McLean County Nursing Home

Based on interview and record review the facility failed to identify/track resident specific behaviors to justify the use of an antipsychotic and failed to implement nonpharmacological interventions for one resident (R65) of five residents reviewed for unnecessary medication in a sample list of 35 residents. Findings Include: R65's medical record documents current physician's orders for the following psychotropic medications: 1. Fluoxetine (antidepressant) 10 mg (milligram) on Sundays Fluoxetine 20 mg on Monday, Tuesday, Wednesday, Thursday, Friday, Saturday. 2. Lorazepam (antianxiety) 2mg/ml (milliliter) 0.25ml every 2 hours PRN (as needed). 3. Quetiapine (antipsychotic) 37.5 mg at bedtime. R65's Treatment Administration Record (TAR) for August 2024 documents Acknowledgement of Behaviors: Episodes of self-isolating and refusal of care. There is no documentation of nonpharmacological interventions attempted. There is no specific behavior identified or tracked to justify the use of an antipsychotic medication. On 8/14/24 at 11:00AM V17, Registered Nurse (RN) Unit Manager stated The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to administer medications in accordance with Physician's Orders and manufacturer's recommendations for two of five residents (R4, R25) reviewed for medication administration in the sample list of 35. The facility had 2 medication errors out of 30 opportunities resulting in a 6.67% (percent) medication error rate. Findings include: The facility's Medication Administration Policy with a reviewed date of February/2024 documents, Medications will be administered to residents as prescribed and by persons lawfully authorized to do so in a manner consistent with good infection control and standards of practice. The (insulin aspart) manufacturer's instructions dated [DATE] documents, Throw away all opened insulin aspart vials after 28 days even if they still have insulin left in them. 1.) R4's Medication Administration Record (MAR) dated [DATE] through [DATE] documents an order dated [DATE] for insulin aspart U-100 insulin solution 100 units/ml…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview the facility failed to label medication with date opened for two residents (R150, R151) of 25 residents reviewed for medication in a sample list of 35 residents Findings Include: 1.) R150's Medication Administration Record (MAR) includes a current physician's order for Refresh tears 0.5% (percent) two drops in each eye as needed every six hours. On 08/14/24 at 11:37 AM an opened bottle of Refresh eye drops with R150's name was observed on the 400 Hall medication cart not labeled with date opened. 2.) R151's Medication Administration Record (MAR) includes a current physician's order for Maxitrol (neomycin-polymyxin b-dexameth) 3.5mg(milligram)/g(gram)-10,000 unit/g-0.1 % ointment apply to right eye, ophthalmic (eye), At Bedtime. The insert for the Maxitrol eye ointment indicates it should be discarded 30 days after opening. On 08/14/24 at 11:36 AM an opened bottle of Maxitrol Eye drops with R151's name was observed on the 400 Hall medication cart not labeled with date opened. On 08/14/24 at 11:36 AM V25, Licensed Practical nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to timely report a resident change of condition to the resident's representative and physician for one (R1) of four residents reviewed for change in condition and injury of unknown origin in the sample list of four. Findings include: The Progress Note dated 05/31/2024 at 09:16 PM by V3, Nurse, states R1 noted to be complaining of pain during cares. The progress note states that R1 was saying ow over and over and when R1 was asked if she hurts R1 said yes. The Note documents R1's right knee was observed to be swollen and painful. The Note documents no redness or bruising was noted and alert charting to monitor for the next three days was started. The Note documents Management was made aware, and a pillow was placed under R1's knee for support and Tylenol was administered for pain. R1's Minimum Data Set completed on 5/16/2024 documents a Brief Interview for Mental Status (BIMS) score of 99. A score of 99 indicates R1 is severely cognitively impaired and unable to complete the interview. R1's Care Plan with revised…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to have a certified dietary manager on staff. This failure has the potential to affect all 103 residents in the facility. Findings include: The facility resident census and condition report dated 8/29/23 documents 103 residents in the facility. On 8/28/23 at 9:20 AM, V5 Dietary Manager attempted to test the low temperature dishwasher with high temperature heat strip. When this did not change for heat, V5 Dietary Manager stated that he did not realize that he needed to test the machine with a chlorine strip, but that his staff know how to test the machine. On 8/29/23 at 11:40 AM, residents were observed being served lunch at the same