Every finding on record at La Bella of Caseyville

Caseyville, Illinois · CCN 145585

39 findings across 25 inspections, in the inspector's own words, 24 of them at actual harm or above.

Data as of September 30, 2026, released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

Based on interview and record review, the facility failed to adequately develop an ongoing infection control program that adequately collected data to calculate and analyze infection rates and failed to operationalize infection control policies to adequately define infection control practice in the facility. This has the potential to affect all 88 residents living in the facility. Findings Include: The facility Infection Control Log was requested for the entire year since the last survey. On 5/28/2024 at 9:02 AM, An infection control log was provided but did not have any dates or organisms listed or documented. On 5/28/2024 at 10:43 AM, V3, Assistant Director of Nursing (DON) stated, I just recently was hired and took over as the infection control preventionist in March. I have completed this course and got my certificate. All of the surveillance, everything should be in the book. I am new to this position, and I just have not gotten the surveillance/infection control where it needs to be at. I know there are no organism listed. The infection control book provided by V3 on 5/28/2024 listed residents' names and identified urinary tract infections along with the medication but none of the urinary tract infections had organisms documented and no organisms were provided for the entire book. The book was incomplete. The Long -Term Care Facility Application for Medicare and Medicaid form, dated 5/28/2024, had a census of 87 residents. The Facility Infection Control Program Policy revision date or 8/2017 documented, The facility will maintain an infection control program that is designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. The ICP (Infection Control Preventionist) will investigate, control and prevent the infections in the facility by monitoring laboratory reports and physician orders and following symptomatic trends within the facility that may indicate patters of infection.

F584E · No harm, potential for more than minimal, pattern

Based on observation, interview and record review, the facility failed to ensure resident clothes were being maintained, cleaned, and returned in a timely manner for 5 out of 7 residents (R32, R36, R70, R77, R82) reviewed for laundry in the sample of 42. Findings include: On 5/28/2024 at 8:45 AM, V7, Activity Director, was asked to bring 4-5 residents to a group meeting that were able to answer questions and were interviewable. The following residents were brought to the meeting R32, R36, R70, R77 and R82. During the group meeting on 5/29/2024 at 8:45 AM, R32, R36, R70, R77 and R82 all stated they were having issues with missing laundry and the facility was not doing anything about it. 1.R36's Minimum Data Set (MDS), dated [DATE], documented that she was cognitively intact for decision making of activities of daily living. On 5/29/2024 at 9:01 AM, R36 stated, We have issues with laundry too and things go missing and they never find it or replace it. It's not right! 2.R72's MDS, dated [DATE], documented that R72 was cognitively intact for decision making for activities of daily living. On 5/29/2024 at 8:56 AM, R72 stated, I have had lots of missing clothing lost and never returned and not replaced. 3. R82's Minimum Data Set (MDS), dated [DATE], documented that R82 was moderately impaired for decision making of activities of daily living. On 5/29/2024 at 8:59 AM, R82 stated, Clothes are always going missing and staff do not really help you or really care. I have lost lots of clothes, told them about it and they were never replaced. 4. R77's MDS dated [DATE] documented, R77 was cognitively intact for decision making for activities of daily living. On 5/29/2024 at 8:52 AM, R77 stated, We have some issues with clothes going missing and the facility not even trying to find them or replace them. This has been going on for months now. They lose your clothes and don't care or even try to find you something different. I went inside the laundry room because they told me any clothing without labels is put in a bin for residents to go through. When I asked, I was told the bin was empty because they had donated the clothes. That does not make sense to me. Why would you donate our clothes? How does that make sense nobody told me there was a bin of unidentified clothes I could go through. 5- R32's Minimum Data Set (MDS), dated [DATE], documented that R32 was cognitively intact for decision making of activities of daily living. On 5/29/2024 at 8:52 AM, R32 stated, They don't care about our clothes. They lose our clothes and don't find them or replace them. R58's Resident Family Grievance, dated 12/27/2023, documented, Resident stated that CNA's take her clothes out of her room for laundry but not returning them. She's missing about 10 pair of slacks shirts and socks. R60's Resident Family Grievance, dated 3/6/2024, documented, Rude answer about my clothing. Plan to resolve: This writer spoke to housekeeping/laundry supervisor in regards to clothes. Supervisor will get with (R60) resident was advised to have name marked in clothing so laundry will know they belong to him. I am missing tons of shirts and pants. R62's Resident / Family Grievances, dated 1/5/2024, documented, Resident's father stated that resident's blue sweat suit that he received as a gift for Christmas is missing, it's a pullover hoodie no zipper with pants to match. Resident's father wants a replacement. Findings of investigation, Resident clothes were not found. POA (Power of Attorney) did not want to go to laundry to identify belongings. Plan to Resolve: Have resident's POA identify clothing in laundry. On 5/29/2024 at 10:08 AM, V6, Ombudsman, stated, I have been having a lot of complaints from residents and family members regarding laundry being lost and never found or replaced. I talked with (V1) about for several months, but it does not seem to improve or get better. V18, Laundry Supervisor, stated that residents sign a contract when they come in the facility that their clothing is to be marked with their name on it and clothing will be thrown away if not claimed after 60 days. We contact the POA (Power of Attorney) or family representative and tell them to come in and go through the lost and found clothing before the items are thrown away. We only have so much room for storage. On 5/31/2024 at 10:10 AM, A review of admission contract was reviewed, and it does not document that clothing with no name will be discarded after 60 days. On 5/31/2024 at 10:36 AM, in the laundry room with the wheelchairs was a rack with 5 large boxes approximately 24 inches by 18 inches by 24 inches each box contained resident clothing that was not labeled. (e.g., shirts, pants, pajamas). On 5/31/2024 at 10:39 PM, V18, Laundry Supervisor, stated, These 5 boxes have clothes that do not have labels or names. The Resident Right Policy with a revision date of 11/18, documented, Nursing home residents have the right to: Dignity, respect and a comfortable living environment. The Notification of Policy Regarding Personal Property, undated, documented, This facility understands the value and importance of everyone's personal property. Because we care, we make every effort to assure that your possessions are not lost, misplaced or stolen.

