THE PEAKS HEALTH & REHABILITATION
Non profit - Other
58 Beds
THE GOODMAN GROUP
Data: November 2025
Trust Grade
40/100
#124 of 139 in AZ
Photo by The Peaks Health & Rehabilitation
Photo by The Peaks Health & Rehabilitation
Photo by The Peaks Health & Rehabilitation
Photo by The Peaks Health & Rehabilitation
1 / 5 photos
Last Inspection: November 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
The Peaks Health & Rehabilitation has a Trust Grade of D, indicating it is below average and has some concerning issues. It ranks #124 out of 139 nursing homes in Arizona, placing it in the bottom half of facilities statewide, and is #4 out of 4 in Coconino County, meaning there are no better local options. The facility is showing signs of improvement, as it reduced its issues from 11 in 2024 to just 2 in 2025. Staffing is a relative strength with a 4 out of 5-star rating, but the turnover rate of 60% is concerning as it exceeds the state average of 48%. While there are no fines on record, which is a positive sign, there have been serious incidents, such as a significant medication error affecting a resident and failures to maintain proper documentation regarding grievances and medication administration, which could potentially harm residents.
- Trust Score
- D
- In Arizona
- #124/139
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Arizona facilities.
- Skilled Nurses ✓ Good
- Each resident gets 56 minutes of Registered Nurse (RN) attention daily — more than average for Arizona. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 28 deficiencies on record. Higher than average. Multiple issues found across inspections.
40/100
Bottom 11%
Needs review
11 → 2 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 11 issues
2025: 2 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
2-Star Overall Rating
Below Arizona average (3.3)
Below average - review inspection findings carefully
Staff Turnover: 60%
14pts above Arizona avg (46%)
Frequent staff changes - ask about care continuity
Chain: THE GOODMAN GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (60%)
12 points above Arizona average of 48%
The Ugly 28 deficiencies on record
1 actual harm
Jul 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of clinical record, and review of facility policy, the facility failed to ensure an allegation of ab...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of clinical record, and review of facility policy, the facility failed to ensure an allegation of abuse was reported to mandated entities within 2 hours for one resident (#5). The deficient practice could lead to an allegation of abuse not being investigated by all mandated entities timely, resulting in possible ongoing abuse to a resident.-Findings include:Resident #5 was admitted to the facility February 29, 2024, with diagnoses that included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, aphasia following unspecified cerebrovascular disease, bipolar disorder, dysarthria, and acquired absence of right leg above knee.An admission minimum data set (MDS) assessment dated [DATE], revealed Resident #5 had a brief interview for mental status (BIMS) score of 10, indicating moderate cognitive impairment. Section E revealed no potential indicators of psychosis and no behavioral symptoms were present.A care plan dated March 13, 2024, revealed Resident #5 is at risk for impaired cognitive function or impaired thought processes due to expressive aphasia following cerebrovascular accident.An additional care plan dated March 13, 2024, revealed the resident is at risk for communication problem due to expressive aphasia and dysarthria following cerebrovascular accident.There was no evidence of a care plan or interventions to address a potential behavior of the resident making abuse allegations.A facility self-report submitted to the State Agency on December 12, 2024, revealed that on December 12, 2024, Resident #5 alleged that a male (possibly plural males) have hit him on the back while he is using the toilet or in the shower. The resident is unspecific as to person, place, or time.A Clinical Note dated July 1, 2025, revealed Resident #5 had difficulty breathing and thick white sputum. The provider was contacted, and an order was given to send the resident to the emergency room.A Provider Note dated July 7, 2025, revealed Resident #5 was readmitted to the facility July 6, 2025. The resident was treated in the hospital for aspiration pneumonia. While in the hospital, the resident reported that he was being sexually abused. Per the documentation, the resident has reported a different history to different staff members. Sexually transmitted infection screening was negative. Social services was consulted for assistance with next steps, and additionally, the resident has not made this allegation to anyone at the facility.There was no evidence that the facility reported Resident #5's abuse allegation to mandated reporting sources including the police, the ombudsman, adult protective services, or the State Agency.A written statement by a Speech Language Pathologist (Staff #29) dated July 8, 2025, revealed regarding Resident #5's complaint of possible sexual abuse at the facility, recent documentation from the hospital reports the resident made it sound like it was staff versus two other providers, and he has said that a different resident attempted to sexually abuse him. Additionally, the statement revealed I have worked with the above patient in speech therapy for over a year and the resident has a history of a previous cerebrovascular accident (stroke) with resulting dysarthric speech characteristics, decreased speech intelligibility, expressive aphasia, and memory impairments. The resident has mentioned above issues various times during therapy sessions with significant inconsistencies in information. He has been observed to give differing information to different people/staff members regarding this topic.An additional written statement by the Social Services Director (Staff #30) dated July 8, 2025, revealed regarding the discussion with Resident #5 regarding rape allegation at the hospital, that Resident #5 stated he was raped at this facility by a white man in he hall maybe 5 months ago, he could not recall the exact conversation he had with hospital staff on July 2, 2025. He stated it has happened in the past unsure as to the date, time, or place. The resident was unable to describe anyone who may have participated other than a white male, and unsure if the white male was a resident or staff member. The resident denies physical injury.A formal request was submitted to the facility on July 10, 2025, at 12:03 PM, for a full facility investigation regarding Resident #5's allegation of abuse in July 2025, and to include any evidence of submission of mandated reporting to the State Agency.The facility administrator signed a statement dated July 10, 2025, that revealed Resident #5 made no complaint or allegation to the facility regarding any physical or sexual abuse. On July 2, 2025, the hospital called the facility Social Services Director and stated that Resident #5 complained that he was sexually abused at the facility, and that the hospital was reporting the incident to adult protective services. Upon the resident's return to the facility, the Social Services Director asked Resident #5 about the statement made to the staff at the hospital. Resident #5 stated that it was about 5 months ago. On December 12, 2024, Resident #5 reported physical abuse and then recanted his statement when the police arrived to question him.An interview was conducted with a Certified Nursing Assistant (CNA / Staff #11) on July 10, 2025, at 11:04 AM. Staff #11 stated that she works with Resident #5, and that she has never heard the resident make any allegations or accusations, and if she did, that she would report it to management.An interview was conducted with a CNA (Staff #41) on July 10, 2025, at 11:13 AM. The CNA stated that he has not heard Resident #5 make any accusations or allegations since he has worked with him.An interview was conducted with a CNA (Staff #50) on July 10, 2025, at 11:16 AM, who stated that she normally works the unit with Resident #5, and that she has never heard the resident make any accusations or allegations.An interview was conducted with the Director of Nursing (DON / Staff #80) on July 10, 2025, at 11:18 AM. The DON stated that if there is an allegation of abuse, then the facility reports the allegation to the administrator immediately, and to mandated entities within 2 hours. Regarding Resident #5, the DON stated that she was made aware that the hospital called the facility and informed that Resident #5 made an allegation of rape from a staff or a resident while at the facility. The DON stated that she was not aware that the allegation was reported to mandated entities by the facility but that she believed it was reported, and that the DON was not involved in any part of an investigation conducted by the facility.An interview was conducted with the Social Services Director (Staff #30), on July 10, 2025, at 11:25 AM. Staff #30 stated Resident #5 made a report of a physical abuse allegation around December of last year (2024), and that the police were called, and that the resident kept changing his story. Staff #30 stated that she was notified of a call from the hospital regarding Resident #5, and returned the call to the hospital case manager on July 2, 2025. The hospital case manager stated that the resident told the hospital staff multiple stories alleging rape while at the facility. Staff #30 stated that the hospital staff said that they were going to report it (the allegation) to a mandated entity. Staff #30 stated that the resident re-admitted to the facility over the weekend, and on Tuesday (July 8, 2025), Staff # 30 went to the resident's room to talk to him about the allegation. Staff #30 stated that Resident #5 said that yes he talked to the hospital about the rape allegation, and that he said he was pushed outside and raped, and that it occurred at 8:00 AM today (July 8, 2025), and that he was pointing to indicate it happened in the hallway, and it was a white man. Additionally, Staff #30 stated that Resident #5 stated it happened in his room and outside.An interview was conducted with the Administrator (Staff #3) on July 10, 2025, at 12:51 PM. The Administrator stated that the Social Services Director (Staff #30) stated that Resident #5 reported while he was at the hospital, that he was abused at the facility, and that the hospital staff said they were reporting it. The Administrator stated that when the resident returned to the facility, the facility's investigation started. The Administrator stated that the facility did not report the allegation of abuse to mandated entities because the hospital staff said they were reporting it.Review of the facility policy titled Abuse, Neglect, and Exploitation, revised June 21, 2019, revealed each resident has the right to be free from abuse, including verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, and any physical or chemical restraint not required to treat the resident's medical symptoms. Anytime that the nursing facility receives an allegation of abuse, the facility must comply with the reporting and investigation procedures set forth in this policy and with any state-specific policy and take steps to prevent further potential abuse. Sexual Abuse is non-consensual sexual contact of any type with a resident. Anyone with knowledge or concerns about the care of a resident in the facility must report suspected abuse to the Facility administrator, abuse agency hotline or file a complaint with the state survey agency and adult protective services (if applicable under state law) immediately (but not later than 2 hours after an allegation is made if the events that lead to the allegation involve abuse or result in serious bodily injury) or not later than 24 hours if the events that lead to the allegation do not involve abuse and do not result in serious bodily injury. Reporting and investigation should be in accordance with state law/regulation.
Jan 2025
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on staff interview, review of facility documentation, and policy, the facility failed to ensure that facility documents regarding grievances, reportables and resident council meeting minutes wer...
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Based on staff interview, review of facility documentation, and policy, the facility failed to ensure that facility documents regarding grievances, reportables and resident council meeting minutes were available. The deficient practice could result in documentation regarding residents' issues and concerns pertaining to life and safety not being readily available.
Findings include:
The copy of the December 2023 self-reports and investigations, December 2023 grievance logs, and December 2023 Resident Council Meeting Minutes was requested from the facility on January 29, 2025 at 8:24 a.m.
An email from the Executive Director (ED/staff #96) was received on January 29, 2025 at 10:13 a.m. The email stated that they are unable to locate the December 2023 reportables, grievance logs, and resident council meeting minutes.
During an interview with the Interim Director of Nursing (Interim DON/staff #100) conducted on January 29, 2025 at 4:55 p.m., staff #100 stated that they did not know how long they have to keep documentation such as grievances or resident council meeting minutes. The Interim DON noted that the importance of maintaining documents is to be able to track them for investigators and to document the care that the facility provided. Staff #100 stated it is important documentation for residents. According to staff #100 the impact of not maintaining documentation is that the facility would not have support for their claims, they would not be able to track the care or interventions provided during the resident's stay.
An interview with the Executive Director (ED/staff #96) was conducted on January 29, 2025 at 4:56 p.m. The ED stated that his expectation is that documentation is accurate, time and inclusive of all pertinent information. Staff #96 said that he expects for documentations/records to be retained on file within the required timeframe. The ED noted that the importance of maintaining documentation/records is to ensure that it is easily accessible. The impact of not maintaining documentation/records is that when it is requested by an agency it is not available and would not be able to provide accurate systems in place.
The facility policy titled All Department Record Retention Policy and Schedule with a review date of January 11, 2024 indicated that the facility will maintain records for the appropriate time period as required by federal and state law and regulations. The policy included a record retention schedule. The retention schedule indicated that for resident complaint report (grievance) the retention period is permanent/electronic. The retention period for Committee Minutes is 10 years. While the retention period for all correspondence with Department of Health is permanent.
Nov 2024
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, resident and staff interviews, and review of facility policy, the facility failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, resident and staff interviews, and review of facility policy, the facility failed to ensure one sampled resident (#5) was assessed for medication self-administration. The deficient practice could result in resident not taking or able to take the medication needed for treatment.
Findings include:
Resident #5 was admitted to the facility on [DATE], with diagnoses of chronic respiratory failure with hypoxia, acute and subacute allergic otitis media, unspecified ear, and acute post hemorrhagic anemia
The admission Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident had moderate cognitive impairment.
Reviewed of the care plan revealed no evidence of a focus for medication self-administration.
Physician orders revealed the following active medications:
- Systane Solution eye drop (ocular lubricant) applied in both eyes with an order date of March 22, 2023; and.
- Fluticasone Propionate Suspension (nasal corticosteroid) applied one spray in each nostril with an order date of July 17, 2024.
Review of the clinical record revealed no evidence that the resident was assessed for medication self-administration; and that, self-administration was determined to be clinically appropriate for resident #5.
During an observation conducted in the resident's room on November 5, 2024 at 9:08 a.m. a bottles of Fluticasone Propionate Suspension nasal spray, and Systane complete eye drop were observed on the resident's bedside table. The resident stated that she liked to keep her nasal spray and eye drops with her so she does not have to ask the nurses in case she needed them.
An interview was conducted on November 07, 2024, at 12:11 p.m. with a Registered Nurse (RN/Staff #33) who reviewed the clinical record and stated that Systane eye drops and fluticasone orders were active orders for resident #5. She stated that there was no evidence of an order for the resident to self-administer medication.
An interview was conducted with the Director of Nursing (DON/staff #123) on November 7, 2024 at 10:24 a.m. The DON said that she had not been in the resident's room, but eye drops, and nasal spray should never be left at the bedside of a resident. The DON stated that there was absolutely no reason for any medication to be kept at the bedside unless there was an order to do so; and, when medication self-administration assessment was not conducted. The DON stated that this practice was against facility policy; and,the risk could result in someone else taking the medication. The DON further stated that there was no self-administration evaluation found in the clinical record for Resident #5.
Review of the facility's policy titled, Self-administration of Medication, revealed that the facility policy is to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of clinical record, facility documentation, and facility policy, the facility failed to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of clinical record, facility documentation, and facility policy, the facility failed to ensure policies were implemented regarding investigating and timely reporting of allegations of abuse for 3 sampled residents (#13, #19, and #29). The deficient practice could lead to allegations of abuse not being investigated timely, and could lead to continued harm to residents.
Findings include:
-Resident #13 admitted to the facility on [DATE], with diagnoses that included rheumatoid arthritis, collapsed vertebra, depression, and myasthenia gravis.
Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) assessment score of 11, indicating moderate cognitive impairment.
Review of the clinical record revealed no evidence of any documentation on October 29, 2024, regarding a resident-to-resident incident.
A communication note dated October 31, 2024 revealed that an RN and an MDS coordinator spoke with the resident about an incident that happened on October 29, 2024. Per the documentation, Resident #13 reported that another resident (#29) grabbed her left wrist and twisted it; and that, her left wrist hurt.
The communication note dated November 1, 2024 revealed that staff called and left a voicemail to the resident's power of attorney (POA) to inform about the alleged abuse.
Another communication note dated November 1, 2024 revealed the nurse practitioner was informed of an alleged abuse that a resident (#29) grabbed and twisted the wrist of Resident #13 when they were in the dining area eating lunch.
Despite documentation of an allegation of abuse, there was no evidence found that the allegation of abuse was reported to the State Agency (SA).
The care plan revised on November 03, 2024, revealed that Resident #13 had an alteration in comfort related to left wrist pain and swelling. Interventions included to administer scheduled pain medications per physician orders and for certified nursing assistants (CNAs) to report pain concerns to nurse.
On November 06, 2024 at 7:57 a.m., an interview was conducted with Resident #13 who stated that the incident happened last week; and that, a resident (#29) grabbed her left wrist intentionally. The resident stated that resident #29 was like that and was mad. Resident #13 stated she went back to her room; and, staff asked if she was ok. Resident #13 further stated that her left wrist hurt.
-Resident #29 was admitted on [DATE] with diagnoses that included unspecified fracture of right wrist and hand, hemiplegia affecting the right side, and Alzheimer's disease.
Review of the quarterly MDS assessment dated [DATE] revealed the BIMS assessment could not be completed because the resident was rarely understood.
The care plan dated July 29, 2024 revealed the resident had the following episodes of physical aggression:
-On July 26, 2024, the resident was yelling unintelligible words while swaying her arms to nurse and CNA and tried to grab anything. Per the documentation, resident grabbed her disposable gown and punched her in her abdomen;
-On September 20, 2024, while being offered medications, resident smacked the nurse and was screaming at the nurse; and,
-On October 26, 2024, resident grabbed another resident's arm trying to stop the other resident from touching her iPad.
The care plan revealed interventions to intervene as necessary to protect the rights and safety of others, and to monitor, document, and report any signs and symptoms of resident posing danger to self and others.
A nursing note dated September 05, 2024 written by a licensed practical nurse (LPN/Staff #111) revealed that the resident tried to hit other residents that were sitting and eating at her table. Per the documentation, resident hit another resident (#19) and tried to scratch him with her nails but the other resident (#19) was able to move. It also included that redirection was continued.
Despite documentation of the incident, the clinical record and facility-provided documentation revealed no evidence that the incident report for the allegation of abuse on September 05, 2024 was reported to any manager and SA; and that, the facility had completed an investigation of the incident.
