Nexus at Columbia

Inspectors wroteBased on interview and record review the facility failed to initiate Cardiopulmonary Resuscitation (CPR) to an unresponsive resident for 1 of 1 (R2) resident reviewed for CPR in the sample of 6. This failure resulted in an Immediate Jeopardy that began on [DATE] and resulted in the death of R2, who had an unknown code status and was found breathless and unresponsive and did not receive lifesaving Cardiopulmonary Recusation efforts. On [DATE] at 11:39 AM V1, Administrator, V2, Director of Nursing (DON), and V9, [NAME] President of Clinical Operations, were notified of the Immediate Jeopardy. The surveyor confirmed by interview and record review, the Immediate Jeopardy was removed on [DATE], but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include: [...]

Inspectors wroteBased on interview and record review, the Facility failed to report an allegation of abuse for 1 of 3 residents (R4) reviewed for abuse in the sample of 11.

Inspectors wroteBased on interview and record review, the Facility failed to thoroughly investigate an allegation of abuse for 1 of 3 residents (R4) reviewed for abuse in the sample of 11.

Inspectors wroteBased on interview and record review, the facility failed to prevent resident-to-resident physical abuse in 1 of 4 residents (R2) reviewed for abuse in the sample of 5. This failure resulted in R2 feeling unsafe in the facility and being hit in the breast.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to ensure residents wear treated in a dignified manner by providing timely toileting assistance and respecting the resident's right to a home-like environment for 2 of 6 residents (R1 and R4) reviewed for resident's rights in the sample of 6. This failure caused R1 to feel like V4 was mean to R1, resulting in R1 crying, and R4 feeling a little depressed.

Inspectors wroteBased on interview and record review, the facility failed to provide showers for 4 of 4 (R1, R11, R12, R15) residents reviewed for Activities of Daily living in a sample of 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food at a palatable temperature for 4 of 4 residents (R13, R14, R15, R1) in a sample of 15. Findings Include: The (facility) Grievance/Concern reporting form, dated 2/6/2025, documents Resident council concerns relates to dietary. The resident Council met on 2/6/25. Most concerns were dietary, or food related. 4. The wire racks with room trays does not keep the food warm. The food is cold when the resident receives it. Investigation: met with regional dietary manager bases and lids to keep food warm. On 2/18/2025 at 12:40 PM, hall trays were prepared. Each tray had a lid, but no base. The plate was placed directly on the tray that was placed on a wire cart. The hall cart left the kitchen at 12:45 PM and sat at the nurse's station. First tray removed 12:48 PM and completed at 12:53 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the Power of Attorney of medication changes for 1 of 3 (R5) residents reviewed for notification in a sample of 15.

Inspectors wroteBased on interview and record review, the facility failed to obtain consent for psychotropic medication for 1 of 3 (R5) residents reviewed for unneccessary medication in a sample of 15.

Inspectors wroteBased on interview and record review, the facility failed to prevent resident verbal and physical abuse for 1 of 8 residents (R2) reviewed of abuse in a sample of 8. This failure resulted in an Immediate Jeopardy on 12/19/24, when V6, R2's brother, who was known to have a history of abusing R2, was allowed to have unsupervised visits with R2 and verbally abused her. Subsequently, on 12/29/24, V6 verbally and physically abused R2. Using a reasonable person concept, this would have caused psychosocial harm resulting in feelings of being unsafe, sadness, fear, and humiliation. The Immediate Jeopardy began on 12/19/24, when the facility failed to prevent V6 from verbally abusing R2 and implement interventions to prevent future abuse. On 12/29/24, V6 again verbally and physically abused R2. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure physician visits were alternated with the Nurse Practitioner visits every 60 days after the first 90 days of admission for 4 of 4 residents (R1, R2, R6 and R7) reviewed for physicians' visits in the sample of 8.

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin and allegations of abuse to the Administrator and Illinois Department of Public Health for 2 of 4 residents (R2, R8) reviewed for abuse in a sample of 8.