F550E · No harm, potential for more than minimal, pattern

Based on interview and record review, the facility failed to ensure call lights were being answered in a timely manner for 5 of 7 residents (R32, R36, R70, R77, R82) reviewed for call lights in the sample of 54. Findings include: On 5/28/2024 at 8:45 AM, V7, Activity Director, was asked to bring 4-5 residents to a group meeting that were able to answer questions and were interviewable. The following residents were brought to the meeting; R32, R36, R70, R77 and R82. During the group meeting on 5/29/2024 at 8:45 AM, R32, R36, R70, R77 and R82 all stated they were having issues with the call lights not being answered in a timely manner on all shifts. They stated the average wait time is probably 30 minutes with some times even longer depending on what is going in in the facility. R32's Minimum Data Set (MDS), dated [DATE], documented that R32 was cognitively intact for decision making of activities of daily living. On 5/29/2024 at 8:52 AM, R32 stated, We have been having issues with call lights and we have talked about it at the resident council meeting. It does not seem to be getting better. It depends on the day and what else is going on but for those of us that need help we have to wait and call light has been a big problem here. R70's MDS, dated [DATE], documented, R70 was moderately impaired for cognition for decision making of activities of daily living. On 5/29/2024 at 8:54 AM, R70 stated, I am in a wheelchair, and I do not even use the call light because why bother when they never answer it. Thankfully, I just yell for help or go and find someone when I need help. R72's MDS dated [DATE], documented R72 was cognitively intact for decision making for activities of daily living. On 5/29/2024 at 8:56 AM, R72 stated, I am getting ready to leave soon. I have been in a wheelchair, and I need help. The call lights are a big problem because staff are not answering them or worse, yet they come in and answer the call light then turn off the light and never come back. R82's Minimum Data Set (MDS), dated [DATE], documented R82 was moderately impaired for decision making of activities of daily living. On 5/29/2024 at 8:59 AM, R82 stated, I can do most things by myself, but everyone has been complaining (that needs help) about the call lights taking a long time to answer. R77's MDS, dated [DATE], documented, R77 was cognitively intact for decision making for activities of daily living. On 5/29/2024 at 9:00 AM, R77 stated, I am fortunate that I can do most things by myself. I have been coming to these meetings for about four months and residents have been complaining about call lights not being answered. Residents needing help and residents not getting help. R36's MDS, dated [DATE], documented that she was cognitively intact for decision making of activities of daily living. On 5/29/2024 at 9:01 AM, R36 stated, Call lights are a problem and we have told (V1) and the ombudsman but they are still not answered in a timely manner. Resident Council Meeting Minutes, dated 5/20/204, documented, Call lights need answered ASAP. Resident Council Meeting Minutes, dated 2/26/2024, documented, Long call light time. Resident Council Meeting Minutes, dated 3/26/2024, documented, Call lights take time to be answered. R190's Grievance, dated 2/27/2023, documented, No one answer call lights. Do not work together. Findings of investigation: Ongoing issues, Put in place call light audit. Plan to resolve Complaint: Call light audit, in-services. Grievance was not resolved. Resident Council Meeting Minutes, dated 4/25/2023, documented, Call lights not being answered timely or coming in and saying, I'll be back then not returning. On 5/29/2024 at 10:02 AM, V6, Ombudsman, stated, I have been having a lot of complaints from residents and family members regarding call lights for the past three months. I have approached (V1, Administrator) and she tells me she is going to address it, but it is still happening and nothing has changed. On 5/29/2024 at 3:02 PM, V1, Administrator stated, We have had in-services on call lights. I have been told there are some issues with call lights. I am not sure when the last audit was done or what the results were from that audit. On 5/29/2024 at 4:02 PM, V1 stated, There was no policy on call lights. The Resident Right Policy with a revision date of 11/18, documented, Nursing home residents have the right to: Dignity, respect and a comfortable living environment. The Resident Right Policy with a revision date of 11/18, documented, Nursing home residents have the right to: Dignity, respect and a comfortable living environment.