A Behavior Note dated October 16, 2024, revealed that Resident #29 was aggressive towards CNA during brief change. The documentation included that the resident nodded 'Yes' when asked for permission to her change brief; but, then grabbed one of the CNAs by the throat.
A Provider Note dated October 25, 2024, revealed that documentation of multiple episodes of aggressive behaviors from June through October 2024 such as hitting, attacking staff, clawing staff with her fingernails, increased agitation and combativeness, and violent at times.
Continued review of the clinical record revealed no documentation of any regarding a resident-to-resident incident on October 29, 2024.
However, a nursing manager investigation note dated November 1, 2024 included that an incident occurred on October 29, 2024, where Resident #29 grabbed another resident's wrist because the other resident tried to lower the volume of her tablet while they were at the dining room. Per the documentation, an intervention put into place was to not put the involved residents in the same table during meal time or together during activities.
A Reportable Event Report dated November 4, 2024 revealed that on October 29, 2024 at 12:15 p.m., Resident #29 was using her tablet at the dining room table when another Resident (#13) reached over to turn the volume down on the resident's tablet. According to the documentation, the resident then grabbed and twisted the other resident's hand and twisted; and that, there were no injury occurred and both residents were immediately separated. The report further revealed that the resident had acted aggressively toward staff in the past, but not toward any other resident until this incident.
A Communication note dated November 04, 2024 included that staff had told the resident's family regarding the resident grabbing and twisting another resident's (#13) wrist.
-Resident #19 was admitted on [DATE] with diagnoses of Parkinson's disease and dementia.
The quarterly MDS assessment dated [DATE], revealed a BIMS score of 11 indicating the resident had moderate cognitive impairment.
Review of the care plan revealed no evidence of any adjustments related to an incident of alleged abuse on September 05, 2024.
Review of the progress notes revealed no evidence of any notes regarding an incident of alleged abuse on September 05, 2024.
However, review of the clinical record for resident #29 revealed a nursing note dated September 05, 2024 that the resident #29 tried to hit other residents that were sitting and eating at her table. Per the documentation, resident #29 hit resident #19 and tried to scratch him with her nails but the resident #19 was able to move. It also included that redirection was continued.
There was no evidence that this incident was reported to any manager and SA on September 5, 2024; and that, an investigation of this was completed by the facility.
A telephone interview with Resident #29's family was conducted on November 4, 2024 at 1:21 p.m. The family stated that resident #29 and another new resident was sitting in the dining area; and that, resident #29 had her electronic tablet with her and the volume was on high. The family stated that the new resident reached over and tried to grab the tablet, and resident #29 grabbed the other resident's arm to try to defend her property. She stated there was a CNA nearby who reacted and diffused the situation; and that, the other resident was complaining of a sore wrist. The family further stated that the facility told her that resident #29 and the new resident would not be placed together again.
On November 6, 2024 at 2:07 p.m. an interview was conducted with the LPN (Staff #111) who stated that she heard that there was an incident between residents #29 and #13. A review of the clinical record was conducted with the LPN who said that she recalled an incident that occurred on September 05, 2024. The LPN stated she was the nurse on the unit that day, and she witnessed Resident #29 hit and attempt to scratch another resident (#19) who was extremely friendly and wanted to be involved in peoples' spaces. The LPN said that she saw Resident #29 make contact with the other resident but that there was not any sort of force behind the contact. Further, the LPN stated that a risk management report was not completed for this incident.
An interview was conducted on November 6, 2024 at 3:10 p.m. with the Director of Nursing (DON/ Staff #123) who stated that her expectation was that staff would report any allegation of abuse immediately; and that, mandatory reporting occurs within 2 hours of the incident. The DON stated that she became aware of the incident of regarding Resident #29 twisting the arm of Resident #13 on October 31, 2024 when the receptionist brought it up to management staff. The DON stated that staff have received an in-service since then on abuse reporting. Regarding the resident-to-resident altercation between resident #29 and resident #19 on September 05, 2024, the DON stated that she was not aware of the incident; and that, no staff reported the incident to her. She stated that if she had learned of this incident, she would have separated both residents and reported the incident to the abuse coordinator. The DON further stated that moving forward, to prevent further resident-to-resident incidents, residents #29 and #13 would not sit together; and, staff would monitor for behaviors.
An interview was conducted on November 6, 2024 at 3:40 p.m. with the former administrator (Staff #149) who was the administrator at the time of the incident between residents #29 and #19 on September 5, 2024. The former administrator stated that any allegation of abuse should be reported immediately, should be investigated immediately, and should be reported to mandated sources within 2 hours. Regarding the allegation of abuse on September 5, 2024, staff #149 stated that he just found out about it; and that, no staff came to him at the time of the incident to report it. He further stated that there was no investigation done/completed for this incident.
An interview was conducted on November 6, 2024 at 4:09 p.m. with the unit manager (Staff #6) who stated that no staff had reported to her the incident of between resident #29 hitting and attempting to scratch resident #19 on September 5, 2024. She stated that an incident report should have been done; however, there were no risk management (incident) report was done/completed for this incident. The unit manager said that if an incident report had been done, it would trigger an alert for an investigation to be completed. Regarding the incident between residents #29 and #13, the unit manager said that the incident was not reported by any staff when the incident occurred. The Unit manager stated that a staff member heard about the incident from another resident; and, it was not reported to management and investigated until October 31, 2024. Further, the unit manager stated that any allegation of abuse should be reported immediately and the investigation should start right away; and that, the importance of timely reporting was so staff could assess for any injuries and protect the resident's safety and wellbeing. The Unit manager further stated that if an incident was not reported timely, the incident could happen again.
An interview was conducted on November 7, 2024 at 8:52 a.m. with a CNA (staff #122) who was in the dining room when the incident between resident #13 and #29 occurred. The CNA stated she was in the dining room approximately 2-3 feet away from the two residents; and, she saw Resident #13 turn down the volume on the tablet of Resident #29 who then grabbed the wrist of Resident #13. She stated the contact lasted approximately 1 second and the wrist of resident #13 was not twisted. She stated after the incident, the two residents are to remain separated and supervised in the dining room.
An interview with the Administrator (Staff #58) was conducted on November 7, 2024 at 11:25 a.m. The administrator stated that staff were to report allegations of abuse immediately and mandatory reporting should be done within 2 hours. He stated that the importance of timely reporting was that it allows the facility to start the investigation and to protect the residents involved. He stated that if the facility's abuse policy was not followed, it allows for continued potential abuse to occur. The Administrator stated that that he was not the Administrator at the time of the incident between residents #29 and #19 occurred on September 5, 2024. He said that he became Administrator on October 01, 2024; and, he just became aware of the incident yesterday when staff was made aware by the state survey agency. He stated that it does not meet his expectation that staff failed to report both incidents (September 5 and October 29, 2024) within the timeframes specified by the abuse policy.
Review of the facility's policy titled The Behavioral Management, reviewed October 07, 2024, revealed that inappropriate behaviors that may put the resident, other residents, staff, or guests at risk for injury are identified in an attempt to redirect or modify the behavior so proper treatment can be provided to the resident. The procedures revealed to notify the nurse in charge immediately when a resident is having any inappropriate behaviors, separate affected residents, document the behavior in the resident's medical record, follow through appropriate steps to modify the behavior, and modify the care plan to reflect the current interventions.
Review of the facility's policy titled Incidents and Accidents, reviewed October 14, 2024, revealed that licensed staff will utilize the on-line risk management system to report all incidents and accidents and assist with completion of any investigative information to identify root causes. Combative behavior, resident-to-resident altercations, observed accidents, and alleged abuse are listed as incidents / accidents that require a report to be completed. Any injuries will be assessed by the LPN, and the supervisor and/or designee will be notified of the incident / accident. The nurse will enter the documentation of the incident / accident within 24 hours of the occurrence.
Review of the facility's policy titled Abuse, Neglect, and Exploitation, reviewed January 11, 2024, revealed each resident has the right to be free from abuse. Abuse is defined as the willful infliction of injury, with 'willful' further defined as deliberate action by an individual. The facility will make reasonable efforts to protect residents after alleged abuse. Allegations of abuse must be reported by staff to the administrator immediately, and allegations involving abuse must be reported to the state survey agency within 2 hours. An investigation should be initiated immediately. Further, the actions taken should be documented in the resident's medical record.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of clinical record, facility documentation, and facility policy, the facility failed to...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of clinical record, facility documentation, and facility policy, the facility failed to ensure alleged violations of abuse were reported to proper authorities within prescribed timeframes for 3 residents (#13, #19, and #29). The deficient practice could lead to allegations of abuse not being investigated timely, and could lead to continued harm to residents.
Findings include:
-Resident #13 admitted to the facility on [DATE], with diagnoses that included rheumatoid arthritis, collapsed vertebra, depression, and myasthenia gravis.
Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) assessment score of 11, indicating moderate cognitive impairment.
Review of the clinical record revealed no evidence of any documentation on October 29, 2024, regarding a resident-to-resident incident.
A communication note dated October 31, 2024 revealed that an RN and an MDS coordinator spoke with the resident about an incident that happened on October 29, 2024. Per the documentation, Resident #13 reported that another resident (#29) grabbed her left wrist and twisted it; and that, her left wrist hurt.
The communication note dated November 1, 2024 revealed that staff called and left a voicemail to the resident's power of attorney (POA) to inform about the alleged abuse.
Another communication note dated November 1, 2024 revealed the nurse practitioner was informed of an alleged abuse that a resident (#29) grabbed and twisted the wrist of Resident #13 when they were in the dining area eating lunch.
Despite documentation of an allegation of abuse, there was no evidence found that the allegation of abuse was reported to the State Agency (SA).
On November 06, 2024 at 7:57 a.m., an interview was conducted with Resident #13 who stated that the incident happened last week; and that, a resident (#29) grabbed her left wrist intentionally. The resident stated that resident #29 was like that and was mad. Resident #13 stated she went back to her room; and, staff asked if she was ok. Resident #13 further stated that her left wrist hurt.
-Resident #29 was admitted on [DATE] with diagnoses that included unspecified fracture of right wrist and hand, hemiplegia affecting the right side, and Alzheimer's disease.
Review of the quarterly MDS assessment dated [DATE] revealed the BIMS assessment could not be completed because the resident was rarely understood.
A nursing note dated September 05, 2024 written by a licensed practical nurse (LPN/Staff #111) revealed that the resident tried to hit other residents that were sitting and eating at her table. Per the documentation, resident hit another resident (#19) and tried to scratch him with her nails but the other resident (#19) was able to move.
Despite documentation of the incident, the clinical record and facility-provided documentation revealed no evidence that the incident report for the allegation of abuse on September 05, 2024 was reported to any manager and SA.
A Provider Note dated October 25, 2024, revealed that documentation of multiple episodes of aggressive behaviors from June through October 2024 such as hitting, attacking staff, clawing staff with her fingernails, increased agitation and combativeness, and violent at times.
Continued review of the clinical record revealed no documentation of any regarding a resident-to-resident incident on October 29, 2024.
However, a nursing manager investigation note dated November 1, 2024 included that an incident occurred on October 29, 2024, where Resident #29 grabbed another resident's wrist because the other resident tried to lower the volume of her tablet while they were at the dining room.
A Reportable Event Report dated November 4, 2024 revealed that on October 29, 2024 at 12:15 p.m., Resident #29 was using her tablet at the dining room table when another Resident (#13) reached over to turn the volume down on the resident's tablet. According to the documentation, the resident then grabbed and twisted the other resident's hand and twisted; and that, there were no injury occurred and both residents were immediately separated. The report further revealed that the resident had acted aggressively toward staff in the past, but not toward any other resident until this incident.
A Communication note dated November 04, 2024 included that staff had told the resident's family regarding the resident grabbing and twisting another resident's (#13) wrist.
-Resident #19 was admitted on [DATE] with diagnoses of Parkinson's disease and dementia.
The quarterly MDS assessment dated [DATE], revealed a BIMS score of 11 indicating the resident had moderate cognitive impairment.
Review of the care plan revealed no evidence of any adjustments related to an incident of alleged abuse on September 05, 2024.
Review of the progress notes revealed no evidence of any notes regarding an incident of alleged abuse on September 05, 2024.
However, review of the clinical record for resident #29 revealed a nursing note dated September 05, 2024 that the resident #29 tried to hit other residents that were sitting and eating at her table. Per the documentation, resident #29 hit resident #19 and tried to scratch him with her nails but the resident #19 was able to move.
There was no evidence that this incident was reported to any manager and SA on September 5, 2024.
On November 6, 2024 at 2:07 p.m. an interview was conducted with the LPN (Staff #111) who stated that she heard that there was an incident between residents #29 and #13. A review of the clinical record was conducted with the LPN who said that she recalled an incident that occurred on September 05, 2024. The LPN stated she was the nurse on the unit that day, and she witnessed Resident #29 hit and attempt to scratch another resident (#19) who was extremely friendly and wanted to be involved in peoples' spaces. The LPN said that she saw Resident #29 make contact with the other resident but that there was not any sort of force behind the contact. Further, the LPN stated that a risk management report was not completed for this incident.
An interview was conducted on November 6, 2024 at 3:10 p.m. with the Director of Nursing (DON/ Staff #123) who stated that her expectation was that staff would report any allegation of abuse immediately; and that, mandatory reporting occurs within 2 hours of the incident. The DON stated that she became aware of the incident of regarding Resident #29 twisting the arm of Resident #13 on October 31, 2024 when the receptionist brought it up to management staff. The DON stated that staff have received an in-service since then on abuse reporting. Regarding the resident-to-resident altercation between resident #29 and resident #19 on September 05, 2024, the DON stated that she was not aware of the incident; and that, no staff reported the incident to her. She stated that if she had learned of this incident, she would have separated both residents and reported the incident to the abuse coordinator. The DON further stated that moving forward, to prevent further resident-to-resident incidents, residents
An interview was conducted on November 6, 2024 at 3:40 p.m. with the former administrator (Staff #149) who was the administrator at the time of the incident between residents #29 and #19 on September 5, 2024. The former administrator stated that any allegation of abuse should be reported immediately, should be investigated immediately, and should be reported to mandated sources within 2 hours. Regarding the allegation of abuse on September 5, 2024, staff #149 stated that he just found out about it; and that, no staff came to him at the time of the incident to report it. He further stated that there was no investigation done/completed for this incident.
An interview was conducted on November 6, 2024 at 4:09 p.m. with the unit manager (Staff #6) who stated that no staff had reported to her the incident of between resident #29 hitting and attempting to scratch resident #19 on September 5, 2024. She stated that an incident report should have been done; however, there were no risk management (incident) report was done/completed for this incident. The unit manager said that if an incident report had been done, it would trigger an alert for an investigation to be completed. Regarding the incident between residents #29 and #13, the unit manager said that the incident was not reported by any staff when the incident occurred. The unit manager stated that a staff member heard about the incident from another resident; and, it was not reported to management and investigated until October 31, 2024. Further, the unit manager stated that any allegation of abuse should be reported immediately and the investigation should start right away; and that, the importance of timely reporting was so staff could assess for any injuries and protect the resident's safety and wellbeing. The unit manager further stated that if an incident was not reported timely, the incident could happen again.
An interview with the Administrator (Staff #58) was conducted on November 7, 2024 at 11:25 a.m. The administrator stated that staff were to report allegations of abuse immediately and mandatory reporting should be done within 2 hours. He stated that the importance of timely reporting was that it allows the facility to start the investigation and to protect the residents involved. He stated that if the facility's abuse policy was not followed, it allows for continued potential abuse to occur. The Administrator stated that that he was not the Administrator at the time of the incident between residents #29 and #19 occurred on September 5, 2024. He said that he became Administrator on October 01, 2024; and, he just became aware of the incident yesterday when staff was made aware by the state survey agency. He stated that it does not meet his expectation that staff failed to report both incidents (September 5 and October 29, 2024) within the timeframes specified by the abuse policy.
Review of the facility's policy titled Abuse, Neglect, and Exploitation, reviewed January 11, 2024, revealed each resident has the right to be free from abuse. Abuse is defined as the willful infliction of injury, with 'willful' further defined as deliberate action by an individual. The facility will make reasonable efforts to protect residents after alleged abuse. Allegations of abuse must be reported by staff to the administrator immediately, and allegations involving abuse must be reported to the state survey agency within 2 hours. An investigation should be initiated immediately. Further, the actions taken should be documented in the resident's medical record.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to ensure an allegation of abuse was thoroughly investigated, and to prevent further abuse from occurring during the investigation for two residents (#19 and #29). The deficient practice could lead to allegations of abuse not being investigated thoroughly, and residents not being protected from further abuse and retaliation.
Findings include:
-Resident #13 admitted to the facility on [DATE], with diagnoses that included rheumatoid arthritis, collapsed vertebra, depression, and myasthenia gravis.
Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) assessment score of 11, indicating moderate cognitive impairment.