Inspectors wroteBased on interviews and record review, the facility failed to investigate allegations of verbal abuse and injury of unknown origin for one of 4 residents (R2) reviewed for investigation of abuse in the sample of 8.

Inspectors wroteBased on interview, record review, and observation, the facility failed to provide the required amount of protein to serve the residents. This has the potential to affect all residents in the facility. Findings Include: The facility recipe for Oven Herb Roasted Turkey Breast documents, slices 2.5 ounces of weighed portions. Serve 2.5 ounces of weighed portions to provide 2 ounces protein serving. Use scale to weigh and portion accurately. The facility was not observed initially utilizing a scale to weigh the turkey portions. V21, District Manager, stated, It's about one slice per person. On 10/22/24 at 12:00 PM, the kitchen was serving oven herb roasted turkey, with the portions appearing small. On 10/22/24 at 12:05 PM, V21, District Manager, brought out the scale. The oven roasted turkey breast portion was weighed and it was only 2 ounces. [...]

Inspectors wroteBased on interview, record review, and observation, the facility failed to employ hygienic practices and then handled food. This has the potential to affect all the residents in the facility. Findings Include: On 10/22/24 at 12:15 PM, V23, Dietary Aide, was putting diet cards on the residents trays; she was also putting lids on the resident's tray. V23, Dietary Aide, was rubbing her nose repeatedly and rubbing sweat off the brow. The Direct Care staff were standing at the kitchen door asking her to wash her hands, but she seemed confused and did not wash her hands. V14, Area Manager, asked V23, Dietary Aide, to wash her hands. V23, Dietary Aide, then washed her hands, but immediately rubbed her nose again. V23, Dietary Aide, continued to scoop ice cream from a 5-gallon ice cream bucket and place it into bowls. [...]

Inspectors wroteBased on interview and record review, the facility failed to respect a resident's right to privacy and dignity during care and when care was needed by being on their cell phones in 4 of 4 residents (R60, R61, R87, R94) reviewed for resident rights in the sample of 45.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide personal hygiene to 2 of 2 residents (R2, R43), reviewed for ADL (Activities of Daily Living Care) in the sample of 45.

Inspectors wroteBased on interview and record review, the facility failed to ensure that 1 resident (R81) received medications as ordered out of 4 residents reviewed for medications in the sample of 45.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure a resident was free from abuse, from a resident with a history of prior altercations, for 2 of 2 (R2 and R5) residents reviewed for abuse in the sample of 6. This resulted in R2 receiving physical harm, facial bruising, including right cheek, bridge of her nose, and below both eyes and utilizing the reasonable person concept, this failure resulted in psychosocial harm by R2 yelling out in fear Hit me one more time and I swear. Findings Include: R5's Facesheet documents an admission date of 6/2/2023. Diagnosis include Dementia, Displaced Intertrochanteric Fracture of Right Femur, Subsequent Encounter for Routine Healing, Chronic Obstructive Pulmonary Disease, Protein Calorie Malnutrition, and Cirrhosis of the Liver. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to maintain a clean environment for 3 of 6 residents (R1, R3, R4), reviewed for safe/functional/sanitary/comfortable environment in the sample of 6.