F881D · No harm, potential for more than minimal, isolated

2 findings

F604G · Actual harm, isolated

2 findings

F441L · Immediate jeopardy, widespread

A. Based on observation, interview and record review, the facility failed to follow isolation precautions / protocols, when caring for residents with infections, failed to clean and disinfect medical equipment, and failed to implement ongoing surveillance of employee isolation practices, for residents with Methicillin Staphylococcus Aureus (MRSA) and Clostridium Difficile (C-diff). This has the potential to affect all 117 residents in the facility. This failure resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 4/18/12, the facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of the Infection Control policies and procedures. Findings include: 1. On 4/13/12 at 9:05 AM, E4, Licensed Practical Nurse, (LPN) prepared to give medications to R16 per Gastrostomy Tube ([DEVICE]). E4 stated that R16 took his medications via Tube ([DEVICE]). Two signs were observed hanging on the door to R16's room and they documented; Droplet Precautions, and Contact Isolation. E4 put on gloves and a mask and brought the medications into R16's room and set them on top of the night stand. In the room a stethoscope and blood pressure cuff were observed sitting on top of a cabinet across from R16's bed. E4 then took her personal stethoscope from around her neck and used it to auscultate R16's [DEVICE] site. When finished E4 placed the stethoscope back around her neck/shoulders. Once finished giving the medications, E4 removed her gloves and mask, washed her hands and left the room. E4 failed to clean the stethoscope around her neck, and after pushing the medication cart up the hall towards the nurses station, E4 began putting her supplies away in the cart drawers. On 4/13/12 at 9:33 AM, E2, Director of Nurses came to the medication care where E4 was working. E2 stated "The facility policy is that staff are to use the stethoscope that has been placed in the room of all residents with[DIAGNOSES REDACTED]. Staff are not to use personal stethoscopes on residents placed on contact isolation. E4, agreed with E2 that this was the facility policy. E4 then gasped and said, "Oh, I used my stethoscope on R16." When asked what is the policy for cleaning medical equipment E4 stated "it should be cleaned with a bleach wipe." E4 showed where the container with the bleach wipes was stored on the cart. E4 then continued putting her supplies away. At 9:35 AM, E4 was asked if she had cleaned her stethoscope since leaving R16's room. E4 stated, "Oh, No, I forgot to do it. Do you want me to clean it now?" E4 then cleaned her stethoscope. On 4/17/12, at 8:50 AM, E10 identified the following residents currently have infections; R15 and R16 have active[DIAGNOSES REDACTED], and R10, R7, R16, R83 have MRSA infections. E10 stated "I do infection control inservices with staff, quaterly throughout the year. Staff train on all aspects of infection control including contact isolation. Inservices are mandatory for nursing / cna staff and they include a written test when completed. Housekeeping also is trained on how to clean rooms of residents with[DIAGNOSES REDACTED]. At this time we have no program for monitoring staff once they complete the inservices. The nurses should know what to do, they are taught this in nursing school." Per the facility policy, residents on contact isolation are to have their own stethoscope and blood pressure cuff in their room as well as thermometer, and glucometer if necessary. Nurses are told "not" to use their own personal stethoscopes on infected patients, and not to bring them into an isolated residents' room." If there is a concern, or I see some one do something wrong when I am on the floor, I will discuss it with the staff member involved. I do not follow staff and check on how they practice infection control unless I am told there might be a problem. No one has told me, and I have not seen, any nurses bringing their personal stethoscopes into the rooms of residents on contact isolation. No one has told me that staff are not using masks when going into the rooms of residents on droplet precautions for MRSA of the Nares. On 4/17/12 at 9:20 AM, E2 Director of Nursing stated, "Currently there is no program for monitoring staff once they have had attended the inservice on infection control policies. If I am out on the hall and see a staff do something wrong, I will retrain the staff at that time or have E10 do it. There is a nurses meeting once a month, if they tell me there is a concern with infections, I address it at that time. No one has told me that the nurses are taking stethoscopes into the resident's rooms with contact isolation. I rely on E10 to be aware of any infection issues, as I am not always able to be out on the floor with the residents due to all the paperwork I do." 2. During tour of the facility on 4/10/12, at 9:20 AM, E16, Registered Nurse (RN) reported R7 was on droplet precaution isolation for MRSA (Methicillin resistant staphylococcus aureus) of the nares. A yellow isolation sign was posted on R7's door. During the medication pass on 4/10/12, at 12:14 PM, E16 entered R7's room wearing gloves. E16 did not apply a mask to her face. R7 was not wearing a protective mask. E16 leaned over R7 and lanced her right forefinger to check her blood sugar. After removing her gloves and washing her hands, E16 left R7's room and prepared medication for R8. 3. On 4/10/12, at 4:20 PM, E16 entered the room of R6 to check her gastrostomy tube for placement with use of her personal stethoscope that was hanging around her neck. After completing the medication pass and water flush for R6, E16 removed her gloves and entered R15's room to wash her hands. E16 did not gown or glove prior to entry to R15's room . An orange sign for contact isolation was posted on R15's door. E16 used her personal stethoscope to auscultate R15's chest. E16 failed to use the dedicated stethoscope located in R15's room, due to his [DIAGNOSES REDACTED]. In an interview on 4/12/12, E16 stated, "I remember listening to his (R15) lungs using my own stethoscope, and I cleaned it with alcohol pads." E16 confirmed there was a stethoscope in R15's room she should have used. E16 reported R15 has had no diarrhea or loose stools since she began taking care of him since 4/07/12. E16 reported R15 began to display shortness of breath on 4/10/12. In an interview on 4/11/12, at 3:00 PM, E10, Infection Control Nurse reported R15 had been treated at the hospital for[DIAGNOSES REDACTED] prior to his admission to the facility on [DATE]. E19 reported R15 had not been tested for[DIAGNOSES REDACTED] since admission, although the physician had ordered stool cultures on 4/02/12. E10 reported she thought the culture was ordered because R15 started having loose stools. No documentation of R15 having loose stools or diarrhea could be found in R15's Nurses Notes or the bowel movement record listed on the Medication Administration Record (MAR) for April 2012. 4. On 4/16/12, at 12:23 PM, a visitor came out of R7's room with her mask on. R7 remained on droplet isolation. The visitor walked toward the nurses station and did not cleanse her hands. The visitor quickly returned with the mask hanging from her ear, threw it away and reapplied a new mask. E58, Certified Nurses Aide, (CNA) was in R7's room with gloves and a mask on, cleansing R7's chair with bleach wipes. E8 looked at R7's visitor and stated, "She (the visitor) always does that." On 4/16/12, at 12:30 PM, E58 left R7's room after removing her gloves and mask, but did not wash or cleanse her hands. In an interview on 4/17/12, at 9:15 AM, E7, CNA reported she had been inserviced by the Infection Control Coordinator, E10. However, the facility has not asked for a return demonstration to demonstrate competency related to infection control and isolation procedures. E7 reported she has been employed at the facility for 2 years. E7 reported alcohol swabs are used to clean stethoscopes. E7 reported she does not know what product is used to clean a resident's room who is infected with[DIAGNOSES REDACTED]. E7 stated, "It's in a small spray bottle." In an interview on 4/18/12, at 11:55 AM, E8, CNA reported the facility had never asked her to perform a return demonstration related to infection control and isolation procedures until the morning of 4/18/12. The facility's policy and procedure, entitled, 'Respiratory/Cough Etiquette' documents, in part, "6. Droplet Precautions, a. Advise healthcare personnel to observe droplet Precautions (wearing a surgical or procedure mask for close contact), in addition to standard precautions when examining a patient with symptoms of a respiratory infection, particularly if fever is present." The facility's policy and procedure entitled, 'Isolation Precautions' documents, in part, "Isolation precautions will be instituted as an infection control measure to decrease the risk of transmission of virulent and/or clinically significant organisms to residents, staff, and /or visitors. Adhere to proper isolation and standard precautions when caring for the resident. The infection control coordinator will; e. verify that the isolation techniques are implemented in accordance with facility policy. f. Make periodic rounds to verify staff are adhering to established infection control practices and to monitor the ongoing implementation of isolation techniques. 5. On 4/11/12 at 12:15 PM, E26, Licensed Practical Nurse (LPN), entered R10's room. R10 had an isolation sign on her door and E26 advised surveyor to wear a mask because R10 was on "Droplet Precautions". E26 carried R10's cardboard box with [MEDICATION NAME] solution into the room. E26 set the box directly on R10's overbed table. E26 mixed the nebulizer solution into the nebulizer and turned on the nebulizer for R10, and replaced the box back onto the overbed table. After the treatment was completed, E26 removed her gloves, touched the box of [MEDICATION NAME], and carried the box over to the sink, setting the box onto a dresser near the sink. E26 washed her hands, picked up the box, left the room, and returned the box of [MEDICATION NAME] into the bottom drawer of the medication cart. The facility's Isolation Precautions dated 8/24/09 documented (in part), "Make periodic rounds to verify staff are adhering to established infection control practices and to monitor the ongoing implementation of isolation techniques......Supply.... equipment required for regular nursing care inside the room.....Disinfect and or/clean and remove...equipment upon discontuance of isolation precautions.". On 4/17/12 at 11:53 AM, E2, DON, stated that equipment and medication should not be carried into and out of the isolation room without cleaning/disinfecting. 6. On 4/17/12 at 8:30 AM, E43, CNA, stated she had received in-service training in Infection Control approximately one month ago. She stated the Infection Control information covered Isolation policies and procedures. When asked about a resident in isolation that had used a bedpan or emesis basin, E43 stated after the equipment was used, she would place the bedpan or emesis basin into a plastic bag and carry it to the soiled utility room to clean. E43 demonstrated the procedure by walking with the surveyor to the soiled utility room across from the Nurse's Station, between the 200 and 300 Halls. E43 explained that the bedpan or emesis basin should be sprayed with disinfectant, but could not state the name or type of disinfectant. There was no disinfectant available in the soiled utility room, on the counter or in drawers and cabinets.. E43 stated if there was no disinfectant available, the staff was to request the disinfectant from the housekeeper. E43 stated the equipment was to be sprayed with disinfectant and placed into the sink of the soiled utility room. E43 stated a different shift was responsible for removing the soiled equipment from the sink. 7. On 4/17/12 at 8:45 AM, E42, Housekeeper, was asked by E43 to provide the disinfectant for cleaning the soiled equipment. E42 stated she would ask E21, Housekeeping Supervisor, but E42 stated she would use bleach water or cleanser with bleach. E42 poured bleach into a cup with a black line at the 4 ounce level. R42 poured the bleach into a 32 ounce spray bottle, added water to the 10 ounce mark on the spray bottle, and stated, "That's a 10% solution of bleach water." The bleach solution was incorrectly measured, was a 40% solution. 8. On 4/17/12 at 8:40 AM, E35, CNA Coordinator, stated he had training in Isolation less than 6 months ago. E35 was asked if a resident on isolation had diarrhea what was the procedure for disposal and cleaning of the bedpan? E35 stated he would dump the contents into the toilet, rinse it out, and bring the bedpain into the soiled utility room for cleaning. The facility's Isolation Policy documented (in part) that equipment required for regular nursing care should be kept inside the room....Disinfect and/or clean and remove isolation equipment upon discontinuance of isolation precautions. 9. On 4/10/12 at 9:55 AM, during the initial 300 hall tour, E19, Certified Nurse's Aide (CNA), and E20, CNA, were observed entering R10's room which had a sign posted on the door "Droplet Precautions." E19 and E20 walked into the room without donning a mask. E10, Infection Control Nurse, redirected E19 and E20. E10 stated, they should have masked before entering R10's room. On 4/10/12 at 9:55 AM, E10 stated, R10 was on droplet precautions for MRSA (methicillin resistant staphylococcus aureus) in the nares. 10. The Resident Census and Conditions of Residents, CMS 672, dated 4/11/12 documents that the facility has 117 residents living in the facility. The Immediate Jeopardy situation was identified and determined to have begun on 4/17/12, at 10:30 AM, after observations and interviews failed to show the facility had an ongoing program in place for infection control. E1, Administrator and E2, Director of Nursing were notified of the Immediate Jeopardy on 4/17/12 at 10:30AM.. Based on observation, interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1. The facility reviewed procedures for disinfection and management of equipment used in isolation rooms. All staff were inserviced on these policies. 2. Staff were inserviced on the proper infection control procedures including but not limited to; entering and exiting isolation environments, disinfection of equipment, and use of proper chemical concentration for disinfection. Demonstrations of these techniques were done in addition to verbal instruction. 3. The facility performed a review of all isolation rooms and utility rooms to ensure the proper Personal Protective Equipment (PPE) and disinfection equipment was present and available for staff use. 4. A quality assurance / improvement review was started on 4/17/12 to verify staff are adhering to the facility's policies and procedures related to infection control as listed in items 1, 2, and 3 above. B. Based on observation, interview and record review the facility failed to provide adequate hand washing during incontinent care to prevent the spread of infection for 1 of 15 residents (R10) reviewed for incontinent care in the sample of 24. 1. On 4/11/12 at 9:40 AM, E18, CNA, and E19, CNA, were observed providing peri care for R10. R10 had been incontinent of bowel and bladder. E18 had on gloves and cleansed R10's vaginal area. E18 did not change gloves prior to placing her hands on R10's left side and thigh area to roll R10 to her side. E18 cleansed R10's rectal area. E18 removed the soiled gloves, but did sanitize or wash her hands. E18 left R10's room to get more supplies. When E18 returned, she sanitized her hands and put on gloves. E18 cleansed R10's buttocks area. E18 did not change gloves prior to placing her hands on R10's side and thigh to roll R10 to her left side. The facility's Hand Hygiene/Hand Washing Policy, effective 9/1/09, documents (in part): 2. Employees must wash their hand for 10-15 seconds using soap and water under the following conditions; b. After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin; c. After handling items potentially contaminated with blood, body fluids, or secretions" 3. If hands are not visibly soiled then the use of an alcohol based hand rub/gel containing 60-95%[MEDICATION NAME] or [MEDICATION NAME] for all the following situations;" f. Before moving from a contaminated body site to a clean body site during resident care. j. after removing gloves 4. The use of gloves does not replace handwashing/hand hygiene." On 4/20/12 at 8:15 AM, E1 Administrator, stated she would expect the CNA to change gloves and sanitize hands after care of a soiled area before touching a clean area.

