SNF
Department of Health & Human Services Centers for Medicare & Medicaid Services
Printed: Form Approved OMB No. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information)
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE (X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet Page 1 of
146077 02/25/2021
Park Pointe Healthcare & Rehab 1223 Edgewater Morris, IL 60450
F 0552
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Ensure that residents are fully informed and understand their health status, care and treatments.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure that a consent was obtained prior to administering a higher dosage of [MEDICAL CONDITION] medication to a resident.
This applies to 1 of 5 residents (R65) reviewed for [MEDICAL CONDITION] medication in the sample of 18.
The findings include:
R65 has multiple [DIAGNOSES REDACTED].
R65's electronic records shows that the resident was sent out to the hospital on [DATE] with [DIAGNOSES REDACTED]. R65's medication review report from 12/16/2020 - 12/17/2020 shows the resident had an order, dated 4/21/20 until the discharge date on 12/16/21, for [MEDICATION NAME] Tablet 25 mg (Quetiapine [MEDICATION NAME]), give 25 mg by mouth one time a day for hallucinations.
R65 was readmitted back to the facility from the hospital on [DATE]. The hospital discharge medication list, dated 12/21/20, shows the resident was receiving [MEDICATION NAME] 100 mg daily at the hospital.
R65's current facility medication review report shows an order dated 12/21/20 for [MEDICATION NAME] tablet 100 mg (Quetiapine [MEDICATION NAME]), give 100 mg by mouth one time a day for mood.
R65's MAR (Medication Administration Record) shows that the [MEDICATION NAME] 100 mg was administered to the resident from 12/24/20 through 2/24/21, every 8:00 AM as documented by the nurses.
R65's [MEDICAL CONDITION] medication care plan, specifically for [MEDICATION NAME], initiated on 12/22/20 with a goal target date of 5/18/21, shows multiple interventions which included, Obtain informed consent prior to administering of first dose or for dose increases. Date initiated 12/22/2020.
The facility provided a consent signed by R65's POA (Power of Attorney), dated 4/27/20, for [MEDICATION NAME] 25 mg daily. However, no consent was provided to the State Agency with regards to the increase in the dosage of the [MEDICATION NAME] to 100 mg.
(continued on next page)
146077 15
11/02/2021
Department of Health & Human Services Centers for Medicare & Medicaid Services
Printed: Form Approved OMB No. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information)
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet Page of
146077 02/25/2021
Park Pointe Healthcare & Rehab 1223 Edgewater Morris, IL 60450
F 0552
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
On 2/24/21 at 12:30 PM, V2 (Director of Nursing) stated she has been looking for the [MEDICATION NAME] 100 mg consent and that she cannot find it in the resident's records. V2 stated there is no consent obtained for the use of the [MEDICATION NAME] 100 mg.
On 2/25/21 at 8:41 AM, V17 (Physician and Medical Director) stated that a consent should be obtained before administering any [MEDICAL CONDITION] medication for the first time and before administering an increase dose of the same [MEDICAL CONDITION] medication.
The facility's policy regarding [MEDICAL CONDITION] medication, last updated on 7/11/11, shows, 1. All residents with physician's orders [REDACTED].
152146077
11/02/2021
Department of Health & Human Services Centers for Medicare & Medicaid Services
Printed: Form Approved OMB No. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information)
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet Page of
146077 02/25/2021
Park Pointe Healthcare & Rehab 1223 Edgewater Morris, IL 60450
F 0578
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide documentation of information on provision of rights of treatment and to formulate an advance directive for a resident.
This applies to 1 of 3 residents (R170) reviewed for advance directives in the sample of 18.
The findings include:
R170 was admitted on [DATE] with [DIAGNOSES REDACTED]., malignant neoplasm of bone and prostate, [MEDICAL CONDITION], and [MEDICAL CONDITION] nodule.
On 2/22/21 at 11:39 AM, R107 was sitting in a wheelchair being given medication by a nurse. R107 needed reminders earlier to stay in his room due to being on 14 day observation.