Review of the clinical record revealed no evidence of any documentation on October 29, 2024, regarding a resident-to-resident incident.
A communication note dated October 31, 2024 revealed that an RN and an MDS coordinator spoke with the resident about an incident that happened on October 29, 2024. Per the documentation, Resident #13 reported that another resident (#29) grabbed her left wrist and twisted it; and that, her left wrist hurt.
The communication note dated November 1, 2024 revealed that staff called and left a voicemail to the resident's power of attorney (POA) to inform about the alleged abuse.
Another communication note dated November 1, 2024 revealed the nurse practitioner was informed of an alleged abuse that a resident (#29) grabbed and twisted the wrist of Resident #13 when they were in the dining area eating lunch.
Despite documentation of an allegation of abuse, there was no evidence found that the facility conducted an investigation of this incident.
On November 06, 2024 at 7:57 a.m., an interview was conducted with Resident #13 who stated that the incident happened last week; and that, a resident (#29) grabbed her left wrist intentionally. The resident stated that resident #29 was like that and was mad. Resident #13 stated she went back to her room; and, staff asked if she was ok. Resident #13 further stated that her left wrist hurt.
-Resident #29 was admitted on [DATE] with diagnoses that included unspecified fracture of right wrist and hand, hemiplegia affecting the right side, and Alzheimer's disease.
Review of the quarterly MDS assessment dated [DATE] revealed the BIMS assessment could not be completed because the resident was rarely understood.
A nursing note dated September 05, 2024 written by a licensed practical nurse (LPN/Staff #111) revealed that the resident tried to hit other residents that were sitting and eating at her table. Per the documentation, resident hit another resident (#19) and tried to scratch him with her nails but the other resident (#19) was able to move.
Despite documentation of the incident, the clinical record and facility-provided documentation revealed no evidence that the incident was thoroughly investigated by the facility.
A Provider Note dated October 25, 2024, revealed that documentation of multiple episodes of aggressive behaviors from June through October 2024 such as hitting, attacking staff, clawing staff with her fingernails, increased agitation and combativeness, and violent at times.
Continued review of the clinical record revealed no documentation of any regarding a resident-to-resident incident on October 29, 2024.
However, a nursing manager investigation note dated November 1, 2024 included that an incident occurred on October 29, 2024, where Resident #29 grabbed another resident's wrist because the other resident tried to lower the volume of her tablet while they were at the dining room.
A Reportable Event Report dated November 4, 2024 revealed that on October 29, 2024 at 12:15 p.m., Resident #29 was using her tablet at the dining room table when another Resident (#13) reached over to turn the volume down on the resident's tablet. According to the documentation, the resident then grabbed and twisted the other resident's hand and twisted; and that, the resident had acted aggressively toward staff in the past, but not toward any other resident until this incident.
A Communication note dated November 04, 2024 included that staff had told the resident's family regarding the resident grabbing and twisting another resident's (#13) wrist.
-Resident #19 was admitted on [DATE] with diagnoses of Parkinson's disease and dementia.
The quarterly MDS assessment dated [DATE], revealed a BIMS score of 11 indicating the resident had moderate cognitive impairment.
Review of the care plan revealed no evidence of any adjustments related to an incident of alleged abuse on September 05, 2024.
Review of the progress notes revealed no evidence of any notes regarding an incident of alleged abuse on September 05, 2024.
However, review of the clinical record for resident #29 revealed a nursing note dated September 05, 2024 that the resident #29 tried to hit other residents that were sitting and eating at her table. Per the documentation, resident #29 hit resident #19 and tried to scratch him with her nails but the resident #19 was able to move. It also included that redirection was continued.
There was no evidence that the facility investigated this incident on September 5, 2024.
On November 6, 2024 at 2:07 p.m. an interview was conducted with the LPN (Staff #111) who stated that she heard that there was an incident between residents #29 and #13. A review of the clinical record was conducted with the LPN who said that she recalled an incident that occurred on September 05, 2024. The LPN stated she was the nurse on the unit that day, and she witnessed Resident #29 hit and attempt to scratch another resident (#19) who was extremely friendly and wanted to be involved in peoples' spaces. The LPN said that she saw Resident #29 make contact with the other resident but that there was not any sort of force behind the contact. Further, the LPN stated that a risk management report was not completed for this incident.
An interview was conducted on November 6, 2024 at 3:10 p.m. with the Director of Nursing (DON/ Staff #123) who stated that her expectation was that staff would report any allegation of abuse immediately; and that, mandatory reporting occurs within 2 hours of the incident. The DON stated that she became aware of the incident of regarding Resident #29 twisting the arm of Resident #13 on October 31, 2024 when the receptionist brought it up to management staff. The DON stated that staff have received an in-service since then on abuse reporting. Regarding the resident-to-resident altercation between resident #29 and resident #19 on September 05, 2024, the DON stated that she was not aware of the incident; and that, no staff reported the incident to her. She stated that if she had learned of this incident, she would have separated both residents and reported the incident to the abuse coordinator. The DON further stated that moving forward, to prevent further resident-to-resident incidents, residents
An interview was conducted on November 6, 2024 at 3:40 p.m. with the former administrator (Staff #149) who was the administrator at the time of the incident between residents #29 and #19 on September 5, 2024. The former administrator stated that any allegation of abuse should be reported immediately, should be investigated immediately, and should be reported to mandated sources within 2 hours. Regarding the allegation of abuse on September 5, 2024, staff #149 stated that he just found out about it; and that, no staff came to him at the time of the incident to report it. He further stated that there was no investigation done/completed for this incident.
An interview was conducted on November 6, 2024 at 4:09 p.m. with the unit manager (Staff #6) who stated that no staff had reported to her the incident of between resident #29 hitting and attempting to scratch resident #19 on September 5, 2024. She stated that an incident report should have been done; however, there were no risk management (incident) report was done/completed for this incident. The unit manager said that if an incident report had been done, it would trigger an alert for an investigation to be completed. Regarding the incident between residents #29 and #13, the unit manager said that the incident was not reported by any staff when the incident occurred. The unit manager stated that a staff member heard about the incident from another resident; and, it was not reported to management and investigated until October 31, 2024. Further, the unit manager stated that any allegation of abuse should be reported immediately and the investigation should start right away; and that, the importance of timely reporting was so staff could assess for any injuries and protect the resident's safety and wellbeing. The unit manager further stated that if an incident was not reported timely, the incident could happen again.
An interview with the Administrator (Staff #58) was conducted on November 7, 2024 at 11:25 a.m. The administrator stated that staff were to report allegations of abuse immediately and mandatory reporting should be done within 2 hours. He stated that the importance of timely reporting was that it allows the facility to start the investigation and to protect the residents involved. He stated that if the facility's abuse policy was not followed, it allows for continued potential abuse to occur. The Administrator stated that that he was not the Administrator at the time of the incident between residents #29 and #19 occurred on September 5, 2024. He said that he became Administrator on October 01, 2024; and, he just became aware of the incident yesterday when staff was made aware by the state survey agency. He stated that it does not meet his expectation that staff failed to report both incidents (September 5 and October 29, 2024) within the timeframes specified by the abuse policy.
Review of the facility's policy titled Abuse, Neglect, and Exploitation, reviewed January 11, 2024, revealed each resident has the right to be free from abuse. Abuse is defined as the willful infliction of injury, with 'willful' further defined as deliberate action by an individual. The facility will make reasonable efforts to protect residents after alleged abuse. Allegations of abuse must be reported by staff to the administrator immediately, and allegations involving abuse must be reported to the state survey agency within 2 hours. An investigation should be initiated immediately. Further, the actions taken should be documented in the resident's medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #29 admitted on [DATE], with diagnoses of fracture of right wrist and hand, hemiplegia affecting the right side, and A...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #29 admitted on [DATE], with diagnoses of fracture of right wrist and hand, hemiplegia affecting the right side, and Alzheimer's disease.
A physician order dated June 14, 2024 included for oxygen therapy, titrated between 1-5 L (liters) via nasal cannula to maintain oxygen saturation at or above 90%; and, may wean to room air as appropriate.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had received oxygen therapy.
A nurse practitioner (NP) note dated October 28, 2024 revealed the resident remained on 2 liters of oxygen via nasal cannula.
Despite documentation that the resident was on oxygen, there was no evidence found that care plan with interventions for the use of oxygen was developed and implemented.
An observation was conducted on November 5, 2024 at 10:34 a.m. Resident #29 was self-propelling in her wheelchair to the doorway of her room with a portable oxygen tank hanging on the back of her wheelchair. The oxygen cannula tubing was not on the resident's face, but was wrapped around the left armrest of her wheelchair.
Another observation was conducted on November 6, 2024 at 12:22 a.m. and revealed Resident #29 lying in bed, wearing an oxygen nasal cannula connected to an oxygen concentrator at bedside.
A telephone interview was conducted on November 4, 2024 at 1:21 p.m. with the resident's family who stated that three separate occasions, she had noticed resident #29 wearing the oxygen cannula tubing, but the portable oxygen tank was not on. She stated that she requested staff to address this, and on each time, staff took the tank, and would refill it.
An interview was conducted on November 5, 2024 with a certified nursing assistant (CNA /Staff #122) who stated that Resident #29 was always on oxygen.
On November 7, 2024 at 10:52 a.m., an interview was conducted with an MDS coordinator (staff #61) who stated that she assists in editing and adjusting resident's care plans and uses the care area triggers from the MDS assessment as a guide to know what the resident needs on their care plan. She stated if a resident was on oxygen, the staff will usually add this to the resident's care plan.
In an interview with the unit manager (staff #6) conducted on November 7, 2024 at 10:58 a.m., the unit manager stated that care items that need to be addressed on a resident's care plan would be a resident's code status, narcotic use, anticoagulant use, fall risk interventions, and oxygen therapy. A review of the clinical record was conducted with the unit manager who stated that she could not find the care plan for oxygen use for resident #29; and that, it should have been in the resident's care plan. The unit manager stated that a potential outcome of not having necessary care items on a care plan may affect the continuity of care between staff members.
An interview was conducted on November 7, 2024 at 11:06 a.m. with the Director of Nursing (DON / Staff #123) who stated that oxygen use should be on a resident's care plan. A review of the clinical record was conducted with the DON stated that resident #29 had a care plan for oxygen use added on November 7, 2024. The DON stated that the resident did not have a care plan for oxygen use prior to November 7, 2024. Further, the DON stated that a resident having a physician order for oxygen but no care plan for oxygen use, did not meet her expectation. The DON stated that the importance of having patient-centered care plans was that it lets the caregivers know how to care for the residents appropriately.
Review of the facility's policy on Care Plan Revisions Upon Status Change, reviewed October 14, 2024, revealed that the care plan will be modified with the new or modified intervention, that care plans will be modified as needed by the MDS Coordinator or other designated staff member, and the Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in a resident's care.
Based on observation, clinical record review, staff interview, and policies and procedures, the facility failed to ensure a comprehensive person-centered care plan with interventions was developed and implemented related to dialysis care and assessment for one resident (#22); and, oxygen use for one resident (#29). The deficient practice could result in staff not being aware of changes in interventions and asessments.
Findings include:
Resident #22 was readmitted to facility September 9, 2024 with diagnoses of urinary tract infection, type 2 diabetes mellitus, end stage renal disease (ESRD) and kidney disease.
A review of physician orders dated September 9, 2024 revealed the following:
- Dialysis appointment: Patient on hemodialysis (Tuesday, Thursday, Saturday) at (US Renal) Dialysis Center. Please complete pre-dialysis form and fax to dialysis center then place the form in MD box.
- POST DIALYSIS: Assess dialysis site Q 30 mins x 4 hours post dialysis treatment. Assess for bruit/thrill and for sign/symptom bleeding, infections, or any issues. Document in nurses note if any issues are present and Notify MD.
The care plan dated September 10, 2024 revealed that the resident had a potential for alteration in skin integrity related to ESRD on Dialysis. The care plan revealed no evidence of interventions related to pre and post dialysis care as ordered.
Review of the Treatment Administration Records (TAR) from September through November, 2024, revealed that the resident was receiving dialysis every Tuesday, Thursday and Saturday as ordered, and upon return, vital signs and the assess site were monitor per order.
The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment. Active diagnoses included ESRD, dependence on renal dialysis and that the resident was receiving dialysis on admission and while a resident.
Review of the clinical record September through November 2024 revealed no evidence of post dialysis access site monitoring.
An interview was conducted on November 6, 2024 at 7:31 a.m. with the resident who stated that he goes to dialysis three times a week and that staff checks his vitals when he returns from dialysis.
An interview was conducted with the Quality Infection Control (QIC/ staff #6) on November 6, 2024 at 3:08 p.m. The QIC stated that the care plan must be triggered within 24 hr. by the admission nurse and reviewed by a unit manager and MDS coordinator. The QIC reviewed the clinical record and stated that there was no evidence in the care plan related to dialysis or interventions for dialysis that included vital signs and assessment of assess site; and, there should be.
An interview was conducted with the Director of Nursing (DON/ staff #123) on November 7, 2024 at 8:51 p.m. The DON said that the care plan was specific to each individual resident. A review of the clinical record was conducted with the DON who stated that there was no evidence in the care plan that related specifically to dialysis interventions of post dialysis vital sign monitoring and assessment of the dialysis assess site. She said that the facility did not follow our policy; and, risk of not having the care plan could result in staff not having full information regarding residents. The DON further stated that the care plan for resident #22 was corrected yesterday.
Review of the facility policy titled, Dialysis Communication and Site Monitoring, reviewed on October 14, 2023, revealed that when a resident is admitted and requires dialysis as a part of their care, dialysis care plan interventions will be implemented to list the specific cares needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #18 was admitted on [DATE] with diagnoses of sacral fracture, Type 2 Diabetes Mellitus, history of fall, transient isc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #18 was admitted on [DATE] with diagnoses of sacral fracture, Type 2 Diabetes Mellitus, history of fall, transient ischemic attack (TIA), and cerebral infarction.
The progress note dated June 16, 2024 revealed the resident was found on the floor with an increased pain; and that, 911 was called for further evaluation and transfer to the hospital.
Review of a care plan initiated on June 19, 2024 included the resident had potential for falls. The goal was that the resident will be free from fall related injury through the next review. Interventions included educate/ reminders regarding safety precautions, fall risk assessment admission and quarterly, therapy screen/evaluation as ordered.
On June 23, 2024, the resident was found on the floor next to his bed which was in the lowest position. Immediate actions included pain and skin assessments. The report also revealed that there was a skin abrasion on left elbow and the resident was reeducated on call light use.
The Care Plan initiated on June 25, 2024 revealed that the resident had an actual fall on June 16, 2024 with major injury that resulted in nondisplaced anterior S2 fracture. Interventions included to continue interventions on the at-risk plan. However, there was no evidence that the care plans were evaluated for the effectiveness of its interventions; and, there was no evidence that it was revised with each fall to include new interventions to prevent recurrent falls.
The documentation on June 30, 2024 included that the resident was found on the floor, and trying to reach his milk. The clinical record revealed that the resident was non-compliant with fall prevention, confused at times, ordered fall mattress, process e-examined and corrected.
The progress note dated July 1, 2024 included that the current preventive measures in place were call light education, 4Ps, Hi/lo bed, Therapy evaluation, frequent checks and scoop mattress. Per the documentation, there were no new interventions required at this time.
A progress note dated July 12, 2024 revealed the resident was found on the floor and did not have skid socks on.
On August 21, 2024, the resident was found on the floor; and, the resident reported that he was trying to get out of bed to go to the bathroom. Per the documentation, there were no injury reported.
The documentation on September 4, 2024 revealed that the resident was found on the floor beside his bed; and that, the resident reported that he was trying to get off of his blanket. It also included that the resident did not have any injury.
A progress note dated September 6, 2024 included that the resident was found on the floor beside his bed; and that, the resident wanted to crawl down from bed because wanted sleep on floor. Per the documentation, there were no injuries noted.
The clinical record documentation dated September 9, 2024 revealed the resident had two falls with no injury.
On September 11, 2024, the resident was found lying on the floor on stomach on fall mat and had no injury.
The quarterly admission Minimum Data Set (MDS) assessments dated September 24, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident had mild cognitive impairment. The MDS also included that the resident displays behaviors of rejection evaluation of care for 1 to 3 days, and the resident had two or more falls since admission or prior to assessment.
Despite documentation that the resident had multiple falls, there was no evidence found that fall care plan interventions were revised to include new interventions and revised with each fall to include new interventions to prevent recurrent falls after June 25, 2024.
There was no evidence that the care plans were evaluated for the effectiveness of its interventions.
An interview was conducted on November 6, 2023 at 11:10 a.m. with a Licensed Practical Nurse (LPN/Staff #111) who stated that the intervention for the June, 16, 2024 fall sending the resident to the hospital; and, it should have been documented in the care plan. She also stated that new interventions should been placed in to the care plan after the falls on June 30, July 12, September 4, and September 9, 2024. The LPN stated that the risks for not having no new interventions would be that the resident will be in higher risk for recurrent falls and cause injuries.
