title of: Licensed Practical Nurse (Nurse) documents: Qualifications: Licensed Practical Nurse with current unencumbered state licensure.
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 F0807
(Tag F0807)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to provide beverages to residents. This failure has the p...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to provide beverages to residents. This failure has the potential to affect all 52 residents residing at the facility. Findings include:1. R1's Transfer/Discharge report dated 08/28/25 documents in part an admission date of 04/12/23 with diagnoses in part of acute kidney failure, urinary tract infection and need for assistance with personal care.
R1's MDS (Minimum Data Set) dated 06/30/25 documents a BIMS (Brief Interview for Mental Status) score of 03 which indicates severely impaired cognition.
R1's Care Plan documents a focus of risk for dehydration with a date initiated of 04/08/24.
On 08/28/25 at 12:47PM, V31 (Family Member) stated he must ask the facility to pass out water more often for R1, because they don't pass out ice and water all that often. V31 said that R1 had a history of urinary tract infections and when he visits R1 she doesn't have any water available in her room.
2. R2's admission record dated 09/10/25 documents an admission date of 09/01/20 with diagnoses in part of atrial fibrillation and need for assistance with personal care.
R2's MDS dated [DATE] documents in Section C a BIMS score of 15 which indicates R2 is cognitively intact.
R2's Care Plan documents a focus area of risk for dehydration with a date initiated of 04/03/24.
On 09/03/25 at 1:45PM, R2 stated that over the weekend they did not get passed any water on day shift or evening shift. R2 said she was dying of thirst and had to ask the midnight staff to get her some water since they didn't get passed any water at all. R2 stated she has brought up in resident council about staff not passing ice and water out.
3. R4's admission record dated 09/12/25 documents an admission date of 12/07/22 with diagnoses in part of epilepsy, need for assistance with personal care, and overactive bladder.
R4's MDS dated [DATE] documents in Section C a BIMS score of 06 which indicates severely impaired cognition.
R4's Care plan documents a focus area of Risk for dehydration with a date initiated of 04/04/24.
On 08/28/25 at 10:00AM, R4 who was alert and oriented stated that she has a problem with them not giving her water often. R4 said that she will go all day and then maybe they will give her water in the evening.
On 09/09/25 at 10:50AM, observed R4 in her room saying that she was thirsty. There was no water in her room or even a cup within reach of resident.
On 09/09/25 at 2:30PM, V26 (Family Member) stated that when she comes to visit R4 that sometimes she will have water in her room other times she will have to go get R4 some water and ice.
4. R7's admission record dated 09/13/25 documents an admission date of 06/25/25 with diagnoses in part of iron deficiency anemia, muscle weakness, and need for assistance with personal care.
R7's MDS dated [DATE] document in Section C a BIMS score of 15 which indicates R7 is cognitively intact.
R7's Care plan documents a focus of Risk for dehydration with a revision date on 09/09/25.
On 08/28/25 at 11:16AM, R7 stated that staff doesn't bring her drinks often. R7 stated they will pass out water sometimes but not all the time.
5. R20's Transfer/Discharge report dated documents an admission date of 05/28/25 with diagnoses in part of need for assistance with personal care, thrombocytosis, cirrhosis of liver, diarrhea, and polyneuropathy.
R20's MDS dated [DATE] documents in Section C a BIMS score of 14 which indicates R20 is cognitively intact.
R20's Care plan documents a focus area of Risk for Dehydration with a revision date of 05/03/24.
On 09/03/25 at 11:06AM, R20 stated that they sometimes pass water and ice at the facility, but not all the time.
On 09/03/25 at 12:15PM, V10 (Certified Nurse Assistant/CNA) stated that some of the residents complained that they don't get water and ice on day shift and that he tries to make sure to pass water and ice when he works.
On 09/09/25 at 2:50PM, V29 (Activity Director) stated the facility does have a problem with not passing ice and water out to the residents.
On 09/10/25 at 11:02AM, V2 (Director of Nursing) stated they did have a complaint in resident council about residents not getting water and ice. V2 said that she did do an in-service with staff about making she they passed ice and water. V2 stated that she has not done a follow up with the residents to see if staff passing ice and water had improved.
On 09/08/25 at 10:44 AM, V40 (Agency LPN) stated residents did not get drinks passed to them. V40 stated, he felt they did not have enough staff.
The concern/compliment form by R2 dated 08/30/25 documents the nature of concern/compliment as: ice water not being passed in the morning.
The concern/compliment form by V31 (Family) concerning R1 dated 08/30/25 documents the nature of concern/compliment as: ice water being in her room and within reach.
The concern/compliment form by R11 dated 08/07/25 documents the nature of concern/compliment as: no drinks at night but water, CNA gets mad when asked for something different than water.
The concern/compliment form by R13 dated 08/07/25 documents the nature of concern/compliment as: they do not leave anything to drink between meals.
The facility document titled, Inservice Form dated 07/18/25 documents: in-service title snacks & water with the summary of the in-service stating: pass ice water and snacks (pureed or cooled snacks will be in the milk cooler).
Resident council minutes dated 07/07/25 document under the section titled, Nursing ice water not being passed.
The room roster provided 08/28/25 documents 52 residents residing at the facility.
Aug 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 ensure medications were administered as ordered for 1 ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications were administered as ordered for 1 of 1 (R5) resident reviewed for medication administration in the sample of 9. Findings Include:R5's facility Transfer/Discharge Report with a print date of 8/18/25 documents R5 was admitted to the facility on [DATE] with diagnoses that include bipolar disorder, delusional disorder, insomnia, and moderate intellectual disability.R5's MDS (Minimum Data Set) dated 6/30/2025 documents a Brief Interview for Mental Status score of 15, indicating R5 is cognitively intact.R5's Order Summary Report Active Orders as of: 04/19/2025 includes the following physician order with a start date of 04/18/2025, Preservision AREDS 2 Soft gel Give 1 capsule orally one time a day for Supplement Take 1 Capsule by Mouth Once Daily (Supplement).R5's Medication Administration Records (MAR) dated 4/1/2025 through 4/30/25, 5/1/2025 to 5/31/2025, 6/1/2025 to 6/30/2025, 7/1/2025 to 7/31/2025, and 8/1/2025 to 8/31/2025 document a physician order for Preservision AREDS 2 Soft gel to be given once daily by mouth. These same MAR's document initials on each indicating R5 was administered Preservision AREDS 2 one capsule daily.R5's current Care Plan does not document a Focus area related to the diagnosis of Macular Degeneration.On 8/18/25 at 11:29 AM, R5 stated she called the State Survey Agency yesterday because the facility was giving her Ocuvite for her Macular Degeneration, instead of the Preservision her physician had ordered. R5 stated she had told nursing (unknown), Administration (V1), Director of Nursing/DON (V2), and the Assistant Director of Nursing/ADON (V14) and they hadn't done anything to correct it. R5 asked this surveyor to walk with her to the medication cart to see they were administering the wrong medication. At the medication cart, V8 (Licensed Practical Nurse/LPN) pulled out a bottle of medication at R5's request and showed this surveyor it was Preservision. V8 told R5 we got the Preservision this morning. The bottle had a date of 8/18 handwritten on the lid. R5 stated to V8, so you got it after I called it in to state?On 8/18/25 at 12:56 PM, V8 (LPN) stated the pharmacy stopped sending stock medications in the cards and she had ordered the Preservision but all she could get was the Ocuvite. V8 stated they called the pharmacy and were told it was the same formulary and were told to use the Ocuvite by V2 (Director of Nurses), so they administered the Ocuvite in place of the Preservision. When asked how long R5 received the Ocuvite in place of the Preservision, V8 stated she wasn't sure. V8 stated they tried to call the physician who prescribed it but they hadn't received a call back. V8 stated it had been weeks, maybe months.On 8/18/25 at 1:13 PM, V10 (LPN) stated when she got to work on the night of 8/17/25, R5 was worked up, about the Preservision. V10 stated she tried calling R5's physician on 8/18/25 and notified V2 (DON) and V14 (ADON). V10 stated they went out and purchased the Preservision this morning.On 8/18/25 at 3:20 PM, V2 (DON) stated R5 had an order for the Preservision and was getting it from the pharmacy and then it wasn't covered by R5's insurance anymore. V2 stated the only thing she was able to order was the Ocuvite. V2 stated the pharmacy was called and they said it was the same thing. V2 stated they tried to reach out to R5's Primary Physician to the get the order changed. When asked how long R5 was receiving the Ocuvite instead of the Preservision, V2 stated she didn't know. When asked if the physician order was still Preservision and if the facility nursing staff were signing, they administered Preservsion instead of Ocuvtie, V2 stated she didn't know.On 8/19/25 at 10:57 AM, V14 (ADON) stated V2 wasn't in the facility today but she was familiar with R5 and the Preservision order. V14 stated the pharmacy was providing the Preservision initially and then they stopped providing it. V14 wasn't sure why but she thought it had something to do with R5 reaching her maximum allowed amount. V14 stated she was made aware on 8/8/25 by R5 that she was receiving Ocuvite and not Preservision as ordered.On 8/19/25 at 11:08 AM, V15 (Pharmacist) stated R5's Preservision was filled on 4/28/25 for a 30-day supply and had not been filled by their pharmacy since then. V15 stated the Preservision has a different formula than Ocuvite with different concentrations of vitamins and minerals. V15 stated they didn't send any to the facility after 4/28/25 because they didn't have any refills and if the facility would fax over a new prescription for the Preservision they would fill it.The facility Medication Administration through Certain Routes of Administration policy dated 11/15/24 documents, Applicability: Policy 6.7 establishes guidelines for the safe and effective administration of medications through various routes of administration in a long-term care (LTC) facility. It ensures that medications are administered according to best practices, physician orders, and in compliance with current practice guidelines, and state and federal regulations.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications were available to be administered a...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications were available to be administered as ordered for 1 of 1 (R5) resident reviewed for pharmacy services in the sample of 9. Findings Include:R5's facility Transfer/Discharge Report with a print date of 8/18/25 documents R5 was admitted to the facility on [DATE] with diagnoses that include bipolar disorder, delusional disorder, insomnia, and moderate intellectual disability.R5's MDS (Minimum Data Set) dated 6/30/2025 documents a Brief Interview for Mental Status score of 15, indicating R5 is cognitively intact.R5's Order Summary Report Active Orders as of: 04/19/2025 includes the following physician order with a start date of 04/18/2025, Preservision AREDS 2 Softgel Give 1 capsule orally one time a day for Supplement Take 1 Capsule by Mouth Once Daily (Supplement).R5's Medication Administration Records (MAR) dated 4/1/2025 through 4/30/25, 5/1/2025 to 5/31/2025, 6/1/2025 to 6/30/2025, 7/1/2025 to 7/31/2025, and 8/1/2025 to 8/31/2025 document a physician order for Preservision AREDS 2 Soft gel to be given once daily by mouth. These same MAR's document initials on each indicating R5 was administered Preservision AREDS 2 one capsule daily.R5's current Care Plan does not document a Focus area related to the diagnosis of Macular Degeneration.On 8/18/25 at 11:29 AM, R5 stated she called the State Survey Agency yesterday because the facility was giving her Ocuvite for her Macular Degeneration, instead of the Preservision her physician had ordered. R5 stated she had told nursing (unknown), Administration (V1), Director of Nursing/DON (V2), and the Assistant Director of Nursing/ADON (V14) and they hadn't done anything to correct it. R5 asked this surveyor to walk with her to the medication cart to see they were administering the wrong medication. At the medication cart, V8 (Licensed Practical Nurse/LPN) pulled out a bottle of medication at R5's request and showed this surveyor it was Preservision. V8 told R5 we got the Preservision this morning. The bottle had a date of 8/18 handwritten on the lid. R5 stated the V8 so you got it after I called it in to state.On 8/18/25 at 12:56 PM, V8 (LPN) stated the pharmacy stopped sending stock medications in the cards and she had ordered the Preservision but all she could get was the Ocuvite. V8 stated they called the pharmacy and were told it was the same formulary and were told to use the Ocuvite by V2 (Director of Nurses) so they administered the Ocuvite in place of the Preservision. When asked how long R5 received the Ocuvite in place of the Preservision, V8 stated she wasn't sure. V8 stated they tried to call the physician who prescribed it but they hadn't received a call back. V8 stated it had been weeks, maybe months.On 8/18/25 at 1:13 PM, V10 (LPN) stated when she got to work on the night of 8/17/25, R5 was worked up, about the Preservision. V10 stated she tried calling R5's physician on 8/18/25 and notified V2 (DON) and V14 (ADON). V10 stated they went out and purchased the Preservision this morning.On 8/18/25 at 3:20 PM, V2 (DON) stated R5 had an order for the Preservision and was getting it from the pharmacy and then it wasn't covered by her insurance anymore. V2 stated the only thing she was able to order was the Ocuvite. V2 stated the pharmacy was called and they said it was the same thing. V2 stated they tried to reach out to R5's Primary Physician to the get the order changed. When asked how long R5 was receiving the Ocuvite instead of the Preservision, V2 stated she didn't know. When asked if the physician order was still Preservision and if the facility nursing staff were signing, they administered Preservsion instead of Ocuvtie, V2 stated she didn't know. On 8/19/25 at 10:57 AM, V14 (ADON) stated V2 wasn't in the facility today but she was familiar with R5 and the Preservision order. V14 stated the pharmacy was providing the Preservision initially and then they stopped providing it. V14 wasn't sure why but she thought it had something to do with R5 reaching her maximum allowed amount. V14 stated she was made aware on 8/8/25 by R5 that she was receiving Ocuvite and not Preservision as ordered.On 8/19/25 at 11:08 AM, V15 (Pharmacist) stated R5's Preservision was filled on 4/28/25 for a 30-day supply and had not been filled by their pharmacy since then. V15 stated the Preservision has a different formula than Ocuvite with different concentrations of vitamins and minerals. V15 stated they didn't send any to the facility after 4/28/25 because they didn't have any refills and if the facility would fax over a new prescription for the Preservision they would fill it.The facility Medication Administration through Certain Routes of Administration policy dated 11/15/24 documents, Applicability: Policy 6.7 establishes guidelines for the safe and effective administration of medications through various routes of administration in a long-term care (LTC) facility. It ensures that medications are administered according to best practices, physician orders, and in compliance with current practice guidelines, and state and federal regulations.
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 ensure they had RN (Registered Nurse) coverage 8 hours/day, 7 days/week. This failure has the potential to affect all 50 residents who resi...
Read full inspector narrative →
Based on interview, and record review the facility failed to ensure they had RN (Registered Nurse) coverage 8 hours/day, 7 days/week. This failure has the potential to affect all 50 residents who reside at the facility. Findings Include:The undated facility Room Roster documents 50 residents currently reside at the facility. On 8/18/25 at 3:20 PM, V2 (Director of Nurses) stated she didn't have a Registered Nurse on staff. V2 stated she does have agency Registered Nurses that work at the facility at times. The facility schedules dated July 2025 and August 2025 documents the facility did not have RN coverage on 7/18, 7/19, 8/9, 8/10, and 8/23/25. On 8/18/25 at 4:25 PM, V2 confirmed in email the facility did not have RN coverage on the above listed dates.
Jun 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency 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 ensure a resident requiring dialysis received dialysis treatments f...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident requiring dialysis received dialysis treatments for 1 of 2 residents (R1) reviewed for dialysis in the sample of 11. This failure resulted in R1 being admitted to the hospital to receive dialysis treatment and pulmonary venous congestion.
Findings include:
R1's admission Record documents an admission date of 3/31/25 and diagnoses including peripheral vascular disease, end stage renal disease, iron deficiency anemia, chronic diastolic heart failure, dependence on renal dialysis, sepsis, bacteremia, and essential hypertension. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 15, indicating R1 is cognitively intact. The same MDS documents under special treatment, procedures, and programs that R1 is receiving dialysis.
R1's most recent Care Plan documents a focus area with an initiation date of 3/31/25 of R1 receives dialysis and a goal area of R1 will remain free of complications related to dialysis.
On 5/28/25 at 12:49 AM, R1 stated he has missed appointments for dialysis since the van has been broken down and dialysis is a life sustaining treatment. R1 said he has been sent to the hospital twice for dialysis. R1 stated the first time they did not even do dialysis there and he was sent back to the facility without receiving dialysis and the next time he was sent to a different hospital and had to stay overnight to receive dialysis. R1 stated the facility does keep checking his blood he guesses because he missed his dialysis. R1 stated he is unsure how many times he has actually missed. R1 stated they gave him grief at the hospital because he did not know they did not do dialysis, that is where he was sent, he did not have any control over that. R1 stated the next time he was sent to another hospital and stayed overnight but then he received dialysis in the morning. R1 said that he did not refuse to go to dialysis on 5/16/25, the transportation van was broken down. R1 stated his dialysis is every Monday, Wednesday, and Friday.
R1's Progress Notes document the following:
5/16/25 at 5:12 AM: Resident refused AM meds and is now refusing to go to dialysis. Transportation aide made aware. Will monitor for change.
5/19/25 at 8:06 AM: R1 did not attend dialysis.
5/19/25 at 12:45 PM: Call placed to (name of dialysis center) r/t (related to) missed dialysis appointment this am. New order received to send res (resident) to ER (Emergency Room). This writer spoke with (R1), he is in agreeance .
5/19/25 at 3:00 PM: V15 (Medical Records/Transportation) reached out to a local transportation company, and they stated they do not start transporting early enough to transport R1 to dialysis.
5/19/25 at 6:00 PM: Resident returned from (name of local hospital). Nurse on duty stated that resident did not receive Dialysis because labs did not indicate he needed Dialysis at this time and ER cannot do Dialysis. Resident would need to be admitted there was no need for him to be admitted because his condition is stable but resident needs to go to Dialysis tomorrow. Writer informed DON (Director of Nurses).
5/20/25 at 3:05 PM: V15 called a local transportation company, and they told her they do not service their area.
5/21/25 at 5:40 AM: Resident up in dining room at this time awaiting ride for dialysis. Transportation aide here and notified this nurse that transportation van is unavailable for transport at this time and would need to be transported another way to dialysis. DON notified and awaiting further orders.
5/21/25 at 6:34 AM: The dialysis center was called due to R1 missing dialysis treatment today. New orders were received to send R1 to the emergency room. EMS (Emergency Management Service) was called to transport R1 to the local hospital.
5/21/25 at 2:15 PM: Spoke with (name of hospital Case Manager) at (name of local hospital). She states resident is telling them we will not take him to his dialysis appts (appointment), she is wanting to know what is going on with this. This nurse explained resident missed his appt Friday the 16th due to his own refusal, he did not want to go to dialysis that day. Resident missed dialysis Monday the 19th due to the van lift not working that morning. We contacted (name of dialysis center) to let them know what was going on. They stated they would like resident to go to the ER. Resident was sent to (name of a local hospital) for eval and possible dialysis. (Name of a local hospital) reported to us they did labs and he does not require dialysis at this time. Resident missed dialysis this am (Wednesday 21st) due to van lift still being broken and unable to find other transportation. (Name of dialysis center) was notified, they stated to send to ER. Resident was then sent to them at (name of local hospital). (Name of hospital Case Manager) states understanding. I let her know we were having a lot of trouble finding transportation for him while our van is being repaired. (Name of hospital Case Manager) suggested (name of a transportation company), I let her know we have already tried them and they do not service [NAME] County. But if she has any other suggestions for transportation to please let us know and we will try. (Name of hospital Case Manager) said she will call us back with any suggestions. (Name of hospital Case Manager) asked if this will be an issue for Friday as well, are we going to send him back to them for dialysis? I told her I could not say for sure. At this time we do not have transportation for Friday, but we are working on it. (Name of hospital Case Manager) states they may admit and keep (R1) until after her receives dialysis Friday. They are unsure of that plan at this time, they will call us back to let us know.
5/23/25 at 5:30 AM: The dialysis center was called to inform them that the facility's van was still out of service and R1 has no transportation to his dialysis appointment today. The dialysis center's staff stated to monitor intake and output and to monitor for noticeable decline in condition and if condition changes send to the emergency room to get dialysis.
5/26/25 at 6:23 AM: The dialysis center was called related to missed dialysis treatment today. The dialysis center's nurse stated to monitor R1 for nausea, vomiting, diarrhea, and increased shortness of breath and if these symptoms are noted send to the emergency room.
5/27/25 at 11:28 AM: V15 spoke with a local transportation company to see if they could privately pay the transportation company to transport R1 to dialysis and the transportation company said they do not provide transportation that early. V15 then called R1's dialysis center to see if there was a later chair time for R1, they stated they would look and call them back.
5/27/25 at 12:00 PM: V15 spoke with the dialysis center, and they could do a later chair time at a different dialysis clinic location, but the transportation company does not run as late as the appointment and would not be available to transport R1 back to the facility after the appointment.
R1's local hospital document titled Hospital Discharge Summary Brief Overview dated 5/22/2025 documents an admission date of 5/21/2025 and a discharge date of 5/22/2025 and a primary discharge diagnosis of End Stage Renal Disease. R1's local hospital Dialysis Note, Hemodialysis Post Treatment Summary dated 5/21/2025 documents R1 received a dialysis treatment with a duration of treatment of 3 hours. R1's Chest Radiograph from local hospital dated 5/21/25 at 10:13 AM-5/21/25 at 10:35 AM documents under impression: 3. Pulmonary venous congestion with equivocal interstitial edema and trace bilateral pleural effusions.
On 5/28/25 at 10:16 AM, V6 (Registered Nurse at dialysis center) stated R1 has not been to treatment since 5/14/25 due to transportation. V6 stated the facility told them their transportation van was broken down and they didn't have any other transportation. V6 stated today was his first day there since 5/14/25.
On 05/28/25 at 3:25 PM, V3 (Assistant Director of Nursing) stated the facility van has been broken for approximately 1.5 weeks. R1 has been sent to the hospital twice to receive dialysis, one time he received dialysis and one time he did not receive dialysis. The first hospital stated they do not do dialysis, but they did his labs and stated he did not need dialysis immediately, so they returned him to the facility. The next time they sent him out, they sent him to (a different local hospital) he was admitted and stayed overnight and received dialysis the next day. V3 stated, dialysis is always beneficial for a resident that is on dialysis treatment but maybe not always immediately crucial. V3 stated, R1 missed dialysis on the previous Friday (05/16/25) because he refused, on 05/19/25 he was sent to the hospital but did not receive dialysis, on 05/21/25 he was sent to the hospital and received dialysis, on 05/23/25 and 05/26/25 he did not receive dialysis, today (05/28/25) they were able to borrow a van and he went to dialysis. V3 stated he believes he missed four days total of dialysis due to the van not working. V3 stated, the moment they were aware the lift gate on the van didn't work they started looking into other options to get him to dialysis.
On 05/28/25 at 11:26 AM, V4 (Licensed Practical Nurse) stated the facility van has been broken for about a week that she is aware of, she has been at school. V4 said that R1 has missed dialysis due to the van being broken. V4 said R1 was able to go to dialysis today due to borrowing a van from another facility.
On 5/29/25 at 8:41 AM, V12 (Registered Nurse dialysis center) stated R1 needs to be at dialysis for his scheduled treatment 3 days a week per the physician order. V12 stated R1's creatinine was reasonably high at his last labs so that indicates R1 does need dialysis. V12 stated R1's fluid status wasn't bad when he came to treatment on 5/28/25. V12 stated R1 had lost 4.6 kilograms since the last treatment. V12 stated there is also the risk of R1 becoming uremic if he doesn't get dialysis as ordered.
On 5/29/25 at 10:01 AM, V13 (Nephrologist) stated R1 does need dialysis at this time. V13 stated they drew labs on 5/28/25 at the dialysis center but those labs have not resulted yet.
On 5/29/25 at 1:17 PM, V14 (Regional Administrator) stated they have purchased a new accessible van, and it should be here in about one week, it was shipped from another state.
On 5/29/25 at 1:17 PM, V1 (Administrator) stated until the new van arrives, they will be borrowing a van from a sister facility. The transportation aide is picking the borrowed van up today and it will be available to transport residents to their dialysis appointments until the new van arrives. V1 stated it is the expectation that if they accept a resident that is on dialysis, they are responsible for providing the transportation to their dialysis appointments.
The facility policy dated 2/13/18, titled Dialysis Monitoring and Observation documents under Purpose: To ensure residents receiving hemodialysis are monitored for complications. The facility policy dated 12/19/23, titled Transportation for Residents documents under Guidelines 4. Designated personnel shall assist residents in obtaining transportation when it is necessary to obtain medical, dental, diagnostic, or other services outside the facility.
Mar 2025
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility failed to notify the proper authorities in an abuse investigation in 1 (R14...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility failed to notify the proper authorities in an abuse investigation in 1 (R14) of 1 resident reviewed for abuse.
The findings include:
R14's admission Record documented admission to the facility on 2/13/25 and included diagnoses of peripheral vascular disease, heart failure, Type 2 Diabetes Mellitus, chronic pressure ulcers on right buttock, stage 3, non-pressure related chronic ulcers of left heel and mid foot and left lower leg.
R14's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R14 is cognitively intact.
The facility's Report to IDPH Regional Office documented an initial report dated 3/10/25, noting there was an allegation of staff to resident abuse (verbal). Actions taken included the CNA's (Certified Nurse Assistant's) in question were suspended, the physician and Power of Attorney (POA) were notified on 3/10/25. The document also notes an investigation was initiated. There was no documentation on the Initial Report to show that the Local Police were notified. The facility's Report to IDPH Regional Office doucmented a Final Report was submitted on 3/13/25 and noted R14 reported to dayshift CNA that the night shift CNA's were rude to him and that they took his laptop away from him. This report has sections to note if Resident Representative/Family and Physician are notified and those sections are marked Yes. The document does not include a section to note whether law enforcement is notified and the report does not include this information.
On 3/13/25 at 2:30PM, after being asked if the facility notified law enforcement, V1 (Regional Director of Operations) stated she did not notify the police.
The facility document titled Abuse Prevention and Reporting-Illinois Effective date 11-28-16, revised 10/24/22 documented the purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by .Filing accurate and timely investigative reports .Informing Local Law Enforcement. The facility shall also contact local law enforcement authorities (i.e., telephoning 911 where available) in the following situations:
·
Physical abuse involving physical injury inflicted on a resident by a staff member or a visitor.
·
Physical abuse involving physical injury inflicted on a resident by another resident except in situations where the behavior is associated with dementia or developmental disability.
·
Sexual abuse of a resident by a staff member, another resident, or visitor.
·
When there is a reasonable suspicion that a crime has been committed in the facility by a person other than a resident.
·
When a resident death has occurred other than by disease processes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure behavioral interventions and procedures for suicide observat...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure behavioral interventions and procedures for suicide observation and prevention were provided to a resident with suicidal ideations for 1 (R23) of 1 resident reviewed for behavioral health services in the sample of 27.
The findings include:
R23's admission Record documents that she was admitted to the facility on [DATE] and included diagnoses of major depressive disorder, schizophrenia, borderline personality disorder, anxiety disorder, panic disorder, cognitive communication deficit, vascular dementia, moderate with psychotic disturbance, unspecified sequelae of cerebral infarction and epilepsy.