On 2/22/21, review of R170's EHR (Electronic Health Records) did not show his code status. The profile page showed R170's mother was the Power of Attorney (POA) for healthcare. No documentation was found that the resident or the POA were provided information regarding the rights to accept or refuse treatment.
On 2/24/21 at 8:50 AM, V18 (Social Service Coordinator) was requested to provide information on Advance Directive. V18 stated she has not contacted R170's POA yet, and has not documented any information in the EHR.
On 2/24/21 at 9:25 AM, V1 (Administrator) and V2 (Director of Nursing) were requested to provided information or policy on what care the nurses were expected to provide in the event of medical emergency since there was no order or code status in the medical records. No additional information was provided.
The facility policy titled, Advance Directives Policy, updated 8/31/11, requires, 1. Prior to or upon admission of a Resident to our facility, the Social Services Director or designee will provide written information to the Resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives. 3. Prior to or upon admission of a Resident, the Social Services Director of designee will inquire of the Resident, and/or his/her family members, about the existence of any written advance directives. 4. Information about whether or not the Resident has executed an advance directive shall be displayed prominently in the medical record.
153146077
11/02/2021
Department of Health & Human Services Centers for Medicare & Medicaid Services
Printed: Form Approved OMB No. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information)
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet Page of
146077 02/25/2021
Park Pointe Healthcare & Rehab 1223 Edgewater Morris, IL 60450
F 0677
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
Provide care and assistance to perform activities of daily living for any resident who is unable.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to assist residents identified as needing assistance with personal hygiene.
This applies to 5 of 5 residents (R10, R14, R23, R35 and R47) reviewed for ADL (activities of daily living) in the sample of 18.
The findings include:
1. R10 has multiple [DIAGNOSES REDACTED].
R10's annual MDS (Minimum Data Set), dated 12/3/20, shows the resident is moderately impaired with cognition and would require assistance from the staff with his ADL.
On 2/22/21 at 12:29 PM, R10 was sitting in his wheelchair inside his room. R10 is alert, oriented, and verbally responsive. R10 was observed with weakness on his right side. R10 had accumulation of long facial hair. R10 stated he wants the staff to shave him. V4 (LPN/Licensed Practical Nurse)was present and was aware of R10's request to be shaved. V4 stated R10 has weakness on his right side and the resident used to be able to shave himself, but lately has been having problem doing it himself.
R10's current care plan, revised on 1/31/20, shows the resident has an ADL self-care performance deficit related to dementia, [MEDICAL CONDITION] with history [MEDICAL CONDITION] and polio[DIAGNOSES REDACTED]. The same care plan shows R10 requires a staff assistance with grooming.
R10's electronic records shows no documentation that the resident had refused assistance from the staff with regards to removing his unwanted facial hair.
2. R14 has multiple [DIAGNOSES REDACTED].
R14's admission MDS, dated [DATE], shows the resident is cognitively impaired with cognition and would require assistance from the staff with her ADL including personal hygiene.
On 2/22/21 at 12:54 PM, R14 was in bed, awake, alert, and verbally responsive. R14's fingernails were long and jagged. R14 stated, I need my fingernails trimmed. V5 (CNA/Certified Nursing Assistant) was present in the room and heard the conversation.
R14's current care plan, revised on 11/13/20, shows the resident has impaired physical mobility requiring assistance related to [MEDICAL CONDITION] and weakness. The same care plan shows multiple interventions which included, Ensure that all hygiene needs have been met, e.g. (for example) skin care, oral care, hair, nails, etc.
3. R23 has multiple [DIAGNOSES REDACTED].
R23's annual MDS, dated [DATE], shows the resident is cognitively intact and would require extensive assistance with most of her ADL, including personal hygiene.