An interview was conducted on November 6, 2024 at 12:24 p.m. with the Director of Nursing (DON/Staff #123) who stated that the facility process for care planning was to complete initial and baseline care plan upon admission, and add interventions as necessary.
In another interview with the DON conducted on November 6, 2024 at 12:42 p.m., the DON stated that she oversees the residents' care plan; however, she was not able read the care plan for resident #22. She also stated that floor nurse was expected to put interventions on to the care plan and update the care plan as necessary.
A policy titled, Care plan revision upon change, reviewed on October 14, 2024, revealed that the purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The comprehensive care plan will be reviewed, and revised as necessary.
Based on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure that a care plan was revised after each fall for two sampled residents (#18 and #22). The deficient practice could result in resident not getting the appropriate care they need.
Findings include:
-Resident #22 was readmitted to facility September 9, 2024 with diagnoses of urinary tract infection, type 2 diabetes mellitus, end stage renal disease (ESRD) and kidney disease.
An admission evaluation dated September 9, 2024 revealed that the resident was a fall risk related to poor vision. Interventions included the following:
-4P's rounding (pain concerns, positioning needs, personal items are within reach and personal needs are being met)
-Mat next to bed
-Hi/low bed
A care plan initiated on September 10, 2024 revealed the resident had the potential for falls related to ESRD, T2 DM and PVD. Interventions included 4P's rounding (pain concerns, positioning needs, personal items are within reach and personal needs are being met); to anticipate needs as able; call light within reach when in room; to educate and/or provide cues, prompts, and reminders regarding safety precautions as needed; Fall Risk Assessment on admission and Quarterly; to observe for sign and symptom of drug related side effects and report to physician; to orient resident to new surrounding as applicable; and, therapy screen/evaluation as ordered or as needed.
Further review of the actual care plan revealed that the resident had fall incidents on October 9 and November 4, 2024; and that, the resident with pain on right side of the body. However, the care plan revealed no evidence that interventions were revised.
A post fall progress note dated October 14, 2024 revealed that current preventive measures were in place: 4P rounding, Hi/low bed, PT/OT/ST Keep wheelchair close to bed; and that, there were no new interventions required at this time.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated resident had moderate cognitive impairment. The assessment also included impaired vision, need partial/moderate assistance with chair/bed to chair transfer
A post fall progress note dated November 5, 2024 revealed that current preventive measures were in place: Call light education, 4P's, high/low bed, mat next to bed, frequent checks. No new interventions required at this time.
An interview was conducted with the resident on November 4, 2024, at 12:44 p.m., who stated that he fell this morning and his back to the head was hurting. He stated that two staffs were present when he fell and no pain medication was given so far.
An interview was conducted with the resident on November 6, 2024, at 7:31 a.m. who stated that he was getting up on November 4 and that a provider and a male staff were present in the room. He said that the provider was assisting his roommate when while he was dressing up he fell and hit on wall between the bed and table. The resident said that few minutes later, the male staff came and pulled his shirt out and stated that there was no bruise and put me back on bed. The resident also said that his lower back started hurting and they rushed him to the hospital; and that, he was given a shot at the hospital and he came back at the facility on the same day around noon. He further stated that he was not on any medication for fall.
An interview with a certified nurse assistance (CNA/staff # 137) was conducted on November 6, 2024, at 7:31 a.m. The CNA stated that resident #22 was a stand by assist and does not need any help getting up; but, staff want to ensure the resident was safely getting up without any obstruction in his path and also no loose cloth to prevent tripping. The CNA said that staff usually assist resident #22 in the morning to get him up in wheelchair; and that, the resident was mostly independent rest of the evening. Regarding resident #22, the CNA said that the resident was not a fall risk, did not have injury due to a fall, does not have any pain and does not refuse any fall intervention. The CNA stated that if the resident refuses intervention then the CNA was not sure what to do and whom to ask. The CNA said that resident #22 had fall on November 4 and the CNA was not sure who was present with the resident in the room at the time of the incident. The CNA said that the facility then took measures such as frequent monitoring every 4 hr.
In an interview conducted with Registered Nurse (RN/staff 8) on November 6, 2024 at 12:32 p.m., the RN stated that staff would always tell resident #22 to wait for a CNA; but, the resident always wanted to do things by himself. The RN said that on November 4, 2024, the resident tried to stand up and hit his right side of trunk of body; however, there was no bruise, cut or open wound were found. The RN stated that interventions put in place after a fall included for CNAs to be on high alert, answering call lights and lowering the resident's bed. The RN further stated that he thinks the interventions were working; and that, the resident does not have any pain.
An interview was conducted with Quality Infection Control (QIC/ staff #6) on November 6, 2024 at 03:08 p.m. The QIC stated that the care plan must be triggered within 24 hr. by the admission nurse and reviewed by a unit manager and MDS coordinator. Regarding resident #22, the QIC said that the resident had two falls since admission and the resident did not report the incidents immediately. The QIC said that during admission, the resident was assessed for fall risk due to poor vision; and, interventions put in place included high or low bed and mat next to bed. The QIC also said that after the resident's fall on October 14, interventions included call light educations, high or low bed and activities/exercises. The QIC also said that the resident had a second fall on November 4 and had a head strike. She said that 911 was called, vital signs were monitored and resident was given some pain pills, family/provider were notified, and lab result was negative. The QIC further stated that there were no new interventions required at this time which means intervention in place were basically the same. She further stated that the facility/staff had used and exhausted all its resources and was using the same intervention. The QIC further stated that if a care plan was not updated then will not able to provide continuity of care.
During an interview with the Director of Nursing (DON/ staff #123) conducted on November 7, 2024 at 8:51 p.m., the DON stated that the care plan was specific to each individual resident. A review of the clinical record was conducted with the DON who stated that there was no intervention was changed or added in the resident's care plan after the fall on October 14 and November 4, 2024. She said that the facility did not follow our policy; and, risk of not having the care plan could result in staff not having full information regarding residents. The DON further stated that the care plan for resident #22 was corrected yesterday.
Review of the facility's policy titled Care Plan Revisions Upon Status Change, reviewed October 14, 2024, revealed that the care plan will be modified with the new or modified intervention, that care plans will be modified as needed by the MDS Coordinator or other designated staff member, and the Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in a resident's care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation, staff interviews, and review of facility policy, the facility failed to ensure that one medication was disposed of in accordance with professional standards of practice, the defi...
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Based on observation, staff interviews, and review of facility policy, the facility failed to ensure that one medication was disposed of in accordance with professional standards of practice, the deficient practice could result in medications not being disposed of properly. The sample was 28 medication administrations observed.
Findings include:
During a medication administration observation with a Registered Nurse (RN/Staff #8) conducted on November 6, 2024 at 7:23 AM, the RN dispensed a multiple vitamins capsule into a medication cup with other medications and then verified on the order that it was the incorrect medication. The RN then used gloved hands to retrieve the capsule and put it back into the multiple vitamins container.
An interview was conducted with a RN (Staff #8) on November 6, 2024 at 9:43 AM who stated that he usually does not put the medication back into the container after it being dispensed and that he would dispose of it in the drug buster. He further stated that he should not have put the capsule back into the container because of aseptic technique and that it could be contaminated by touching the other medications that were already dispensed into the medication cup.
During an interview with the Director of Nursing (DON/Staff #123) on November 7, 2024 at 9:48 AM, the DON stated that the process for disposing non-controlled medications would be to discard the medication and not put it back into the container. She also stated the risks of placing the medication back into the container after it was dispensed would be that it could contaminate the other vitamins that are in the container. She further stated that this did not meet facility expectations.
The facility provided documentation that there was not a policy for disposition of non-controlled medications and that medications are placed in the Drug Buster per standards of practice.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, facility document review, and facility policy review, the facility failed to ensure that one...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, facility document review, and facility policy review, the facility failed to ensure that one sampled resident (#342) did not receive a pneumococcal vaccine. The deficient practice could result in residents not receiving vaccines.
Findings included:
Resident #342 was admitted on [DATE] with diagnoses of type 2 diabetes mellitus, fracture of unspecified part of neck of right femur, and muscle weakness.
A progress note dated September 20, 2024, revealed that the resident would like to receive a pneumococcal vaccination during skilled nursing facility stay.
The admission Minimal Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment.
Review of an Immunization Informed Consent-V7 form dated October 29, 2024, revealed a signed consent by the resident's sister to receive the pneumonia vaccine Prevnar 20.
Despite documentation that the family agreed to the vaccination, there was no evidence that the medical record of a physician order for the pneumonia vaccine Prevnar 20.
Progress note dated October 29, 2024 to November 7, 2024 revealed no evidence that the vaccine had been administered or ordered.
An interview was conducted with Quality Infection Control (QIC/ staff #6) on November 7, 2024 at 12:13 p.m., who stated that the resident consented for pneumonia on October 29, 2024. She further stated that immunizations are offered upon admission and during the flu season. The QIC reviewed the clinical record and stated that the resident did not receive the pneumonia vaccine. She further stated that she did not place the order for pneumonia into the resident's record. She then stated that the risk could result resident's getting pneumonia.
An interview was conducted with the Director of Nursing (DON/ staff #123) on November 7, 2024 at 12:47 p.m., who stated that the facility conducts a yearly flu/pneumonia clinic in September. She also stated that the resident's pneumonia vaccination was missed, and that she will order it. She further stated that the risk could resulted in residents becoming sick with pneumonia and flu.
Review of facility policy titled, Pneumococcal vaccine (series), reviewed on October 16, 2023, revealed that each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized. Following assessment for any medical contraindications the immunization may be administered in accordance with physician-approved standing orders.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of facility policy, the facility failed to ensure that care and services met...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of facility policy, the facility failed to ensure that care and services met professional standards of practice regarding medication administration for one of six sampled residents (#3). The deficient practice could result in residents not receiving the appropriate medication and for additional errors in medication administration.
Findings include:
Resident #3 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes without complications, essential hypertension, hyperlipidemia, and Alzheimer's disease.
Review of physician order summary revealed the following active orders:
-Ascorbic Acid (supplement) tablet 500 milligrams (mg) give two tablets by mouth one time a day for supplement;
-Bupropion hydrochloride (antidepressant) ER (extended release) give 150 mg orally in the morning for mood disorder;
-Levothyroxine (thyroid hormone) 50 mcg (microgram), take one tablet by mouth once daily in the morning and to take one hour before a meal on an empty stomach for hypothyroid;
-Atorvastatin Calcium (anticholesterol) oral tablet 40 mg give one tablet orally in the morning for hyperlipidemia;
-Oxybutynin chloride ER (anticholinergic) tablet 10 mg, give one tablet by mouth in the morning for overactive bladder (OAB); and,
-Metoprolol Succinate ER (beta blockers) oral tablet 25 mg, give 0.5 tablet by mouth one time a day for congestive heart failure (CHF).
During a medication administration observation conducted with a Registered Nurse (RN/staff #8) on November 6, 2024 at 7:23 a.m., the RN dispensed one ascorbic acid 500 mg tablet into a medication cup; however, the physician's order indicated two tablets. While dispensing the medication the RN was interrupted by a NP to look up another resident's orders and put in orders in for that resident. After dispensing all medications, the RN did not dispense the atorvastatin calcium 40 mg tablet into the medication cup. While preparing to place medication into the medication cup the RN was interrupted by a CNA who provided vital sign information about a different resident. The RN then placed the medication card back into the medication cart without dispensing the the atorvastatin medication. The RN stated that he was ready to administer the medications to resident #3; and that, the RN counted the medications that were dispensed into the medication cup and stated that he had only one ascorbic acid tablet in the medication cup. The RN then reviewed the physician's order for ascorbic acid and stated that there should have been two tablets dispensed. He then dispensed another ascorbic acid tablet into the medication cup. The RN then stated he had prepared all the medications for the resident. He pulled the atorvastatin medication card from the medication cart and verified that atorvastatin tablet was not in the medication cup. The RN then dispensed the tablet into the medication cup. During the same observation, the RN administered one levothyroxine sodium 50 micrograms (mcg) to the resident #3 after the resident had eaten breakfast. The RN did not ask resident #3 whether or not the resident had eaten breakfast. Resident #3 stated that she ate some oatmeal and milk prior to the medication administration observation.
However, the physician orders was for levothyroxine to be administered one hour before a meal on an empty stomach.
During the same observation, the RN crushed and administered one Bupropion (ER) 150 mg tablet, one Metoprolol Succinate ER tablet, and one Oxybutynin Chloride ER tablet to the resident and mixed it in the chocolate pudding.
However, review of the drug specification documentation provided by the facility revealed the following:
-Bupropion hydrochloride ER tablets were not to be chewed, cut, or crushed; and, the tablets must be swallowed whole;
-Oxybutynin ER tablets must be swallowed whole with the aid of liquids, and must not be chewed, divided, or crushed; and,
-Metoprolol succinate ER tablets are scored and can be divided. However, the whole or half tablet should be swallowed whole and not chewed or crushed.
In an interview with RN (staff #8) on November 6, 2024 at 9:43 a.m., the RN stated that he double checks everything during medication administration including counting the pills to make sure he has the accurate amount; and, that, he should not have missed the second ascorbic acid and atorvastatin tablet. He stated that it was normal for other staff members to interrupt while he is in the middle of medication administration. The RN also said that medications could be crushed if there was an order to crush them; and that, there were medications that cannot be crushed and it usually states not to crush them in the order. The RN stated that ER means extended release but was not sure if extended release medications could be crushed or not. The RN also stated that Levothyroxine should be given after breakfast, and stated that the resident (#3) told him she did not eat.
An interview was conducted on November 7, 2024 at 9:48 a.m. with the Director of Nursing (DON/Staff #123) who stated that the process for medication administration included making sure it was the right resident, right route, right medication, right dose, following physician orders as it was written, and following manufacturers recommendations about medication administration. The DON also stated that extended release medications should not be crushed, and that the risk to the resident would result in resident receiving the whole dose of the medication immediately rather than it being absorbed over a period of time. She further stated that for metoprolol succinate ER specifically the risks could be cardiac issues and arrythmias. The DON stated that levothyroxine should be administered before the resident eats breakfast; and the risk of administering after the resident eats would be that it interferes with the absorption of the medication. The DON stated that it does not meet the facility's expectation is staff does not administer medications/treatment as ordered by the physician.
During a telephone interview with the Nurse Practioner (NP/Staff #60) on November 6, 2024 at 3:05 p.m., she stated that extended release medications should not be crushed; and that, the outcome of the resident receiving crushed extended release medications would be that the dose would be stronger and be released faster, and the resident could overdose on the medication. She also stated that she expected staff to follow orders as written and to contact her to discuss an order if they had questions. She further stated that levothyroxine would be given thirty minutes to an hour before the resident eats in the morning.
Review of the facility's policy, Medication Administration, dated October 14, 2024, revealed that medications are administered in accordance with the written orders of the attending physician. It also revealed that crushing may be done using standards of practice; and crushing of long acting or enteric-coated medications is allowable only when there is a specific physicians order to do so.
Review of the facility's policy, Medication Error Monitoring, revision #4, revealed that the facility shall ensure medications will be administered as follows: according to physician orders, per manufacture's specifications regarding the preparation and administration of the drug or biological, and in accordance with accepted standards and principles which apply to professionals providing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and policy review, the facility failed to ensure the medication error ra...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and policy review, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered for one resident (#3). The medication error rate was 21.43%. Six medication administration errors were identified out of 28 opportunities during medication administration observation. The deficient practice could result in further medication errors.
Findings include:
Resident #3 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes without complications, essential hypertension, hyperlipidemia, and Alzheimer's disease.
Review of the physician order dated March 6, 2024 revealed an order for Ascorbic Acid tablet 500 mg give two tablets by mouth one time a day for supplement
Review of the physician order summary revealed an order for the following:
-Atorvastatin Calcium oral tablet 40 mg give one tablet orally in the morning for hyperlipidemia.
-Bupropion hydrochloride (antidepressant) ER (extended release) give 150 mg orally in the morning for mood disorder;
-Oxybutynin chloride ER (anticholinergic) tablet 10 mg, give one tablet by mouth in the morning for overactive bladder (OAB); and,
-Metoprolol Succinate ER (beta blockers) oral tablet 25 mg, give 0.5 tablet by mouth one time a day for congestive heart failure (CHF).
Review of the drug specification documentation provided by the facility revealed the following:
-Bupropion hydrochloride ER tablets were not to be chewed, cut, or crushed; and, the tablets must be swallowed whole;
-Oxybutynin ER tablets must be swallowed whole with the aid of liquids, and must not be chewed, divided, or crushed; and,
-Metoprolol succinate ER tablets are scored and can be divided. However, the whole or half tablet should be swallowed whole and not chewed or crushed.