R23's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, indicating R23 has moderate cognitive impairment. Under the section for Mood, R23 is documented as having the following symptoms: Little interest or pleasure in doing things, feeling down, depressed, or hopeless, Trouble falling or staying asleep, or sleeping too much, feeling tired or having little energy, poor appetite or overeating, and feeling bad about self - or that you are a failure or have let self or family down. At the time of this assessment, R23 was not documented as having thoughts that she would be better off dead, or of hurting self in some way. Under the section for Behavior, delusions was documented as a potential indicator of psychosis, and the following behavioral symptoms were checked: physical behavioral symptoms directed towards others, verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others which were noted to significantly interfere with the resident's care and the resident's participation in activities or social interactions.
R23's Care Plan documents Focus Areas of Risk for Depression, Behavior Management, R23 uses antidepressant medication, R23 uses antipsychotic medications r/t (related to) Schizophrenia, and R23 may display s/s (signs/symptoms) of depression. Interventions listed for Risk for Depression include to notify provider any risk for harm to self and/or others (initiated 5/9/24) and observe resident for any signs/symptoms of depression, including: hopelessness, anxiety, sadness .verbalizing negative statements, repetitive anxious or health-related complaints and tearfulness (initiated 5/9/24). Interventions listed for Behavior Management include monitor for cognitive factors that may contribute to new behavior(s) and provide emotional support regarding new onset disruptive behavior, refer to SSD (Social Services Director) PRN (as needed (initiated 3/7/25), and utilize diversion techniques as needed (initiated 3/6/25). Interventions listed for R23's use of antidepressant medication include to monitor/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions, social isolation, suicidal thoughts, withdrawal, etc. (initiated 4/4/24). Interventions listed for R23's use of antipsychotic medications r/t diagnosis of schizophrenia include to monitor/document/report PRN any adverse reactions of psychotropic medications: including suicidal ideations, social isolation and behavior symptoms not usual to the person (initiated 4/4/24). Interventions for R23's potential to display s/s of depression include: monitor/document/report PRN any risk for harm to self; suicidal plan, past attempt at suicide, risky actions, intentionally harming or trying to harm self .sense of hopelessness or helplessness, impaired judgement or safety awareness (initiated 4/4/24), monitor/document/report PRN any s/s of depression including hopelessness, anxiety, sadness .verbalizing negative statements, repetitive anxious or health related complaints, tearfulness (initiated 4/4/24), and the resident needs time to talk. Encourage the resident to express feelings (initiated 4/4/24).
A Progress Note dated Sunday 3/9/25 at 9:03 PM, documented a behavioral note written by V14 (Agency Licensed Practical Nurse/LPN) noting Resident stated several times per this shift that she wants to kill herself. Writer spoke with resident she had no plan on how she was going to kill herself she just wants to die. Staff monitored resident closely per this shift. There were no other progress notes in the medical record on this date or through the night shift hours documenting whether R23's mood or behavior improved or worsened, no documentation to show a suicide checklist or assessment was completed, no documentation noting the physician had been notified, nor any documentation to show evidence that any follow-up monitoring had been implemented.
The next behavioral Progress Note regarding R23's suicidal ideation behavior was dated Monday 3/10/25 at 9:41 AM by V15 (Social Service Assistant/SSA) and documented Was reported per DON (Director of Nursing) that R23 wasn't feeling well this weekend and had made several threats that she wanted to die without a plan. I checked on (R23) twice this morning and she appears to be sleeping I will c/t to monitor (R23) closely and provide 1:1's as needed for safety and comfort. This note also does not document the physician was notified of R23's suicidal ideation behaviors.
A Progress Note dated 3/10/25 at 2:53 PM documented a behavior note written by V15 that stated I spoke with (R23); she was calling out. I asked what she was up to. She said she had to pee. I assured her that some (sic) had just helped her and left her room. I assured her I would get someone to help. I asked (R23) what was going on this weekend about her comment about not wanting to live anymore. She shook her head and said, 'I just want someone to take me to poop.' I will c/t monitor Renee's cognitive change.
A Suicidal Threat Checklist (No Attempt Has Been Made) was completed by V15 dated 3/10/25, a day after R23 verbalized suicidal threats. This checklist includes 5 tasks/questions, with number 1 stating to check resident's Suicide Potential Assessment (located in Chart). Question #2 - Ask the Resident why they made the threat is answered I don't know I just want someone to take me to poop. #3 - Ask the resident if there is a staff member who can solve the problem and how is answered I want out of this stupid chair. #4 - If staff and resident can't solve the problem does the resident still want to harm himself is answered No, I want someone to take me pee. #5 - Ask the resident if there is a plan to harm himself and what the plan is, is answered I aint got no plan, look at me. The Options document send to hospital, place on 1:1, place on 15 min check, counseling and the items written in are 1:1 Counseling with cognitive behavioral skills building training. Under Risk Level is documented R23 is at low risk due to cognitive and memory impairment. R23 is bed ridden at this time.
On Tuesday 3/11/25 at 2:36 PM, V14 documented Writer telephoned NP (Nurse Practitioner) to inform of resident's suicidal threats left message to telephone facility.
On 3/13/25 at 3:10PM, V14 (Agency LPN) stated she assessed R23 and did not think she was serious, so she did not notify the Physician. V14 said she did not think to notify the physician (at that time) but did notify them on 3/11/5 at 2:36 PM. V14 said she just kept an eye on R23 that night and did not document any checks.
On 3/14/25 at 10:00AM, V2 (Director of Nursing/DON) stated she did not know about R23 having suicidal ideations until she read the note. V2 said that she went to morning meeting (3/10/25) where they discussed it and she asked V15 (SSA) to go talk to R23 and see how she was doing. V2 said the Physician had not been notified. V2 said if she would have known about it at the time it occurred, she would have notified the Physician, implemented every 15-minute checks and ensured Social Service completed a suicide assessment.
On 3/14/25 at 11:00AM, V15 (Social Services Assistant) said she was told about R23's suicidal ideations during morning meeting on 3/10/25. V15 said she talked with R23 and also did a suicide assessment in which she determined R23 was not at risk of suicide. V15 said that R23 had forgotten all about it and was hyper focused on toileting and had just went to the bathroom.
On 3/14/25 at 11:15AM, V2 (DON) said she did notify the Physician on 3/11/25 and he called back and said to have her seen by Psych. V2 said that R23 was going to be seen anyway on 3/12/25.
The facility's undated Suicide Observation and Prevention policy documents the purpose is to protect resident from self-injury or death, to increase resident's control of self-destructive impulse and to provide opportunity to talk about problems. The policy documents the responsibility as nursing personnel and interdisciplinary team members and states It is the policy of the Nursing Department to implement nursing interventions for residents who exhibit suicidal tendencies. Under Procedure, #2 documents Continuous monitoring includes mental and psychosocial status as well as physical and under Rationale/Amplification documents All changes in condition require prompt notification of physician and sponsor/family member. The same document notes .Initiate a monitoring form or document checks every 15 minutes and stay within visual and close access of the resident at all times as determined necessary by Charge Nurse and M.D. (Medical Doctor) until medical psychiatric evaluation indicates it is no longer necessary.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to safeguard medical record information against loss/destruction and ens...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to safeguard medical record information against loss/destruction and ensure records were readily accessible for 3 (R2, R33, R38) of 3 residents reviewed in the sample of 27.
The Findings Include:
1. R33's Electronic Health Record (EHR) included an admission Record documenting R33 admitted to the facility on [DATE]. R33's EHR was missing records dated prior to 1/29/25 (such as progress notes, behavior tracking, physician orders, etc.).
2. R38's EHR included an admission Record documenting R38 admitted to the facility on [DATE]. R38's EHR included an Minimum Data Set (MDS) assessment dated [DATE] documenting a discharge with return not anticipated assessment an listed a discharge status of Nursing Home (long-term care facility). R38's EHR was missing records dated prior to 1/29/25 (such as progress notes, physician orders, and a discharge summary, etc.).
3. R2's EHR included an admission Record documenting R2 admitted to the facility on [DATE]. R2's EHR included an MDS assessment dated [DATE] documenting a discharge with return anticipated and listed a discharge status of Short-Term General Hospital. R2 had an MDS entry completed on 5/2/2024 to show R2 returned to the facility on this date. R2 had another MDS completed on 9/28/24 documenting a discharge with return anticipated assessment that listed a discharge status of Short-Term General Hospital with a subsequent entry completed on 10/3/2024 to show R2 returned to the facility on this date. R2's EHR was missing several records dated prior to 1/29/25 (such as progress notes, physician orders, and any records related to hospitalizations, etc.).
On 3/13/2025 at 8:30 AM, in response to being asked to provide previous medical records for R2, R33 and R38, V13 (Medical Records) stated the medical records room had water damage related to a water pipe busting in the facility's sprinkler system. V13 stated half of the room holding residents' paper medical records dating prior to the facility's electronic health records going live on 1/29/25 are damaged and unreadable.
On 3/13/2025 at 10:00 AM, V1 (Regional Director of Operations) stated the facility's electronic medical records went live on 1/29/25 but the facility did not have any way to obtain R2, R33 and R38's medical records dated prior to that date because of the medical records room flooding during a cold snap, leaving the paper documents illegible.
On 3/13/2025 at 11:00 AM, surveyor requested documentation regarding R2's hospitalizations and V7 (Financial Coordinator) stated that she did not have any way to obtain R2's medical records for these dates due to the room where the medical records were kept flooded and all of the paper records are illegible. V7 clarified that the facility's electronic medical records went live on 1/29/25, so many of the paper records prior to that date were not available due to being destroyed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure that dietary supplements were provided to residents as ordered for 4 (R4, R13, R19, and R20) of 4 residents reviewed fo...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to ensure that dietary supplements were provided to residents as ordered for 4 (R4, R13, R19, and R20) of 4 residents reviewed for nutrition status in the sample of 27.
The Findings Include:
1. R4's admission Record documents an admission to the facility on 1/13/2025 and included the following diagnoses: dementia, Vitamin D deficiency and Vitamin B12 deficiency.
R4's current Physician Orders for diet are as follows: regular diet and mighty shakes twice a day for low Body Mass Index (BMI).
R4's Care Plan has a focus area of: I have a potential nutritional problem. A goal for this focus area included: I will maintain adequate nutritional status daily through the review date. The interventions include: provide diet as ordered.
2. R13's admission Record documents an admission date of 8/25/2020 and included the following diagnoses: bipolar disease, anxiety, depression, and muscle wasting and atrophy.
R13's current Physician Orders have a diet order of mighty shakes with meals for significant weight loss for 6 months, No added salt diet.
R13's Care Plan includes a focus area of: risk for malnutrition. The goal for this focus area is: resident intake of nutrients will meet metabolic needs. Interventions include to provide diet as ordered and a mighty shake at breakfast and supper.
3. R19's admission Record documents an admission to the facility on 1/17/2023 and included the following diagnoses: unspecified dementia, Alzheimer's disease, and cognitive communication deficit.
R19's current Physician Orders include a regular diet and mighty shakes with three meals.
R19's Care Plan includes a focus area of: the resident has a potential nutritional problem. The goal listed for this focus area is: The resident will maintain adequate nutritional status as evidenced by maintaining weight, no signs or symptoms of malnutrition, and no indication of issue with diet consistency through the next review. The interventions include the following: mighty shakes three times a day related to weight loss.
4. R20's admission Record documented an admission date of 9/29/2024 and included the following diagnoses: Alzheimer's, anxiety, major depressive disorder, and muscle wasting and atrophy.
R20's current Physician Orders include a diet order of regular diet with mighty shakes at meals for encouraging increase in intake with weight loss.
R20's Care Plan includes a focus area of: the resident has a potential nutritional problem. The goal for this focus area is: The resident will consume diet in amount adequate to meet nutritional needs as evidenced by maintaining weight with no excessive loss. The interventions include: provide and serve diet as ordered.
On 3/11/2025 during the lunch meal observation at 12:00 PM, V5 (Dietary Manager) stated that the truck did not come in until lunch meal service started and the mighty shakes were frozen when delivered. V5 stated that the residents that are ordered mighty shakes did not get them for breakfast or lunch today. At this time, V5 stated that residents who are ordered supplements twice a day get them at breakfast and lunch, residents who have them ordered once a day get them at lunch, and residents who are ordered supplements three times a day get them with each meal.
On 3/11/2025 at 2:00 PM, V5 provided a list of residents that are to receive supplements and it listed R4 to receive mighty shakes twice a day, R13 to receive mighty shakes three times a day, R19 to receive mighty shakes three times a day, and R28 to receive mighty shakes once a day.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure Registered Nurse (RN) coverage 8 consecutive hours a day, 7 days per week. This failure has the potential to affect all 40 residents...
Read full inspector narrative →
Based on interview and record review, the facility failed to ensure Registered Nurse (RN) coverage 8 consecutive hours a day, 7 days per week. This failure has the potential to affect all 40 residents living in the facility.
Findings Include:
The facility's agency nursing time reports documented no RN was on shift for 11/10/2024, 11/23/2024, 11/24/2024, 11/28/2024, 11/30/2024, 12/7/2024, 12/8/2024, and 12/21/2024.
On 3/13/2025 at 7:50 AM, V10 (Licensed Practical Nurse/LPN) stated there were some days in October 2024 - December 2024 that they did not have RN coverage for 8 consecutive hours a day.
On 3/13/2025 at 10:05 AM, V2 (Director of Nursing) stated there were no RN punch times noted on the agency nursing reports for 11/10/2024, 11/23/2024, 11/24/2024, 11/28/2024, 11/30/2024, 12/7/2024, 12/8/2024, and 12/21/2024.
On 3/13/2025 at 10:30 AM, V1 (Regional Director of Operations) stated the facility did not have documentation of a Registered Nurse on shift for at least 8 consecutive hours a day on 11/10/2024, 11/23/2024, 11/24/2024, 11/28/2024, 11/30/2024, 12/7/2024, 12/8/2024, and 12/21/2024. V1 stated the facility follows the regulations for staffing because they don't have a policy on RN coverage 8 Hours per day/7 days a week.
The Long-Term Care Facility Application for Medicare and Medicaid document dated 3/11/2025, documents 40 residents residing 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 properly maintain the hot water source to reach minimum washing temperatures in the dish machine and handle food properly to pr...
Read full inspector narrative →
Based on observation, interview and record review the facility failed to properly maintain the hot water source to reach minimum washing temperatures in the dish machine and handle food properly to prevent cross contamination. These failures have the potential to affect all 40 residents residing in the facility.
The Findings Include:
1. On 3/11/25 at 1:00 PM, the kitchen staff were in the process of washing the lunch dishes after the meal was served in the dish machine. When the temperature in the dish machine was checked with a kitchen provided calibrated thermometer, the water temperature was 80 degrees. At this time V5 (Dietary Manager) verified their dish machine was a low temperature dishwasher that uses chemical sanitization. V5 stated that they have trouble sometimes with the water temperatures because of the way the system works. V5 stated that they have two 40 gallon water heaters, but one of them feeds both the three compartment sink and the dish machine. V5 stated that she typically would like the water temperature above 110 degrees Fahrenheit.
On 3/11/25 at 2:00 PM, V4 (Maintenance) stated that he thinks that they need to make sure that they don't fill the 3 compartment sink and run the dishwasher at the same time, that is why they are running out of hot water. V4 further stated that he checked it now, and the water was up to 100 degrees Fahrenheit. V4 stated that he will tell the kitchen staff this is new procedure until they have a long term fix. At this time they are hand washing the dishes in the sink with the appropriate water temperature.
On 3/12/2024 at 2:00 PM, V5 checked the temperature of the water in the dish machine without the 3 compartment sink filled, and it was at 100 degrees Fahrenheit. V5 stated that they have not been using it this afternoon recently, but they would be sure to take the temperature before they wash anything to make sure it is hot enough.
A policy titled Dietary Policies and Procedures Mechanical Ware Washing documents the dish machine should be used in accordance with the manufacturer's specifications 2. Record the parts per million (PPM), wash and rinse temperatures for the low temperature dish machine. 6. The logs should be completed before beginning to wash the breakfast, lunch and dinner dishes. The requirements for the machine must be met before washing/sanitizing the dishes. Follow the manufacturer's directions for checking temperature and sanitizer. Contact the chemical/machine company for any concerns.
According to www.americandish.com, the manufacturer's guidelines for the American Dish Service dish machine used at the facility recommends a minimum of 120 degrees Fahrenheit for proper dish cleansing and sanitization.
2. On 3/11/25 at 11:40 AM, V6 (Cook) was taking temperatures of foods in steam table to be served for lunch. V6 washed his hands, placed gloves on, opened a cabinet drawer to get a thermometer out, opened a drawer to get the serving utensils out, took off the covers to the food items on the steam table and with those same gloved hands while checking the temperature of the turkey, V6 picked up 3 slices of turkey and stated it sure feels hot. As the lunch service continued on, V6 used his same gloved hands to push foods off the serving spoon, and/or move the food around on the plate. V5 (Dietary Manager) stated at this time she would have a talk with V6 about not touching the food with his hands whether gloved or not.
The facility's Proper Hand Washing and Glove Use policy documents: All employees will use proper hand washing procedures and glove usage in accordance with state and federal sanitation guidelines .7.Gloves are changed any time hand washing would be required. This includes when leaving the kitchen for a break, or to go to another location in the building; after handling potentially hazardous raw food; or if the gloves become contaminated by touching the face, hair, uniform, or other non-food contact surface, such as door handles and equipment. 8. Staff should be reminded that gloves become contaminated just as hands do, and should by changed often. When in doubt, remove gloves and wash hands again.
The Long Term Care Facility Application for Medicare and Medicaid signed and dated 3/11/25, documents 40 residents residing in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to maintain documentation of holding quarterly Quality Assurance and Performance Improvement meetings (QAPI). This has the potential to affect...
Read full inspector narrative →
Based on record review and interview, the facility failed to maintain documentation of holding quarterly Quality Assurance and Performance Improvement meetings (QAPI). This has the potential to affect all 40 residents residing in the facility.
The Findings Include:
During the investigation and review of facility records no evidence of quarterly QAPI meeting attendance or meeting information was found or produced by the facility.
On 03/13/25 10:41 AM, V1 (Regional Director of Operations) stated the facility has been having quarterly QAPI meetings but she was unable to find any documentation of minutes or attendance sheets to show that the facility held quarterly QAPI meetings past 2/16/2024.
The facility policy for Quality Assurance Performance Improvement Program with last revision date of 10/24/22 documents the following:
Purpose: To ensure the organization has an organized quality assessment and improvement process program that includes performance measurement, performance assessment, and performance improvement and addresses the care and unique services provided by the facility.
Guidelines: It is the policy of this facility to systematically improve its performance by having an organized Quality Assurance Performance Improvement Committee that assures a quality assessment and improvement program is planned, systematic, ongoing, and focused on those important processes or outcomes related to resident care and organizational functions. The committee functions and program shall be in accordance with the Quality Assessment and Improvement Standards of the Joint Commission on Accreditation of Healthcare Organizations for Long Term Care and federal and state regulations and in coordination with the overall Quality Assurance Performance Improvement program of this facility.
Identification, Reporting, Investigation, Analysis & Prevention: The Committee shall identify issues with respect to quality assessment and assurance activities and assess results of specific quality assurance assessment reports during regularly scheduled meetings. Members assigned to attend per schedule shall present their reports in writing whenever possible and avoid the use of resident names or positive identifiers. The Committee will develop and implement appropriate plans of action and/or performance improvement plans to correct undesirable variations in performance. The status of identified problems or opportunities for improvement and action plans will be monitored by the committee to assure resolution.
The Long Term Care Facility application for Medicare and Medicaid dated 3/11/25, documents 40 residents reside in the facility.
Dec 2024
2 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0605
(Tag F0605)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free from chemical restraints when staff admin...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free from chemical restraints when staff administered an injectable anti-psychotic medication twice within an 8 hour time frame without the resident's consent and without a physician's order to include adequate indications for use, and failed to attempt less restrictive alternative treatments prior to administration of the medication for 1 (R1) of 3 residents reviewed for chemical restraints in the sample of 7. This failure resulted in R1 being sent to the emergency room for lethargy, facial swelling, and possible allergic reaction to the anti-psychotic medication administered.
This failure resulted in an Immediate Jeopardy, which was identified to have begun on 12/3/24 at approximately at 10:30 PM when V10 (Licensed Practical Nurse) administered Chlorpromazine (Thorazine) 100mg Intramuscular injection and again on 12/4/2024 at 5:30AM.
V1 (Administrator) was notified of the Immediate Jeopardy on 12/17/24 at 3:40 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed, and the deficient practice corrected on 12/18/24, but the noncompliance remains at Level Two due to additional time needed to evaluate implementation and effectiveness of training.
The findings include:
R1's admission Record documents an admission date of 9/6/2023 and includes diagnoses of Parkinsonism, Paranoid Schizophrenia, unspecified Psychosis, Heart Failure, Anxiety Disorder, Hypertension, Schizoaffective Disorder and Major Depressive Disorder. R1's admission Record also documents R1's allergies as Clonazepam (Klonopin), Fluphenazine (Prolixin), Haloperidol (Haldol), and Mellaril (Thioridazine).
R1's Minimum Data Set (MDS) dated [DATE] documents in section C, Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 99, indicating that R1 was unable to complete the interview. Section E, Behavior, Delusions is marked under potential indication for Psychosis. Section E also documents that verbal behavioral symptoms directed toward others occurred 4 to 6 days, but less than daily, during the 7 day look back period. Physical and other behavioral symptoms directed at others is marked as the behavior was not exhibited. Section N, Medications, documents that R1 received antipsychotics on a routine basis only.
R1's Physician Orders dated 9/6/2023 documents an order for Chlorpromazine 100mg IM every 6 hours as needed for Psychosis. Offer by mouth first give with Benztropine in same syringe. R1's Physician Orders for September, October, November, and December 2024 were reviewed with no orders noted for Chlorpromazine (Thorazine). R1's document titled Medication Administration Record for December 2024 has no documentation of an order for, or administration of, Chlorpromazine (Thorazine).
On 12/13/2024 at 10:58AM, V18 (Registered Pharmacist) stated R1's order for Chlorpromazine (Thorazine) 100mg IM was ordered on 9/2/2023 and stopped on 9/21/2023 and the reason for that date is because the order was processed on 9/7/2023 and 14 days later it was stopped on 9/21/2023. V18 said that there was not a restart date or updated order date for Chlorpromazine (Thorazine). V14 stated the order was stopped on 9/21/2023 due to being an as needed psychotropic medication and cannot be valid after 14 days so it is stopped by the pharmacy due to regulations.
On 12/11/2024 at 2:40PM, V12 (Certified Nurse Assistant/CNA) stated she worked on the night of 12/3/2024-12/4/2024 from 8PM -6AM and she was the one-on-one sitter for R1. V12 stated when she arrived at work that evening, she was told in report that R1 had thrown a urinal at staff. V12 stated at approximately 9:30PM she was being assisted by another CNA with R1's care and R1 spit on the other CNA. V12 stated V10 came in and told R1 she was going to give him something to calm him down if he didn't stop having behaviors. V12 stated around 10:30PM she and another CNA (V14) was standing R1 up so he could use the urinal, and V10 came in and went behind R1 and gave him a shot in his bottom. V12 stated R1 said That was a sneaky thing you just did. V12 stated earlier in the shift, V11 (LPN) had come into the room and told R1 she would give him a shot if he had any behaviors. V12 stated after the injection R1 had behaviors for about 15 minutes then he went to sleep and slept like a baby all night. V12 was asked if she witnessed the 2nd Injection that was said to have been given at approximately at 5:30AM on 12/4/2024, V12 stated I did not and I was watching him very closely as I would push a resident just up to the dining room and then went back in to check on R1, not leaving him out of my sight for more than a couple of minutes at a time. V12 stated when she left at 6:00AM, R1 was sleeping soundly. V12 stated V10 told her she had given a second shot, but she didn't witness this and R1 was sleeping.
On 12/11/2024 at 3:28PM, V10 (LPN) stated she was familiar with R1, and she worked on the night shift that started on 12/3/2024 at 10:00PM and ended at 6:00AM on 12/4/2024. V10 stated R1 started having behaviors of biting, spitting, and kicking staff so she pulled 2 ampules of Chlorpromazine (Thorazine) to administer to R1. V10 stated the medication was in a box in the medication cart with R1's name on the box with instructions. V10 stated she went to R1's room and 2 CNA's (V12 and V14) were standing him up with his pants down to either change him or let him use the urinal. V10 stated each CNA had ahold of R1's arms. V10 stated I sneaked in behind them and jabbed him in the butt with the shot of medication of Chlorpromazine. V10 was asked if she explained to R1 what she was doing and V10 stated Lord no, he would not have let me do it. V10 was asked what R1's response was when she gave him his injection, V10 stated well he swung at me and I dodged the hit and R1 stated, that was sneaky and that was not right. V10 was asked if she validated the orders for R1 before administration and V10 stated No. V12 stated she gave a second injection on 12/4/24 at 5:30AM.
R1's Nurse's Note dated 12/3/2024 at 10:30PM, authored by V10 (LPN), documents Resident screaming and cursing staff during care spitting on CNA's PRN (as needed) injection given. Remains 1:1.
On 12/12/2024 at 2:45PM, V10 was asked why the injection of Chlorpromazine (Thorazine) was given at 5:30AM on 12/4/2024, V10 stated he was acting up and starting to get revved up again. V10 stated she can't remember who assisted her with the injection, but she did give him an injection at 5:30AM on 12/4/24. V10 was asked if she explained to R1 what she was administering and V10 stated No I just jabbed it in his arm. V10 stated V10 is very strong and can hurt people. V10 was asked why there is no documentation of giving this injection, V10 stated I was busy trying to pass medications and I was helping the CNA's as well. V10 stated she had not had time to check physician orders or the medication administration record prior to administering the medication or even after she administered either dose she had administered.
On 12/12/2024 at 12:10PM, V13 (CNA) stated he was aware R1 received an injection at 10:30PM the night of 12/3/2024. V13 stated he worked 10PM to 6AM on 12/3/204-12/4/2024. V13 stated he was unaware that a second injection was given at 5:30AM on 12/4/2024. V13 stated he went and checked on R1 before he left at 6:00AM and he was really sleeping. V13 stated the reason the injection was given at 10:30PM on 12/3/2024 is R1 was starting to kick us and using obscene language. V13 stated after the injection R1 slept all night.
On 12/12/2024 at 12:52PM, V14 (CNA) stated she worked 10PM-6AM on 12/3/2024-12/4/2024. V14 stated R1 was yelling down the hall and spit on staff around 10PM. V14 stated that R1 was trying to get out of bed. V14 said she was told by V10 to help V12 get R1 in a standing position and pull his pants down so V10 could give him an injection. V14 stated V10 came in the room and got behind us and gave the injection in R1's buttocks, this occurred around 10:30PM. V14 stated R1 swung at V10 and R1 stated that was sneaky. V14 stated we offered R1 the urinal after the injection and he refused to use the urinal. V14 stated R1 rested the rest of the night, and he was fine throughout the night. V14 stated she was not aware of a second injection being given. V14 stated she checked on R1 before she left at 6:00AM and he was sleeping well.
On 12/12/2024 at 1:17PM, V15 (CNA) stated she came to work on 12/4/2024 at 5:00AM. V15 stated she did not know of any behaviors from R1 and did not get anything in report, but she was assigned to a different hall. V15 stated she did see V10 with a syringe in her hand but did not know who the medication was for and what room V10 went into.