(continued on next page)
154146077
11/02/2021
Department of Health & Human Services Centers for Medicare & Medicaid Services
Printed: Form Approved OMB No. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information)
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet Page of
146077 02/25/2021
Park Pointe Healthcare & Rehab 1223 Edgewater Morris, IL 60450
F 0677
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
On 2/22/21 at 11:51 AM, R23 was sitting in her wheelchair inside her room. R23 is alert, oriented, and verbally responsive. R23's fingernails were long and jagged. R23 stated she wanted the staff to trim and file her fingernails. V4 was present during the observation and is aware of R23's request.
R23's current care plan, revised on 11/26/19 with target goal dated of 4/7/21, shows the resident has an ADL self-care performance deficit related to limited mobility. The same care plan shows R23 requires staff assistance with regards to personal hygiene.
4. R35 has multiple [DIAGNOSES REDACTED].
R35's annual MDS, dated [DATE], shows the resident is severely impaired with cognition and would require extensive assistance with most of her ADL, including personal hygiene.
On 2/22/21 at 12:11 PM, R35 was in bed, alert, confused, but verbally responsive. R35's fingernails were long, jagged with black substances underneath and her nail polish was chipped. R35 stated she needs the staff to trim and clean her fingernails. V4 was present during the observation and heard about R35's request. V4 acknowledged that R35's fingernails needed to be trimmed and cleaned.
R35's current care plan, revised on 1/18/20, shows the resident has an ADL self-care performance deficit related to confusion, [MEDICAL CONDITIONS] arthritis, [MEDICAL CONDITION] and hypertension. The same care plan shows R35 requires a staff assistance with regards to grooming.
On 2/24/21 at 12:43 PM, V2 (DON/Director of Nursing) stated it is part of the nursing care for the nursing staff to make sure resident's fingernails are trimmed and clean. It is also part of the nursing care for the nursing staff to shave or remove unwanted facial hair if desired by the resident.
5. R47's face sheet showed that R47 is an [AGE] year old who has multiple medical [DIAGNOSES REDACTED]. Minimum Data Set (MDS), dated [DATE], showed R47 is alert and oriented and requires assistance with activities of daily living (ADL) care including hygiene/grooming.
On 2/23/21 at 9:00 AM, R47 was sitting on her recliner, displaying overgrown fingernails, some of which were chipped with rough edges. R47 stated she does not like having long fingernails and is not comfortable with it. Requested nail clipping.
On 2/23/21 at 10:50 AM, V9 (CNA) stated nail clipping is part of grooming care. They provide it after shower.
155146077
11/02/2021
Department of Health & Human Services Centers for Medicare & Medicaid Services
Printed: Form Approved OMB No. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information)
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet Page of
146077 02/25/2021
Park Pointe Healthcare & Rehab 1223 Edgewater Morris, IL 60450
F 0690
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide peri-care in a manner that would prevent potential infection.
This applies to 4 of the 5 residents (R8, R40, R41, R49) reviewed for bowel and bladder care in the sample of 18.
The findings include:
1. R49's face sheet showed R49 is a [AGE] year-old who has multiple medical [DIAGNOSES REDACTED].
On 2/23/21 at 2:10 PM, V10 (Certified Nursing Assistant/CNA) assisted R49 to the toilet for bowel movement. After R49 completed her bowel movement, V10 cleaned R49 from behind then she pulled up R49's brief and pants, assisted her back to the wheelchair, without cleaning the frontal perineum.
2. On 2/23/21 at 2:22 PM, V9 (CNA) provided incontinence care to R40 who had a bowel movement. V9 cleaned R40's buttocks, then he (V9) applied new incontinence brief and transferred R40 back to the wheelchair, without cleaning the perineum.
3. R8 has indwelling urinary catheter related to [MEDICAL CONDITION] bladder as shown in her care plan.
On 2/24/21 at 10:01 AM, V11 and V12 (Both CNAs) assisted R8 to the rest room for bowel movement. After R8 completed her bowel movement, V12 cleaned R8 from behind (buttocks and back peri-area), then she pulled up R8's brief and pants and assisted R8 back to the wheelchair. V11 and V12 did not clean R8's frontal perineum and indwelling catheter.