During a medication administration observation on November 6, 2024 at 7:23 AM with a Registered Nurse (RN/Staff #8), the RN was observed to administer the following:
-One Ascorbic Acid 500 milligram (mg) tablet;
-One Bupropion Extended Release (ER) 150mg tablet, one Metoprolol Succinate ER tablet, and one Oxybutynin Chloride ER tablet were crushed and administered to the resident in chocolate pudding; and,
-One Levothyroxine sodium oral tablet 50 micrograms (mcg) was administered after resident ate breakfast.
The RN (staff #8) also pulled the Atorvastatin medication card from the medication cart, was interrupted by a CNA, and then was observed to place the medication card back into the medication cart without dispensing the medication into the medication cup. The RN verified that the Atorvastatin tablet was not in the medication cup and then dispensed the tablet into the medication cup. The RN (staff #8) counted the medications that were dispensed into the medication cup and verified that he had only one ascorbic acid tablet. The RN reviewed the physician's order and stated that there should have been two tablets dispensed. The RN did not ask resident #3 whether or not the resident had eaten breakfast. Resident #3 stated that she ate some oatmeal and milk prior to the medication administration observation.
During an interview conducted on November 6, 2024 at 9:43 a.m., the RN (staff #8) stated that medications could be crushed if there is an order to crush them, and stated that there are medications that cannot be crushed and it usually states not to crush them in the order. The RN further stated that ER means extended release but was not sure if extended release medications could be crushed or not. He also stated that he should not have missed the second ascorbic acid and atorvastatin tablet. The RN further stated that Levothyroxine should be given after breakfast, and stated that the resident (#3) told him she did not eat.
An interview was conducted on November 7, 2024 at 9:48 a.m. with the Director of Nursing (DON/Staff #123) who stated that the process for medication administration included making sure it was the right resident, right route, right medication, right dose, following physician orders as it was written, and following manufacturers recommendations about medication administration. The DON also stated that extended release medications should not be crushed, and that the risk to the resident would result in resident receiving the whole dose of the medication immediately rather than it being absorbed over a period of time. She further stated that for metoprolol succinate ER specifically the risks could be cardiac issues and arrythmias. The DON stated that levothyroxine should be administered before the resident eats breakfast; and the risk of administering after the resident eats would be that it interferes with the absorption of the medication. The DON stated that it does not meet the facility's expectation is staff does not administer medications/treatment as ordered by the physician.
During a telephone interview with the Nurse Practioner (NP/Staff #60) on November 6, 2024 at 3:05 p.m., she stated that extended release medications should not be crushed; and that, the outcome of the resident receiving crushed extended release medications would be that the dose would be stronger and be released faster, and the resident could overdose on the medication. She also stated that she expected staff to follow orders as written and to contact her to discuss an order if they had questions. She further stated that levothyroxine would be given thirty minutes to an hour before the resident eats in the morning.
Review of the facility's policy, Medication Administration, dated October 14, 2024, revealed that medications are administered in accordance with the written orders of the attending physician. It also revealed that crushing may be done using standards of practice; and crushing of long acting or enteric-coated medications is allowable only when there is a specific physicians order to do so. The policy indicated that medication time may be altered to meet resident and facility needs all while following medical doctors (MD) orders.
Review of the facility's policy, Medication Error Monitoring, revision #4, revealed that the facility shall ensure medications will be administered as follows: according to physician orders, per manufacture's specifications regarding the preparation and administration of the drug or biological, and in accordance with accepted standards and principles which apply to professionals providing services. The policy also indicated that the facility must ensure that it is free of medication error rates of 5% or greater as well as significant medication error events.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -During a medication room observation conducted with a Registered Nurse (RN/staff #6), on November 6, 2024 at 12:39 p.m., there ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -During a medication room observation conducted with a Registered Nurse (RN/staff #6), on November 6, 2024 at 12:39 p.m., there were two Semglee insulin glargine pens in Ekit #1 in the fridge with an expiration date of June 2024; and, Moderna covid-19 vaccines in a black locked box in the fridge had a sticker on the box indicating the expiration date to be June 30, 2023.
During the medication room observation with RN (staff #6) conducted on November 6, 2024 at 12:39 p.m., the following supplies were found having exceeded their expiration date:
-Autoshield duo cap for insulin pen in Ekit #1 from fridge with an expiration date of February 2023;
-Statlock intravenous kit with an expiration date of December 28, 2023;
-Entraflo safety spike plus pump set with enfit with an expiration date of June 28, 2023;
-Powerloc port access kit with an expiration date of October 31, 2024; and,
-Even care blood glucose test strips with an expiration date of September 6, 2024
In an interview with RN (staff #6) conducted on November 6, 2024 at 12:39 p.m., the RN stated that the medications, vaccines and supplies found in the medication room exceeded their expiration date and would be disposed of immediately. The RN further stated they were trying to figure out where to send the expired vaccines instead of disposing of them.
During an interview with the Director of Nursing (DON/staff #123) conducted on November 7, 2024 at 10:09 a.m., the DON stated that the risks of using expired medications or supplies on a resident would affect the efficay of the medications and supplies.
The facility policy on Expired Drugs/Supplies, revealed that expired drugs and supplies should be disposed of with proper record keeping and prior to expiration date. The policy also indicated that the medication room supplies should be randomly checked and discarded prior to expiration date, and stock medications are to be discarded prior to expiration date.
Based on observations, staff interviews, and policy review, the facility failed to ensure that medications the facility failed to ensure that medications were not left at bedside for one residents (#5); and failed to ensure that expired medications and supplies were discarded and readily available for resident use. The facility census was 41, and the sample was 13 residents. The deficient practice could result in adverse effects and residents, staff, and visitors having access to medications.
Findings include:
-Resident #5 was admitted to the facility on [DATE], with diagnoses that include chronic respiratory failure with hypoxia, acute and subacute allergic otitis media, unspecified ear, acute post hemorrhagic anemia
A physician order dated March 22, 2023 revealed an order for Systane Solution eye drop in both eyes.
A physician order dated July 17, 2024 included Fluticasone propionate suspension, one spray in each nostril.
During an observation of the resident's room conducted on November 5, 2024, at 9:08 a.m., there was a bottle containing Fluticasone Propionate Suspension nasal spray and Systane complete eye drop at the resident's bedside table.
In another observation conducted on November 6, 2024 at 9:39 a.m. Fluticasone and Systane eye drops were on the resident's bedside table.
An observation was conducted November 7, 2024, at 8:38 a.m. and revealed that the Fluticasone and Systane eye drops were observed on the resident's bedside table.
An interview was conducted on November 5, 2024, at 9:10 a.m. with with the Resident #5 who stated that she liked to keep the nasal spray and eye drops with her so she did not have to ask the nurses for them in case she needed them.
An interview was conducted with a Registered Nurse (RN/Staff #33) on November 7, 2024, at 12:11 p.m. A review of the clinical record was conducted with the RN who stated that the orders for the Systane Solution eye drops and Fluticasone Propionate were active. The RN further stated that there was no evidence of an order for Resident #5 to self-administer medication.
In an interview with the Director of Nursing (DON/staff #123) was conducted on November 8, 2024 at 10:24 a.m., the DON stated that she had not been in the resident's room, but eye drops and nasal spray should never be left at the bedside per facility policy. The DON stated that there was no reason for any medication to be kept at the bedside unless there was an order to do so. The DON further stated that there was no evidence that a medication self-administration was conducted for resident #5. The DON stated that the risk of leaving medication at the bedside could result in someone else taking the medication.
The facility policy on Medication Storage (Medication Cart/Narcotics), included that it was their policy is to ensure that all medications housed on our premises are stored in the pharmacy and/or Medication rooms according to the manufacturer's recommendations and sufficient to ensure security.
Sept 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected multiple residents
Based on review of employee personnel file, staff interviews and policy review, the facility failed to ensure personnel records for 2 staff (#4 and #101) included documentation of orientation and in-s...
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Based on review of employee personnel file, staff interviews and policy review, the facility failed to ensure personnel records for 2 staff (#4 and #101) included documentation of orientation and in-service education as required by policies and procedure. The deficient practice could result in incompetent care of residents. The facility census was 32 and the sample was 12.
Findings include:
The personnel file of a certified nurse assistant (CNA/staff # 4) revealed a hire date of August 06,2007. The file revealed no evidence of Abuse/neglect/exploitation, Resident rights, Dementia care, Infection control and Communication training since April 25, 2021.
The personnel file of a certified nurse assistant (CNA/staff # 101) revealed a hire date of May 31,2023. The file revealed no evidence of Abuse/neglect/exploitation, Resident rights, Dementia care, Infection control and Communication training.
An interview was conducted on September 20, 2023 around 3:25 p.m. with the Business Office Manager (staff # 26), he stated that staff # 4's, last in-service training was done on April 25,2021 and staff #101 hasn't completed her new hire orientation in last 3 months.
An interview was conducted on September 21, 2023 at 10:15 a.m. with the Director of Nursing (DON/ staff # 51), he stated that new hire staffs are required to complete Abuse/neglect/exploitation, Resident rights, Dementia care, Infection control and Communication training within 30 days of being hired. He further stated that Inservice training for staff are done annually or as needed.
A review of the facility Training Requirements policy revealed that Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment.
Aug 2022
14 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0760
(Tag F0760)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documents and closed clinical record review, staff interviews, and review of policies, the facility failed to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documents and closed clinical record review, staff interviews, and review of policies, the facility failed to ensure one resident (#81) was free from a significant medication error. The deficient practice could result in adverse medication side effects for a resident.
Findings include:
Resident #81 was admitted to the facility on [DATE] and discharged from the facility on December 3, 2021. Diagnoses included dementia with Lewy bodies, mood disorder, anxiety disorder, and Parkinson's disease.
Review of the resident's care plan revealed an undated problem: Black Box Warnings for Antipsychotics: Seroquel; Adverse cardiovascular effects, risk for infections, falls, blood glucose and lipid elevations, abnormal involuntary movement, cerebrovascular adverse events like stroke, sedation. The goal included: Side effects and adverse reactions for antipsychotics will be minimized, recognized early, or prevented daily. Interventions stated to observe for dizziness, sedation, unsteady gait, especially during initiation of therapy or with dosage changes. Report to the physician immediately.
Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate impaired cognition. The assessment included a diagnosis of dementia.
Review of the physician's orders revealed an order dated December 27, 2020, for Seroquel 25 milligrams (mg) times one dose.
Review of the Medication Administration Record (MAR) for December 2020 included Seroquel 25 mg was administered at 7:45 a.m. by a Registered Nurse (RN/staff #98).
Review of a nurse progress note dated December 27, 2020 revealed: Resident Alert and Oriented (A&O) times two, recently started on Aricept before sleep (HS). The resident had aggressive behaviors toward nursing staff today. The resident was grabbing at nursing staff, holding their arms very tightly, and resistant to letting go. The resident appeared agitated and was attempting to get up several times during the early morning. The RN contacted the on-call provider and informed her of the resident's behaviors at approximately 7:00 a.m. The on-call provider ordered Ativan (antianxiety) as needed (PRN) and a one-time dose of Seroquel (antipsychotic), administered Seroquel at 7:45 a.m. The resident fell asleep after about a half hour, and remained asleep throughout lunch and did not want to eat despite being roused by staff. At around 3:00 p.m. the resident became increasingly sedated, pupillary response brisk, resident responded physically to verbal stimuli by squeezing fingers. The resident was not responding verbally. The RN notified the provider of the resident's condition and the resident was sent to the Emergency Department (ER) via ambulance at 4:15 p.m.
Review of facility documentation revealed a medication error report for resident #81 dated December 27, 2020 that included the resident was sent to the hospital, was non-responsive, and referred to a nurse's note on December 27, 2020 under notes.
Review of facility documentation revealed a Facility Self Report regarding an incident that occurred on December 27, 2020 and included that resident (#81) was given an incorrect dose of medication with possible adverse reaction, the resident was sent to the Emergency Department as a precaution.
Review of a nurse progress note dated December 28, 2020 at 6:33 a.m. revealed the nurse received a report from the hospital nurse that the resident was admitted to the Intensive Care Unit (ICU) at 9:00 p.m.
Review of a nurse progress note dated December 28, 2020 revealed the resident re-entered the facility from an overnight stay at the hospital.
Review of the facility investigation revealed that on December 27, 2020 resident #81 was exhibiting behaviors including aggression. The RN (staff #98) called the physician and was given orders including an order for a one-time dose of Seroquel 25 mg. The RN (staff #98) unknowingly gave 200 mg of Seroquel instead of 25 mg. At 3:00 p.m., the nurse noted that the resident was having increased lethargy and only responding to voice. The RN (staff #98) then checked the bubble pack card and realized that she had given the wrong dosage. The provider's direction was to send the resident to the hospital for further evaluation and the resident was transferred via ambulance. The resident returned to the facility on December 28, 2020 and was observed to be at baseline but still exhibiting aggressive behaviors. The conclusion stated the facility determined that the RN (staff #98) failed to confirm the proper dose prior to administering Seroquel which precipitated an unintended reaction from the resident causing the resident to be sent to the Emergency Department as a precaution. Plan of Correction included the Director of Nursing (DON) and/or designee would re-educate nurses regarding The Five Rights of Medication Administration; Written Correction for staff #98 for failure to follow the Five Rights of Medication Administration; DON and/or designee would perform random audits including quizzing nurses on the Five Rights of Medication Administration; and the (QAPI) Quality Assurance and Performance Improvement Committee would review the audits of the DON and/or designee for a period of 90 days and/or until the committee had determined that substantial compliance had been achieved.
-RN (staff #98) was interviewed by the facility on December 28, 2020: She checked the emergency kit for Seroquel and did not see it there. She remembered that the night nurse mentioned having someone on Seroquel. Resident #81's behaviors were pretty bad, she was trying to address the resident behaviors before they got worse. She went to the other hall to borrow some Seroquel from the medication cart. The other nurse (RN/staff #99) was there doing medication passes and the RN (staff #98) told her what she was doing. She (RN/staff #98) popped it out of the card. At around 3:00 p.m. resident #81 was still lethargic and after the resident refused lunch she started to worry that the resident was not responding. She called the Nurse Practitioner (NP) and received direction. She realized that she was in such a hurry that when she pulled the medication she had not looked at the card for the actual dosage. She went to look at the card and realized that she gave the resident 200 mg of Seroquel. She called the NP to tell her what happened.
-The timeline included: Seroquel administered at 7:45 a.m. on December 27, 2020; by 8:15 a.m. the resident had fallen asleep; by 3:00 p.m. the resident became increasingly despondent and would only squeeze the nurse's hand but would not verbally engage and the NP was notified of the resident's condition; At 3:45 p.m. the nurse discovered the error and called the provider, at that time was advised to send the resident to the hospital for further evaluation; At 4:00 p.m. the resident was transferred to the hospital; On December 28, 2020 the resident returned to the facility and appeared to be at baseline.
-Included in the documentation was a page that started with: Medication Error with associated adverse event December 27, 2020 that included that on December 27, 2020 at 7:15 p.m. the resident had been intubated and sent to the ICU for further monitoring.
Review of hospital records for an admission date of December 27, 2020 revealed resident #81 was admitted to the hospital for an unintentional iatrogenic Seroquel overdose with severely diminished Level of Consciousness (LOC). The final diagnoses included: Altered mental status with encephalopathy secondary to accidental iatrogenic medication overdose (Seroquel), and Acute respiratory failure. The hospital course included: The resident was accidentally given 200 mg of Seroquel on December 27, 2020 instead of the normal dose of 25 mg. Upon arrival at the emergency department, the patient was intubated for airway protection. Question of seizure activity noted with brief eyelid fluttering post intubation. The patient was admitted to ICU and was extubated overnight without issue. The patient was discharged back to the facility as the resident was at baseline. The resident discharge date was December 28, 2020.
A NP progress note dated December 29, 2020 revealed nursing reports that the resident is declining and has been unable to feed self in the last few weeks. Patient was recently hospitalized after receiving an increased dose of Seroquel. Today, nursing reports the resident cognition is at baseline. Assessment and plan included: Seroquel overdose, patient was sent to the hospital and returned December 28, 2020. Patient is at baseline this morning.
Review of the personnel record for RN (staff #98) revealed a Corrective Action Notice signed December 31, 2020 for a concern of inefficient, negligent or substandard performance. The description included that on 12/27/2020 she failed to obtain medication via standard operating procedures and to follow the Five Rights of medication administration, specifically the right dose. These actions resulted in resident #81 receiving the wrong dose of Seroquel. In turn, it required a transfer to the hospital for further evaluation. Required corrective action included: When performing medication administration, she was expected to practice the 5 Rights of Medication Administration which included; right patient, right drug, right dose, right route, and the right time.
Review of the personnel record for RN (staff #99) revealed a Corrective Action Notice signed January 1, 2021 for a concern of inefficient, negligent or substandard performance. The description included that on December 27, 2020 she failed to keep both of her medication carts locked at all times. This resulted in the availability of her medications to others that resulted in a medication error.