On 12/12/2024 at 1:30PM, V16 (CNA) stated she worked on 12/4/2024 from 5:00AM to 1:00PM. V16 stated when she arrived at work and made some rounds, she did not know of any residents having behaviors. V16 stated she was busy getting residents up and she did see V10 with a syringe in her hand but did not know who it was for. V16 stated she did not witness or assist with any injections being given.
On 12/12/2024 at 12:15PM, V9 (LPN) stated on 12/4/2024 she was the charge nurse for R1. V9 stated she received report from V10 (LPN) at 6:00AM, V10's report included information that V10 had administered Haldol IM (intramuscular injection) at 10:30PM on 12/3/2024 and 5:30AM on 12/4/2024. V10 reported to V9 that R1 had been aggressive. V9 stated she went to check on R1 before breakfast and R1 was sleeping, and he didn't arouse when she softly called his name. V9 stated R1 did not eat breakfast because he was sleeping. V9 stated I just thought he was tired from the medication. V9 stated she went back to his room to check on him a short time before lunch and she could not get him to wake up, so she asked V7 (LPN) to come help her with him. V9 stated she and V7 went immediately back to R1's room and turned him over a little and noted R1 to arouse a little and he was mumbling with worsened slurred speech, lips swollen, side of his face was red with some edema noted and the top of his head was very red with a rash like appearance. V9 stated she ran and got V3 (LPN/Assistant Director of Nursing), and this is when they called EMS (Emergency Medical Services) to transport R1 to the ER (Emergency Room). V9 stated she then went to investigate what actual medication was given. V9 stated she noted a box of Chlorpromazine with 20 ampules in the box and the box had contained 25 ampules when it was filled.
R1's Nurse's Note dated 12/4/2024 at 12:20PM, authored by V9 (LPN), documents that EMS in facility to transport resident to ER.
On 12/11/2024 at 2:22PM, V3 (Licensed Practical Nurse/Assistant Director of Nursing) stated on 12/4/2024 she arrived at work around 11:00AM. V3 stated V7 (Licensed Practical Nurse/LPN) and V9 (Licensed Practical Nurse) were working the floor at the time, and reported to V3 that R1 was not acting right, and his eyes were swollen, as well as his mouth. V3 stated she called the ambulance. V3 stated R1 was sent out to the emergency room. V3 stated during her investigation she spoke with V12 (Certified Nurse Assistant/CNA) who was the sitter on the previous night of 12/3/2024, for R1. V3 stated that V12 reported she witnessed an injection being given to R1 by V10 (Licensed Practical Nurse/LPN) the night of 12/3/2024. V3 stated she was under the impression that R1 had to be held for the injection and that is not allowed as that is physically restraining a resident, then giving the medication to calm him down is a chemical restraint.
R1's Nurse's Note dated 12/4/2024 at 11:30AM, Medication removed from medication cart Chlorpromazine IM (Intramuscular) vials removed and discarded.
R1's Nurse's Note dated 12/4/2024 at 11:59AM, authored by V3 (LPN/Assistant Director of Nursing), documents Resident noted to have symptoms of allergic reaction. Upon entering residents (R1) room this nurse noted that resident has a swollen face, eyes, and hives. Called (V8-Physician) with symptoms and gave orders to send to ER (Emergency Room) for eval and treat. EMS (Emergency Medical Service) called.
R1's Nurse's Note dated 12/4/2024 at 12:45PM, authored by V7 (LPN), documents that report called to local hospital ER.
On 12/12/2024 at 12:31PM, V7 (LPN) stated she was working the day of 12/4/2024. V7 stated she was asked to go with V9 to check on R1. V7 stated we got him aroused, his face/jaw area was swollen, and I remember the top of his head was so red with a rash noted. V9 stated she noted his tongue seemed a little thick and his speech was really slurred. V7 stated when EMS got to the facility R1 was still lethargic and he didn't even resist care as he normally does. V7 stated all R1 did was mumble. V7 stated she has never given R1 any type of injections and she did not know those injections were in the medication cart.
R1's Emergency Department document titled: Physician Documentation dated 12/4/2024 at 1:29PM documents this [AGE] year-old white male presents to Emergency Department by EMS (Emergency Medical Service) with complaints of possible allergic reaction. Patient at nursing home was sent in because nurses thought he was having an allergic reaction to some medication. Patient was seen yesterday by this Emergency Department, was found to have emergency medical condition (complaint was abdominal pain). Patient was given Benadryl Intravenously in rout by EMS they felt like his face was flushed and had some swelling, patient knocked out from Benadryl, he does react if you touch him. Will CAT SCAN head. The ER Notes documents allergies of: Fluphenazine, Haldol, Klonopin, Mellaril, Penicillin, Porlixin. The ER Course documents at 2:48PM: in lieu of the labs done yesterday that were within normal limits and patient is back to normal limits after IV (Intravenous) Benadryl wore off. Will return to nursing home. There is no allergic reaction to medication because he did not get any yesterday while in this Emergency Department and he did not get any nursing home medications today either.
On 12/12/2024 at 7:11PM, V17 (emergency room Physician) stated he was working the day of 12/4/2024 and he provided care for R1. V17 pulled the ER visit that occurred on 12/4/2024 and was reading his report to this surveyor. V17 read the report stating R1 had not received any medications the day before (12/3/2024) while in the emergency room and there is no evidence of medications being given in between ER visits. V17 was asked if he was aware R1 had received 2 injections of Chlorpromazine (Thorazine) with one being on 12/3/2024 at 10:30PM and the other one at 5:30AM on 12/4/2024, V17 stated I was not aware of that at all, and nobody reported this to me. V17 stated well this changes things because it makes sense why the paramedics administered IV (Intravenous) Benadryl, this patient probably was having an allergic reaction. V17 stated the paramedics would not have administered any medications while in route if it was not deemed necessary for the safety for the patient. V17 stated I saw (R1) probably at least 30 minutes after the Benadryl was administered and the redness and swelling would have decreased from the Benadryl by that time. V17 stated (R1) was really lethargic but I thought it was from the Benadryl. V17 stated No wonder he was so out of it, he had a big dose of Thorazine just a few hours before and one before that 6 hours apart. V17, stated I reviewed (R1's) medication sheets and those did not even list Thorazine and there sure was no documentation of Thorazine given. V17 was asked if this was a potential for harm to this patient and V17 Absolutely and not even just the allergic reaction, the fact that this patient had received 2 large doses of Thorazine within hours of coming to the ER and me as the physician not even knowing that, this could have been a bad situation for the patient. I could have ordered a medication that was contraindicated with Thorazine.
Attempts were made on 12/13/2024, 12/16/24, and 12/17/24 to reach the ambulance service for an ambulance report for R1 on 12/4/2024 without success.
On 12/13/2024 at 10:58AM, V8 (Physician) stated he does recall being informed R1 was administered 2 separate doses of Thorazine and was sent to the emergency room due to possible reaction. V8 stated he was not notified until R1 was in the Emergency Room. V8 was asked if he was aware the order for Thorazine was discontinued on September 21st, 2023, V8 stated I am not sure I knew that part. V8 stated he recalls the ER did not think it was an allergic reaction for some reason. V8 was informed the ER was unaware of the Thorazine injections. V8 stated Ok, makes sense. V8 stated I hope that is now on his allergy list along with other psych medications on his list. V8 stated R1's Psychosis has worsened since November. R1 started refusing his medications and was very paranoid of his medications.
On 12/10/2024 at 1:45PM, V1 (Administrator) stated she was aware of the medication error that was made on R1. V1 stated she had terminated 2 nurses over the incident. V1 stated one nurse was fired because she intended to give the medication if a behavior would have occurred on her shift and the other nurse (V10) actually gave the medication not once but twice. V1 stated she could not believe a nurse would give a medication without checking the records. V1 stated there is nothing she could have done to stop it unless she was asked prior to administering the medication. V1 stated R1 was sent to the hospital with what looked like an allergic reaction.
An incident report titled Report to IDPH (Illinois Department of Public Health) Regional Office dated 12/4/2024, documents the following Description of Occurrence: On early AM 12/5/2024 (R1) was unable to speak clearly, noted his face and lips are slightly swollen, and some red rashes on his upper torso. (V8-Physician) was called immediately, and the order was received to transport resident to local hospital for further evaluation. It was discovered that a med that was given in the past had been used for (R1) due to behaviors. These injections were discontinued in September of 2023. The medication was good until 3/2025. This medication was accidently given to the resident at 10:30PM and again at 5:30AM for continued behaviors. The Action Taken on the incident report documents the following: Patient (R1) transported to (name of local hospital) by ambulance for treatment and observation. Resident was evaluated and a CT (Computed Tomography) was completed with no finding. Resident was returned to the facility with acting behaviors. Resident was placed on 1:1 with a staff member and referrals were sent to several facilities. The Final Summary documents the following: (R1) was taken immediately to local hospital, he was gone only a short time and returned to our facility with no findings of medications being the issue. They did perform a CT without contrast, and it came back clear as well.
R1's Care Plan documents a Focus area of the resident is/has potential to be verbally aggressive with an initiation and revision date of 5/6/2024. Documented interventions for this focus area include the following: Provide positive feedback for good behavior, Emphasize the positive aspects of compliance (5/8/2024); Psychiatric/Psychogeriatric consult as indicated (5/8/2024); the resident tolerates minimal people at a time. The resident needs much amount of personal space. The resident reacts to touch by striking (5/8/2024); When the resident becomes agitated, intervene before agitation escalates. Guide away sources of distress. Engage calmly in conversation, if response is aggressive, staff to walk away calmly and approach later (5/8/2024).
R1's Care Plan also documents a Focus area of the resident is/has potential to be physically aggressive with an initiation date of 6/10/24. The documented Goal of The resident will not harm self or others thru the next 90 days with an initiation date of 6/10/2024 and a revision date of 12/5/24. Documented Interventions include: administer medications as ordered. Monitor/document for side effects and effectiveness (6/10/2024), assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. (6/10/2024) Communication: provide physical and verbal cues to alleviate anxiety, give positive feedback, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated (6/10/2024). Give the resident as many choices as possible about care and activities (6/10/2024). Modify environment (6/13/2024). Monitor, document observed behavior and attempted interventions in behavior log (6/13/2024). Monitor/document/report any signs or symptoms of resident posing danger to self and others 6/10/2024). Psychiatric/Psychogeriatric consult as indicated (6/10/2024). When the resident becomes agitated intervene before agitation escalates. Guide away from source of distress. Engage calmly in conversation. If aggressive, staff to walk calmly away and approach later (6/10/2024).
R1's Care Plan also documents a Focus are of The resident uses anti-psychotic medications with a Goal of The resident will remain free of psychotropic drug related complication, including movement disorder, discomfort, hypotension, gait disturbances, constipation/ impaction, or cognitive/behavioral impairment through review date with an initiation date of 5/8/2024. Intervention: Administer Psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift. (5/6/2024). Review behavior/interventions and alternate therapies attempted and their effectiveness as per facility protocol. Educate the resident/family/ caregivers about risk, benefits and the side effects and toxic symptoms (5/8/2024).
R1's Behavior Tracking was requested from V3 on 12/12/2024 and 12/13/2024 for December 2024 and none was provided. R1's Behavior Tracking was requested again from V1 on 12/19/24 and was received. R1's Behavior Tacking Records provided documents the dates of 12/17/24-12/31/24 and do not document any behaviors occurring or need to attempt interventions. There were no Behavior Tracking Records for R1 provided for December prior to 12/17/24.
The facility policy titled Medication Administration (undated) documents under procedures #2, Review and confirm medication order for each resident on the Medication Administration Record prior o administering medications to each resident. Review medication administration record for any tests or vital signs that need to be determined prior to preparing the medications. Number 9 documents, chart medication administration on Medication Administration Record immediately following each resident's medication administration.
The facility policy titled Psychotropic Medication Policy with a revision date of 11/28/2017, documents it is the policy of this facility that residents shall not be given unnecessary drug. Definition of Chemical Restraint documents any medication that is administered with the intent of altering consciousness, responsiveness, or to modify behavior, convenience, punishment, or discipline. The section titled procedure documents #1. Attempt to rule our social and environmental factors as causative agents of maladapted behavior. 2. Psychotropic medications shall not be prescribed prior to attempted non-pharmacological interventions to decrease behaviors. 5. Psychotropic medication shall not be prescribed or administered without the informed consent of the resident, the resident's guardian, or other authorized representative.
The immediate jeopardy that began on 12/3/24 was removed on 12/18/24 when the facility took the following actions to remove the immediacy and correct the deficient practice as confirmed through observation, interview, and record review:
Facility Restraint Policy was reviewed by Regional Director of Operations (V19) on 12/17/24 and was found to be in compliance with state and federal regulations.
Facility Administrator (V1) initiated in-servicing, for all staff, on the use of non-pharmacological interventions for resident behaviors initiated on 12/18/2024 all other staff will be in-serviced before the beginning of the next shift.
The Administrator (V1) will interview 3 staff members, 3 times weekly x4 weeks to ensure that staff, understand using non-pharmacological interventions for resident behaviors.
Director of Nursing (V2) in-serviced all nurses to obtain orders for the administration of an injectable anti-psychotic initiated on 12/17/2024 to be completed by the beginning of the next scheduled shift.
Director of Nursing (V2) in-serviced all nurses on documenting all medication administration in the MAR initiated on 12/17/2024 to be completed by the beginning of the next scheduled shift.
Social Service Director will interview 3 residents, 3 times weekly x4 weeks to ensure that residents are getting their medication as prescribed.
IDT (Interdisciplinary Team) has assessed R1 and care plan updated to reflect non-pharmacological interventions for behaviors on 12/17/24.
IDT team reviewed all residents for the potential to not be free of abuse and care plans updated to reflect interventions to protect residents from abuse. Completed on 12/18/24.
IDT in-serviced by Regional Director of Operations (V19) on 12/18/24 to review any resident for changes in behaviors, increase in behaviors or new behaviors in order to investigate and identify any potential triggers prior to an incident, ensure that person centered interventions are developed to alleviate/decrease behaviors and to communicate identified triggers and interventions to staff.
Residents who trigger during this IDT review will be discussed during morning meeting and a root cause analysis will be completed to determine potential triggers. Individualized intervention will be developed to decrease episodes of behaviors, in order to prevent situations that may cause abuse to a resident. (on-going)
On 12/4/24 the nurses in question (V10 and V11) were suspended pending investigation of the med error and ultimately terminated on 12/5/24.
ADON (Assistant Director of Nursing-V3) completed an audit of the medication carts and medication room on 12/5/24 to ensure there were no medications present that did not have orders from the physician.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to timely remove discontinued medication from the working...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to timely remove discontinued medication from the working stock for 1 of 3 residents (R1) reviewed for medication storage in a sample of 7.
The findings include:
R1's admission Record documents an admission date of [DATE] and diagnoses including Parkinsonism, Paranoid Schizophrenia, Psychosis, Heart Failure, Anxiety, Hypertension, Schizoaffective Disorder, and Major Depressive Disorder.
R1's Physician Orders dated [DATE] documents an order for Chlorpromazine 100mg IM every 6 hours as needed for Psychosis. Offer by mouth first give with Benztropine in same syringe.
R1's Physician Orders for September, October, November, and [DATE] were reviewed with no orders noted for Chlorpromazine (Thorazine).
R1's Medication Administration Record (MAR) for [DATE] was reviewed with no orders or documentation of the administration of Chlorpromazine (Thorazine) noted.
On [DATE] at 3:15PM, V11 (Licensed Practical Nurse/LPN) stated she worked the evening of [DATE]. V11 stated R1 was not acting out but she pulled out a medication (she called Compazine) labeled with R1's name to have ready just in case she needed it. V11 stated she thought the medication was Compazine and she did not check the MAR (Medication Administration Record) or the POS (Physician Order Sheet) to validate the orders with this medication. V11 stated she would have checked if she would have needed to administer the medications. V11 stated R1 did not have behaviors. V11 stated when her shift was over, she wasted the vial of medication and reported to V10 she had pulled the medication and wasted it. V11 stated she later learned the medication was Chlorpromazine (Thorazine) that she had pulled off the medication cart.
On [DATE] at 3:28PM, V10 (Licensed Practical Nurse) stated she was familiar with R1, and she worked on the night shift that started on [DATE] at 10:00PM and ended at 6:00AM on [DATE]. V10 stated when she got report from V11 on R1 she was told R1 returned with the police after being in jail for assault, and V11 told her she had pulled an ampule of an injectable medication to have just in case she needed it for behaviors for R1. V10 stated R1 started having behaviors of biting, spitting, and kicking staff so she pulled 2 ampules of Chlorpromazine (Thorazine) to administer to R1. V10 stated the medication was in a box in the medication cart with R1's name on the box with instructions. V10 stated the box had been on the cart ever since she had worked at the facility which was a few months.
R1's Nurse's Note dated 12//3/2024 at 10:30PM, authored by V10 (LPN), documents Resident screaming and cursing staff during care spitting on CNA's (Certified Nurse's Assistants) PRN (as needed) injection given. Remains 1:1.
On [DATE] at 12:15PM, V9 (Licensed Practical Nurse) stated on [DATE] she was the charge nurse for R1. V9 stated she received report from V10 at 6:00AM, V10's report included information that V10 had administered Haldol IM (intramuscular injection) at 10:30AM on [DATE] and 5:30AM on [DATE]. V10 reported to V9 that R1 had been aggressive. V9 stated she then went to investigate what actual medication was given to R1. V9 stated she noted the box of Chlorpromazine (Thorazine) with 20 ampules in the box and the box had contained 25 ampules when it was filled. V9 stated she then called the pharmacy to see when the order was processed for the Chlorpromazine (Thorazine). V9 stated the pharmacy told her the order had been discontinued in 2023. V9 stated she had never seen this box before and she works the same cart all the time. V9 stated it must have been in the back of the drawer.
On [DATE] at 12:31PM, V7 (Licensed Practical Nurse) stated she has never given R1 any type of injections and she did not know those injections were on the cart.
On [DATE] at 2:22PM, V3 (Licensed Practical Nurse/ Assistant Director of Nursing) stated on [DATE] she arrived at work around 11:00AM. V3 stated the medication Chlorpromazine (Thorazine) was present on the medication cart, the ampules were in a box with R1's name on it. V3 stated she spoke with V11 (Licensed Practical Nurse) and V11 stated the medication was Compazine. V3 stated she educated V11 the medication was not Compazine it was Thorazine, and she needed to always look up the medication to validate what the medication actually was and its indications. V3 stated that all medications that are discontinued should be removed from the medication cart and be either destroyed or sent back to pharmacy.
R1's Nurse's Note dated [DATE] at 11:30AM, documents medication removed from medication cart Chlorpromazine IM (Intramuscular) vials removed and discard.
On [DATE] at 10:58AM, V18 (Registered Pharmacist) stated that R1 had an order for Chlorpromazine 100mg IM dated [DATE] and stopped on [DATE] and the reason for that date is because the order was processed on [DATE] and 14 days later it was stopped on [DATE]. V14 stated the order was stopped on [DATE] due to being an as needed psychotropic medication and cannot valid after 14 days, so it is stopped by the pharmacy due to regulations.
The pharmacy policy titled Disposal/Destruction of Expired or Discontinued Medication with a revision date of [DATE] documents under Procedure step 2 Once an order to discontinue a medication is received, facility staff should remove this medication from the resident's medication supply. Procedure step 4 documents Facility should place all discontinued or outdated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction.
May 2024
5 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
Based on interview and record review the facility failed to ensure residents are free from physical and verbal abuse for 2 of 5 residents (R26, R44) reviewed for abuse in the sample of 14. This failur...
Read full inspector narrative →
Based on interview and record review the facility failed to ensure residents are free from physical and verbal abuse for 2 of 5 residents (R26, R44) reviewed for abuse in the sample of 14. This failure resulted in R26 experiencing incidents of mental anguish, fear, anxiety, and feeling unsafe as a result of V34's (Certified Nursing Assistant/CNA) mental and verbal abuse.
The Immediate Jeopardy began on 5/7/24 at approximately 2:00 AM when V34 (Certified Nursing Assistant/ CNA) verbally and physically abused R26 by ripping R26's clothing while transferring R26 to the wheelchair and wheeling R26 to the dining room to wait for breakfast. V44 (Regional Director of Operations) was notified of the Immediate Jeopardy on 5/15/24 at 12:35 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 5/16/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.
Findings include:
1. R26's document titled admission Record documented an admission date of 8/23/2019 with diagnoses including: Ischemic Cardiomyopathy, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Peripheral Vascular Disease, Hypertension, Hyperlipidemia, Chronic Kidney Disease stage 3, Schizoaffective Disorder, Atrial Fibrillation, Anxiety, Chronic Obstructive Pulmonary Disease, presence of Automatic (implantable) Cardiac Defibrillator, Alzheimer's Disease, Unilateral Inguinal Hernia, Diabetes Mellitus, and Unspecified Urinary Incontinence.
R26's MDS (Minimum Data Set) dated 4/23/2024 documented a BIMS (Brief Interview for Mental Status) with score of 10, indicating moderate cognitive impairment. R26's 4/23/24 MDS section GG documented R26 required maximal assistance with toileting and hygiene; dependent for shower and bathing, and lower body dressing; and partial to moderate assistance with transferring.
R26's care plan did not document R26 having the potential for abuse.
On 5/8/2024 at 10:32 AM, R26 was an alert and oriented resident sitting in the dining room. R26 stated his care is good here except for the night shift. R26 stated he gets his clothes ripped by a night shift CNA (Certified Nursing Assistant), V34. R26 pointed to the upper right shoulder area of his shirt that was ripped and stated V34 ripped it when he was pulling me out of bed. R26 stated, He (V34) gets me up at 2:00 AM-3:00 AM and brings me to the dining room and I have to sit here until breakfast.
On 5/10/2024 at 12:15 PM, R26 stated I get tired of the treatment from (V34) CNA. I don't feel safe when (V34) is working. I want to just pull my pacemaker out and end it all sometimes, but only when (V34) is taking care of me. R26 then stated if R26 used the bathroom in bed V34 would roughly get R26 out of bed, ripping R26's clothes at times, and wheel R26 to the dining room to wait for breakfast. R26 stated V34 was also verbally abusive. R26 said the last time V34 had been abusive like this to R26 was within the past week of this survey (5/3/24 through 5/10/24). R26 stated facility staff were aware of V34 being abusive but nobody does anything about it. R26 was not able to give any staff names.
On 5/10/24 at 3:14 PM, V34 (CNA) stated he assisted R26 with care around 2:00 AM on 5/7/24, 5/8/24, 5/9/24, and 5/10/24 during bed check. V34 said R26 was usually one of the last residents V34 would assist because R26 was usually not wet. V34 said he did not like to put a wrap around pullup on R26 because it gave R26 an excuse to pee in the bed instead of using the urinal. V34 stated he was not trying to be a d**k, but I know (R26) can use the urinal during the day. V34 said he was not trying to argue with (R26) but If (R26) wets the bed, I make (R26) get up in his chair so I can change the bed and put a pullup on (R26). V34 stated (R26) was not an easy resident to care for. V34 said when he is providing care for R26, V34 just tells (R26) like it is when things have to get done. V34 said he was very direct with residents and I feel like being direct is the only was for a resident to fully understand what is about to happen.
On 5/10/2024 at 12:30 PM, R37 a roommate of R26 stated nightshift gets (R26) up around 3:00 AM and will make (R26) stay up if (R26) has soiled the bed. (V34 CNA) is very dismissive and verbally aggressive with (R26). R37 stated he has heard V34 tell R26 You must stay up because you pissed the bed. R37 said he had witnessed V34 handling R26 rough when getting R26 out of bed at night. R37 stated the last time it happened was this past week. R37 states V1 (Administrator) knows but nothing happens. R37's 3/26/24 MDS (Minimum Data Set) documented a BIMS (Brief Interview for Mental Status) score of 15, indicating R37 was cognitively intact.
R26's 5/15/24 final reportable incident documented in part . Regional Director interviewed the resident (R26) and he stated that CNA (V34) grabs his shirt pocket and rips them when he is attempting to get him out of bed. Resident stated that CNA gets him up at 2 or 3 AM for no reason . Resident state that CNA talks rudely to him . Regional Director interviewed (R26's) roommate (R37). (R37) is (alert and oriented times 4). (R37) stated that (R26) is pulled around by (V34) in the middle of the night because resident doesn't want to get up at 2 AM. (R37) stated that (V34) is verbally demeaning to resident and his tone of voice is aggressive when speaking with (R26) . Conclusion After a thorough investigation the facility is able to substantiate the allegation. (V34) has been terminated .
2. R44's face sheet documented an initial admission date of 6/30/23 with diagnoses including, aftercare following joint replacement surgery, paranoid schizophrenia, conversion disorder with seizures or convulsions, gout, hypertension, schizoaffective disorder bipolar type, anxiety disorder, and hyperlipidemia.
R44's 3/8/24 MDS documented a BIMS score of 00, indicating severe cognitive impairment. R44's 3/8/24 MDS section GG documented R44 was dependent for all Activities of Daily Living (ADL) except eating.
R44's care plan did not document R44 was at risk for abuse.
On 5/10/2024 at 12:20 PM, R44 was interviewed but was a poor historian with some confusion noted.
On 5/10/24 at 3:14 PM, V34 (CNA) said he recalled when R44 returned to the facility from the hospital because it was a sad time because R44 was very sick. V34 said after answering R44's call light one night, V34 had gotten about halfway back down the hall after answering R44's call light when R44 turned his call light on again. V34 said he had joked with R44 saying what do you need now? It's been 5 seconds since I left. V34 said there were times R44 has been half awake and V34 did not know if R44 knew he was joking. V34 said staff will get frustrated with R44 using the call light. V34 said R44 was a very confrontational resident. V34 said he had gotten frustrated with R44 in the past when R44 would not use the urinal. V34 said when R44's urinal is empty, V34 has told R44 that V34 knows no staff have emptied R44's urinal and R44 needs to start using it. V34 said he was not sure if V34 telling R44 to use the urinal would be taken as threatening because we have to tell (R44) that every night.
On 5/10/24 at 12:15 PM, V37 (CNA) said he had worked in the facility for about 7 months. V37 said he had never witnessed any physical abuse while in the facility but had witnessed verbal abuse. V37 said R44 had just returned from the hospital and there was something wrong with R44's stomach. V37 said R44 kept turning on the call light thinking R44 had to use the restroom but when staff would get to R44's room R44 would say he didn't have to go anymore. V37 said he witnessed V34 (CNA) say to R44 that V34 was going to take R44's call light away from R44 if R44 did not stop turning the call light on. V37 said he did not report the incident because he wanted to give V34 a chance, but it didn't do any good. V37 said he knew what V34 had done to R44 was abuse. V37 said V34 could be rough with residents during care.
R44's 5/14/2024 Incident Investigation Form documented an interview by V37 (CNA) .(R44) was on the light quite a bit thinking he had pooped. He had been on the call light a lot. (V34 CNA) told (R44) if you didn't s**t, I'm going to take that call light away from you. Didn't report because (V37) was busy and didn't want to see (V34) get in trouble .
On 5/14/24 at 12:57 PM, V44 (Regional Director of Operations) said that she had forgotten about R44's abuse allegation on 5/10/24. V44 said she would have R44's investigation completed on that day (5/14/24).
On 5/14/24 at 4:00 PM, V44 (Regional Director of Operations) presented R44's 5/4/24 facility investigation and verified the one staff interview of V37 (CNA) was the complete investigation. R44's 5/14/24 facility investigation file did not contain any other staff interviews or resident interviews.
