What is Allure Of Zion's CMS rating?

Allure Of Zion has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Does Allure Of Zion have any serious inspection findings?

Yes, Allure Of Zion has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 51 total deficiencies from recent inspections.

What are the staffing levels at Allure Of Zion?

Allure Of Zion has a two-star staffing rating from CMS with 0.56 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is Allure Of Zion located?

Allure Of Zion is located in ZION, IL. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does Allure Of Zion have?

Allure Of Zion has 115 certified beds.

Who owns Allure Of Zion?

Allure Of Zion is a for profit - corporation facility and is part of the ALLURE HEALTHCARE SERVICES chain.

Is Allure Of Zion safe?

Allure Of Zion has documented safety concerns including 1 immediate jeopardy citation. Families should ask about corrective actions taken.

Do nurses at Allure Of Zion stick around?

Allure Of Zion has average staff turnover at 45%, which is typical for the nursing home industry.

Was Allure Of Zion ever fined?

Yes, Allure Of Zion has been fined $240,949 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is Allure Of Zion on any federal watch list?

No, Allure Of Zion is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at Allure Of Zion?

Medicare inspectors have found 51 deficiencies at Allure Of Zion: 1 critical, 8 serious, 42 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting Allure Of Zion?

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

How does Allure Of Zion compare to other nursing homes?

Allure Of Zion has a 1-star overall rating, which is below average compared to other nursing homes in IL. Families should carefully review inspection findings and consider alternatives.

Allure Of Zion | 0/100 (Grade F)

Jun 2025 2 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to supervise a resident at high risk for falls for one of six resident...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to supervise a resident at high risk for falls for one of six residents (R1) reviewed for safety/supervision in the sample of six. This failure resulted in R1 experiencing a fall and rib fracture that resulted in R1 transferring to the local hospital. The findings include: R1's Discharge paperwork from the local hospital shows R1 was admitted to the local hospital from [DATE]-June 13, 2025, with diagnoses of wet gangrene, osteomyelitis, and dementia. R1's admission Record dated June 25, 2025, shows he was admitted to the facility on [DATE] with diagnosis of vascular dementia. R1's Fall Risk assessment dated [DATE], shows R1 was a high risk for falling with a score of 16. On June 25, 2025, at 12:44 PM, V9 Registered Nurse (RN) stated R1 arrived in the facility prior to her getting to the facility for her shift that started at 3:00 PM. V9 stated when she arrived for her shift, R1 had not been admitted by a nurse yet. V9 stated she did rounds on R1 first since he was not officially admitted by a nurse yet. V9 stated during report she (V9) was told R1 was a high fall risk. V9 stated she gave R1 a urinal, oriented R1 to his room and asked R1 to use the urinal and his call light. V9 stated she was at the nurse's station when the Certified Nursing Assistant (CNA) came and got her because R1 had fallen. V9 stated R1 reported head and back pain. V9 stated R1 was sent to the hospital since the fall was unwitnessed and R1 reported that he hit his head. On June 25, 2025, at 1:31 PM, V10 CNA stated she got to work at 2:00 PM and got report from the other CNA. V10 stated she got report that there was a new admission, but he had not been checked in by the nurse or CNA. V10 stated she asked the day nurse who was going to do R1's admission, and the day nurse said the 2nd shift nurse was going to do R1's admission. V10 stated that R1 was at the facility before her shift started at 2:00 PM. V10 stated the nurses get to the facility at 3:00 PM. V10 stated that at the time of R1's fall on June 13, 2025, she was performing incontinence care to R1's roommate. V10 stated she could hear R1 trying to get up from his bed because she could hear the mattress creaking. V10 stated she looked around the privacy curtain and asked R1 if he needed something. V10 said that R1 was sitting on the edge of the bed. V10 said that R1 told her that he needed to use the bathroom. V10 said she told R1 to use his urinal. V10 said she did not know if R1 could walk or not because he had not been evaluated by the nurse yet. V10 said there was a walker by R1's closet but she was not sure if it was R1's or not. V10 said she asked R1 if he wanted to use the walker and unfolded it. V10 said that R1 was still trying to get up without the walker when V10 left the room to throw away the trash from R1's roommate. V10 said, Obviously he did not wait for me. I heard a loud noise and the resident across from the hall from R1's room said R1 fell. V10 said R1 was on the floor in the fetal position. V10 said she thought R1 hit his head. V10 said that R1 was sent to the local emergency room. On June 24, 2025, at 4:32 PM, V11 (R1's daughter) said R1 was admitted to the facility June 13, 2025. V11 said R1 fell the day he got to the facility. V11 stated on June 13, 2025, she was waiting for a phone call from the facility telling her that R1 arrived at the facility because she knew that R1 would be disoriented and needed V11 to be at the facility. V11 said, Next thing I know, about 5:00 PM, the facility called me and stated my father had fallen and the ambulance was on its way. V11 stated the facility said that R1 hit his head so it was protocol to send him to the local hospital. V11 stated the hospital just did a cat scan on R1's head that came back negative and R1 was sent back to the facility. V11 stated her father has advanced dementia. V11 said she saw her father about mid night at the facility when he came back from the hospital on June 14, 2025. V11 said she saw her father in the evening on Saturday June 14, 2025, and her father was grabbing his side. V11 stated she demanded X rays from the facility because when she saw her father on June 15, 2025, R1 was still in pain and holding onto his right side. V11 stated her father was in pain each time he took a deep breath. V11 stated she never saw her father like this. V11 stated the facility got X rays done and the facility called her and said R1 had a broken rib. The facility told V11 that they were sending R1 back to the local hospital. On June 25, 2025, at 2:00 PM, V3 Assistant Director of Nursing stated R1 had a fall shortly after he arrived at the facility. V3 stated the facility called R1's daughter (V11) and told her about the fall. V3 stated that V11 told her that R1 should have been 1:1. V3 stated the facility was not aware of that and the hospital that R1 came from did not report that to the facility staff. R1's Medication Administration Record shows he received tylenol 650 mg (milligram) for pain rated at a 5/10 on June 14, 2025. R1's Progress Notes dated June 15, 2025, by V8 RN shows, At approximately 11:30 AM, the resident's daughter arrived at the facility and informed the nurse on duty that the resident was experiencing pain on the right side near the rib area, as well as in both hips. Nurse Practitioner ordered a stat bilateral rib x ray and bilateral hip x ray. R1's Radiology Results Report dated June 15, 2025, shows, Minimally displaced fracture of the right eighth rib laterally. The facility's Accidents and Supervision policy dated 2024 shows, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents.

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 and record review, the facility failed to administer medications as ordered by the physician for one of six r...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer medications as ordered by the physician for one of six residents (R1) reviewed for medications in the sample of six. The findings include: R1's Discharge Instructions from the local hospital dated June 13, 2025, shows R1 was admitted to the local hospital on June 4, 2025, with diagnoses including wet gangrene, osteomyelitis, and dementia. Amoxicillin-clavulanate (Augmentin 500 mg(milligram)-125 mg oral tablet/antibiotic) one tablet every eight hours with next dose due on June 13, 2025, at 5:00 PM was ordered by the discharging physician. R1's Physician Orders shows an order was entered for Augmentin one tablet three times per day for toe amputation with a start date of June 13, 2025. R1's Physician Orders show that R1 was admitted to the facility on [DATE]. R1's Medication Administration Record shows Augmentin was not administered until June 15, 2025, at 9:00 AM. On June 26, 2025, at 11:26 AM, via telephone interview with V2 Director of Nursing (DON), V2 stated R1's Augmentin was not delivered yet when the day nurse came on June 14, 2025. V2 stated the day nurse went to the facility's convenience box to look for Augmentin, but did not know the facility's convenience box had Augmentin in the box. V2 said R1's Augmentin was not delivered until the evening of June 14, 2025. V2 stated the facility's convenience box does contain Augmentin. At 11:47 AM, V3 Assistant Director of Nursing (ADON) stated V8 RN updated R1's Augmentin order on June 14, 2025, because the pharmacy said the medication was not available. R1's Administration Notes dated June 14, 2025, at 8:59 AM and 11:18 AM shows the Augmentin was not available. The facility's Medication Administration Policy dated 2025 shows, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.

May 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure low air loss mattresses were provided for 2 of...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure low air loss mattresses were provided for 2 of 3 residents (R2 and R3) with Stage 4 sacral pressure ulcers reviewed for pressure ulcers in the sample of 3. The findings include: R2's admission Record dated 5/5/25 shows R2 was admitted to the facility on [DATE] with pressure induced deep tissue damage of her right heel and a Stage 4 pressure ulcer of her sacrum. R2's Specialty Physician Initial Wound Evaluation & Management Summary dated 2/27/25 shows the wound physician's, V10, plan of care for R2's Stage 4 sacral pressure wound includes a low air loss mattress. R2's care plan initiated on 2/27/25 shows R2 has a low air loss mattress as an intervention for her Stage 4 pressure wound of her sacrum. On 5/5/25 at 10:18 AM, V2, was lying in bed watching TV. V2 did not have a low air loss mattress on her bed. When asked if she had a special mattress for her bed, V2 replied, No. On 5/5/25 at 1:25 PM, V4, Wound Care Nurse, said every resident with a pressure wound goes on a low air loss mattress. V4 said R2 and R3 should all be on a low air loss mattress. V4 said they keep low air loss mattresses in the building and maintenance brings them up for the residents. On 5/5/25 at 1:38 PM, V4 walked down to R2's room to verify she does not have a low air loss mattress. V4 said R2 should be on a low air loss mattress, it is beneficial for a pressure ulcer. On 5/5/25 at 11:34 PM, R3 was sitting in her wheelchair in her room. R3 verified she does have a wound on her bottom. During this interview, V11, Maintenance, enters R3's room and proceeds to remove the mattress from R3's bed, which is not a low air loss mattress. R3 said she is getting a new mattress, an air mattress because the wound care doctor recommended it. R3 said she has been living in the facility for about a month. R3's admission Record dated 5/5/25 shows she was admitted to the facility on [DATE]. R3's Specialty Physician Initial Wound Evaluation & Management Summary dated 4/3/25 shows R3 has a Stage 4 pressure wound of her sacrum. V10's plan of care for R3's Stage 4 sacral pressure wound includes a low air loss mattress. The facility's Pressure Injury Prevention and Management Policy (undated) shows under the heading Interventions for Prevention and to Promote Healing, evidence-based interventions for all residents who have a pressure injury present include providing an appropriate, pressure-redistributing support surface.

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to follow Enhanced Barrier Precautions (EBP) for 1 of 3 residents (R1) reviewed for infection control in the sample of 3. The f...

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Based on observation, interview, and record review, the facility failed to follow Enhanced Barrier Precautions (EBP) for 1 of 3 residents (R1) reviewed for infection control in the sample of 3. The findings include: R1's Order Summary Report dated 5/5/25 shows R1 has a current order for Enhanced Barrier precautions. R1's current care plan provided by the facility shows R1 has a Stage 4 pressure wound to her sacrum. On 5/5/25 at 9:56 AM, V4, Wound Care Nurse, V5, Certified Nursing Assistant (CNA), and V6, Life Enrichment were in R1's room assisting/changing R1's dressings. V6 was holding R1's leg, V5 was changing R1's left heel dressing. V5 assisted R1 to turn onto her side to allow visualization of R1's backside. V4, V5, nor V6 wore gowns while providing these direct cares. On 5/5/25 at 1:25 PM, V4 said residents with pressure wounds need to be on EBP. Staff should wear gowns and gloves while giving direct care to residents on EBP. On 5/5/25 at 1:42 PM, V3, Infection Prevention Nurse, said staff need to wear a gown, gloves, and mask when providing any close contact care to a resident on Enhanced Barrier Precautions (EBP). V3 said a resident with a wound that is a Stage 4 or greater requires EBP. V3 said the facility follows the CDC guidelines for EBP. The facility's Enhanced Barrier Precautions Policy (undated) shows EBP is an infection control intervention which employs gown and gloves use during high contact resident care activities. An order for EBP will be obtained for residents with pressure ulcers and PPE (personal protective equipment), gowns and gloves, is necessary when performing high contact care activities. High contact resident care activities include dressing, transferring, and wound care.

Jan 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on interview and record review the facility failed to carry out a physician order for an Infectious Disease consultation for 1 of 3 residents (R2) reviewed for Quality of Care in the sample of 9...

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Based on interview and record review the facility failed to carry out a physician order for an Infectious Disease consultation for 1 of 3 residents (R2) reviewed for Quality of Care in the sample of 9. The findings include: On 1/8/25 at 10:45 AM, R2 was in bed and appeared drowsy and unable to stay awake during a conversation with this surveyor. Outside of R2's doorway was a sign indicating she (R2) is on contact isolation. R2's urinalysis report dated 12/19/24 shows her urine tested positive for ESBL (extended-spectrum beta- lactamases) via a urine culture that was completed on 12/22/24. A facility provided timeline for R2 shows R2 had a Urinary Tract Infection (UTI's) on 9/11/24 which did not require treatment. One 10/25/24 which required antibiotic usage and another on 12/19/24 which also required antibiotic treatment, with Ertapenm sodium solution for 7 days. On 1/8/25 at 11:44 AM, V4 (Nurse Practitioner) stated she had been monitoring R2's increase in UTI's and her recent diagnosis of ESBL in her urine and decided she should refer her to an Infectious Disease doctor for further consultation as R2 has been overall declining. V4 stated a couple weeks ago she gave an order to V5 (Registered Nurse/RN) to start the referral process because it can take a while to get in to see the physician sometimes. V4 stated she was looking at R2's Physicians orders today and did not see that the order was ever entered by V5, so she entered it herself. V4 stated she expected when she gave the order to V5 she would enter it the same day and start the process and call for the appointment. V4 was able to indicate it was 12/26/24 when she gave V5 this order because of the charting in R2's medical record completed by V5. R2's nursing progress notes completed by V5 on 12/26/24 do not show any order or documentation about R2 being referred to an Infectious Disease doctor by V4. On 1/8/25 at 12:26 PM, V5 (RN) stated now that she thinks about it, she does remember V4 giving her an order for two residents to see the Infectious Disease doctor and that she (V5) did not enter the order for R2 and did not call for an appointment. On 1/8/25 at 2:31 PM, V2 (Director of Nursing) stated she was not aware before today of V5 not carrying out the order for R2 to see the Infectious Disease doctor. V2 stated she would expect nurses to carry out any physician order immediately and to start the referral process. On 1/8/25 at 2:32 PM, V3 (Assistant Director of Nursing) stated the Infectious Disease doctors will sometimes do a tele health appointment which can be done usually pretty quick, and the facility also has transportation to get residents to appointments so if V5 had started the process R2 could have possibly been seen quick. The facility provided undated Consulting Physician/ Practitioner Orders policy that shows the nurse should note and carry out a physicians order.

Aug 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Transfer Requirements (Tag F0622)

Could have caused harm · This affected 1 resident

Based on interview, and record review the facility failed to ensure transfer paperwork was sent to the hospital/emergency room for the correct resident for 1 of 3 residents (R2) reviewed for transfers...

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Based on interview, and record review the facility failed to ensure transfer paperwork was sent to the hospital/emergency room for the correct resident for 1 of 3 residents (R2) reviewed for transfers in the sample of 3. The findings include: On 8/12/24 at 8:40 AM, V1 (Administrator) stated in March of 2024 R2 was sent to the hospital with R1's transfer paperwork. On 8/12/24 at 9:31 AM, V4 (Registered Nurse) stated she was the nurse taking care of R2 on 3/6/24 when R2 was sent to the hospital with R1's transfer paperwork. V4 stated R2 pulled out his gastrostomy tube (g-tube) and was sent to the emergency room to have it replaced. V4 stated about 20 minutes after R2 left the facility she received a phone call from an emergency room nurse saying R1 was in the emergency room. V4 stated she corrected the emergency room nurse and informed them that R2 and not R1was in the emergency room. According to V4, the emergency room nurse stated the transfer paperwork sent with R2 had R1's name on it. V4 stated V2 (Director of Nursing) was the one that printed the transfer paperwork for R2. On 8/12/24 at 9:12 AM, V2 stated she printed R1's face sheet and code status and that paperwork was sent with R2 to the emergency room. On 8/12/24 at 11:55 AM, V3 (R1's wife) stated once she became aware that R1's paperwork was sent with R2 to the hospital she went to the hospital billing department. V3 stated R1 had a charge for a tube feeding procedure done on 3/6/24. V3 added that R1 did not have a tube feeding and was never in the hospital on 3/6/24. A hospital statement showed R1 had a charge for a procedure dated 3/6/24. On 8/12/24 at 1:14 PM, V2 stated R1 was not sent to the hospital on 3/6/24 and remained at the facility. R2's progress notes dated 3/6/24 showed he was sent to the emergency room after having his g-tube removed. The facility's Transfer and Discharge (including AMA) policy undated showed for transferring a resident to another provider, for any reason, the following information must be provided to the receiving provider: Contact information of the practitioner, resident representative information, advance directive information and other information necessary to meet the resident's needs.

