Pearl Of Orchard Valley

Penalty

Inspection fine: $277,045

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to protect residents from sexual abuse when a male dementia resident engaged in sexual contact with a female dementia resident’s breast in the dining room. The incident occurred when the female resident, who had a documented history of socially inappropriate and sexually oriented behaviors, including objectifying males and making crude sexual remarks, was left unsupervised with the male resident in the dining room. Her behavior care plan, in place since 2015, specifically identified her lack of boundaries, sexually oriented comments, and gestures, and included an intervention that unsupervised visiting with male residents should be discouraged and prevented when possible. Despite this, staff allowed her to remain in the dining room with a male resident without continuous supervision before the meal was served. The male resident also had a behavior care plan for socially inappropriate behavior, including flirtatious behavior toward a peer, and had diagnoses of dementia, major depressive disorder, and anxiety disorder, with documented poor insight and judgment and significant cognitive deficits. Both residents had psychiatric evaluations indicating they were oriented only to person, with significant short- and long-term memory deficits and impaired attention and concentration. The psychiatric nurse practitioner and LCSW stated that neither resident had the decision-making capacity to consent to sexual activity or make informed decisions. The facility’s own Sexual Abuse Prevention and Management of Sexual Behaviors policies defined sexual abuse as non-consensual sexual contact and stated that consent cannot be given if a resident is cognitively impaired, and that the facility must intervene when one or both individuals lack the ability to provide informed consent. On the day of the incident, a dietary aide entered the dining room while setting up for lunch and observed the male resident sucking on the female resident’s breast after she had lifted her shirt. The aide reported that no other staff were present in the dining room at that time and that security footage showed the two residents making inappropriate contact whenever staff left the dining room and stopping when someone entered. A CNA confirmed that she had placed drinks and seen the two residents sitting together, then left the dining room before food arrived, leaving no staff present. Multiple staff interviews showed that staff were aware the female resident could be sexually inappropriate, made sexual comments, and asked other residents to perform sexual acts, but CNAs reported they were unaware of any special interventions beyond separating her when she made inappropriate comments, and that continuous monitoring of the dining room only occurred once meals were served. The abuse coordinator and regional nurse consultant later stated they believed sexual abuse was unsubstantiated because both residents appeared to enjoy the act, despite the facility’s policies and professional assessments that cognitively impaired residents could not provide informed consent.

Removal Plan

• R2 continues to reside in the facility with no further incidents and suffered no negatives effects.
• R2's physician and responsible party were notified; responsible party had no concerns.
• R2 was sent to the hospital; no new findings and no new orders were received.
• R2 was moved to the secured female unit.
• R3 continues to reside in the facility with no further incidents and suffered no negative effects.
• R3's physician and daughter were notified; daughter voiced no concerns.
• R3 was sent to the hospital; no new findings and no new orders were received.
• R3 was on a 1:1 with staff until R3 left for the hospital.
• R3 was moved to the secured male unit.
• Law Enforcement was notified and concluded investigation with no findings.
• Social Services completed assessments on behavior, potential abuse and trauma for R2 and R3.
• Care plans were reviewed and updated as indicated on potential for abuse, behavior and trauma.
• Assessments and care plans will be completed per assessment schedule and as needed.
• Social Services completed and reviewed assessments on residents identified with sexually inappropriate behaviors.
• Care plans were reviewed and updated as needed for residents identified with sexually inappropriate behaviors.
• DON/ADON and/or designee communicated plan of care to staff.
• A behavior monitoring binder was created and placed at the nurses' station showing residents with behaviors and their plan of care; binder will be reviewed and updated weekly and as needed by DON/ADON/Social Services and/or designee.
• For identified residents with sexually inappropriate behaviors, behavior monitoring started every 2 hours for 2 weeks and every shift thereafter while awake by nursing staff, documented on a behavior monitoring log.
• Findings from behavior monitoring will be escalated to the abuse officer and ADON for protocol implementation immediately.

Penalty

Inspection fine: $277,045

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to follow its policy for immediate notification of a resident’s change in condition after an unwitnessed fall. The resident was admitted with multiple significant diagnoses, including COPD, atrial fibrillation, cirrhosis, bone disorders, prior fractures, and was on an anticoagulant. An MDS showed the resident was cognitively intact and required staff assistance for toileting and transfers. The resident reported that during the night she activated her call light because her incontinence brief was wet; a CNA responded, was told the resident needed to be changed, and stated she would return. The resident stated she could not wait, attempted to transfer herself to her wheelchair to go to the bathroom, and fell forward. She reported using her cell phone to call the facility to report the fall, sustaining a skin tear on her left arm, and experiencing back pain throughout the night. The next morning, a pulmonary nurse assessed the resident around 8:30 AM and found her confused, with mentation documented as alert and oriented times one, a quarter-sized hematoma on the right forehead, and a skin tear on the left upper extremity. The resident told the nurse she had fallen the previous night and had back pain, and the nurse noted the resident was on apixaban and arranged for transfer via EMS. The progress note documented notification of the Administrator and DON and that the nurse practitioner was notified, but the DON later stated that facility policy requires the nurse to immediately notify the primary physician, make at least two attempts, and if unsuccessful, escalate to the medical director, with all attempts documented. The DON reported that the nurse said she left a message with the resident’s doctor, but there was no documentation of further attempts or actual physician contact, nor documentation of medical director notification. The facility also lacked documentation that the resident’s representative was immediately notified of the fall, and the fall event assessment listed the representative as notified at 5:00 AM without clear correlation to the time of the fall, demonstrating noncompliance with the facility’s notification policy.