On 5/15/2024 at 2:10 PM, V1 (Administrator) stated the staff she usually interviews are the supervisors and/or directors. V1 stated she usually only interviews the staff that are around. V1 stated I only interview the residents that are alert and oriented.
R44's 5/15/24 final reportable to Illinois Department of Public Health (IDPH) documented in part . Summary . it was reported to (V44 Regional Director of Operations) by (V37 CNA) that at an unknown date and time (R44) had recently returned from the hospital and was on his call light quite a bit. (V34 CNA) came into work at 6pm and (R44) had been continually putting on his call light thinking that he had had a (bowel movement) but had not. (V37) stated that one time when the call light went off he went to answer it and (V34) went with him. (V37) then stated that (R34) told (R44) if you have not s**t I'm taking the call light away for the rest of the night . Conclusion . After a thorough investigation the facility is able to substantiate the allegation. (V34) has been terminated .
On 5/8/24 at 10:55 AM, V19 (CNA) said she worked day shift in the facility. V19 said she had heard a resident say the guys on midnight shift are mean. V19 said V34 (CNA) was related to someone who used to be in management at the facility.
On 5/8/24 at 1:16 PM, V42 (Licensed Practical Nurse/ LPN) said on 5/4/24 she had reported other allegations to V1 (Administrator) regarding V34 (CNA) as being physically and verbally abusive. V42 said (V34 CNA) was related to someone who used to be in management at the facility. V42 said she had heard some things about V34 being rough but had never witnessed any abuse by V34 herself.
On 5/14/2024 at 4:20pm, V44 (Regional Director of Operations) stated the investigations were completed for the allegations of abuse on both R26 and R44 and both investigations substantiated that abuse occurred. V44 stated she terminated V34 on this date.
Document titled Abuse Prevention Program with Revised date of 11/28/2016 documented in part .this facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property and exploitation .
The Immediate Jeopardy that began on 5/7/24 was removed on 5/16/24 when the facility took the following actions to remove the immediacy.
Immediate actions:
1. For the Resident found to be affected by the alleged deficient practice, the following corrective action has been taken to achieve compliance:
A.
IDT (Interdisciplinary Team) team has assessed (R26) and care plan updated to reflect potential for abuse and interventions to protect (R26) from abuse. Completed on 5/15/2024.
B.
(V34 CNA) had been suspended on 5/10/2024 pending outcome of an investigation and was terminated on 5/14/24.
2. The following systematic measures have been implemented to ensure that the revised 11/28/16 Abuse Prevention Program policy is being followed:
A.
Facility Abuse Prevention Policy was reviewed on 5/13/24 and was found to be in compliance with state and federal regulations.
B.
On May 14, 2024 (V44) Regional Director in-serviced the Administrator (V1) on the Abuse Prevention Policy, which included identifying types of abuse, investigating and reporting all alleged abuse allegations and immediately suspending employee, accused.
C.
Facility Administrator (V1) initiated in-servicing, for all staff, on the Abuse Prevention Policy on 5/16/2024 prior to their shift, all staff on shift and will inservice all other staff prior to their next shift.
D.
The Administrator (V1) will interview 3 staff members, 3 times weekly x 4 weeks to ensure that staff, understand the Abuse Prevention Policy, timely reporting of abuse, who to report abuse to, types of abuse and immediately separating residents or suspending a suspected staff member. Initiated on 5/14/2024.
E.
Resident council meeting was conducted on 5/14/24 to review the Abuse Prevention Policy and how to report abuse or perceived mistreatment. Resident council president and IDT team members present.
F.
Social Service Director (V6) will interview 3 residents, 3 times weekly x 4 weeks to ensure understanding of abuse and reporting of any abuse or perceived mistreatment, by another residents or a staff member. Initiated on 5/14/2024.
G.
IDT team reviewed all residents for the potential of abuse and care plans updated to reflect interventions to protect residents from abuse. Completed on 5/16/2024.
H.
IDT in-serviced to review any resident for changes in behaviors, increase in behaviors or new behaviors in order to investigate and identify any potential triggers prior to an incident, ensure that person centered interventions are developed to alleviate/decrease behaviors and to communicate identified triggers and interventions to staff. Initiated on 5/14/2024.
3. As part of the facilities ongoing quality assurance program:
A.
Residents who trigger during this IDT review will be discussed during morning meeting and a root cause analysis will be completed to determine potential triggers. Individualized intervention will be developed to decrease episodes of behaviors, in order to prevention situations that may cause abuse to a resident. (on-going).
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly and timely investigate an allegation of staff to residen...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly and timely investigate an allegation of staff to resident abuse, and failed to prevent further abuse from occurring while allowing staff to continue to have direct care with residents after allegations were made for 4 of 5 residents (R26, R44, R46, and R300) reviewed for abuse in a sample of 14 residents. Due to this failure R26 was verbally and physically abused by V34 (Certified Nursing Assistant/CNA) on 5/7/24 at approximately 2:00 AM. This also had the potential to affect all 47 residents residing in the facility.
Findings include:
1. Document titled admission Record documented R300 admission date as 4/5/2024 with diagnoses including Intervertebral Disc Degeneration, Thoracic Region, Polyarthritis, Chronic Obstructive Pulmonary Disease, Atherosclerotic Heart Disease, Anemia, Vitamin D Deficiency, Hypertension, Mild cognitive impairment.
R300's Minimum Data Set (MDS) dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 13, which indicates R300 is cognitively Intact.
On 5/8/2024 at 9:59 AM, R300 was alert and oriented stated, I know why you are here so I will explain what happened to me. On the night that I was admitted (4/5/2024) I just wanted to go back to live in my car or go live with my grandson that lives her in (town of facility). R300 stated I was walking outside of the building when V34 CNA (Certified Nursing Assistant) grabbed me around the waist, tackled me from behind, and drug me to the ground face first. I didn't see anyone else outside, but I thought I heard someone say, get him. R300 stated I have a bad back from a vehicle wreck that happened years ago, and this just made the pain worsen. My pain has increased since this occurred. R300 stated he told people about being tackled but wasn't sure of their name as he was new in the facility or the time he reported it. R300 stated I do not feel safe, and I have to sleep lightly because V34 is always in my room taking care of my roommate. R300 then stated, I am afraid that V34 will come in here with a club and hit me in the head.
On 5/10/2024 at 11:20 AM, V38 PRSC (Psychiatric Rehabilitation Service Counselor) stated R300 came to her on Friday evening (5/3/2024) and reported his allegation of physical abuse. V38 stated R300 came to her and told her when he was out front a guy came up and wrapped his arms around R300 and threw R300 down. V38 stated I just didn't think it happened on dayshift. V38 said R300 described the guy that allegedly did this was Mexican and the facility did not have anyone employed that fit that description. V38 stated the way it was brought to me by (R300) didn't give me all the details. He was just looking for the guy that threw him on the concrete. V38 stated she didn't report this to V1 (Administrator) until the following Monday (5/6/2024) and V1 came in and asked V38 for a grievance form. When V38 was questioned about abuse training, V38 stated abuse is to be reported immediately to the administrator. V38 also stated she knew what an allegation of abuse was and assists in training facility staff with abuse training.
On 5/10/2024 at 10:58 AM, V6 SSD (Social Service Director) stated on 5/7/2024 R300 came and told her he knew the name of the guy that tackled him in front of the building, and it was V34 (CNA). V6 stated she asked him what he was talking about and V6 stated she was unaware of any situation like that.
On 5/7/24 at 9:10 AM, V1 (Administrator) said R300 had reported the allegation of abuse to V6 (Social Services Director) on the evening of 5/6/24.
On 5/15/2024 at 2:10 PM, V1 (Administrator) stated she questioned V34 (CNA) on the allegation involving R300 but was unsure of the date and time. V1 then stated she interviewed V34 on 5/10/2024 and V34 was suspended at that time.
On 5/10/24 at 3:14 PM, V34 (CNA) said he was never questioned about R300's allegations. V34 said he was not aware there was any suspicion he was the alleged perpetrator. V34 said he had worked in the facility on 5/6/24, 5/7/24, 5/8/24, and 5/9/24. V34 said he was not suspended related to R300's abuse allegations prior to 5/10/24.
V34's undated facility timecard provided by the facility on 5/10/24 documented V34 was working in the facility on 5/3/24 from 5:54 PM to 5/4/24 at 6:03 AM, 5/6/24 from 9:56 PM to 5/7/24 at 6:03 AM, 5/7/24 from 9:55 PM to 5/8/24 at 6:05 AM, 5/8/24 from 9:56 PM to 5/9/24 at 6:11 AM, and 5/9/24 from 9:54 PM to 6:01 AM.
On 5/13/2024 at 4:25 PM, via phone interview V12 (CNA) stated, I heard V34 shoved R300 down to the ground. V12 said she did not witness V34 shove R300 but have heard about in the facility. V12 stated she works 6:30 AM to 2:00 PM shift. V12 stated I have been told that V34 will call R6 a fat a** and lazy a** the CNA that says these things is V34.
On 5/17/24 at, 2:50 PM, V44 (Regional Director of Operations) said she expected staff to be suspended pending an investigation. V44 said she expected V34 (CNA) to have been suspended on 5/6/2024. V44 said she expects all staff to be interviewed in an abuse allegation investigation.
On 5/10/2024 at 1:00 PM, R300's investigation file was reviewed and noted initial time of staff acknowledgment was on 5/3/2024, but investigation was not started until 5/6/2024. V34 was the perpetrator named by R300 and no statement or interview was completed by V34. V34 was allowed to work on 5/3/2024, 5/6/2024/, 5/7/2024/ 5/8/2024 and 5/9/2024. V34 was interviewed on 5/10/2024 and at this time V34 was included in R300's facility investigation.
2. R26's document titled admission Record documented an admission date of 8/23/2019 with diagnoses including: Ischemic Cardiomyopathy, Atherosclerotic heart Disease of Native Coronary Artery without Angina Pectoris, Peripheral Vascular Disease, Hypertension, Hyperlipidemia, Chronic Kidney Disease stage 3, Schizoaffective Disorder, Atrial Fibrillation, Anxiety, Chronic Obstructive Pulmonary Disease, presence of Automatic (implantable) Cardiac Defibrillator, Alzheimer's Disease, Unilateral Inguinal Hernia, Diabetes Mellitus, and Unspecified Urinary Incontinence.
R26's MDS (Minimum Data Set) dated 4/23/2024 documented a BIMS (Brief Interview for Mental Status) with score of 10, indicating moderate cognitive impairment.
On 5/8/2024 10:32 AM, R26 was an alert and oriented resident sitting in the dining room. R26 stated his care is good here except for the night shift. R26 stated he gets his clothes ripped by night shift CNA, V34. R26 pointed to the upper right shoulder area of his shirt that was ripped and stated V34 ripped it when he was pulling me out of bed. R26 stated he (V34) gets me up at 2:00 AM-3:00 AM and brings me to the dining room and I have to sit here until breakfast.
On 5/10/2024 at 12:15 PM, R26 stated I get tired of the treatment from (V34) CNA. I don't feel safe when (V34) is working. I want to just pull my pacemaker out and end it all sometimes, but only when (V34) is taking care of me. R26 stated if R26 used the bathroom in bed V34 would roughly get R26 out of bed, ripping R26's clothes at times, and wheel R26 to the dining room to wait for breakfast. R26 stated V34 was also verbally abusive. R26 said the last time V34 had been abusive like this to R26 was within the past week of this survey. R26 stated facility staff were aware of V34 being abusive but nobody does anything about it.
On 5/10/24 at 2:07 PM, R26 said the last time he had issues with his care by V34 (CNA) had been Monday night 5/6/24 / Tuesday morning 5/7/24.
On 5/10/24 at 3:14 PM, V34 (CNA) said R26 was assisted with care around 2:00 AM during bed check. V34 said R26 was usually one of the last residents V34 would assist because R26 was usually not wet. V34 said he did not like to put a wrap around pullup on R26 because it gave R26 an excuse to pee in the bed instead of using the urinal. R26 stated he was not trying to be a d**k, but I know (R26) can use the urinal during the day. V34 said he was not trying to argue with (R26). If (R26) wets the bed, I make (R26) get up in his chair so I can change the bed and put a pullup on (R26). V34 stated (R26) was not an easy resident to care for and V34 just tells (R26) like it is when things have to get done. V34 said he was very direct with residents and I feel like being direct is the only was for a resident to fully understand what is about to happen.
R26's 5/15/24 final reportable incident documented in part . Regional Director interviewed the resident (R26) and he stated that CNA (V34) grabs his shirt pocket and rips them when he is attempting to get him out of bed. Resident stated that CNA gets him up at 2 or 3 AM for no reason . Resident states that CNA talks rudely to him . Regional Director interviewed (R26's) roommate (R37). (R37) is (alert and oriented times 4). (R37) stated that (R26) is pulled around by (V34) in the middle of the night because resident doesn't want to get up at 2 AM. (R37) stated that (V34) is verbally demeaning to resident and is tone of voice is aggressive when speaking with (R26) . Conclusion After a thorough investigation the facility is able to substantiate the allegation. (V34) has been terminated .
On 5/10/2024 at 12:30 PM, R37 was alert and oriented. R37 is a roommate of R26 and stated nightshift gets (R26) up around 3:00 AM and will make (R26) stay up if (R26) has soiled the bed. (V34) CNA is very dismissive and verbally aggressive with (R26). R37 stated he has heard V34 tell R26 You must stay up because you pissed the bed. R37 said he had witnessed V34 handling R26 rough when getting R26 out of bed at night. R37 stated the last time it happened was this past week. R37 states V1 knows but nothing happens.
R37's 3/26/24 MDS (Minimum Data Set) documented a BIMS (Brief Interview for Mental Status) score of 15, indicating R37 was cognitively intact.
On 5/17/24 at, 2:50 PM, V44 (Regional Director of Operations) said she expected staff to be suspended pending an investigation. V44 said she expected V34 (CNA) to have been suspended on 5/6/2024 due to the R300 abuse allegation.
3. R44's document titled admission Record documented an admission date of 6/30/2024 with diagnoses including aftercare following Joint Replacement Surgery, Paranoid Schizophrenia, Atherosclerotic Heart Disease, Conversion Disorder with Seizures or Convulsions, Gout, Hypertension, Schizoaffective Disorder, Bipolar Type, Hypothyroidism, Anxiety, Polyosteoarthritis, Hyperlipidemia.
R44's MDS (Minimum Data Set) dated 3/8/2024 documented a BIMS (Brief Interview for Mental Status) score of 00, indicating severe cognitive impairment.
On 5/10/2024 at 12:15 PM, V37 (CNA) stated he has received training on abuse during employment at the facility. V37 stated, I have never witnessed physical abuse, but I have witnessed verbal abuse and threats to residents. V37 stated he had witnessed an incident of verbal abuse/threat to R44 by V34 (CNA). V37 stated R44 had just returned from the hospital, and something was wrong with his stomach. V37 stated R44 kept putting on his call light thinking he felt like he needed to use the restroom but when staff would get to R44's room, R44 felt like the need to use the restroom had passed. V37 stated that he went into the room with V34 and witnessed V34 threaten R44 by telling him he (V34) was going to take his call light away from him if he didn't stop turning the call light on. V37 stated he didn't report the incident involving verbal abuse to R44 because he wanted to give V34 a chance but it didn't do any good, I guess.
On 5/10/2024 at 12:20 PM, R44 was interviewed but was a poor historian with some confusion noted.
On 5/10/24 at 3:14 PM, V34 (CNA) said he recalled when R44 returned to the facility from the hospital because it was a sad time because R44 was very sick. V34 said he had joked with R44 after answering R44's call light V34 had gotten about halfway down the hall when R44 turned his call light on again. V34 said he had joked with R44 saying what do you need 5 seconds later. V34 said there were times R44 has been half awake and V34 did not know if R44 knew he was joking. V34 said staff will get frustrated with R44 using the call light. V34 said R44 was a very confrontational resident. V34 said he had gotten frustrated with R44 in the past when R44 would not use the urinal. V34 said when R44's urinal is empty V34 has told R44 V34 knows no staff have emptied R44's urinal and R44 needs to start using it. V34 said he was not sure if V34 telling R44 to use the urinal would be taken as threatening because we have to tell (R44) that every night.
On 5/13/2024 at 4:25 PM, via phone interview V12 CNA (Certified Nurse Assistant) stated she has received training on abuse but, unsure of last time. I have never seen abuse, but I have been told that midnight CNAs call resident's names, names that are not nice, and the main one that does this is R34. V12 stated I know he tells R44 not to push his f**king call light anymore. I didn't witness this but was told about it, so I didn't report it. V12 states she has never been questioned or part of an investigation for abuse.
R44's document titled Incident Investigation Form documents V44 (Regional Director of Operations) interviewed V37 (CNA) dated 5/14/2024. Document reads .(V34) - (R44) was on the light quite a bit thinking he had pooped. He had been on the call light a lot. (V34 CNA) told (R44) if you didn't s**t, I'm going to take that call light away from you. Didn't report because he was busy and didn't want to see (V34) get in trouble .
On 5/14/24 at 12:57 PM, V44 (Regional Director of Operations) said that she had forgotten about R44's abuse allegation on 5/10/24. V44 said she would have R44's investigation completed on that day (5/14/24).
On 5/14/24 at 4:00 PM, V44 (Regional Director of Operations) presented R44's 5/4/24 facility investigation and verified the one staff interview of V37 (CNA) was the complete investigation. R44's 5/14/24 facility investigation file did not contain any other staff interviews or resident interviews.
On 5/15/2024 at 2:10 PM, V1 (Administrator) stated the staff she usually interviews are the supervisors and/or directors. V1 stated she usually only interviews the staff that are around. V1 stated I only interview the residents that are alert and oriented.
4. R46's face sheet documented an initial admission date of 8/24/23 with diagnoses including: pulmonary hypertension, chronic obstructive pulmonary disease, post- traumatic stress disorder, attention- deficit hyperactivity disorder, hypothyroidism, anxiety disorder, depression, borderline personality disorder, mild intellectual disabilities, need for assistance with personal care.
R46's 2/28/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating R46 was cognitively intact.
On 5/8/24 at 9:56 AM, R46 said a CNA told him to turn his f**king music down. R46 said he (V34/CNA) was always complaining about R46's music. R46 said he has not had any problems with any other staff. R46 said this incident happened on 5/3/24. R46 said the next day (5/4/24) V1 (Administrator) came to speak with R46. R46 said V1 had told him that V34 had never cussed at him, and the incident didn't happen. R46 said V1 told him that V1 did not believe him. R46 said he did not feel safe when V34 was working. R46 said he had not told V1 he did not feel safe while V34 was working because V1 had never asked.
On 5/8/24 at 12:26 PM, V40 (Housekeeper) said she reported that R46 had made an abuse allegation to her on 5/4/24. V40 said R46 had made an allegation V34 (Certified Nursing Assistant/ CNA) had cussed R46 out in the dining room on 5/3/24 due to R46's tablet being too loud. V40 said she had reported R46's abuse allegation to V42 (Licensed Practical Nurse/ LPN) and had given V42 a written statement.
On 5/8/24 at 1:16 PM, V42 (LPN) said on 5/4/24 V40 (Housekeeper) had reported an abuse allegation pertaining to R46. V42 said she asked V40 to complete a written statement and called V1 (Administrator) to report the abuse allegation. V42 said there were 2 abuse allegations reported to her very close together on 5/4/24 and V42 had reported both to V1 via telephone. V42 said she went to speak with R46 on 5/4/24 and R46 reported V34 (CNA) on midnight shift had cussed at him over R46's music being too loud.
On 5/8/24 at 2:20 PM, V1 produced written statements by staff pertaining to R46's abuse allegation. A 5/4/24 Nurses Note written and signed by V40 (Housekeeper) documented in part . (R46) told me this morning that a black haired CNA cussed him out and was yelling at him over his TV being to (sic) loud. I said are you talking about (V34) and he said yes. I told him to tell the nurse about it . Another 5/4/24 Nurses Notes written and signed by V42 (LPN) documented in part . This nurse asked resident (R46) what happened in the middle of the night, (R46) said that he was cussed out by (V34) (R46) said that (V34) told him to turn the f**king music down.
On 5/8/24 at 2:20 PM, V1 (Administrator) said R46's abuse allegation was not substantiated so V1 did not feel the allegation needed to be reported. V1 presented R46's 5/4/24 facility investigation documents with all persons questioned. R46's 5/4/24 facility investigation file documented only staff were interviewed but no residents were interviewed. On 5/15/2024 at 2:10 PM, V1 (Administrator) stated I feel like our standard investigations are good. V1 stated yes we do notify the physicians when there is an abuse allegation.
On 5/15/2024 at 1:53 PM, this surveyor received a return call from V33 (Physician). V33 stated he was not notified of allegation of abuse on R300 or R26. V33 stated he was not aware of any of this, but he ordered x rays for R300 because of increased pain but thought it was from old injuries from an accident. V33 stated he changed R300's pain medication because he knew that the pain medication (tramadol) was a medication that the resident was on for a long time. V33 stated he changed R300's pain medications to help reduce the pain that he knew was a chronic issue.
On 5/15/2024 at 2:10 PM, V1 (Administrator) stated on Monday morning (5/6/2024) V38 (PRSC) reported an allegation of abuse to R300. V1 stated she instructed V6 (Social Services Director) to go talk to R300. V1 stated the staff she usually interviews are the supervisors and/or directors. V1 stated she usually interviews the staff that are around. V1 stated I only interview the residents that are alert and oriented. While V1 was being questioned about the investigation procedure of an abuse allegation by a resident V1 stated sometimes it is the resident's fault. When V1 was asked to clarify what she meant by sometimes it is the resident's fault V1 said yeah and turned her chair around at her desk and started going to through papers and refused to say any more.
On 5/13/2024 at 3:23 PM, via phone interview V43 (housekeeper) stated she has worked for 4 and a half years at the facility. V43 stated I have never received abuse training and has never been questioned about any abuse investigations. V43 stated she has witnessed verbal abuse on several occasions in the past by CNA's and Nurses' especially loudly in the hallway. V34 states I recently took family leave and was off about a month. V43 stated I think you need to go talk to the residents and see if they tell you anything. V43 stated she didn't report because everyone hears it.
The facility's undated census list provided on 5/7/24 documented 47 residents residing in the facility.
Document titled Abuse Prevention Program with Revised date of 11/28/2016 documented in part .Upon learning of the report, the administrator or designee shall initiate an investigation. 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 . 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 .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0559
(Tag F0559)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to allow residents to choose to reside in the same room with their spouse and visit other residents for 2 out of 3 residents (R30...
Read full inspector narrative →
Based on observation, interview, and record review the facility failed to allow residents to choose to reside in the same room with their spouse and visit other residents for 2 out of 3 residents (R300 and R301) reviewed for resident rights in a sample of 14.
Findings include:
1. On 5/8/2024 at 9:55 AM, R300 was interviewed and stated My wife lives here, and they made her move so they could put this man in here. My wife moved here from another facility so we could be together and now we can't be together. I can't go to her room and visit her because I cannot go past the double doors. (V34 Certified Nursing Assistant/ CNA) told me I cannot go down that hall through the double doors so I can't even get my haircut.
R300's document titled admission Record documented an admission date as 4/5/2024 with diagnoses including: Intervertebral Disc Degeneration, Thoracic Region, Polyarthritis, Chronic Obstructive Pulmonary Disease, Atherosclerotic Heart Disease, Anemia, Vitamin D Deficiency, Hypertension, Mild cognitive impairment.
R300's 4/15/2024 MDS (Minimum Data Set) documents the BIMS (Brief Interview for Mental Status) score of 13, which indicates R300 is cognitively Intact.
On 5/8/2024 at 10:46 AM, R301 who was alert and oriented stated I came here because my husband was admitted here, we were in the same room, but they moved me. There was too much drama going on and now they won't let him come down here and visit me. My husband was told by (V34) that he could not come down here and visit and I don't know why. We only see each other at meals. My husband (R300) and I do not know exactly why they moved me, but they admitted a new man and put him in the room with my husband (R300). R301 stated I would like to be in the room with my husband but (V6 Social Services Director) told me that I had to move. R301 stated Nobody has even been back down or asked me if I wanted to be with my husband. I moved here to be with my husband.
On 5/8/24 at 12:10 PM, R301 was in the dining room talking and having lunch with her husband (R300). R301 asked if they could be back in the room together.
2. R301's document titled admission and Discharge Record documents an admission date of 4/10/2024 and was admitted from another long term care facility. This same document also included diagnoses of: Type 2 DM, Anxiety, Hypertension, Anemia, Angina Pectoris, GERD, Heart Failure, Depression, History of TIA, and Cerebral Infarct with no residual.
R301's MDS (Minimum Data Set) dated 4/22/2024 documented a BIMS (Brief Interview for Mental Status) score of 15, indicating intact cognition.
On 5/10/2024 at 10:58 AM, V6 SSD (Social Service Director) stated she was unaware of a reason why R300 could not go down to visit R301. V6 stated (R300) had said he couldn't go through the double doors, but I was unaware of reason why he was told that. V6 stated R300 reported (V34 CNA) told him he could not go through the double doors, but nobody knows why and there is no rule about that. V6 stated R301 came and told her that R300 was getting on her nerves and wanted to move rooms. V6 stated she moved R301 to another room. V6 was asked if she has followed up to see if R301 was happy not being with her husband (R300) and V6 stated No, I have not followed up.
On 5/10/2024 at 10:22 AM, R301 stated I told them I wanted to move but they wouldn't do it. I think they needed that room for that other man.
On 5/8/24 at 2:00 PM, R301's medical record was reviewed and there were no notes pertaining to R301 and R300's rooming preferences under the social services tab.
On 5/10/2024 at 12:05 PM, V6 brought in a document titled Social Service Progress Notes with a written note dated 5/10/2024 which documented in part .Spoke (with R301) regarding room (change). Requested to be moved back in (with) husband (R300). Explained we could do it but will require us to move a few people, (and) may not happen until Monday 5/13/2024. (R301) stated she was ok with waiting. Will follow up Monday (morning with changes.) signed by V6.
On 5/16/24 at approximately 12:00 PM, the facility presented another document titled Social Progress Notes allegedly from R301's medical record. The first entry on the documented was dated 5/4/25'24 (sic) and the second entry was dated 5/3/24. The 5/4/25'24 (sic) entry documented in part . Resident stated that she wanted to get away from husband (R300). (Change) rooms. Asked resident why. Stated she wanted to get away from him. I don't want to talk (with) him. She asked if she could move down at the other end of hall (with another resident). Spoke (with other resident) regarding (R301) as room-mates. (other resident) was happy (and) like (R301). Spoke with admin regarding request for room (change) . signed by V6. The 5/3/24 entry documented in part . (R301) requested to (change) rooms because room-mate kept her up last night yelling screaming. Spoke (with) nursing staff regarding (R301) unable to sleep. Stated room-mate was up a lot last night, had some (medication changes). Spoke (with R301) stated will check to see if we could move, but room availability was slim. Asked if (R301) would like to move in (with) husband (R300) or another female. (R301) stated she did not want to move in (with R300) . signed by V6.
On 5/14/2024 at 9:10 AM, R301 was sitting in the dining area with her husband and stated, We are in the room together finally.
