HAVEN OF GLOBE
For profit - Limited Liability company
104 Beds
HAVEN HEALTH
Data: November 2025
Trust Grade
60/100
#50 of 139 in AZ
Photo by Google Maps
Photo by Haven Health Globe
Photo by Haven Health Globe
Photo by Haven Health Globe
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Last Inspection: February 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Haven of Globe has a Trust Grade of C+, indicating it is slightly above average but not without its issues. It ranks #50 out of 139 facilities in Arizona, placing it in the top half statewide, and #2 out of 4 in Gila County, meaning only one nearby option is better. However, the facility's trend is worsening, with the number of reported issues increasing from 3 in 2024 to 5 in 2025. Staffing is a concern, as it received only 2 out of 5 stars, although its turnover rate of 44% is below the state average of 48%, suggesting some stability. On a positive note, the facility has had no fines, which is encouraging, and it offers more RN coverage than average, crucial for monitoring residents’ health closely. Specific incidents raise concerns about resident care. For example, one resident with an indwelling urinary catheter did not receive adequate care to prevent skin breakdown, which could lead to serious complications. Additionally, there were instances of residents being at risk of abuse from others, highlighting potential safety issues. While there are strengths in the quality measures and lack of fines, families should weigh these against the troubling trends and incidents reported.
- Trust Score
- C+
- In Arizona
- #50/139
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 44% turnover. Near Arizona's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Arizona facilities.
- Skilled Nurses ○ Average
- Each resident gets 35 minutes of Registered Nurse (RN) attention daily — about average for Arizona. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 24 deficiencies on record. Higher than average. Multiple issues found across inspections.
60/100
Top 35%
Needs review
3 → 5 violations
★★★★☆
4.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★★
5.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 3 issues
2025: 5 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (44%)
4 points below Arizona average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 44%
Near Arizona avg (46%)
Typical for the industry
Chain: HAVEN HEALTH
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 24 deficiencies on record
2 actual harm
Apr 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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, facility documentation and policy review, the facility failed to ensure four reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, facility documentation and policy review, the facility failed to ensure four residents (#50, #150, #100 and #250) were free from abuse from other residents (#100, #250, #200). The deficient practice could lead to other resident to resident altercations which could result in harm.
Findings include:
Resident #100 was admitted to the facility on [DATE] with a diagnosis of dementia with behavioral disburbances, chronic kidney disease, alcohol abuse and major depressive disorder.
Review of the MDS (Minimum Data Set) dated August 14, 2022 reveals a BIMS (Brief Interview for Mental Status) score of 99, indicating resident #100 to be severely cognitively impaired.
Resident #250 was admitted to the facility on [DATE] with a diagnosis of vascular dementia with behavioral disturbance and post-traumatic stress disorder.
Review of the MDS dated [DATE] reveals a BIMS score of 99, indicating resident #250 to be severely cognitively impaired.
On the morning of March 13, 2022, resident #250 woke up from sleeping in his chair and saw his shoelace was broken lying on the floor next to him. He got out of his chair and started punching resident #100 in the face. Resident #100 began swinging back at resident #250. This incident was witnesssed by a staff member #82, who immediately seperated the residents. Resident #100 sustained minor injury to his lip.
Resident #200 was admitted to the facility on [DATE] with a diagnosis of dementia with behavioral disturbances, wandering and difficulty walking.
Review of the MDS dated [DATE] reveals a BIMS score of 99, indicating resident #200 to be severely cognitively impaired.
Resident #150 admitted to the facility on [DATE] with a diagnosis of vascular dementia with anxiety, wandering, anxiety disorder and major depressive disorder.
Review of the MDS dated [DATE] reveals a BIMS score of 99, indicating resident #150 to be severely cognitively impaired.
On June 11, 2022, staff #5 was at the medication cart when he heard resident #200 and #150 speaking to each other. The conversation appeared to be getting louder. Staff #5 told the residents to move away from each other. Resident #200 grabbed the back of resident #150's wheelchair and began slapping resident #150 several times in the back of the head. Staff #5 seperated both residents but resident #200 continued to yell at resident #150 claiming he stole her shoes. Resident #150 did not have any shoes with him and were not found in his room.
Resident #50 was admitted to the facility on [DATE] with a diagnosis of dementia with behavioral disturbances, major depressive disorder, age related macular degeneration, adult failure to thrive and alzheimers disease.
Review of the MDS dated [DATE] reveals a BIMS score of 99, indication resident #50 to be severely cognitively impaired.
On August 15, 2022 as residents were exiting the dining room, resident #50 and resident #100 wheelchairs became caught up on each other. As staff were approaching to seperate the residents, resident #100 punched resident #50 with a closed fist on the right cheek of her face. Staff immediately seperated both residents. Resident #50 was noted to have a reddish/pink discoloration to her face.