tables, at different times, leaving some to wait and watch others eat for long periods of time. At 1:01 PM, V2 Director of Nursing said that serving times were all over the place, and that she would prefer for the residents to be served at the same time but sometimes, it's all over the place. On 8/29/23 at 11:55 AM, R97 was sitting in the dining room eating lunch and was given a lunch tray with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to answer call lights in a timely manner for five of 21 residents (R23, R85, R28, R19, R79) reviewed for call lights in the sample list of 49. Findings include: The facility's Call Light Policy with a revised date of 11/17/19 documents, Objective: To respond to the residents' request and needs in a timely manner. Procedure: Answer the resident's call light as soon as possible. The Resident Council Meeting Minutes dated May 3, 2023, documents concerns that residents have (call) lights on and the CNA (Certified Nursing Assistant) come in and turn off the call light and tell the residents they will be right back and never show up again on all of the shifts, (call) lights are not answered in a decent time on all shifts. The Resident Council Meeting Minutes dated July 7, 2023, documents concerns that the CNAs don't answer the call lights on time, and they sit at the nurse's station and chat and don't answer the call lights. 1.) R23's Minimum Data Set (MDS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prevent significant medication errors by failing to administer hormone medication to ensure for proper absorption contributing to abnormal lab results for a resident and failing to administer medication for a resident on dialysis. This failure affects two of five residents (R89, R36) reviewed for significant medication errors on the sample list of 49. Findings Include: 1.) R89's ongoing Census documents R89 was admitted to the facility on [DATE]. R89's ongoing TSH laboratory results document, historically from 2017 - 2019, R89's TSH levels ranged between 0.872 - 2.289 (Normal Value is 0.3 - 5.0). This ongoing TSH results do not document any other results until 8/10/23, in which R89's TSH level is 25.271. R89's Progress Notes dated 8/14/23 documents new orders received to increase R89's Levothyroxine dose based on R89's TSH (Thyroid Stimulating Hormone) level. R89's August 2023 Physician Order Sheets document a diagnosis of Hypothyroidism…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure Scheduled II medications were locked in a permanently affixed compartment, date insulin and liquid protein when opened, resident medications were properly labeled with a pharmacy label and dispose of discontinued medication for residents. This failure affects 10 of 49 (R89, R16, R23, R13, R40, R12, R81, R28, R14, and R26) residents reviewed for medication storage and labeling on the sample list of 49. Findings Include: The facility's Drug Labeling Policy dated December 2021 documents the label of each individual container shall clearly indicate the resident's full name, physician's name, prescription number, name and strength of drug, directions for administration, date of issue, the initials of the pharmacist filling the prescription, and the amount of medications contained in each individual prescription. In addition, the pharmacy's name, address, and telephone number shall be on all prescription labels. Medication containers having soiled, damaged, incomplete, illegible, or makeshift labels shall be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assess and obtain physician's order for self-administration of medication for two of two (R90, R61) residents reviewed for self-administration of medication in a sample list of 49. Finding Include: The facility's Medication Administration policy with a reviewed date of February 2023 documents, Self-Administration: Residents with appropriate cognitive status will be able to self-administer medication. The facility will complete a self-medication administration assessment to determine if resident is able to give their own medications appropriately. 1. R90's Physician's Order Summary includes a physician's order which was initiated 5/9/23 for albuterol sulfate HFA aerosol inhaler; 90 mcg/actuation; amt: 2 puffs; inhalation Special Instructions: rinse mouth after each use every 6 hours. There is no self-medication assessment documented and no physician's order to self-administer albuterol. On 08/28/23 at 12:34 PM, R90 stated he's Miserable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to accurately code the Resident Assessment Instrument (Minimum Data Set) for two of 32 residents (R61, R89) reviewed for Minimum Data Set assessments in the sample list of 49. Findings include: The facility's Minimum Data Set (MDS) policy with a reviewed date of February 2023 documents, A Minimum Data Set will be completed for facility resident as outlined in the Resident Assessment Instrument (RAI) Manual. The facility will conduct admission and scheduled assessments for all facility residents. The assessment process includes direct observation, as well as communication with the resident and direct care staff. The MDS should reflect the resident's status and identify resident need and enhance resident-focused care planning. 