Review of a nurse in-service revealed re-education related to preventing medication errors, accessing and troubleshooting the RxNow machine (emergency medication supply), 5 rights, and securing medication carts dated January 1, 2021 and revealed a sign in sheet with 15 signatures, including staff #98 and staff #99.
Review of the facility documentation revealed 13 nurses completed a quiz on Avoiding Medication Errors on January 1, 2021 which included the 5 Rights of Medication Administration, borrowing medication, and medication storage.
Review of facility QAPI documentation revealed:
-January 18, 2021: A quality metric for Medication Errors which included a goal of zero, a current rate of zero, and the area was trending in the right direction and no action was needed.
-February 15, 2021: A quality metric for Medication Errors which included a goal of zero, a current rate of zero, and the area was trending in the right direction and no action was needed.
-March 22, 2021: A quality metric for Medication Errors which included a goal of zero, a current rate of zero, and 2/15-no action needed, 1/18 the area was trending in the right direction and no action was needed.
An interview was conducted on August 10, 2022 at 8:47 a.m., with a RN (staff #3). She stated the nurses are expected to follow the physician's order as written and exercise the 5 rights of medication administration which included the right medication, route, time, patient, and dose. She stated the nurse was expected to follow the physician's order as it appears on the MAR. She stated using one resident's medication for another resident would be administering to the wrong resident. She stated the risk of not following the 5 rights of medication administration were that the resident could get the wrong medication, including the wrong dose, and it could cause a health issue for the resident.
An interview was conducted on August 10, 2022 at 8:57 a.m. with the Director of Nursing (DON/staff #97). She stated that she expected the nurses to follow the physician's order as written and the Rights of Medication Administration included the right medication, right patient, right dose, right time, right route, and right diagnosis. She stated if a nurse did not follow the rights of medication administration, it would be a medication error and could cause adverse effects to the patient. Regarding resident #81, she stated from what she had seen the resident was having behavioral issues and was ordered a one-time medication order for Seroquel. She stated the nurse borrowed the medication from another resident, did not note the dosage, and gave 200 mg of Seroquel instead of 25 mg which was a significant medication error. The resident became very lethargic and was sent to the hospital. The DON stated the error caused the resident to receive emergency medical attention related to effects from the medication (severe LOC and a hospital visit). The DON stated the nurse gave way too much, which would be considered harm.
An interview was conducted on August 10, 2022 at 2:48 p.m. with a RN (staff #98). She stated that she remembered the incident that occurred with resident #81. She stated that she had received an order to administer Seroquel 25 mg to resident #81. The RN stated that when she was unable to find the medication in the emergency medication kit she borrowed Seroquel from another resident's medication supply. She stated that she administered the medication to the resident and throughout the day the resident became more somnolent. She stated that she called the provider and told her that she did not know if the resident was tolerating the medication. She stated that she was looking in the resident's chart and at the medication and that she saw that the other resident was on a different dose of the medication, both 25 mg and 200 mg. She stated that she realized there were two dose amounts that could have been administered and went and looked at the medication cards. She stated that she notified the provider immediately after realizing that she gave a dose of 200 mg, and the provider had her send the resident to the E.R. She stated that she had to do a report of the incident and receive counseling. The RN stated that she should have confirmed the medication dosage before administering the medication and should not have borrowed from another resident. She stated that she did not follow the rights of medication administration because she gave the medication to the wrong resident, and gave the wrong dose. She stated that the resident suffered harm as a result of the medication error and that it was a significant medication error of an antipsychotic medication.
Review of a facility policy for Medication Administration dated October 21, 2021 included: Medications will be administered to residents as prescribed by the physician or only by persons lawfully authorized to do so in a safe and prudent manner. Medications are administered in accordance with the written orders of the attending physician. Each resident is to be identified before administering medications. Medications provided for one resident are not to be used for another resident.
Review of a facility policy for Medication Incident dated October 21, 2021 included: Medication incidents are to be reported to the Director of Nursing so that an investigation can be initiated. The following will be considered medication incidents: Omission of ordered medication, Medication given to the wrong resident; The wrong dosage, form, route or time in administration of medication; Unordered medication given to the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and review of policy, the facility failed to ensure one resident (#85) was pro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and review of policy, the facility failed to ensure one resident (#85) was provided with the required information concerning the formulation of advance directives. The sample size was 3. The deficient practice could result in residents not being informed of the right to formulate advance directives.
Findings include:
Resident #85 was admitted to the facility on [DATE] with diagnoses that included Methicillin Resistant Staphylococcus Aureus infection, acquired absence of left leg below knee, and encounter for orthopedic aftercare.
Review of the physician's orders revealed an order for a Full code, dated July 25, 2022.
The active care plan was reviewed, it did not include the resident's advance directives/code status.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact.
However, a clinical record review was conducted on August 8, 2022 at 1:11 p.m. and did not reveal evidence that the facility informed and provided written information to the resident concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
An interview was conducted on August 9, 2022 at 3:35 p.m. with the Director of Nursing (DON/staff #97). She stated, in the facility, staff did a verbal confirmation with the resident to determine if the resident wished to be full code or Do Not Resuscitate (DNR) and then an order would be written. The DON stated if a resident was a DNR they would have an orange form in the record. She stated if the resident was a full code, there would be no documentation that the resident chose to be full code, except an order written. She stated the facility did not provide the resident with written information concerning the right to accept or refuse treatment and to formulate an advance directive. The DON stated when she started working at the facility, she asked the question about advanced directives and was informed that the facility did not do the advance summary form anymore and only used the orange do not resuscitate form. She stated that she was aware of the requirement to offer the resident the opportunity to form advance directives and that she was aware that the requirement was not being met in the facility. She stated this presented a risk factor that the staff would not know what treatments the resident wanted when the resident was not able to speak for themselves and had no one else to speak for them. The DON stated that advance directives included more than the code status.
The facility policy for Advance Directive and Physician's Orders for Life-Sustaining Treatment (POLST) dated December 28, 2021 included: It is our policy to inform and provide information to all new residents upon admission regarding the right to accept or refuse medical or surgical treatment, and at the resident's option, formulate an advance directive. We will inquire of all new residents upon admission whether he or she has an advance directive or POLST in place or would like to create an advance directive. At the time of admission, the facility shall document in a prominent part of the resident's medical record whether or not the individual has executed an advance directive or POLST and place the document in the medical record. Provide written information to residents regarding rights to formulated, at the resident's option, advance directives.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews, and policy review, the facility failed to ensure the physician was not...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews, and policy review, the facility failed to ensure the physician was notified of one resident's (#182) fall. The deficient practice could result in physicians not being notified of changes in residents' conditions.
Findings include:
Resident #182 was admitted to the facility on [DATE] with diagnoses that included fracture of the left femur, orthopedic after care, seizures, major depressive disorder, type 2 diabetes mellitus, and weakness.
The clinical record indicated that the resident was his own responsible party.
Review of the admission Evaluation dated October 26, 2021 revealed the resident was alert and oriented x 4 (person, place, time, and situation).
Review of the medical record revealed a nursing note dated October 27, 2021, stating that the resident was found lying on the floor, flat on his back at 9:20 AM.
Further review of the clinical record revealed no evidence that the physician was notified regarding the resident's fall at 9:20 AM on October 27, 2021.
However, review of the clinical record revealed a physician's order on October 27, 2022 at 12:00 PM, to send the resident to the emergency room for changes in level of consciousness post fall.
Review of corresponding nursing notes revealed the resident had been transferred to the hospital on October 27, 2021 at 12:52 PM.
Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had been discharged from the facility on October 27, 2021 to an acute hospital. The assessment included the resident had one fall since admission with major injury.
An interview was conducted on August 10, 2022 at 2:42 PM with a Registered Nurse (RN/staff #3), who stated the facility policy is to call the physician and family immediately after a fall occurs. She stated that the risk could be internal bleeding.
An interview was conducted on August 11, 2022 at 10:30 AM with an RN (staff #1), who stated that the facility process is to call the physician immediately after a fall, and notify family. She reviewed the medical record progress notes and stated that the resident had a fall at 9:20 AM on October 27, 2021. She also stated that there was no documentation that the physician had been notified at the time of the fall.
An interview was conducted on August 11, 2022 at 11:17 AM with the Director of Nursing (DON/staff #97), who stated that the facility process is to notify the physician and family when the resident falls. She also stated that the risk could be that the resident would not be treated in a timely manner. She reviewed the resident record and stated that there was no documentation that the physician had been notified at the time the resident fell. The DON further stated that there was no documentation that the family had been notified of the fall when it occurred.
The facility policy titled, Resident Accident Incident Policy, revealed that the physician, family, and DON are to be notified immediately if the resident has sustained an injury severe enough to require transportation to the hospital. All other incidents will be followed up with notification to the physician and family during normal business hours.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #91 was admitted to the facility on [DATE] with diagnoses that included acute kidney failure, chronic pulmonary coccid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #91 was admitted to the facility on [DATE] with diagnoses that included acute kidney failure, chronic pulmonary coccidioidomycosis, and type II diabetes.
The Discharge Summary revealed the resident was discharged from the facility on December 11, 2021.
Review of the clinical record did not reveal that the resident received a Notice of Medicare Non-Coverage (NOMNC), prior to the service end date.
-Resident #92 was admitted to the facility on [DATE] with diagnoses that included anorexia, diaphragmatic hernia without obstruction or gangrene, and hypothyroidism.
Review of a progress note dated May 10, 2022 revealed that the resident was discharged to an assisted living facility.
Review of the clinical record did not reveal that the resident received a (NOMNC), prior to the service end date.
An interview was conducted on August 11, 2022 at 3:58 p.m. with the Medical Records Assistant (staff #63), who stated that resident #91 was discharge to home and resident #92 was discharged to an assisted living facility and neither resident was given the NOMNC, prior to the service end date. She stated that the residents were supposed to receive the NOMNC within 48 hours prior to discharge to let them know skilled nursing is no longer covered by insurance.
On August 11, 2022 at 3:58 p.m., the Executive Director (staff #82) stated that the facility did not have a policy re: issuing the NOMNC or the ABN notice. She stated that the NOMNC is required when a resident discharges from Medicare A services with days left over and an ABN is required if the resident will be staying in the facility after Medicare A services ended.
Based on clinical record reviews, staff interviews, and review of policy, the facility failed to ensure required notifications were made at the time of Medicare A discharge and/or payment changes for 3 residents (#82, #91, #92). The deficient practice could result in unforeseen charges to the resident.
Findings include:
-Resident #82 was admitted to the facility on [DATE] and discharged on March 26, 2021 with diagnoses that included right femur fracture, acute post-hemorrhagic anemia, and acute kidney failure.
Review of an admission Minimum Data Set (MDS) assessment dated [DATE] included the resident had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition.
A Notice of Medicare Non-Coverage (NOMNC) form was provided: The Effective Date Coverage of your current Skilled Nursing Facility Services will end February 4, 2021 and liability begins on February 5, 2021. Your Medicare provider and/or health plan have determined that Medicare probably will not pay for your current Skilled Nursing Facility services after the effective date indicated above. You may have to pay for any services you receive after the above date. The form was signed by the resident on February 3, 2021 and included document of contact with the resident representative on February 3, 2021 at 4:15 p.m., in which the facility representative explained that the last covered days would be February 4, 2021 and that if they disagree with the notice, they could appeal the decision. The staff member gave the name and number of the review organization and explained that in order to request a fast appeal the organization must be called before NOON on February 3, 2021. Liability begins February 5, 2021.
However, the notice was provided after the deadline for the fast appeal.
The resident remained in the facility and no Advance Beneficiary Notice of Noncoverage (ABN) notice was provided to the resident.
Review of a Medical Record note dated February 5, 2021 revealed: Spoke with resident's family, the resident's insurance had extended the resident's stay by lowering the level of care from level two to custodial care and that the resident was also pending the State's Medicaid program.
An authorization request dated February 20, 2021 included a partial approval effective January 5, 2021 expiring February 20, 2021. The notice included to notify the member of the authorization determination. Obtaining authorization does not guarantee payment.
However, no documentation of communication with the resident was found.
Review of a Payer Source Change dated March 19, 2021 included room and board changes, therapies changes, lab changes, and pharmacy changes. The area where the patient/responsible party was aware of patient liability was not check marked. The form was signed by the Executive Director.
An authorization determination letter dated March 23, 2021 was reviewed. The resident was approved for additional days at custodial level. Please notify the member of this authorization determination. Obtaining authorization does not guarantee payment. Members may be responsible for a sum of copays.
However, no documentation of communication with the resident was found.
An Account Inquiry was provided which revealed a remaining balance for Therapies and for Private Pay.
A Transaction report was provided which revealed ongoing payments for private pay and a remaining total for the resident.
An interview was conducted on August 10, 2022 at 2:24 p.m. with the Executive Director (staff #82). She stated that the facility billing was done offsite. She stated that she did some research and found that the facility had an insurance case manager that would be responsible to discuss with the resident when a co-pay would start. She stated she did not know who the staff person was at the time the resident was at the facility, or whether the conversation was conducted regarding the resident liability. She stated that, originally, the resident was brought in on a Medicare advantage plan that ended with a NOMNC on February 4, 2021. She stated the resident switched to an access plan which covered all but a deductible. She stated it was her understanding that Medicare advantage plan coverage ended during the resident's stay. She stated that the insurance documentation of change directs the facility to notify the member of the change and that there was no documentation that the member was notified. Staff #82 stated there was no ABN notice found for this resident.
An interview was conducted on August 11, 2022 at 2:07 p.m. with the Director of Nursing (DON/staff #97). She stated that an ABN notice would have told the resident what the resident would have to pay the facility per day. She stated that the facility was responsible for letting residents know what their payment liability would be prior to the charges going into effect. She stated, otherwise, the resident would not know their liability piece. She stated that no ABN notice was provided to the resident and should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility records, closed clinical record review, staff interviews, and review of policy, the facility failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility records, closed clinical record review, staff interviews, and review of policy, the facility failed to ensure the services provided by the facility met professional standards of quality related to medication administration for one resident (#81) by failing to ensure resident #81 was not administered another resident's medication. The deficient practice could result in medication errors and insufficient resident supply of medication.
Findings include:
Resident #81 was admitted to the facility on [DATE] and discharged from the facility on December 3, 2021. Diagnoses included dementia, mood disorder, anxiety disorder, and Parkinson's disease.
Review of a Facility Self Report investigation regarding an incident that occurred on December 27, 2020 included: Resident #81 was exhibiting behaviors including aggression. The Registered Nurse (RN/staff #98) called the MD (Medical Doctor) and was given orders including an order for a one-time dose of Seroquel (antipsychotic) 25 milligrams (mg). The RN (staff #98) obtained medication contrary to standard operating procedure and another RN (staff #99) failed to secure the medication in her cart. The RN (staff #99) had a written corrective action for failure to secure medication in her charge, and RN (staff #98) had written corrective action which included failure to obtain mediation via standard operating procedure. The documented interview with the RN (staff #98) on December 28, 2020 included that the other nurse (RN/staff #99) mentioned one of her residents had been taking Seroquel and then he left. Staff #98 stated she borrowed Seroquel from the other medication cart.
An interview was conducted on August 10, 2022 at 8:47 a.m., with a RN (staff #3). She stated that if she received an order for a medication and she did not have the medication she would call the pharmacy to make sure the medication had been entered into the system and was out for delivery. She stated she could also check the emergency medication kit for the ordered medication. The RN stated if unable to obtain the medication she would check with the doctor and tell him what the facility had available. She stated if another resident in the building has the medication the staff is not permitted to borrow/use one resident's medication for another resident. She stated the medication is meant for, and paid for by, the resident listed on the label. The RN stated the nurse would not be following the 5 rights of medication administration if the nurse took the medication for one resident from the medication card for another resident, because it would be the wrong patient. She stated staff are required to obtain medication through the proper channels, supplied specifically for the resident or from the emergency medication kit.
An interview was conducted on August 10, 2022 at 8:57 a.m. with the Director of Nursing (DON/staff #97). She stated if an ordered medication was not available the nurse should call the pharmacy to see when the medication was expected to be delivered. The DON stated the nursing staff had access to their emergency medication supply and she expected the nurse to see if the medication was one supplied. She stated if the medication was unavailable and another resident was receiving the same medication, the nurse was not permitted to borrow medications from another resident as it would be misappropriation. She stated resident #81 had a one-time medication order for Seroquel and the nurse borrowed from another resident, which was not permitted. The DON stated the nurse did not follow expectations for obtaining medication.
An interview was conducted on August 10, 2022 at 9:33 a.m. with an RN (staff #99) She stated that she remembered the incident involving resident #81. She stated that she was aware that the other nurse (RN/staff #98) had taken medication from her cart and that the facility did not permit staff to borrow a resident's medication for administration to another resident. She stated that she should have locked her medication cart and told the other nurse (staff #98) that she was not permitted to borrow the medication. The RN stated that borrowing a medication to administer to another resident would be considered misappropriation.