Review of the facility investigation for all three incidents reveal that each one was substantiated by the facility.
Feb 2025
4 deficiencies
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
Deficiency F0660
(Tag F0660)
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 that a resident's represen...
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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 that a resident's representative was notified of a transfer. The deficient practice could result in resident's representative being unaware of residents discharge.
Findings include:
Resident #147 was admitted on [DATE] with diagnoses of metabolic encephalopathy, schizoaffective disorder bipolar type, dementia and major depressive disorder. This resident discharged on May 21, 2021.
A care plan dated May 5, 2021 included resident and spouse/representative have expressed wish for discharge home to prior living with supportive services in home depending on outcome and care needs with interventions to set up home health service per resident/representative choice. However, this resident was not discharged to home.
A clinical resident profile included that this resident had a Power of Attorney (POA) designated for financial and care, and that this POA was also the emergency contact.
An alert charting note dated May 8, 2021 included that the resident was in a physical altercation and included that this resident's POA was notified via phone.
An activity progress note dated May 19, 2021 included that this resident was transferred to Haven Health Showlow and the pick up time for the discharge. This note included that the staff Gathered medications and instructed patient of the transfer.
However, review of the clinical record did not find any record that the resident's representative was informed of the transfer, or whether the resident received her belongings
A Complaint/Incident Investigation Report was filed with Arizona Department of Health Services on May 27, 2021 that included that this resident was transferred to another facility without informing the resident's representative and that the resident' s belongs were missing.
An interview was conducted on February 4, 2025 at 01:53 PM with Resident Relations (staff #98) who said that as soon as a resident arrives it populates a form and it includes questions such as, Is your goal to go home, or to long term care? Do you need transport, and do need you equipment?. This staff said this form gives her the basics and that she will follow up 3-4 days later to see the resident's progress because sometime the residents are weaker than expected, and that she will ask Is the plan the same?. This staff said that she will meet back with them in another 2 weeks, see if any obstacles, and ask are we going to look at long term, are they meeting therapy goals or insurance restrictions, and when it gets close to discharge a Notice of Medical Non-Coverage (NOMNC) is provided 3 days in advance. This staff said that some of the required items for discharge she can order through hospital and that insurance determines home health. This staff said that she then gets the scripts signed and determines who will be providing transport, whether it is family or the facility vehicle or a transport company. This staff said that she may have the records of this resident locked in the back.
An interview was conducted on February 4, 2025 at 2:48 PM with the Assistant Director of Nursing (ADON/staff #104) who said that they would get the discharge information from Resident Relations (staff #98) and that they would do half and the nurses would do the other half, and that they would get the prescription form the doctor. This nurse said that if resident is alert and oriented, they do not need to call family, if not that they do and that the family are usually transporting the resident. This staff said that family should know about it before they are ever discharged . This staff reviewed the resident record and said that the patient had dementia and was pretty dependent, as well as encephopathy and that normally with someone who is impaired the staff would notify the family. This staff said that she did not see anything in the record that says the family knows where this resident is going and that her family should have been notified.
An interview was conducted on February 4, 2025 at 4:36 P.M. with the Operations Manager (staff #94) who said that the facility does not have a record of resident representative notification of transfer or that the belongings were returned to the resident or representative.
An interview was conducted on February 4, 2024 at 3:29 PM with the Director of Nursing (DON/staff #80) who said that staff should be referred for any outpatient needs including home health, therapy, be provided discharge planning and then be given discharge medications, NOMNC notices and physician orders. This DON reviewed the clinical record and stated that the resident's Brief Interview for Mental Status score was 9 (indicating moderate impairment) and that she had schizophrenia, metabolic encephalopathy, dementia and Major Depressive Disorder, and that all she saw in the record regarding discharge is that she was transferred. She said that her expectation was that family would be notified and that the resident's belongs would be transferred with them.
A policy titled Admissions/Transfers/Discharges: Transfer or Discharge- Preparing a Resident for Discharge in effect January 1, 2024 included that residents will be prepared in advance for discharge and included a post-discharge plan is developed for each resident prior to his or her transfer or discharge. This document included this plan will be reviewed with the resident, and/or his or her family, before the resident's discharge or transfer from the facility and that nursing services was responsible for packing and collecting personal possessions if the resident is not expected to return.
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, interviews, and review of facility policies and procedures, the facility failed to ensure neces...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, and review of facility policies and procedures, the facility failed to ensure necessary blood pressure medications and insulin were administered according to provider instruction for one resident (#68). This deficient practice could result in side effects leading to negative resident outcomes.
Findings include:
-Resident # 68 was admitted to the facility on [DATE], with diagnoses that include hypertension, Type 2 Diabetes Mellitus, dysphagia (difficulty swallowing), and dependence on renal dialysis.
The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had mild cognitive impairment.