Penalty

Inspection fine: $277,045

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to follow established fall-prevention interventions and care plan directions for a resident identified as a high fall risk. The resident was admitted with multiple diagnoses including COPD, hypertension, anxiety, metabolic encephalopathy, vertebral compression fracture, bone disorders, history of falls, femur fracture, atrial fibrillation, hypothyroidism, lack of coordination, UTI, and cirrhosis. An MDS showed the resident was cognitively intact but required maximal assistance with toileting hygiene and moderate assistance with transfers. The resident’s fall risk care plan, initiated at admission and updated after a prior fall, identified her as at risk for falls related to weakness, fatigue, activity intolerance, pain, and history of falls, and included interventions such as staff assessing and anticipating ADL and toileting needs during rounds, providing timely incontinence care, making frequent safety rounds, and maintaining bilateral safety mats at the bedside. On the night of the fall, the resident activated the call light because her incontinence brief and bed sheets were wet and requested incontinence care. The CNA who responded told the resident she would return after completing another task, then proceeded to deliver ice water to another resident, obtain sheets from the linen cart, and go to another floor to obtain incontinence briefs. During this delay, the resident, who was known to be a high fall risk and required assistance with toileting and transfers, attempted to get to her wheelchair to use the bathroom independently and fell forward. The resident later reported she used her cell phone to call the facility to notify staff of the fall and that she had sustained a skin tear on her left arm and was experiencing back pain. The next morning, a pulmonary nurse assessed the resident and found her confused compared to baseline, with a protruding hematoma on the right forehead and a skin tear on the left upper extremity. The resident reported she had fallen the previous night and had back pain. The DON confirmed the fall was unwitnessed, that the resident was on high fall risk precautions, and that staff were expected to follow the care plan and immediately attend to the resident’s incontinence needs. The DON also stated that at the time of the fall, only one fall mat was in place on the right side of the bed, while the resident’s care plan called for bilateral safety mats, and the resident had fallen from the left side where no mat was present. The facility’s fall prevention policy required universal fall precautions, individualized high-risk interventions, purposeful rounding to address toileting and incontinence needs, and adherence to high-risk fall precautions, which were not followed in this incident.

Penalty

Inspection fine: $40,740

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to assess a resident after an unwitnessed fall. The resident had severe cognitive impairment, vascular dementia, unsteadiness on feet, abnormal gait and mobility, muscle weakness, and required partial to moderate staff assistance for transfers and toileting. The resident’s care plan identified impaired cognition and thought process, and the cognitive assessment showed severe cognitive impairment. The resident was also taking Aspirin 325 mg daily, which the physician stated would be treated as an anticoagulant dose requiring immediate transfer for evaluation when there is an unwitnessed fall or change in mental status. After the fall, the record contained a fall event, a progress note, and a fall assessment completed by the RN on duty, and a skilled charting note completed by the night shift LPN the next morning. A follow-up falls form was completed two days later. However, there were no progress notes or documented assessments on the resident for several days after that, and the next progress note documented the resident was fatigued and needed more staff assistance for transfers and ambulation. The DON was unable to provide any neuro assessments after the fall, and the facility’s supporting documents did not include documented neuro checks after the fall despite the facility’s 72-hour neurological flow sheet requiring serial neuro checks. The resident’s POA reported that she was told the resident had an unwitnessed fall and expressed concern that he may have hit his head because of his confusion. She stated she requested hospital evaluation, but the resident was not sent out at that time. She later reported the resident became unable to talk and barely able to move, and the physician later directed that the resident be sent to the hospital. The ED record showed the resident presented with altered mental status after a likely fall one week earlier and was found to have acute on chronic bilateral subdural hematomas with significant mass effect. The physician stated that if staff were unsure whether the resident hit his head, or if there were changes in mental status, the resident should have been sent to the hospital immediately, especially given the resident’s cognitive impairment and Aspirin use.

Penalty

Inspection fine: $183,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a female resident with severe cognitive impairment from abuse by another male resident with a known history of wandering and inappropriate behaviors. The male resident, who was cognitively intact but exhibited behaviors such as wandering, rummaging, and public sexual acts, entered the female resident's room without staff awareness and remained there with the door closed for approximately eight minutes. During this time, staff were not present in the hallway, and the male resident was later found standing at the head of the female resident's bed with his pants lowered and genitals exposed near her face. The female resident was asleep, unable to verbalize her needs, and fully dependent on staff for activities of daily living. Staff interviews and record reviews revealed that the male resident was known among staff for entering other residents' rooms and taking their belongings, and that staff had expressed concerns about his behavior prior to the incident. Despite these known risks, there was no individualized care plan addressing his inappropriate wandering or sexually inappropriate behaviors, aside from standard two-hour monitoring. Staff also reported that they were responsible for supervising a high number of residents, making it difficult to provide adequate supervision, and that the male resident would take advantage of moments when staff were not watching. Following the incident, it was discovered that the facility did not promptly notify the female resident's family, hospice care team, or primary physician about the alleged abuse. This delay in notification meant that appropriate medical assessments and interventions, such as evaluation for trauma or sexually transmitted infections, were not conducted in a timely manner. The facility's failure to supervise the male resident and protect the vulnerable female resident from harm constituted a significant breakdown in resident safety and resulted in an Immediate Jeopardy to health and safety.