F323J · Immediate jeopardy, isolated

A. Based on observation, record review and interview, the facility failed to thoroughly identify, evaluate, implement and monitor the use of siderails for two of eleven residents (R7, R13) reviewed for siderail entrapment in the sample of 24. This failure resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 4/18/12, the facility remains out of compliance at severity level two, while the facility continues to educate staff on siderail assessment and recognition of potential hazards related to the use of siderails as positioning devices. Findings include: 1. The Minimum Data Set, ((MDS) dated [DATE], documents R7 is moderately impaired with cognition, long and short term memory impairment, no impairment to upper extremities and bilateral lower extremity impairment. The MDS documents R7 requires extensive assistance with transfers and bed mobility, with an unsteady balance while standing. The Care Area Assessment (CAA) dated 3/06/12, documents R7 has a history of impaired safety awareness that has resulted in a previous fall from her wheelchair on 1/15/12. The physician's orders [REDACTED]. The Fall Risk assessment dated [DATE], documents R7 is a high risk for falls. The most current Restraint: Side Rail Utilization Assessment, dated 9/15/2010, documents R7 uses quarter siderails to assist in positioning and/or transfers. The Side Rail Assessment documents R7 has no risk for the use of side rails except for a history of falls. The Assessment documents R7 does not attempt to get out of bed by climbing over or around the side rails. The Care Plan, dated 3/07/12, documents R7 "is at risk for falls due to history of falls while transferring unassisted, has impaired cognition and severely impaired balance. Interventions include, in part; "Assist with all transfers using assist of 2, remind her to call for assist with ADL's (activities of daily living) as needed, remind her not to get up without assistance, side rails to assist with positioning and bed mobility, and wheelchair and bed mat alarms to be used at all times." On 4/17/12, at 5:30 PM, R7 was observed to have a "T" shaped siderail attached at the center of her bed. The stem or center upright bar was 15.5 inches high and 16 inches wide. The crossbar on top was 32 inches wide and 10 inches high. There was an opening in the center upright bar 8 inches wide and 15 inches high. The cross bar had an 8 inch open area on each side. The right side of R7's bed was against the wall. According to the U.S. Food and Drug Administration publication, "Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment - Guidance for Industry and FDA Staff", issued March 10, 2006; "to reduce the risk of head entrapment, openings in the bed system should not allow the widest part of the head to be trapped." The FDA uses a head breadth dimension of 4 3/4 inches as the basis for its dimensional limit recommentations. On 4/17/12, at 5:35 PM, R7 was interviewed. R7 was confused. R7 reported she would not get out of bed without assistance. Then R7 reported if it was at night and she needed to use the bathroom, she would not want to bother anyone and would get up and use the bathroom. The Nurses Note, dated 2/16/12, at 4:00 AM, documents R7 had "multiple attempts made to get out of bed. One on one given with success noted. Will monitor." During an interview on 4/18/12, at 10:00 AM, E2, Director of Nursing (DON) confirmed R7 has not fallen out of bed, but did try to get up unassisted before her last hospitalization in February 2012. E2 reported that R7's bed was donated to them, and the facility was not aware of the safety hazard of those particular siderails. E2 confirmed no other residents in the facility have the type of siderails as R7. The facility's policy and procedure, entitled, 'Fall Prevention Protocol' documents, in part, "This facility is committed to establishing guidelines and procedures to minimize the risk of falls and their effects so as to maximize every resident's well being. This standard dictates a mode of action to identify, assess and implement interventions for each resident and that facilitates an environment that is safe as possible." The policy identifies a type if fall as "Accidental: Falls that can be attributed to an environmental factor or mishap." The policy does not directly identify the use of side rails as a potential risk factor for resident injury or entrapment. 2. On 4/18/12 at 10:00 AM, R13's bed was found to have a canoe mattress and 2 half-rail length side rails attached to it. The side rails were in an up position, but leaning away from the side of the bed and were loose when moved back and forth. Additional padding for the rails was in the room, but not on the bed at this time. The right side of the bed was pushed up against the wall. On the left side of the bed, a gap between the bottom of the rail and the mattress was observed. At 10:10 AM, E69, Maintenance Director, came into the room with Z2, Corporate Compliance Officer, to look at the bed. The gap between the bottom of the siderail and R13's mattress was measured and found to be 5 inches wide. . According to the U.S. Food and Drug Administration publication, "Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment - Guidance for Industry and FDA Staff", issued March 10, 2006; "to reduce the risk of head entrapment, openings in the bed system should not allow the widest part of the head to be trapped." The FDA uses a head breadth dimension of 4 3/4 inches as the basis for its dimensional limit recommentations and under, "Zone 3 - Between the Rail and Mattress documents the dimension between the rail and the mattress should be less that 4 3/4 inches." At 9:30 AM, E2, Director of Nursing, came to the room, and indicated that the bed had been provided by R13's hospice provider to enable R13 to turn and position herself in bed. E2 indicated the rail pads were to keep R13 from becoming bruised on the rails. E2, indicated that with the pads added to the rails the space between the rail and mattress was smaller, approximately 3 inches, but not eliminated entirely. E2 stated that she did not think R13 was using the rails at this time, as she recently had fractured her right clavicle on 4/8/12, and could not turn on her own without assistance. A review of R13's care plan dated 4/9/12 indicated R13 was diagnosed with [REDACTED]. The Immediate Jeopardy situation was identified and determined to have begun on 4/17/12, at 5:30 PM, after an evaluation of the siderails on R7's bed determined the rails to be a potential entrapment hazard for R7. E1, Administrator and E2, Director of Nursing were notified of the Immediate Jeopardy on 4/17/12 at 7:10 PM. Based on observation, interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1. On 4/17/12, R7's side rail was removed and replaced with an appropriate rail. 2. On 4/18/12, R13's side rail was removed. 3. On 4/18/12, the facility completed an audit of all facility beds to verify any remaining siderails are safely attached and present no hazard to the residents using them. 4. On 4/18/12, maintenance personal received inservice on the current FDA bed safety recommendations for side rail use. 5. On 4/18/12, the facility inserviced all direct care staff, and staff that perform functions in resident rooms, on recognition, and reporting of potential bed related hazards. 6. On 4/18/12, the facility reviewed all residents using siderails to verify assessments are complete and are a reflection of the needs of the resident. 7. On 4/18/12 the facility amended it's equipment policies to include: Any new equipment supplied by an outside vendor such as but not limited to hospice, will be inspected by maintenance personnel prior to being used for any resident. Documentation on all checks will be initiated in accordance with the audit noted in item #3 (above). B. Based on observation, interview and record review the facility failed to identify causative factors contributing to falls, accidents and injuries, implement interventions based on these identified factors, and failed to provide safe transfer techniques to prevent injury for 9 of 24 residents (R1, R3, R4, R5, R7, R12, R13, R22, R23) reviewed for falls and other safety concerns in the sample of 24 and two residents (R27 and R46) in the supplemental sample. This failure resulted in R13 sustaining a fracture to her right clavicle. 