Jul 2024 10 deficiencies 2 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) R56's electronic face sheet printed on 7/11/24 showed R56 has diagnoses including but not limited to dementia with behaviors,...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) R56's electronic face sheet printed on 7/11/24 showed R56 has diagnoses including but not limited to dementia with behaviors, sciatica, bipolar disorder, osteoarthritis, pressure ulcer of left hip-unstageable, and non-pressure chronic ulcer of left buttock. R56's facility assessment dated [DATE] showed R56 has no cognitive impairment and has no pressure injuries. R56's care plan dated 6/19/24 showed, The resident has pressure ulcer or potential for pressure ulcer development related I have 2 wounds and am being seen by the wound doctor/nurse. (SITE 6) unstageable (due to necrosis) of the left hip. 6/21/24 this is now a stage 4 .Follow facility policies/protocols for the prevention/treatment of skin breakdown. Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size (length X width X depth), stage R56's physician's orders for May 2024 showed no orders for R56 to have weekly skin assessments. R56's May 2024 skin checks showed R56 had 1 skin check for the month of May on 5/30/24 (the same day R56's unstageable wound was identified). R56's wound assessment dated [DATE] showed, Unstageable left hip pressure ulcer. 100% thick adherent black necrotic tissue. 2.5x3.6 cm (centimeters). R56's wound assessment dated [DATE] showed, Stage 4 left hip pressure ulcer 2.9 x 1.3 x 0.2 cm . moderate serous exudate (clear drainage) Surgical Excision Debridement Procedure: Post-debridement assessment of this previously unstageable necrotic wound has revealed the underlying deep tissue at the muscle/fascia level, which had been obscured by necrosis prior to this point. This wound has now revealed itself to be a Stage 4 pressure injury. On 7/11/24 at 2:08PM, V11 (wound care nurse) stated, (R56's) pressure ulcer started as a blister that was not opened. I can't say how it developed but we applied a foam dressing until the wound care nurse practitioner could evaluate it on 5/31/24. The wound care physician debrided it and found it to be a stage 4 pressure ulcer. I was notified by the nursing staff on 5/30/24 that she had the blister, so I went down and assessed it and notified the wound care nurse practitioner and she came and saw her on 5/31/24. The only weekly assessments I have is the one I gave you for 5/30/24. The staff should have been doing weekly skin assessments on (R56) due to her high risk for skin breakdown and existing surgical wound on her other hip. I can't say why they didn't do the weekly assessments but perhaps we could have caught this before it developed into an unstageable wound and had to be debrided. The facility's policy titled, Pressure Injury Prevention and Management dated February 2023 showed, This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries .c. Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record .e. nursing assistants will inspect the skin during bath and will report any concerns to the resident's nurse immediately after the task . Based on observation, interview, and record review, the facility failed to identify areas of pressure for 2 of 3 residents (R45, R56) reviewed for pressure in the sample of 24. This failure resulted in R45 developing two stage 4 pressure injuries, one on each heel, requiring surgical debridement to remove non-viable tissue, and R56 developing an unstageable pressure injury to her left hip requiring debridement. The findings include: 1. R45's admission Record, provided by the facility on 7/11/24, showed she had diagnoses including a stage 4 pressure ulcer of right heel, and a stage 4 pressure ulcer of left heel, protein-calorie malnutrition, acute embolism, and thrombosis of unspecified deep veins of left lower extremity, and bilateral primary osteoarthritis of knees. R45's 6/10/24 facility assessment showed R45 had severe cognitive impairment, required substantial/maximal assistance from staff for toileting, personal hygiene, upper and lower body dressing, rolling side-to-side in bed, and transfers. R45's care plan initiated on 5/1/24, showed she had the potential for impaired skin integrity as evidenced by Braden Scale for Predicting Pressure Ulcer Risk. High risk for pressure ulcer. The care plan showed Evaluate skin integrity .Provide skin care per facility guidelines and as needed. On 7/11/24 at 9:24 AM, V11 (Wound Nurse/LPN) performed a dressing change to the wounds on R45's bilateral heels. V11 stated he thinks the wounds on R45's heels were there for a while before he noticed them and did his assessment. V11 stated no one notified him of the wounds. V11 stated R45 has MRSA (Methicillin-resistant Staphylococcus aureus-an infection that's become resistant to many of the antibiotics used to treat ordinary staph infections) in her wounds and was currently receiving antibiotics. The wound on R45's right heel was about the size of a dime. The border of the wound had white, moist tissue all around the edge of the wound bed. V11 cleaned the wound with normal saline-soaked gauze, dried the area, and applied an ointment used to remove damaged tissue from the wound bed. V11 applied calcium alginate dressing (a dressing that can absorb excess moisture and promote wound healing) to the wound, then covered the wound with foam dressing and wrapped R45's heel and foot with kerlix gauze. V11 removed the dressing from R45's left heel. R45's left heel was at least twice the size of the right heel. The wound bed was not as red/beefy looking like the right heel. V11 cleansed R45's left heel wound and applied the same treatment as the right heel. At 11:54 AM, V11 said both of R45's heel wounds were identified at the same time. V11 stated he thinks he saw R45's skin sheet and it showed something on her heels, so he checked her heels and saw the open areas. At 12:07 PM, V11 stated he would expect staff to identify an area of skin concern prior to it becoming a stage IV pressure ulcer and report it to him right away so he could assess it and start interventions. V11 stated no staff reported it to him. he saw the skin sheet in his mailbox on 6/4/24 and assessed her. When asked about his initial assessment identifying R45's wounds as unstageable. V11 stated he does not stage the wound; he lets the wound doctor/nurse practitioner stage the wounds. V11 provided surveyor with R45's skin sheet dated 6/3/24 showing both heels circled. The skin sheet showed Open Wound. V11 was asked to provide skin sheets for R45 prior to the 6/3/24 skin sheet. No additional skin sheets were provided prior to exiting the facility. R45's Wound Observation Tool, electronically signed by V11 on 6/5/24, showed a facility acquired unstageable pressure area to her left heel effective as of 6/3/24 measuring 2.2 cm (centimeters) long x 2.5 cm wide x 0.1 cm depth. Infection suspected. Moderate serous drainage, odor, and inflammation/induration (localized hardening of soft body tissue) present. R45's Wound Observation Tool, electronically signed by V11 on 6/5/24, showed a facility acquired unstageable pressure area to her right heel effective as of 6/3/24 measuring 2.7 cm in length x 4.0 cm in width x 0.1 cm in depth. Infection suspected. Moderate serous drainage, odor, and inflammation/induration present. R45's 6/7/24 Initial Wound Evaluation and Management Summary performed by V13 (facility contracted Wound Doctor) showed a stage 4 pressure wound of the right heel measuring 2.3 cm x 2.2 cm x 0.1 cm. The evaluation also showed a stage 4 pressure wound of the left heel measuring 3.0 cm x 4.0 cm. The evaluation showed the depth of the wound was not measurable due to presence of nonviable tissue and necrosis (thick adherent black non-viable skin tissue). The evaluation showed 100% necrotic tissue (eschar). A surgical debridement procedure was performed to remove the thick adherent eschar and devitalized tissue, establish the margins of viable tissue, and remove infected tissue. V13's procedure note showed surgical excision of devitalized tissue and necrotic muscle level tissues were removed at a depth of 0.3 cm to R45's left heel. The evaluation also showed a deep wound culture of the stage 4 pressure wound on R45's left heel was recommended by V13 on 6/7/24. R45's 7/9/24 Wound Evaluation and Management Summary by V13 showed the pressure wound to her left heel measured 2.5 cm x 2.3 cm x 0.2 cm, and the pressure wound to her right heel measured 0.9 cm x 0.8 cm x 0.2 cm. The evaluation showed MRSA positive wound culture to R45's right heel. The evaluation also showed X-Ray pending on pressure wound of the heel as of 7/9/24. The Radiology Results Report dated 7/9/24 showed X-rays were performed on R45's left and right heels. The results showed no osteomyelitis (inflammation of the bone caused by infection spreading from nearby tissue) was seen. On 7/11/24 at 12:56 PM, V2 (Director of Nursing) stated the CNAs (Certified Nursing Assistants) usually alert first regarding skin concerns and put the information on the resident's shower sheet. V2 stated the CNAs have to report the concern to her. She (V2) lets V11 (Wound Nurse) know, and he will do an assessment. V2 stated she would expect the nurses and the CNAs to identify an area of skin concern, prior to it becoming a stage 4 that looked infected. V2 added, Clearly there would have been something there prior. On 7/12/24 at 8:59AM, V18 (Nurse Practitioner) stated, (R45) is definitely at increased risk for pressure ulcers with all of her comorbidities. She is dependent on the staff for her cares and repositioning so this should have been caught way sooner. I got a call from an agency nurse that they found pressure ulcers and I just couldn't believe it. I feel bad because I thought we were on top of her care and obviously the skin checks weren't being done otherwise we would have caught it sooner. It is unacceptable to find a wound when it is at a stage 4. At this point, we are back-peddling and trying to play catch-up with her wound care to try and heal it because it is more advanced. When you catch a wound in its earlier stages it is much easier and quicker to heal but now this will take some time and diligence with wound care. Weekly skin checks should be done on all residents that are at high risk for skin breakdown and these 2 residents are high risk residents. (R56) already has a surgical wound on her right hip and now we have to try and heal her left hip pressure ulcer. It makes me sad that these 2 residents are going through this because I thought we were really on top of their care. Both of these wounds should have been identified sooner and I believe they would have been if we were doing the weekly skin checks and observing their skin more closely during daily cares. R45's June 2024 Medication Administration Record (MAR) showed she was started on Keflex 500 mg (milligrams) every 12 hours for 10 days on 6/4/24, for prophylaxis for wound infection. The June MAR showed that order was discontinued, and she was started on Bactrim DS 800-160 mg twice daily on 6/11/24 through 6/21/24 for MRSA in wound. R45's June 2024 Treatment Administration Record showed an order on 6/3/24 to apply santyl (a debridement ointment) and cover with a dressing to bilateral heels. The TAR showed on 6/5/24 orders were changed to Cleanse with normal saline, pat dry, apply Santyl, apply alginate calcium once daily and as needed. Gauze island with border dressing, apply once daily and as needed for right and left heels. The facility's February 2023 policy and procedure titled Skin Audits by Nursing Assistants showed It is the facility's policy to communicate changes in skin condition to appropriate personnel as part of their systematic approach for pressure injury prevention and management. 1. Nursing assistants shall inspect all skin surfaces during bath/shower and report any concerns to the resident's nurse immediately after the task. 2. Nursing assistants shall also report changes in skin condition that are noted during any care procedure. 3. Skin conditions that shall be reported include but are not limited to: a. Redness b. Bruising c. Swelling d. Rashes, hives e. Blisters (clear or blood-filled) f. Skin tears g. Open areas, ulcers, lesions.

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Deficiency F0692 (Tag F0692)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform weekly weights as ordered by a physician for ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform weekly weights as ordered by a physician for 1 of 7 residents (R58) reviewed for nutrition in the sample of 24. This failure resulted in R58 experiencing a significant weight loss of 7.96% within a 3-month period before it was identified by facility staff and R58 was referred to the facility dietician. The findings include: R58's electronic face sheet printed on 7/11/24 showed R58 has diagnoses including but not limited to traumatic subdural hemorrhage, type 2 diabetes, unspecified protein-calorie nutrition, anemia, and history of pneumonia. R58's facility assessment dated [DATE] showed R58 has severe cognitive impairment and has weight loss of 5% or more in the last month or 10% or more in the last 6 months. R58's care plan contained no problems or interventions for R58's weight loss. R58's physician's orders dated 8/24/23 showed, Weight every day shift every Thursday. R58's medication administration record (MAR) for April 2024 showed R58 weighed 120.6lbs on 4/19/24. No weight was obtained for R58 the following week on 4/25/24. R58's MAR for May 2024 showed no weight was obtained for R58 on 5/2/24. 3 weeks passed without weekly weights being obtained for R58. On 5/9/24, R58 weighed 114lbs. This was a 5.47% weight loss within less than one month. R58's weight as of 7/6/24 was 111lbs which is an additional 3lb weight loss since May 2024. R58's dietician assessment dated [DATE] showed, Weight 5/6/24 114lbs. comparative weight loss 10.5% within 6 months Weight no lower desired. On 7/11/24 at 1:54PM, V2 (Director of Nursing) stated, The dietician is here at least once a week. I believe she is seeing (R58). We have a risk meeting every week and review all of the weekly weights and any concerns. For this week, (R58) is not on the list that the dietician reviewed. I can see where this is an issue. Staff should have been documenting the weights and obtaining them as ordered. (V17-lead certified nursing assistant) is the one who puts the weight list out for the aides on the floor, so they know who needs to be weighed. V17 then entered the room for the interview and stated she was unaware that R58 needed to be a weekly weight and she has not been notifying staff to weigh her weekly; therefore, there are no weekly weights being done for R58. On 7/11/24 at 2:38PM, V13 (Dietician) stated, I go through the weights each month and look at who needs to be assessed by me. (R58's) nurse practitioner wanted me to see her and have weekly weights done on her because she has lost more weight. I haven't followed up on the last weight they were supposed to do earlier this week. (R58 had no weekly weight done as of 7/11/24). In May she was on my list, so I added a supplement for her. If she triggers on the weight change or MDS (minimum data set) then I would see her. Whatever comes up on the weights and exception report on (computer system) is who I see, and I don't recall her being on that. Obviously if there were weights ordered weekly that's what they should have been doing so we could have maybe caught this prior to it becoming significant. I suppose she wouldn't show up on the weight report if they aren't doing the weights and entering them so that is also a problem. The facility's policy titled, Weight Monitoring dated February 2023 showed, Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise .Weight can be a useful indicator of nutritional status. Significant unintended changes in weight or insidious weight loss may indicate a nutritional problem .4. Interventions will be identified, implemented, monitored, and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status .5. A weight monitoring schedule will be developed upon admission for all residents: c. residents with weight loss-monitor weight weekly.

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to obtain physician's orders for a resident (R67) code status for 1 of 1 resident reviewed for advanced directives in the sample of 24. The fi...

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Based on interview and record review, the facility failed to obtain physician's orders for a resident (R67) code status for 1 of 1 resident reviewed for advanced directives in the sample of 24. The findings include: R67's electronic face sheet printed on 7/11/24 showed R67 has diagnoses including but not limited to Parkinson's without dyskinesia, unsteadiness on feet, repeated falls, lack of coordination, and syncope & collapse. R67's physician's orders for July 2024 showed no physician's orders for code status. R67's electronic medical record did not display his code status. R67's care plan dated 6/14/23 showed, Resident has following code: DNR .Note physician order and DNR is present on resident chart if applicable. R67's POLST (Physician's Orders for Life-Sustaining Treatment) dated 12/8/21 showed R67 has elected to be a DNR (Do Not Resuscitate). On 7/11/24 at 1:55PM, V9 (Registered Nurse) stated, If a resident has an emergency, I look at the banner on the resident profile in their EMR (electronic medical record). If it's not there, then I would go to their physician's orders. If it's not there, then we would have to look through the chart under scanned documents to try and find the POLST form which would waste time during an emergency. On 7/11/24 at 1:57PM, V2 (Director of Nursing) stated, All residents should have their code status displayed by their name in their EMR and a physician's order should be obtained with the correct code status. We would waste precious time in an emergency if we had to go through the chart and dig for the POLST form. The facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives dated February 2023 showed, It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive .

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** 2) R41's electronic face sheet printed on 7/11/24 showed R41 has diagnoses including but not limited to bipolar disorder, major ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) R41's electronic face sheet printed on 7/11/24 showed R41 has diagnoses including but not limited to bipolar disorder, major depressive disorder, hyperlipidemia, hypertension, and type 2 diabetes. R41's document titled, Interagency Certification of Screening Results dated 11/5/2019 showed R41 has no mental illness and does not require a level two PASARR (Preadmission Screening and Resident Review). On 7/11/24 at 12:23PM, V1 (Administrator) stated, Admissions does the PASARR's and she will be retrained on the process. She would be responsible for ensuring that the level 2 is done. Technically, R41 should have had a level 2 done upon admission because he has a diagnosis of bipolar disorder and major depressive disorder. The facility's policy titled, Resident Assessment-Coordination with PASARR Program dated October 2023 showed, This facility coordinates assessments with the PASARR program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs .9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review . Based on interview and record review the facility failed to ensure a PASRR (Preadmission Screening and Resident Review) level 2 was completed on residents with serious mental illness. This applies to 2 of 2 residents (R66 and R41) reviewed for PASRR in the sample of 24. The findings include: R66's admission Record (Face Sheet) shows his diagnoses to include unspecified psychosis not due to a substance or known physiological condition, and anxiety. The same document shows R66 was admitted to the facility on [DATE]. R66's PASRR level 1, shows it was completed on 6/4/23, and shows no level 2 was required because there was no serious mental illness, intellectual disability, or developmental disability. On 07/10/24 at 12:10 PM, V5 (Admissions Director) stated, she was not aware that a PASRR level 2 should have been done if a resident has serious mental illness. V5 stated, she was never trained on how or when to request a level 2 PASRR. V5 stated, she is not a nurse and wouldn't know if a resident got a diagnosis of a serious mental illness. V5 stated, she was trained to do a PASRR level 1 if the resident came from Wisconsin. On 07/11/24 at 12:27 PM, V1 (Administrator) stated, the PASRR Level 2 is to make sure the residents get the proper care. V1 stated, the facility needs to get a better process in place. V1 stated, V5 will be properly trained to know how and when to request a PASRR 2. On 07/11/24 11:28 PM, V2 DON (Director of Nursing) stated, if a resident has a PASRR Level 1, and has a serious mental illness then a PASRR Level 2 needs to be done to make sure the resident gets the proper treatment. V2 stated, a PASRR Level 2 should have been done for R66. R66's June 2024 MAR (Medication Administration Record) shows R66 has an order for Quetiapine, Risperidone, and Haloperidol, all medication listed as antipsychotic medications by WebMD. R66's Care plan (initiated 6/11/24) shows R66 is receiving antipsychotic medications.