Penalty

Inspection fine: $183,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to timely report allegations of sexual and verbal abuse involving two residents, as required by its abuse prevention policy. In the first incident, a female resident with severe cognitive impairment and under hospice care was found in her room with a male resident who had exposed himself and remained alone with her for approximately eight minutes. The incident was observed by staff and confirmed by video surveillance. Despite the clear identification of sexual abuse, notifications to the resident's Power of Attorney (POA), physician, the Illinois Department of Public Health (IDPH), and local police were significantly delayed, with the POA and IDPH notified six to seven days after the incident and the police notified ten days later. Both the hospice and primary physicians confirmed they were not informed, which prevented timely evaluation or treatment. In the second incident, a resident with moderate cognitive impairment sustained a skin tear and bleeding after being startled by another resident's shouting during a verbal altercation. This abuse allegation was also not reported to IDPH until six days after the event. The facility administrator attributed the delays in both cases to being new in the role. The facility's abuse prevention policy explicitly requires immediate notification of the resident's representative, physician, and local police in cases of suspected criminal activity, which was not followed in these instances.

Penalty

Inspection fine: $183,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct a comprehensive investigation into an allegation of sexual abuse involving two residents. Staff discovered one resident standing at the head of another resident's bed with his pants lowered to his knees, exposing his buttocks, while the other resident was asleep and facing him. The staff member who discovered the incident questioned the resident, who immediately pulled up his pants and replied that he was doing nothing. Video surveillance confirmed that the resident was alone in the other resident's room with the door closed for eight minutes, and exited the room with his pants not fully pulled up. There was no staff present in the hallway during this period. Interviews with staff revealed that the resident who entered the room was known to wander, enter other residents' rooms, and take their belongings. Staff expressed concerns that this may not have been the first such incident. The resident was described as cognitively intact, aware of boundaries, and able to converse, but continued to exhibit wandering and inappropriate behaviors. The facility did not have an individualized plan to address these behaviors beyond standard monitoring. The resident who was found in bed was severely cognitively impaired, dependent on staff for all activities of daily living, and unable to verbalize needs. The facility's investigation was incomplete. While staff checked the resident in bed for skin issues and documented this, there was no documentation of a thorough assessment for possible physical contact or environmental evidence. The investigation did not include a review of the video surveillance footage as part of the process, nor did it explore the cause of the resident's presence in the other resident's room or review the resident's wandering behavior. The facility concluded the allegation was unsubstantiated without completing all required investigative steps.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident who is cognitively intact and requires substantial to maximal assistance for toileting was observed in bed wearing a hospital gown. The resident reported that the night shift staff did not respond to her call light requests for incontinence care, sometimes leaving her waiting for 5-6 hours before anyone would assist. On one occasion, a staff member entered the room, expressed frustration about having to provide care, stated she would return, but never did. As a result, the resident remained in a soiled incontinence brief containing stool and urine for several hours. The resident further stated that when she reminded the same staff member the following day about not returning to provide care, the staff member acknowledged leaving her in that condition and responded with an attitude. The resident expressed feelings of being a burden and reported being afraid to urinate at night due to the prolonged wait for assistance. The facility's policy requires care to be provided in a manner that respects resident rights, dignity, and autonomy, which was not upheld in this instance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to document and obtain treatment orders for a resident at risk for skin breakdown who reported redness and burning to her buttock area. The resident, who was cognitively intact and required substantial assistance for toileting, complained of being left in urine and feces for extended periods during the night shift, sometimes waiting 5-6 hours for incontinence care after activating her call light. During incontinence care, redness and a dressing were observed on the resident's buttocks, and upon further inspection, three open areas surrounded by denuded skin were noted. The wound nurse acknowledged seeing redness the previous day and applying a dressing but did not document the assessment or obtain treatment orders at that time. The resident's care plan indicated she was at risk for skin breakdown and required her skin to be kept clean and dry, with any changes reported to the physician. However, the wound summary lacked measurements, and there was no documentation of the initial assessment or treatment orders prior to the surveyor's observation. Staff interviews confirmed that prolonged exposure to moisture contributed to the skin damage, and the resident's complaints about delayed care were consistent with the observed condition.