1.) R61's Physician Order Report dated 8/29/23 documents diagnoses including Coronary Artery Disease and Hypertension. On 8/28/23 at 9:38 AM, R61 was not in R61's room, there was a CPAP (Continues Positive Airway Pressure)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) level I screening and a PASARR level II screening was completed for two (R55, R97) of seven residents reviewed for PASARR screenings from a total sample list of 49 residents reviewed. Findings Include: The facility's admission procedure dated 6/13/19 documents that the facility will obtain an Omnibus Budget Reconciliation Act (OBRA), otherwise known as PASARR, level screening upon admission. 1. R55's level I PASARR dated 12/10/21, obtained by the facility on 8/30/23, documents a level II PASARR is not required due to R55 not having an SMI (Severe Mental Illness) Diagnosis upon admission to the facility on [DATE]. R55's diagnosis sheet dated 3/2/22 documents new diagnoses of Psychotic disorder with delusions and Unspecified Dementia with Behavioral Disturbances. R55's August 2023 physician order sheet documents Seroquel 25 milligrams to be given in the morning and Seroquel 50 milligrams to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to timely complete a treatment as ordered by the physician for one of one (R4) resident reviewed quality of care on the sample list of 49. Findings Include: R4's August 2023 Physician Orders document an order to apply elastic bandage wraps to bilateral lower extremities between 4:00 am - 7:00 am daily for localized edema and then remove between 8:00 pm - 11:00 pm. R4's Care Plan dated 6/26/23 documents R4 has limited ability with ADLs (Activities of Daily Living) and requires assistance with ADLs due to chronic pain, easily fatigued and impaired mobility related to Osteoarthritis, Heart Failure and Muscle Weakness with an intervention for staff to apply the elastic bandage wraps every morning to R4's bilateral lower extremities and remove them at bedtime. On 8/28/23 at 9:20 AM, R4 was sitting up in a wheelchair with slippers on, feet not elevated. R4's legs were extremely edematous, with a scabbed area to left shin. R4 did not have the elastic bandage wraps on. On 8/29/23 at 8:15 AM, R4 was sitting up in Dining…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to perform hand hygiene and prevent cross contamination during catheter care, ensure an indwelling catheter was secured to prevent it being pulled, ensure a dignity cover was covering the catheter drainage bag, ensure the catheter drainage bag was kept off of the floor, and obtain an urological consult for two of three residents (R89, R94) reviewed for indwelling catheters on the sample list of 49. Findings Include: The facility's Catheter Care Policy last reviewed in February 2023 documents do not tug or pull onto the catheter and secure indwelling catheter as needed. 1. On 8/28/23 at 9:25 AM, R89 was in a wheelchair being pushed down the hall by an unidentified staff member. R89's catheter drainage bag did not have a dignity cover on it, and the drainage bag was dragging on the floor under the wheelchair. R89's Care Plan dated 6/21/2023 documents R89 requires an indwelling urinary catheter Related to diagnosis of Neurogenic Bladder with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to obtain a Physician's Order for the use of a CPAP (Continuous Positive Airway Pressure) machine, failed to obtain an order to clean the CPAP equipment and failed to protect the CPAP mask and tubing from contamination for one of three residents (R61) reviewed for respiratory in the sample list of 49. Findings include: The facility's Oxygen Administration policy with a reviewed date of February 2022 documents, Administration of oxygen under positive pressure may be ordered. Positive pressure is achieved by using a special face mask with a valve which permits expiration against a controlled, calibrated resistance, ranging up to 6 cm (centimeters) of water. The optimum pressure is the maximum tolerated by the resident. Keep a plastic bag available to store the oxygen delivery (cannula or mask) when not in use. Date the bag when placed and change weekly. Guidelines for changing/cleaning respiratory equipment will be as follows: CPAP masks and reservoir - weekly. On 8/28/23 at 9:38 AM, R61 was not in R61's room, there…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to have ongoing communication and collaboration with the dialysis facility regarding care for one of one resident (R36) reviewed for dialysis on the sample list of 49. Findings Include: On 8/28/23 at 10:00 am, R36 stated R36 goes out to dialysis three times a week. R36's Care Plan dated 6/10/23 documents R36 receives