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 provide thorough incontinence care for a dependent re...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide thorough incontinence care for a dependent resident. This applies to 1 of 2 residents (R37) reviewed for activities of daily living in the sample of 24. The findings include: R37's electronic face sheet printed on 7/11/24 showed R37 has diagnoses including but not limited to hemiplegia and hemiparesis, cerebral infarction, and dementia with behaviors. R37's facility assessment dated [DATE] showed R37 has severe cognitive impairment and is always incontinent of bladder. R37's care plan dated 6/23/23 showed, I have an ADL (activities of daily living) self-care performance deficit. I require assistance with ADL's because I have impaired balance, functional impairment in activity, hemiplegia, and general weakness. On 7/9/24 at 1:15PM, V14 (Certified Nursing Assistant) provided toileting assistance to R37. V14 removed 2 incontinence briefs from R37. V14 stated they put 2 incontinence briefs on R37 in case he urinates, and it leaks out of one brief. R37 had a strong urine odor coming from him and V14 stated both incontinence briefs were wet with urine and the inner brief had feces on it. V14 then cleansed R37's buttocks and applied a clean brief without cleansing R37's perineal and groin area. V14 stated she did not realize she did not clean R37's groin area but she should have because he was heavily incontinent of urine. On 7/11/24 at 1:57PM, V2 (Director of Nursing) stated, Perineal care should be performed after each incontinent episode to prevent infection and provide dignity to each resident. The resident's buttocks and groin area should be thoroughly cleaned every time the resident receives incontinence care. (V14) might not have done it because she's newer and needs some more education. The facility's policy titled, Incontinence dated February 2023 showed, Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services .4. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infection and to restore continence to the extent possible.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure fall prevention measures were in place for 2 o...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure fall prevention measures were in place for 2 of 11 resident's (R3, R30) reviewed for safety & supervision in the sample of 24. The findings include: 1) R3's electronic face sheet printed on 7/11/24 showed R3 has diagnoses including but not limited to congestive heart failure, left eye blindness, weakness, anxiety disorder, and altered mental status. R3's facility assessment dated [DATE] showed R3 has sever cognitive impairment and does not use alarms. R3's fall risk assessment dated [DATE] showed R3 is at risk for falls. R3's physician's orders dated 7/9/24 showed, clip alarm in place. R3's care plan dated 4/25/24 showed, The resident is at risk for falls related to incontinence. Clip alarm while in bed and wheelchair. On 7/9/24 at 10:16AM, R3 was laying in her bed with her alarm hooked to the right side of her bed. The end of the clip alarm was laying in the bed next to R3, not clipped to anything. V6 (Licensed Practical Nurse) came into the room with this surveyor and stated R3's clip alarm would not be considered in place because it is not attached to R3. V6 stated R3's alarm should be clipped to her so that we know when she tries to get up and can attend to her before she falls. On 7/11/24 at 1:57PM, V2 (Director of Nursing) stated, Clip alarms should be applied correctly to alert staff if a resident tries to get up. Once the alarm sounds, staff would respond immediately in an attempt to get to the resident before they fall. I entered orders for all of the residents with clip alarms on 7/9/24 because none of them had orders present in their chart. The facility's policy titled, Fall Prevention Program dated February 2023 showed, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls . 2) R30's electronic face sheet printed on 7/11/24 showed R30 has diagnoses including but not limited to tachycardia, low back pain, pain to left hip, history of falls, and major depressive disorder. R30's facility assessment dated [DATE] showed R30 has severe cognitive impairment. R30's care plan with a review date of 7/10/24 showed, The resident is at risk for falls. Clip alarm while in bed and wheelchair. R30's fall risk assessment dated [DATE] showed R30 is at risk for falls. R30's physician's orders dated 7/9/24 showed, Clip alarm in place. On 7/9/24 at 11:01AM, R30 was laying in her bed on her left side. R30's alarm was attached to her left side rail with the cord hanging down next to the bed with no clip present on the end of the cord. On 7/10/24 at 1:37PM, R30's clip alarm was in the same position and condition as surveyor's previous observation on 7/9/24. R30 was laying in her bed with her knees hanging off of the left side of the bed. V19 (Certified Nursing Assistant) came into R30's room with surveyor and stated V19 does use a clip alarm for fall prevention. V19 agreed that R30's alarm was not clipped to her and there was no way the alarm could have been clipped to her due to the absence of the clip on the end of the cord. V19 stated if the alarm is not clipped to R30 then staff will not be made aware if R30 tries to get up and she could fall. V19 took R30's clip alarm to be replaced with a functioning alarm. On 7/11/24 at 10:20AM, R30 was laying in her bed with a functioning alarm hooked onto the left side rail on her bed. R30's clip alarm was not clipped to her and was hanging off the side of the bed. R30's knees were hanging off the left side of the bed. Surveyor notified V9 (Registered Nurse) who came into R30's room and clipped her alarm to her.

CONCERN (D)

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

Respiratory Care (Tag F0695)

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 oxygen was administered at the physician prescr...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure oxygen was administered at the physician prescribed rate and failed to handle oxygen tubing in a manner to prevent cross contamination for 1 of 1 resident (R36) reviewed for oxygen in the sample of 24. The findings include: R36's face sheet printed on 7/11/24 showed diagnoses including but not limited to heart disease, pleural effusion (buildup of excess fluid around the lungs), and pneumonia. R36's facility assessment dated [DATE] showed total staff dependence needed for toileting, hygiene, dressing, and transfers. The same assessment showed no cognitive impairment and frequently incontinent of urine and bowel. R36's July order summary report showed a physician order start dated 6/7/24 for: Oxygen at 2 liters per minute every shift. R36's care plan showed a focus area initiated 6/25/24 for oxygen therapy related to shortness of breath. Interventions included give medication as ordered by physician and oxygen at 2 liters per NC (nasal cannula). On 7/9/24 at 11:13 AM, R36 was lying in bed and was heavily incontinent of bowel. R36 had opened her brief and was attempting to clean herself. Bowel movement was observed on her hands and inner thighs. Soiled bed linens and bowel movement was observed on the floor next to her bed. R36's oxygen tubing was laying on top of the soiled linens and floor. The oxygen level was set and running at 4 liters per minute. V7 and V8 (CNAs-Certified Nurse Aides) entered the room and began to assist R36 with incontinence care. V8 picked up the nasal cannula from the floor and placed it directly into R36's nose. The aides completed pericare and transferred R36 from the bed to her wheelchair using a mechanical sit to stand lift. R36 continued wearing the oxygen during the process. The tubing was tangled and stretched taut while she was wheeled backwards to the wheelchair. The tubing ripped out of her nose and fell onto the bowel covered floor. Again, the tubing was picked up and placed directly back into her nose. The tubing had a white tape with an illegible date written on it. On 7/10/24 at 11:52 AM, R36 was seated in her wheelchair and wearing her oxygen which was running through the same tubing. R36 stated she needs to wear the oxygen every day. R36 stated she especially needs it when she gets panicky while getting dressed or being transferred. On 7/10/24 at 1:42 PM, V7 (CNA) stated oxygen tubing needs to be replaced right away if it gets dirty from the floor. We tell the nurse it needs to be changed. Dirty oxygen supplies can cause respiratory problems. Once it is on the floor it is contaminated and is an infection control issue. It needs to be changed out right away. On 7/11/24 at 11:23 AM, V2 (Director of Nurses) stated oxygen is a medication and needs to be administered as ordered by the physician. If it is running too high, too much will get into the resident's respiratory system and the body will store it wrong. Breathing issues could develop. Tugging on oxygen tubing can cause pain. Nasal cannulas laying on the floor are an infection control issue. It should not be used until it has been changed. Laying in bowel movement is exposing it to E. Coli (a harmful bacteria) which can transfer to the face and that is serious infection issue. The facility's undated Oxygen Administration policy states: 1. Oxygen is administered under orders of a physician . and 5. b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to initiate isolation precautions for a resident (R56) w...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to initiate isolation precautions for a resident (R56) with a wound and peripherally inserted central catheter (PICC) lined, failed to perform hand hygiene before and after catheter care for a resident (R248), and failed to wear personal protective equipment for a resident (R248) on enhanced barrier precautions. These failures apply to 2 of 7 residents reviewed for infection control in the sample of 24. The findings include: 1) R56's electronic face sheet printed on 7/11/24 showed R56 has diagnoses including but not limited to dementia with behaviors, sciatica, bipolar disorder, anemia, pressure ulcer of left hip-unstageable, non-pressure chronic ulcer of left buttock, history of urinary tract infections, and anxiety disorder. R56's facility assessment dated [DATE] showed R56 has no cognitive impairment. R56's physician's orders for July 2024 showed no orders for R56 to be on enhanced barrier precautions. R56's wound assessment dated [DATE] showed R56 has a stage 4 pressure ulcer draining large amounts of serous (clear) drainage and a surgical wound. On 7/9/24 at 10:42AM, R56 was laying in her bed and had a PICC line to her right arm. R56 stated staff do not wear any gowns or eye protection when they are in her room or caring for her PICC line or wounds. R56's doorway had no isolation signs or PPE (personal protective equipment) located outside her room. As of 7/11/24 at 1:15PM, R56's room still had no isolation sign or PPE outside of her room. On 7/11/24 at 1:20PM, V2 (Director of Nursing/Infection Preventionist) stated, A resident should be placed on enhanced barrier precautions if identified as having MDROs (multidrug-resistant organisms), an indwelling catheter, a large wound, or if they have any devices going into their body. The facility's policy titled, Enhanced Barrier Precautions dated April 2, 2024 showed, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organism .b. an order for enhanced barrier precautions will be obtained for residents with any of the following: i. wounds (e.g. chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g. central lines, urinary catheters .PICC lines .) even if the resident is not known to be infected or colonized with a MDRO. 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room .b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities .4. High-contact resident care activities include g. Device care of use: central lines, urinary catheters .PICC lines .h. wound care: any skin opening requiring a dressing . 2. R248's admission Record, provided by the facility on 7/11/24, showed he had diagnoses including retention of urine, a personal history of urinary tract infections, and chronic kidney disease, stage 4 (severe). R248's care plan initiated on 5/6/24, showed he requires enhanced barrier precautions (EBP) related to an indwelling catheter. The care plan showed Wear personal protective equipment (PPE) properly. The care plan also showed staff should maintain strict asepsis for dressing changes, wound care, intravenous therapy, and catheter handling .Staff is instructed for a resident on EBP, PPE is employed when performing the following high-contact resident care activities .changing briefs or assisting with toileting .Device care or use .urinary catheter. R248's 5/8/24 facility assessment showed he was cognitively intact, had an indwelling urinary catheter, and required supervision or touching assistance with toileting hygiene. The assessment showed R248 required substantial/maximal assistance with lower body dressing. On 7/10/24 at 1:48 PM, V15 (Certified Nursing Assistant-CNA) entered R248's room to empty his urinary drainage leg bag. The sign on the door showed the resident was on isolation. V15 did not perform hand hygiene or put a gown on prior to emptying R248's urinary drainage bag. V15 put gloves on, emptied the urinary drainage bag into a urinal, emptied the urinal into the toilet, then removed the gloves. V15 did not perform hand hygiene. V15 touched the back of her scrub shirt, then exited R248's room. V15 went to R26's room and propelled R26 down the hall to grab the supplies for R26's smoke break from the medication room. V15 pulled a cigarette and lighter out for R26, then propelled her down to the smoking area. V15 entered the code into the door keypad, took R26 out into the smoking area, and lit R26's cigarette for her. On 7/10/24 at 1:58 PM, V2 (Director of Nursing-DON) said R248 is on enhanced barrier precautions. V2 said staff should wear a gown and gloves when emptying a urinary drainage bag. Staff should perform hand hygiene before and after providing direct care/emptying the urine drainage bag. On 7/11/24 at 1:29 PM, V2 stated it is important for staff to wear PPE (personal protective equipment) and perform hand hygiene before and after care for a resident on isolation, or on enhanced barrier precautions to prevent the spread of infection.

CONCERN (E)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a MRR (Medication Regimen Review) was being completed by a li...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a MRR (Medication Regimen Review) was being completed by a licensed pharmacist on a monthly basis. This applies to 5 of 5 residents (R8, R26, R41, R56, and R61) reviewed for MRR's in the sample of 24. The findings include: R8's admission Record (Face Sheet) shows she was admitted to the facility on [DATE], with diagnoses to include type 2 diabetes mellitus, major depressive disorder, and hypertension. R8's only MRR for 2024 was in June. R26's admission Record (Face Sheet) shows she was admitted to the facility on [DATE], with diagnoses to include anxiety, depression, atrial fibrillation, and type 2 diabetes mellitus. R26's only MRR for 2024 was in July. R41's admission Record (Face Sheet) shows he was admitted to the facility on [DATE], with diagnoses to include bipolar disorder, hypertension, COPD (Chronic Obstructive Pulmonary Disease), and type 2 diabetes mellitus. R41's only MRR for 2024 was in June. R56's admission Record (Face Sheet) shows she was admitted to the facility on [DATE], with diagnoses to include bipolar disorder, atrial fibrillation, and osteoarthritis. R26's only MRR for 2024 was in June. R61's admission Record (Face Sheet) shows he was admitted to the facility on [DATE], with diagnoses to include anxiety, major depressive disorder, and Parkinson's disease. R61's only MRR for 2024 was in June. On 07/11/24 at 1:02 PM, V1 (Administrator) stated, a lot of information went missing after our old DON (Director of Nursing) left. V1 believes that the MRR's were some of the documents that disappeared, and we don't know where they went. V1 said the facility switched pharmacies recently and they are now doing our MRR's and documenting in EMR (Electronic Medical Records). V1 stated, old DON had access to our old pharmacy's system and was supposed to be printing the MRR's out but obviously she wasn't. The undated pharmacy services policy and procedure shows, the facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biological to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. The licensed pharmacist will collaborate with facility leadership and staff to coordinate pharmaceutical services within the facility, guide development and evaluation of pharmaceutical services procedures, and help the facility identify, evaluate, and resolve pharmaceutical concerns which affect resident care, medical care, or quality of life.

CONCERN (F)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review the facility failed to store medications according to their policy and failed to ensure medication refrigerator temperatures were maintained. These ...

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Based on observation, interview, and record review the facility failed to store medications according to their policy and failed to ensure medication refrigerator temperatures were maintained. These failures have the potential to affect all residents in the facility. The findings include: The CMS 671 form dated 7/9/24 showed 91 residents reside in the facility. 1. On 7/10/24 at 12:11 PM, the 400-hall medication cart was reviewed with V9 (Registered Nurse) present. A box of liquid Norco (pain medication) and a box of liquid Lorazepam (antianxiety medication) were in the narcotic box. At 12:33 PM, the 200-hall medication cart was reviewed with V10 (LPN-Licensed Practical Nurse) present. A box of liquid Lorazepam was in the narcotic box. All three boxes were clearly labeled with stickers showing to store the medications in the refrigerator. 2. On 7/10/24 at 12:16 PM, the 200-hall medication cart was unlocked. This surveyor had full access to every drawer of medications (except the double locked narcotic box). The cart was parked directly next to a visitor/common use bathroom. Multiple people were observed passing the unlocked cart including visitors, staff, and residents. At 12:33 PM, V10 (LPN) was shown the unlocked cart. V10 stated the cart should always be locked and that she must have forgot to lock it when she walked away from it. On 7/11/24 at 11:19 AM, V2 (DON-Director of Nurses) stated medication carts should be locked at all times for safety and to prevent medications from being taken. Missing or wrong medications can adversely affect residents. There is the potential for a resident to get into a cart and take something that does not belong to them. Medication marked as needing refrigeration should be stored there. It is a safety issue and keeps it at the correct storage temperature. It helps to ensure the integrity of the medication. There is the potential to be less effective when not stored under the proper conditions. 3. On 7/10/24 at 2:34 PM, the facility's one medication room was reviewed with V16 (LPN) present. V16 was unable to locate any temperature logs for the medication room refrigerators. V16 stated she would contact V2 (DON) and determine where they are kept. On 7/11/24 at 11:51 AM, V2 (DON) and V12 (Regional Nurse Consultant) stated they were unable to locate any temperature logs for the refrigerators. V2 and V12 said there is no way of knowing if the refrigerators are storing items under the proper temperatures. Medication has the potential to be less effective if it is not stored correctly. The facility's undated Medication Storage policy states under the general guidelines section: a. All drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) . The policy states under the refrigerated products section: a. All medications requiring refrigeration are stored in refrigerators located in the pharmacy and at each medication room. B. Temperatures are maintained within 36-46 degrees Fahrenheit. Charts are kept on each refrigerator and temperature levels are recorded daily by the charge nurse or other designee.

Apr 2024 1 deficiency 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement dressing change orders for a resident admitt...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement dressing change orders for a resident admitted with an open wound. This applies to 1 of 4 residents (R501) reviewed for pressure/treatment interventions in the sample of 6. The findings include: On 5/6/2024 at 9:33AM, R501 stated she was admitted in the last two weeks and came in with a wound on her backside. On 5/6/2024 at 10:25AM, R501 stated she is unsure when the dressing change was started after she was admitted to the facility. On 5/6/2024 at 12:16PM, V7 Wound Care Nurse stated he was not told about the resident's wound upon admission. V7 stated if a wound is identified by the admitting nurse, they can call the primary physician and have orders placed for the resident until the wound doctor rounds on the patient. On 5/6/2024 at 12:47PM, V4 Registered Nurse (RN) stated she took care of R501 on 4/27/2024 and 4/28/2024. V4 stated she did not do a dressing change on R501 because there was no order to do one on the Treatment Administration Record (TAR) or Medication Administration Record (MAR). V4 stated she did not see R501's backside when she took care of her. V4 stated she did not receive any report from the night shift nurse that R501 had a wound. On 5/6/2024 at 12:53PM, V3 Wound Care Doctor stated I saw the resident for the first time on 5/3/2024. V3 stated if a resident comes in with or has an open area/wound staff should address it that same day it was identified. V3 stated she is available on days she is not rounding at the facility for a telemedicine visit and is willing to put in orders for a resident. V3 stated it the physician's job to stage the wound. R501's admission Record shows R501 was admitted to the facility on [DATE]. R501's Minimum Data Set, dated [DATE], Section C shows a BIMS (brief interview for mental status) score of 14 cognitively intact. R501's admission Progress Notes on 4/26/2024 show R501 was admitted with an open wound, location coccyx, no dimensions listed. R501's Order Summary Report active as of 5/6/2024 shows an order for buttock wound. Cleanse with normal saline, pat dry, apply santyl, alginate calcium and cover with 4x4 foam dressing daily and prn (as needed) started on 5/3/2024. R501's Order Summary Report does not show any orders for wound dressing changes prior to 5/3/2024. R501's TAR dated 5/1/2024 to 5/31/2024 shows an order buttock wound. Cleanse with normal saline, pat dry, apply santyl, alginate calcium and cover with 4x4 foam dressing daily and prn/as needed one time per day for buttock wound started on 5/3/2024. R501's TAR dated 4/1/2024 to 4/31/2024 shows no orders for dressing changes. The facility provided Wound Observation Tool dated 5/3/2024 shows a stage 4 pressure ulcer 1.5cm x 1 cm x 0.1 cm completed by V7 on 5/4/2024 lists the wound as First Observation, no reference under Overall Impression.