Penalty

4 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adequately monitor and care for a resident's skin, resulting in a pressure injury progressing to a stage 3 ulcer and becoming infected. Observations on multiple occasions showed the resident lying on a regular mattress without being repositioned, despite being on contact and droplet isolation precautions due to a MRSA/Strep A infection in the wound. The resident's skin assessment tool initially showed no concerns, but a subsequent wound assessment revealed a stage 3 sacral pressure ulcer. The wound care nurse incorrectly assessed the ulcer as stage 2 and did not implement necessary interventions such as using a low air-loss mattress or repositioning the resident every two hours. The resident, who was severely cognitively impaired and incontinent, was on a turning/repositioning program and used pressure-reducing devices. However, the facility did not follow its own policies for skin prevention and treatment, as evidenced by the lack of regular skin inspections and failure to implement recommended interventions. The Director of Nursing expected staff to check residents' skin daily and follow prevention processes, but these expectations were not met, leading to the deterioration of the resident's condition.

Penalty

4 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain the kitchen in a manner that prevents foodborne illness, affecting 132 residents receiving dietary services. The dishwasher, which is supposed to disinfect dishes at 180 degrees Fahrenheit, consistently failed to reach the required temperature, with maximum temperatures recorded at 172 degrees Fahrenheit for the wash cycle and 160 degrees Fahrenheit for the final rinse cycle. The test strips used to verify the temperature were expired, and the facility did not provide a dishwasher policy. Additionally, a fan in the dishwashing area was covered with grease and dust, potentially contaminating clean dishes. The facility also failed to properly use and label sanitization buckets, with a green bucket containing sanitizer instead of soapy water, and no red sanitization bucket in use. The kitchen staff did not adhere to proper labeling and dating procedures for food items, with several items in the reach-in coolers and freezers lacking use-by dates or proper wrapping, leading to potential contamination. The facility's policy on labeling and dating was not followed, and the Regional Dietary Director acknowledged that all food items should be labeled and dated according to the facility's chart. Additional deficiencies included unclean equipment and utensils, such as a meat slicer and stand mixer with crumbs and drips, and rusty, dirty drawers containing clean utensils. Dented cans were found in dry storage, which the Regional Dietary Director stated could develop botulism. Furthermore, a dietary manager failed to perform hand hygiene after handling a resident's measuring cup, potentially contaminating meal trays. The facility's policies on handwashing and food service were not adhered to, increasing the risk of foodborne illness among residents.

Penalty

4 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for several residents, leading to deficiencies in personal hygiene and care. Resident R109, who is severely cognitively impaired, was observed with soiled clothing and an improperly fitted incontinence brief, indicating a lack of timely incontinence care. Additionally, R109 exhibited poor oral hygiene with noticeable residue buildup on his teeth, further highlighting the neglect in providing necessary assistance with daily hygiene tasks. Resident R71, who requires substantial assistance due to a stroke, reported not receiving scheduled showers and oral care. His hair was unkempt, and his nails were long and dirty, suggesting a failure to adhere to his care plan, which mandates regular showers and hygiene assistance. Similarly, Resident R117, who is cognitively impaired, was found with overgrown facial hair, unkempt nails, and poor oral hygiene, indicating a lack of grooming and personal care support from the staff. Residents R90 and R19 also experienced neglect in personal hygiene care. R90, with severely contracted hands, had long nails causing discomfort, while R19 expressed dissatisfaction with her long, dirty nails and facial hair, which had not been addressed by the staff. The facility's policy on ADLs emphasizes maintaining residents' comfort, safety, and dignity, yet the observations and resident reports indicate a significant lapse in meeting these standards, as staff failed to provide the necessary assistance and care as outlined in the residents' care plans.

Penalty

4 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate supervision for residents who smoke, leading to potential safety hazards. Five residents were identified as not being properly assessed or supervised while smoking. One resident was found with a cigarette burn on her wheelchair cushion, and another was observed passing a lit cigarette to a peer without staff supervision. The facility's policy requires smoking risk assessments to be conducted quarterly and as needed, but several residents had outdated assessments or were not reassessed after significant changes in their condition. Additionally, a resident with a history of traumatic brain injury and cognitive impairment was not reassessed for smoking safety after admission, despite engaging in unsafe behaviors such as picking up and smoking cigarette butts. The facility's policy mandates supervision for residents who require it, but observations revealed that staff were not present during smoking times, leaving residents unsupervised and at risk of accidents. The Social Services Director acknowledged the importance of supervision but was unaware of specific incidents involving the residents.

Penalty

4 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain physician orders for medications brought from home and did not secure resident medications in locked compartments, affecting four residents. Resident R195 had a bottle of Tylenol, a tube of Icy-Hot, and a bottle of Sooth in her room without physician orders. Despite being cognitively intact, as indicated by a BIMS score of 14, there were no orders for these medications in her March Physician Order Sheet. The Director of Nursing confirmed that medications brought from home require a physician's order and should be stored securely. Resident R78 had several unlabeled medications, including Cranberry tablets, Gas-X, Fexofenadine Hydrochloride, Phenylephrine Hydrochloride, and Melatonin, in her room. There were no physician orders for these medications, except for Melatonin, which was documented in her Medication Administration Record. Resident R86 had Salonpas patches without an active order, and Resident R54 had Nystatin powder without an active order. The facility's policy requires medications to be stored securely and accessible only to authorized personnel, which was not adhered to in these cases.