The resident care plan dated November 19, 2024, required that anti-hypertensive medications to be given as ordered, and to monitor for side effects such as orthostatic hypotension (low blood pressure caused by position change) and tachycardia (increased heart rate).
A physician order dated November 6, 2024 revealed Hydralazine HCL 25 mg (milligrams) to be given three times a day for hypertension (high blood pressure) unless the systolic blood pressure is less than 100.
A physician order dated November 6, 2024 revealed Metoprolol Tartrate 50 mg to be given twice a day for hypertension unless the systolic blood pressure is less than 100.
A physician order dated November 20, 2024 revealed Insulin Glargine to be given every day for Type 2 Diabetes Mellitus unless the blood sugar was less than 110.
Review of the Medication Administration Record (MAR) for December 2024 revealed multiple dates (December 6, 19, 20, and 30) where Insulin Glargine was administered with a blood sugar less than 110.
Review of the clinical record failed to support the medication being given out of parameter.
Review of the Medication Administration Record (MAR) for January 2025 revealed two dates (January 7 and 14) where Hydralazine HCL was administered with a systolic blood pressure lower than 100.
Review of the Medication Administration Record (MAR) for February 2025 revealed Hydralazine HCL was administered with a systolic blood pressure lower than 100 on three dates (February 1, 7, and 14).
Review of the clinical record failed to support the medication (Hydralazine) being given out of parameter.
An interview was conducted with the resident #68 on February 3, 2025 at 8:50 a.m. The resident stated that he trusts that the nursing staff are administering their medications as ordered. The resident stated he would feel let down if he was to find out otherwise because he depends on them (nurses).
An interview with Registered Nurse (RN/Staff # 19) was conducted on February 4, 2025 at 8:47 a.m. The nurse reviewed the clinical record with the surveyor and reviewed the clinical documentation for resident # 68's Hydralazine HCL, Metoprolol Tartrate, and Insulin Glargine administrations. The nurse was able to identify episodes when the blood pressure and insulin were given outside of parameters, which she stated goes against facility expectation, and can cause adverse side effects in the resident. The nurse further explained that if a medication was to be given out of parameter, the provider would have to be notified and then documented in the clinical record. The nurse stated that there are quite a few interruptions that occurs during medication pass, and feels that if these interruptions were minimized, greater focus can be devoted to ensuring medication errors do not occur.
An interview with the Assistant Director of Nursing (ADON/Staff # 112) was conducted on February 4, 2025 at approximately 11:00 a.m. The ADON reviewed the clinical record with the surveyor identified incidents of medications given out of parameter for resident #68. The ADON was unable to produced documentation to support the administration of medications outside of parameter for this resident. The assistant director revealed that interruptions during med pass does occur, however that should not impact any nurse's ability to administer medications correctly as long as the nurse adheres to the Rights of Medication Administration.
An interview was completed with Licensed Practical Nurse (LPN/Staff # 110) on February 4, 2025 at 11:44 a.m. The LPN revealed that when following the MAR and if the order needs clarification, the provider is contacted. When giving insulin and blood pressure medicine, the nurse prefers to reassess blood pressure and blood sugars before the medication is administered.The nurse admits to being interrupted with various incidents during medication administration times and will stop med pass in order to address the issue. The nurse feels that enough staff support is available to administer medications. In addition, the nurse feels that there is a problem that may be too much to handle, they have other staff who are able to help during med pass.
The facility's Resident Examination and Assessment policy advises that the orders are to be completed in accordance with physician orders determined at the resident's time of admission or throughout the resident stay.
The facility's Administering Medications policy advises that staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. In addition, it revealed vital signs, if necessary, are to checked/verified for each resident prior to administering medications.
The facility's Adverse Consequences and Medication Errors revealed a medication error can include administering a drug without a physician's order. In addition, documentation of the clinical rationale for using the medication if prescribed outside the accepted standard of practice is required.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations, staff interview, and policy, the facility failed to ensure the kitchen (lower kitchen) and the serving area (upstairs kitchen) was clean and sanitary when preparing food for res...
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Based on observations, staff interview, and policy, the facility failed to ensure the kitchen (lower kitchen) and the serving area (upstairs kitchen) was clean and sanitary when preparing food for residents. The deficient practice could increase the risk of foodborne illness.
Findings include:
The initial lower kitchen observation conducted on February 2, 2025 at 9:54 am revealed an open ceiling tile towards the dishwashing sink, and three other ceiling tiles with discolorations. Vents in the kitchen were covered in blackish/gray fuzzy particles. The dishwashing sink and counter area was unattended. The counter had a red sanitizer disinfectant bucket towards the top left corner, and a saturated kitchen towel towards the bottom left corner. The counter has a covering of a mix of suds and left-over food particles. The sink drain was clogged with a discolored fluid, suds, and food particles which flooded over into the sink. Small flying insects were in area and landing intermittently on the wall. Two square clear containers were also present in the sink. The initial upper kitchen observation revealed fans and vents covered in a layer of blackish/ gray fuzzy particles.