4. R41's face sheet showed R41 is a[AGE] year-old who has multiple medical [DIAGNOSES REDACTED].
On 2/24/21 at 10:15 AM, V11 and V12 assisted R41 to the toilet for voiding. Right after she (R41) voided, V11 proceeded to wiped R41 from behind (cleaning the back peri-area including rectum and buttocks) then she (V11) and V12 assisted R41 back to the wheelchair, without providing frontal perineum care.
R8's, R40's, R41's and R49's most recent Minimum Data Sheet (MDS) showed these residents require assistance with bowel and bladder care.
On 2/24/21 at 3:22 PM, V2 (Director of Nursing/DON) stated when staff provide bladder and bowel care, the staff must clean from front to back meaning entire frontal perineum such as the labia, urethra, groins and pubic area to prevent potential infection.
Facility's Incontinence Care Policy showed:
(continued on next page)
156146077
11/02/2021
Department of Health & Human Services Centers for Medicare & Medicaid Services
Printed: Form Approved OMB No. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information)
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet Page of
146077 02/25/2021
Park Pointe Healthcare & Rehab 1223 Edgewater Morris, IL 60450
F 0690
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
Policy: To cleanse the perineum and surrounding areas after an incontinent episode in order to assist the resident with keeping their skin clean, intact and dry. Perineal care with be done with AM and PM care and after each incontinent episode.
157146077
11/02/2021
Department of Health & Human Services Centers for Medicare & Medicaid Services
Printed: Form Approved OMB No. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information)
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet Page of
146077 02/25/2021
Park Pointe Healthcare & Rehab 1223 Edgewater Morris, IL 60450
F 0758
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to monitor and document behavior/symptoms to support the continued use of the [MEDICAL CONDITION] medication. The facility also failed to ensure that a resident who receives [MEDICAL CONDITION] medications is monitored for any side effects, to determine the effectiveness of the medication being administered and for potential drug reduction.
This applies to 1 of 5 residents (R65) reviewed for [MEDICAL CONDITION] medications in the sample of 18.
The findings include:
R65 has multiple [DIAGNOSES REDACTED].
On 2/22/21 at 12:02 PM, R65 was sleeping in bed. On 2/22/21 at 12:44 PM, R65 in bed, awake, alert and verbally responsive. Stated she does not want to eat. V5 (CNA/Certified Nursing Assistant) stated R65 had a few bites of the chili beans and spit it out. According to V5, R65 does not want to eat, and had only couple of bites of the cake. On 2/22/21 at 12:50 PM, R65 was sleeping in bed.
On 2/24/21 at 10:34 AM, R65 was in bed awake and verbally responsive. V3 (Treatment Nurse) informed R65 she would clean and apply treatment on her (R65) pressure injury. R65 stated she is sleepy and would like to take a nap after her wound treatment.
R65's electronic records shows that the resident was sent out to the hospital on [DATE] with [DIAGNOSES REDACTED]. R65's medication review report from 12/16/2020 - 12/17/2020, shows the resident had an order, dated 4/21/20 until the discharge date on 12/16/21, for [MEDICATION NAME] Tablet 25 mg (Quetiapine [MEDICATION NAME]), give 25 mg by mouth one time a day for hallucinations.
R65 was readmitted back to the facility from the hospital on [DATE]. The hospital discharge medication list, dated 12/21/20, shows the resident was receiving [MEDICATION NAME] 100 mg daily at the hospital.
R65's current facility medication review report shows an order dated 12/21/20 for, [MEDICATION NAME] tablet 100 mg (Quetiapine [MEDICATION NAME]), give 100 mg by mouth one time a day for mood.
R65's MAR (Medication Administration Record) shows the [MEDICATION NAME] 100 mg was administered to the resident from 12/24/20 through 2/24/21, every 8:00 AM as documented by the nurses.