Inspectors wroteBased on interview, observation, and record review, the facility failed to cohort residents with the same infectious conditions and follow infection control protocol for COVID-19. This has the potential to affect all 112 residents in the facility. Findings Include: 1. The Facility's Infection Surveillance Monthly Report, dated 7/16/24, documents R5 and R6 were both positive for Covid-19 on 7/6/24. The July Infection Surveillance report documents there are 48 residents in the facility with Covid-19 infection. On 7/16/2024 at 9:00 AM, V10, OT (Occupational Therapist), was in R5 and R6's room with a N95 mask intact, no other PPE noted. V10 stated she thought they (R5 & R6) were off (isolation) today. Contact/droplet precautions signage was on the R5's and R6's door of the room they were residing in. On 7/16/24 At 10:00 AM on 500 Hall, isolation carts were on the hall. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify positive COVID test results to Family Representatives and or Power of Attorney for 2 of 4 residents (R3 and R4) reviewed for COVID notification in the sample of 4. Findings Include: 1. R3's Minimum Data Set (MDS), dated [DATE], documents R3 is moderately cognitively impaired. R3's Physician Order Sheet, dated 7/9/24, documents strict contact/droplet isolation related to COVID until 7/20/24 for all services rendered in room. R3's Nurses Note for 7/9/24 did not document her responsible party was notified of her being COVID positive. R3' s Electronic Health Record documents the facility's electronic messaging system, dated 7/15/24, a message was left about COVID in the building. The Electronic Health Record (EHR) did not document any other messages were left. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to administer medications timely to 4 of 4 residents (R1, R2, R3, R4) reviewed for Pharmacy Services in the sample of 4.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to ensure resident clothes were being maintained, cleaned, and returned in a timely manner for 6 out of 13 residents (R1, R2, R6, R7,R8, R9 and R13) reviewed for laundry in the sample of 13. 1-R9's MDS (Minimum Data Set), dated 5/8/2024, documents R9 was cognitively intact for decision making of activities of daily living. On 5/24/2024 at 7:55 AM, R9 stated, Laundry is a mess here and I mean a mess. You never get your clothes back and they want you to wear someone else's clothes. Your clothes are not treated as important. They always have an excuse of why your clothes are missing or why they can't seem to find them, or worse they find them but then they have white spots all over them. I don't want to talk about it because it upsets me so much. [...]

Inspectors wroteBased on observation and interview, the Facility failed to provide food that is appetizing and at palatable temperatures for 7 of 8 residents (R1, R2, R3, R4, R6, R8, R9) reviewed for food palatability in the sample of 11.

Inspectors wroteBased on interview and record review, the facility failed to have a Registered Nurse (RN) in the facility for 8 hours daily. This has the potential to affect all 107residents living in the facility. Findings Include: The Facility Staff Schedules were reviewed from 4/1/24 through 4/30/24, with no issues for the Certified Nursing Assistant. The Registered Nurse (RN) Staffing Schedule was reviewed for 4/1/24 through 4/30/24, and it appeared there was an RN for eight hours every shift. The Time Cards for V13, Registered Nurse, did not document he was staying until 8:00 AM Sunday 4/7, 4/14, 4/21; for these Sundays the facility did not have an RN for eight hours, because V13 was supposed to work from 12:00 AM to 8:00AM, so the facility would meet it's requirement of a Registered Nurse for 8 hours on Sundays. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and assess an arteriovenous shunt for one of two residents (R2) reviewed for quality of care in the sample of 7. Findings Include: R2's MDS (Minimum Data Set), dated 4/2/2024, documents R2 is severely cognitively impaired. R2's Nurses Note, dated 4/14/24, documents, (R2) moan when left arm was touched. Has large shunt like in left arm. Husband notified. States 'for resident to go to(Regional Hospital) for evaluation' Hospital called report given. R2's (Regional Hospital) After Summary Visit Report, dated 4/14/24, documents, You were sent to the Emergency Department for evaluation of your left upper extremity. Per review of your chart you had a aterio venous shunt (AVShunt) placed in 2019 by vascular surgery to facilitate dialysis there is normal thrill in that site and no external malfunction. [...]

Inspectors wroteBased on interview and record review, the Facility failed to ensure residents were free from abuse in 4 of 4 residents, (R1, R2, R3, R4) reviewed for abuse in the sample of 6.

Inspectors wroteBased on interview and record review, the Facility failed to report allegations of abuse in 1 of 4 residents (R2) reviewed for abuse in the sample of 6.