Penalty

4 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect residents from physical abuse, as evidenced by an incident involving two residents, R67 and R124. R124 reported that R67 stepped on her toe, leading her to push him, and claimed that R67 pushed her back. However, R67 denied pushing R124 and stated that R124 hit him with a grabber. The incident was reported to the facility's administrator, who documented the event and submitted a report to the department of health. Despite the conflicting accounts, the facility's response included a wellness check on R67 and a head-to-toe assessment, but there was no clear resolution or prevention of further incidents. The facility's documentation and interviews reveal inconsistencies in the handling of the incident. The Social Services Director and a Registered Nurse were instructed by the administrator on how to document the incident, but there was no clear communication or investigation into the claims of physical contact. The facility's policy on abuse prevention states that residents have the right to be free from physical abuse, yet the actions taken did not adequately address the allegations or ensure the safety of the residents involved. The lack of a thorough investigation and appropriate measures to prevent further incidents highlights a deficiency in the facility's abuse prevention and response protocols.

Penalty

4 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to submit reports of suspected abuse to the Illinois Department of Public Health within the mandated timeframes. This deficiency involved a resident who reported missing personal items, including money, a debit card, an ID, and a birth certificate, from her purse. The resident, who was cognitively intact, suspected a CNA might have taken them and reported the theft to the Administrator/Abuse Coordinator. However, the Administrator did not take immediate action or document the complaint, and the initial report to the state was delayed. The Administrator acknowledged that the resident had informed him of missing money and an ID but claimed no knowledge of the other missing items. Despite the resident's cognitive intactness, the Administrator questioned the validity of her claims and failed to document the incident or initiate a timely investigation. The facility's policy requires an immediate report to the state licensing agency after an allegation of theft, but this was not followed. The initial report to IDPH was only made after the resident explicitly mentioned theft, and the facility's final report concluded that abuse was not substantiated.

Penalty

4 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to immediately initiate an investigation into allegations of abuse involving a resident, leading to a deficiency. A cognitively intact resident reported an altercation with another resident, where the latter allegedly stepped on her injured toe, prompting a physical confrontation. The resident informed the Administrator/Abuse Coordinator the day after the incident, but the facility did not promptly investigate or document the occurrence in the resident's electronic medical record. The report to the Illinois Department of Public Health (IDPH) was delayed and contained inaccuracies regarding the timing of the notification and the resident's ability to provide details about the incident. Interviews with staff revealed that the altercation was known to the CNA and LPN on duty, who reported it to the Director of Nursing. However, there was no documentation or immediate assessment of the resident following the incident. The facility's Abuse Prevention Training Program mandates immediate reporting to the state licensing agency after assessing the resident and removing the alleged perpetrator, which was not adhered to in this case. The lack of timely investigation and documentation of the incident led to the deficiency identified by the surveyors.

Penalty

4 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate restorative services to residents with contractures, specifically affecting two residents. One resident, R90, was unable to extend his fingers due to severe contractures, with his hands in a fixed fist position. Despite having a care plan for daily passive range of motion (PROM) exercises, R90 could not recall the last time he received these exercises. The Restorative Aide, V12, confirmed that she was unable to perform PROM on R90's hands due to the severity of the contractures. Additionally, R90's fingernails were excessively long, causing indentations in his palms, which also had a brown substance with a foul odor. The resident's mobility assessment indicated a decline in the range of motion, contradicting the care plan's goal to maintain his current level of function. Another resident, R71, experienced similar neglect in restorative care. After suffering a stroke, R71's left side was very weak, and his left arm and hand were stiff and contracted. Although his care plan included daily PROM exercises for his left extremities, R71 reported that he no longer received these exercises. V12 attempted to demonstrate PROM on R71 but was unable to due to the severity of his contractures. R71's fingernails were also long and unkempt, with a brown substance underneath, causing indentations in his palm. V12 admitted that she could not perform PROM on all residents as she was also responsible for CNA duties, and it appeared that R71 and R90 had not been receiving their prescribed exercises. The facility's policy emphasized maintaining residents' functional levels, yet the lack of contracture prevention devices and consistent restorative care contributed to the deficiency.

Penalty

4 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate catheter care to two residents, R54 and R90, who were reviewed for urinary care. On March 19, 2025, a Certified Nurse Assistant (CNA) was observed providing incontinence care to R54, who had an indwelling urinary catheter. The CNA cleaned R54's perineal and buttock area after an incontinence episode but did not provide catheter care as required by R54's care plan, which specified that catheter care should be provided during routine perineal care. On March 20, 2025, a Registered Nurse (RN) was observed providing catheter care to R90, who also had an indwelling urinary catheter and had recently been treated for a urinary tract infection. The RN cleaned R90's catheter tubing using repeated downward and upward strokes with the same wipe, contrary to the facility's policy, which requires wiping the tubing with a downward stroke using a clean cloth. The Director of Nursing (DON) confirmed that the nursing staff is expected to provide incontinence and catheter care according to the facility's policy.