R65's progress notes and MAR from 12/21/20 through 2/24/21, shows no documentation with regards to any manifested behavior/symptom and/or specific behavior/symptom monitoring that could support the use of the [MEDICAL CONDITION] medication [MEDICATION NAME].
(continued on next page)
158146077
11/02/2021
Department of Health & Human Services Centers for Medicare & Medicaid Services
Printed: Form Approved OMB No. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information)
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet Page of
146077 02/25/2021
Park Pointe Healthcare & Rehab 1223 Edgewater Morris, IL 60450
F 0758
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
R65's progress notes, dated 2/2/21 (11:34 AM), shows, Upon entering room to interview res, she presented heavily asleep having difficulty to arouse. Nurse and CNA also reported difficulty getting to eat or consume meds (medications). In interviewing 2 different CNA's it was concluded that res has been requiring 2 person for transfers and bed mobility more consistently. Further review of R65's progress notes from 2/2/21 through 2/3/21, shows no documentation the physician was informed that the resident was heavily asleep and the staff was having difficulty in arousing the resident on 2/2/21.
R65's [MEDICAL CONDITION] medication care plan specifically for [MEDICATION NAME], initiated on 12/22/20 with a goal target date of 5/18/21, shows, Administer [MEDICAL CONDITION] medications as ordered by the physician. Monitor for side effects and effectiveness Q (every shift).
On 2/24/21 at 11:30 AM, V2 (Director of Nursing) was informed on 2/22/21 during the tour of the unit and during lunch observation, R65 was observed sleeping most of the time. V2 was informed R65 is currently receiving 100 mg of [MEDICATION NAME] and the resident used to be receiving only 25 mg, prior to her hospitalization on [DATE].
On 2/24/21 at 12:14 PM, V5 (Certified Nursing Assistant) stated she had noticed lately that R65 has been sleeping more and that her appetite is not good.
On 2/24/21 at 12:17 PM, V4 (Licensed Practical Nurse) stated she is the regular day shift nurse in the unit where R65 resides. V4 stated R65 may have a day or so of being very sleepy, which is not a normal behavior of the resident. V4 stated she also noticed R65 to be very sleepy on 2/22/21. V4 stated R65 is on [MEDICATION NAME] because of hallucinations. However, since R65 came back from the hospital on December 2020 to the present, she has not observed any hallucinations, or has not received reports of hallucinations from the staff.
R65's order note, dated 2/24/21 (12:29 PM), shows, Resident admitted to the (hospital) on 12/16/20, was readmitted on [DATE]. [MEDICATION NAME] dose increased from 25 mg to 100 mg while hospitalized . Spoke with MD today and requested dose reduction of [MEDICATION NAME] due to fatigue. MD agreed with reduction and gave new order for [MEDICATION NAME] 50 mg daily. Order entered.
R65's electronic records shows an order, dated 2/24/21, to reduce the [MEDICATION NAME] from 100 mg to 50 mg, after prompting.
(continued on next page)
159146077
11/02/2021
Department of Health & Human Services Centers for Medicare & Medicaid Services
Printed: Form Approved OMB No. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information)
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet Page of
146077 02/25/2021
Park Pointe Healthcare & Rehab 1223 Edgewater Morris, IL 60450
F 0758
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
On 2/25/21 at 8:41 AM, V17 (Physician and Medical Director) was asked why [MEDICATION NAME] 100 mg was ordered for R65. V17 responded when R65 was readmitted back to the facility on [DATE], he just continued the hospital order of [MEDICATION NAME] 100 mg daily with the expectation the facility will monitor the resident's behavior/symptom and any potential side effects of the medication regularly (on a consistent basis) to be able to support the use of the current [MEDICATION NAME] dosage and to determine if the [MEDICATION NAME] medication needs to be reduced. V17 stated t he does not know what behavior/symptoms R65 had at the hospital that warranted the resident to receive [MEDICATION NAME] four times her usual dose. V17 stated he expects the facility to ensure all residents who are receiving any type of [MEDICAL CONDITION] medication are regularly evaluated/seen by the psychiatrist to determine the effectiveness of the [MEDICAL CONDITION] medication being administered and for potential drug reduction. V17 was asked if he was called/informed by the facility that on 2/2/21 regarding R65 being heavily asleep, staff having difficulty arousing the resident, and R65 requiring more assistance from the staff with transfers and bed mobility. V17 reviewed his notes regarding the calls he received from the facility and responded he was not informed by the facility about R65's condition on 2/2/21. V17 further stated if he was informed that R65 was heavily asleep and was hard to arouse on 2/2/21, he would review the resident's medication profile, order some laboratory tests, and reduce R65's [MEDICAL CONDITION] medication as needed. V17 was asked why he reduced R65's [MEDICATION NAME] on 2/24/21 from 100 mg to 50 mg. V17 responded the nurse asked for the [MEDICATION NAME] to be reduced because R65 has increased sleepiness and is constantly tired.