An interview was conducted on August 10, 2022 at 2:48 p.m. with a RN (staff #98). She stated that she remembered the incident that occurred with resident #81. She stated that she had received an order to administer Seroquel 25 mg to resident #81. The RN stated that when she was unable to find the medication in the emergency medication kit she borrowed Seroquel from another resident's medication supply. She stated that she had to do a report and received counseling. She stated that when she was unable to obtain the medication from the emergency medication kit she should have called the pharmacy to make sure it was not under another name. The RN stated she should not have borrowed from another resident. She stated that if she had no other option, she should have called the physician and asked for another medication that was available in the emergency medication kit. The RN stated that it would also be considered misappropriation/drug diversion as the other resident's insurance paid for the medication.
Review of a facility policy for Medication Administration dated October 21, 2021 included: Medications provided for one resident are not to be used for another resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure one...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure one resident (#133) had a home health agency (HHA) in place prior to discharge. The deficient practice has the potential to result in an ineffective transition to post-discharge care and increases the risk factors leading to preventable readmission.
Findings include:
Resident #133 was admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease of the native coronary artery without angina pectoris and chronic respiratory failure.
The admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact.
The clinical record contained an order dated July 7, 2021 for home health, physical therapy, and nursing evaluation and treat.
Review of a note written by the Social Services Assistant (staff #79) dated July 8, 2021 on a Post-It revealed that the resident lived alone and had a caregiver seven days a week for 2 to 3 hours per day.
Review of the skilled nursing discharge orders dated July 13, 2021 revealed that home health services were crossed out.
The physical therapy progress and Discharge summary dated [DATE] stated the resident had generalized weakness, unsteadiness on feet. discharged home with 24/7 caregiver support, continue with home health services.
The occupational therapy patient Discharge summary dated [DATE] stated the resident was discharged to home setting with recommendations including extensive support in home on a daily basis.
Documentation by the Director of Therapy (staff #45) revealed that the resident was discharged on July 14, 2021 to home with recommendations for 24/7 care due to the resident's risks of falls, limited strength and activity tolerance. The resident's level of function at discharge included supervision for sit to stand, supervision for dressing, and standby assistance for toileting.
The discharge plan of care dated July 15, 2021 included home health services/referrals were needed.
The discharge planning comprehensive assessment checklist stated the resident has a caregiver who comes Monday, Wednesday, and Friday for 3 hours and Tuesday for 2 hours, but did not reveal that the resident needed home health services.
Review of a progress note dated July 15, 2021 at 8:50 a.m. revealed that the resident was discharged on July 15, 2021 at 2:00 p.m. Reviewed Discharge Plan of Care with resident. Discharge medications/treatments reviewed with resident/POA (power of attorney). All questions regarding discharge medications/treatments were answered prior to discharge. Discharge medications obtained from the pharmacy and sent with the resident/family. Documents sent home on discharge included: Copy of this Discharge Plan of Care (Summary); Schedule II handwritten scripts.
A Progress note dated July 15, 2021 stated the resident was discharged on July 15, 2021 at 2:00 pm. Reviewed Discharge plan of care with resident. Discharge medications/treatments reviewed with resident's POA. The resident had BIMS of 14.
An interview was conducted on August 10, 2022 at 7:46 a.m. with the Social Services Director (staff #21), who stated that she knows what type of care the resident needs because she does an initial assessment of the home environment and discusses with the resident where the resident wants to discharge. She said she knows how many hours and specific services are needed because it is discussed during the Interdisciplinary Team meeting (IDT) meeting when they go over the resident's needs, and she goes by the physical therapy (PT) and occupational therapy (OT) recommendations along with the recommendations from other disciplines. Staff #21 stated home health services does an assessment and most of the time, the home health agency will reach out and let the resident know when they are coming. Staff #21 stated they usually talk to the family in order to confirm the family member is available to provide care and if not, she would need to find someone else to provide the care. Staff #21 stated if she is not able to confirm that there is someone to provide the care, she would not discharge the resident because it is not a safe discharge. On August 10, 2022 at 8:25 a.m. Social Services Assistant (staff #79) joined the interview, and stated the in-home health agency usually assesses the resident's needs on Friday and will begin services on Monday or Tuesday depending on staff availability.
An interview was conducted on August 10, 2022 at 12:43 p.m. with the Social Services Assistant (staff #79). She acknowledged that she wrote a note a Post It dated July 8, 2021 stating the resident was being discharged home, lives alone, and has a caregiver 7 days a week 2 to 3 hours a day. She said that the resident had an order for outpatient physical therapy, but did not need in-home health because the resident had a caregiver and did not have a recommendation for in-home health from therapy.
An interview was conducted on August 10, 2022 at 2:45 p.m. with the Director of Nursing (DON/staff #97) and the Director of Therapy (DOT/staff #45). Staff #97 reviewed the order for home health, PT and nurse evaluation and treatment. She stated that all should have occurred and if there were no home health services available in the area where the resident lives, the PT and nurse assessment would still need to be addressed. Staff #45 joined the interview and stated that he wrote the order dated July 7, 2021 for home health, PT, and a nursing evaluation and treatment. He said that he gives the order to social services and they are supposed to follow-up on the order. He stated that social services told him that there was no home health agency available near the resident, so he wrote a new order for outpatient PT and did not include the home health and the nursing evaluation and treatment in the new order. Staff #45 stated the home health and the nursing evaluation and treatment were not his responsibility. He stated he just wrote the orders together, so there was only one order to give the physician for approval. He said he did not contact nursing to let them know that home health care was not available in the area and did not update the new order to include home health and nursing evaluations and treatment. Staff #45 stated nursing was not aware that the home health and nursing evaluation and treatment orders were still needed and not done. Staff #45 stated since the order was not completed, the evaluations were not completed and services/treatments were not determined. He also said that he did not explain to social services why he did not include home health and nursing evaluations and treatment orders in the new order, and it is social services responsibility to take the order and ensure the order is signed by the physician. He stated that he thinks the orders should be written separately from now on. Staff #97 stated that the process will need to be discussed and agreed that the home health and nursing evaluations should have been addressed and did not get done.
The facility's policy, Transfer and Discharge, reviewed July 24, 2021 stated according to Federal regulations, the facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is appropriate because the resident health has improved sufficiently so the resident no longer needs the service provided by the facility. The Social Service Designee or other designated staff member should handle all non-emergency transfers or discharges. The physician should document medical reasons for transfer or discharge in the medical record, when the reason for transfer or discharge is for any reason other than nonpayment of the stay or the facility ceasing to operate. A copy of the physician's order for discharge should be attached to the discharge notice. A Discharge Summary and plan of care should be prepared for the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews, and review of policy, the facility failed to ensure one resident (#82)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews, and review of policy, the facility failed to ensure one resident (#82) received Activities of Daily Living (ADL) care/incontinence care to maintain good grooming/personal hygiene. The deficient practice could result in negative medical and psychosocial impact.
Findings include:
Resident #82 was admitted to the facility on [DATE] and discharged on March 26, 2021 with diagnoses that included right femur fracture, post hemorrhagic anemia, and acute kidney failure.
Review of a Nurse Practitioner (NP) admission note dated January 6, 2021 included the resident had urinary incontinence and came to them with a Foley catheter. The note also included will discontinue and use briefs.
Review of the physician's orders revealed an order dated January 6, 2021 to discontinue the Foley catheter.
Review of a nurse progress note dated January 6, 2021 revealed the urinary catheter was removed per provider's order.
Review of the Occupational Therapy Plan of Care dated January 6, 2021 revealed the resident required total assistance with toileting.
Review of a Nurse progress note dated January 10, 2021 revealed the resident was incontinent of both.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderately impaired cognition. The assessment revealed the resident received extensive assistance with bed mobility, transfers, dressing, and toileting. The resident did not walk, only received personal hygiene assistance once or twice, and received physical help in part with bathing. The assessment included the resident had impairment of functional range of motion for both upper extremities and to one lower extremity. The resident had occasional bowel incontinence and an indwelling urinary catheter.
Review of the nurse progress note dated January 24, 2021, February 4 and 8, 2021 included the resident's brief was changed.
Review of a Nurse progress note dated February 13, 2021 revealed the resident required two persons assistance for brief changes.
Review of the February 2021 task documentation for toileting each day (24 hours) revealed: (8 indicated that the activity did not occur.)
-February 4, toileting was documented at 5:35 a.m., at 7:53 a.m., and at 6:02 p.m., which was over 10 hours from the last documented toileting/incontinence care;
-February 5, toileting was documented at 12:21 a.m., which was over 6 hours from the last documented toileting/incontinence care, at 8:58 a.m., which was over 8 hours from the last documented toileting/incontinence care, and staff documented an 8 at 7:30 p.m.;
-February 6, toileting was documented at 12:11 a.m., which was over 15 hours from the last documented toileting/incontinence cares, at 9:28 a.m., which was over 9 hours from the last documented toileting/incontinence cares, and at 5:13 p.m., which was over 7 hours from the last documented toileting/incontinence care documentation;
-February 7, an 8 was documented for toileting at 2:18 a.m., toileting was documented at 7:29 a.m., which was over 14 hours from the last documented toileting/incontinence cares, and at 3:50 p.m., which was over 8 hours from the last documented toileting/incontinence cares;
-February 8, toileting was documented at 5:45 a.m., which was over 13 hours from the last documented toileting/incontinence cares, at 1:55 p.m., which was over 8 hours from the last documented toileting/incontinence cares, an 8 was documented at 5:54 p.m.
-February 9, toileting was documented at 2:55 a.m., which was 13 hours from the last documented toileting/incontinence cares, at 11:02 a.m., which was over 8 hours from the last documented toileting/incontinence cares, and at 9:45 p.m., which was over 10 hours from the last documented toileting/incontinence cares;
-February 10, toileting was documented at 2:58 a.m., which was over 5 hours from the last documented toileting/incontinence cares, at 10:32 a.m., which was over 7 hours from the last documented toileting/incontinence cares, and at 9:10 p.m., which was over 10 hours from the last documented toileting/incontinence cares;
-February 11, toileting was documented at 12:10 a.m., an 8 was documented at 12:00 p.m., and toileting was documented at 10:05 p.m., which was over 21 hours from the last documented toileting/incontinence cares.
-February 12, toileting was documented at 3:58 a.m., which was over 5 hours from the last documented toileting/incontinence cares, at 9:44 a.m., which was over 5 hours from the last documented toileting/incontinence cares, and an 8 was documented for toileting at 8:45 p.m.;
-February 13, toileting was documented as an 8 at 5:11 a.m., toileting was documented at 10:58 a.m., which was over 25 hours from the last documented toileting/incontinence cares, and at 9:34 p.m., which was over 10 hours from the last documented toileting/incontinence cares;
-February 14, toileting was documented as an 8 at 5:35 a.m., toileting was documented at 11:42 a.m., which was over 14 hours from the last documented toileting/incontinence cares, and at 4:25 p.m., which was over 4 hours from the last documented toileting/incontinence cares;
-February 15, an 8 was documented for toileting at 12:55 a.m., toileting was documented at 12:20 p.m., which was over 19 hours from the last documented toileting/incontinence cares, and at 5:21 p.m., which was over 5 hours from the last documented toileting/incontinence cares;
-February 16, toileting was documented at 6:56 a.m., which was over 13 hours from the last documented toileting/incontinence cares, at 11:28 a.m., which was over 4 hours from the last documented toileting/incontinence cares, and at 8:05 p.m., which was over 8 hours from the last documented toileting/incontinence cares;
-February 17, toileting was documented at 12:57 a.m., which was over 4 hours from the last documented toileting/incontinence cares, at 7:53 a.m., which was over 6 hours from the last documented toileting/incontinence cares, there was no documentation of incontinence care/toileting from after 7:53 a.m. to Midnight (over 16 hours).
Review of the care plan report revealed a problem for Self-Care Deficit and that the resident required assistance with ADLs due to decline in functional status. The interventions included assisting with ADLs, positioning, and mobility as needed. The care plan did not address the resident's incontinence.
An interview was conducted on August 11, 2022 at 10:53 a.m. with a Licensed Nursing Assistant (LNA/staff #32). She stated that incontinent residents should be receiving incontinence care every 2 hours, or as needed. She stated she would check the resident for incontinence before and after every meal and would also toilet the resident/change them for incontinence at the resident request. The LNA stated that there should be charting each shift the resident was toileted and how much assistance was given. The LNA stated if the care was not charted, she could not show the care was provided. She stated if the toileting/incontinence care was not provided there is a risk for infection, urinary tract infection, and skin breakdown, and it could make the resident feel that they were not being attended to.
An interview was conducted on August 11, 2022 at 12:42 p.m. with the Director of Nursing (DON/staff #97). She stated if a resident had incontinence, staff should check the resident every couple of hours and when the resident calls for assistance. She stated staff is expected to document the care provided each shift in the electronic record and that incontinence care is expected to be performed and documented at least once each shift, but that she would anticipate that incontinence care would need to be provided more than one time per shift. The DON stated if staff did not document toileting on each shift, it would not meet her expectations. She stated that she was not aware of anywhere else to look for documentation that the care was given. The DON stated if toileting/incontinence care was not provided the risks included skin breakdown and infections, and the lack of provision of toileting cares fell in the line of treating the resident with basic dignity.
Review of a facility policy for Activities of Daily Living (ADL) dated October 25, 2021 included: The facility ensures that the resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. ADLs include the resident ability to: bathe, dress, and groom; transfer and ambulate; toilet; eat; and use speech, language or other functional communication systems. Provide necessary services for residents who are unable to carry out activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure the n...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure the necessary hospice services were coordinated with the facility for one sampled resident (#8). The deficient practice could result in residents not receiving needed services and treatment.
Findings include:
Resident #8 was admitted to the facility on [DATE], with diagnoses that included secondary malignant neoplasm of unspecified lung, pulmonary hypertension due to lung diseases and hypoxia, and chronic pulmonary embolism.
Review of the hospice binder located at the nurse station and the resident's clinical record did not reveal documentation of nurse and certified nurse assistant orders or visits to the resident.
The combined disciplinary plan of care dated June 15, 2022 revealed an order for hospice aide visit frequency of 2 visits per week dated May 29, 2022.
Hospice Nurse progress note dated July 14, 2022 stated the resident will continue to receive assistance from facility staff and hospice staff to complete activities of daily living.
Review of the Brief Interview for Mental Status (BIMS) dated July 14, 2022 revealed a score of 7 indicating the resident had severe cognitive impairment.
An interview was conducted on August 11, 2022 at 12:54 p.m. with the Director of Nursing (DON/staff #97), who stated that the hospice nurse is there 2 times a week and the hospice certified nursing assistant (CNA) is there 2 times a week. It was observed that there was no order for hospice nurse or CNA services in the hospice book located at the nurse station or in the resident's clinical record. Staff #97 stated that she is relatively new and her plan is to assign hospice coordination to Social Services. She said that they are contacting hospice to get documentation of visits and care provided in July and August 2022.
During an interview conducted on August 11, 2022 at 1:18 p.m. with the (DON/staff #97), she stated that she is looking for documentation on hospice visits by the nurse and CNA, but her nurses are telling her that the hospice CNA has not been here for the last two weeks. She stated that the facility CNAs have been providing the showers, but she knows that the hospice CNA does other things.
During an interview conducted on August 11, 2022 at 1:40 p.m. with the Administrator (staff #82) and the (DON/staff #97), staff #97 stated that the nurse from hospice just dropped off paperwork showing that he was there once a week. She stated that the hospice told the former DON that the CNA quit back in June, so there has not been a hospice CNA to provide care for the resident since then. She agreed that the services were not coordinated because facility staff who were coordinating services/care would have contacted hospice to follow-up. She also stated that hospice nursing services were provided, but agreed that this was confirmed now and not a continued coordination of services.
The facility policy, The Guidelines for Hospice Care, reviewed October 21, 2021 stated residents who have elected the Hospice Medicare Benefit must have their plan of care (as it relates to the terminal illness) developed and managed by the Hospice Interdisciplinary Group (HIG). The Hospice plan of care is communicated to the facility IDT (interdisciplinary team) and incorporated into the facility plan of care. Members of the HIG document their visit to NF (nursing facility) residents and that documentation is placed in the NF chart. Recommendations and/or orders requested by the Hospice nurse must be obtained promptly and follow-up supervision of the plan of care implemented.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure each resident's drug regim...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure each resident's drug regimen was free of unnecessary drugs, by failing to ensure one resident (#20) received pain medication as ordered by the physician. The sample size was 5. The deficient practice could result in residents receiving medications that may not be necessary.
Findings include:
Resident #20 was admitted on [DATE] with diagnoses that included encephalopathy, diastolic heart failure, type 2 diabetes mellitus, opioid dependence, depression, major depressive disorder, and anxiety disorder,
Review of the resident's care plan initiated on June 14, 2022, revealed the resident is on pain medication therapy related to chronic back pain. An intervention included administering analgesic medications as ordered by the physician.