During the puree demonstration on February 3, 2025 at approximately 11:00 a.m., observed with dietary aide (Staff # 89) and the dietary manager (Staff #95) a deceased small brown insect was removed from the wall in the puree prep area.
A facility walk-through began at 11:46 a.m. on February 3, 2025, with the [NAME] President (Staff # 125), the Director of Nursing (Staff # 80), the Dietary Manager (Staff # 75), the Maintenance Director (Staff # 113), and Maintenance Technician (Staff # 146). The group fan blades and vents were still covered in blackish/grayish particles in the upper kitchen. The lower kitchen same ceiling tile was partially opened, and three ceiling tiles with discolorations, and vents covered with blackish/grayish fuzzy particles.
Reviewed Extermination Services receipts for kitchen visits on the dates of : November 4, 2024, November 20, 2024, December 10, 2024, January 14, 2025, and February 2, 2025.
Work Order #2576 was initiated on February 3, 2025 and completed by February 4, 2025 by 11:11 am for kitchen and serving area ceiling, fans, doors, and vents.
A joint interview was conducted with the Dietary Manager, and the Registered Dietitian (RD/Staff # 126) on February 4, 2025 at 10:08am. The dietary manager stated that multi-tasking is an expected skill to have when working in the kitchen. Multi-tasking involves being able to simultaneously prepare, serve, and clean up after meals. The dietary manager feels they have enough staff to meet expectations, as well as fulfilling deep cleaning tasks on a routine basis. In regards to the condition of the vents and fans, the dietary manager revealed this task was initially not on the deep cleaning list, but will be immediately added. The manager and dietitian stated the issues with dust on fan blades and vents include contamination of the food. The manager and dietitian also identified insects are unwelcomed in the food prep and service areas due to food contamination and spread of diseases. The manager stated that they are in process of fixing all the ceiling tiles, and that insects can hide in the open tiles. The manager does admit that she is unaware of how long the roach was on the wall in the puree station, but there is no acceptable reason for it to be present at any time. The dietary manager and dietitian were both asked if they would patronize their own kitchen with the knowledge of the insect and cleanliness issues, both parties declined to provide a response. The dietary manager is grateful that the facility has had no food borne outbreaks over the past year. Both parties do admit that the findings in the upper and lower kitchen does not meet facility expectations. The dietary manager reported having no food borne outbreak over the past year.
An interview with the [NAME] President Staff # 125 during the facility walk through revealed that the dust on the fan blades can introduce contaminants in the food, which does not meet facility expectations.
The General Sanitation of Kitchen policy reveled the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. In addition, on the cleaning schedule, employees will initial and date tasks when completed.
The Infection Control Program aim is to maintain a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
Based on observation, interviews, and review of facility documentation and policy, the facility failed to ensure an effective pest control program was maintained. This deficient practice can result in...
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Based on observation, interviews, and review of facility documentation and policy, the facility failed to ensure an effective pest control program was maintained. This deficient practice can result in the spread of disease, and not promoting a home like environment for the residents.
Findings include,
An initial kitchen walkthrough was conducted on February 2, 2025 at 9:54 a.m. During the walkthrough, observed multiple small flying insects in the area of the dishwashing sink. The sink area was unattended and contained standing discolored solution with food remnants clogged in the drain, which pooled into the sink. During walkthrough of the dry storage, encountered additional small flying insects in the area.
Observed on February 2, 2025 at 10:06 a.m. with the dietary aid (Staff # 89), the sink with standing fluid and food and flying insects in the area.
During observation of the lunch puree process on February 3, 2025 at approximately 11:00 a.m., observed alongside the dietary aide (Staff #89), the dietary manager (Staff #95) remove a deceased small brown insect from the wall, close to the red sanitizer solution bucket.
During medication pass, accompanied with a Licensed Practical Nurse (LPN/Staff #65), on February 3, 2025 at 12:38 p.m.; small flying insects were observed in the 600 Hall, living room area, and the Gila unit medication room.
Observed with the rehab manager (Staff #15) on February 4, 2024 at 7:55 a.m. inside the rehab services room, surveyor was able to kill a flying insect at the meeting desk.
The Safety Data Sheet was provided to the surveyor with the revision date of July 16, 2021 for the facility use of Maxforce FC Insect Control Roach Killer Bait Gel. The hazard statement includes to Keep exposed gel away from open food and food contact services.
The receipt from the workorder dated February 2, 2025 from the facility's pest control provider referenced the service was for call-out gnats.
A signed statement from the Operations Manager revealed no cleaning logs were available for the Gila medication room.