Penalty

4 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate care for a resident's ostomy bag, as observed during a survey. On two consecutive days, the resident's ostomy bag was noted to be almost full and not emptied or changed by the staff, despite the resident's complaints. The resident, who is cognitively intact, expressed that the ostomy bag is frequently full and takes a long time to be changed by the staff. The facility's policy requires the pouch to be emptied when it is one-quarter to one-half full, which was not adhered to in this case. The resident has a medical history of colon cancer and a fistula, with a physician order to change the colostomy pouch every three days. However, there was no care plan in place for the resident's ostomy or fistula, as confirmed by the Regional Nurse Consultant and the Director of Nursing. The lack of a care plan and the failure to follow the facility's policy on ostomy care led to the deficiency observed during the survey.

Penalty

4 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to administer tube feedings and care for enteral tubes as ordered for residents with gastrostomy tubes. For one resident, a registered nurse did not check for tube placement or residual before initiating a feeding infusion, contrary to the resident's medical orders. The resident's order summary specified that prior to initiating feeding, the nurse should aspirate gastric content, measure and record it, and check for placement. If the aspirate was more than 60 ml, the physician should be notified, and if no aspirate was obtained, the nurse should check for placement using auscultation. The nurse did not follow these procedures, which were clearly outlined in the resident's care plan. Another resident was found to have a gastrostomy tube site with brownish dry buildup drainage and no dressing, despite orders to cleanse the insertion site daily and cover it with gauze. The facility's policy on gastrostomy tube care emphasized the importance of daily cleaning and observing the peristomal skin for any signs of irritation or leakage. The Director of Nursing stated that nurses are expected to verify enteral feeding orders and provide site care as per the facility's policy, which was not adhered to in this case.

Penalty

4 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to administer medications as ordered, resulting in a medication error rate of 6.6%, which exceeds the acceptable threshold of 5%. During a medication pass, two errors were observed among 30 opportunities. The first error involved a registered nurse administering Ferrous Sulfate 325 mg to a resident, despite the medication being on hold according to the resident's Physician Order Sheet and Medication Administration Record. The second error occurred when a licensed practical nurse failed to administer Amiodarone Hydrochloride 200 mg to another resident, despite an order for the medication to be given orally in the morning. The Director of Nursing stated that nurses are expected to follow physician's orders and adhere to the five R's of medication administration: right drug, right dose, right route, right time, and right patient. The facility's Medication Administration Policy emphasizes the importance of safe and appropriate medication administration to aid residents in overcoming illness and preventing symptoms.

Penalty

4 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to serve a resident his prescribed diet, which was identified during an observation on 3/18/2025. The resident, who had a swallowing problem related to dysphagia, was supposed to receive nectar-thickened liquids as per his care plan and order summary report dated 3/20/2025. However, during the observation, the resident was served a thin consistency yellow drink instead of the prescribed nectar-thickened liquid. This discrepancy was confirmed by an agency registered nurse (RN) who verified that the resident was not served the correct consistency of drink. The Director of Nursing (DON) later stated that nursing staff are expected to check residents' meal tray items and tickets before serving to ensure they receive their prescribed diet.

Penalty

Inspection fine: $12,191

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement necessary interventions to prevent a resident from developing a pressure ulcer. The resident, who was admitted with multiple diagnoses including acute cystitis, acute respiratory failure, sepsis, bacteremia, heart failure, and acute kidney failure, was identified as having a high risk for pressure ulcers with a Braden Scale score of 10. Despite having a care plan that required frequent turning and repositioning, the resident developed a stage 2 pressure ulcer on the left ischium due to inadequate repositioning and prolonged exposure to soiled incontinence briefs. Observations and interviews revealed that the resident was often left in bed without being repositioned, and staff did not consistently respond to the resident's call light in a timely manner. The resident reported waiting for extended periods, sometimes over three hours, for incontinence care, which contributed to the development of the pressure ulcer. Staff interviews confirmed that the resident was not regularly repositioned, and documentation showed a lack of consistent repositioning as per the care plan. The wound nurse practitioner assessed the resident's pressure ulcer and attributed its development to prolonged sitting and exposure to stool. The facility's policies on wound prevention and ADL support were not adequately followed, as evidenced by the lack of documentation and staff actions that failed to meet the resident's care needs. The facility's failure to adhere to the care plan and provide timely incontinence care and repositioning led to the resident acquiring a pressure ulcer.