On 5/17/2024 at 2:50 PM, V44 RDO (Regional Director of Operations) stated there was no policy for resident rights pertaining to romantic partners choosing to reside in the same room, but she would expect for a married couple to be able to share a room if that is what they request, and residents should be able to visit other residents if they wish to do so.
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 identify and report allegations of staff to resident verbal abuse i...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify and report allegations of staff to resident verbal abuse immediately to the Administrator and failed to report and allegation of abuse to the Illinois Department of Public Health (IDPH) for 3 of 5 residents (R44, R46, and R300) reviewed for abuse in the sample of 14.
Findings include:
1. R46's face sheet documented an initial admission date of 8/24/23 with diagnoses including: pulmonary hypertension, chronic obstructive pulmonary disease, post- traumatic stress disorder, attention- deficit hyperactivity disorder, hypothyroidism, anxiety disorder, depression, borderline personality disorder, mild intellectual disabilities, need for assistance with personal care.
R46's 2/28/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating R46 was cognitively intact.
On 5/8/24 at 9:56 AM, R46 said a CNA (Certified Nursing Assistant) told him to turn his f**king music down. R46 said he (V32/CNA) was always complaining about R46's music. R46 said he has not had any problems with any other staff. R46 said this incident happened on 5/3/24. R46 said the next day (5/4/24) V1 (Administrator) came to speak with R46. R46 said V1 had told him that V34 had never cussed at R46, and the incident didn't happen. R46 said V1 told him that V1 did not believe R46. R46 said he did not feel safe when V34 was working. V46 said he did not feel safe when V34 was working. V46 said he had not told V1 he did not feel safe while V34 was working because V1 had never asked.
On 5/8/24 at 12:26 PM, V40 (Housekeeper) stated R 46 told her V34 had cussed him out in the dining room on 5/3/2024 due to his music being played too loud. V40 said she had reported R46's abuse allegation to V42 (Licensed Practical Nurse/ LPN) and had given V42 a written statement.
On 5/8/24 at 1:16 PM, V42 (LPN) said on 5/4/24 that V40 had reported an abuse allegation pertaining to R46. V42 said she asked V40 to complete a written statement and called V1 (Administrator) to report the abuse allegation. V42 said there were 2 abuse allegations reported to her very close together on 5/4/24 and V42 had reported both to V1 via telephone. V42 said she went to speak with R46 on 5/4/24 and R46 reported V34 (CNA) on midnight shift had cussed at him over R46's music being too loud.
On 5/8/24 at 2:20 PM, V1 (Administrator) said she was aware of R46's abuse allegation but had not reported it to Illinois Department of Public Health (IDPH). V1 said R46's abuse allegation was not substantiated so V1 did not feel the allegation needed to be reported.
On 5/8/24 at 2:20 PM, V1 produced written statements by staff pertaining to R46's abuse allegation. A 5/4/24 Nurses Note written and signed by V40 (Housekeeper) documented in part . (R46) told me this morning that a black haired CNA cussed him out and was yelling at him over his TV being to loud. I said are you talking about (V34) and he said yes. I told him to tell the nurse about it . Another 5/4/24 Nurses Notes written and signed by V42 (LPN) documented in part . This nurse asked resident (R46) what happened in the middle of the night, (R46) said that he was cussed out by (V34) (R46) said that (V34) told him to turn the f**king music down.
2. R44's document titled admission Record documented an admission date of 6/30/2024 with diagnoses including aftercare following Joint Replacement Surgery, Paranoid Schizophrenia, Atherosclerotic Heart Disease, Conversion Disorder with Seizures or Convulsions, Gout, Hypertension, Schizoaffective Disorder, Bipolar Type, Hypothyroidism, Anxiety, Polyosteoarthritis, Hyperlipidemia.
R44's MDS (Minimum Data Set) dated 3/8/2024 documented a BIMS (Brief Interview for Mental Status) score of 00, indicating severe cognitive impairment.
On 5/10/2024 at 12:15 PM, V37 CNA (Certified Nurse Assistant) stated he has received training on abuse during employment at the facility. V37 stated I have never witnessed physical abuse, but I have witnessed verbal abuse and threats to residents. V37 stated he had witnessed an incident of verbal abuse/threat to R44 by V34 (CNA). V37 stated R44 had just returned from the hospital, and something was wrong with his stomach. V37 stated R44 kept putting on his call light thinking he felt like he needed to use the restroom but when staff would get to R44's room, R44 felt like the need to use the restroom had passed. V37 stated that he went into the room with V34 and witnessed V34 threaten R44 by telling him he (V34) was going to take his call light away from him if he didn't stop turning the call light on. V37 stated he didn't report the incident involving verbal abuse to R44 because he wanted to give V34 a chance but it didn't do any good, I guess.
On 5/10/2024 at 12:20 PM, R44 was interviewed but was a poor historian with some confusion noted.
3. Document titled admission Record documented R300 admission date as 4/5/2024 with diagnoses including Intervertebral Disc Degeneration, Thoracic Region, Polyarthritis, Chronic Obstructive Pulmonary Disease, Atherosclerotic Heart Disease, Anemia, Vitamin D Deficiency, Hypertension, Mild cognitive impairment.
R300's MDS dated [DATE] documents a BIMS a score of 13, which indicates R300 is cognitively intact.
On 5/8/2024 at 9:59AM R300 who was alert and oriented stated, I know why you are here so I will explain what happened to me. On the night that I was admitted (4/5/2024) I just wanted to go back to live in my car or go live with my grandson that lives her in (town of facility). R300 stated I was walking outside of the building when V34 CNA (Certified Nursing Assistant) grabbed me around the waist, tackled me from behind, and drug me to the ground face first. I didn't see anyone else outside, but I thought I heard someone say, get him. R300 stated I have a bad back from a vehicle wreck that happened years ago, and this just made the pain worsen. My pain has increased since this occurred. R300 stated he told people about being tackled but wasn't sure of their name as he was new in the facility or the time R300 reported it. R300 stated I do not feel safe, and I have to sleep lightly because V34 is always in my room taking care of my roommate. R300 then stated, I am afraid that V34 will come in here with a club and hit me in the head.
On 5/10/2024 at 11:20 AM, V38 PRSC (Psychiatric Rehabilitation Service Counselor) stated R300 came to her on Friday evening (5/3/2024) and reported his allegation of physical abuse. V38 stated R300 came to her and told her when he was out front a guy came up and wrapped his arms around R300 and threw R300 down. V38 stated I just didn't think it happened on dayshift. V38 said R300 described the guy that allegedly did this was Mexican and the facility did not have anyone employed that fit that description. V38 stated the way it was brought to me by (R300) didn't give me all the details. He was just looking for the guy that threw him on the concrete. V38 stated she didn't report this to V1 (Administrator) until the following Monday (5/6/2024) and V1 came in and asked V38 for a grievance form. When V38 was questioned about abuse training, V38 stated abuse is to be reported immediately to the administrator. V38 also stated she knew what an allegation of abuse was and assists in training facility staff with abuse training.
On 5/10/2024 at 10:58 AM, V6 SSD (Social Service Director) stated on 5/7/2024 R300 came and told her he knew the name of the guy that tackled him in front of the building, and it was V34 (CNA). V6 stated she asked him what he was talking about and V6 stated she was unaware of any situation like that.
On 5/7/24 at 9:10 AM, V1 (Administrator) said R300 had reported the allegation of abuse to V6 (Social Services Director) on the evening of 5/6/24.
On 5/10/2024 at 1:00 PM, R300's investigation file was reviewed and noted initial time of staff acknowledgment was on 5/3/2024, but investigation was not started until 5/6/2024. V34 was the perpetrator named by R300 and no statement or interview was completed by V34. V34 was allowed to work on 5/3/2024, 5/6/2024/, 5/7/2024/ 5/8/2024 and 5/9/2024. V34 was interviewed on 5/10/2024 and at this time V34 was included in R300's facility investigation.
Document titled Abuse Prevention Program with Revised date of 11/28/2016 documented in part, section 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 . Supervisors shall immediately inform the administrator or his/her designated presentative (specified by the administrator in the case of a planned absence) of all reports of potential/alleged mistreatment, exploitation, neglect, and abuse of residents of residents and misappropriation of resident property. VII. External Reporting of Potential Abuse . 1. Initial Reporting of Allegations. The facility must ensure that all alleged violations involving mistreatment, exploitation, neglect or abuse . are reported immediately to the administrator of the facility . 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 on law enforcement agency of jurisdiction and IDPH immediately after forming the suspicion . otherwise, the report must be made not later than 24 hours after forming the suspicion .
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility administration knowingly failed to report abuse allegations, thoroughly and ti...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility administration knowingly failed to report abuse allegations, thoroughly and timely investigate abuse allegations, suspend staff pending facility abuse investigations, and inaccurately document resident assessments for 3 of 5 residents (R26, R46, and R300) reviewed for administration in a sample of 14. This failure has the potential to affect all 47 residents residing in the facility.
Findings include:
1. On 5/10/2024 at 11:20 AM, V38 PRSC (Psychiatric Rehabilitation Service Counselor) stated R300 came to her on Friday evening (5/3/2024) and reported an allegation of physical abuse. V38 stated R300 came to her and told her when he was out front a guy came up and wrapped his arms around R300 and threw R300 down. V38 stated I just didn't think it happened on dayshift. V38 said R300 described the guy that allegedly did this was Mexican and the facility did not have anyone employed that fit that description. V38 stated the way it was brought to me by (R300) didn't give me all the details. He was just looking for the guy that threw him on the concrete. V38 stated she didn't report this to V1 (Administrator) until the following Monday (5/6/2024) and V1 came in and asked V38 for a grievance form. When V38 was questioned about abuse training, V38 stated abuse is to be reported immediately to the administrator. V38 also stated she knew what an allegation of abuse was and assists in training facility staff with abuse training.
R300's Minimum Data Set, dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 13, which indicates R300 is cognitively Intact.
On 5/7/24 at 9:10 AM, V1 (Administrator) said she was aware R300 had reported the allegation of abuse to V6 (Social Services Director) on the evening of 5/6/24.
On 5/15/2024 at 2:10 PM, V1 (Administrator) stated she questioned V34 (CNA) on the allegation involving R300 but was unsure of the date and time. V1 then stated she interviewed V34 on 5/10/2024 and V34 was suspended at that time.
On 5/10/24 at 3:14 PM, V34 (CNA) said he was never questioned about R300's allegations. V34 said he was not aware there was any suspicion he was the alleged perpetrator of R300's abuse allegations. V34 said he had worked in the facility on 5/6/24, 5/7/24, 5/8/24, and 5/9/24. V34 said he was not suspended related to R300's abuse allegations prior to 5/10/24.
On 5/10/2024 at 1:00 PM, R300's investigation file was reviewed and noted initial time of staff acknowledgment was on 5/3/2024, but investigation was not started until 5/6/2024. V34 was the perpetrator named by R300 and no statement or interview was completed by V34. V34 was allowed to work on 5/3/2024, 5/6/2024/, 5/7/2024/ 5/8/2024 and 5/9/2024. V34 was interviewed on 5/10/2024 and at this time V34 was included in R300's facility investigation.
V34's undated facility timecard provided by the facility on 5/10/24 documented V34 was working in the facility on 5/3/24 from 5:54 PM to 5/4/24 at 6:03 AM, 5/6/24 from 9:56 PM to 5/7/24 at 6:03 AM, 5/7/24 from 9:55 PM to 5/8/24 at 6:05 AM, 5/8/24 from 9:56 PM to 5/9/24 at 6:11 AM, and 5/9/24 from 9:54 PM to 6:01 AM.
On 5/17/24 at 2:50 PM, V44 (Regional Director of Operations) said she expected staff to be suspended pending an investigation. V44 said she expected V1 (Administrator) to have suspended V34 (CNA) on 5/6/2024 when the abuse allegation was made my R300. V44 said she expects all staff to be interviewed in an abuse allegation investigation.
On 5/10/24 at 12:11 PM, V51 (Licensed Practical Nurse/ Care Plan Coordinator/ Minimum Data Set Coordinator) said she had revised R300's care plan on 5/7/24 due to R300 making false allegations. V51 said the only allegation V51 was aware of was R300 alleging being tackled by a staff member on the nightshift. V51 said she had been made aware of R300 making false allegations about staff members during the morning meeting on 5/7/24. V51 said she was unable to recall who had reported to her in the 5/7/24 morning meeting R300 needed a care plan about making false allegations. V51 said she had updated R300's care plan to reflect the behavior tracking sheets (completed on 5/7/24 by V6 Social Services Director) in the behavior tracking binder.
R300's care plan documented a date initiated 5/7/24 documenting in part . The resident voices false allegations . with 5/7/24 interventions including Reward the resident for appropriate behaviors (as needed) and If reasonable, discuss the resident's behavior. Explain/ reinforce why behavior is inappropriate and/ or unacceptable to the resident.
On 5/10/24 at 12:31 PM, V6 (Social Services Director) said on 5/7/24 around 2:00 PM V6 had been asked by V1 (Administrator) to make behavior tracking sheets for R300 pertaining to R300 making false allegations. V6 said she was not aware of R300 making any false allegations or any staff members reporting to V6 that R300 was making false allegations. V6 was asked if a resident makes an allegation of abuse, and it is not substantiated does the resident automatically get a behavior tracking sheet for making false allegations? V6 responded no. V6 said a resident would get a behavior tracking sheet if they made allegations such as not getting a meal tray when staff knew the resident had received a meal tray. V6 reviewed R300 5/7/24 care plan The resident voices false allegations and said she was unsure why V47 (LPN/ Care Plan Coordinator/ Minimum Data Set Coordinator) had updated R300 care plan on 5/7/24. V6 said she did not know what the reward would be after reading the 5/7/24 intervention of Reward the resident for appropriate behavior (as needed). V6 said she did not think the 5/7/24 care plan intervention If reasonable, discuss the resident's behavior. Explain/ reinforce why behavior is inappropriate and/ or unacceptable to the resident was an appropriate intervention and that could cause staff not to believe R300 when R300 made abuse allegations.
R300's medical record Nurses Notes from 4/5/24 through 5/14/24 were reviewed and did not document any instances of R300 making false allegations or being physically aggressive with staff.
R300's May 2024 Behavior Tracking Record documented in part . Diagnosis: Anxiety . Target Behavior: (R300) makes False accusations involving staff and other residents . documentation by staff started on 5/7/24 on the 10:00 PM to 6:00 AM box.
On 5/10/24 at 12:53 PM, V48 (Registered Nurse/ RN) said she was familiar with R300. V48 said she would sit and talk to R300 at the nurse's station regularly. V48 said she was not aware of R300 making any false allegations about staff. V48 said if R300 made an abuse allegation she would report it to V1 (Administrator) immediately. V48 was then read R300 5/7/24 care plan . The resident voices false allegations . with 5/7/24 interventions including Reward the resident for appropriate behaviors (as needed) and If reasonable, discuss the resident's behavior. Explain/ reinforce why behavior is inappropriate and/ or unacceptable to the resident. V48 said she would try to follow a resident's care plan as best as she could. V48 said with R300's 5/7/24 intervention of If reasonable, discuss the resident's behavior. Explain/ reinforce why behavior is inappropriate and/ or unacceptable to the resident she would explain why the behavior is inappropriate to R300 if R300 made an allegation of abuse. V48 said she didn't know what would be an appropriate reward would be for R300 not reporting abuse.
On 5/15/2024 at 2:10 PM, V1 (Administrator) stated on Monday morning (5/6/2024) V38 (PRSC) reported an allegation of abuse to R300. V1 stated she instructed V6 (Social Services Director) to go talk to R300. V1 stated the staff she usually interviews are the supervisors and/or directors. V1 stated she usually interviews the staff that are around. V1 stated I only interview the residents that are alert and oriented. While V1 was being questioned about the investigation procedure of an abuse allegation by a resident V1 stated sometimes it is the resident's fault. When V1 was asked to clarify what she meant by sometimes it is the resident's fault V1 said yeah and turned her chair around at her desk and started going to through papers and refused to say any more.
2. On 5/8/2024 10:32 AM, R26 was an alert and oriented resident sitting in the dining room. R26 stated his care is good here except for the night shift. R26 stated he gets his clothes ripped by night shift CNA, V34. R26 pointed to the upper right shoulder area of his shirt that was ripped and stated V34 ripped it when he was pulling me out of bed. R26 stated he (V34) gets me up at 2:00 AM-3:00 AM and brings me to the dining room and I have to sit here until breakfast.
R26's MDS (Minimum Data Set) dated 4/23/2024 documented a BIMS (Brief Interview for Mental Status) with score of 10, indicating moderate cognitive impairment.
On 5/10/2024 at 12:15 PM, R26 stated I get tired of the treatment from (V34) CNA. I don't feel safe when (V34) is working. I want to just pull my pacemaker out and end it all sometimes, but only when (V34) is taking care of me. R26 stated if R26 used the bathroom in bed V34 would roughly get R26 out of bed, ripping R26's clothes at times, and wheel R26 to the dining room to wait for breakfast. R26 stated V34 was also verbally abusive. R26 said the last time V34 had been abusive like this to R26 was within the past week of this survey. R26 stated facility staff were aware of V34 being abusive but nobody does anything about it.
On 5/10/24 at 2:07 PM, R26 said the last time he had issues with his care by V34 (CNA) had been Monday night 5/6/24 / Tuesday morning 5/7/24.
R26's 5/15/24 final reportable incident documented in part . Regional Director interviewed the resident (R26) and he stated that CNA (V34) grabs his shirt pocket and rips them when he is attempting to get him out of bed. Resident stated that CNA gets him up at 2 or 3 AM for no reason . Resident state that CNA talks rudely to him . Regional Director interviewed (R26's) roommate (R37). (R37) is (alert and oriented times 4). (R37) stated that (R26) is pulled around by (V34) in the middle of the night because resident doesn't want to get up at 2 AM. (R37) stated that (V34) is verbally demeaning to resident and is tone of voice is aggressive when speaking with (R26) . Conclusion After a thorough investigation the facility is able to substantiate the allegation. (V34) has been terminated .
On 5/17/24 at, 2:50 PM, V44 (Regional Director of Operations) said she expected staff to be suspended pending an investigation. V44 said she expected V34 (CNA) to have been suspended on 5/6/2024 due to the R300 abuse allegation.
3. On 5/8/24 at 9:56 AM, R46 said a CNA told him to turn his f**king music down. R46 said he (V34 Certified Nursing Assistant/ CNA) was always complaining about R46's music. R46 said he has not had any problems with any other staff. R46 said this incident happened on 5/3/24. R46 said the next day (5/4/24) V1 (Administrator) came to speak with R46. R46 said V1 had told him that V34 had never cussed at him, and the incident didn't happen. R46 said V1 told him that V1 did not believe him. R46 said he did not feel safe when V34 was working. R46 said he had not told V1 he did not feel safe while V34 was working because V1 had never asked.
R46's 2/28/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating R46 was cognitively intact.
On 5/8/24 at 1:16 PM, V42 (LPN) said on 5/4/24 V40 (Housekeeper) had reported an abuse allegation pertaining to R46. V42 said she asked V40 to complete a written statement and called V1 (Administrator) to report the abuse allegation. V42 said there were 2 abuse allegations reported to her very close together on 5/4/24 and V42 had reported both to V1 via telephone. V42 said she went to speak with R46 on 5/4/24 and R46 reported V34 (CNA) on midnight shift had cussed at him over R46's music being too loud.
On 5/8/24 at 2:20 PM, V1 (Administrator) said R46's abuse allegation was not substantiated so V1 did not feel the allegation needed to be reported. V1 presented R46's 5/4/24 facility investigation documents with all persons questioned. R46's 5/4/24 facility investigation file documented only staff were interviewed but no residents were interviewed.
On 5/15/2024 at 2:10 PM, V1 (Administrator) stated I feel like our standard investigations are good.
The facility's undated census list provided on 5/7/24 documented 47 residents residing in the facility.
Document titled Abuse Prevention Program with Revised date of 11/28/2016 documented in part .this facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property and exploitation. 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 secured environment. The facility is committed to protecting our residents from abuse by anyone including but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members, or legal guardians, friends, or any other individuals . section 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 . Supervisors shall immediately inform the administrator or his/her designated presentative (specified by the administrator in the case of a planned absence) of all reports of potential/alleged mistreatment, exploitation, neglect, and abuse of residents of residents and misappropriation of resident property. Upon learning of the report, the administrator or designee shall initiate an investigation. 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 . 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 . VII. External Reporting of Potential Abuse . 1. Initial Reporting of Allegations. The facility must ensure that all alleged violations involving mistreatment, exploitation, neglect or abuse . are reported immediately to the administrator of the facility . 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 on law enforcement agency of jurisdiction and IDPH immediately after forming the suspicion . otherwise, the report must be made not later than 24 hours after forming the suspicion .
The facility's undated Administrative Services policy received on 5/10/24 at 10:29 AM documented in part .(Facility company name) shall designate a Nursing Home Administrator who is licensed by (or is eligible for licensure in) the State in which the facility is located . the Administrator shall be familiar with, and responsible for, meeting all applicable regulations and familiarizing employees with regulations applicable to their responsibilities .
Mar 2024
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Practitioner Orders for Life-Sustaining Treatment (POLST) st...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Practitioner Orders for Life-Sustaining Treatment (POLST) status reflected resident wishes as desired throughout the Clinical Health Record for 2 (R8, R151) of 2 residents reviewed for Advanced Directives in the sample of 36.
1. Review of R8's Profile Face Sheet documented an original admission date to the facility of [DATE]. Diagnoses listed on this same sheet included but were not limited to: Rhabdomyolysis; Acute Kidney Failure, Unspecified; Type 2 Diabetes Mellitus without complications, etc .
R8's Illinois Department of Public Health Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form dated [DATE] documented orders for patient in cardiac arrest as, No CPR (cardiopulmonary resuscitation): Do Not Attempt Resuscitation.
R8's Physician's Orders dated for [DATE] - [DATE] documented a code status of Full Code.
R8's Care Plan documented a problem area for Advanced Directives as, No Advanced Directives chosen- Resident will be resuscitated.
On [DATE] at 02:17 PM, V7 (Regional Director of Operations) confirmed that R8's wishes for life sustaining measures were not accurately reflected throughout her record. V7 stated an audit will be conducted to ensure no other residents are affected.
2. R151's admission and Discharge Record documents R151 was admitted to the facility on [DATE]. This same document included the following diagnoses: Spinal Stenosis, Physical Deconditioning, Memory Impairment, Anxiety and Depression.
R151's POLST form located in the medical chart was signed and dated [DATE] by V8 (Power of Attorney/POA) as a DNR (Do Not Resuscitate).
R151's current physician orders for March of 2023 document R151's code status as a full code.
On [DATE] at 11:00 AM, V1 (Administrator) stated that they will call pharmacy to update the order sheet, and they will correct the order sheet by hand in the chart at this time to reflect the information on POLST form.
The Advanced Directive policy with a most recent reviewed date of [DATE] documented, It is the policy of this facility to honor resident's wishes as expressed in advanced directives regarding medically indicated treatments whenever possible. This facility shall take all steps necessary to comply with state ands (sic) federal legislation relating to advance directives.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure comprehensive assessments were completed in accordance with required time frames for 3 (R32, R23 and R151) of 3 residents reviewed f...
Read full inspector narrative →
Based on interview and record review, the facility failed to ensure comprehensive assessments were completed in accordance with required time frames for 3 (R32, R23 and R151) of 3 residents reviewed for comprehensive assessments and timing in the sample of 36.
Findings Include:
1. R23's Profile Face Sheet documents an admission date of 4/3/20, and includes the following diagnoses: Major Depressive Disoder, Dementia, Muscle Weakness and Aphasia.
R23's most recent completed Minimum Data Set (MDS) was dated 10/11/23 and coded as a quarterly assessment.
On 3/21/24 at 11:30 AM, V4 (MDS Coordinator) stated that R23 was due for a comprehensive annual MDS 1/16/24, but this was not completed and transmitted until 3/14/24.
R23's current comprehensive annual MDS Section Z was reviewed and noted to be signed by V4 and dated 3/14/24.
2. R151's admission and Discharge Record documents an admission date of 1/31/24. This same document includes the following diagnoses: Anxiety, Depression, Skin Rash and Memory Impairment.
On 3/20/24 at 2:00 pm, V4 stated that R151's MDS assessment had not been started yet.
Review of R151's medical record revealed no MDS assessment had been completed as of 3/20/24.
3. R32's Profile Face Sheet documents an admission date of 9/1/20 and includes the following diagnoses: Sepsis, Hallucinations, and Weakness.
On 3/21/24 at 11:30 AM, V4 stated that R32 was due for a comprehensive annual MDS on 11/14/23, but this was not completed and transmitted until 3/6/24.
R32's current comprehensive annual MDS Section Z was reviewed and noted to be signed by V4 and dated 3/6/24.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to implement a baseline care plan for 1 (R151) of 12 residents reviewed for baseline care plans in a sample of 36.
Findings Include:
R151's ad...
Read full inspector narrative →
Based on record review and interview, the facility failed to implement a baseline care plan for 1 (R151) of 12 residents reviewed for baseline care plans in a sample of 36.
Findings Include:
R151's admission and Discharge Record documents an admission date of 1/31/24. This same document includes the following diagnoses: Spinal Stenosis, Physical Deconditioning, Anxiety, Memory Impairment and Depression.
Review of R151's medical record revealed no care plan could be found.
On 3/20/24 at 2:34 PM, V4 (Minimum Data Set [MDS]/Care Plan Coordinator) stated that she does not have a care plan (Comprehensive or Baseline) started. V4 further stated that usually the nurses start the baseline care plan on admission or within 24-48 hours of admission, and then she creates the comprehensive care plan.
The Baseline Care Planning policy with a revision date of 3/16/22 documents 3. the 'Baseline Care Plan' and 'Care Plan Summary' shall be completed within 48 hours of admission by the admitting nurse or designee .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to revise a comprehensive plan of care to meet current resident needs for 2 (R28 and R34) of 13 residents reviewed for care plan timing and re...
Read full inspector narrative →
Based on interview and record review, the facility failed to revise a comprehensive plan of care to meet current resident needs for 2 (R28 and R34) of 13 residents reviewed for care plan timing and revision in the sample of 36.
Findings Include:
1. Review of R28's admission and Discharge Record documented an original admit date to the facility of 10/20/23. R28's Cumulative Diagnosis Log documented diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease, Hyperglycemia, Weakness, Developmental Disorder, etc .
R28's Nurse's Notes document on 11/13/23 at 2:00 PM, an entry detailing the onset of a new 1 centimeter by 1 centimeter open area on his left buttock. An additional entry on 3/20/24 at 6:00 PM, documented an evaluation was made by V11 (Wound Physician), in which the wound to R28's left buttock was determined to be resolved as of this date.
On 3/21/24 at 1:10 PM, V4 (Minimum Data Set/Care Plan Coordinator [MDS/CPC]) confirmed that R28's current plan of care did not, and had not included a revision to incorporate a focus area for current or the potential impairment of skin integrity.
On 3/21/24 at 1:32 PM, V2 (Director of Nursing) stated that a resident experiencing actual or being at risk for skin breakdown should have a plan of care developed to address those concerns.
2. R34's Profile Face Sheet documented an original admit date to the facility of 9/17/21. Diagnoses listed on this same document included, but were not limited to: Unspecified Dementia, Parkinson's disease, Essential Hypertension, etc .
On 03/19/24 at 09:49 AM, R34 was observed lying in bed, with Jevity 1.5 calorie observed running at 45 milliliters (mL)/hour (hr) via gastrointestinal tube. R34 was observed as not being alert or oriented to person, place or time during this observation.
R34's Physician Orders for 3/1/24 - 3/31/24 documented an active dietary order starting 11/23/23 for Jevity 1.5 running at 45 mL/hr x 23 hr.
Review of R34's current plan of care documented a Problem/Need area with a start date of 9/29/21 for, Resident in need of nutrition in form of REGULAR DIET . An additional Problem/Need area on the same plan of care with a start date of 10/14/22 for, Restorative Nursing Program - Eating Problem/Need Needs reminders to pick up utensils and to take drinks .
On 3/20/24 at 11:37 AM, V4 (MDS/CPC) stated that R34 receives nutrition via gastrointestinal tube, and does not eat by mouth. V4 confirmed that R34's Plan of Care was not revised/updated to reflect her current status, as R34's current plan of care listed a regular diet with a restorative nursing eating program involving the use of utensils in place.
The Comprehensive Care Planning policy with a most recent revision date of 11/1/17 documented stated, 4. Comprehensive Care Plans shall strive to describe: .b. The resident's medical, nursing, physical, mental and psychosocial needs and preferences.
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 offer pneumococcal and/or covid vaccinations in accordance with gui...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer pneumococcal and/or covid vaccinations in accordance with guidelines for 2 (R15 and R41) of 5 residents reviewed for immunizations in a sample of 36.
Findings include:
1. R15's Profile Face Sheet documents an admission date of 7/27/2018, and a date of birth (DOB) indicating R15 is [AGE] years of age. R15's face sheet documents diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Essential Hypertension, Malignant Neoplasm of Prostate, Peripheral Vascular Disease, Atherosclerosis of the aorta, Atherosclerotic Heart Disease of native coronary artery.
The facility document titled Resident Immunization Tracking Log dated 10/1/2023 through 3/31/2024 documents R15 received the PCV13 (Pneumococcal Conjugate Vaccine) on 12/20/2022.
No documentation could be found in R15's medical record of R15 having been offered or administered a PCV (Pneumococcal Conjugate Vaccine) 20 or PPSV (Pneumococcal Polysaccharide Vaccine) 23 vaccine.
2. R41's Profile Face Sheet documents an admission date of 9/6/2023 and a DOB indicating R41 is [AGE] years of age. R41's cumulative Diagnosis Log (undated) documents diagnoses including Schizophrenia, Anxiety Disorder, Major Depressive Disorder, Heart Failure, Essential Hypertension, Atrial Fibrillation, and Venous Insufficiency (Chronic) (Peripheral).
R41's Resident Influenza and Pneumonia Vaccine Consent dated 9/27/2023, indicated that R41 refused to sign consent for Influenza Vaccine, PPSV23 and PCV13 vaccine.
On 3/19/24 V2 (Director of Nursing/DON) provided the Resident Immunization Tracking Log. This document indicated that R41 refused the influenza, PCV13 and PPSV23 vaccines, however it did not indicate the COVID or PCV20 vaccines were offered.
R41's Physician Order Sheet (POS) dated for March 2024 documents an order for Influenza Vaccine Yearly.
On 3/20/2024 at 1:15pm, V2 stated that she recently took the position of Director of Nursing, and after review there is no documentation of R15 or R41 receiving Prevnar 20 vaccinations, and confirmed that R15 has only received the PCV13.
According to https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html#note-pneumo, the following recommendations were retrieved as of 3/20/24:
Age 65 years or older who have:
Not previously received a dose of PCV13, PCV15, or PCV20 or whose previous vaccination history is unknown: 1 dose PCV15 OR 1 dose PCV20.
If PCV15 is used, administer 1 dose PPSV23 at least 1 year after the PCV15 dose (may use minimum interval of 8 weeks for adults with an immunocompromising condition,* cochlear implant, or cerebrospinal fluid leak).
Previously received only PCV7: follow the recommendation above.
Previously received only PCV13: 1 dose PCV20 OR 1 dose PPSV23.
If PCV20 is selected, administer at least 1 year after the last PCV13 dose.
If PPSV23 is selected, administer at least 1 year after the last PCV13 dose (may use minimum interval of 8 weeks for adults with an immunocompromising condition,* cochlear implant, or cerebrospinal fluid leak).
Previously received only PPSV23: 1 dose PCV15 OR 1 dose PCV20. Administer either PCV15 or PCV20 at least 1 year after the last PPSV23 dose.
If PCV15 is used, no additional PPSV23 doses are recommended.
Previously received both PCV13 and PPSV23 but NO PPSV23 was received at age [AGE] years or older: 1 dose PCV20 OR 1 dose PPSV23.
If PCV20 is selected, administer at least 5 years after the last pneumococcal vaccine dose.
If PPSV23 is selected, see dosing schedule at cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf.
Previously received both PCV13 and PPSV23, AND PPSV23 was received at age [AGE] years or older: Based on shared clinical decision-making, 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine dose.
For guidance on determining which pneumococcal vaccines a patient needs and when, please refer to the mobile app, which can be downloaded here: cdc.gov/vaccines/vpd/pneumo/hcp/pneumoapp.html.
Age 19-64 years with certain underlying medical conditions or other risk factors who have:
Not previously received a PCV13, PCV15, or PCV20 or whose previous vaccination history is unknown:
1 dose PCV15 OR 1 dose PCV20.
If PCV15 is used, administer 1 dose PPSV23 at least 1 year after the PCV15 dose (may use minimum interval of 8 weeks for adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak).
Previously received only PCV7: follow the recommendation
Previously received only PCV13: 1 dose PCV20 OR 1 dose PPSV23.
If PCV20 is selected, administer at least 1 year after the PCV13 dose.
If PPSV23 is selected, see dosing schedule at cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf
Previously received only PPSV23: 1 dose PCV15 OR 1 dose PCV20. Administer either PCV15 or PCV20 at least 1year after the last PPSV23 dose.
If PCV15 is used, no additional PPSV23 doses are recommended.
Previously received PCV13 and 1 dose of PPSV23: 1 dose PCV20 OR 1 dose PPSV23.
If PCV20 is selected, administer at least 5 years after the last pneumococcal vaccine dose.
If PPSV23 is selected, see dosing schedule at cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf
For guidance on determining which pneumococcal vaccines a patient needs and when, please refer to the mobile app which can be downloaded here:
cdc.gov/vaccines/vpd/pneumo/hcp/pneumoapp.html
*Note:
Underlying medical conditions or other risk factors include alcoholism, chronic heart/liver/lung disease, chronicrenal failure, cigarette smoking, cochlear implant, congenital or acquired asplenia, CSF leak, diabetes mellitus, generalized malignancy, HIV infection, Hodgkin disease, immunodeficiencies, iatrogenic immunosuppression, leukemia, lymphoma, multiple myeloma, nephrotic syndrome, solid organ transplant, or sickle cell disease or other hemoglobinopathies
COVID-19 vaccination:
Routine Vaccination
Age 19 years or older
Unvaccinated:
1 dose of updated (2023-2024 Formula) Moderna or Pfizer-BioNTech vaccine
2-dose series of updated (2023-2024 Formula) Novavax at 0, 3-8 weeks
Previously vaccinated with 1 or more doses of any COVID-19 vaccine:
1 dose of any updated (2023-2024 Formula) COVID-19 vaccine administered at least 8 weeks after the most recent COVID-19 vaccine dose.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to keep resident care areas clean and in a good state of repair for 14 (R7, R18, R10, R16, R23, R21, R41, R45, R29, R22, R25, R35...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to keep resident care areas clean and in a good state of repair for 14 (R7, R18, R10, R16, R23, R21, R41, R45, R29, R22, R25, R35, R15, and R20) of 14 residents reviewed for homelike environment in the sample of 36.
Findings Include:
On 03/19/24 09:56 AM, R7's room was observed to have two brown stained ceiling tiles, a missing cover on the baseboard heater, and a brownish-orange discoloration to the floor near the baseboard under the sink. In R7's room and bathroom, chipped paint was noted on multiple areas of the walls as well as chipped wood on the door inside bathroom.
On 03/19/24 at 10:17 AM, R18, R10 and R16's adjoining bathroom had missing baseboard with stained drywall exposed.
On 03/19/24 10:21 AM, R23's room revealed the front cover was missing off the baseboard heater. The cover for a portion of the heater was lying on the floor in front of the heater. There were wood chunks missing out of the corner of the door and missing paint with wood exposed.
On 03/21/2024 at 11:30 AM, R21, R41, and R45's shared room was noted to have three-fourths of the ceiling tiles with brown stains and all of the room's base boards were missing. R29's room was observed this same date and time and was also noted to have three-fourths of the ceiling tiles with brown stains and all of the room's base boards are missing.
On 3/21/2024 at 11:33 AM, R22, R25 and R35's shared room was noted to have all of the base boards missing.
On 3/21/2024 at 11:35 AM, R15 and R20's shared room revealed one brown stained ceiling tile and all of the base boards were missing.
On 03/20/24 at 02:20 PM, V1 (Administrator) stated that there are building repairs scheduled to be made.
On 3/21/2024 at 11:50 AM, a tour with V9 (Maintenance) was conducted. V9 acknowledged the brown stained ceiling tiles, missing base boards, discoloration of the floor, chipped paint and doors, and base board heating system that is missing the front cover. V9 stated all need replaced and/or removed. V9 stated that she took this position in July 2022 and is still in the process of trying to complete construction projects throughout the facility. V9 stated that she does not have a budget with funds specific to her department. V9 stated, the process to be approved for funds is to fill out a request form with a list of construction supplies needed, then she will fax the request form to V10 (Vice President of Operations). V9 stated the company has been struggling financially and (V9) has not been able to get approval for supplies.
The facility policy titled Facility Physical Plant and Environmental Policy & Guidelines (undated) documents under Policy Statement: It is of the utmost importance to provide a safe, hospitable, clean and organized facility and grounds to ensure an environment that is conducive to providing the best care, comfort and home-like surroundings for residents. A well maintained building and environment is also important for creating safe work surroundings across all departmental staffing and their ability to effectively, and efficiently provide care and great living environment to all residents and all necessary resources to do so. The building and grounds must be maintained in the best presentable state and must be done so through routine maintenance and upkeep, housekeeping, and ensuring compliance with current federal, state, local and NFPA (National Fire Protection Association) codes .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure timely completion of quarterly assessments for 4 (R5, R7, R26, R45) of 4 residents reviewed for quarterly assessments in the sample ...
Read full inspector narrative →
Based on interview and record review, the facility failed to ensure timely completion of quarterly assessments for 4 (R5, R7, R26, R45) of 4 residents reviewed for quarterly assessments in the sample of 36.
Findings Include:
1. R5's Profile Face Sheet documents an admission date of 5/21/19. This same document includes the following diagnoses: Schizoaffective Disorder, Major Depression Disorder, Anxiety, and Dementia.
On 2/21/24 at 11:00 AM, V4 (Minimum Data Set/MDS Coordinator) stated that R5's quarterly MDS (Minimum Data Set) assessment was due on 2/7/24 and it was not completed and transmitted until 3/20/24.
R5's current quarterly MDS Assessment Section Z was reviewed and noted to be signed by V4 and dated 3/20/24.
2. R7's Profile Face Sheet documents an admission date of 9/23/22. This same document includes the following diagnosrs: Major Depressive Disorder, Anxiety, and History of falling.
On 2/21/24 at 11:00 AM, V4 stated that R7 had a quarterly MDS assessment due on 1/2/24 and it was not completed and transmitted until 3/11/24.
R7's current quarterly MDS Assessment Section Z was reviewed and noted to be signed by V4 and dated 3/11/24.
3. R26's Profile Face Sheet documents an admission date of 8/23/19. This same document includes the following diagnoses: Alzheimer's Disease, Hypertension, Major Depressive Disorder.
On 2/21/24 at 11:00 AM, V4 stated that the quarterly MDS assessment was due 1/23/24 but was not completed and transmitted until 3/19/24.
R26's current quarterly MDS Assessment Section Z was reviewed and noted to be signed by V4 and dated 3/19/24.
4. R45's Profile Face Sheet documents an admission date of 7/28/23 and includes the following diagnoses: Schizophrenia, Cachexia, and Bipolar Disease.
On 2/21/24 at 11:00 AM, V4 stated that the quarterly MDS assessment was due on 2/6/24 and it was not completed and transmitted until 3/18/24.
R45's current quarterly MDS Assessment Section Z was reviewed and noted to be signed by V4 and dated 3/18/24.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure Registered Nurse (RN) coverage 8 hours a day, 7 days per week. This failure has the potential to affect all 44 residents who reside ...
Read full inspector narrative →
Based on interview and record review, the facility failed to ensure Registered Nurse (RN) coverage 8 hours a day, 7 days per week. This failure has the potential to affect all 44 residents who reside in the facility.
Findings Include:
The facility's nursing schedules for February and March 2024 documented the following dates were lacking 8 hours of Registered Nurse (RN) coverage: 2/4/2024, 2/5/2024, 2/11/2024, 2/25/2024, 3/9/2024, 3/10/2024, 3/16/2024 and 3/17/2024.
On 3/19/24 at 2:40 PM, V2 (Director of Nursing/DON) confirmed that the facility's February and March 2024 nursing schedules were accurate.
On 3/19/24 at 2:46 PM, V1 (Administrator) confirmed the lack of Registered Nursing coverage on the above listed dates. V1 stated the weekend dates are difficult for them to get RN coverage.
The Long-Term Care Facility Application for Medicare and Medicaid dated 3/19/24 documented a facility census of 44.
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 date and label opened food items/leftovers. This failure has the potential to affect all residents residing in the facility wh...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to date and label opened food items/leftovers. This failure has the potential to affect all residents residing in the facility who receive food from the kitchen.
The Findings Include:
On 3/19/24 at 9:00 AM, during the initial tour of the kitchen, items in the refrigerator were found to be opened without identifying and dating the food. Items found not dated and labeled after opening were salad dressing, corn, tortillas, shredded cheese and a container of meat.
At this time, V3 (Dietary Manager) stated that she has new employees that maybe do not know they need to do this. V3 further stated she was unsure what was even in the one container that appeared to be a type of meat.
The facility's storage policy with a revision date of 10/20 documents that it is the policy of (Facility Name) that food shall be stored on shelves in areas that provide the best preservation. Food shall be stored at the proper temperature and for appropriate lengths of time to protect quality of food and food cost .5. Store leftovers in covered, labeled and dated containers under refrigeration or frozen. 6. When using only part of a product, the remaining product should be in the original package or air tight container and labeled and dated
The Long Term Care Application for Medicare and Medicaid, dated 3/19/24, documents 44 residents reside in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
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 maintain an effective pest control program to ensure t...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests. This has the potential to affect all 44 residents residing in the facility.
The findings include:
On 03/19/24 at 09:56 AM, R7's room was observed to have gnats flying in the bathroom above the toilet.
On 3/20/2024 at 08:54 AM, gnats were seen flying around in the dining room around a table and near the coffee bar.
On 03/20/24 at 08:54 AM, V3 (Dietary Manager) stated there was a big problem with gnats and the facility has had them all winter. V3 stated, the gnats are always around the coffee station and garbage cans and there is a problem with one of the drains in the kitchen. V3 stated corporate maintenance is supposed to come fix it, but V3 didn't know when.
On 03/20/24 at 02:20 PM, V1 (Administrator) acknowledged that the facility has had gnats. V1 stated that they do have an active pest control contract, and the facility was recently serviced. V1 stated that a kitchen drain had recently been replaced, with other building repairs scheduled to be made, which she hopes will help with the gnats in the facility.
On 3/22/2024 at 9:45 AM, V9 (Maintenance) stated that the outside pest control company does a monthly evaluation and treatment for gnats. V9 acknowledged there was a gnat problem in the building, but stated it had improved since the pest control company came last month. V9 stated there had been standing water on the outside wall of the kitchen due to the water lines needing to be replaced. V9 stated the line was repaired in [DATE] which helped the water to drain, and the gnats have decreased throughout the building.
A statement of the summary of services from the contracted pest control company dated 2/05/2024 documents services of .Targeted Pest: Flies, Drain/Moth Flies. Device of Application: Drains. Equipment Used: Aerosol. Recommendations: The divot in the floor under the dishwasher is holding water. Please repair to prevent pest entry.
The facility policy titled Facility Physical Plant and Environmental Policy & Guidelines (undated) documents under Policy Statement: It is of the utmost importance to provide a safe, hospitable, clean and organized facility and grounds to ensure an environment that is conducive to providing the best care, comfort and home-like surroundings for residents. A well maintained building and environment is also important for creating safe work surroundings across all departmental staffing and their ability to effectively, and efficiently provide care and great living environment to all residents and all necessary resources to do so. The building and grounds must be maintained in the best presentable state and must be done so through routine maintenance and upkeep, housekeeping .
The facility Pest Control Policy dated April 5th, 2021, documented under Routine Services-Specification Services for insect Management is scheduled monthly. Insect management procedures includes, the use of insect monitoring devices, strategic placement of insect management bait, application of insects management dust formulations, .Under Section, Call for Additional Service: In the event additional services are necessary between our regularly scheduled visits, such services will be rendered promptly without an additional charge .
Jul 2023
1 deficiency
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to provide Registered Nurse coverage for eight hours a day, seven days a week. This has the potential to affect all 46 residents residing at th...
Read full inspector narrative →
Based on interview and record review the facility failed to provide Registered Nurse coverage for eight hours a day, seven days a week. This has the potential to affect all 46 residents residing at the facility.
Findings include:
On 07/13/23 at 10:10 AM V2 (Director of Nursing) stated, besides her, they have one Registered Nurse (RN) that works part time at the facility because she also works at the hospital so she has not worked for the last few weeks and V3 (Assistant Director of Nursing) just became a RN on July 5 so that will be helpful, but they struggle to have RN coverage because she could not work seven days a week. V2 said hopefully that will be better with V3 (ADON) but they are always looking for another RN to work at the facility.
The July 2023 Nursing Schedule documents no Registered Nurse (RN) coverage for July 1st, and July 8th, and only 4 hours of RN coverage on July 2nd, July 4th, and July 9th. The June 2023 Nursing Schedule documents no RN coverage for June 3rd, 4th, 10th, 11th, 18th, 24th, 25th, and 29th.
The Midnight Census Report with an updated date of 07/11/23 documents 46 residents residing at the facility.
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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from abuse for 2 of 3 residents (R2, R3)...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from abuse for 2 of 3 residents (R2, R3) for abuse in the sample of 6.
The findings include:
1. A final abuse report dated 2/2/23 documents on 1/28/23 at approximately 6:00pm, R2 yelled out, She hit me in the face. R2 was in the dining room at that time and R1 was noted to be in the dining room in close proximity to R1. The two were immediately separated and assessed with no injuries. During the investigation it was noted that this incident was not witnessed by staff or other residents but did hear R2 yell out. Nurse assessed R2 when she yelled out and discovered only slight redness around her mouth. Offers of ice pack and tylenol refused. R2 stated she was in the dining room when R1 entered the dining room and struck her in the face with a closed hand. R2 was wiping off the tables in the dining room and did not engage in conversation when R1 came in the dining room. R1 was interviewed and asked what happened. R1 stated she did not know and asked What happened about what?. In conclusion the facility was able to substantiate the allegation of a resident to resident altercation.
A final abuse report dated 2/17/23 documents that on 2/11/23 at approximately 6:45pm, an allegation of resident-resident physical abuse was reported to V1 (Administrator). Residents were immediately separated and no obvious injuries noted. This incident was not witnessed but LPN (Licensed Practical Nurse) on duty (V3) heard R2 say No, no, no then ow. V3 looked to notice R2 sitting in wc (wheelchair) in hallway near Activity calendar. R1 was in her wheelchair moving towards the nurses station, R1 continued to move away from R2. When asked what happened R2 reported that R1 struck her right arm underneath the shoulder with the back of her hand. R1 stated she didn't know what happened and refused to have vital signs taken and is often tactile defensive. In conclusion the facility failed to substantiate the allegation of resident to resident abuse.
R1's document labeled Profile Face Sheet notes that R1 was admitted to the facility on [DATE]. The same document lists some of R1's diagnoses as Unspecified dementia with behavioral disturbance, Schizoaffective disorder. R1's MDS (Minimum Data Set) dated 12/9/22 note that R1 has a BIMS (Brief Interview of Mental Status) of 06 which indicates that R1 has severe cognitive impairment.
R1's Care Plan with start date of 8/27/22 documents R1 has severe impulse control, has attention seeking behaviors that leads to frequent outburst and negative behaviors. R1 is resistant with care, wanders the halls going into other rooms and taking belongings back to her room. R1 will often throw herself out of her wheelchair into the floor and pretend to be unresponsive. R1 has personal space issues of 5 feet. R1 has a short attention span, is very impatient and wants immediate attention. R1 will scream out, attempts to push throw staff and doors. R1 is almost impossible to redirect. R1 has frequent medication reviews and redosing. R1 refuses medications by mouth and has to have injections as need and now recurrent to manage behaviors. R1 has been involved in multiple peer/peer confrontations although rarely causing injury.
R2's document labeled Profile Face Sheet notes that R2 was admitted to the facility on [DATE]. The same face sheet note some of R2's diagnoses as Schizotypal disorder, Schizoid personality disorder, Rhabdomyolysis, unsp (unspecified) psychosis not due to a substance or known phy (physiological), mental disorder, not otherwise specified. R2's MDS dated [DATE] notes R2 has a BIMS of 15 which indicates R2 is cognitively intact.
On 2/21/23 at 1:00pm, R2 said on 1/28/23 she was cleaning the tables off in the dining room and putting dishes into the kitchen. R2 said R1 had previously kicked a chair but had calmed down and was watching TV. R2 said she got beside R1 putting dishes up when R1 hit her on the left side of her head. R2 said that it did hurt and that staff offered her tylenol and she refused. R2 also said that the area was red by her mouth but there was no bleeding. R2 said that on 2/11/23 again she had been in the dining room and had ice cream after she was cleaning. R2 said she had pushed a dining cart out of her way and it went towards R1. R2 said after that R1 hit her on the left upper arm. R2 said staff offered her an x-ray but what was that going to do? R2 also said and really what is tylenol going to do. R2 said she is not afraid of R1.
2. A final abuse report dated 2/13/23 documents that on 2/8/23 at approximately 11:25am, it was reported that staff witnessed R1 graze the left arm of R3 with the tips of her fingers. The two were immediately separated and assessed with no injuries noted. During investigation it was noted that this incident was witnessed by staff. Both residents were sitting in SSD (Social Services Department) office and noted to be approximately an arm's length apart when R1 swung her arm toward R3, grazing R2's left arm with fingertips. In conclusion the facility was able to substantiate the allegation of a resident to resident altercation.
R3's document labeled Profile face sheet note R3 was admitted to the facility on [DATE] with diagnosis to include unspecified psychosis not due to a substance or known physiological condition and schizoffective disorder.
On 2/21/23 at 3:00pm, R3 said the resident that hit her arm can't help it and did not hurt her. R3 said she hasn't hurt anybody and that she if not afraid of her. R3 said that there are a few residents that are out there like her that are loud. R3 was alert and oriented at first, then went off the subject talking about all of the people out to get her. R3 did not mention R1 when naming the people out to get her.
On 2/21/23 at 2:30pm, V2 (Director of Nurses) said that they have a meeting every Monday morning on resident behaviors and medications. V2 said that R1 has a television in her room since she likes to watch it. V2 said that R1 also likes music, and likes snacks. V2 said a lot of times when R1 gets agitated, they can take her to her room and turn the television on or some music and it will calm her down. V2 said that R1 likes to go watch movies in the MDS (Minimum Data Set) coordinators office on the computer. V2 said it depends on how agitated R1 is as to how easy it is to calm her down. V1 said that most of the time R1 will take off down the hall by herself. V2 said they continue to track R1's behaviors. V2 said that since R1 has been refusing her medications, they have changed the depakote to the sprinkles and started liquid haldol. V2 said she thinks R1's behaviors are improving with these meds. V2 said that R1's behaviors started a while ago and is care planned for this and they also do behavior tracking.
On 2/21/23 at 2:15pm, V1 (Administrator) said they have every intervention they can think of in place for R1 and they do have QA (Quality Assessment) meeting on her behaviors. V1 said she is hoping the medication changes will help R1. V1 said that R1 has been known to lash out to other residents when she feels threatened or someone is in her space.
On 2/21/23 at 12:45pm, V3 (LPN/Licensed Practical Nurse) said that R1 can sometimes be difficult. V3 said when offering R1 her medications and she refuses, she will wait a bit and then re-approach. V3 said she has found the best thing is to move her to something else she likes and then re-approach. V3 said that R1 will refuse her medications even after re-approaching 3 or more times. V3 said she is not sure if its the scrubs, but usually as soon as she sees you coming, she will tell you to go away. V3 said that R1 has had a few incidents with other residents she thinks.
On 2/21/23 at 2:45pm, V4 (Social Services Director) said she talks to R2 at least weekly and has not had any negative effects from the incidents with R1. V4 said that R2 frequently talks about the incident to other residents and seems to always instigate R1 in some manner. V4 said that R2 will continually bring stuff up over and over. V4 said she has no documentation on her talks with R2 but does talk to her. V4 said she talks a lot with R1 and can sometimes re-direct her and that V4 does have a history of hitting other residents.
Document labeled Facility Abuse Prevention Policy, revised 11/28/16 note that the facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation .The facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents and has attempted to establish a sensitive and resident secure environment .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. This will be done by: .identifying occurrences and patterns of potential mistreatment, exploitation, neglect and abuse of residents and misappropriation of resident property, dementia management and resident abuse prevention .Implement systems to investigate all reports and allegations of mistreatment, exploitation, neglect, abuse of residents and misappropriation of resident property; promptly and aggressively and making necessary changes to prevent future occurrences.
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 8 hours of daily Registered Nurse (RN) coverage. This has the potential to affect all 46 residents residing in the facility.
Findin...
Read full inspector narrative →
Based on interview and record review the facility failed to provide 8 hours of daily Registered Nurse (RN) coverage. This has the potential to affect all 46 residents residing in the facility.
Findings Include:
The facility Daily Census Form dated 2/21/23 documents 46 residents reside at the facility
On 2/21/23 at 11:00am, V1 (Administrator) stated they have 3 RN's (Registered Nurses) that have committed to coming in May. V1 said they have tried to hire but no luck.
On 2/21/23 at 2:00pm, V2 (DON/Director of Nurses) said that there is only 1 RN to work other than herself and she can not work a lot of days due to having another job.
Facility nursing schedules from 2/10/23 to 2/21/23 document the facility did not have RN coverage on 2/11/23, 2/17/23, 2/18/23, 2/19/23.
Feb 2023
11 deficiencies
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 interview and record review the facility failed to ensure residents were allowed to vote for 1 of 5 (R32) residents rev...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were allowed to vote for 1 of 5 (R32) residents reviewed for resident rights in the sample of 46.
Findings Include:
R32's undated Profile Face Sheet documents R32 was admitted to the facility on [DATE]. R32's MDS (Minimum Data Set) dated 11/14/22 documents R32 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates R32 is cognitively intact.
On 2/7/23 at 2:30 PM, R32 stated she was not able to vote at the last general election. R32 stated she called the County Clerk and was told the County Clerks office never received a list of residents who wanted to vote so they were not able to send out ballots.
On 02/08/23 at 2:17 PM, V9 (Activities Director) stated she has been in the position since August 2022, and didn't know there was an election in November. V9 stated the residents had inquired about voting but that was several months prior to November.
On 02/08/23 at 2:24 PM, V1 (Administrator) stated the mail in ballots were sent to facility and were put in a drawer, then the desk was moved. V1 stated the ballots were located but it was too late for the residents to vote.
When asked for the policy related to voting V1 provided this surveyor with the Resident Rights pamphlet that documents, Remember, you do not lose your rights as a citizen of Illinois and the United States because you live in a long-term care facility. You have the right to vote .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
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 ensure residents the freedom of managing financial affairs for 1 of 1 r...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed ensure residents the freedom of managing financial affairs for 1 of 1 resident (R40) reviewed for personal funds in a sample of 46.
The Findings Include:
R40's undated profile face sheet documents a date of birth of [DATE] and an admission date of [DATE].
R40's most recent Minimum Data Set assessment dated [DATE] Section C documents a Brief Interview of Mental Status score of 15 indicating that R40 is cognitively in tact.
On [DATE] at 9:30 AM, R40 stated that she had a death benefit payout that she should have received from her deceased sons insurance company in December. R40 went on to state the facility staff opened her mail and cashed the check without her knowledge. R40 only learned of the facility cashing the check after she called the insurance company a third time. R40 first called the insurance company when she didn't receive the a check after learning that she was to receive a payout. The insurance then resubmitted a check for payment. R40 stated that when she called the last time to say she still hadn't received it, the insurance company saw that both checks have been cleared.
On [DATE] at 11:00 AM, V6 (Business Office Manager) stated that she did get R40's mail and open it and deposit the checks and then had to reimburse the insurance agency once learning duplicate checks had been sent. V6 stated that R40 has a mail release form signed stating that staff can open her mail. The form is dated with [DATE] which is also her admission date. V6 stated that she discussed with R40 that she had a large outstanding bill with the facility and that they needed to apply that money to her account. V6 went on to state that R40 was not happy with the news, but knew it had to be done. V6 could not provide evidence that any of this information regarding conversations that V6 had with R40 regarding R40's insurance check was documented in R40's records. When V6 was questioned why she cashed a check when R40 has a designated financial payee she stated that she was unaware at the time of depositing the check into the resident trust account due to not having worked at the facility for very long. V6 then stated that her corporate office instructed her to transfer the entire amount of the insurance check to apply to her outstanding balance owed to the facility.
On [DATE] at 11:15 AM, V8 (Guardian) stated that she is R40's daughter and lives out of state. V8 explained that when R40 admitted to the facility she was spending too much money on online purchases and that is when the guardianship took place and the bank took over as financial payee. V8 stated that the insurance check should have not been written to R40 to begin with, but the facility should have forwarded it to the bank who is in charge of her financial affairs. V8 stated that she has not been sending R40 any money or gift cards in the mail recently because she is now unsure that R40 will receive it.
On [DATE] at 2:00 PM, V7 (Guardian) stated that when the facility received the insurance check for R40 the facility should have sent the check to the trust bank who is the financial payee, he is unsure of how they cashed the check. V7 stated that the bank is now involved as well because they are looking into check fraud.
A printout of R40's resident trust fund in the facility shows a deposit of $8,344.25 on [DATE] and on [DATE]. Handwritten in on the statement it states 'returned to comp' on the deposit line with an amount of $8,344.25 withdrawn out of the account also on [DATE]. On [DATE] five separate entries were deducted from the account in the same amount of $1478.00 with the description of the withdrawal as 'Room and Board and a sixth withdrawal for 'Room and Board' in the amount of $954.25. The total for these 6 payments total $8344.25. This left an ending balance in the resident trust account of -$15.77.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0576
(Tag F0576)
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 resident's received unopened mail documents for 1 of 1 reside...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure resident's received unopened mail documents for 1 of 1 resident (R39) reviewed for privacy in the sample of 46.
The Findings Include:
R39's profile face sheet documents an admission date of 12/9/22 and a date of birth of [DATE].
R39's most recent admission Minimum Data Set Assessment (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) 15 indicating that R39 is cognitively intact.
On 2/9/23 at 11:00 AM, R39 stated that he has had his mail opened by the staff prior to them delivering it on more than one occasion. R39 stated that around the holiday season he received a card that had been opened by facility staff (he wishes not to name who that is in fear of the staff being fired) and the money had been removed prior to him seeing it and placed in his resident trust account. R39 stated that there has been other occasions where he has received packages that come to him opened prior to delivery as well. R39 stated that he has never signed a release to allow facility staff to open his mail, nor does he want to. R39 stated that that isn't right.
During a review of R39's Clinical Records there was no Mail Release found for R39.
On 2/9/23 at 11:30 AM, V6 (Business Office Manager) confirmed that there is not a Mail Release document in R39's record indicating that he has allowed the staff to open his mail.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
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 Advanced Beneficiary Notice of Non-Coverage to 2 of 3 reside...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide Advanced Beneficiary Notice of Non-Coverage to 2 of 3 residents (R6 and R29) reviewed for Beneficiary Notice in the sample of 46.
Findings Include:
1. R6's undated Profile Face Sheet documents R6 was admitted to the facility on [DATE] with diagnoses that include fracture of left femur, reduced mobility, schizoaffective disorder, dementia, and muscle weakness.
When asked for the Advanced Beneficiary notice for R6 the facility provided this surveyor with a copy of R6's therapy discharge notice that documents R6 was discharged from physical and occupation therapy on 9/27/22 with the reason documented as Max (maximum) rehab potential met.
2. R29's undated Profile Face Sheet documents R29 was admitted to the facility on [DATE] with diagnoses that include cerebral infarct, anemia, chronic obstructive pulmonary disease, unsteadiness on feet, chronic kidney disease, weakness, and reduced mobility.
When asked for the Advanced Beneficiary notice for R29 the facility provided this surveyor with a copy of R29's Rehabilitation Screen dated 8/24/22 that documents quarterly review, evaluation indicated for physical, occupation, and speech language therapy.
The facility was unable to provide reproducible evidence Advance Beneficiary Notices were provided for R6 and R29.
On 2/08/23 at 8:31 AM, V6 (Business Office Manager) stated there was no Advanced Beneficiary Notice of Non-Coverage for R6 or R29.
On 02/10/23 at 9:28 AM, V1 stated the Advanced Beneficiary notices should have been completed for R6 and R29.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
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 assessments were submitted for 1 of 20 residents (R36) review...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure assessments were submitted for 1 of 20 residents (R36) reviewed for assessments in the sample of 46.
Findings Include:
R36's undated Profile Face Sheet documents R36 was admitted to the facility on [DATE].
R36's MDS (Minimum Data Set) dated 8/24/22 documents R36 was discharged from the facility on 8/24/22.
On 02/09/23 at 10:46 AM, V15 (MDS Coordinator) stated R36's discharge MDS was done on 8/24/22 but was not submitted and that is why the date of 8/24/22 on the MDS is correct. V15 stated there was nothing that would document it wasn't submitted but it was flagged in her computer system as not submitted.
V15 provided this surveyor with a Electronic Transfer Register dated 2/9/23 that documents R36's assessment dated [DATE] was submitted on 2/9/23.
On 2/10/23 at 9:28 AM, V1 (Administrator) stated she would expect the discharge MDS assessments to be submitted.
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 refer a resident to the appropriate state-designated agency for a L...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to refer a resident to the appropriate state-designated agency for a Level II PASARR (Preadmission Screening and Resident Review) for 1 of 3 residents (R2) reviewed for PASARR screenings in the sample of 46.
The findings include:
R2's undated Profile Face Sheet documents that R2 was admitted to the facility on [DATE]. The same profile sheet documents R2's diagnoses to include: Schizoaffective disorder, unspecified dementia, unspecified severity, with behavioral disturbances. Section C of R2's MDS (Minimum Data Set) dated 12/9/22 document that R2 has a BIMS (Brief Interview of Mental Status) of 6 which indicates R2 has severe cognitive impairment.
R2's Illinois PASRR Level 1 form with a review date of 8/20/22 document the Level 1 outcome as Refer for Level II onsite and the Rationale as A PASRR Level II evaluation must be conducted. That evaluation will occur as an onsite/face-to-face evaluation.
Documentation of a PASRR Level II could not be located in R2's Clinical Records.
On 3/9/23 at 3:00pm, V1 (Administrator) said they do not have a Level II PASARR screening for V2.
On 2/10/23 at 12:30pm, V6 (BOM/Business Office Manager) said that she handles the PASARR's. V6 said that as soon as a resident is admitted , she submits the request to the Screening agency and they usually respond within 48 hours. V6 said that every resident must have one. V6 said that she was not employed at the facility in August and that she did not catch it when she started in the position. V6 said that they do not have a policy, she just goes by the guidelines and what the screeners recommend.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents received routine nail care for 1 of 1 ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents received routine nail care for 1 of 1 resident (R28) reviewed for nail care in the sample of 46.
The Findings Include:
R28's undated resident profile face sheet documents a date of birth of [DATE] and a current admission date of 12/7/22.
R28's most recent admission minimum data set assessment dated [DATE] Section C documents a Brief Interview of Mental Status of 11, indicating that R28 is moderately impaired.
On 2/7/23 at 11:45 AM, R28 was in her room with her mother and aunt and stated that her toenails are so long that they are about to poke through her socks. R28 stated that they look like talons and she is embarrassed to show what they look like. R28 went on to state that they have not trimmed her toenails since she has been here, but doesn't know exactly how long that has been. R28 stated that she had been getting showers at the facility since admission. When asked if they trim her fingernails she stated that they do not because she has the bad habit of chewing them. R28's toenails were observed at this same time and were to be overgrown past the skin line by approximately an inch. The toenail polish showed the outgrowth.
On 2/9/23 at 11:15 AM, V5 (Certified Nurse Assistant) stated that resident fingernail trims are done on Sundays because of no showers scheduled on that day. Resident toe nails are trimmed typically on/during the scheduled shower. V15 stated that she does not shower R28 due to her shower being scheduled on second shift, so she is unsure of the last time R28 had her nails trimmed. V5 went on to state that if residents toe nails are too thick for the CNA's to cut they would tell the nurse and then if nursing was unable to trim the resident is referred to the foot doctor for a scheduled trim. The foot doctor typically comes once a month for nail care.
An undated policy titled Nail Care documents that resident's nails will be trimmed, clean and free of ragged edges. If a resident is alert and oriented and refuses nail care, it will be reflected in the care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure resident's medication was administered per faci...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure resident's medication was administered per facility policy for 1 of 20 residents (R20) reviewed for medication administration in a sample of 46.
The findings include:
R20's undated profile face sheet documents R20 was admitted to the facility on [DATE]. The same face sheet document diagnoses in part as major depressive disorder, chronic obstructive pulmonary disease, unspecified psychosis. Section C of R20's MDS (Minimum Data Set) dated 11/21/22 document that R20 has a BIMS (Brief Interview of Mental Status) of 15, which indicates R20 is cognitively intact.
On 2/7/23 at 10:00am, R20 was observed to have 4 pills sitting in an emesis basis on her bedside table. There were 2 brown pills, 1 white pills and 1 pink pill noted in the basin.
On 2/7/23 at 10:00am, R20 said that she had to go to the bathroom and had the nurse leave her pills for her to take once she returned. R20 said she likes to write each med they give her down on paper to make sure she gets the right meds. R20 also said that most nurses do leave them for her because they don't like to wait on her to write them down.
On 2/7/23 at 10:00 am, V3 (LPN/Licensed Practical Nurse) said she observed R20 take her medications this morning. V3 said that typically she watches her take all of them, but left the room before she took all of the medications.
On 2/9/23 at 11:30am,V2 (DON/Director of Nurses) said it would be her expectation that nurses stay with the resident until they have swallowed their medicine.
On 2/8/22, V1 (Administrator) said she would expect the nurses to offer the medicine and if they refuse they should come back later and offer them again. V1 the stated that the nurse needs to stay in the resident's room and observe them swallowing them.
R2's Medication Discrepancy Report dated 2/4/23 notes the medication on the POS (Physician's Order Sheet) and MAR (Medication Administration Record) as Senna 8.6 mg (milligrams), 2 tabs by mouth daily, Plavix 75 mg a tab by mouth daily, and Vitamin D 2000 units 1 tab by mouth daily were the medications left on the bedside table. The same document note the reason for discrepancy as pills were left with resident to take, nurse didn't watch resident take 8 am meds. The same document also documents physician notification was done on 2/7/23 at 2:30pm. The intervention to prevent further errors as Nurses are to watch residents take all of their medications.
The Facility Medication Administration Policy dated 11/18/17 documents in part, Procedure: 14. Observe the resident consume the medication to insure (sic ensure) resident swallows medication. Never leave prepared medications unattended. No medications should be left at bedside unless specifically ordered by the physician and then only in limited amounts as described by the physician.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the facility shower room doors were in working ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the facility shower room doors were in working order for 7 of 46 residents (R14, R21, R26, R32, R35, R37, and R40) reviewed for environment in the sample of 46.
Findings Include:
On 2/7/23 at 2:30 PM, R32 stated the door to her shower room that is located on her hallway does not latch when you attempt to shut it. R32 stated the facility staff told her she could lift the door up and it would then latch. R32 stated a lot of us can't physically lift the door to get it to latch.
On 02/08/23 at 9:27 AM, this surveyor observed the door to the shower room located on R32's hall. When the this door is shut it does not latch and is easily pushed open.
On 02/08/23 at 9:30 AM, V1 (Administrator) stated maintenance was aware of the door not catching. V1 stated they have to lift the door up to get it to catch. V1 stated she wasn't sure if it was an ongoing or recent issue. When asked if they had plans to get it repaired, V1 stated, the regional maintenance was aware and was planning to look at it on their next visit to the facility. V1 stated she would have to see if they had residents who were independent with showering on that hallway.
On 02/08/23 at 9:36 AM, V1 stated there are a couple of residents who are independent with showers and they let staff know when they are taking a shower.
V1 provided this surveyor with a list of Residents who are Independent/Set up for showering on R32's hall. This documents R14, R21, R26, R32, R35, R37, and R40 all reside on the same hall and are independent/set up for showering.
On 02/08/23 at 9:45 AM, V11 (Maintenance Director) stated she was aware the shower room door on V32's hallway was not latching. When asked how long it had not been latching, V11 stated, a couple of months, maybe. V11 stated it would latch but only after pulling up on the door. V11 stated she was going to get it fixed today (2/8/23), and she had informed the Certified Nursing Assistants how to get the door to latch.
On 2/8/23 at 9:55 AM, V16 and V17 (Certified Nursing Assistants) stated R14, R21, R26, R35, R37, R32, and R40 only required set up assistance with their showers. When asked if they could lift the shower door to get it to latch, V16 and V17 stated they close the door for them.
R14's undated Profile Face Sheet documents R14 was admitted to the facility on [DATE] with diagnoses that include hypertension, chronic obstructive pulmonary edema, and malignant neoplasm of prostate. R14's MDS (Minimum Data Set) dated 1/31/23 documents R14 requires oversight/supervision with showers.
R21's undated Profile Face Sheet documents R21 was admitted to the facility on [DATE] with diagnoses that include diabetes, heart disease, and dementia. R21's MDS dated [DATE] documents R21 requires oversight/supervision with showers.
R26's undated Profile Face Sheet documents R26 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary edema, heart failure, dementia, and hypertension. R26's MDS dated [DATE] documents R26 requires oversight/supervision with showers.
R32's undated Profile Face Sheet documents R32 was admitted to the facility on [DATE] with diagnoses that include muscle weakness, hypertension, and difficulty walking. R32's MDS dated [DATE] documents R32 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates R32 is cognitively intact. R32's MDS, Section G, documents R32 requires oversight/supervision with showers.
R35's undated Profile Face Sheet documents R35 was admitted to the facility on [DATE] with diagnoses that include paranoid schizophrenia, major depressive disorder, and diabetes. R35's MDS dated [DATE] documents R35 requires oversight/supervision with showers.
R37's undated Profile Face Sheet documents R37 was admitted to the facility on [DATE] with diagnoses that include anxiety disorder, diabetes, sleep apnea, and hypertension. R37's MDS dated [DATE] documents R37 requires oversight/supervision with showers.
R40's undated Profile Face Sheet documents R40 was admitted to the facility on [DATE] with diagnoses that include psychosis, disorientation, major depressive disorder. R40's MDS dated [DATE] documents R40 requires supervision and physical help limited to transfer only for assist with showers.
The facility Resident Council Meeting Minutes dated 1/4/23 documents under, Problems, Complaints, Concerns- Shower door on (R32's hall) will not stay shut or latching like it should.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to provide 8 hours of daily Registered Nurse (RN) coverage. This has the potential to affect all 46 residents residing in the facility.
Findin...
Read full inspector narrative →
Based on interview and record review the facility failed to provide 8 hours of daily Registered Nurse (RN) coverage. This has the potential to affect all 46 residents residing in the facility.
Findings Include:
The facility Resident Census and Conditions of Residents Form dated 2/7/23 documents 46 residents reside at the facility.
On 02/07/23 at 4:46 PM, V1 (Administrator) stated they do not have RN coverage 8 hours a day/7 days a week. V1 stated they hired a new Assistant Director of Nurses who was an RN, and she quit the next day. V1 stated they have two nurses who will be graduating from the RN program in May.
Review of the nursing schedules from 11/1/22 to 1/31/23 documents the facility did not have RN coverage on 11/4, 11/5, 11/12, 11/13, 11/19, 11/26, 11/27, 12/4, 12/10, 12/11, 12/17, 12/18, 12/23, 12/28/22, 1/1, 1/6, 1/8, 1/14, 1/16, 1/17, 1/18, 1/22, 1/28, and 1/29/23.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review the facility failed to ensure that dishes were being sanitized per manufacturer recommendations. This has the potential to affect all 46 residents in ...
Read full inspector narrative →
Based on observation, interview and record review the facility failed to ensure that dishes were being sanitized per manufacturer recommendations. This has the potential to affect all 46 residents in the facility.
The Findings Include:
On 2/7/23 at 9:30 AM , the dish machine sanitizer level was checked by V10 (Dietary Supervisor) using a chorine test kit and when the strip was compared to the guide it registered at or above 200 ppm (Parts per million) of chlorine on the test strip. V10 stated that it is higher than the recommended level and should be a purple but it is almost a black color. V10 verified that the manufacturer recommendation for the chlorine sanitizer level should be between 50-100 ppm. Also at this time it is observed that water in the basin of the dish machine where the level of sanitizer is checked is very sudsy and V10 confirmed that this is irregular. V10 went on to state that the 3 compartment sink which would be the back up if the dish machine breaks down uses a quaternary sanitizer and has not been being used because the water is too hot and they have a hard time keeping the sanitizer at the proper level due to the heat breaking down the chemicals. V10 also stated that there is also a water pressure issue that in the 3 compartment sink it takes a long time to fill up to the fill line and that takes too much time to wash the dishes. V10 stated she is going to call the dishmachine company to schedule a service call so they can come out and service the machine to determine why the sanitizer level is too high.
On 2/8/23 at 11:00 AM the dish machine was still registering at 200 ppm of chlorine when tested with a chorine test kit by V10 and was in use. V10 states that the serviceman will not be here before 2/10/23.
On 2/8/23 at 11:15 AM, Spoke with V1 (Administrator) regarding the issues with the dish machine and she was going to speak with V10 regarding a back up plan to use while the dish machine was out of service.
On 2/9/23 at 9:30 AM, V1 stated that they are using the 3 compartment sink with bleach water to properly sanitize the dishes while they are awaiting the dish machine to be fixed.
The undated policy titled Ware-Washing-Dishmachine documents in part, For chlorine sanitizers, the level should be 50-100ppm
The undated policy title Ware-Washing-3 Compartment Sink documents in part, 'It is the policy of (name of facility) that utensils and dishes that cannot be cleaned and sanitized by mechanical dishwasher will be cleaned and sanitized in a 3 compartment sink
The Resident Census and Conditions of Residents Form dated 2/7/23 documents 46 residents are residing in the facility.
Nov 2022
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
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide an adequate reason for discharge for 1 of 3 residents (R2) who was Involuntarily discharged from the facility in a sample of 10.
F...
Read full inspector narrative →
Based on interview and record review, the facility failed to provide an adequate reason for discharge for 1 of 3 residents (R2) who was Involuntarily discharged from the facility in a sample of 10.
Findings Include:
R2's Physician Order Sheet dated 11/16/22 to 11/30/22 documents: R2's admission Date as 11/16/22, R2's Advance Directives as a Full Code, R2 is certified level of care is SNF (Skilled Nursing Facility), along with her medications and 02/15/66 date of birth .
The undated facility document titled, Cumulative Diagnosis Log documents R2's diagnosis of: Schizoaffective disorder, history of Covid-19 pneumonia, morbid obesity, Diabetes Mellitus type II, Neuropathy, History of respiratory failure, Iron deficiency Anemia, Hypertension, Hyperlipidemia, Schizophrenia, Anxiety, Depression, Hypothyroidism, GERD, Seizures, Acute Renal Failure with other specified pathological lesions in kidneys, Allergic Rhinitis, Arthritis, Asthma, history of MRSA, and allergies: Penicillin.
R2's Diet Order Form dated 11/16/22 documents her physician, room number, allergies and that she is a new admission.
The facility document titled, Baseline Care Plan with an admission date documented as 11/16/22, documents: Bed Mobility as independent, Locomotion as Supervision and Set up/Clean up, Bathing as Assist of 1 with set up/clean up, Groom/hygiene as Assist of 1 and Set up/Clean up, Toileting as Supervision and Set up/Clean up, Transfer as Supervision and Set up/Clean up, Ambulation as Supervision and Set up/Clean up, Dressing as Assist of 1 and Set up/Clean up, and Eating as Independent and Bedroom. The Baseline Care Plan documents: Identified Safety Risks: Safety Plan of Care: as Poor Safety awareness, Identified Skin Risks: Skin Plan of Care: as obesity, noncompliant, weekly skin checks, and Diabetes, Sensory & Communication Vision as Adequate, Hearing as Impaired - hard of hearing, communication/Language as English, Cognition as Alert to : self and others, and Oral Care as own teeth with a completed date of 11/16/22 by V22 (Licensed Practical Nurse/LPN).
R2's medical chart contained The HPI (History of Present Illness) dated 11/06/22 from R2's previous hospital documents: admitted from geropsy (geropsychiatric unit). On 11/14/22 Hospital daily progress note documents: R2 is vitally stated, On and off agitated, on multiple psych medications including fluphenazine intramuscular, waiting for placement, R2 refused to go to Geropsych (geropsychiatric unit)/refused to go home. On 11/15//22 R2's discharge plan documents: transfer back to geropsy (geropsychiatric unit), R2 is awake and alert, R2 refuses to go back to seventh floor (geropsychiatric unit).
Clinical Notes found in R2's Records document the following:
On 11/14/22 at 1:02 PM, V9 (Social Worker) documents: R2 is accepted at Long term care facility for 11/15/22.
On 11/15/22 at 8:24 AM, Notes from previous hospital document: hospital contacted at Long term care facility to discuss transportation. R2 will need to transport by ambulance. V1 (Administrator) reports that facility is having morning meeting to determine which room R2 will go to. Hospital to follow up after 9:30 AM morning meeting. R2's PASRR (Preadmission Screening and Resident Review) has been completed.
On 11/15/22 at 1:35 PM, V9 (Social Worker) spoke with V1 (Administrator) who reports that facility attempted to move residents around to find appropriate bed for R2. Facility states this was unsuccessful but should have open bed tomorrow.
On 11/16/22 at 8:06 AM, V9 (Social Worker) documents: R2 will discharge to Long term care facility by ambulance.
On 11/16/22 at 8:06 AM, V23 (Registered Nurse) documents: facility is ready to accept R2 today. R2 will need transport by ambulance to facility, will call report and fax orders to facility.
R2's Nurse's Notes dated 11/16/22 at 12:00 PM document: R2 arrived to facility via ambulance, allowed staff to take v/s (vital signs). R2 has since refused all assessments and care. R2 threw a remote at staff when asked if she wanted to watch TV. R2 then asked where her phone was, when staff provided it to her R2 threw phone at staff. Staff then removed themselves from room. R2 was yelling for staff to get out. Staff was informed to try again later to provide care and gave R2 time to adjust and rest. R2 then came walking down the hallway yelling give me my phone. R2 attempted to leave out the front door. R2 kicked the door and attempted to throw chair through the front door. R2 pulled the fire alarm and knocked over table and glass cabinet shattering glass over front lobby floor.
R2's Nurse's Notes dated 11/16/22 at 3:00 PM document: R2 left via ambulance to hospital for mental health evaluation.
There is no documentation in R2's medical record that V19 (Physician) was contacted concerning R2's transfer to the Emergency Department (ED).
R2's Nurse's Note dated 11/16/22 at 10:30 PM documents: V12 (Registered Nurse from the hospital) called to inform facility that R2 would be returning to facility. Message taken by V20 (LPN) and relayed to V4 (LPN). V20 (LPN) notified V1(Administrator) of R2's impending return, V1 (Administrator) needed to consult with V21 (Regional Administrator) if were going to accept R2 back to the facility.
R2's Nurse's Note dated 11/16/22 at 10:45 PM document: ambulance arrived with R2 and V4 (LPN) met ambulance driver outside and explained to him that until (I) V4 (LPN) was told that it was okay to accept R2 back into our facility R2 would need to remain in the ambulance. We were waiting on a call with confirmation.
R2's Nurse's Note dated 11/16/22 at 11:05 PM document: police arrived at the facility questioning why R2 could not be accepted back to our facility.
R2's Nurse's Notes dated 11/16/22 at 11:10 PM document V21 (Regional Administrator) called and relayed that R2 was not to be accepted back into facility. R2 had not been fully admitted before being sent to Emergency Department (ED) for psychiatric evaluation.
On 11/22/22 at 10:45 AM, V5 (Business office manager) stated, the document dated 11/22/22 titled, MDS 3.0 Details documents the transfers and discharges at the facility.
The facility document dated 11/22/22 titled, MDS 3.0 Details documents: R2 with an entry date of 11/16/22 and a discharge date of 11/16/22.
On 11/22/22 at 3:20 PM, V1 (Administrator) stated, she had accepted R2 from an upstate hospital. V1 stated they did have her transported almost 3 hours to the facility via ambulance. V1 (Administrator) stated, the facility does accept residents with diagnosis including: Schizophrenia, Anxiety Disorders, Psychosis, and behaviors as R2 did have. V1 stated, V2 (Director of Nursing) reviews all medication lists for potential new residents prior to them being accepted, so R2's medications would have been reviewed prior. After arriving to the facility R2 had a Physician Order Sheet with a physician designated, she had a room assigned, she had vitals taken, a baseline care plan done, a cumulative diagnosis log completed and progress notes documented. After R2 had arrived to the facility R2 started to emit aggressive behaviors and it was decided to send R2 to the hospital for a psychological evaluation. V1 stated R2 was willing to go. V1 stated once R2 was cleared to return to the facility R2 was not allowed to return because she was considered to not be fully admitted . She would consider fully admitted admission contract signed and services provided. V1 stated she did not have a signed contract from R2. V1 then stated she did not review the psychological evaluation that R2 had when she was sent out from the facility to the ED and cleared to return to the facility.
On 11/22/22 at 12:40 PM, V2 (Director of Nursing) stated she does not know if anyone called R2's POA regarding send her out to the hospital or not allowing R2 back into the facility. V2 stated she was not here and if it is not in her chart, she would not know, any information on R2 would be in her chart. V2 did not answer when asked if she reviewed R2's medication list prior to her arrival or if there was any discussion on her behaviors.
On 11/23/22 at 10:22 AM, V9 (Social Worker) stated, she had spoke with V1 on November 14th about accepting R2 for admission. V9 stated they would accept R2 and on the 15th they were going to transport R2 down to the facility. V9 then stated they had to move a resident for the available bed and would not be able to accept her until the 16th. The transport via an ambulance was arranged for the approximate 3 hour one way trip.
On 11/29/22 at 5:48 PM, V14 (Licensed Practical Nurse) stated, she was present when R2 arrived at the facility. The paramedic told her R2 received Valium on the transport to the facility due to her getting anxious. Shortly after R2 arrived, she sent V15 (Certified Nursing Assistant/CNA) and V18 (CNA) to R2's room to get R2's vitals. R2 was laying down and V15 and V18 were able to get vitals from her. She was able to get a skin assessment partially performed, the skin she was at least able to see. R2 stated she wanted to be left alone. V14 stated after maintenance had replaced R2's call light she asked R2 if she would like to watch TV and handed her the remote. R2 threw the remote. Later, R2 wanted her phone, after she was given her phone, she thought it was not hers. R2 was getting agitated. They were asking R2 if she needed anything, if there was anything they could help her with. V14 (LPN) stated, she does not know a lot about handling those kind of behaviors, so she was just thinking, make sure the other residents are safe. V14 stated, they called for an ambulance to have R2 transported out for a mental health evaluation and with everything going on she figured she better get it documented.
On 11/22/22 at 10:55 PM, V4 (LPN) stated, the ambulance did show up that evening on 11/16/22 at around 10:30 PM returning R2 to the facility. V4 stated she was only following what she was told to do. She was told she was supposed to wait to see if they could keep her (R2). While she was waiting, the police arrived. V4 stated, she does not know who called the police, the facility did not. V4 stated, she went outside and met the ambulance driver outside and told him she had to wait on a phone call to see if the facility could keep her. V4 stated, R2 stayed in the ambulance and she did not see her or speak to her. V4 then stated she was called by V1 and was told that she was not to allow R2 back into the facility. V4 stated she relayed the information to the ambulance driver and R2 was taken back to the emergency department. V4 stated, she does not know what is meant by fully admitted .
There is no documentation in R2's medical record documenting V19 (Physician) was consulted with the refusal of R2 back into the long term care facility.
On 11/23/22 at 9:30 AM, V8 (Emergency Department (ED) Director) stated, R2 calmed down at while at the emergency department. R2 was evaluated by an outside psychiatric facility personnel and was calm, R2 refused psychiatric evaluation when first asked but agreed to evaluation shortly after. R2 was deemed able to return to the facility and was calm when she left in the ambulance to return to the facility. When R2 was at the emergency department she took all her medications with no problems. When the facility would not allow R2 back into the facility and she returned to the emergency department, V12 (Registered Nurse/RN at the hospital) called her to update her on the situation.
R2's hospital notes from 11/16/22 at 11:55 PM document: R2 was discharged from emergency department back to her facility after she refused psych evaluation and requesting to be discharged . Facility refused R2, who became agitated and police were called and R2 was brought back to the ED. R2 needed to be held down on arrival to the emergency department and also required a chemical restraint. On 11/19/22 at 6:48 PM R2 is alert, pleasant, cooperative, no acute distress. R2's symptoms have improved. R2's symptoms have markedly improved after treatment. Nursing home has declined to have R2 return. R2 is medically cleared to return home. R2 has no suicidal or homicidal ideation. V11 (Family) is due to pick R2 up. On 11/19/22 at 7:52 PM documents: R2 had no adverse reaction to medication taken.
On 11/28/22 at 10:54 AM, V10 (Family/POA) stated she has not received any documents or heard anything from the long term care facility that R2 was transferred to, including anything about her going to the hospital or being discharged and not allowed back in the facility.
On 11/28/22 at 2:09 PM, V13 (Ombudsman) stated she was not informed about the situation with R2 from the long term care facility. She was informed of the situation with R2 from the hospital. V13 stated, she has not received any paperwork concerning R2, nothing with the bed hold, the transfer, or the discharge. She was informed by V12 that the hospital cleared her to be returned to the facility and the facility would not accept her back.
The Facility Assessment Tool dated 07/28/22 documents: the facility may accept residents with , or may develop, the following common diseases, conditions, physical and cognitive disabilities, or combinations of conditions that require complex medical care and management. The Category Psychiatric/Mood Disorders document Common diagnoses as: Psychosis (Hallucinations, Delusions, etc.), Impaired Cognition, Mental Disorder, Depression, Bipolar Disorder (i.e., Mania/Depression), Schizophrenia, Post-Traumatic Stress Disorder, Anxiety Disorder, Behavior that needs Interventions.
The undated Transfer and Discharge Policy and Procedure documents: It is the policy of (the facility) not to transfer or discharge a resident unless: 1. The transfer or discharge is necessary to meet the residents welfare, and the residents welfare cannot be met in the facility, or 2. The transfer is appropriate because the residents health has improved sufficiently so that the resident no longer needs the services provided by the facility or, 3. The safety of individuals in the facility is endangered or, 4. The health of individuals in the facility would be endangered, or 5. The resident has failed, after reasonable and appropriate notice, to pay for a stay in the facility, or 6. The facility ceases to operate. In all cases except the last, documentation in the resident's clinical record shall be required. The residents attending physician must document in the resident's clinical record that the facility cannot provide for the residents welfare, or that the resident no longer requires the facilities services. Documentation in the resident's clinical record by any physician that the health of other individuals would be endangered is cause for transfer or discharge. Types of Transfer and discharge: Less than 30 day notice: Transfers and discharges with less than 30 days' notice may occur in limited circumstances: 1. The health or safety of others in the facility is endangered, 2. The health of the resident has improved to allow more immediate transfer or discharge, 3. The residents urgent medical needs require more immediate transfer, 4. The resident has not resided in the facility for 30 days. Involuntary transfers or discharges: Except for the case of late payment or nonpayment, the facility shall notify the resident and resident's family member, surrogate or representative of the transfer and the reasons for the transfer as stated in the clinical record. Notice of involuntary transfer/discharge shall be on the forms prescribed by Illinois Department of Health. In all other instances of involuntary transfer or discharge the mandated federal and state 30 day Notice Transfer or Discharge will be issued and the following steps taken. 1. The planned involuntary transfer or discharge shall be discussed with the resident, guardian, resident's representative and/or the person or agency responsible for the resident's placement, maintenance and care in the facility. 2. The discussion shall be carried out by the administrator or his/her designee. The content of the discussion and explanation shall be summarized in writing, including the names of those in attendance. The summary shall be made a part of the resident's clinical record. 3. A physician's discharge order shall be obtained in the resident's record prior to discharge. 4. Prior to transfer or discharge the Social Service Director shall counsel the resident and summarize the counseling session in the resident's 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
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to provide a resident/resident representative a written notice of discharge with appeal rights and notice of hospital transfer for 1 of 3 resid...
Read full inspector narrative →
Based on interview and record review the facility failed to provide a resident/resident representative a written notice of discharge with appeal rights and notice of hospital transfer for 1 of 3 residents (R2) reviewed for transfers and discharges in a sample of 10.
R2's Physician Order Sheet dated 11/16/22 to 11/30/22 documents: R2's admission Date as 11/16/22, R2's Advance Directives as a Full Code, R2 is certified level of care is SNF (Skilled Nursing Facility), along with her medications and 02/15/66 as date of birth .
The undated facility document titled, Cumulative Diagnosis Log documents R2's diagnosis of: Schizoaffective disorder, history of Covid-19 pneumonia, morbid obesity, Diabetes Mellitus type II, Neuropathy, History of respiratory failure, Iron deficiency Anemia, Hypertension, Hyperlipidemia, Schizophrenia, Anxiety, Depression, Hypothyroidism, GERD, Seizures, Acute Renal Failure with other specified pathological lesions in kidneys, Allergic Rhinitis, Arthritis, Asthma, history of MRSA, and allergies: Penicillin.
R2's Diet Order Form dated 11/16/22 documents her physician, room number, allergies and that she is a new admission. The facility document titled, Baseline Care Plan with an admission date documented as 11/16/22, documents: Bed Mobility as independent, Locomotion as Supervision and Set up/Clean up, Bathing as Assist of 1 with set up/clean up, Groom/hygiene as Assist of 1 and Set up/Clean up, Toileting as Supervision and Set up/Clean up, Transfer as Supervision and Set up/Clean up, Ambulation as Supervision and Set up/Clean up, Dressing as Assist of 1 and Set up/Clean up, and Eating as Independent and Bedroom. The Baseline Care Plan documents: Identified Safety Risks: Safety Plan of Care: as Poor Safety awareness, Identified Skin Risks: Skin Plan of Care: as obesity, noncompliant, weekly skin checks, and Diabetes, Sensory & Communication Vision as Adequate, Hearing as Impaired - hard of hearing, communication/Language as English, Cognition as Alert to : self and others, and Oral Care as own teeth with a completed date of 11/16/22 by V22 (Licensed Practical Nurse/LPN).
R2's Progress Nurse's Notes dated 11/16/22 at 3:00 PM document: R2 left via ambulance to hospital for mental health evaluation.
R2's Nurse's Note dated 11/16/22 at 10:45 PM document: ambulance arrived with R2 and V4 (LPN) met ambulance driver outside and explained to him that until (I) V4 (LPN) was told that it was okay to accept R2 back into our facility R2 would need to remain in the ambulance. We were waiting on a call with confirmation.
R2's Nurse's Note dated 11/16/22 at 11:05 PM document: police arrived at the facility questioning why R2 could not be accepted back to our facility.
R2's Nurse's Notes dated 11/16/22 at 11:10 PM document V21 (Regional Administrator) called and relayed that R2 was not to be accepted back into facility. R2 had not been fully admitted before being sent to Emergency Department (ED) for psychiatric evaluation.
On 11/22/22 at 10:45 AM, V5 (Business office manager) stated, the document dated 11/22/22 titled, MDS 3.0 Details documents the transfers and discharges at the facility.
The facility document dated 11/22/22 titled, MDS 3.0 Details documents: R2 with an entry date of 11/16/22 and a discharge date of 11/16/22.
On 11/23/22 at 1:18 PM, V10 (Family/Power of Attorney/POA) stated she was the POA for R2. V10 stated after R2 had behaviors she was notified by the hospital that she was taken to the ED because of R2's agitation and the situation that was going on and R2 was being evaluated at the hospital. V10 (Family) stated, she has not received any documents or heard anything from the long term care facility that R2 was transferred to, including anything about her going to the hospital or being discharged .
On 11/22/22 at 12:40 PM, V2 (Director of Nursing) stated, she does not know if anyone called R2's POA, she was not here and if it is not in her chart, she would not know. V2 stated, the nurse on duty would have sent the paperwork (R2's face sheet, physician order sheet and the bed hold) with the ambulance.
On 11/22/22 at 3:20 PM, V1 (Administrator) stated, she had accepted R2 from an upstate hospital. V1 stated they did have her transported almost 3 hours to the facility via ambulance. V1 (Administrator) stated, the facility does accept residents with diagnosis including: Schizophrenia, Anxiety Disorders, Psychosis, and behaviors as R2 did have. V1 stated, V2 (Director of Nursing) reviews all medication lists for potential new residents prior to them being accepted, so R2's medications would have been reviewed prior. After arriving to the facility R2 had a Physician Order Sheet with a physician designated, she had a room assigned, she had vitals taken, a baseline care plan done, a cumulative diagnosis log completed and progress notes documented. After R2 had arrived to the facility R2 started to emit aggressive behaviors and it was decided to send R2 to the hospital for a psychological evaluation. V1 stated R2 was willing to go. V1 stated once R2 was cleared to return to the facility R2 was not allowed to return because she was considered to not be fully admitted . She would consider fully admitted admission contract signed and services provided. V1 stated she did not have a signed contract from R2. V1 stated since the facility did not consider R2 to be fully admitted to the facility no discharge paperwork was sent out regarding R2.
On 11/28/22 at 2:09 PM, V13 (Ombudsman) stated, she was not informed about the situation with R2 from the long term care facility. She was informed of the situation with R2 from the hospital. V13 (Ombudsman) stated, she has not received any paperwork concerning R2, nothing with the bed hold, the transfer, or the discharge. She was informed by V12 (Registered Nurse (hospital)) that the hospital cleared her to be returned to the facility and the facility would not accept her back.
There was no documentation in R2's medical chart to indicate the resident's family representative was notified in writing: of the transfer, the reason for the transfer, the location to which the resident was transferred, or for the discharge and the name and contact information for the Office of the Long Term Care Ombudsman.
The undated Transfer and Discharge Policy and Procedure documents: It is the policy of (the facility) not to transfer or discharge a resident unless: 1. The transfer or discharge is necessary to meet the residents welfare, and the residents welfare cannot be met in the facility, or 2. The transfer is appropriate because the residents health has improved sufficiently so that the resident no longer needs the services provided by the facility or, 3. The safety of individuals in the facility is endangered or, 4. The health of individuals in the facility would be endangered, or 5. The resident has failed, after reasonable and appropriate notice, to pay for a stay in the facility, or 6. The facility ceases to operate. In all cases except the last, documentation in the resident's clinical record shall be required. The residents attending physician must document in the resident's clinical record that the facility cannot provide for the residents welfare, or that the resident no longer requires the facilities services. Documentation in the resident's clinical record by any physician that the health of other individuals would be endangered is cause for transfer or discharge. Types of Transfer and discharge: Less than 30 day notice: Transfers and discharges with less than 30 days' notice may occur in limited circumstances: 1. The health or safety of others in the facility is endangered, 2. The health of the resident has improved to allow more immediate transfer or discharge, 3. The residents urgent medical needs require more immediate transfer, 4. The resident has not resided in the facility for 30 days. Involuntary transfers or discharges: Except for the case of late payment or nonpayment, the facility shall notify the resident and resident's family member, surrogate or representative of the transfer and the reasons for the transfer as stated in the clinical record. Notice of involuntary transfer/discharge shall be on the forms prescribed by Illinois Department of Health. In all other instances of involuntary transfer or discharge the mandated federal and state 30 day Notice Transfer or Discharge will be issued and the following steps taken. 1. The planned involuntary transfer or discharge shall be discussed with the resident, guardian, resident's representative and/or the person or agency responsible for the resident's placement, maintenance and care in the facility. 2. The discussion shall be carried out by the administrator or his/her designee. The content of the discussion and explanation shall be summarized in writing, including the names of those in attendance. The summary shall be made a part of the resident's clinical record. 3. A physician's discharge order shall be obtained in the resident's record prior to discharge. 4. Prior to transfer or discharge the Social Service Director shall counsel the resident and summarize the counseling session in the resident's 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
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide the resident or their representative with bed hold informati...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide the resident or their representative with bed hold information at the time of transfer for 2 of 2 residents (R2, R3) reviewed for hospitalizations in a sample of 10.
Findings Include:
1. R2's Progress Notes dated 11/16/22 at 3:00 PM document: R2 left via ambulance to hospital for mental health evaluation.
R2's medical chart does not contain evidence that the notice of bed hold policy was given to R2 or R2's representative after transfer to the hospital on [DATE].
On 11/23/22 at 9:30 AM, V8 (Emergency Department (ED) Director) stated, R2 did not have a bed hold sent with her to the Emergency Department when she arrived on 11/16/22.
On 11/28/22 at 10:54 AM, V10 (Family/Power of Attorney) stated, she has not received any documents or heard anything from the long term care facility R2 was transferred to, including anything about her going to the hospital or being discharged .
On 11/28/22 at 2:09 PM, V13 (Ombudsman) stated, she has not received any paperwork concerning R2, nothing with the bed hold, the transfer, or the discharge. She was informed by V12 (Registered Nurse (hospital)) that the hospital cleared her to be returned to the facility and the facility would not accept her back.
2. R3's Medical Chart contains the facility document titled Nursing Home to Hospital Transfer Form which documents R3 was transferred to the hospital on [DATE].
R3's medical chart does not contain evidence that the notice of bed hold policy was given to R3 after transfer to the hospital on 9/25/22. R3 medical chart documents R3 does not have a Power of Attorney and makes own decisions.
On 11/22/22 at 12:40 PM, V2 (Director of Nursing) stated, when a resident gets transferred to the hospital the face sheet, medication list, and a copy of the bed hold goes with the ambulance. They do not have a keep a copy of the bed hold inside the resident chart the only copy goes with the ambulance. V2 stated they do not make a copy and keep it for themselves.
The facility document titled, Bed Hold Guarantee Policy dated 08/2017 documents: Upon leaving this facility for admission to a hospital or for a therapeutic leave, a resident shall be guaranteed a bed in this facility upon return if: 1. The resident's condition is such that he/she is appropriate for the level of care provided by the facility, and 2. A Medicaid eligible resident was not in the hospital or on leave for more than 10 consecutive day, or 3. The Medicaid resident or responsible party has agreed to pay the Public Aid rate for days in excess of the 10 days, or 4. Private pay resident has insured hold on a bed through reimbursement at the current private pay rate. If a resident in an Intermediate Care Facility leaves the facility for admission to the hospital and requires skilled care (Medicare) upon discharge, they will not be able to return to the Intermediate Care Facility. This facility strives to insure that each Medicaid resident, who is discharged to an acute care setting or takes a therapeutic leave, has a bed reserved for his/her return. Beds shall be held for 10 days for hospitalization and therapeutic leave for Medicaid recipients and indefinitely for Private Pay residents who elect to pay the charges. The resident, resident family or legal representative will be given the appropriate notice of Bed Hold Policy at the time of discharge or therapeutic leave if possible, but notice will be given no longer than 24 hours after discharge or initiation of leave. If the facility determines that a resident who was transferred with an expectation of returning to the facility cannot return to the facility, the facility must comply with 42 CFR, Sec 483.15 (c).
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Transfer
(Tag F0626)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to allow a resident to return to the facility after a hospital stay for 1 of 3 residents (R2) reviewed for returning to the facility after tra...
Read full inspector narrative →
Based on interview and record review, the facility failed to allow a resident to return to the facility after a hospital stay for 1 of 3 residents (R2) reviewed for returning to the facility after transfer in the sample of 10.
Findings Include:
R2's Physician Order Sheet dated 11/16/22 to 11/30/22 documents: R2's admission Date as 11/16/22, R2's Advance Directives as a Full Code, R2 is certified level of care is SNF (Skilled Nursing Facility), along with her medications and 02/15/66 as date of birth .
The undated facility document titled, Cumulative Diagnosis Log documents R2's diagnosis of: Schizoaffective disorder, history of Covid-19 pneumonia, morbid obesity, Diabetes Mellitus type II, Neuropathy, History of respiratory failure, Iron deficiency Anemia, Hypertension, Hyperlipidemia, Schizophrenia, Anxiety, Depression, Hypothyroidism, GERD, Seizures, Acute Renal Failure with other specified pathological lesions in kidneys, Allergic Rhinitis, Arthritis, Asthma, history of MRSA, and allergies: Penicillin.
R2's Nurse's Notes dated 11/16/22 at 3:00 PM document: R2 left via ambulance to hospital for mental health evaluation.
R2's Nurse's Note dated 11/16/22 at 10:30 PM documents: V12 (Registered Nurse from the hospital) called to inform facility that R2 would be returning to facility. Message taken by V20 (LPN) and relayed to V4 (LPN). V20 (LPN) notified V1(Administrator) of R2's impending return, V1 (Administrator) needed to consult with V21 (Regional Administrator) if were going to accept R2 back to the facility.
R2's Nurse's Note dated 11/16/22 at 10:45 PM document: ambulance arrived with R2 and V4 (Licensed Practical Nurse/LPN) met ambulance driver outside and explained to him that until (I) V4 was told that it was okay to accept R2 back into our facility R2 would need to remain in the ambulance. We were waiting on a call with confirmation.
R2's Nurse's Note dated 11/16/22 at 11:05 PM document: police arrived at the facility questioning why R2 could not be accepted back to our facility.
R2's Nurse's Notes dated 11/16/22 at 11:10 PM documents V21 (Regional Administrator) called and relayed that R2 was not to be accepted back into facility. R2 had not been fully admitted before being sent to Emergency Department (ED) for psychiatric evaluation.
On 11/22/22 at 10:45 AM, V5 (Business office manager) stated, the document dated 11/22/22 titled, MDS 3.0 Details documents the transfers and discharges at the facility.
The facility document dated 11/22/22 titled, MDS 3.0 Details documents: R2 with an entry date of 11/16/22 and a discharge date of 11/16/22.
On 11/22/22 at 3:20 PM, V1 (Administrator) stated, she had accepted R2 from an upstate hospital. V1 stated they did have her transported almost 3 hours to the facility via ambulance. V1 (Administrator) stated, the facility does accept residents with diagnosis including: Schizophrenia, Anxiety Disorders, Psychosis, and behaviors as R2 did have. V1 stated, V2 (Director of Nursing) reviews all medication lists for potential new residents prior to them being accepted, so R2's medications would have been reviewed prior. After arriving to the facility R2 had a Physician Order Sheet with a physician designated, she had a room assigned, she had vitals taken, a baseline care plan done, a cumulative diagnosis log completed and progress notes documented. After R2 had arrived to the facility R2 started to emit aggressive behaviors and it was decided to send R2 to the hospital for a psychological evaluation. V1 stated R2 was willing to go. V1 stated once R2 was cleared to return to the facility R2 was not allowed to return because she was considered to not be fully admitted . She would consider fully admitted admission contract signed and services provided. V1 stated she did not have a signed contract from R2. V1 then stated she did not review the psychological evaluation that R2 had when she was sent out from the facility to the ED and cleared to return to the facility.
On 11/22/22 at 10:55 PM, V4 (LPN) stated, the ambulance did show up that evening on 11/16/22 at around 10:30 PM returning R2 to the facility. V4 stated she was only following what she was told to do. She was told she was supposed to wait to see if they could keep her (R2). While she was waiting, the police arrived. V4 stated, she does not know who called the police, the facility did not. V4 stated, she went outside and met the ambulance driver outside and told him she had to wait on a phone call to see if the facility could keep her. V4 stated, R2 stayed in the ambulance and she did not see her or speak to her. V4 then stated she was called by V1 and was told that she was not to allow R2 back into the facility. V4 stated she relayed the information to the ambulance driver and R2 was taken back to the emergency department. V4 stated, she does not know what is meant by fully admitted .
On 11/23/22 at 9:30 AM, V8 (Emergency Department (ED) Director) stated, R2 calmed down at while at the emergency department. R2 was evaluated by an outside psychiatric facility personnel and was calm. R2 was deemed able to return to the facility and was calm when she left in the ambulance to return to the facility. When she was at the emergency department she took all her medications with no problems. When the facility would not let her back in and she returned to the emergency department, V12 ( Registered Nurse/RN for the hospital) called her to update her on the situation.
R2's hospital notes from 11/16/22 at 11:55 PM document: R2 was discharged from emergency department back to her facility after she refused psych evaluation and requesting to be discharged . Facility refused R2, who became agitated and police were called and R2 was brought back to the ED. R2 needed to be held down on arrival to the emergency department and also required a chemical restraint. On 11/19/22 at 6:48 PM R2 is alert, pleasant, cooperative, no acute distress. R2's symptoms have improved. R2's symptoms have markedly improved after treatment. Nursing home has declined to have R2 return. R2 is medically cleared to return home. R2 has no suicidal or homicidal ideation. V11 (Family) is due to pick R2 up. On 11/19/22 at 7:52 PM documents: R2 had no adverse reaction to medication taken.
The facility document titled, Bed Hold Guarantee Policy dated 08/2017 documents: Upon leaving this facility for admission to a hospital or for a therapeutic leave, a resident shall be guaranteed a bed in this facility upon return if: 1. The resident's condition is such that he/she is appropriate for the level of care provided by the facility, and 2 A Medicaid eligible resident was not in the hospital or on leave for more than 10 consecutive day, or 3 The Medicaid resident or responsible party has agreed to pay the Public Aid rate for days in excess of the 10 days, or 4 Private pay resident has insured hold on a bed through reimbursement at the current private pay rate. If a resident in an Intermediate Care Facility leaves the facility for admission to the hospital and requires skilled care (Medicare) upon discharge, they will not be able to return to the Intermediate Care Facility. This facility strives to insure that each Medicaid resident, who is discharged to an acute care setting or takes a therapeutic leave, has a bed reserved for his/her return. Beds shall be held for 10 days for hospitalization and therapeutic leave for Medicaid recipients and indefinitely for Private Pay residents who elect to pay the charges. The resident, resident family or legal representative will be given the appropriate notice of Bed Hold Policy at the time of discharge or therapeutic leave if possible, but notice will be given no longer than 24 hours after discharge or initiation of leave. If the facility determines that a resident who was transferred with an expectation of returning to the facility cannot return to the facility, the facility must comply with 42 CFR, Sec 483.15 (c).
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 2 life-threatening violation(s), 3 harm violation(s), $157,866 in fines, Payment denial on record. Review inspection reports carefully.
- • 59 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $157,866 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
✓ Report will be sent to your email
About This Facility
What is Axiom Healthcare Of West Frankfort's CMS Rating?
CMS assigns AXIOM HEALTHCARE OF WEST FRANKFORT an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Illinois, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Axiom Healthcare Of West Frankfort Staffed?
CMS rates AXIOM HEALTHCARE OF WEST FRANKFORT's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 65%, which is 19 percentage points above the Illinois average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Axiom Healthcare Of West Frankfort?
State health inspectors documented 59 deficiencies at AXIOM HEALTHCARE OF WEST FRANKFORT during 2022 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 3 that caused actual resident harm, and 54 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Axiom Healthcare Of West Frankfort?
AXIOM HEALTHCARE OF WEST FRANKFORT is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by AXIOM HEALTHCARE, a chain that manages multiple nursing homes. With 96 certified beds and approximately 47 residents (about 49% occupancy), it is a smaller facility located in WEST FRANKFORT, Illinois.
How Does Axiom Healthcare Of West Frankfort Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, AXIOM HEALTHCARE OF WEST FRANKFORT's overall rating (1 stars) is below the state average of 2.5, staff turnover (65%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Axiom Healthcare Of West Frankfort?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, the facility's high staff turnover rate, and the below-average staffing rating.
Is Axiom Healthcare Of West Frankfort Safe?
Based on CMS inspection data, AXIOM HEALTHCARE OF WEST FRANKFORT has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Illinois. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Axiom Healthcare Of West Frankfort Stick Around?
Staff turnover at AXIOM HEALTHCARE OF WEST FRANKFORT is high. At 65%, the facility is 19 percentage points above the Illinois average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Axiom Healthcare Of West Frankfort Ever Fined?
AXIOM HEALTHCARE OF WEST FRANKFORT has been fined $157,866 across 2 penalty actions. This is 4.6x the Illinois average of $34,658. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Axiom Healthcare Of West Frankfort on Any Federal Watch List?
AXIOM HEALTHCARE OF WEST FRANKFORT is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.