1. A review of an incident report dated 4/4/12, documented R13 had fallen from her bed onto the floor. R13 was not able to explain how she fell , and sustained a large bump to her fore head and bruising the right side of her face and right arm. On 4/8/12, the nurses notes documented R13 "moaning and grimacing when right shoulder touched. Purple and yellow discoloration to the shoulder, MD called." On 4/9/12 an X-ray revealed R13 had sustained "Subacute fracture of the distal third of the clavicle, no significant displacement." The most recent Minimum (MDS) data set [DATE], documented R13 is moderately cognatively impaired, and needs assistance of at least 1 staff for all activities of daily living, transfers and mobility. R13 currently wears a splint / arm immobilizer on her right arm / shoulder. On 4/11/12 at 11:00 AM in an interview with E32, Licensed Practical Nurse, (LPN) stated "R13 had been in a canoe mattress prior to the fall. On 3/29/12, the mattress was changed to a low air loss mattress. The mattress had been fitted with bolsters on the sides to prevent falling. On 4/5/12 after R13's fall, the bed was examined by myself (E32) and the hospice owner, who determined the bolsters had been put on the bed backwards/upside down, and this allowed R13 to roll off the bed. We figured that when R13 got near the edge of the bed the bolsters did not stay upright, but some how flattened down and R13 rolled off the bed. Now R13 is back in the canoe bed she had before the fall." E32 stated "there is another resident on the 100 hall with the same bed, we checked his bolsters and they were okay. That is how we were able to see R13's bolsters were on wrong." On 4/13/12 at 10:15 AM, E6 and E23, both Corporate Nurses, indicated they thought the bolsters on R13's bed were applied "ok", but were not high enough to keep R13 in the bed. They thought R13 fell because the bolster being used was not the one recommended for the low air loss mattress, but a generic bolster the hospice company was using, that may not have been adequate enough for the low air loss mattress. On 4/13/12 at 1:30 PM, E2, Director of Nurses (DON), gave a written statement regarding R13's fall and documented, "On 4/4/12, (after R13's fall) I laid in the bed to try and determine how R13 rolled out. I did not feel the bolster was sufficient to keep R13 from rolling out. Called Hospice who came out and inspected the bolster mattress and stated he agreed that the bolster mattress may not prevent this resident from rolling out of bed again and the decision was made to change to the concave mattress. R13 has no history of falls, and the possibility that this could occur was unknown until the event." On 4/13/12 at 1:50 PM, E2 stated there was no policy regarding examining equipment for safety when brought in by an outside vendor. E2 indicated she felt R13's fall on 4/4/12 was and accident, and not the fault of the facility. 2. R13's nurses notes document she has a fractured right clavicle, and currently wears a splint / arm immobilizer on her right arm/shoulder. 4/11/12 at 9:40 AM, R13 was sitting in the hall outside the dining room. At that time, E31, Certified Nurses Aide (CNA), stated she would be putting R13 to bed soon. At 10:10 AM, R13 was in her bed. E31, stated that she had transferred R13 with a gait belt and the help of E35, CNA. E31 stated "R13 does not always bear weight and sometimes her knees buckle during the transfers." On 4/11/12, 10:25 AM, in an interview with E35, he stated "No, I have not been on the 100 hall this morning. I did not help E31 transfer R13 to bed this morning." At 10:30 AM, E31 stated, "I borrowed a belt from another staff, and transferred R13 by myself. She is a 1-person transfer in the care plan. I told you I had help to transfer R13 because I got nervous." A review of R13's care plan failed to show evidenceof documentation of any updates regarding how many staff are to assist R13 with transfers and mobility while R13 has a fractured shoulder and is using a sling. On 4/11/12 at 11:30 AM, in an interview with E46, Rehab/Restorative Supervisor stated she was aware that R13 had a fractured shoulder, and wore a brace. E46 stated she had not been asked to assess R13 for appropriate assist with transfers since her fall. On 4/11/12 at 2:00 PM, E46 indicated she and E70 and E71, Physical Therapy Aides, had reviewed R13 for transfers. E46, E70, and E71 all agreed R13 should be a two person assist for transfers with gait belt. E46 stated, a two person transfer would be safest and prevent putting pressure on R13's arm and fractured right shoulder. All three staff E46, E70, and E71 indicated that they had not been asked to assess R13 for safety/transfer concerns since her fall, and that staff should not be transferring R13 alone. On 4/11/12 at 4:30 PM, E2, Director of Nursing, stated she had not been aware of E31's transferring R13 by herself and telling the surveyor that two staff had done the transfer. E2 stated she had no information on why R13 had not been assessed for safe transfers after diagnosed with [REDACTED]. 3. On 4/18/12, R1 ' s bed had a metal side rail clamp attached to it. The clamp was attached to the frame, had sharp metal edges and was for holding a side rail in place. R1 had no side rails on her bed. The clamp was extending out from the bed frame 2 to 3 inches and had the potential to cause an injury should R1 fall or brush up against the bed frame. 4. A review of R7 ' s updated care plan dated 3/14/12 documented, " R7 is a great risk for falls due to history of falls, history of transferring unassisted, impaired cognition and severely impaired balance. Wheel chair and bed mat alarms to be used at all times, check placement each shift. On 4/10/12 and 4/11/12, at various times throughout the day when R7 was in her wheel chair, she was observed with no wheel chair alarm on. On 4/12/12, at 4:00 PM, E2 Director of nursing stated she did not know why staff had not checked to ensure the alarm was attached to R710. On 4/18/12, at 9:28 AM, R12 and R46 had half side rails on their beds. The side rails were made of hollow metal. Part of the side rails extended to the floor and had no end cap exposing sharp edges. 5. R23 was admitted to the facility on [DATE] with partial [DIAGNOSES REDACTED]. R23 was admitted to the facility receiving Hospice Services for Cirrhosis of the Liver. Hospice Care Plan Condition Summary dated 11/1/11 stated (in part) that the facility informed Hospice Care Manager that R23, "returned to facility intoxicated x 2. 10/17 & 10/20. Pt. refused to say or contribute to CP (Care Plan) meeting." Interventions listed on the Summary include: "will look into tx (treatment) program.......pt. will not leave facility with anyone but POA (Power of Attorney." There are no additional interventions to address supervision of R23 for alcohol consumption and potential harm that may occur due to continuing alcohol consumption. Hospice Care Plan Summary dated 1/10/12 documented, "...SW (Social Worker) reported that pt. was witnessed buying alcohol and going out with other family members." Social Progress Notes dated 1/25/12 documented (in part), ".....CNA reported that she (R23) was acting drunk and smelled of alcohol after returning from an LOA (leave of absence) with sister. On 12/24/11, she was noted as having left facility multiple times without signing out.". There are no new intervention or care plan updates. There were no new assessments for potential harm due to alcohol use. Nursing Notes dated 3/4/12 documented that R23's POA was called to inform her, "resident going to store and obtaining alcohol and drinking it out of facility.....not acceptable behavior....DON and ADON notified....". On 3/6/12 another entry into Nursing Notes documented, "Rehab supervisor reported to E38, Social Services, that R23's roommate was crying...spelled out that her roommate (R23)....has been cussing her and drinking alcohol in room...". Nursing Notes dated 3/18/12 documented, "Resident discharged home with meds." On 4/18/12 at 12:30 PM, E38, Social Services Director, stated R23, " was admitted on Hospice for cirrhosis of the liver. She recovered and was recently discharged ." E38 was asked if there were any behavior problems and he replied, "There were concerns with her drinking but she never had any blood work to confirm alcohol use." E38 stated he was never specifically notified of R23 leaving the facility to obtain alcohol. There was no notations in E38's Social Service notes that R23's need for alcoholism treatment and continued alcohol consumption were addressed by the facility. On 4/18/12 at 1:05 PM, E2, Director of Nursing, stated, "It's never been confirmed that she was drinking in her room. Someone reported she bought booze at (nearby store). We never found the booze." E2 stated there was no formal investigation. E2 was asked if R23 was screened by laboratory tests to determine if alcohol was being consumed, either in the facility or while out with family. E2 stated no alcohol screens were obtained. 