Inspectors wroteBased on interview and record review, the Facility failed to investigate allegation of abuse in 1 of 4 residents (R2) reviewed for abuse in the sample of 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of biohazardous material in a proper way to prevent the transmission of infections. This failure has the potential to affect all 108 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, facility failed to dispose of trash in a proper manner. This failure has the potential to affect all 108 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe transfer was done for 1 of 3 residents (R3) reviewed for transfers in the sample of 6. This failure resulted in R3 being sent to the hospital and receiving 7 staples to his head.

Inspectors wroteBased on interview and record review, the Facility failed to ensure a thorough investigation was completed for 1 of 3 residents (R2) reviewed for investigations in the sample of 12.

Inspectors wroteBased on interview and record review, the facility failed to implement safety measures and failed to make sure the bed was properly maintained for 1 of 4 residents (R1) reviewed for falls in a sample of 4.

Inspectors wroteBased on interview, observation, and record review, the facility failed to develop/implement a Care Plan focus area to address compliance with tube feedings and recommendations to remain elevated after feedings for one of two residents (R25) reviewed for tube feeding in the sample of 35. Findings Include: R25's Minimum Data Set, dated [DATE], documents R25 is cognitively intact. R25's Physician Order Sheet (POS), dated 7/20/23, documents R25 is NPO (nothing by mouth). R25's POS, dated 8/11/23, documents water flush 200ML (milliliters) additional water in between feedings. R25's POS, dated 8/14/23, documents Osmolite 1.5 340ML four times per day. (bolus) On 8/31/23 at 2:00PM, V1 (Administrator) stated, We don't have a Tube Feeding Care Plan, it is included with the ADL (Activities of Daily Living) and Hydration Care Plans. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to implement fall interventions for 4 of 10 residents (R3, R11, R55, R74) reviewed for falls in the sample of 33. Findings Include: 1. R55's Fall Care Plan, dated 10/25/22 and 8/2/22, documents R55 is at risk for falls related to impaired cognition, activities of daily living deficit, weakness, and medication. The goal will remain free of falls causing hospitalizations related to injury through next review. On 8/19/22 (interventions include), visual reminder in room and bathroom to use the call light, evaluate cause of falls, gather and assess information on past falls, (review) medication ordered, staff to assist resident with activity (and) set up (the) television. This care plan did not document a fall intervention for the fall of 6/15/22. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their abuse policy. This failure placed residents at risk of both physical and verbal abuse from a resident with a known history of verbal and physical abuse toward other residents. This affected 4 of 4 residents (R39, R57, R63 and R240) in a sample of 33 reviewed for abuse. This failure led to R63 being afraid to be in R63's room due to verbal abuse from R57, R39's wound on face being re-injured and R240 being verbally and physically abused by R57.

Inspectors wroteBased on interview and record review, the Facility failed to thoroughly investigate allegations of abuse in 3 of 4 residents (R46, R57, R74) reviewed for abuse in the sample of 33.

Inspectors wroteBased on interview and record, the facility failed to follow Physician's Orders and administer Intravenous Antibiotics (IV) for 1 of 3 residents (R238) in a sample of 33.

Inspectors wroteBased on interview and record review, the Facility failed to provide effective pain management in 1 of 2 residents (R14) reviewed for pain in the sample of 33.

Inspectors wrote2. R11's Face Sheet documents, R11 has diagnosis of urinary tract infection, site not specified. R11's Minimum Data Set (MDS), dated [DATE], documents, R11 is significantly cognitively impaired, requires extensive 1-plus person assistance with bed mobility, requires extensive 2-plus person assistance with transfer, and is always incontinent of bowel and bladder. R11's Physician Order Sheet (POS) documents, Macrobid Capsule, (Nitrofurantoin Monohyd Macro), - Give 100 mg, (milligrams), by mouth one time a day for chronic UTI, (Urinary Tract Infection), with start date of 4/29/22. R11's Care Plan, dated 10/22/22, documents, Resident is on Macrobid Capsule once daily for UTI/prophylactic use, dated 4/28/2022. [...]