McLeansboro Rehab & Hlth C Ctr

Inspectors wroteBased on interview and record review, the facility failed to have a Registered Nurse working 8 consecutive hours a day, 7 days a week. This failure has the potential to affect all 35 residents residing in the facility. The Findings Include: Nursing schedules reviewed for June 7, 2024 through June 24, 2024 revealed the facility did not have Registered Nurse (RN) coverage on Saturday, 6/15/24 and Sunday, 6/16/24. On 6/24/2024 at 1:45pm, V5 (Corporate Administrator) said the facility does not have the required 8 hours of continuous RN coverage per day. V5 said the lack of RN coverage occurs on the weekends. On 6/24/24 at 2:00pm, V1 (Administrator) said there are weekends that the facility does not have the required RN coverage of 8 hours a day minimum. V1 said she was just happy to have nurses to work over the weekends even if they are not RNs. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a Registered Nurse working 8 consecutive hours a day, 7 days a week. This failure has the potential to affect all 30 residents residing in the facility. The Findings Include: On 6/6/24 at 11:00 AM, V3 (Director of Nursing/DON) stated that there are weekends that she sometimes cannot get covered with a Registered Nurse (RN) working. V3 further stated that they do not use a staffing agency, but they have a PRN (as needed) float pool within the company and a list of facility specific PRN RN's that they attempt to have cover these shifts. V3 stated that they do have advertisements out to hire RN's but if there are times they cannot get RN's to cover the shift they use their LPN (Licensed Practical Nurses) staff. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for 1 (R8) of 12 reviewed for accuracy of assessments in the sample of 23. Findings Include: R8's admission Record documented R8 is [AGE] years old with an Initial admission Date to the facility of 01/03/2019. Diagnoses listed on this document included anxiety disorder, schizophrenia, anemia, depression, and unspecified dementia. The OBRA Initial Screen for R8 dated 09/04/2017 documented under Part III, The individual has been formally diagnosed with a mental illness verified by a DSMIV classification which subsequently impairs the person's cognitive, emotional and/or behavioral functioning, excluding organic disorders/dementia, developmental disabilities, and alcohol/substance abuse. This section had an X marked to indicate the answer Yes. [...]

Inspectors wroteBased on interview and record review, the facility failed to add new person centered fall interventions to prevent falls for 1 (R120) of 2 residents reviewed for falls in the sample of 23.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents are free from staff to resident abuse for one of three residents (R1) reviewed for abuse in the sample of 3. This failure resulted in R1 experiencing burning pain and irritation as a result of hand sanitizer being applied to her bottom and legs, some areas of which had excoriation. A reasonable person would also experience feelings of intimidation, fear, emotional distress, and helplessness as a result.

Inspectors wroteBased on interview and record review, the facility failed to implement abuse policies by not reporting abuse within the designated time frames for 2 of 3 residents (R1 and R3) reviewed for abuse in a sample of 3. Findings Include: 1. R1's face Sheet documents an admission date of 6/23/2017 with diagnoses including Alzheimer's Disease, Dementia, Chronic Pain, Excoriation (skin picking) Disorder, Anxiety, Hypertension, GERD, and Osteoporosis. R1's Minimum Data Set, dated for 4/17/2024, documents a Brief Interview for Mental Status (BIMS) score of 2, indicating that R1 has severe cognitive impairment. The same MDS documents that R1 is totally dependent of at least two persons for transfers, bed mobility, dressing, eating, and toileting needs. [...]

Inspectors wroteBased on interview and record review the facility failed to initiate and thoroughly investigate an allegation of abuse for 1 of 3 residents (R3) reviewed for abuse in a sample of 3. The Findings Include: R3 's Face Sheet documented an admission date of 2/4/2021 with diagnoses including Chronic Obstructive Pulmonary Disease and Anxiety. R3's Minimum Data Set, dated for 4/23/2024, documented R3 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R3 is cognitively intact. The same MDS documents that R3 requires set up assistance with showers/bathing and assistance of 1 to transfer in and out of shower chair for safety. On 5/2/2024 at 9:30am, R3 stated she was abused during a shower. R3 stated V12 (CNA) wadded up a washcloth and jabbed it in her stomach (belly button area). R3 stated it left a big red area and bothered her for a bit. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide or obtain the required specialized rehabilitative services for 1 of 3 residents (R2) reviewed for therapy services in a sample of 3.

Inspectors wroteBased on interview and record review the facility failed to have a registered nurse, at least 8 consecutive hours, 7 days a week. This has the potential to affect all 23 residents who reside at this facility.

Inspectors wroteBased on interview, observation and record review, the facility failed to follow through with a wound referral for a worsening pressure ulcer, failed to timely reassess and identify worsening pressure ulcer, and timely treat new wounds for 1 of 2 residents reviewed for pressure ulcers in the sample of 16. This failure resulted in the worsening and infection of R12's pressure ulcer to the right ankle.

Inspectors wroteBased on interview, and record review the facility failed to provide 8 hours daily, 7 days a week of Registered Nurse coverage for the facility. This failure has the potential to affect all 19 residents living in the facility. Findings Include: The Nursing Schedules from January 2023 - May 4, 2023 documents no RN coverage was provided at the facility on 1/3, 1/14, 1/18, 1/19, 1/20, 1/21, 1/25, 1/26, 1/27, 2/4, 2/7, 2/8, 2/11, 2/18, 3/4, 3/11, 3/14, 3/22, 3/25, 3/26, 3/27, 3/31, 4/7, 4/8, 4/9, 4/14, 4/15, 4/20, 4/21, 4/22, 4/27, 4/28, & 5/1. On 5/4/2023 at 12:00 p.m., V1 (Acting Administrator) stated there are three registered nurses (RNs) that work at the facility. V1 stated that there is not a current Director of Nursing at the facility and that V3 (Regional RN) fills in at the facility at times. [...]