6. R22 was re-admitted to the facility on [DATE]. R22's most recent Bed Rail Consent Form is dated 6/24/09. The consent form listed risks of using bed rails, including bruises, skin tears, fractures, entrapment with asphyxiation. Quarterly reviews on 2/24/11, 5/19/11 documented that siderails "continue to be indicated.". Side Rail Assessments dated 8/9/11, 11/l/11 1/18/13 were unchanged, with no changes, "At this time, side rails are indicated to assist with positioning/support." R22's Accident/Incident Reports from 7/11/11 until 2/4/12 documented six incidents with injuries due to hitting wheelchair arms and legs, hitting her siderails with arms and legs. On 8/16/11 at 10:30 AM, R22 had a skin tear measuring 2.8 cm by 0.6 cm. Steristrips were applied to the injury. The investigation documented, "Resident restless and attempted to get out of bed, hit leg on side rail per CNA report.....". R22's Care Plan for Skin Breakdown documented the new intervention (in part), "......CNA reports res. restless attempted to get out of bed, hit leg on side rail.....". The intervention listed is to pad the leg rests of the wheelchair. The siderails are not addressed as a possible cause and no intervention involving the siderail was initiated. On 9/26/11 at 7:30 PM, E34, CNA, reported that she was putting R22 to bed. R22 became combative, kicking. E34 reported to the nurse, "Looks like someone took a chunk out of her leg....". R22 was sent to the emergency room and required 16 sutures to repair the laceration to her lower right leg. E2, Director of Nursing (DON), documented on 9/27/11 that, "Blood was noted on the frame of bed....It appeared that while CNA was putting resident to bed, she hit her leg on the bed frame. CNA counseled. Restorative Nurse to inservice CNA on proper transfers." On 11/14/11 at 8:00 AM, R22 was noted to have bruising to both arms. R22's Incident Report stated she is combative with care. Geri-sleeves were ordered and side rails were padded. On 12/15/11 at 5:45 AM, E60, Night Nurse, noted a 4 cm. laceration to R22's right middle finger. Three steri-strips were applied. There are no new interventions following this incident. On 2/4/11 at 12:00 AM, E61, CNA, reported R22 obtained a skin tear. The incident report documented, "CNA stated resident resistive with care & hit hand on S/R (side rail) while repositioning." The skin tear measured 2 cm x 3 cm x 0.2 cm. The intervention listed is "given SR pads." There is no new intervention listed. There is no explanation why side rails were not padded since the incident dated 11/14/11 when side rail pads were first initiated. 7. R4's 8/29/11 Care Area Assessment (CAA) for falls documented (in part), that she has [DIAGNOSES REDACTED]. R4 is incontinent of bowel and bladder, has restricted mobility, is transferred with a mechanical lift. She is a risk for falls. The facility's Incident/Accident Reports documented 6 falls/injuries since 7/1/11. On 12/26/11 at 10:35 AM, R4 had a contusion noted to her forehead above her left eye. The incident report documented that shower aides had bumped her face with the mechanical lift causing a contusion to her left forehead. The contusion was caused by facility staff's improper use of the mechanical lift, failure to prevent R4's head from hitting the frame of the mechanical lift. The intervention documented is "Shower CNAs counseled on safe use of (mechanical) lift." The facility's Policy and Procedures for Lifting and Transferring Residents dated 1/3/11 documented that "All residents requiring assistance with transfers will be lifted and/or transferred in a safe manner using appropriate support and equipment......Members of the nursing staff are responsible for using good body mechanics, knowing the proper transfer procedures and properly operating assistive devices." 8. R5's Fall Risk assessment dated [DATE] assessed her as High Risk for falls with a score of 14. Score of 10 or above indicated a High Risk. R5's current Care Plan dated 12/14/11 documented that R5 requires extensive to total assist.....assist of two for transfers. She is at risk for falls d/t (due to) severely impaired balance. One intervention documented was, "Bed mat alarm at all times while in bed. Respond & reapply/reset as needed." On 4/10/12 at 1:40 PM, R5 was in bed. The bed was a canoe mattress in low position with a blue mat on the floor beside the bed. There was a sign posted on the wall above the bed stating "Bed Alarm". There was no bed alarm on the bed or on the mat beside the bed to alert staff that R5 was attempting to get out of bed. On 4/10/12 at 4:05 PM, R5 was transferred from the bed by E44 and E45, CNAs. R5 was assisted into a sitting position on the low bed. R5's sitting balance was poor. She was unable to stay in the sitting position without support from the CNAs. A gait belt was applied and E44 and E45 lifted R5 from the low bed, using the gait belt and their arms hooked under R5's arms. R5 was lifted out of the bed, with her weight suspended from her axilla. Her feet did not touch the floor, as she was lifted out of the bed and placed into the geriatric recliner with a pommel cushion in the seat. Both CNAs confirmed that R5 was unable to bear weight. 9. On 4/10/11 at 11:40 AM in the main dining room, R27 was seated in a wheelchair with a Pommel cushion. There were no staff next to her. R27's laptop cushion on the floor next to her wheelchair. R27 began to propel herself away from the table and towards the door. There was a sign posted next to the exit door in the dining room which documented "Attention Staff: Do not remove (laptop cushions) at mealtime until staff are sitting with residents." 10. On 4/18/12, at 9:28 AM, R12 and R46 had half side rails on their beds. The side rails were made of hollow horizontal and vertical metal bars. The vertical ends of the side rails had sharp edges with no caps on the ends to prevent a resident from being accidentally cut on them. 11. R3's physician's orders [REDACTED]. The facility's Management PCE (Patient Care Event) Tracking Log documents R3 has a history of skin tears on 3/31/12, 2/25/12, and 10/27/11. On 4/10/12 at 1:55 PM, R3 was observed with a gauze dressing to her left lower leg. R3 did not have skin protector sleeves on any of her extremities. On 4/20/12 at 8:15 AM, E1, Administrator, stated R3 "should have (skin protector) sleeves on all extremities. It might have been that they were being laundered." C. Based on observation and record review, the facility failed to ensure chemicals and therapeutic agents are kept in areas which are inaccessible to residents for four of 24 residents (R1, R11, R17 and R18) observed during the environmental tour in the sample of 24 and 20 residents ( R27, R32, R43, R45, R47, R48, R49, R58, R71, R72, R74, R76, R83, R84, R92, R94, R102 and R104-R106) in the supplemental sample. Findings include: 1. On 4/17/12 at 11:05 AM , in R11's and R45's room, there was a can of Lysol Disinfectant Spray and a container of Clorox Disinfecting Wipes. The Lysol Disinfectant Spray Material Safety Data Sheet (MSDS), dated 7/9/10, documented "Extremely Flammable. CAUTION. Contents under pressure. Do not puncture or incinerate container. containers may explode when heated. Keep away from heat, sparks and flame. Causes moderate eye irritation. Avoid contact with skin, eyes or clothing. Wash thoroughly with soap and water after handing and before eating, drinking, chewing gum or using tobacco. Keep about of reach of children." The Clorox Disinfecting Wipes' Material Safety Data Sheet, dated prepared 6/07, documented "FIRST AID: EYES- Flush with plenty of water. Call a physician if irritation persists. IF SWALLOWED- Drink a glassful of water. Call a physician or poison control center. SKIN- Wash thoroughly with soap and water after handing. INHALATION- If breathing is effected, move to fresh air." 2. On 4/17/12 at 11:15 AM, in R17's and R48's room, there was a tube of Sensicare, barrier cream on an overbed table. There was a tube of Vagicaine next to the sink. Both warning labels on these tubes documented "Keep out of reach of children. If swallowed call Poison Control or physician right away." 3. On 4/17/12 at 11:27 AM, in R71's and R72's room, there was a 1.5 ounce tube of Musclerub. The warning label documented if swallowed "induce vomiting. Seek medical attention or call Poison Control." 4. On 4/17/12 at 1:30 PM, in R32's and R84's room, there was a tube of Derma Fungal anti-fungal cream on top of the television. The warning label on the tube documented "In case of accidental ingestion call doctor of Poison Control Center immediately." 5. On 4/20/12, the facility provided a list documenting the residents who are cognitively impaired, mobile and wear patient monitoring devices. The residents on list were R1, R18, R27, R43, R47, R49, R58, R74, R76, R83, R92, R94, R102, and R104-R106.