On 2/25/21 at 9:52 AM, V2 was asked if R65 was evaluated or is being followed by the psychiatrist for the use of the [MEDICAL CONDITION] medications. V2 stated she had reviewed R65's records and the resident has not been seen by the psychiatrist since readmission on 12/21/20.
The facility's policy regarding [MEDICAL CONDITION] medication, last updated on 7/11/11, shows, 3. All residents with a physician's orders [REDACTED].
.
1510146077
11/02/2021
Department of Health & Human Services Centers for Medicare & Medicaid Services
Printed: Form Approved OMB No. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information)
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet Page of
146077 02/25/2021
Park Pointe Healthcare & Rehab 1223 Edgewater Morris, IL 60450
F 0812
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Based on observation and interview, the facility failed to ensure food and beverages that were stored in the unit refrigerators were marked to indicate what date the opened items must be either consumed by or discarded. This had the possibility to affect 15 of 18 sampled residents (R8, R9, R14, R20, R23, R35, R40, R41, R43, R44, R52, R53, R63, R65, R170) on three units (A, B, and C) reviewed for medication administration.
The findings include:
On February 23, 2021 at 1:10 PM, V14 (Ward Clerk) was present and participated in the tour of the
C-wing refrigerator. Multiple cartons of opened beverages were noted that did not have a label denoting a resident name, or denoting date the item was opened, or the date when item should be discarded after opening. The items included multiple-use quart containers of tomato juice, prune juice, pineapple juice, and multi-use carafes of colored beverages. A half-gallon milk container was noted with a manufacturer's best by date of February 16, 2021. V14 confirmed that the milk was outdated, and should have been used or discarded by the expiration date, and the items without open dates or discard dates should have been labeled by staff, and added this was required by the facility.
On February 24, 2021 at 1:20 PM, V13 (Consultant Dietician) was present during the review of unit refrigerators on A wing, B wing and C wing. V13 stated the unit refrigerators are intended for residents' food, snacks, supplements and food brought in by families for their resident. The unit refrigerators reviewed were full-sized refrigerators as typically seen in home use.
V13 stated when items stored in the refrigerators are opened, the items should be labeled with the resident's name, date the item was opened, and date it should be discarded. V13 stated the open food items in the refrigerator are good for seven days and should be discarded if not used by the seventh day, and she added the nursing staff was responsible for ensuring items were discarded if not used by the seven days. V13 stated this was required by the facility and staff is repeatedly educated on this expectation. Multiple juice containers were noted opened and not dated to show the date the items should either be used by or discarded. Other items noted included a carton of a quart of milk, a four-quart container of pineapple chucks, a half-empty personal sized diet soda, two pieces of unwrapped cake (no name or date), and a resident's pink bedside water pitcher without a lid, and half full of liquid. Also noted was a paper plate with partially eaten cake and plastic fork (which appeared used), was not labeled with name or date.
V13 provided the facility's policy, Sanitization Manual Food Labeling (not dated), which stated in part that the purpose was, To reduce the risk of food borne illness. In addition the policy stated that items in the refrigerator, will be marked to indicate which date or day the food must be consumed or discarded.