Jan 2024 6 deficiencies 2 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have pressure relieving devices in place and failed t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have pressure relieving devices in place and failed to perform ordered treatments for a resident with pressure injuries for one of three residents (R1) reviewed for pressure injuries in the sample of eight. This failure contributed to R1's worsening pressure injuries. The findings include: R1's Order Summary Report dated December 27, 2023, shows R1 was admitted to the facility on [DATE], with diagnoses including anxiety disorder, urinary tract infection, and restlessness and agitation. Orders for apply pressure relieving mattress on bed and pressure relieving cushion on chair every shift and float heels while in bed were entered on February 28, 2023. R1's Pressure Injury Risk dated November 3, 2023; shows she is at risk for developing pressure injuries. R1's Care Plan initiated on May 1, 2023, shows ensure that pressure relieving boots are on resident at all times while in bed. R1's Wound Evaluation and Management Summary dated November 20, 2023, shows R1 had a Stage III pressure injury on her sacrum that measured 1.2 cm long by 0.5 cm wide and 0.3 cm deep and an unstageable deep tissue injury to her right heel that measured 2.0 cm long by 4.0 cm wide. Recommendations were to off load the wounds and float heels in bed. Treatment for R1's sacrum wound was alginate calcium with silver, gauze island dressing daily and skin prep to the peri wound daily. Treatment for R1's unstageable right heel wound was betadine apply once daily for 30 days. R1's Treatment Administration Record (TAR) dated November 1, 2023-November 30, 2023, shows R1 treatment to her sacrum was not documented as being done on November 24-26, 2023, and November 28, 2023. R1's TAR shows her treatment was not documented as being done on November 25-26, 2023, and November 28-30, 2023. R1's Wound Evaluation and Management Summary dated December 20, 2023, shows R1 has a stage IV pressure injury on her sacrum that measures 4.0 cm long by 2.5 cm wide and 0.3 cm deep. Treatment recommendations include alginate calcium with silver and gauze island with border dressing once daily and as needed. Off load wound. R1 has a stage III pressure injury to her right heel that measures 1.5 cm long by 3.0 cm wide, and 0.3 cm deep. Treatment recommendations for alginate calcium with silver, gauze roll, and skin prep daily and as needed. Off load wound, float heels in bed. On December 26, 2023, at 11:18 AM, R1 was sitting in her wheelchair. There was no cushion in R1's wheelchair. R1 said her buttocks hurt. R1 said she used to have a cushion in her wheelchair. At 2:00 PM, R1 was taken to the bathroom to be toileted. V10 CNA (Certified Nursing Assistant) said R1 got up in the wheelchair before breakfast. There was no cushion in R1's wheelchair. R1's right heel did not have a gauze roll in place. On December 27, 2023, at 10:20 AM, R1 was laying in bed. R1's heels were directly on the mattress. There still was no gauze roll in place to R1's right heel. V9 CNA said she does not remember R1 having a wheelchair cushion. On December 28, 2023, at 1:02 PM, V1 Administrator said R1's wheelchair cushion needed to be clean and another one was not put in place while it was getting cleaned. The facility's Wound Treatment Management policy dated 2023 shows, Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. The facility will follow specific physician order for providing wound care, and treatments will be documented on the treatment administration record or in the electronic health record. The facility's Pressure Injury Prevention and Management policy dated February 2023 shows, This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. Evidence based interventions for prevention will be implemented for all resident who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to: Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.) and provide appropriate, pressure redistributing, support surfaces.

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure fall prevention interventions were in place and...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure fall prevention interventions were in place and failed to supervise a resident with a history of falls for one of three residents (R1) reviewed for safety/supervision in the sample of eight. This failure resulted in R1 experiencing a fall that required a local emergency room transfer and sutures to her head. The findings include: R1's Order Summary Report dated December 27, 2023, shows she was admitted to the facility on [DATE], with diagnoses including history of falling, urinary tract infection, anxiety disorder, altered mental status, diabetic polyneuropathy, mood affective disorder, encephalopathy, and restlessness and agitation. R1's Fall Risk Evaluation dated November 27, 2023, shows R1 is at risk for falls, has had three or more falls in the past three months, is chair bound, has poor vision, and requires use of assistive devices. R1's Care Plan initiated March 14, 2023 shows R1 sustained a fall on March 13, 2023 while attempting to transfer from her wheel chair to the toilet unassisted, March 30, 2023 related to sliding out of the wheelchair, June 12, 2023 while attempting to transfer from the wheel chair to bed unassisted, September 20, 2023 while attempting to toilet herself unassisted, November 26, 2023 while trying to ambulate out of bed, and November 27, 2023 while trying to ambulate unassisted. Interventions/Tasks: Is at risk for falls due to history of falls and chronic ulcers of bilateral feet with necrosis of muscle. Resident has a history of not asking staff for assistance when needed and fall interventions are: provided 1:1 education on preventing additions falls that could result in serious injury, encourage to ask for assistance when help is needed. March 31, 2023-anti slip sheet placed under resident's wheelchair cushion. R1's Progress Notes dated December 19, 2023, at 11:28 AM and entered by V3 LPN (Licensed Practical Nurse) shows, [R1] went to her room by herself, advised her do not go to her bed, wait for the CNA (Certified Nursing Assistant). One PT (Physical Therapist) called that [R1] was on the floor. Called 911 at 9:55 AM. On December 27, 2023, at 11:10 AM, V3 LPN said R1 is alert but confused. V3 said R1 always screams for help. V3 said that R1 wanted to go to bed before her fall and V3 told R1 to stay near V3 while V3 finished passing out her morning medication pass. V3 said R1 wheeled herself to her room. V3 said she let V4 and V5 (both CNAs) know that R1 wanted to go to bed, but V4 and V5 were finishing up feeding residents. V3 said that V4 and V5 were very busy and she doesn't know if V4 or V5 went into R1's room prior to the fall. V3 said V6 Physical Therapist came and told V3 that R1 was on the floor. V3 went into R1's room and saw R1 on the floor laying on her right side and R1's head was on the ground. V3 said there was a lot of blood and called 911. V3 said R1 now has sutures in her head. V3 said that R1 has transferred herself in the past. On December 27, 2023, at 2:14 PM, V6 PT said he was walking past R1's room and saw her laying on the floor and immediately went and told V3. On December 27, 2023, at 1:50 PM, V4 CNA said he was helping another resident with a mechanical lift transfer with V5 CNA prior to R1's fall. V4 said right before they were getting ready to transfer the other resident, V3 LPN came into the resident's room and said that R1 was on the floor. V4 said that R1 was laying near the foot of her bed. V4 said he remained with R1. V4 said that prior to the fall, R1 was asking for her daughter and was not oriented. V4 said that V3 mentioned to him to put R1 back to bed, but V4 said he let V3 know that he was working with another resident. V4 said that there was blood around R1's head which was on the floor. V4 and him and V5 were trying to help other residents prior to R1's fall, because other residents were waiting. On December 27, 2023, at 2:17 PM, V5 CNA said her and V4 were working on the hall together. V5 said it was busy with just the two of them. V5 said R1 fell after breakfast and after V4 and V5 finished gathering the breakfast trays. V5 said her and V4 were in another resident's room when the nurse came in and said that R1 was on the floor in her room. V5 said she followed V3 and V4 into R1's room and saw that R1 was on the floor with her right face and right shoulder on the ground. V5 said that R1 was bleeding. V5 said V3 asked her to take care of the other residents that had a call light on, so she left R1's room. R1's emergency room visit notes dated December 19, 2023, shows R1 was seen due to fall and blunt head trauma. R1's medical doctor progress note dated December 20, 2023, shows, fall yesterday trying to stand unassisted, resulting in scalp laceration and emergency room visit. She was noted to have bruising/selling/pain to right hand on return, unsure if this was evaluated in the emergency room. She has bilateral periorbital hematomas. Discontinue sutures at seven days. On December 26, 2023, at 11:18 AM, R1 was observed sitting in her wheelchair in the dining room with other residents present, but no staff were present. There was no cushion or anti slip sheet in R1's wheelchair. R1 was calling out for help. R1 said her buttocks hurt. R1's entire face was covered in a yellow/blue color. R1 had a dressing intact to the middle of her forehead. R1 was trying to push against the table but was not able to. R1 was still yelling for help at 11:32 AM. At 11:39 AM, V10 CNA gave R1 some water to drink. At 12:29 PM, R1 was eating her lunch. No staff were present at this time. The facility's Fall Prevention Program dated October 2022 shows, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Implement universal environmental interventions that decrease the risk of resident falling, implement routine rounding schedule, monitor for changes in resident's cognition, gait, ability to rise/sit, and balance. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care.

CONCERN (D) 📢 Someone Reported This

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

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide Activities of Daily Living (ADL) assistance f...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide Activities of Daily Living (ADL) assistance for residents requiring extensive assistance for two of three residents (R6, R5) reviewed for ADLs in the sample of eight. The findings include: 1. R6's admission Record shows he was admitted to the facility on [DATE], with diagnoses including lack of coordination, low back pain, non-pressure ulcer of buttock, restlessness and agitation, anxiety disorder, major depressive disorder, and repeated falls. R6's Care Plan shows R6 requires total dependence with bed mobility and toileting and had urinary incontinence and needs assistance from staff. R6's MDS (Minimum Data Set) dated September 28, 2023, shows R6 is not cognitively intact. On December 26, 2023, at 12:13 PM, V9 CNA (Certified Nursing Assistant) and V12 (Licensed Practical Nurse) performed incontinence care to R6. There was a strong urine smell. R6 had two incontinence briefs on that were saturated with dark urine from front to back. R6 was laying on a thick incontinence pad that was also wet with urine. R6's fitted sheet had a large ring of urine on it. The edges of the urine ring were darker in color and dry. R6's Task Bowel and Bladder elimination shows the last time his incontinence was documented was December 17, 2023. 2. R5's admission Record shows he was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, dementia, anxiety disorder, major depressive disorder, lack of coordination, weakness, and repeated falls. R5's Care Plan shows, provide assistance with ADLS as needed and clean peri area with each incontinence episode. R5's MDS dated [DATE], shows R5 is dependent on staff for toileting hygiene. On December 26, 2023, at 11:52 AM, R5 was attempting to get out of bed unassisted. V9 and V10 CNAs provided incontinence care to R5. R5 had two incontinence briefs on. Both briefs were completely saturated with urine. R5's sheet was also saturated with a ring of urine on it. R5's Task ADL-Toilet use shows it was last documented on December 17, 2023. On December 27, 2023, at 3:12 PM, V11 CNA said incontinence care should be perform at least every two hours or more so that residents do not get rashes. At 3:36 PM, V2 Director of Nursing said residents should only be wearing one incontinence briefs. V2 said that staff informed her they use two incontinence briefs, but V2 said there needs to be an order for that. R6 nor R5's had an order for two incontinence briefs. The facility's Activities of Daily Living policy dated February 2023 shows, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility's Incontinence Care policy dated February 2023 shows, Based on the resident's comprehensive assessment, all residents that are incontinent will received appropriate treatment and services. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible.

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 physician ordered treatments were in place to ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure physician ordered treatments were in place to non-pressure wounds for two of three residents (R3, R1) reviewed for non-pressure wounds in the sample of eight. The findings include: 1. R3's Order Summary Report dated December 27, 2023, shows R3 was admitted to the facility on [DATE], with diagnoses including idiopathic urticaria, urinary tract infection, anxiety disorder, and hemiplegia. An order for Bilateral buttock: Cleanse with normal saline, allow to air dry, apply hydrocolloid sheet to irritated area every night shift for skin integrity was entered on December 22, 2023. On December 26, 2023, at 11:07 AM, R3 buttocks was red with scratches and open areas throughout her buttocks area. R3 said her buttocks was painful. There was no dressing on R3's buttocks. R3's Resident Skin Check dated December 26, 2023, shows she has dryness, scratches, and a rash to her buttocks. R3's Treatment Administration Record dated December 1, 2023-December 31, 2023, shows her treatment to her buttocks was not signed on as done at night on December 25, 2023. On December 27, 2023, at 3:12 PM, V11 CNA (Certified Nursing Assistant) said R3 does not have a dressing on her buttocks. On December 27, 2023, at 3:36 PM, V2 Director of Nursing (DON) said a hydrocolloid sheet is a brown dressing and it is used to help protect R3's buttocks. 2. R1's Order Summary Report dated December 27, 2023, shows she was admitted to the facility on [DATE], with diagnoses including history of falling, urinary tract infection, type II diabetes mellitus with foot ulcer, non-pressure chronic ulcer of other part of left foot, and non-pressure chronic ulcer of left heel and midfoot with necrosis of muscle. Left heel: Cleanse with normal saline, allow to air dry, apply alginate calcium with silver, abdominal pad followed by kerlix daily was written on December 22, 2023. Order left lower extremity PRAFO (Pressure Relief Ankle Foot Orthosis) boot to be worn out of bed at all times except if bathing was ordered on June 5, 2023. V13's (Wound care medical doctor) note dated December 20, 2023, shows, Primary dressing-alginate calcium with silver apply once daily and as needed, secondary dressing-gauze roll 4.5 apply once daily and as needed, peri wound treatment-skin prep apply once daily and as needed. R1's Treatment Administration Record (TAR) dated December 1, 2023-December 31, 2023, shows R1's treatment to her left heel was not signed off a being done on December 25, 2023 and December 26, 2023. There is no order in R1's TAR to reflect the skin prep to the peri wound daily and as needed. On December 26, 2023, at 12:53 PM, R1 had a dressing in place to her left heel but did not have a gauze roll in place. On December 27, 2023, at 10:20 AM, R1 did not have a gauze roll in place to her left heel. There was no boot in place to R1's left lower extremity on December 26, 2023, or December 27, 2023. On December 28, 2023, at 1:02 PM, V1 Administrator said via electronic messaging said R1's PRAFO boot was in R1's room on top of her closet. The facility's Wound Treatment Management policy dated 2023 shows it is the policy of this facility to provided evidence-based treatments in accordance with current standards of practice and physician orders. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of change. The facility will follow specific physician orders for providing wound care, and treatments will be documented on the Treatment Administration Record or in the electronic health record.

CONCERN (D) 📢 Someone Reported This

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

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform incontinence care in a manner to prevent urin...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform incontinence care in a manner to prevent urinary tract infections for one of three residents (R6) reviewed for incontinence care in the sample of eight. The findings include: R6's admission Record shows he was admitted to the facility on [DATE], with diagnoses including lack of coordination, low back pain, non-pressure ulcer of buttock, restlessness and agitation, anxiety disorder, major depressive disorder, and repeated falls. R6's Care Plan shows R6 requires total dependence with bed mobility and toileting and has urinary incontinence and needs assistance from staff. R6's MDS (Minimum Data Set) dated September 28, 2023, shows R6 is not cognitively intact. On December 26, 2023, at 12:13 PM, V9 CNA (Certified Nursing Assistant) and V12 (Licensed Practical Nurse) performed incontinence care to R6. There was a strong urine smell. R6 had two incontinence briefs on that were saturated with dark urine from front to back. R6 was laying on a thick incontinence pad that was also wet with urine. R6's fitted sheet had a large ring of urine on it. The edges of the urine ring were darker in color and dry. V9 and V12 cleansed R6's right side of his buttocks but did not cleanse the left side of his buttocks nor anywhere else on his back side that was laying in the foul smelling urine. R6's Task Bowel and Bladder elimination shows the last time his incontinence was documented was December 17, 2023. On December 27, 2023, at 3:12 PM, V11 CNA said both sides of the residents buttocks should be cleansed. The facility's Incontinence care policy dated February 2023 shows, Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible.

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 and record review, the facility failed to provide a physician ordered antibiotic for one of three residents (...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a physician ordered antibiotic for one of three residents (R1) reviewed for medications in the sample of eight. The findings include: R1's Order Summary Report shows she was admitted to the facility on [DATE] with diagnoses including history of falling, urinary tract infection, non-pressure chronic ulcer of other part of right foot, non-pressure chronic ulcer of other part of left foot, non-pressure chronic ulcer of left heel and midfoot with necrosis of muscle, non-pressure chronic ulcer of other part of right foot with necrosis of bone, non-pressure chronic ulcer of other part of right foot with necrosis of muscle, and local infection of the skin and subcutaneous tissue. On December 26, 2023, at 2:18 PM, V15 (R1's Power of Attorney/granddaughter) said that the facility took R1 to a foot doctor appointment on December 12, 2023. V15 said R1's foot doctor called her on December 15, 2023, and told her that R1 needed to be on Bactrim (antibiotic) because R1 had an infection in her foot. V15 said she told the physician that R1 was in a nursing facility and provided the doctor with the facility's information. V15 said she called the facility on December 15, 2023, to verify that R1 began the antibiotic and spoke to R1's nurse who said she would put a note in R1's record. V15 said she called the facility again the following Monday-December 18, 2023, and R1 still was not on the antibiotic. V15 said she met with the facility again after R1 experienced a fall on December 19, 2023, and inquired about the antibiotic and why R1 was still not on it. December 27, 2023, at 3:36 PM V1 administrator said R1's family came into the facility on December 19, 2023, regarding some concerns that they had. V1 said that [V15] said there was supposed to be an order for Bactrim. V8 ADON (Assistant Director of Nursing) said that she will follow up with the physician's office. V1 said that typically a packet is sent along with a resident to outside doctor appointments and a CNA (certified nursing assistant) is sent along with the resident. V1 said the CNA usually comes back with notes from the doctor's appointment, but it doesn't always happen. V1 said that the nurse or medical records will follow up with outside doctors' appointments if the resident doesn't come back with orders. V1 said she did not know if anyone followed up after R1's doctor's appointment. On December 28, 2023, at 12:02 PM, V1 said a CNA went along with R1 to her appointment on December 12, 2023. V1 said that V8 followed up on December 19, 2023, with the foot doctor's office and got the order for the antibiotic and implemented the antibiotic the same day. At 1:07 PM, V1 said no new orders were sent back with R1 on the day of her foot doctor appointment and the nurse did not request the visit summary. R1's Progress Notes dated December 21, 2023 entered by V8 ADON shows, This writer spoke with nurse with [said doctor's office] and new order was given for Bactrim DS 800/160 mg twice daily for fourteen days due to specimen result collected during visit on December 12, 2023. Culture received and new order carried out per medical doctor order. R1's Medication Administration Record dated December 1, 2023-December 31, 2023, shows R1 did not receive her first dose of Bactrim antibiotic until the evening of December 21, 2023. The facility's Medication Administration Policy dated 2023 shows, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.