Inspection of July 6, 2011

2 findings

F309G · Actual harm, isolated

Based on record review, observation and interview, the facility failed identify and perform accurate assessments of skin and vascular ulcers and/or wounds and to provide pain management for one of one residents (R2) reviewed for vascular ulcers and pain management in the sample of 5. The facility did not provide timely pain management for treatment of [REDACTED]. This failure resulted in R2 developing a Vascular/Diabetic wound and expressing signs of pain during treatments. Findings include: R2's Minimum Data Set (MDS), dated [DATE], documented R2's diagnoses, in part, as Dementia and Diabetes Mellitus, totally dependent on two plus persons physical assistance with mobility and bilateral upper and lower extremities functional limitation range of motion. The facility's General Wound Report, dated 6-17-11 to 6-24-11, documented R2's right heel as a Vascular/Diabetic wound measuring 10.5cm x 9cm x 0.3 cm. It was also noted 100% slough, large amount serosanguinous drainage and foul odor. During an interview with Z1, Physician, on 7-6-11 at 9:00a.m., Z1 stated R2's disease process was in the end stage and R2's skin was comprised. Z1 also stated pressure sore(s)/wound(s) would decline quickly due to R2's declining health condition. R2 Treatment Record, dated 3-1-11 to 3-31-11, and Nursing Notes, dated 3-1-11 to 3-28-1l, did not document any areas of redness, discoloration, breakdown, drainage, sloughing or blisters prior to the identification of R2's vascular wound on 3-29-11, with the exception of Nursing Notes, dated 3-19-11, documented "area inside (rt) (right) heel, raised fluid filled - skin intact 6cm x 5.5cm - raised approx (approximately) red around the edges. No s/s (signs/symptoms) infection." During interview with E6, Regional Nurse, on 7-6-11 at 2:30p.m., E6 stated if Nurses staff were not documenting R2's skin assessments in the Nursing Notes or on R2's Treatment Record then they were not checking her skin for breakdown or blisters. R2's Daily wound Status Monitor sheets, dated 4-1-11 to 4-3-11, 5-22-1 to 5-31-11 and 6-1-11 to 6-30-11, documented status of R2's dressings, symptoms of infection and pain but did not document what areas of skin breakdown were being assessed. During interview with E6, on 7-6-11 at 2:30pm., E6 stated staff were not documenting what wound they were monitoring or the status of R2's vascular wound either for decline or improvement on R2's Daily Wound Status Monitor Sheets. E6 also stated the form would be changed. The facility's Wound Management policy and procedure, dated 2-1-07, documented, in part, "A program of prevention, care and treatment of [REDACTED]. It is the policy of this facility to conduct a uniform wound assessment that will provide a consistent means of wound evaluation.." During observation of R2's dressing change, on 7-1-11 at 11:20a.m., E2, Director of Nursing (DON) and Z2, Outside Wound Management, removed R2's right heel dressing. R2' right heel appeared 80 to 90% eschar, foul odor and moderately draining. Z2 obtained a debridement kit. As Z1 pulled eschar tissue away from R2's right heel to remove with a scapula, R2 was observed jerking and restless. R2 continued to display restlessness, jerking movements and rubbing her head with her hands throughout the debridement process. R2's Physician Order, dated 6-17-11, documented, in part, R2 was ordered " [MEDICATION NAME] 5/500 1 po (by mouth) 30 min (minutes) prior to skin care treatment." During an interview with E2 (DON), on 7-1-11 at 2:50p.m., E2 stated she instructed a nurse to administer R2's "[MEDICATION NAME]" prior to the treatment change, on 7-1-11. E2 also stated the nurse did not document the effectiveness of the "[MEDICATION NAME]" after she administered. R2's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[MEDICATION NAME]" prior to treatments. It was also noted the effectiveness of the medication was not consistently documented. R2's Care Plan, target date 7-25-11, did not document a care plan for pain. R2's Pain Assessments, last dated 4-25-11, did not document a pain assessment after R2's physician order [REDACTED]. During an interview with E1, Administrator, on 7-6-11 at 1:30p.m., E1 stated R2 did not have a care plan for pain. The facility's Pain Management policy and procedure, not dated, documented "It is the right of the resident to expect from the staff a commitment of on-going pain management." It was also noted that anytime the resident stated that pain was present or demonstrated nonverbal signs of pain, the resident would be assessed for pain and a plan of care for residents pain management including pain assessment tools would be put into place.