1511146077
11/02/2021
Department of Health & Human Services Centers for Medicare & Medicaid Services
Printed: Form Approved OMB No. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information)
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet Page of
146077 02/25/2021
Park Pointe Healthcare & Rehab 1223 Edgewater Morris, IL 60450
F 0880
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
Provide and implement an infection prevention and control program.
Based on observation, interview, and record review, the facility failed to follow standard infection control practices with regards to hand hygiene and glove change during provisions of bowel, bladder and wound care. In addition, the facility failed to ensure the availability of recommended personal protective equipment (PPE) in the quarantine unit.
This applies to 16 of the 16 (R1, R8, R20, R40, R41, R49, R59, R65, R170, R220, R221, R222, R223, R224, R225, R226) residents reviewed for infection control practices.
The findings include:
1. R20's Medication Administration Record [REDACTED].
On 2/23/21 at 1:47 PM, V10 (Certified Nursing Assistant/CNA) provided peri-care to R20. As V10 was cleaning R20's buttocks she (V10) was also doing different task such as changing soiled linen with clean ones, returning R20's belongings on top of the bed, opening bathroom door, and touching clean clothes while wearing same soiled gloves.
2. On 2/23/21 at 2:10 PM, V10 (CNA) assisted R49 to the toilet for bowel movement. V10 cleaned R49, then she (V10) pulled the brief and pants up and transferred R49 back to the wheelchair, while wearing same soiled gloves.
3. On 2/23/21 at 2:22 PM, V9 (CNA) provided incontinence care to R40 who had a bowel movement. V9 cleaned R20, applied new incontinence brief and transferred R20 back to the high back wheelchair, while wearing same soiled gloves.
4. On 2/24/21 at 10:01 AM, V11 and V12 (Both CNAs) assisted R8 to the rest room for bowel movement. V12 cleaned R8, then she (V12) pulled the incontinence brief and pants up and transferred R8 back to the wheelchair, while wearing same soiled gloves.
5. On 2/24/21 at 10:15 AM, V11 and V12 assisted R41 to the toilet. After R41 complete her voiding, V11 wiped R41 from the back then V11 pulled the brief and pants up and transferred R41 back to the wheelchair, while wearing same soiled gloves.
On 2/24/21 at 3:22 PM, V2 (Director of Nursing/DON) stated when providing care, the staff must change gloves and sanitize hands from dirty to clean task, prior to touching clean surface and or clean clothes to prevent cross contamination and/or spread of infection.
6. During pressure injury treatment observation made on 2/24/21 on 10:30 AM, V3 (Treatment Nurse) prepared and administered the wound treatment to R65.
R65 was in bed awake and verbally responsive. V3 using a pair of gloves turned and repositioned the resident and lowered the head of the bed using the bed control. Using the same pair of gloves, V3 cleaned the pressure injury of R65 on the right buttock area with a gauze and normal saline. After cleaning the right pressure injury, V3 removed both her used gloves and then put on a new pair of gloves, without performing handwashing or hand sanitizing. V3 then continued to apply the treatment on R65's pressure injury.
(continued on next page)
1512146077
11/02/2021
Department of Health & Human Services Centers for Medicare & Medicaid Services
Printed: Form Approved OMB No. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information)
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet Page of
146077 02/25/2021
Park Pointe Healthcare & Rehab 1223 Edgewater Morris, IL 60450
F 0880
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
On 2/24/21 at 1:00 PM, V3 was informed of the above observation and acknowledged she used the same pair of gloves to clean R65's pressure injury even though she had used the same pair of gloves to turn and reposition the resident and had manipulated the bed control. V3 also acknowledged no hand hygiene was performed after removing her gloves post cleaning the pressure injury and before putting on a new pair of gloves to apply the treatment.
Facility's Hand Hygiene Policy and Procedure showed:
Policy: The facility considers hand hygiene the primary means to prevent spread of infection.