hemodialysis related to ESRD (End Stage Renal Disease) and will at times refuse dialysis with interventions of assessing for fluid excess, monitoring/recording food/fluid intake and output, monitor weights daily and notify the physician and family of significant weight changes, report abnormal labs indicative of fluid volume excess, and educate on the risks of refusing dialysis. R36's medical record did not contain any dialysis communication forms. On 8/29/23 at 9:45 AM, V7 RN (Registered Nurse) stated there is no communication between dialysis and the nursing home on a routine basis. V7 stated, V7 can only recall R36 returning to the facility once with any papers and that was because they were wanting an updated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to administer medications according to Physician's Orders and Manufacture's Recommendations for two of four residents (R4, R89) reviewed for medication administration on the sample list of 49. The facility had three errors out of 32 opportunities for a medication error rate of 9.38%. Findings Include: 1.) R89's August 2023 Physician Orders document orders for Levothyroxine {Thyroid Hormone} 200 mcg (Microgram) one tablet every morning, and Levothyroxine 25 mcg one tablet every morning to be taken with the 200 mcg for a total of 225 mcg every day, both to be given between 5:00 am - 10:00 am. On 8/29/23 at 8:25 AM, V7 RN (Registered Nurse) prepared all of R89's morning medications, including R89's ordered Levothyroxine, while R89 sat at the dining room table eating breakfast. There was no warning label on the Levothyroxine Card indicating that the medication needed to be given on an empty stomach. By the time, V7 had prepared R89's medications, R89 had completed breakfast and returned to the unit. V7 left the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure medical records contained preadmission screenings for three of four residents (R97, R51, R80, R55) reviewed for preadmission screenings on the sample list of 49. Findings include: 1. R51's Electronic Medical Record documents R51 was admitted to the facility on [DATE] at 7:26 AM. On 8/28/23 at 12:00 PM, R51's medical record did not contain a PASSAR screen. On 8/29/23 at 9:39 AM, V1 Administrator stated R51's PASSAR screen was not printed when it was obtained and was not put into R51's medical record. 2. R80's Electronic Medical Record documents R80 was admitted on [DATE] at 9:59 AM. On 8/28/23 at 12:00 PM, R80's medical record did not contain a PASSAR screen. On 8/29/23 at 9:39 AM, V1 Administrator stated R80's PASSR screen was not printed when obtained and put into R80's medical record. 3. R55's face sheet documents admission to the facility on [DATE]. On 8/28/23 at 2:25PM, V6 Admissions Coordinator stated, I can't find R55's PASARR. On 8/29/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to utilize Personal Protective Equipment (PPE) and implement infection control interventions for one (R90) of four residents reviewed for infections in a sample list of 49. Findings Include: R90's Face Sheet printed includes the following diagnoses: Chronic Systolic (Congestive) Heart failure, Cough, Essential (Primary) Hypertension, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Generalized Anxiety Disorder, Venous Insufficiency (Chronic) (Peripheral), and Lymphedema R90's progress note dated 08/26/2023 at 9:36 AM documents (R90), has productive cough, audible wheezing noted. (R90) taking Norco prn (as needed) for rib pain due to coughing. Hospice called and will be out later to see (R90). 08/26/2023 at 11:45AM documents (R90), had COVID test and was negative. On 08/28/23 at 12:34 PM R90 stated he's, Miserable from a respiratory infection. R90 was experiencing frequent wet sounding coughs. R90 was not covering his cough. R90 stated, I am really congested. R90 had visible…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to follow antibiotic stewardship guidelines for one (R300) of four residents reviewed for infections in a sample list of 49. Findings Include: R300's hospital history and Physical dated 8/7/23 documents (R300) was admitted with diagnoses of Sepsis due to Urinary tract Infection, Right Hip Fracture, and Left ankle Fracture. R300's Face Sheet dated 8/18/23 (date of admission) also documents R300 has Metastatic Cancer and was admitted to the facility on hospice care. R300's progress Note dated 08/27/2023 at 7:59 AM documents (R300's) output from (Urinary Catheter) this AM was pink and thick. Called hospice to notify. Also reported edema in AL hand/forearm. Hospice will be calling back with any new orders. R300's progress Note dated 08/27/2023 at 9:27 AM documents Hospice called back with orders to change catheter now and start Levaquin 250 mg for 5 days. Power of Attorney called and aware of orders. There is no documentation of a culture. On 8/29/23 at 2:00 PM V2, Director of Nursing (DON) stated, We didn't get a culture (R300)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.