F314G · Actual harm, isolated

Based on record review, observation and interview, the facility failed to implement pressure relieving measures, conduct on-going assessments, provide pressure relieving devices and timely turn and reposition three (R1, R2, R3) of five residents reviewed for pressure sores in the sample of 5. This failure resulted in R2 developed an in-house Stage III coccyx pressure ulcers. R3 developed an in-house Stage III right medial heel pressure sore. Findings include: 1. R2's MDS, dated [DATE], documented R2's diagnosis, in part, as Dementia, totally dependent on two plus persons physical assistance with mobility and at risk for pressure sore development. R2's Pressure Ulcer Risk Assessment, dated 4-25-11, documented R2 was at high risk for for pressure sore development. The facility's Pressure Ulcer Weekly Report, dated 5-20-11 to 5-27-11, documented an in-house developed unstageable area, measuring 3.8cm x 4.0cm, was found on R2's coccyx on 5-26-11. It was also noted 100% slough with moderate serosanguinous drainage. The facility's Pressure Ulcer Weekly Report, dated 6-17-11 to 6-24-11, documented R2's unstageable area was a Stage III coccyx pressure sore measuring 4.4cm x 2.00cm x 1.0cm. It was also noted 80% pink, 20% slough, moderate serosanguinous drainage and no odor. During observation of R2's incontinent care, on 7-1-11 at 9:15a.m., a Stage III pressure sore was observed on R2's coccyx. During an interview with Z1, Physician, on 7-6-11 at 9:00a.m., Z1 stated R2's disease process was in the end stage and R2's skin was comprised. Z1 also stated pressure sore(s)/wound(s) would decline quickly due to R2's declining health condition. R2 Treatment Record, dated 5-1-11 to 5-31-11, and Nursing Notes, dated 5-1-11 to 5-25-1l, did not document any areas of redness, discoloration, breakdown, drainage or sloughing prior to the identification of R2's coccyx pressure sore on 5-26-11. During interview with E6, Regional Nurse, on 7-6-11 at 2:30p.m., E6 stated if Nurses staff were not documenting R2's skin assessments in the Nursing Notes or on R2's Treatment Record then they were not checking her skin for breakdown. E6 also stated a Stage III pressure sore, unstageable area, should be detected and treated before the skin declines to an unstageable, Stage III pressure sore. R2's Daily wound Status Monitor sheets, dated 4-1-11 to 4-3-11, 5-22-1 to 5-31-11 and 6-1-11 to 6-30-11, documented status of R2's dressings, symptoms of infection and pain but did not document what areas of skin breakdown were being assessed. During interview with E6, on 7-6-11 at 2:30pm., E6 stated staff were not documenting what wound they were monitoring or the status of R2's pressure sore for decline or improvement on R2's Daily Wound Status Monitor Sheets. The facility's Pressure Ulcers, Prevention, Treatment and Care policy and procedure, dated 3-1-02, documented, in part, the following: "A program of prevention, care and treatment of [REDACTED]. Residents who are particularly prone to the development of pressure ulcers include but are not limited to: a. Residents with rapidly declining condition. Complete skin checks are performed in as dictated by level of risk but should include a review of the following areas for redness, discoloration, breakdown or blisters...G. sacrum & (and) coccyx..."K. Heels. Any resident admitted to and residing at this facility is determined to be at high risk for skin breakdown when, after assessment utilizing the facility recognized skin risk assessment tool, the score from that toll indicates the resident is at high risk. Wounds will also be assesses daily during dressing changes for...induration, drainage, fever, [DIAGNOSES REDACTED], pain and [MEDICAL CONDITION]." 2. R3's MDS, dated [DATE], documented R3's diagnosis, in part, as Dementia, totally dependent on one person physical assistance with transfers and at risk for pressure sore development. The facility's Pressure Ulcer Weekly Report, dated 6-17-11 to 6-24-11, documented an in-house developed Stage III pressure sore, measuring 3.0cm x 3.0cm x 0.3cm, was found on R3's right medial heel on 6-17-11. It was also noted 90% slough, 10% red, moderate serosanguinous drainage and no odor. R3's Treatment Records and Nursing Notes, dated 5-1-1 5-31-11 and 6-1-11 to 6-16-11, did not document any areas of redness, discoloration, breakdown, draining and/or sloughing prior to R3's identification of a Stage III pressure sore on her right medial heel. R3's Daily Wound Status Monitor sheet, dated 6-17-11 to 6-30-11, documented the status of R3's dressing, symptoms of infection and pain but did not document the status of her pressure sore either for decline or improvement. During an interview with E6, on 7-6-11 at 2:30p.m., E6 stated if Nursing staff were not documenting R3's skin assessments in R3's Treatment Records or in her Nursing Notes then staff were not checking her skin. 3. R1's Minimum Data Set (MDS), dated [DATE], documented R1's diagnosis, in part, as Dementia, incontinent of bowel and bladder, totally dependent on one person physical assistance with toileting, mobility and at risk for pressure sore development. R1's Care Plan, target date 8-17-11, documented turn and reposition every two hours. R1 was observed, on 7-1-11 from 9:25a.m. to 1:25p.m., sitting up in a wheel chair without turning and repositioning every two hours. During observation of R1's transfer and incontinent care, on 7-1-11 at 1:25p.m., E4, Certified Nursing Assistant (CNA) and E5 (CNA) transferred R1 from her wheel chair to bed. R1's coccyx, buttock and bilateral thighs were reddened and deeply creased after E4 removed R1's adult diaper. The deep creasing of R1's coccyx, buttock and bilateral thighs remained unbalanced during the observation which ended at 1:40p.m.

Inspection of September 30, 2010

2 findings

F157G · Actual harm, isolated

Based on interview and record review, the facility failed to notify the physician and the family immediately after a resident fell sustaining an injury for one resident in the sample of 14 (R2). This failure resulted in R2 not receiving treatment for [REDACTED]. The findings include: Review of an incident report dated 8/14/10 showed R2 fell from the wheelchair at 2:05 pm. Review of the Nurse's Notes dated 8/14/10 at 2:05 pm, states " (R2) up in (wheelchair) in front of nurses desk at 1410 alerted to resident by alarm resident fell to floor. landed on (right) side next to (wheelchair)...". This entry also documents R2 sustained an injury, "Hematoma noted to right side of her head...". An entry at 3:30 pm documents R2 experiencing pain, "(Resident) holding (right) upper thigh area moaning when nurse touch upper (right) thigh area". And at 4:00 pm staff documented their attempt to notify R2's daughter and of leaving a telephone message. An entry at 4:30 pm documents, "(Z1) Hospice nurse here to evaluate resident's condition". Another entry at 5:00 pm documents, "(R2) yelling out and holding (right) upper thigh area". Thirty minutes later, staff wrote "call placed to (Z3's, physician) Physician's Exchange". At 6:05 pm, the nurse documented a second call was placed to the physician at 6:05 pm, who gave orders to send R2 to the hospital. Interview with E16, Licensed Practical Nurse confirmed Z2, (family) was not notified of the fall with injury and pain until 1 hour and 50 minutes after the fall occurred. E16 also confirmed Z3, physician was not notified of the fall with injury and pain until 4 hours after the incident occurred. According to the Nurse's Notes on 8/14/10 at 8:10 pm, the hospital called "facility informed nurse resident will be admitted with [DIAGNOSES REDACTED]. .

F309G · Actual harm, isolated

Based on interview and record review the facility failed to provide treatment and failed to provide pain medication for one of one residents on the sample of 14 with pain (R2). This failure resulted in R2 yelling and crying out in pain, while holding her leg, with no treatment for [REDACTED]. The findings include: Review of an incident report dated 8/14/10 showed R2 stood up from her wheelchair and fell to the floor at 2:05 pm. Review of a Nurse's Notes entry dated 8/14/10 at 2:05 pm shows " (R2) up in (wheelchair) in front of nurses desk , (staff) alerted to resident by alarm, resident fell to floor. landed on (right) side next to (wheelchair)...". This entry also documents R2 sustained an injury, "Hematoma noted to right side of her head...". An entry at 3:30 pm documents R2 experiencing pain, "(Resident) holding (right) upper thigh area moaning when nurse touch upper (right) thigh area". An entry at 4:30 pm documents, "(Z1) Hospice nurse here to evaluate resident's condition". Another entry at 5:00 pm documents, "(R2) yelling out and holding (right) upper thigh area". Thirty minutes later, staff wrote "call placed to (Z3's) Physician's Exchange". At 6:05 pm, E16, Licensed Practical Nurse,LPN, documented a second call was placed to the physician at 6:05 pm, who gave orders to send R2 to the hospital. When questioned on 9/23/10 at 2:45 pm, E16 said R2 had physician's orders [REDACTED]. E16 also stated that she did not do any type of pain assessment and did not give any reason why she did not give R2 pain medication. Review of the August Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. During interview with Z2, Power of Attorney (POA), on 9/23/10 at 2:10 pm, she stated,"I was told that my mother was fine. My mother had a fall with no complaints of pain". Z2 stated about 30 minutes later, she received a call from the Z1, Hospice Nurse who said she couldn't believe the resident was still sitting up in the wheelchair because she was in extreme pain. During interview with Z1, Hospice Case Manager on 9/23/10 at 3:25 pm, she said, (R2) would occasionally grab at her right in pain. Z1 said she could not examine R2 sitting up in the wheelchair because she had her leg drawn. Z1 said (R2's) pain was excruciating and (R2) was screaming out in pain with her leg drawn. This made it difficult for Z1 to assess the leg for shortening or to identify the source of the pain. Because of this, Z1 directed staff to send (R2) to the hospital. Interview with Z2, POA, the admitting [DIAGNOSES REDACTED]. .

← Back to the La Bella of Caseyville record

Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction