Warren Barr Lincoln Park

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 deficiency involves the facility’s failure to adequately supervise and implement effective fall-prevention measures for a resident with a known history of falls and severe cognitive impairment. The resident had diagnoses including syncope, collapse, falling, transient cerebral ischemic attack, hypertension, abnormal gait and mobility, chronic fatigue, and Alzheimer’s disease. An MDS documented a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment, and showed the resident required supervision or touching assistance for toileting hygiene and walking 10 feet with a walker. The care plan identified the resident as at high risk for falls related to dementia, behavioral and mood disturbances, anxiety, poor awareness, decreased comprehension, impulsivity, and memory deficits, and documented that the resident required assistance with all ADLs, including toileting and walking, and demonstrated movement behaviors such as wandering, pacing, or roaming. Despite these identified risks, the facility did not maintain accurate fall risk assessments or ensure consistent implementation of fall precautions. A fall risk assessment completed on the date of the fall scored the resident as high risk with a score of 13, but subsequent fall risk evaluations in December and January documented a score of 0, categorizing the resident as low risk for falls, which the DON later stated was not accurate. The resident’s orders allowed use of bed and chair alarms, and the care plan included use of a chair/bed alarm related to potential falls and frequent monitoring. However, staff interviews revealed uncertainty about whether the bed alarm was in place at the time of the fall, and one CNA reported that the bed alarm in use had a very faint sound, suggesting low battery, and could not be heard in the hallway. The DON stated that only residents at high risk for falls should have bed alarms and that any resident who has fallen is automatically considered high risk, indicating a discrepancy between policy and the documented low-risk scores. On the day of the incident, the resident was found lying on his back on the bathroom floor with a laceration to the forehead after an unwitnessed fall. The resident reported having walked to the bathroom, used it, and then only remembered waking up on the floor. The resident did not have his walker with him in the bathroom at the time of the fall. Staff reported that the resident was impulsive, would get up by himself when he had the urge to use the bathroom, and required frequent monitoring and supervision when ambulating or going to the bathroom. The LPN and CNA assigned to the resident stated that he should have been supervised for toileting and ambulation and that if he had assistance with toileting, the fall could have been prevented. At the time of surveyor observation, the resident’s call light was found on the floor at the head of the bed, out of reach, despite staff acknowledging that the call light should always be within reach. Staffing on the unit consisted of one nurse and three CNAs for 38 residents, and both the DON and floor staff described this as a staffing problem that affected the ability to provide quality care and adequate supervision, contributing to the failure to prevent the resident’s fall and resulting head laceration requiring sutures.

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 accounting and administration of narcotic medications, as well as adherence to medication administration protocols. During a shift change, a registered nurse (V10) did not sign the narcotic record documents, and discrepancies were found in the count of R23's Pregabalin 75 MG. Similarly, a licensed practical nurse (V11) found discrepancies in the narcotic counts for two residents, with missing tablets of Oxycodone and Morphine Sulfate. Both nurses admitted to forgetting to sign the records, which is a violation of the facility's policy requiring accurate documentation and accountability for controlled substances. Additionally, the facility failed to follow proper procedures for administering medications via gastronomy tube. A licensed practical nurse (V12) prepared multiple medications for R69 without separating them into individual cups, contrary to the policy that requires each medication to be flushed independently with water. V12 also failed to maintain cleanliness by touching high-touch areas and the enteral tube with the same gloves used for medication administration, which could compromise the sterility of the procedure. The facility also did not ensure the availability of insulin as per physician orders, leading to a delay in administration. A licensed practical nurse (V13) attempted to administer expired Humalog insulin to R11, realizing the error only after being questioned. The insulin had been opened beyond its 28-day expiration period, and V13 was unable to find a non-expired insulin vial, resulting in a delay until a one-time dose was authorized by the physician. This incident highlights the facility's failure to adhere to medication labeling and expiration protocols, as outlined in their 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 properly label and store medications, including insulins and controlled substances, as per their policy and professional standards. During an inspection, it was observed that several insulin vials for residents were not dated when opened, and some were found to be expired but still stored in the medication cart. Specifically, insulins for residents were either missing open dates or were past their expiration dates, yet remained in use. Additionally, an eye drop medication was found without a date in the medication cart. Controlled substances were not stored according to the required double-lock protocol. A Lorazepam vial, a controlled substance, was found in an unlocked refrigerator at the nurse station, which was supposed to be secured. Furthermore, this medication had been discontinued but was still present in the storage area. The Director of Nursing confirmed that all narcotics should be double-locked and that discontinued medications should be destroyed per pharmacy guidelines. These lapses in medication management affected six residents reviewed for drug storage.

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 maintain medical records in accordance with accepted professional standards for eight residents. This deficiency was identified through interviews and record reviews. A Certified Nursing Assistant (CNA), identified as V14, was found to be allowing another CNA, V15, to document resident care under her login credentials. V15, who works through an agency and occasionally at the facility, stated she was unable to log into her account and thus documented care under V14's account. This practice was confirmed by V14, who mentioned that the documentation of care was what mattered, regardless of who logged it. The Assistant Director of Nursing, V3, stated that all agency staff are provided with individual electronic login access to document their work, and another CNA, V32, confirmed that staff are not allowed to share login information. Despite this, the facility's floor assignment records showed that V15 was responsible for several residents, yet documentation for these residents was completed under V14's login. This included tasks related to bowel and bladder management, as well as behavior monitoring and intervention. The facility's policy emphasizes the importance of safeguarding resident information and maintaining accurate medical records, which was not adhered to 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

The facility failed to accurately complete a comprehensive annual assessment for a resident, identified as R29. The issue arose when the Minimum Data Set (MDS) was incorrectly submitted as a quarterly assessment instead of an annual one. This error was identified during an interview with the MDS Consultant, who noted that the resident's census line contained an error due to the resident's hospital admission and subsequent return to the facility as a dual Medicaid and Medicare payor. The MDS was scheduled in sequence, but the quarterly assessment was mistakenly submitted in place of the required annual assessment. The facility did not have a current MDS Coordinator, and someone from another facility was covering the MDS responsibilities, contributing to the oversight. The error was recognized on the last day to complete the annual assessment, prompting the inactivation of the quarterly assessment and the initiation of the annual assessment process.

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 initiate a new Level I PASARR screening for a resident, identified as R70, who was reviewed for Pre-Admission Screening and Record Review (PASARR). R70 was admitted to the facility with an exempted hospital discharge, which allowed for a 30-day length of stay without a new PASARR screening. However, this exemption expired, and the facility did not conduct a new Level I PASARR screening as required. The administrator, V1, acknowledged that the resident's PASARR screening had expired and that a new screening was necessary but had not been completed. The facility's policy mandates that residents with mental disorders or intellectual disabilities receive PASARR screenings within the allowed timeframe. Despite this policy, the facility did not adhere to the requirement for R70, whose exemption status had lapsed. The administrator also demonstrated a lack of understanding regarding the determination of needs (DON) score ranges and their implications, which are crucial for deciding if a resident requires a Level II PASARR screening for severe mental illness. This oversight resulted in a deficiency related to the facility's failure to ensure appropriate PASARR screenings were conducted in a timely manner.

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 address a high blood sugar result for a resident with diabetes mellitus, leading to a deficiency in care. The resident, who was receiving Paxlovid for Covid-19, had a physician's order to monitor blood sugar levels and notify the doctor if results were below 60 or above 300. On the day of the incident, the resident's blood sugar was recorded at 333, which required physician notification according to the order. However, there was no documentation indicating that the physician or nurse practitioner was informed of this elevated result. Later, the resident's blood sugar further increased to 397, and the resident was pronounced expired by EMS at 3:15 PM. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's elevated blood sugar levels. The Director of Nursing was not present at the time and was unsure if the physician was notified, while the Restorative Director stated she was not informed of the elevated levels. The Nurse Practitioner acknowledged being informed of the initial high result but was unaware of the subsequent increase to 397. He admitted to not documenting the elevated blood sugar or any actions taken to address it, highlighting a failure in following the physician's order and ensuring proper care for the resident.

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 preventative measures for two residents, R4 and R62, who were both on low air loss mattresses as per their physician orders. R4's physician order summary indicated the need for a low air loss mattress for pressure reduction, yet observations revealed that R4 was lying on a mattress with a fitted sheet and a flat sheet folded twice, which is against the facility's protocol. Similarly, R62, who required the mattress due to active wounds, was found with a fitted sheet and a folded flat sheet, contrary to the guidelines that specify only a single sheet, a blue pad, and a brief should be used. The Wound Care Manager confirmed that the facility's protocol does not allow for both a fitted and a flat sheet, nor the use of a folded flat sheet as a draw sheet, as this creates excessive layers. The Proactive Medical Products Operation Manual and the Med-Aire 8 Alternating Pressure Mattress Replacement System User Manual both recommend minimal layering to prevent pressure injuries. The facility's failure to adhere to these guidelines resulted in a deficiency in providing appropriate pressure ulcer care and prevention for the residents involved.

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 adhere to its policy on accommodating resident food preferences, specifically for one resident, R70, who was part of a sample of 21 residents reviewed. R70's Nutrition Progress Note indicated that her diet should include food preferences and alternatives as needed. Despite this, the facility served eggs to R70 for breakfast on multiple occasions, even though she had explicitly informed the staff, including the Dietary Manager (V8), that she disliked eggs. R70's food preference interview form, which documented her preference against eggs, was not reflected on her dietary meal ticket, leading to repeated servings of eggs. The Dietary Manager, V8, acknowledged awareness of R70's preference against eggs and admitted to completing a food preference interview form for R70. However, the form was initially misplaced and later found in a storage clipboard. The oversight was attributed to the failure to document R70's no-egg preference on her dietary meal ticket, which should have been updated according to the facility's policy. This lapse resulted in R70 refusing her breakfast meal tray when eggs were served, highlighting a breakdown in the communication and implementation of dietary preferences within the facility.

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 the appropriate use of personal protective equipment (PPE) by staff caring for a resident with a known infectious disease. A resident diagnosed with shingles was placed on contact isolation precautions, requiring staff to wear gowns and gloves before entering the room. However, observations revealed that staff members, including a CNA Supervisor and a CNA, entered the resident's room without donning the required PPE, despite being aware of the resident's condition and the posted contact precautions. Both staff members acknowledged their failure to adhere to the PPE requirements and recognized the potential risk of cross-contamination and spreading the infection to other residents. Additionally, the facility did not maintain clean technique and infection control practices during a bed bath for another resident. The resident, who required substantial assistance for bathing, reported inadequate cleaning by certain CNAs, particularly in the perineal area. During an observed bed bath, a CNA used the same washcloth for multiple body areas, including the perineal area, without changing gloves or washcloths, contrary to best practices for infection prevention. The CNA acknowledged that the observed procedure was not her usual practice, and the facility lacked a specific bed bath procedure policy. The facility's infection prevention and control policy required the use of gowns and gloves for contact precautions and emphasized maintaining clean techniques during hygienic care. However, the staff's actions during the observed incidents did not align with these policies, leading to deficiencies in infection prevention and control practices for the residents involved.

Penalty

Inspection fine: $180,750

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 resident from physical abuse by a Certified Nursing Assistant (CNA), which was identified as an Immediate Jeopardy situation. The incident involved a resident with dementia who was handled roughly and hit on the arm and back by the CNA while attempting to redirect the resident. The abuse occurred on 06/30/24, but the facility's video recording system did not retain footage from that date, as it only stored recordings for seven days. The resident, who does not speak English and has a history of dementia with agitation, was unable to recall or speak of the abuse incident. The CNA admitted to hitting the resident after the resident allegedly hit her first. Another CNA witnessed the incident and reported it to a nurse on duty, but no action was taken until the surveyor's investigation. The facility's policy clearly states that abuse, including hitting, is not acceptable under any circumstances. Despite the facility's investigation concluding that the allegation of abuse could not be substantiated, multiple staff members, including the Director of Nursing and the Social Services Director, acknowledged that hitting a resident is a form of abuse. The Medical Director suggested that the incident might be considered self-defense but emphasized that staff should de-escalate situations without resorting to aggression. The facility's policy mandates immediate reporting of any abuse allegations to the administrator.

Removal Plan

• V20 suspended.
• R1 is no longer residing at the facility. R1 has been discharged to another Long-Term Care.
• R1 full skin assessment conducted.
• R1 seen by psychotherapist.
• R1 evaluated by Physiatrist.
• R1 screened for abuse/neglect.
• V21 was suspended for not reporting to V1, pending investigation.
• Staff are being educated on Abuse, with quiz to monitor effectiveness.
• Abuse in-service completed.
• Abuse in-service on Handling Aggressive Behaviors with quiz for 5 staff members three times per week for 12 weeks on-going.
• Social Work outside consultation group initiated monthly in-service on de-escalation techniques and handling aggressive residents.
• Staff training on facility code gray for aggressive behavior/violence, initiated and completed.
• QA (Quality Assurance) audit on 3 times weekly times 12 weeks to ensure direct staff care staff (Nurses and CNA's).
• Thirteen residents R1, R7, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, and R22, were reviewed for abuse and aggressive behaviors. List of residents with behaviors provided and posted at the nurse's station inside a closed cupboard.
• V27 (Medical Director) interviewed and was aware of the removal plan with V27's approval.

Penalty

Inspection fine: $180,750

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 medication carts were locked and within the visual proximity of licensed nurses when not in use, posing a potential hazard to residents. On the 3rd floor, a treatment cart was observed unlocked and unattended in the hallway. The RN on duty, V16, acknowledged the facility's policy that medications should be locked when not in use but stated that they were not responsible for the cart. The Wound Care Nurse, V18, confirmed that the cart should have been locked to prevent resident access. Similarly, on the 2nd floor, a medication cart was found unlocked and unattended. The LPN, V24, admitted that the cart should have been locked when not in visual proximity, explaining that they had left it to administer medication in the dining room. The facility's policies on hazards and medication storage clearly state that medications must be secured to prevent resident access, yet these protocols were not followed, creating a potential risk for all residents on the affected floors.

Penalty

Inspection fine: $180,750

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 report an allegation of abuse to the Illinois Department of Public Health (IDPH) within the required time frame. This incident involved a resident with dementia, who was handled roughly and hit on the arm and back by a Certified Nursing Assistant (CNA) in an attempt to redirect the resident. The incident was witnessed by another CNA, who reported that the resident was hit multiple times and handled roughly, which was not appropriate even if the resident was combative. Despite the witness reporting the incident to the nurse on duty, no action was taken until the surveyor's visit. The facility's policy on abuse and neglect, revised in June 2024, mandates that all allegations of abuse must be reported immediately to the administrator, who is the Abuse Coordinator, and to the IDPH. The policy defines abuse as willful infliction of mistreatment, including physical actions such as hitting and grabbing. The failure to report the incident promptly and the lack of immediate action by the staff on duty contributed to the deficiency identified by the surveyors.

Penalty

Inspection fine: $180,750

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 an alleged physical abuse incident involving a resident, identified as R1, who was handled roughly and physically hit by a Certified Nursing Assistant (CNA), V20. R1, who has dementia and other medical conditions, was reportedly hit on the arm and back by V20 in an attempt to redirect R1 from sitting on the floor. V20 admitted to hitting R1 after being elbowed by the resident, but did not report the incident to the facility's Abuse Coordinator, V1, as V20 did not initially perceive it as abuse. The incident was captured on a hallway camera, but no action was taken until the surveyor's visit. Another CNA, V21, witnessed the incident and confirmed that V20 hit R1 multiple times and handled the resident roughly. V21 reported the incident to the nurse on duty, V10, but no investigation was initiated. The facility's policy on abuse and neglect mandates immediate reporting and investigation of such incidents, which was not followed in this case. The policy outlines that abuse includes hitting and rough handling, and all staff are required to report any alleged abuse immediately to the Abuse Coordinator.

Penalty

Inspection fine: $180,750

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 medication was administered as ordered for a resident, identified as R3, who was reviewed for medication administration. R3's Medication Administration Record (MAR) and Physician Order Sheet (POS) indicated an order for Potassium chloride crys ER 20 meq tablet extended release to be given by mouth once a day every Monday, Wednesday, and Friday. However, R3 was administered this medication on a Thursday, which was not in accordance with the prescribed schedule. On the day of the incident, R3 was observed in bed with two plastic medication cups containing pills, including a large whitish pill identified as potassium. R3 expressed stress and confusion about the medication, stating that the nurse had not provided assistance in identifying the pills. The Registered Nurse (RN), identified as V16, was unaware that R3 had not taken the medication and proceeded to administer the potassium despite the error in timing. V16 did not document the administration of potassium at the correct time and signed off the scheduled medication as given at 9:00 am, although it was administered later. The facility's Director of Nursing (DON), identified as V2, confirmed that medications should be administered as ordered and not left at the bedside unless the resident is assessed to self-administer safely. The facility's policies on medication pass and physician orders emphasize adherence to federal and state regulations and following physician orders as written, which were not followed 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

The facility failed to follow their policy on enteral tube feeding care by not labeling the date and time the feeding was started for two residents. Resident 2 (R2) had severe cognitive impairment and was on a Jevity1.5 enteral feeding at 75ml/hour. During an observation, it was noted that the nutritional supplement bottle was not labeled with the date and time it was started. The LPN on duty was unaware of when the feeding was initiated, which is against the facility's policy. Similarly, Resident 3 (R3), who also had severe cognitive impairment, was on a Jevity1.2 enteral feeding at 60ml/hour. The nutritional supplement bottle for R3 was also found without a date and time label, and the LPN did not know when it was started. Both residents' nutritional supplements were running at the prescribed rates, but the lack of labeling posed a risk for potential gastrointestinal issues and infections due to the possibility of using the supplement beyond the recommended 24-hour period. The Registered Dietitian and the Director of Nursing confirmed that the facility's policy requires the date and time to be labeled on the feeding bottles to ensure they are changed within 24 hours to prevent infections and ensure the residents receive fresh feedings. The failure to label the feeding bottles as per the policy was observed during the survey, and it was acknowledged by the staff that this oversight could lead to significant health risks for the residents, including gastrointestinal issues and potential infections due to compromised health conditions.