Oct 2023 4 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 F0697 (Tag F0697)

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 clarify a resident's pain management orders with the primary care ph...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to clarify a resident's pain management orders with the primary care physician prior to administering additional opiate pain medications and failed to discontinue a residents pain patch. These failures resulted in R2 experiencing a mental status change, lethargy, and required emergent hospitalization for suspected opiate overdose. This applies to 1 of 6 residents (R2) reviewed for pain management in the sample of 13. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 8/10/23, when V20 (Registered Nurse/RN) failed to clarify R2's Morphine (pain medication) plan of care prescription from a pain consultant with her primary care physician prior to carrying out the order. R2 received 11 doses of morphine 15 milligrams (mg.) every 6 hours from 8/11/23 until 8/14/23. This was in addition to a Fentanyl 12 mcg (microgram)/hr (hour) patch that R2 was already receiving. On 8/14/23 an order was given by (V8) Nurse Practitioner to immediately decrease the scheduled dose of R2's morphine and to remove R2's Fentanyl pain patch. The pain patch was not removed until 8/15/23. The Immediate Jeopardy was identified on 10/18/23. V1 (Administrator) was notified of the Immediate Jeopardy on 10/18/23 at 10:20 AM. This surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 10/18/23 however, noncompliance, remains at a level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R2's face sheet shows she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: low back pain, and a fracture in her spine. R2's electronic medical record (EMR) shows she was discharged from the facility to an inpatient hospice center on 9/8/23. R2's EMR shows her weight on 8/3/23 was 110 lbs. R2's nursing progress notes show she went for an appointment with an outside provider V28 (consulting physician) on 8/10/23. A plan of service report for R2 completed by V28 on 8/10/23 shows his plan was to discontinue R2's scheduled Norco (pain medication) and add on Morphine 15 mg. every 6 hrs. and Voltaren 75 mg. (anti-inflammatory medication) every 12 hours. There is no mention in V28's report of being aware R2 was also receiving a Fentanyl (opiate pain medication) patch. R2's physician order summary shows the Morphine order was entered into the system using V19 (R2's primary care physician) as the prescribing doctor (not V28 the actual prescribing physician) and the medication began on 8/11/23. R2's nursing progress notes have no documentation that V19 was contacted prior to the facility starting the Morphine on 8/11/23. R2's Medication Administration Record (MAR) shows she received the following pain medications between 8/11/23 and 8/14/23 Fentanyl pain patch change every 3 days, 7 doses of diclofenac (generic for Voltaren), 4 lidocaine patches on in am and off in pm, and 11 doses of Morphine sulfate 15 mg. R2's nursing progress note completed by V31 (Nurse Practitioner) on 8/14/23 at 4:20 PM, states. Patient seen this morning for a rehab follow-up in her room laying in bed, daughter and son in law are at bedside visiting and are concerned she is lethargic and not very interactive and asking about her pain medication regimen. They mention she saw a back doctor last week who ordered Morphine and diclofenac. She is able to answer some of my questions but doesn't stay engaged and appears very lethargic. Discontinue Fentanyl patch, decrease MSO4 (Morphine) to 1/2 tablet every 8 hours due to lethargy. R2's physician order note states, Please take off Fentanyl patch today 8/14/23, pt (patient) is lethargic on current pain regimen. An EMAR note signed by V23 (RN) on 8/14/23 at 9:13 PM, documents unavailable to remove the Fentanyl patch. R2's nursing progress note completed by V20 on 8/15/23 states, At 10:55 AM, resident noted very lethargic, confused. Seen by {V8 Nurse practitioner} at the same time. New order, send to local community hospital ER (emergency room) by 911. Resident sent to local community hospital ER at 11:07 AM via 911. A nursing progress note on 8/15/23 shows R2 was admitted to the hospital. R2's records from a local community hospital show the following: A physician History and Physical note completed on 8/15/23 shows R2 was admitted through the emergency department and was found to have Acute Encephalopathy- suspected incidental opioid overdose. The notes says that R2 was receiving large amounts of opiates at the skilled nursing facility and had both oral Morphine and Fentanyl patches applied. A hospital consultation notes for R2 completed on 8/16/23 states R2 had Opioid overdose because of cognition Morphine and Fentanyl. She became agitated over the past 24 hours, for which she received Ativan. R2's hospital records show her pain medications were adjusted and she returned to the facility on 8/18/23. A Medication Error Reported completed on 8/15/23 by V2 (Director of Nursing) shows that R2's Fentanyl patch was not removed until 8/15/23 and was supposed to be removed on 8/14/23. On 10/16/23 at 11:36 AM, V2 said (R2) was seen by an outside provider and was on multiple pain medications prescribed by two different providers. She started experiencing altered mental status and went to the hospital. She was alerted by (V8) Nurse Practitioner who discovered the Fentanyl patch that was supposed to be removed on 8/14/23 was not removed. When she asked the nurse (V23) why the patch was still on she told her she didn't see the patch. On 10/17/23 at 12:13 PM, V2 said the nursing staff should have consulted with the R2's Primary Care Physician (V19) before starting the Morphine that was prescribed by V28. She said V8 was furious when she found out about the Morphine being started without consulting their office and (V19) first. V2 said she feels the Morphine was the cause for R2's altered mental status. On 10/16/23 at 3:08 PM, V8 (Nurse Practitioner) said R2 was experiencing a lot of back pain from a fracture but she was not aware of R2 being prescribed the high doses of Morphine until V31 (Nurse Practitioner) called her and told her about it. She said no one contacted their office from the facility about the Morphine and they should have before they started it. V8 said they would not prescribe that high of a dose of Morphine on top of a Fentanyl patch because of the risk of overdose and death could occur from Opiate overdose. V8 said when she saw R2 on 8/15/23 she was very lethargic, and she suspected a Opiate overdose as the cause and she also discovered the Fentanyl patch was still on her. She had the facility call 911 and sent her to the Emergency Room. On 10/17/23 at 9:35 AM, V19 R2's (Primary Care Physician) said he was not contacted by the facility about the Morphine orders. He said the facility should have called me prior to starting the medication because she was already on a Fentanyl pain patch, and I am not sure if the consulting physician (V28) knew that. V19 said he wasn't aware that the facility used his name as the prescribing physician for the Morphine, but he did not, and would have not ordered that pain medication because it is a risky medication. V19 said R2's lethargy was likely the result of the high dose of the pain medication Morphine and Fentanyl combined. On 10/17/23 at 9:25 AM, V20 (RN) said she carried out the Morphine order that V28 had prescribed without consulting V19. She said they facility nurses don't call to consult orders they just carry them out because they are from a physician. V20 said when R2 returned from the appointment she entered the Morphine orders in the computer using V19's name because she could not select V28 as he is not in their system since he is outside physician. She said after the initiation of the Morphine R2 did begin to have lethargy and they called to report it to the Nurse Practitioner. When this surveyor asked V20 if she was aware the facility policy states any outside provider orders should be clarified with the residents Primary Care Physician, she indicated she was not. On 10/17/23 at 11:10 AM, V22 (Licensed Practical Nurse/LPN) said it is the policy of the facility to clarify medication orders and a Morphine order should not just be started without clarifying it with the Primary Care Physician first. On 10/17/23 at 2:08 PM, V23 (RN) said she went to remove R2's pain patch after the Nurse Practitioner told her it needed to be stopped but she looked all over R2 and did not see it. V23 also said the nurses should always reconcile medication orders from an outside provider and not just start the medications. A pain policy was requested from the facility, and they provided the F697 citation text from the State Operations Manual/ SOM which states, The facility must ensure that pain management is provided to the residents who require such services, consistent with professional standards of practice . The facility provided policy titled Consulting Physician/Practitioner Orders says the facility should call the attending physician in a timely manner to verify consulting physician/practitioner orders. The Immediate Jeopardy that began on 8/10/23 was removed on 10/18/23 when the facility took the following actions to remove the immediacy: 1. All staff nurses were re-educated on the process of clarifying medication orders with the primary care physician. The process for dating, securing and removal of pain patches was also re-educated to all nursing staff and completed on 10/18/23. 2. All agency and float pool nurses will be educated about clarifying medication orders and pain patch removal and identification prior to the start of the shift. 3. The facility Medical Director and Director of Nursing have compiled a list and audited all charts of residents with current opioid pain medications to ensure doses are within appropriate levels. Completed on 10/18/23. 4. An emergency QA meeting was held on 10/18/23 and included the Medical Director. 5. Facility policies and procedures for pain management and opioid medication orders were reviewed. 6. The Director of Nursing will conduct audits weekly for 4 weeks, then monthly for 3 months to ensure compliance with opiate medications. These audits will also ensure that the Primary Care Physician was consulted prior to administration of medications from outside providers.

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

Based on interview and record review the facility failed to ensure residents were free from physical and verbal abuse. This failure resulted in R3 and R5 suffering mental anguish and psychosocial harm...

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Based on interview and record review the facility failed to ensure residents were free from physical and verbal abuse. This failure resulted in R3 and R5 suffering mental anguish and psychosocial harm. This applies to 2 of 8 residents (R3, R5) reviewed for abuse in the sample of 13. The findings include: R3's face sheet shows she has diagnoses including anxiety disorder, heart failure, and lack of coordination. R3's cognition care plan initiated on 9/12/23 shows she is cognitively intact, has no apparent memory loss and is oriented. R3's care plan also shows she is able to recall and retain information such as events, directions, time and place of situations. R3's activity of daily living/ADL care plan initiated on 6/12/23 shows she has impaired balance and weakness and requires staff assistance with ADL's. On 10/16/23 at 9:40 AM, R3 said I have been in bed for a couple weeks following an incident where a CNA (Certified Nursing Assistant) who works for an agency was very rough with me. The CNA was very angry and mean spirited and when she was taking me to the bathroom, she ran my knee into the side of the door frame to the bathroom. After the CNA toileted me she then threw me into bed and I was crying out in pain. R3 said her roommate (R5) witnessed the whole incident and yelled at the CNA to Stop hurting {R3} and at that point the CNA then yelled out to shut up and mind your own damn business. She said she contacted her son the following morning and reported the incident, and she was so scared and fearful because of how angry the CNA's demeanor was. She also stated, I have also lost quality of life being in bed since this incident because my knee has been hurting. On 10/17/23 at 10:55 AM, this surveyor verified the date with R3, and she said there was only one incident with this CNA but she could not believe it had been a month ago already. On 10/16/23 at 9:52 AM, R5 said she witnessed the CNA ram (R3) into the door frame by the bathroom. She said R3 cried out in pain and then the CNA also threw R3 into bed and again she cried out in pain. R5 said she yelled at the CNA to stop hurting (R3) and at that point the CNA yelled at me to shut the hell up or we will see what will happen to you. R5 said she cannot recall exactly what date this happened. She said she was so scared she literally laid in bed and prayed that someone would come and help them. R5's 9/27/23 facility assessment shows her cognition is intact. A facility reported State of Illinois Serious Injury Incident and Communicable Disease Report form shows on 9/17/23 R3's son (V11) reported an incident that occurred on 9/16/23 where R3 received poor care from a CNA who was determined to be V25 (Agency CNA). The investigation file provided by V1 (Administrator) shows when R5 was interviewed she confirmed that she saw R3 being slammed against the door by V25. It also shows that she was told to shut the hell up. R3's interview by V1 shows she said she was thrown in bed by the CNA, and she was mean and rude. R3 said she was run into the side of the door by the CNA. The investigation refers to R3 as being very scared and wanted her son to come sit with her. On 10/16/23 at 10:25 AM, V17 (R3's physician) said he was not aware of the abuse incident involving R3, but the facility may have notified her Nurse Practitioner about it. He said R3 did report pain in her left knee, and it has been swollen. On 10/16/23 at 12:50 PM, V11 (R3's son) said his mom called him very upset about an incident where a CNA was rough with her. He said he came into the facility that day and spoke with his mom and R5. R5 had the same story about R3 being thrown into bed by the CNA and being told to shut up and mind her own damn business. V11 said he immediately told the nurse about the incident. V11 said R3 did ask him to come because she was fearful. On 10/16/23 at 11:30 AM, V1 (Administrator) said she investigated the abuse incident involving R3 and substantiated verbal abuse but not physical because. No injury or bruises were found on R3. She said the CNA (V25) was from an agency and was put on the do not return list. V1 did say that R3 and R5 both told her that R3 was bumped into the doorway and thrown into bed by V25. On 10/16/23 at 2:15 PM, V10 (Hospice Nurse) said R3 did tell her a CNA was rough with her during cares that during the transfer her leg was bumped. On 10/17/23 at 9:42 PM, V21 (Licensed Practical Nurse/LPN) said he was the one who got the report of R3's abuse incident. He said R3 confirmed that the CNA was rude, but he thought she told him her arm was bumped during the transfer. He said he checked her and did not note any injuries. On 10/17/23 at 10:06 AM, V18 (Nurse Practitioner/NP) said she was informed that R3 was being taken to the washroom and a CNA banged her left knee. She said R3 did report the CNA was rough with her. On 10/18/23 at 11:45 AM, V18 (NP) said I have serious concerns about this incident and the CNA. What if she did this to patients who were non-verbal. Progress notes in R3's electronic medical record show the following: 9/17/23 completed by V21 (LPN) at 3:53 PM, Got a call from patient son, (V11) complaining of (R3) being treated roughly by V25. 9/24/23 2:17 PM nursing note- resident (R3) complained of left knee pain. 9/27/23 2:33 PM, physician note completed by V18, says R3 complained of left knee pain from an injury sustained during a transfer. R3's progress notes document the pain to her left knee and referring it to an injury during a transfer continuing on the following dates: 10/2/23, 10/11/23, 10/16/23 and again on 10/17/23. The facility provided Abuse, Neglect and Exploitation policy revised 2/23 says all residents have the right to be free from abuse. The policy describes abuse as the infliction of injury, unreasonable confinement, intimidation and punishment with physical harm, pain or mental anguish.

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to ensure fall interventions were implemented for a resident (R4) with history of falls for 1 of 7 residents (R4) reviewed for fa...

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Based on observation, interview, and record review the facility failed to ensure fall interventions were implemented for a resident (R4) with history of falls for 1 of 7 residents (R4) reviewed for falls in the sample of 13. The findings include: On 10/16/23 at 9:27 AM, R4 was in bed sleeping. R4's call light was clipped to the quarter side rail with the touch pad at the end of the cord tucked down between the mattress and the rail. R4's wheelchair was at the foot of the bed. R4's bedside table with food and personal items was approximately 3 feet away from R4's bed (not within reach). On 10/16/23 at 9:30 AM, V4 Registered Nurse said R4 is a fall risk and has had several falls from trying to get up by herself. On 10/16/23 at 10:28 AM, V5 Certified Nursing Assistant said R4 is a fall risk and has sight impairment and at times some confusion. V5 said R4 should have a clip alarm on her wheelchair but was not sure about fall interventions when in bed. On 10/16/23 at 10:38 AM, V2 Director of Nursing (DON) said when a resident falls and investigation is done to determine root cause. V2 said a fall risk assessment is done as part of the investigation and new interventions are determined. V2 said fall interventions should be updated with each fall and the resident's Care Plan is updated. V2 said the previous DON investigated R4's falls and should have put interventions in place. On 10/16/23 at 11:35 AM, V1 Administrator said she recalls that R4 was a fall risk and R4's falls were discussed in the morning meetings, but she could not recall what fall interventions were put in place. R4's most recent Care Plan shows R4 had a fall on 3/29/23 while attempting to move furniture in her room. Another fall on 5/1/23 while ambulating unassisted to open the door to let someone in. R4 is at risk for falls due to impaired vision (legally blind), unsteady gait, and generalized muscle weakness. Fall interventions are staff rearranged furniture to accommodate resident's preference. Keep call light within reach at all times. Requires for call for assistance when needed. (Date initiated 3/29/23). No other interventions were added after 5/1/23 fall. The same Care Plan shows Risk for falls. If resident is a fall risk, initiate fall risk precautions. Resident had a fall occurrence on 6/23/23. No interventions were added after 6/23/23 or 8/29/23 falls. R4's Progress Notes on 8/29/23 shows R4 had a fall at 12:00 AM from her wheelchair while in the dining room and then another falls later that same day in her room. The facility's Fall Prevention Program Policy dated 2022 shows each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. High risk Protocols: The resident will be placed on the facility's Fall Prevention Program-Implement interventions. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care: interventions will be monitored for effectiveness and the plan of care will be revised as needed.

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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected most or all residents

Based on interview and record review the facility failed to follow its abuse policy to ensure staff received abuse training. This failure has the potential to affect all 77 residing in the facility. T...

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Based on interview and record review the facility failed to follow its abuse policy to ensure staff received abuse training. This failure has the potential to affect all 77 residing in the facility. The findings include: The facility provided roster on 10/16/23 shows there were 77 residing in the facility. A facility reported State of Illinois Serious Injury Incident and Communicable Disease Report form shows on 9/17/23 R3's son (V11) reported an incident that occurred on 9/16/23 where R3 received poor care from a CNA who was determined to be V25 (Agency CNA). On 10/16/23 at 11:30 AM, V1 (Administrator) said she investigated the abuse incident involving R3 and substantiated verbal abuse. She said the CNA (V25) was from an agency. On 10/18/23 at 8:50 AM, V1 said the facility does not provide abuse training to agency staff. They only provide a basic orientation to the building. V1 said the facility has a corporate contract with an agency and assumes they provide training. On 10/18/23 at 12:40 PM, V26 (Quality Associate from agency) said their agency consists of independent contractors and they are not directly employed through the agency, so a facility has to provide training or request any staff who work in their buildings to show proof that they were trained in abuse prior to working. A Terms of Use and Master Service Agreement between the agency and the facility signed on 1/25/23 states the following Client shall provide any required orientations such as review of policies and procedures regarding medication administration, documentation procedures, patient rights, Infection Prevention, Fire and Safety, OSHA and EMR/charting where applicable. The policy refers to the facility as the client. The facility provided Abuse, Neglect and Exploitation policy revised 2/23 says all new employees will be educated on abuse, neglect, exploitation, and misappropriation of resident property during initial orientation.