Penalty

Inspection fine: $12,191

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide timely incontinence care to a resident, identified as R2, who was dependent on staff for toileting hygiene due to multiple medical conditions including acute cystitis, acute respiratory failure, sepsis, bacteremia, heart failure, and acute kidney failure. R2's care plan indicated the need for frequent checks and assistance with toileting. However, on February 10, 2025, R2 was observed lying in bed with an activated call light, which had been on since 8:30 AM, waiting for his soiled incontinence brief to be changed. It was not until 10:23 AM that R2 received incontinence care from a registered nurse and a certified nursing assistant, who confirmed the presence of stool in the brief. R2 reported that on multiple occasions, including February 1, 2025, he had to wait over three hours for his soiled incontinence brief to be changed. The facility's policy on incontinence care emphasizes keeping residents dry and odor-free to prevent skin breakdown, and the policy on supportive activities of daily living requires providing necessary services for residents unable to carry out ADLs independently. Despite these policies, R2 experienced delays in receiving incontinence care, highlighting a deficiency in the facility's adherence to its own care protocols.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a staff member was skilled in changing an indwelling pleural catheter dressing appropriately for a resident with respiratory conditions. The resident, who was admitted with multiple diagnoses including toxic encephalopathy, acute respiratory failure, pleural effusions, and other chronic conditions, was supposed to receive care for an indwelling pleural catheter to manage pleural effusions and shortness of breath. On a specific date, during wound care, it was observed that the resident's catheter was not capped, and fluid was present at the open catheter tip, which was noted by both the Wound Care Registered Nurse and the Wound Care Nurse Practitioner. The Director of Nursing stated that nurses are expected to change catheter dressings in a sterile manner and cap the catheter tip to prevent infections. The facility's policy and the manufacturer's instructions both emphasize the importance of capping the catheter to avoid complications such as infections. However, the nurse who last changed the dressing did not cap the catheter, indicating a lack of competence or training in handling indwelling pleural catheters, as highlighted by the Director of Nursing.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to document the assessment of a resident who experienced a change in condition and required a hospital transfer due to abnormal vital signs. The resident, who had multiple diagnoses including toxic encephalopathy, acute respiratory failure, and congestive heart failure, was observed by a wound care RN to be agitated and having difficulty breathing. The resident's vital signs were unstable, with a blood pressure of 56/46 mmHg, a heart rate of 33 bpm, and an oxygen saturation of 77%. The resident was placed on 4 liters of oxygen, which improved the oxygen saturation to 99%, and was then transported to the hospital by emergency paramedics. The wound care RN assumed that the assigned RN documented the change in condition in the resident's EMR, while the assigned RN assumed the wound care RN had done so. As a result, the change in condition was not documented in the resident's medical record. The Director of Nursing stated that nurses are expected to document assessment findings when there is a change in condition. The resident's care plan required monitoring and recording of vital signs and notifying the MD of significant abnormalities, but the SNF/NF to Hospital Transfer form did not reflect the resident's change in condition or the abnormal vital signs observed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a comprehensive care plan was developed within 7 days after the completion of the comprehensive assessment for two residents. Resident 1 was admitted with multiple complex medical conditions, including cellulitis, atrial fibrillation, and end-stage renal disease, among others. Despite the comprehensive assessment being completed, there was no documentation of a care plan meeting or a scheduled meeting throughout the resident's stay, and the resident was eventually discharged to the hospital. Similarly, Resident 3, who was admitted with conditions such as osteomyelitis, diabetes, and hypertension, also did not have a documented care plan meeting. The resident expressed concerns about post-treatment plans and dietary options, indicating a lack of communication and planning. The Social Service Director acknowledged the responsibility for setting up care plan meetings and outlined the expected participants and process, but the facility's policy was not followed, as evidenced by the absence of documented meetings in the residents' medical records.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide timely assistance to a resident (R2) who required extensive help with activities of daily living, specifically in getting to the toilet. R2, who was admitted to the facility and had a physical therapy evaluation indicating a need for substantial assistance with transfers, was left unattended despite repeatedly requesting help to use the bathroom. On the morning of the incident, R2 activated her call light and verbally requested assistance from a Certified Nursing Assistant (CNA), who informed her that she could not be assisted until after a physical therapy evaluation. Despite R2's continued requests and the call light remaining on, she was not assisted until much later, resulting in her being incontinent of stool, which she stated was unusual for her. The Director of Nursing (V2) later clarified that call lights should be answered promptly and that residents do not need to wait for therapy evaluations to receive assistance. The facility's policy on Activities of Daily Living emphasizes the importance of maintaining residents' comfort, safety, and dignity, and ensuring they receive the necessary assistance. However, in this instance, the staff failed to adhere to these guidelines, as R2's plan of care indicated she could be transferred with one staff member using a walker and gait belt, which was not followed, leading to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper pressure ulcer treatment interventions for two residents, R1 and R2, leading to deficiencies in their care. R2, who had a stage 3 sacral pressure wound, was observed without a dressing during incontinence care, causing her pain. The Wound Registered Nurse, V11, confirmed that R2's wound should have had a dressing as per the treatment orders, but she was not notified by the CNAs when the dressing was missing. This lack of communication and adherence to the treatment plan resulted in inadequate care for R2's pressure ulcer. R1 was admitted to the facility with multiple wounds, including stage 4 pressure ulcers on her left hip and left lower leg. The Wound Care Registered Nurse, V11, was unaware of the need for wound vacs for R1's wounds until after admission. There was a delay in ordering and applying the necessary wound vacs, and the Treatment Administration Record (TAR) and Medication Administration Record (MAR) lacked documentation of wound care orders for R1's wounds until several days after admission. This oversight in documentation and communication led to a failure in providing timely and appropriate wound care for R1.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate supervision and safe eating interventions for residents with swallowing and eating disorders, leading to deficiencies in care. One resident, an elderly male with diagnoses including anorexia, dysphagia, and anxiety, was observed feeding himself without staff supervision despite having specific dietary orders requiring supervision and a special eating plan. The staff present, including CNAs and an RN, were unaware of the resident's required interventions and failed to provide the necessary supervision. Additionally, the resident's communication board was not available, further hindering effective communication and supervision. Another resident, an elderly female with diagnoses of protein calorie malnutrition and dysphagia, was observed consuming her food rapidly without staff intervention. Despite having a care plan that required her to eat slowly and chew thoroughly, the CNAs present did not prompt her to slow down or swallow between bites. The staff's inaction in both cases demonstrates a lack of adherence to the residents' care plans and dietary orders, resulting in a failure to ensure a safe eating environment for residents with swallowing and eating disorders.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide nutritional supplements as ordered for residents with weight loss and nutritional needs. This deficiency was observed in two residents. The first resident, a female with diagnoses including protein calorie malnutrition and dysphagia, was observed eating rapidly without prompts from the CNAs to slow down or swallow between bites. Her meal tray was missing the prescribed nutritional supplement dessert. The resident's care plan included interventions for her chewing problem, but these were not followed during the observation. The second resident, who also had a diagnosis of protein calorie malnutrition and dysphagia, was observed being fed by a CNA. This resident's meal tray was also missing the nutritional supplement dessert as ordered. The CNA was unaware of the order for the supplement. The Dietary Director confirmed that the nutritional supplement dessert is stored in unit refrigerators and should be added to trays by nursing staff, but this was not done for the observed residents.

Penalty

Inspection fine: $15,360

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the physician of a significant change in a resident's condition in a timely manner, resulting in a delay in treatment and pain relief. The resident, who had a history of heart failure, psychological disorders, and a previous femur fracture, was admitted to the facility and required extensive assistance with daily activities. On a particular night, the resident was found yelling and guarding her right leg, indicating pain. Despite multiple attempts by a registered nurse to contact the attending physician through an answering service, there was no response, and the administration was not informed of the lack of communication. The resident's condition worsened, with swelling and discoloration observed in the right leg and left arm. Several staff members, including CNAs and LPNs, noted the resident's complaints of pain and visible symptoms but did not escalate the issue to higher authorities or alternative contacts until the following day. It was only after a registered nurse informed the Director of Nursing and the physician assistant that the resident received medical attention, including an x-ray that revealed a supracondylar fracture of the right femur. The facility's policy required immediate notification of a physician or on-call medical personnel in the event of a significant change in a resident's condition. However, the failure to follow this protocol led to a two-day delay in addressing the resident's pain and injury. The attending physician and physician assistant were unaware of the situation until they were contacted directly, highlighting a breakdown in communication and adherence to established procedures.

Penalty

Inspection fine: $15,360

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to utilize a gait belt during the transfer of a resident, which is a violation of their policy on gait belt usage. A Certified Nurse Assistant (CNA) admitted to transferring a resident without using a gait belt, instead opting to pull the resident's brief and pants to lift and transfer her. This action was contrary to the facility's policy, which mandates the use of gait belts to prevent injury during resident transfers. The CNA's method of transfer was not in compliance with the established procedures designed to ensure the safety of both staff and residents. Additionally, the facility did not revise the resident's care plan following a fall incident. The resident, who had a history of falls and was assessed as high risk for falls, experienced a fall on a previous date. Despite this, the care plan was not updated to address additional fall risks, such as the resident's recent hearing loss, blindness, and behaviors of hitting and swaying during care. The lack of revision in the care plan after the fall incident indicates a failure to implement individualized interventions for high-risk residents, as outlined in the facility's fall prevention policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to have a designated certified Infection Preventionist (IP) responsible for the Infection Control Prevention Program, affecting all 130 residents. The Director of Nursing (DON), who assumed the IP role in October 2023, had not completed the required certification exam despite starting an infection preventionist training course approximately six years ago. Both the Administrator and the Regional Nurse Consultant were under the impression that the DON had completed the necessary training and certification. The facility's policy, reviewed in June 2023, mandates that the IP must be a licensed professional nurse who has completed specialized infection training recommended by the CDC.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its Infection Prevention and Control Program by not providing surveillance data to the Local Health Department after a confirmed case of Legionnaire's disease was associated with the facility. The Director of Nursing (DON), who also served as the Infection Preventionist (IP), was notified by the Local Health Department about the positive test result for Legionnaire's disease. However, the DON did not review the hospital medical records, did not notify the resident's care team, and did not document the positive test result in the resident's Electronic Medical Record (EMR). This failure affected eight residents reviewed for communicable diseases of Legionnaire's. The DON admitted to not being familiar with Legionella and its symptoms and only tracked infections requiring transmission precautions, not pneumonia. Despite multiple attempts by the Local Health Department to obtain a complete Legionella Surveillance report, the DON submitted an incomplete report and failed to respond promptly to follow-up communications. The Local Health Department expressed concern over the facility's low responsiveness, emphasizing that one case of Legionnaire's disease in a long-term care facility triggers an investigation and requires cooperation to prevent potential health risks to other residents. The facility's policy on Legionella Surveillance and Detection outlined procedures for training clinical staff on symptoms, notifying physicians, and initiating active surveillance if Legionella is detected. However, the DON did not follow these procedures, resulting in incomplete data collection and delayed reporting. The facility's failure to adhere to its own policy and the Local Health Department's guidelines put other residents at risk for Legionnaire's disease, as evidenced by the identification of additional residents with healthcare-associated pneumonia during the survey.