Procedure:
Employees must wash hands under these conditions
- After contact with blood, body fluids, secretions, mucous membranes or non-intact skin.
- After removing gloves.
- After handling items potentially contaminated with blood, body fluids, or secretions.
The use of gloves does not replace handwashing/hand hygiene.
7. On 2/24/21 at 10:10 AM in Wing A, the designated unit for residents on 14 day observation, did not have the recommended PPE (Personal Protective Equipment) supplies in the isolation storage bins outside the rooms of residents who were on contact and droplet precautions. The residents provided in the Room List on contact and droplet precautions were R1, R59, R170, R220, R221, R222, R223, R224, R225, and R226.
On 2/24/21 at 10:55 AM in the A Wing, wound care treatment to be done by V3 (Treatment Nurse) on R43 (not on isolation) was going to be observed. V3 stated she wears PPE during treatment even if the resident was not on isolation. A gown was requested but V3 was not able to find any gowns in the unit. V3 stated had to get the gowns outside of A Wing.
On 2/24/21 at 2:15 PM, V2 (Director Of Nursing) stated PPE supplies should be stocked be in the carts. On 2/25/21 at 11:25 AM, V2 stated the PPE required for staff to use for residents on 14 day observation is to use the full PPE since these residents are on contact and droplet precautions. The isolation storage carts should contain gowns, surgical mask, face shield or goggles, and gloves. N95 mask should be worn and a surgical mask is donned over the N95 mask when entering the room of residents on contact and droplet precautions. V2 stated the nurses and certified nursing assistants (CNAs) were responsible in stocking the isolation storage bins with supplies.
On 2/24/21 at 4:15 PM, V1 (Administrator) stated there was no policy on who was responsible in stocking the PPE in the unit.
(continued on next page)
1513146077
11/02/2021
Department of Health & Human Services Centers for Medicare & Medicaid Services
Printed: Form Approved OMB No. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information)
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet Page of
146077 02/25/2021
Park Pointe Healthcare & Rehab 1223 Edgewater Morris, IL 60450
F 0880
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
The facility policy titled, Infection Control-Isolation Categories of Transmission Based Precautions Policy, updated 7/17/20, requires, Precaution 4. In addition to Standard Precautions, implement Contact Precaution . c. gloves .d. gowns. 5. Droplet Precaution .d. PPE: i. In addition to Standard Precautions, wear a mask .ii. Gowns, gloves and faceshield/goggles should also be worn when caring for a resident on droplet precautions.
1514146077
11/02/2021
Department of Health & Human Services Centers for Medicare & Medicaid Services
Printed: Form Approved OMB No. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information)
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet Page of
146077 02/25/2021
Park Pointe Healthcare & Rehab 1223 Edgewater Morris, IL 60450
F 0882
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Many
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Based on interview and record review, the facility failed to ensure there was an Infection Preventionist who was certified, or in the certification process, for the specialized responsibility of the Infection Preventionist. This had the possibility to affect all of the facility's 77 residents residing in the facility.
The findings include:
The Resident Census and Condition form (CMS 672) for this survey, showed the facility census on February 22, 2021 was 77.
On February 24, 2021 at 11:05AM, V1 (Administrator) stated that V2 (Director of Nursing/DON) was the facility's Infection Control Nurse, and that the facility did not have anyone with Infection Preventionist certification.
On February 24, 2021 at 1:25 PM, V2 (Director of Nursing) stated she was employed by the facility since April 2019, beginning in the Assistant Director of Nursing position, and became Director of Nursing in May of 2019. V2 stated she was also currently in the the role of the Infection Preventionist, and did not have certification for Infection Preventionist training.
V2 stated the facility's previous Infection Preventionist left the facility's employment in September 2020, and the facility had not hired a replacement for the position, and that no other staff filled the certified position. V2 stated V2 looked into the online Infection Preventionist certification process some months ago and decided she would not have time to complete it because there were so many modules, and acknowledged that therefore she did not have any course documentation to provide for review.
1515146077
11/02/2021