Aug 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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to ensure R1 received physician ordered interventions to reduce pressure ulcer development. This applies to one of three resident...

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Based on observation, interview, and record review the facility failed to ensure R1 received physician ordered interventions to reduce pressure ulcer development. This applies to one of three residents (R1) reviewed for improper nursing care in the sample of three. The findings include: On 08/14/23 at 10:12AM, R1 was lying in bed. R1 did not have an air pressure reduction mattress. R1's right and left heels were resting on the bed. R1's heel protectors were on the floor next to R1's bed. On 08/14/23 at 10:12AM, R1 said, I am supposed to wear my heel boots in bed. The staff forget to put them on. On 08/14/23 at 10:27AM, V6 CNA-Certified Nursing Assistant said, R1 should have her heel protectors on when in bed. R1 is not on an air mattress. R1's Physicians Orders on 08/14/23 shows, ensure heel protectors are on resident's bilateral feet at all times while in bed, order start date 07/09/23. Order air mattress for skin integrity impairment prophylaxis, order start date 07/19/23. The facility's Pressure Injury Prevention Guidelines dated 11/01/22 shows, interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to ensure R2 received her meal in a form that met her needs, for one of three residents reviewed for special diets in the sample ...

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Based on observation, interview, and record review the facility failed to ensure R2 received her meal in a form that met her needs, for one of three residents reviewed for special diets in the sample of three. The findings include: R2's Medical Record on 08/14/23 shows, multiple diagnoses including malnutrition. On 08/14/23 at 12:00PM, R2 had a slice of ham on her plate. R2 stabbed the ham with a fork and placed it in her mouth. After R2 chewed on the ham slice she spit the chewed-up ham out of her mouth and onto her plate. R2 repeated this process with each bite of ham. On 08/14/23 at 12:01PM, V3 [NAME] said, if the diet order shows mechanical soft the meat should be ground. The Certified Nursing Assistance passes the meal trays to the residents. R2's Physicians Order on 08/14/23 shows, NAS (No Added Salt) diet, Mechanical Soft texture, Regular consistency, order start date 01/31/23. The facility's undated Therapeutic Diet Orders policy shows, therapeutic diets, including mechanically altered diets where Appropriate, will be based on the resident's individual needs as determined by the Resident's Assessment. Therapeutic diets may be considered in certain situations, such as but not limited to inadequate nutrition, nutritional deficits, weight loss, medical conditions, swallowing difficulty.

Aug 2023 4 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

Based on interview and record review the facility failed to resolve a family's concern/grievance, involving a facility resident, in a timely manner for 1 of 3 residents (R1) reviewed for grievances in...

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Based on interview and record review the facility failed to resolve a family's concern/grievance, involving a facility resident, in a timely manner for 1 of 3 residents (R1) reviewed for grievances in the sample of 4. The findings include: R1's current care plan showed R1 was cognitively impaired related to her diagnosis of dementia. R1's care conference note dated June 6, 2023, showed a care plan meeting was held with facility staff and R1's power of attorney/family member (V12) in attendance. The note showed, Family concerns: 1. wants (R1) to continue physical therapy. 3. Continue to encourage participation in activities and moving around. On August 7, 2023, at 1:00 PM, V12 (Family of R1) stated, We had a care plan meeting in June (2023) for (R1). One of my concerns that I voiced was that (R1) was not being walked or being exercised. I want her up and moving around as much as she can. I am concerned she is getting weaker. We (R1's children) visit (R1) daily. We never see her up walking or out of her wheelchair. I asked for her to be re-evaluated by therapy, to see if she qualified for physical therapy again, because she used to get it. They said in the meeting that they would get back to me once she was evaluated by physical therapy. I have heard nothing back from anyone. No one has gotten back to me about any of my therapy concerns from the June meeting. I have no idea if she was evaluated by physical therapy, if she is getting physical therapy, or if she is getting any exercise at all. On August 7, 2023, at 12:30 PM, V10 Director of Life Enrichment stated, I attended (R1's) care plan meeting in June. Her family was concerned that she was not being walked. I did not follow up on that concern. I am not sure who did. On August 7, 2023, at 12:35 PM, V1 Administrator stated, I am currently in charge of handling grievances. In May (2023), (V12 Family of R1) sent me an email stating he was concerned that (R1) was not being walked. (V12 Family of R1) wanted (R1) re-evaluated by physical therapy. I did not fill out a grievance form on this. I probably should have. I did not attend (R1's) June care plan meeting but I know (V12) brought up his concern, that (R1) was not being exercised or walked. Someone in the meeting was going to talk to (V11 Director of Rehab/DOR) about the concern. I am not sure if anyone did. Normally, if a family member requests that a resident has therapy services, (V11 DOR) will evaluate that resident, usually within a week of the request. (V11 DOR) will then decide if they resident is a candidate for skilled therapy services or restorative therapy services. (V11 DOR) will notify nursing of his decision. Nursing will then get a physician order for skilled therapy or restorative therapy. This whole process can be done pretty quickly . Grievances are to resolved as soon as possible. I did not follow up with (V12) about this concern. The expectation is that someone that attended (R1's) care plan meeting or (V11 DOR) followed up with (V12 Family of R1). On August 7, 2023, at 12:45 PM, V11 Director of Rehab stated, Someone came to me after (R1's) June care plan meeting to tell me that (R1's) family wanted (R1) to have more physical therapy. She had just completed skilled therapy services and treatment in May (2023). She was not a candidate for more physical therapy but she was a candidate for restorative therapy services. (R1) should have been getting restorative therapy in June and July 2023. I never called or followed up with (V12 Family of R1). The facility's Resident and Family Grievances policy (undated) showed the facility will take prompt efforts to resolve grievances include facility acknowledgement of a complaint/grievance and actively work toward resolution of that complaint/grievance. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished. The Grievance Official (V1 Administrator) will take steps to resolve the grievance, and record information about the grievance, and those actions. All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance.

CONCERN (D) 📢 Someone Reported This

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

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide showering/bathing assistance to residents who n...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide showering/bathing assistance to residents who need extensive assistance with activities of daily living (ADLs) for 2 of 4 residents (R1, R2) reviewed for activities of daily living in the sample of 4. The findings include: 1. R2's resident assessment dated [DATE], showed R2 required the extensive assistance of one staff for bathing/showering. On August 7, 2023, at 9:23 AM, R2 was seated in her room. R2's hair was not combed. R2's hair appeared greasy. R2 stated, I haven't had a shower in a long time. I don't know when the last time I had one. They don't have enough staff so I can't get them. I can't shower by myself. R2's shower records dated June 1, 2023-August 7, 2023, were reviewed. The records showed R2 received 2 showers in June (6/14/23, 6/26/23). The records showed R2's last shower was July 24, 2023. The records showed R2 had not received any showers August 1-6, 2023. 2. R1's resident assessment dated [DATE], showed R1 required the extensive assistance of one staff for bathing/showering. R1's shower records dated July 1, 2023-August 7, 2023, were reviewed. The records showed R1 was offered a shower on July 22, 2023, but she refused. The records showed R1 was not offered a shower again, until August 2, 2023. R1 received a shower on August 2, 2023. On August 7, 2023, at 10:25 AM, V1 Administrator stated, Residents are to have two showers per week. Staff can either document the showers in the computer or on a shower sheet. On August 7, 2023, V4 and V7 Certified Nursing Assistants each stated that resident showers are not always provided twice a week due to a lack of staff. The facility's Resident Council Meeting Minutes dated May 2023-July 2023 were reviewed. The facility's June 2023 minutes showed a concern related to residents not getting their showers.

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 F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide restorative therapy services, including walking...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide restorative therapy services, including walking and range of motion (ROM) exercises, to residents with limited range of motion for 2 of 2 residents (R1, R3) reviewed for restorative/ROM services in the sample of 4. The findings include: 1. R1's Physical Therapy Discharge summary dated [DATE], showed R1 had been discharged from physical therapy. R1's Restorative Observations form dated May 30, 2023, showed R1 had limited ROM to her bilateral arms, hands, legs, and feet. On August 7, 2023, at 1:00 PM, V12 (Family of R1) stated, We had a care plan meeting in June (2023) for (R1). One of my concerns that I voiced was that (R1) was not being walked or being exercised. I want her up and moving around as much as she can. I am concerned she is getting weaker. We (R1's children) visit (R1) daily. We never see her up walking or out of her wheelchair. I asked for her to be re-evaluated by therapy, to see if she qualified for physical therapy again, because she used to get it. They said in the meeting that they would get back to me once she was evaluated by physical therapy. I have heard nothing back from anyone. No one has gotten back to me about any of my therapy concerns from the June meeting. I have no idea if she was evaluated by physical therapy, if she is getting physical therapy, or if she is getting any exercise at all. On August 7, 2023, at 12:45 PM, V11 Director of Rehab (DOR) stated, Someone came to me after (R1's) June care plan meeting to tell me that (R1's) family wanted (R1) to have more physical therapy. She had just completed skilled therapy services and treatment in May (2023). (R1) was re-evaluated in June (2023), per the family's request. She didn't have a physical decline. She was not a candidate for more physical therapy but she was a candidate for restorative therapy services. (R1) should have been getting restorative therapy in June and July (2023) but we don't currently have a restorative program. R1's Physical Therapy Screening Form dated June 8, 2023, showed R1 was evaluated for physical therapy but it was not recommended. R1's Therapy Communication to Restorative Nursing Form dated July 19, 2023 showed R1 was to walk 3-5 times a week with staff. R1 was to complete ROM exercises to her lower body. R1's ROM exercise record dated August 7, 2023, showed R1 had not received/completed any ROM exercises in the last 30 days. R1's Ambulation-Walking record dated August 7, 2023, showed R1 had not been walked by staff in the last 30 days. 2. R3's admission Record dated November 1, 2022, showed R1 was admitted to the facility with a diagnosis of hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting left non-dominant side. R3's current care plan showed R3 had limited ROM to her left arm and left leg related to her stroke. R3's care plan showed no goals or exercises to treat her limited ROM. On August 7, 2023, at 9:48 AM, R3 was seated in her wheelchair in the activity room. R3 stated, I want to walk. I want to get stronger. They were walking me for awhile but that has stopped. We don't have enough staff so I don't get walked. I can't walk on my own. R3's Physical Therapy (PT) Discharge summary dated [DATE]-May 15, 2023, showed R3 was discharged from skilled therapy services with no recommendations for restorative programming. R3's Occupational Therapy (OT) Discharge summary dated [DATE]-July 31, 2023, showed R3 was to receive restorative services which included walking in the hallway, five times a week, upon discharge from skilled therapy services. On August 7, 2023, at 10:57 AM, V11 Director of Rehab (DOR) stated, (R3) used to be on a walking program when we had a restorative program. We don't currently have a restorative program so she is not being walked. She has had skilled therapy services on and off. R3's Physical Therapy (PT) Discharge summary dated [DATE], was reviewed with V11. V11 stated, She should have been on a restorative walking program since her discharge from PT in May (2023). The reason we did not make any restorative recommendations for (R3), upon her discharge from PT, was because we had no restorative program. We just stopped making them (restorative recommendations), upon discharge from skilled therapy, because there was no one to follow up on them. We did pick her back up for OT in July (2023) because she had a decline in physical mobility. We walked her during her OT sessions. She was discharged from OT with restorative instructions for a walking program. R3's medical records dated May 16, 2023-August 7, 2023, were reviewed. These records showed no documentation of R3 receiving restorative services at any time. On August 7, 2023, at 10:30 AM, V8 Staffing Coordinator stated, We don't have restorative aides anymore. They now work on the floor as CNAs (Certified Nursing Assistants). On August 7, 2023, at 11:21 AM, V1 Administrator stated, We are working on getting our restorative program up and running again. (V3 Assistant Director of Nursing) will be running the program but she was just hired 3 weeks ago . Restorative exercise programs and goals should be documented in a resident's care plan .Our CNAs should be doing restorative exercises with residents. On August 7, 2023, V4 and V7 CNA's each stated they are unable to complete ROM/restorative programming on residents due to a lack of staff. The facility's Restorative Nursing Program policy (undated) showed, It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practical level. Restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. Residents may receive restorative nursing services upon admission when not a candidate for specialized rehabilitation services, when restorative needs arise during the course of a longer-term stay, in conjunction with specialized rehabilitation therapy, or upon discharge from therapy.

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 F0725 (Tag F0725)

Could have caused harm · This affected most or all residents

Based on observation, interview and record review the facility failed to provide sufficient nursing staff to meet the needs of the residents. This failure has the potential to affect all 77 residents ...

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Based on observation, interview and record review the facility failed to provide sufficient nursing staff to meet the needs of the residents. This failure has the potential to affect all 77 residents in the facility. The findings include: The Facility Data Sheet dated August 7, 2023, showed a resident census of 77. On August 7, 2023, at 9:23 AM, R2 was seated in her room. R2's hair was not combed. R2's hair appeared greasy. R2 stated, I haven't had a shower in a long time. I don't know when the last time I had one. They don't have enough staff so I can't get them. I can't shower by myself. R2's shower records dated June 1, 2023-August 7, 2023, were reviewed. The records showed R2 received 2 showers in June (6/14/23, 6/26/23). The records showed R2's last shower was July 24, 2023. The records showed R2 had not received any showers August 1-6, 2023. On August 7, 2023, at 1:00 PM, V12 Family of R1 stated he was concerned R1 was not getting showered or walked due to a lack of staff. V12 stated, They have been short-staffed for awhile. We have even heard the staff complaining about being short-staffed. R1's shower records dated July 1, 2023-August 7, 2023, were reviewed. The records showed R1 was offered a shower on July 22, 2023, but she refused. The records showed R1 was not offered a shower again, until August 2, 2023. R1 received a shower on August 2, 2023. On August 7, 2023, at 9:48 AM, R3 was seated in her wheelchair in the activity room. R3 stated, I want to walk. I want to get stronger. They were walking me for awhile but that has stopped. We don't have enough staff so I don't get walked. I can't walk on my own. On August 7, 2023, at 8:30 AM, two (V4 and V7) certified nursing assistants (CNA) were providing care to residents on the the 300 wing of the facility. V4 CNA stated, We are supposed to have 3 CNAs on the 300 wing during the day but we had a call off. This happens a lot. We don't have enough staff. We are getting burnt out. This is a heavy floor. We have residents that need lifts to get up or two of us to provide care. I came in at 5:00 AM today. I am not supposed to start until 6:00 AM. I came in at 5:00 AM to try to get my work done. There are days that residents don't get showers or walked because we just can't get to them. On August 7, 2023, at 9:35 AM, V7 CNA stated, We don't have enough staff. We are supposed to have 3 CNAs on the 300 wing today. Someone is always calling in. We can't get everything done. There are days people don't get showers. This is a heavy floor. We have resident's that need lifts to get up. It's too much for us. We need help . On August 7, 2023, at 8:45 AM, V5 Registered Nurse was passing medications to residents on the 400 wing. V5 stated, I only have 2 CNAs with me today. I am supposed to have 3. We had another call-off. Being short-staffed is typical anymore. On August 7, 2023, at 10:30 AM, V8 Staffing Coordinator stated, The goal for staffing is to make sure the needs of the residents is met. We had some call-offs today. The 300 and 400 wings are short today. They are supposed to have 3 CNAs, on each unit, on the day shift and evening shift. The facility's nursing schedules dated July 24, 2023-August 7, 2023, were reviewed with V8. The schedules showed the facility was short-staffed, related to CNA ill calls, on 9 out of 14 days. The facility's Staffing policy dated October 2017, showed, Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care.

Jun 2023 8 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Deficiency F0697 (Tag F0697)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure pain medication was administered to a resident experiencing p...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure pain medication was administered to a resident experiencing pain after a fall. This failure resulted in (R45) experiencing uncontrolled pain for 4 hours. This applies to 1 of 18 residents (R45) reviewed for pain in the sample of 18. The findings include: R45's face sheet shows she is a [AGE] year old female admitted to the facility on [DATE] with diagnoses including: Parkinson's disease, lack of coordination, and hypertension. R45's 3/28/23 facility assessment shows her cognition is mildly impaired. A post fall evaluation documented by V16 (Licensed Practical Nurse/LPN) on 6/10/23 at 1:57 PM, shows R45 had a fall in her room earlier that day at 7:30 AM. After the fall R45's left hip pain was documented to be a 8/10 on a 1/10 pain scale. The note states R45's pain is constant. R45's nursing progress note completed on 6/10/23 at 2:42 PM, by V16 states, till 12 noon X-ray has not arrived and resident still c/o pain to left hip. NP (Nurse Practitioner- V10) notified with orders to send to the ER. resident left facility with ambulance at 12:30 PM. R45's nursing progress notes show a Health Status Note documented on 6/10/23 at 3:55 PM, that states resident {R45} has a comminuted angulated mildly displaced intratrochanteric fracture of the left hip. Resident will be admitted to {local hospital} for further evaluation and treatment. R45's 6/10/23 and 6/11/23 hospital records show that an X-ray was completed for R45 on 6/10/23 and R45 was found to have a comminuted mildly displaced intratrochanteric fracture of the left hip. The same hospital records show R45 underwent surgical intervention for her hip fracture on 6/11/23. On 6/14/23 at 10:21 AM, V14 (Certified Nursing Assistant/CNA) said she was the CNA assigned to R45 on 6/10/23 the day she fell. V14 said after R45 had fallen (approx. 7:30 AM) she continued to complain of pain to her left hip and V14 told the nurse on duty. On 6/14/23 at 10:43 AM, V15 (CNA) said she was helping care for R45 on 6/10/23 the day she had the fall. V15 said R45 kept asking for pain medication because she was in a lot of pain after the fall that morning. V15 said pain medication was not administered right away and she knows this because R45 kept asking for pain medication after the fall. On 6/14/23 at 11:05 AM, V12 (Registered Nurse/RN) said she was going off duty on 6/10/23 when R45 had her fall. V12 said after R45's fall she was complaining of pain to her left hip. V12 said she did not personally administer pain medication to R45 and cannot speak for when R45 received pain medication. On 6/14/23 at 11:50 AM, V2 (Director of Nursing/DON) said she is still investigating R45's fall from 6/10/23. V2 said she had spoken with V16 (LPN) because there was no documentation that R45 had received any pain medication and V16 informed her that she did give R45 pain medication (Tylenol) at 11:30 AM. V2 was asked if R45 should have received the pain medication sooner after her fall and V2 responded it would have been appropriate to do that. On 6/14/23 at 11:13 AM, V10 (Nurse Practitioner/NP) said that R45 had an order for Tylenol 650 milligrams (mg.) for pain and she should have been given that. V10 said when she was called the second time (later that morning before noon) about R45's X-ray not being able to be done at the facility timely and that R45 was experiencing increased pain to her left hip, she decided to send her to the emergency room. At 12:15 PM, V10 said she was not aware that R45 was not given pain medication (Tylenol) until 11:30 AM and she could have gotten it sooner. On 6/14/23 at 12:02 PM, V11 (R45's daughter) said she was contacted by her mom (R45) at about 7:45 AM on 6/10/23 about having a fall. V11 said R45 was complaining about having hip pain at that time. On 6/14/23 at 1:00 PM, V16 (LPN) said she was the nurse assigned to R45 on 6/10/23 the day she had fallen. V16 said she recalls R45's fall to be around 7:15 AM. V16 said R45 was complaining of hip pain being an 8/10 after the fall and the CNA's also were reporting to her that R45 was continuing to have pain so she gave her Tylenol 650 mg. for the pain at 11:30 AM. (4 hours after R45's fall). V16 was asked by the surveyor if she called a physician for any additional pain medication orders and she said she did not. V16 was asked if there was any reason that R45 was not given the Tylenol for her pain sooner to which V16 replied, Uh No. A Medication Administration note completed by V16 on 6/12/23 at 3:34 PM, was documented as a late entry for 6/10/23 at 11:30 AM. That note shows R45 was given Tylenol 650 milligrams at 11:30 AM. R45's Medication Administration summary does not show any pain medication was given to R45 after her fall on 6/10/23. The facility provided Pain Management policy dated 2022 states, The facility will utilize a systemic approach for recognition, assessment, treatment and monitoring of pain. 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. b. Evaluate the resident for pain and causes upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs (e.g. after a fall.)

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 provide nail care and shaving assistance to residents w...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide nail care and shaving assistance to residents who need extensive assistance with activities of daily living (ADLs) for 3 of 18 residents (R17, R25 and R67) reviewed for ADLs in the sample of 18. The findings include: 1. R17's Minimum Data Set assessment dated [DATE] shows that her cognition is impaired and she requires extensive assistance with personal hygiene. On 06/12/23 at 9:41 AM, R17's fingernails on her left thumb and right fourth digit were 1/4 inch long and had brown debris under them. R17's fingernails on her first and second digit of her right hand had brown debris under them. R17 had scratch marks from itching on her bilateral thighs. R17 stated, Yes-those are pretty long and dirty. 2. R67's Minimum Data Set assessment dated [DATE] shows that she is totally dependant on staff for personal hygiene. On 6/12/23 at 9:59 AM and 6/13/23 at 8:54 AM, R67's fingernails were long and painted. The underside of R67's fingernails had brown debris under them. R67 stated, I think they need to be trimmed, they are pretty long. R67's Self-Care Deficit Care Plan shows,Provide assistance with ADLs/IADLs as needed. 3. R25's Minimum Data Set assessment dated [DATE] shows that he needs extensive assistance with personal hygiene. On 6/12/23 at 11:14 AM, R25 had over 1/4 inch of facial hair outgrowth. R25 said that he does need to be shaved. R25 said that the staff keep telling him that they are going to shave him but no one has done it. On 6/13/23 at 9:30 AM, R25 still had an outgrowth of facial hair present. On 6/13/23 at 11:08 AM, V18 (Certified Nursing Assistant) said that fingernails should be checked for cleanliness and the need for trimming during routine cares and on shower days. V18 said that CNAs can clean and trim nails of residents if they are not diabetic. V18 said that the nurse has to cut them if the resident is diabetic. V18 said that residents should be shaved on their shower days and in between if needed. The facility's undated Grooming a Resident's Facial Hair Policy shows, It is the practice of this facility to assist residents with grooming facial hair to help maintain proper hygiene as per current standards of practice. The facility's undated Nail Care Policy shows,Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. Routine nail care, to include trimming and filing, will be provided on a regular schedule (on shower days). Nail care will be provided between scheduled occasions as the need arises.

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a wound dressing was in place as prescribed by t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a wound dressing was in place as prescribed by the physician. This applies to 1 of 4 residents (R66) reviewed for pressure ulcers in the sample of 18. The findings include: R66's electronic medical record lists her diagnoses to include: Alzheimer's Disease, type II diabetes mellitus, seizures, diastolic (congestive) heart failure, pressure ulcer of sacral region, unstageable, pressure ulcer of right buttock, stage 3, pressure ulcer of left buttock, stage 3, protein-calorie malnutrition, pressure ulcer of left heel, unstageable, diarrhea, and methicillin resistant staphylococcus aureus infection (MRSA infection). R66's wound evaluation and management summary by the wound physician dated June 5, 2023 shows, Site 1: Stage 4 pressure wound sacrum full thickness: Wound size (L x W x D): 8.0 X 4.5 X 2.0 cm (centimeters), Wound progress: deteriorated due to generalized decline of patient . Additional would detail: Pt (Patient) has been sharply declining in all faculties including PO (by mouth) intake, mobility/activity, and mental acuity which no doubt instigated the wound's development; wound presented today with a significant depth and large amount of putrid necrosis with liquefaction; The wound was debrided, revealing tendinous investment in the necrosis (dead tissue). R66's current order listing report shows, Sacrum: Cleanse with NSS (normal saline solution). Allow to air dry, pack wound with Dakins soaked gauze dressings (wet to moist), and cover with bordered gauze. Every night shift and as needed for skin integrity impairment. On June 13, 2023 at 1:38 PM, V7 Certified Nursing Assistant (CNA) turned R66 on her side. V9 Registered Nurse (RN) pulled R66's sacrum dressing back. R66 had a large elongated deep wound on her sacrum. The tissue inside the wound was black and yellow. There was no gauze or packing inside the wound. V9 RN did not notice there was no gauze/packing and put the dressing back in place. At 1:50 PM, V7 CNA turned R66 on her side again. V8 RN pulled R66's sacrum dressing back. She verified there wasn't any gauze or packing in the wound. V7 CNA stated, she removed the gauze/packing earlier because it was full of stool. V7 CNA stated, she didn't remember when exactly she took the gauze/packing. She did not tell the nurse she removed the wound gauze/packing. I've been too busy. On June 14, 2023 at 10:39 AM, V9 RN stated, she couldn't remember if there was gauze/packing in R66's wound when she looked at on June 13, 2023 at 1:38 PM. She also stated, V7 CNA did not report to her that she removed the gauze/packing from R66's wound. If V7 CNA would have told her, she would have changed the dressing. R66's Minimum Data Set, dated [DATE] shows, she is not cognitively intact. The same assessment also shows, she requires extensive assist of one person for bed mobility, toileting and personal hygiene. R66's care plan date initiated April 14, 2023 shows, Focus: Wound management, Intervention/Tasks: Provide wound care per treatment order. The facility's pressure injury prevention guidelines date implemented November 1, 2022 shows, Policy: To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury pressure. Policy Explanation and Compliance Guidelines:. 3. Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them.

CONCERN (D)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to label the enteral feeding administration set (formula...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to label the enteral feeding administration set (formula receptacle and tubing) and syringe for 1 of 3 residents (R64) reviewed for tube feeding in the sample of 18. The findings include: On 6/12/23 at 10:05 AM, R64 was lying in his bed watching TV. R64's enteral feeding bag/tubing was hanging on a pole and was not labeled. There was no resident name, time, date, nurse initials, or description of the contents indicated on the feeding administration set. A [NAME] syringe was inside a graduated cylinder located on R64's bedside stand with no date on either of them. On 6/13/23 at 9:04 AM, V6, Licensed Practical Nurse (LPN), said when the nurse hangs a new bag (of enteral feeding liquid), she is supposed to date and time it with their initials. V6 said a bag is good for 24 hours and then must be replaced with a new bag. V6 said the [NAME] syringe needs to be changed every 24 hours too. R64's admission Record dated 6/13/23 shows his diagnoses include, but are not limited to, gastrostomy status, moderate protein calorie malnutrition, osteomyelitis, local infection of the skin, sacral pressure ulcer, and traumatic brain injury. R64's Order Summary Report dated 6/13/23, shows he cannot take anything by mouth due to high risk of aspiration and shows the feeding administration set (bottle and tubing) are to be changed with each new bottle, with the formula container, syringe, and administration set labeled with the resident's name, date, time, and nurse's initials. The facility's Care and Treatment of Feeding Tubes Policy (undated) shows the, Licensed nurse will ensure the feeding container is labeled with date and time when changed.

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure a resident was monitored during medication administration for 1 of 18 residents (R280) reviewed for medication adminis...

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Based on observation, interview, and record review, the facility failed to ensure a resident was monitored during medication administration for 1 of 18 residents (R280) reviewed for medication administration in the sample of 18. The findings include: On June 12, 2023 at 9:44 AM, R280 was sitting in her wheelchair in her room watching TV, with her over bed table next to her. Two albuterol inhalers, a tube of nystatin and triamcinolone acetonide cream, a bottle of antifungal powder, and a bottle of artificial tears were on R280's bedside table. R280 said she uses the medications when she needs them. On 6/13/23 at 8:54 AM, V6- Licensed Practical Nurse (LPN), said no residents in the facility self-administer their medications. V6 said residents can only keep medications at the bedside with a physician's order. R280's admission Record dated 6/13/23 shows R280's diagnoses include, but are not limited to, polyneuropathy, hemiplegia and hemiparesis following cerebral infarction, asthma, and depression. R280's Order Summary Report, dated 6/13/23, does not show an order for R280 to be able to administer her own medications or to keep medications at her bedside. R280's current care plan provided by the facility does not include any focus, goals, or interventions related to self-administration of medications. The facility was unable to provide a Medication Self-Administration Assessment Form for R280. The facility's Resident Self-Administration of Medication Policy (undated) shows, A resident may only self-administer medications after the facility's interdisciplinary team (IDT) has determined which medications may be self-administered safely. The results of the IDT assessment are recorded on the Medication Self-Administration Assessment Form. The care plan must reflect resident self-administration and storage arrangements for such medications.

CONCERN (D)

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

Deficiency F0810 (Tag F0810)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure adaptive eating utensils were provided for 1 of 18 residents (R36) reviewed for assistive devices in the sample of 18....

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Based on observation, interview, and record review, the facility failed to ensure adaptive eating utensils were provided for 1 of 18 residents (R36) reviewed for assistive devices in the sample of 18. The findings include: On 6/12/23 at 11:56 AM, R36 was in the dining room for lunch. R36 said he can't eat because he needs a special spoon. R36's meal ticket on his lunch tray listed under Adaptive equipment a plate guard and build up foam utensils. R36's plate had no plate guard and he did not have a foam knife or spoon. On 6/12/23 at 12:03 PM, R36 was eating his beef stroganoff and mixed vegetables with his hands. When asked if he needed help, R36 said he needs a spoon. On 6/12/23 at 12:07 PM, Surveyor 40798 approached V5, Dietary Manager, to inquire if R36 required adaptive equipment to eat. V5 said R36 needs a big spoon. V5 came out to the dining area and told R36 to stop eating with his fingers and use his fork. R36 told V5 he wants a spoon. On 6/13/23 at 2:09 PM, V2, Director of Nursing (DON), said if a resident requires an adaptive device, dietary puts it on their tray. The required equipment is printed on their meal ticket. R36's admission Record dated 6/13/23 shows his diagnoses include, but are not limited to, cerebral infarction (stroke), hemiplegia and hemiparesis affecting left side and hemiplegia affecting right side. R36's Restorative Observations, effective date of 3/22/23, shows R36 needs supervision with eating and requires a plate guard and adaptive utensils for all of his meals. R36's current printed meal ticket provided by the facility dated 3/22/23 shows Plate Guard, Built up foam utensils.

CONCERN (E)

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

Deficiency F0688 (Tag F0688)

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 resident with limited range of motion and a co...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident with limited range of motion and a contracture, received Passive Range of Motion (PROM) and splint application for 1 of 2 residents (R25) reviewed for Range of Motion in the sample of 18. The findings include: On 6/12/23 at 11:14 AM, R25 was laying in bed. R25 said that he has had multiple strokes and can not move his left upper or lower extremity. R25's left wrist was contracted. R25's Face Sheet shows that he admitted to the facility on [DATE] with diagnoses of: monoplegia of upper limb following cerebral infarction affecting left non-dominant side and cerebral vascular disease. R25's Occupational Discharge Summary shows that he was discharged from therapy on 4/12/23. The summary shows a goal of, Patient will be able to tolerate resting hand splint for 2 hours on his L (left) hand. This goal was met on 4/4/23. The summary shows, Patient Progress: Patient responded positively to passive techniques to stimulate functional performance and enhanced safety to prevent further decline and patient has made consistent progress with skilled interventions. Discharge recommendations: Patient will remain at this facility. PROM (Passive Range of Motion) to patient's left shoulder, elbow and hand is recommended as well as having good optimal support to his left hand/arm. Prognosis to maintain CLOF (Current Level of Function) = good with consistent staff follow-through. On 6/14/23 at 9:18 AM, V19 (Therapy Director) said that the facility no longer has a restorative program. V19 said that when the facility did have a program, the therapist would write out a recommendation to the nursing department for restorative services and/or splints when they were discharged from therapy. V19 said that they no longer do that. At 10:40 AM, V19 said that he reviewed R25's discharge summary and he should be wearing a splint to his left hand for at least two hours a day and should be getting PROM daily to prevent further contractures and decline but he is not sure who would be doing the interventions since they do not have a restorative program. On 6/14/23 at 9:32 AM, V17 (Certified Nursing Assistant) said that R25 is unable to move his left upper or lower extremities. V17 said that he is totally dependant on staff for mobility and requires a mechanical lift for transfers. V17 said that R25 does not walk. V17 said that R25 does not have a splint that he knows of. V17 said that he does not do any range of motion exercises with R25. On 6/13/23 at 11:26 AM, V2 (Director of Nursing) said that the facility does not have a restorative program and they do not have any CNAs working as restorative CNAs. R25's Restorative Observations Form dated 3/22/23 shows that he has no mobility of his left shoulder, limited assistance with ambulation, uses a wheelchair and a walker, has a left hand splint/brace, is on a transfer, walking, splint/brace assistance program and is cooperative. R25's current Care Plan does not document any interventions for ROM or splints. The facility's undated Prevention of Decline in Range of Motion Policy shows, Licensed Nurses will assess resident's range of motion on admission/readmission, quarterly, and upon a significant change. Residents who exhibit limitations in range of motion, initially and thereafter, will be referred to therapy department for a focused assessment of range of motion .Based on the comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion. The facility will provide treatment and care in accordance with professional standards of practice. This includes, but not limited to: Appropriate services (specialized rehabilitation, restorative, maintenance). Appropriate equipment (braces or splints). Care plan interventions will be developed and delivered through the facility's restorative program. Interventions will be documented on the resident's person centered care plan.

CONCERN (E)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

Based on interview and record review the facility failed to attempt gradual dose reductions for psychotropic medications and failed to ensure their was a duration ordered for as needed anti-anxiety me...

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Based on interview and record review the facility failed to attempt gradual dose reductions for psychotropic medications and failed to ensure their was a duration ordered for as needed anti-anxiety medications for 4 of 5 residents (R7, R35, R43 and R68) reviewed for unnecessary medications in the sample of 18. The findings include: 1. R35's June Physician's Order Sheet shows an order for Risperidone (anti-psychotic) 1 milligram (mg) at bedtime for anxiety. R35's Consultant Pharmacist Recommendation to Physician Form printed on 4/20/23 shows, Federal Guidelines state antipsychotic drugs should have an attempt at gradual dose reduction (GDR) twice per year for the first year in 2 different quarters with at least one month between attempts, then annually thereafter. This resident has been taking Risperidone 1 mg hs (bedtime) since 9/2022 without a GDR. Could we attempt a dose reduction at this time to Risperidone 0.75 mg to verify this resident is on the lowest possible dose? If not, please indicate response below. The response section of the form is not filled out by the physician. 2. R7's June Physician's Order sheet shows an order for Trazodone (anti-depressant) 25 mg daily at bedtime related to depression. R7's Consultant Pharmacist Recommendation to Physician Form printed on 5/18/23 shows, Practice guidelines for major depression in primary care recommend continuing the same dose for 4-9 months following the acute phase. Whether a patient is to continue therapy in this maintenance phase depends on the established history of previous depressive episodes and the physician assessment. A trial dose reduction may be reasonable at this time. This resident has been using Trazodone 25 mg since 5/2022. The response section of this form in not filled out by the physician. R7's Psychotropic Evaluation dated 6/10/23 shows the resident is not feeling down or depressed, does not have little interest or pleasure in doing things and the family/staff do not believe that depression is contributing to impaired quality of life. On 6/14/23 at 12:29 PM, V2 (Director of Nursing) said that the pharmacist reviews the resident's medications and chart monthly. V2 said that the pharmacist will let her know if a GDR is recommended. V2 said that they send her a form explaining what the recommendation are. V2 said that the forms get placed in a file for the physician to review the next time that they are in the building. V2 said that they are in the building frequently and she does not know why they have not address R35 and R7's GDR recommendations. The facility's undated Use of Psychotropic Medication Policy shows, Residents who use psychotropic drugs shall receive gradual dose reductions, unless clinically contraindicated, in effort to discontinue these drugs The physician in collaboration with the consultant pharmacist shall re-evaluate the use of the medication and consider whether or not the medication can be reduced or discontinued upon admission or soon after admission. 3. R68's current order listing report shows, lorazepam intensol oral concentrate 2 mg/ml (milligram/milliter), give 0.25 ml by mouth every 2 hours as needed (PRN) for mild anxiety, restlessness & nausea. Ordered 5/27/2023 with no stop date. 4. R43's current order listing report shows, lorazepam oral tablet 0.5 mg (lorazepam), give 1 tablet by mouth every 24 hours as needed (PRN) for anxiety additional dose during day time for severe anxiety. Ordered 6/10/2023 with no stop date. On 6/14/23 at 1:42 PM, V2 Director of Nursing (DON) stated, PRN (as needed) psychotropic medications should have a stop date of 14 days. The facility's use of psychotropic medication (No date) shows, 9. PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days).

May 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure R2 was transferred in a safe manner for one of e...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure R2 was transferred in a safe manner for one of eight residents (R2) reviewed for transfers in the sample of ten. The findings include: R2's Current Care Plan on 05/24/23 shows, multiple diagnosis including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side. On 05/24/23 at 10:57AM, R2 was sitting in a wheelchair in her room. R2 had a brace on her left wrist. R2's left shoulder rested lower than her right shoulder. On 05/25/23 at 10:57AM, R2 said, they must put me on the sit to stand mechanical lift for transfer. That is the safest way to transfer me. I had a very bad experience a week ago in the morning. It was a male CNA-Certified Nursing Assistant. He was very rude. He did not use the lift. He picked me up by my bad arm and said, don't tell me what to do. I have not been able to use my arm for four years, it has been out of place for a long time. He pulled on my arm when he transferred me, oh my gosh it hurt, I screamed. The nurse came to see what happened. I said he (V9 CNA) better not show up for me again. On 05/24/23 at 1:12PM, V2 DON-Director of Nursing said, the incident happened 5/19/23 around breakfast last Friday. It was V9 CNA. R2 wrote disaster on her menu (05/19/23) to document the incident. R2 showed it to me when I interviewed her. On 05/24/23 at 2:00PM, V2 DON-Director of Nursing said, I can confirm V9 CNA did not bring the mechanical lift into the room to transfer R2. R2 was not transferred with the mechanical lift on 05/19/23. R2's MDS-Minimum Data Set, dated [DATE] shows, Transfer: Extensive Assist of two persons. Functional Limitation in Range of Motion: Impairment on one side upper and lower extremity. The facility's Transfer List on 05/24/23 shows, R2 two person sit to stand mechanical lift. The facility's Safe Resident Handling/Transfers policy dated 02/01/23 shows, it is the policy of this facility to promote a safe, secure and comfortable experience for the resident, while manual lifting techniques may be utilized. The use of mechanical lifts are a safer alternative. Two staff members must be utilized when transferring residents with a mechanical lift.

Mar 2022 9 deficiencies

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 nail care was provided for 2 of 18 residents re...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure nail care was provided for 2 of 18 residents reviewed for activities of daily living in the sample of 18. The findings include: 1. On 03/28/22 at 11:00 AM, R16 had long dirty finger nails with brown debris underneath. On 03/29/22 at 01:00 PM, R16's nails were still long with visible brown debris underneath. On 03/30/22 at 9:48 AM, V2 Director of Nursing stated nail care happens on the weekends, but if staff sees a need during the week, they should take care of the nails as needed. R16's Minimum Data Set, dated [DATE] shows R16 requires extensive assistance for personal hygiene. 2. On 03/28/22 at 9:57 AM, R34 had long, jagged finger nails of various lengths. On 03/29/22 at 09:25 AM, R34 was feeling his nails and stated my nails need to be trimmed a little. Some are rough. The girl will do it whenever she gets around to it, I can't do it myself. R34's Minimum Data Set, dated [DATE] shows R34 is cognitively intact and requires limited assistance of one person for personal hygiene. The undated facility's Activities of Daily Living- Fingernails/Toenails Policy shows The policy and procedures are to clean the nail bed, to keep nails trimmed, and to prevent infections .Nail care includes daily cleaning and regular trimming .Proper nail care can aid in the prevention of skin problems and around the nail bed.

CONCERN (D)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to ensure a resident with a contracture had a brace for 1 of 4 residents (R41) reviewed for contractures in the sample of 18. The...

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Based on observation, interview, and record review the facility failed to ensure a resident with a contracture had a brace for 1 of 4 residents (R41) reviewed for contractures in the sample of 18. The findings include: On 03/28/22 at 11:50 AM, R41's right hand was partially contracted with the pinky finger bent up toward the palm of his hand. R41 stated they lost my brace for my hand. I'm supposed to wear it at nights. When I moved to isolation during lockdown, it got lost. I spoke with therapy and social services about it, and it's been a month now I still don't have it. On 03/29/22 at 01:05 PM, V5 Director of Therapy stated R41 has a brace that he wears at night. It was reported something like a month ago, that it was missing. We were notified, we looked all over and let social services know. The facility's Quality Improvement Form dated 3/18/22 shows notified of R41 missing a hand/wrist black brace with blue Velcro. R41 stated that he last remembers having it in his room on 200 hall (COVID unit). On 03/29/22 at 01:18 PM, V6 Director of Social Services stated I'm aware R41's brace was missing. I haven't finished my investigation yet (11 days after reported missing to her). On 03/30/22 at 9:40 AM, V7 Restorative said the purpose of the splint is to prevent the contractures from getting worse. R41's Therapy Communication to Restorative Nursing Program form dated 1/10/22 shows patient requires right hand resting splint to increase extension in fingers of right hand and to decrease risk for contractures. Patient to wear splint everyday. Put splint on patient as follows: ON- at night when going to bed OFF-in morning with cares. The facility's undated Assistive Devices and Equipment Policy shows Devices and equipment that assist with resident mobility, safety and independence are provided for residents. These include, but are not limited to: Splints/braces.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 03/28/22 at 11:20 AM, R56's left pinky finger had a band aid. R56 stated I got a splinter from the faucet in the bathroom....

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 03/28/22 at 11:20 AM, R56's left pinky finger had a band aid. R56 stated I got a splinter from the faucet in the bathroom. It's a [NAME] faucet, it's jagged. On 03/28/22 at 01:33 PM, the sink faucet in the 400 hall bathroom shower room, had jagged irregular edges at the base of hot and cold handles with areas of the chrome peeled away. On 03/29/22 at 09:28 AM, V4 Licensed Practical Nurse said R56 said she got a splinter from the faucet and keeps making us dig it out. We put a bandaid on just to make her happy. I looked at the faucet and didn't see anything. With this surveyor, V4 looked at faucet and stated I only looked at handles, I didn't pay attention to the base of the faucet. It's possible she could have gotten a splinter from it, it is jagged. On 03/30/22 at 10:00 AM, V2 Director of Nursing (DON) with this surveyor, asked R56 where on the faucet she got the splinter, and R56 stated I told you it's from the corrosion by the hot and cold knobs. On 03/30/22 at 10:02 AM, V2 looked at the faucet and stated yes I can see it's sharp, it could happen. I'll have maintenance fix it. R56's Minimum Data Set, dated [DATE] shows R56 is cognitively intact. Based on observation, interview and record review the facility failed to use a gait belt to safely transfer a resident and failed to ensure a resident was able to safely wash their hands for 2 of 18 residents (R4 and R56) reviewed for safety in the sample of 18. The findings include: R4's Minimum Data Set assessment dated [DATE] shows that she needs assistance of one person for toilet use and is not steady when moving on and off of the toilet. 1. On 3/28/22 at 12:50 PM, V11 (Resident Helper) brought R4 into the bathroom. With no gait belt on R4, V11 assisted R4 from her wheelchair to the toilet. V11 then assisted her back to her wheelchair by lifting under R4's armpit and guiding her hips into the wheelchair. On 3/29/22 at 1:13 PM, V12 (Certified Nursing Assistant) said that gait belts should be used on all assisted transfers for the resident's safety. R4's Basic Needs Care Plan shows, I use the bathroom with extensive assistance of 1 using walker and gait belt. The facility's undated Gait Belt Transfers Policy shows, Gait belts will be used to assist residents who have poor standing balance during transfers and/or ambulation in order to provide maximum control and balance while minimizing threat of injury to a resident being assisted with transfer and/or ambulation.

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide thorough incontinence care for 1 of 2 resident...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide thorough incontinence care for 1 of 2 residents (R11) reviewed for incontinence care in the sample of 18. The findings include: On 03/28/22 at 10:33 AM, V8 Certified Nursing Assistant (CNA) removed a urine soaked brief from R11 and assisted R11 to sit on the toilet. When R11 was done, V8 wiped R11's rectal area with wet disposable towels and stool was visible on the towel. V8 wiped R11's rectal area a second time with the towels and stool was visible on the towel. Without cleaning R11's peri area or wiping R41's rectal area until no stool present on towel, V8 applied a new brief and pulled up R11's pants. On 03/30/22 at 9:48 AM, V2 Director of Nursing said after a resident was incontinent of urine and stool the residents whole area should be cleaned, peri area included, wiping dirty to clean. R11's Minimum Data Set, dated [DATE] shows R11 requires extensive assistance of two persons for toileting and is always incontinent of bowel and bladder. The facility's undated Urinary Incontinence Policy shows Each resident who experiences an episode of incontinence will be appropriately cleaned Wipe urine and/or feces from the resident's skin using a wet washcloth and apply soap or skin cleansing agent .Wash the resident's perineal area front to back with soap and water.

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review the facility failed to ensure a nutritional supplement was given to a resident who had a significant weight loss for 1 of 4 residents (R4) reviewed fo...

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Based on observation, interview and record review the facility failed to ensure a nutritional supplement was given to a resident who had a significant weight loss for 1 of 4 residents (R4) reviewed for weight loss in the sample of 18. The findings include: R4's Weight Report printed on 3/29/22 shows that on 2/7/22, R4 was 118.2 pounds and on 3/7/22 she was 110.6 pounds. A 6.43% loss in 1 month. R4's Physician's Order Sheet shows an order dated 11/3/21 for, Meal supplement: Resource Juice 1 brick/carton lunch supper. On 3/29/22 at 12:45 PM, R4 had completed lunch and no resource juice was provided. On 3/29/22 at 12:45 PM, V4 (Licensed Practical Nurse) said that if resource juice is ordered, it is put on the resident's tray by the kitchen staff. V4 said that she does not know why R4 did not get resource juice on her tray. R4's Nutrition Care Plan shows, I need dietary staff to-provide me with Provide resource juice q (every) lunch .for additional nutrition.

CONCERN (D)

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

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to serve a mechanical soft diet to a resident as ordered f...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to serve a mechanical soft diet to a resident as ordered for 1 of 18 residents (R3) reviewed for diets in the sample of 18. The findings include: R3's Face Sheet shows that he was admitted to the facility on [DATE]. R3's New admission Notification Form dated 3/16/22 shows a diet consistency of mechanical soft. R3's admission Assessment and Baseline Care Plan dated 3/16/22 shows, Dietary Instructions: Low Concentrated Sweets/No Added Salt/Mechanical Soft consistency with thin liquids. R3's Physician's Order shows that R3 was ordered a regular consistency diet on 3/16/22. The diet was changed to mechanical soft consistency on 3/25/22. On 3/28/22 at 11:50 AM, V9 (R1's spouse) said that she has been asking for grinded food for weeks and R1 keeps getting regular food. V9 said that R3 has a hard time chewing due to ill fitting dentures. V9 said that she has told multiple people that R3 needs R3 diet changed. On 3/28/22 at 12:00 PM, V10, Certified Nursing Assistant (CNA) delivered a tray to R3's room. The tray had chicken and broccoli, rice and an egg roll on it. R3's meal ticket said general diet on it. When V10 delivered the tray, V9 said, we told the nurse today, R3 can not have regular food, it needs to be chopped up. The facility's undated Therapeutic Diets Policy shows, Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences .Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes.

CONCERN (E)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected multiple residents

Based on interview and record review the facility failed to ensure pharmacy recomendations were forwarded to the facilty in a timely manner, failed to notify the physician of irregularities of medicat...

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Based on interview and record review the facility failed to ensure pharmacy recomendations were forwarded to the facilty in a timely manner, failed to notify the physician of irregularities of medication regimen in a timely manner and failed to develop a policy that included a timeframe for the different steps in the review process for 4 of 7 residents (R7, R16, R74 and R76) reviewed for Medication Regimen Review (MRR) in the sample of 18. The findings include: 1. R76's MRR dated 1/14/22 shows a recommendation for Quetiapine 25mg BID (twice a day) PRN (as needed). The report says, PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident in person for the appropriateness of renewal. There is a stamp on the paper that shows that they recieved the report on 2/11/22. The report does not show a presciber's response. On 3/29/22 at 2:07 PM, V2 (Director of Nursing) said that she recieved the report on 2/11/22 but has not done anything with it yet. V2 said, It must have got missed. On 3/30/22 at 10:27 AM, V2 said that she addresses MRR irregularities with the physician as soon as she gets the report. The facility's undated Drug Regimen Reviews Policy shows,Notations of the findings and recommendations shall be recorded on the monthly drug regimen review report .Should irregularities be found, the consultant pharmacist will provide the Administrator and/or Director of Nursing with a written, signed and dated copy of the report, listing the irregularities found and recommendations for their solutions. The policy does not address the need or timeframe for the physician to be notified of the irregularities. 2. R7's Drug Regimen Review dated 2/27/22 states, (R7) currently has the following pertinent PRN (as needed) medication order: Lorazepam (Antianxiety) 0.5 mg to 1 mg every 2 hours PRN. R16's Drug Regimen Review dated 2/27/22 states, (R16) currently has the following pertinent PRN (as needed) medication order: Alprazolam (Antianxiety) 0.5 mg Daily PRN. R74's Drug Regimen Review dated 2/27/22 states, (R74) currently has the following pertinent PRN (as needed) medication order: Lorazepam (Antianxiety) 0.5 mg every 4 hours PRN. On 3/30/22 at 10:30 AM V2 (DON-Director of Nursing) stated, I just got these pharmacy recommendations from February this morning in my email after I requested them last night. I'm not sure why they took so long to get to me. They usually come on like the 10th or the 11th of the month but I am not well versed in this yet. The old DON was new too and we sat with the pharmacy consultant in January to learn about the how, what and when of these and in January she emailed them to both of us but I didn't get them this month until I requested them. None of the pharmacy recommendations dated 2/27/22 had been forwarded to the physicians for follow-up as of 3/30/22.

CONCERN (E)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a physician assessed a resident every 14 days for the continu...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a physician assessed a resident every 14 days for the continued need for an as needed (PRN) anti-psychotic medication and failed to have a duration/stop date for a resident on a PRN anti-anxiety medication for 4 of 7 residents (R7, R16, R74 and R76) reviewed for psychotropic medications in the sample of 18. The findings include: 1. R76's Physician's Order Sheet printed on 3/29/22 shows and order dated 1/10/22 for, Quetiapine Fumarate (anti-psychotic) 25 milligrams (mg) by mouth twice a day as needed. R76's Medication Regimen Review dated 1/14/22 shows a recommendation for Quetiapine 25 mg BID (twice a day) PRN. The report says, PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident in person for the appropriateness of renewal. R76's Clinical Records show that she was re-admitted to the facility on [DATE] and did not see an attending physician until 3/30/22. On 3/29/22 at 2:07 PM, V2 said that the pharmacist reviews psychotropic medications and lets the facility know what the recommendations are and then they act upon them. V2 said that PRN anti-psychotics should only be ordered for a 14 day period and then needs to be reviewed by the physician for the continued need for them. On 3/30/22 at 10:49 AM, V2 verified that R76 was re-admitted to the facility on [DATE] and was not seen by a physician until 3/30/22. The facility's undated Use of Psychoactive Medications Policy shows, Purpose: To prevent over-prescribing of psychoactive medication and to remain consistant with Federal Standards. The policy does not include guidance for the use of PRN psychotropic medications. 2. R7's Physician's Order Sheet dated 2/28/22 shows that R7 has an order for Lorazepam (Antianxiety) 0.5 mg every 2 hours as needed for anxiety, restlessness and nausea ordered on 6/29/21. This order does not show a stop date for the medication. R16's Physician's Order Sheet dated 2/28/22 shows that R16 has an order for Alprazolam (Antianxiety) 0.5 mg daily as needed for Anxiety ordered on 1/19/22. This order does not show a stop date for the medication. R74's Physician's Order Sheet dated 2/28/22 shows that R74 has an order for Lorazepam 0.5 mg every 4 hours as needed for anxiety ordered on 9/14/20. This order does not show a stop dated for the medication. R7, R16 and R74's pharmacy forms entitled, Note to Attending Physician/Prescriber all dated 2/27/22 state, State and Federal Guidelines have been updated and include 14 days limits on PRN psychotropics. On 3/30/22 at 12:00 PM, V2(Director of Nursing) stated that she was fairly new to her position and underwent some training in January with the old DON but she was still learning. V2 stated that she was planning to start working on this right away. The undated facility policy entitled Use of Psychotropic Medications does not address the 14 day limit and need for a stop date for as needed (PRN) antianxiety medications.

CONCERN (F)

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

Deficiency F0882 (Tag F0882)

Could have caused harm · This affected most or all residents

Based on interview and record review the facility failed to ensure to have an Infection Control Preventionist on staff which affects all 76 residents in the facility. The findings include: The Residen...

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Based on interview and record review the facility failed to ensure to have an Infection Control Preventionist on staff which affects all 76 residents in the facility. The findings include: The Resident Census and Conditions form (672) dated March 29, 2022 showed the facility census was 76 residents. On March 28, 2022 at 12:35 PM V3 (Executive Director) stated the previous Infection Control Preventionist's (ICP) last day of work was November 17, 2022. The facility currently has no nurses with the completed ICP certification. The facility's COVID-19 testing policy dated March 23, 2021 showed Rolling Hills employs a designated full time Infection Control Nurse. The responsibility of the Infection Control Nurse is to plan, develop, organize, implement, evaluate, and direct Safety / Infection Control care services, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern nursing care facilities.

Allure Of Zion

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Allure Of Zion

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