Review of the annual Minimum Data Set, dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The assessment revealed that the resident experienced frequent pain, with an intensity of 07, and had received PRN (as needed) pain medication.
Review of physician's orders dated May 2022, revealed an order for Percocet 5-325 mg (milligrams) 1 tablet by mouth every 4 hours as needed for pain level 4 - 10.
Review of the physician's order dated July 30, 2022 Percocet 5-325mg 1 tablet by mouth every 4 hours as needed for pain level 4 - 10.
Review of the Medication Administration Record (MAR) dated July 2022, revealed the resident was administered one Percocet tablet 5-325 mg for a pain level of 3 on July 2, July 4, and July 7, 2022.
Further review of the July 2022 MAR revealed the resident was administered one Percocet tablet 5-325 mg for a pain level of 1 on July 10, July 11, and July 14, 2022.
Review of the MAR dated August 2022, revealed the resident was administered one Percocet tablet 5-325mg for a pain level of 3 on August 2, August 8, and August 9, 2022.
An interview was conducted on August 11, 2022 at 9:58 AM with a Registered Nurse (RN/staff #1), who stated that the facility process is to follow physician's orders as written, including any parameters. She reviewed the medical record and stated the physician order is for Percocet tablet 5-325 mg 1 tablet by mouth every 4 hours as needed for pain level 4 - 10. She stated that documentation on the July 2022 MAR showed that one Percocet had been administered for pain levels of 1 or 3 six times in July 2022. She further reviewed the medical record August 2022 MAR and stated that documentation showed that the resident had been administered one Percocet for a pain level of 3, three times in August 2022. She stated that this did not follow physician orders as written, and the risk could be a medication error.
An interview was conducted with the Director of Nursing (DON/staff #97) on August 11, 2022 at 11:28 AM, who stated that the facility policy is to follow physician orders as written including parameters. She reviewed the medical record and stated the resident had orders for Percocet Tablet 5-325 mg 1 tablet by mouth every 4 hours as needed for pain level 4 - 10. The DON reviewed the July and August 2022 MARs and stated that Percocet 5-225 mg had been documented as being administered for pain levels outside of the ordered parameters in July 2022 six times for pain levels of 1 or 3, and also in August 2022 Percocet had been administered three times for a pain level of 3. She stated that Percocet had not been administered according to the physician orders, and that this did not follow the facility policy.
Review of the facility policy titled, Medication Administration-SNF (skilled nursing facility), revealed that medications will be administered to residents as prescribed by the physician. Medications are to be administered per physician order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on review of facility logs, staff interviews, and policy review, the facility failed to provide evidence that temperatures for the walk-in freezer and refrigerator were consistently monitored. T...
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Based on review of facility logs, staff interviews, and policy review, the facility failed to provide evidence that temperatures for the walk-in freezer and refrigerator were consistently monitored. The deficient practice could result in foodborne illness.
Findings include:
During the initial kitchen observation conducted on August 8, 2022 at 10:06 AM, the kitchen log for August 2022 was reviewed.
Review of the August 2022 temperature log for the walk-in freezer and refrigerator revealed no evidence the temperature was checked on:
August 5, at lunch, and dinner
August 6, all day
August 7, breakfast and lunch
During an interview conducted on August 8, 2022 at 10:12 AM with the Kitchen Director (staff #78), he stated the walk-in freezer and fridge temperatures are documented daily at breakfast, lunch and dinner, on the Temperature Log. He reviewed the log and stated that there was no documentation for August 5 Lunch/Dinner, August 6 all day, and August 7 breakfast and lunch. The Kitchen Director stated that this did not meet the facility expectation.
An interview was conducted on August 10, 2022 at 9:21 AM with a kitchen server (staff #38), who stated it is the facility policy that the cook documents the temperatures of the walk-in fridge and freezer temperatures on the log sheet.
In an interview conducted on August 10, 2022 at 9:32 AM with the [NAME] (staff #90), she stated that every day the temperatures for the walk-in freezer and fridge are to be documented on the Temperature Log for every shift at breakfast, lunch and dinner. She also stated that the risk of not monitoring the temperatures could be that food may be in the danger zone and that could make people sick.
Review of the facility policy titled, Refrigerator Temperatures, revealed food should be maintained at a safe temperature. Refrigerator temperatures are to be taken and recorded daily.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0825
(Tag F0825)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and facility policy, the facility failed to ensure one sampled r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and facility policy, the facility failed to ensure one sampled resident (#5) received specialized rehabilitation services in a timely manner. The deficient practice could result in the residents' decline in level of functioning.
Findings include:
Resident #5 was admitted on [DATE] with diagnoses that included cerebral infarction, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side, unspecified osteoarthritis, and obesity.
Review of the care plan for an activities of daily living self-care performance deficit related to decline in functional status related to cerebrovascular accident (CVA) with left side deficits dated August 4, 2021 included the intervention for a physical and occupational therapy evaluation and treatment as per physician orders.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. It also included that the resident received 0 minutes of physical and occupational therapy during the 7-day look-back period.
Review of the resident's orders revealed an order dated June 20, 2022 written by the nurse practitioner (NP) that stated, Is pt eligible for more physical therapy (PT)? She is no longer transferring with one person assist. Requiring a Hoyer lift.
Review of the clinical record revealed an PT order for 12 times/period 30 day(s) from July 18, 2022 through September 12, 2022.
Review of clinical documentation revealed the resident received an PT evaluation on July 18, 2022 and 9 PT treatments from July 18, 2022 through August 8, 2022.
An interview was conducted on August 11, 2022 at 10:48 a.m. with the Director of Therapy (DOT/staff #45), who stated that the resident has an order dated July 18, 2022 for PT, 12 x times in 30 days because the resident was no longer be able to transfer with a one-person assistance, which he attributed to the resident's pain in the lower extremity and general unwillingness to get out of bed. He said that the resident's first therapy session was on July 18, 2022, therapy sessions are 30 to 40 minutes, and if the resident goes to a doctor appointment, he will try to reschedule the therapy session for that week. During the interview, he reviewed clinical documentation and stated that the resident had received PT 9 times. He also stated that the original order dated June 20, 2022, regarding the resident's inability to transfer, was written by the NP (staff #100) and the NP was notifying him that the resident had a decline in transfers. He said that once he is notified of a decline, he evaluates the client. He stated that he evaluated the resident on July 18, 2022, but usually, the evaluation is done the next day. Staff #45 stated there is a risk of weakening, decreased independence, if the evaluation is not done timely.
On August 11, 2022 at 11:44 a.m., an interview was conducted with the Director of Nursing (DON/staff #97). She stated that if it is reported that a resident has a decline of ADLs (activities of daily living), it would be discussed with the interdisciplinary team (IDT) and staff #45 is a part of the IDT team. The DON stated if it is determined appropriate, staff #45 would write the order for therapy and submit the order to the physician for signature. Staff #97 stated staff #45 would evaluate the resident quickly. She stated the risk of not evaluating and providing therapy timely is the continued decline of the patient's ability to function.
The facility's policy, Rehabilitation Services, reviewed March 27, 2021 stated The Nursing Rehabilitation/Restorative Program plan actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. Skill practice in such activities as walking and mobility, dressing and grooming, eating and swallowing, transferring, and communication can improve or maintain function in physical abilities and ADLs prevent further impairment. The facility shall provide or obtain services from an outside resource for specialized rehabilitative services if required by the resident's comprehensive assessment and care plan. Specialized rehabilitative services include physical therapy. The facility will provide interventions consistent with any specialized services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0885
(Tag F0885)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure that resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure that residents' representatives and families were notified that one resident (#200) tested positive for COVID-19. The deficient practice can result in residents and families/representatives not being aware of new COVID-19 cases in the facility and the actions implemented to reduce the risk of transmission.
Findings include:
Resident #200 was admitted to the facility on [DATE] with diagnoses that included hypokalemia, spinal stenosis, lumbar region with neurogenic claudication, and stress fracture, left humerus.
Review of the clinical record revealed that the resident tested positive for COVID-19 on July 26, 2022.
An interview was conducted on August 11, 2022 at 3:02 p.m. with the Director of Nursing (DON/staff #97). Staff #97 stated that she is monitoring infection control and staff #68 is going to be the Infection Control Preventionist (ICP). Staff #97 said the last case for COVID-19 was on July 26, 2022 when a resident tested positive.
During an interview conducted on August 11, 2022 at 3:50 p.m. with the Executive Director (ED/staff #82), she provided a copy of the letter that she emails to family members to notify them of COVID-19 positive test results regarding residents and facility staff. She stated that she did not notify family members/representatives regarding the COVID-19 positive result on July 26, 2022.
The facility policy, COVID Comprehensive Infection Prevention and Control Program, reviewed March 10, 2022 stated to notify HCP (healthcare personnel), residents, and families promptly about identification of SARS-CoV-2 in the facility and maintain ongoing, frequent communication with HCP, residents and families with updates on the situation and facility actions.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #182 was admitted to the facility on [DATE] with diagnoses that included fracture of left femur, orthopedic after care...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #182 was admitted to the facility on [DATE] with diagnoses that included fracture of left femur, orthopedic after care, seizures, major depressive disorder, type 2 diabetes mellitus, and weakness.
The clinical record indicated that the resident was his own responsible party.
Review of the admission Evaluation dated October 26, 2021 revealed the resident was alert and oriented x 4 (person, place, time, and situation).
Review of corresponding nursing notes revealed the resident had been transferred to the hospital on October 27, 2021.
Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had been discharged from the facility on October 27, 2021 to an acute hospital.
Further review of the clinical record revealed no evidence that the resident was notified in writing of the transfer/discharge.
In an interview with a Registered Nurse (RN/staff #1) conducted on August 11, 2022 at 10:30 AM, she stated that when a resident is transferred to the hospital they complete a transfer form that is faxed with other paperwork to the hospital. She also stated that the resident and family are not provided a written copy of the transfer notice. The RN reviewed the medical record and stated that the documentation showed that the resident had a fall and was transferred to the hospital on October 27, 2022.
An interview was conducted on August 11, 2022 at 11:17 AM with the Director of Nursing (DON/staff #97), who stated that when a resident is transferred to the hospital, there is an acute care transfer form that is to be completed and sent to the hospital. The DON stated that it is not a practice of this facility to provide written notification of transfer/discharge to the resident or resident's representative.
Review of the facility policy titled, Transfer and Discharge, revealed emergency transfers should include a physician's order, the nurse should complete and send with the resident a transfer form, a copy of the advanced directive, and a copy of the transfer form should be kept in the medical record. Record the reasons for, the effective date of transfer or discharge, and the location to which the resident is being transferred or discharged , in the medical record and on a discharge for or letter. Give a copy of the discharge notice to the resident and/or the family/legal representative. The review also revealed that the Notice of Discharge should be sent to the Ombudsman. A copy of the notice must be sent at the same time notice is provided to the resident/resident representative at least 30 days prior to the discharge or as soon as practicable. When an emergency transfer/discharge occurs a copy of the transfer notice may be sent when practicable, such as a list of residents on a monthly basis.
Based on clinical record reviews, staff interviews, and policy review, the facility failed to ensure a written notice of transfer/discharge was provided to one resident (#182) and that a copy was sent to the Office of the State Long Term Care Ombudsman for two residents (#12 and #133). The deficient practice could result in residents/representatives not being provided written notice of transfers/discharges and the ombudsman not receiving a copy of the notices.
Findings include:
-Resident #12 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease, acute and chronic respiratory with hypoxia, and acute kidney failure.
Review of a nursing note dated May 28, 2022 at 11:30 a.m. stated that the resident was sent to the emergency room for difficulty breathing, with oxygen saturation decreasing to 87% even with O2 at 3.5 LPM (liters per minute). At the time of discharge the resident was oriented to person, place and time. The resident was informed of the reason for transfer to the hospital in a language and manner they could understand.
Further review of the clinical record did not reveal evidence that the ombudsman received written notification of the transfer/discharge.
-Resident #133 was admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease of the native coronary artery without angina pectoris and chronic respiratory failure.
Review of a nursing note dated July 15, 2021 at 8:50 a.m. stated the resident was discharged on July 15, 2021 at 2:00 p.m. Reviewed Discharge Plan of Care with resident. Discharge medications/treatments reviewed with resident/POA (power of attorney). All questions regarding discharge medications/treatments were answered prior to discharge. Discharge medications obtained from the pharmacy and sent with the resident/family. Documents sent home on discharge included: Copy of this Discharge Plan of Care (Summary); Schedule II handwritten scripts.
Further review of the clinical record did not reveal evidence that the ombudsman received written notification of the transfer/discharge.
On August 11, 2022 at 8:34 a.m., an interview was conducted with the Director of Social Services (staff #21), who stated that she has never notified the ombudsman when a resident is transferred/discharged . Staff #21 stated the prior Director of Social Services told her that she never contacted the ombudsman when there was a discharge.
An interview was conducted on August 11, 2022 at 8:38 a.m. with the Director of Nursing (DON/staff #97), who stated that the ombudsman needs to be notified regarding discharges. The DON stated she spoke to the ombudsman and told him that the facility will begin emailing him the discharge notifications monthly.
During an interview conducted on August 11, 2022 at 2:28 p.m. with the DON (staff #97), she stated that the facility does not have a policy regarding ombudsman notifications because the facility was not aware that the ombudsman had to be notified.
MINOR
(B)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected multiple residents
Based on observation, staff interviews and policy review, the facility failed to ensure current nurse staffing information was posted on a daily basis. The deficient practice could result in staffing ...
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Based on observation, staff interviews and policy review, the facility failed to ensure current nurse staffing information was posted on a daily basis. The deficient practice could result in staffing information not being readily available to residents and visitors.
Findings include:
During an observation conducted on August 8, 2022 at approximately 10:45 AM, no Daily Staffing Posting was observed to be posted in a prominent area in the facility.
On August 8, 2022 at 10:58 AM, a Daily Staff Posting was observed posted outside of the Director of Nursing and Executive Director's offices, across from the nursing station. The posting combined information that included the daily number and hours worked for nurses and certified nursing assistants and the census for each shift.
Observations were conducted on August 9, 2022 at 10:14 AM and 2:44 PM which revealed the daily staff posting was not updated from the previous day of August 8. 2022.
Another observation was conducted on August 10, 2022 at 7:00 AM, the daily staff posting was dated August 8, 2022.
An interview was conducted on August 10, 2022 at 1:26 PM with the Director of Nursing (DON/staff #97), who stated that the daily staffing hours are posted daily, outside of her office. She stated that she removed the August 8, 2022 posting today on August 10, 2022. She further stated that the daily staffing was not posted daily and that it did not meet the facility process. She also stated that the risk of not posting the daily staffing could be that family/representatives would not think there was enough staff in the building.
Review of the facility policy titled, Nurse Staffing Information, revealed that nurse staffing information will contain facility name, current date, current census, total number and actual hours worked by Registered Nurses, Licensed Practical Nurses and Certified Nurse Aides. The facility will post the nurse staffing daily at the beginning of each shift. The information posted will be clear, readable and in a readily accessible area to residents and visitors.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Arizona facilities.
Concerns
- • 28 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade D (40/100). Below average facility with significant concerns.
- • 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 40/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is The Peaks Health & Rehabilitation's CMS Rating?
CMS assigns THE PEAKS HEALTH & REHABILITATION an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Arizona, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is The Peaks Health & Rehabilitation Staffed?
CMS rates THE PEAKS HEALTH & REHABILITATION's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 60%, which is 14 percentage points above the Arizona average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at The Peaks Health & Rehabilitation?
State health inspectors documented 28 deficiencies at THE PEAKS HEALTH & REHABILITATION during 2022 to 2025. These included: 1 that caused actual resident harm, 26 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates The Peaks Health & Rehabilitation?
THE PEAKS HEALTH & REHABILITATION is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by THE GOODMAN GROUP, a chain that manages multiple nursing homes. With 58 certified beds and approximately 43 residents (about 74% occupancy), it is a smaller facility located in FLAGSTAFF, Arizona.
How Does The Peaks Health & Rehabilitation Compare to Other Arizona Nursing Homes?
Compared to the 100 nursing homes in Arizona, THE PEAKS HEALTH & REHABILITATION's overall rating (2 stars) is below the state average of 3.3, staff turnover (60%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting The Peaks Health & Rehabilitation?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's high staff turnover rate.
Is The Peaks Health & Rehabilitation Safe?
Based on CMS inspection data, THE PEAKS HEALTH & REHABILITATION has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Arizona. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at The Peaks Health & Rehabilitation Stick Around?
Staff turnover at THE PEAKS HEALTH & REHABILITATION is high. At 60%, the facility is 14 percentage points above the Arizona average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was The Peaks Health & Rehabilitation Ever Fined?
THE PEAKS HEALTH & REHABILITATION has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is The Peaks Health & Rehabilitation on Any Federal Watch List?
THE PEAKS HEALTH & REHABILITATION is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.