An interview regarding the cleanliness and pest present in the Gila medication room, was conducted with the housekeeping supervisor (Staff 35) revealed housekeeping is responsible for cleaning the room daily.
An interview with the Dietary Manager on February 3, 2025 at approximately 11:00 a.m. revealed the exterminator service treated the facility the day before and will return again the next day.
A joint interview, conducted with the Dietary Manager, and the Dietary Resource/Registered Dietitian (Staff #126) was conducted on February 4, 2025 at 10:08 a.m. The discussion revealed that the facility expectation to be an insect free environment was not met. The panel further explained that insects can harbor disease and they would not want any pest contaminating the food which could cause illness.
A joint interview was conducted on February 4, 2024 at 4:02 p.m. , with the Operations Manager (Staff #94) and the [NAME] President of Clinical Operations (Staff #125). It was revealed that the facility increased the number of exterminator visits from monthly to weekly back in October or November of 2024, however an official Performance Improvement Plan (PIP) was not implemented.
The facility's Infection Control Program revealed the focus of the program is to provide safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection.
The facility's Pest Control policy requires the facility to maintain an on-going pest control program to ensure that the building is kept free from insects and rodents.
Dec 2024
3 deficiencies
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
Free from Abuse/Neglect
(Tag F0600)
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 documentation and policy review, the facility failed to ensure a...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure adequate supervision was provided for two residents (#3) and (#4) to prevent further resident to resident altercations. The deficient practice could result in further incidents of inadequate resident supervision.
Findings include:
Regarding residents #1 and #2:
-Resident #1 was admitted to the facility August 27, 2024 with diagnosis including unspecified dementia, unspecified severity, with other behavioral disturbance, dementia in other diseases classified elsewhere, moderate, with agitation.
A care plan initiated in April 2023 and revised July 2023 revealed the resident had a focus for behavior problems related to resistance to care and wandering and impaired cognitive function/dementia or impaired thought processes related to short and long-term memory loss and dementia. Interventions included administer meds as ordered, intervening as necessary to protect the rights and safety of others. Approach and speak in a calm manner, divert attention, remove from situation and take to alternate location as needed.
The quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 07, indicating severe cognitive impairment. Further review of the MDS revealed no indicators for mood or behaviors.
The progress notes dated April 19, 2024 documented an incident note that revealed CNA reported that resident #1 was struck by another resident and that the patients were separated from each other. The note further states resident #1 had no marks on her and denied pain. Appropriate staff and providers notified of the incident.
The provider notes dated April 20, 2024 revealed resident #1 reported no complaints of right shoulder pain due to being punched by a resident. Per the provider note staff were to monitor pain and level of consciousness (LOC).
-Resident #2 was admitted to the facility March 14, 2016 with diagnosis including dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, major depressive disorder, recurrent, mild.
A care plan initiated in April 2024 revealed the resident had a focus for use of mood stabilizer medication (Depakote) r/t dementia with behaviors and potential to demonstrate physical behaviors hitting others r/t Anger, Dementia, Poor impulse control, physical behaviors. Interventions included to Give mood stabilizer medications ordered by physician. Monitor/document side effects and effectiveness, target symptoms/Behavior Tracking:(mood swings) and Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document.
The quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 99 indicating resident was unable to complete the interview. Further review of the MDS revealed a diagnosis for dementia with no indicators for behaviors.
The progress notes dated April 19, 2024 revealed resident #2 struck another resident after she bumped his wheelchair while ambulating and attempting to pass resident #2 who was seated in his wheelchair in the hallway. The note states that resident #2 struck the resident on her left arm and that both residents were immediately separated while resident was assessed for injuries.
A physician note dated April 20, 2024 revealed resident was seen for being aggressive. The note revealed resident did not recall his punching on one of the residents. The note further documents increasing aggressive behavior.
Review of the facility investigation with discover date of April 19, 2024 included that both resident #1 and #2 were interviewed. Per the documentation, resident #1 stated when asked how she was doing that she was a little sore. When asked what happened resident #1 stated I got bucked off a horse, but I am doing better. Resident #2 was interviewed and when asked how he was doing resident #2 stated yeah. Resident #2 was asked if he had any run-in with another resident, resident #2 laughed and stated no, no, no. Continued review of the facility investigation included that the facility identified this incident was unsubstantiated due to the fact that there was no willful intent to cause harm from either of the residents and that both residents are wandering risk, impaired thought process, and unaware of own safety needs.
An observation was conducted December 6, 2024 at 3: 26 p.m. of the behavioral unit where both residents #1 and #2 reside. Observed both resident's in the dining area with other unidentified residents unsupervised. No staff present. This surveyor continued observation of the residents. Two staff later identified as certified nursing assistant (Staff#61/CNA) and Activities Manager (Staff #10/Activities) walked by at 3:31 p. m.
An interview was conducted on December 6, 2024 at 3: 32 p.m. with Activities Manager (Staff #10/Activities) Staff #10 stated she had provided activities on the unit and had left the unit at 2:00 p. m. Staff #10 stated the residents were left in the dining room and that the staff were somewhere on the unit.
An interview was conducted on December 6, 2024 at 3:33 p.m. with (Staff#61/CNA). Staff #61 stated she had taken the CNA course at the facility and was a [NAME] for the facility prior to that. She stated the staff receive report every morning for any resident that needs an extra eye on them and to keep them close to us and to keep staff on the unit. Staff #61 stated she was unaware of any altercations with any of the residents currently in the dining area. Staff #61 stated she was unaware of the incident with resident #1 and #2 and they should not be left alone unsupervised. Staff #61 stated if there was an altercation with any of the residents she is to de-escalate the situation - remove the residents and report the incident. Staff #61 stated the residents #1 and #2 had been left alone approximately 20 minutes while she provided care for another resident that required the assist of two. Staff #61 stated residents who had a prior altercation require supervision and monitoring because they are a high risk- staff #61 further stated the risk of not supervising or monitoring those residents can be cause for recurrent incidents.
An interview was conducted on December 6, 2024 at 4:12 p.m. with (Staff#12/LPN) Staff # 12 stated he could not recall the incident but the information he documented in the progress note is correct. Staff #12 stated resident #2 has behavior issues he likes his space becomes verbally aggressive and tries to intimidate the other residents. Staff #12 stated resident #2 should not be left alone unsupervised, not monitored with other residents. Staff #12 stated there are two CNA's on the unit plus a nurse. Staff #12 stated it is difficult to monitor the residents when he is down the hallway or outside of the unit passing medications. Staff #12 stated there is not enough staff on the unit to supervise and monitor the residents, given that some of the residents require two people to provide their care. Staff #12 stated the risk of leaving residents on the unit unsupervised or monitored is they can become verbally and physically aggressive.
Regarding residents #3 and #4:
-Resident #3 was admitted to the facility September 16, 2020 with diagnosis including unspecified dementia, unspecified severity, with mood disturbance, unspecified dementia, unspecified severity, with other behavioral disturbance, major depressive disorder, recurrent, unspecified.
A care plan initiated in April 2024 had a focus for impaired cognitive function/dementia or impaired thought processes r/t short term memory loss, dementia and at risk for misappropriation, neglect, abuse, and/or exploitation related to dementia, resides in wandering unit, physical aggression received from another resident. Interventions included provide with compatible staff whenever possible, separate resident from an aggressor, administer meds as ordered.
The quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 05 indicating severe cognitive impairment with no indicators for behaviors or mood.
An alert charting note dated March 1, 2024 for change of condition summary revealed the following documentation; At approximately 1210 while passing noon medications, I heard resident #3 as she was seated to her usual dining table talking loudly, I looked over and saw resident #4 standing behind her wheelchair tugging at the handle trying to pull it backwards. resident #3 continues to state, leave me alone, stop it, don't do that. I then proceeded to walk towards the two resident's when resident #3 tells resident #4 to leave her alone, is when I witnessed him bend down, push his left forearm into her neck, and punched resident #3 twice in the right shoulder arm and proceeded to hit her in the face when I placed my hands on his chest and grabbed both arms to block his arm and held his chest to place space between resident #4 and resident #3 , resident #4 stumbled backwards, where I was able to get resident #3 away when the other CNA's in the Unit came to assist with getting resident #4 out of the dining room. Incident was reported to DON, Charge Nurse and Administrator.
Resident #3 was visibly and emotionally upset and distraught by the incident, resident #4 was removed and redirected down the hall by CNA's in the unit. Resident #3 was assessed and taken back to her room. Resident #3 was assessed, did not have any bruising noted to her right upper arm, shoulder or face. No cuts or open areas to her body. Resident #3 vital signs are stable.
Review of the physician progress note dated March 2, 2024 stated reason for visit - resident got hit by a male resident and complained of shoulder pain with a recommendation for Voltaren for symptom management.
Review of the facility investigation with discover date of March 1, 2024 included that both resident #3 and #4 were interviewed. Resident #3 reported that she was sitting in the dining room at the table and a man came to her and started tugging on her wheelchair, she stated stop, don't do that and resident #3 stated he reached down trying to mess with the brakes then she reached down with her hand to stop him and when she did he leaned into her and punched her twice in the right upper arm she stated after the incident she went straight to her room. An attempt was made to interview resident #4 but revealed resident cognitively understand and continued to wander away from the interviewers. Additional review of the facility investigation revealed a witness statement dated March 1, 2024. Witness states he observed the incident from 20-25 ft. The statement details resident #4 initially circled resident #4 and became verbally loud while standing above resident #3. The witness states resident #3 became frightened and raised her voice asking resident #4 to get away from her. Resident #4 then placed his forearm in a blocking fashion against her neck and pushed. The witness states resident #3 became extremely frightened and became louder when resident #4 proceeded to cuss and 'landed 2-3 punches about resident #3 upper body. The witness states staff separated resident # 3 by removing her from the dining room and that resident #4 remained in a defensive mode for the next 15 minutes or more.
A telephonic interview was conducted on December 6, 2024 at 1:36 p.m. with registered nurse (Staff #30/RN). Staff # 30 had provided a previous interview regarding another incident in the facility. Staff # 30 stated she could not continue with the interview as she was on vacation and her family was waiting on her, but that everything is documented in my nursing note, I saw resident #4 hit resident #3 multiple times.
An interview was conducted on December 6, 2024 at 3:33 p.m. with (Staff #61/CNA). Staff #61 stated she had taken the CNA course at the facility and was a [NAME] for the facility prior to that. She stated the staff receive report every morning for any resident that needs an extra eye on them and to keep them close to us and to keep staff on the unit. Staff #61 stated she was unaware of any altercations with any of the residents currently in the dining area. Staff #61 stated she was unaware of the incident with resident #1 and #2 and they should not be left alone unsupervised. Staff #61 stated if there was an altercation with any of the residents she is to de-escalate the situation - remove the residents and report the incident. Staff #61 stated the residents #1 and #2 had been left alone approximately 20 minutes while she provided care for another resident that required the assist of two. Staff #61 stated residents who had a prior altercation require supervision and monitoring because they are a high risk- staff #61 further stated the risk of not supervising or monitoring those residents can be cause for recurrent incidents.
An interview was conducted on December 6, 2024 at 3:58 p.m. with Director of Nursing (DON/staff #43) stated staff are informed during report about resident incidents and any supervision or monitoring needed. Residents should be observed for escalation of any behaviors and remove from the situation. The DON stated the risks associated with not providing supervision is verbal or physical aggression and feel there is sufficient staff to provide these preventative measures.
Review of the facility policy titled Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program states Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.
The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives:
1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to:
b. other residents
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
Accident Prevention
(Tag F0689)
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 documentation and policy review, the facility failed to ensure a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure adequate supervision was provided for two residents (#3) and (#4) to prevent further resident to resident altercations. The deficient practice could result in further incidents of inadequate resident supervision.
Findings include:
Regarding residents #1 and #2:
-Resident #1 was admitted to the facility August 27, 2024 with diagnosis including unspecified dementia, unspecified severity, with other behavioral disturbance, dementia in other diseases classified elsewhere, moderate, with agitation.
A care plan initiated in April 2023 and revised July 2023 revealed the resident had a focus for behavior problems related to resistance to care and wandering and impaired cognitive function/dementia or impaired thought processes related to short and long-term memory loss and dementia. Interventions included administer meds as ordered, intervening as necessary to protect the rights and safety of others. Approach and speak in a calm manner, divert attention, remove from situation and take to alternate location as needed.
The quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 07, indicating severe cognitive impairment. Further review of the MDS revealed no indicators for mood or behaviors.
The progress notes dated April 19, 2024 documented an incident note that revealed CNA reported that resident #1 was struck by another resident and that the patients were separated from each other. The note further states resident #1 had no marks on her and denied pain. Appropriate staff and providers notified of the incident.
The provider notes dated April 20, 2024 revealed resident #1 reported no complaints of right shoulder pain due to being punched by a resident. Per the provider note staff were to monitor pain and level of consciousness (LOC).
-Resident #2 was admitted to the facility March 14, 2016 with diagnosis including dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, major depressive disorder, recurrent, mild.
A care plan initiated in April 2024 revealed the resident had a focus for use of mood stabilizer medication (Depakote) r/t dementia with behaviors and potential to demonstrate physical behaviors hitting others r/t Anger, Dementia, Poor impulse control, physical behaviors. Interventions included to Give mood stabilizer medications ordered by physician. Monitor/document side effects and effectiveness, target symptoms/Behavior Tracking:(mood swings) and Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document.
The quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 99 indicating resident was unable to complete the interview. Further review of the MDS revealed a diagnosis for dementia with no indicators for behaviors.
The progress notes dated April 19, 2024 revealed resident #2 struck another resident after she bumped his wheelchair while ambulating and attempting to pass resident #2 who was seated in his wheelchair in the hallway. The note states that resident #2 struck the resident on her left arm and that both residents were immediately separated while resident was assessed for injuries.
A physician note dated April 20, 2024 revealed resident was seen for being aggressive. The note revealed resident did not recall his punching on one of the residents. The note further documents increasing aggressive behavior.
Review of the facility investigation with discover date of April 19, 2024 included that both resident #1 and #2 were interviewed. Per the documentation, resident #1 stated when asked how she was doing that she was a little sore. When asked what happened resident #1 stated I got bucked off a horse, but I am doing better. Resident #2 was interviewed and when asked how he was doing resident #2 stated yeah. Resident #2 was asked if he had any run-in with another resident, resident #2 laughed and stated no, no, no. Continued review of the facility investigation included that the facility identified this incident was unsubstantiated due to the fact that there was no willful intent to cause harm from either of the residents and that both residents are wandering risk, impaired thought process, and unaware of own safety needs.
An observation was conducted December 6, 2024 at 3: 26 p.m. of the behavioral unit where both residents #1 and #2 reside. Observed both resident's in the dining area with other unidentified residents unsupervised. No staff present. This surveyor continued observation of the residents. Two staff later identified as certified nursing assistant (Staff#61/CNA) and Activities Manager (Staff #10/Activities) walked by at 3:31 p. m.
An interview was conducted on December 6, 2024 at 3: 32 p.m. with Activities Manager (Staff #10/Activities) Staff #10 stated she had provided activities on the unit and had left the unit at 2:00 p. m. Staff #10 stated the residents were left in the dining room and that the staff were somewhere on the unit.
An interview was conducted on December 6, 2024 at 3:33 p.m. with (Staff#61/CNA). Staff #61 stated she had taken the CNA course at the facility and was a [NAME] for the facility prior to that. She stated the staff receive report every morning for any resident that needs an extra eye on them and to keep them close to us and to keep staff on the unit. Staff #61 stated she was unaware of any altercations with any of the residents currently in the dining area. Staff #61 stated she was unaware of the incident with resident #1 and #2 and they should not be left alone unsupervised. Staff #61 stated if there was an altercation with any of the residents she is to de-escalate the situation - remove the residents and report the incident. Staff #61 stated the residents #1 and #2 had been left alone approximately 20 minutes while she provided care for another resident that required the assist of two. Staff #61 stated residents who had a prior altercation require supervision and monitoring because they are a high risk- staff #61 further stated the risk of not supervising or monitoring those residents can be cause for recurrent incidents.
An interview was conducted on December 6, 2024 at 4:12 p.m. with (Staff#12/LPN) Staff # 12 stated he could not recall the incident but the information he documented in the progress note is correct. Staff #12 stated resident #2 has behavior issues he likes his space becomes verbally aggressive and tries to intimidate the other residents. Staff #12 stated resident #2 should not be left alone unsupervised, not monitored with other residents. Staff #12 stated there are two CNA's on the unit plus a nurse. Staff #12 stated it is difficult to monitor the residents when he is down the hallway or outside of the unit passing medications. Staff #12 stated there is not enough staff on the unit to supervise and monitor the residents, given that some of the residents require two people to provide their care. Staff #12 stated the risk of leaving residents on the unit unsupervised or monitored is they can become verbally and physically aggressive.
Regarding residents #3 and #4:
-Resident #3 was admitted to the facility September 16, 2020 with diagnosis including unspecified dementia, unspecified severity, with mood disturbance, unspecified dementia, unspecified severity, with other behavioral disturbance, major depressive disorder, recurrent, unspecified.
A care plan initiated in April 2024 had a focus for impaired cognitive function/dementia or impaired thought processes r/t short term memory loss, dementia and at risk for misappropriation, neglect, abuse, and/or exploitation related to dementia, resides in wandering unit, physical aggression received from another resident. Interventions included provide with compatible staff whenever possible, separate resident from an aggressor, administer meds as ordered.
The quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 05 indicating severe cognitive impairment with no indicators for behaviors or mood.
An alert charting note dated March 1, 2024 for change of condition summary revealed the following documentation; At approximately 1210 while passing noon medications, I heard resident #3 as she was seated to her usual dining table talking loudly, I looked over and saw resident #4 standing behind her wheelchair tugging at the handle trying to pull it backwards. resident #3 continues to state, leave me alone, stop it, don't do that. I then proceeded to walk towards the two resident's when resident #3 tells resident #4 to leave her alone, is when I witnessed him bend down, push his left forearm into her neck, and punched resident #3 twice in the right shoulder arm and proceeded to hit her in the face when I placed my hands on his chest and grabbed both arms to block his arm and held his chest to place space between resident #4 and resident #3 , resident #4 stumbled backwards, where I was able to get resident #3 away when the other CNA's in the Unit came to assist with getting resident #4 out of the dining room. Incident was reported to DON, Charge Nurse and Administrator.
Resident #3 was visibly and emotionally upset and distraught by the incident, resident #4 was removed and redirected down the hall by CNA's in the unit. Resident #3 was assessed and taken back to her room. Resident #3 was assessed, did not have any bruising noted to her right upper arm, shoulder or face. No cuts or open areas to her body. Resident #3 vital signs are stable.
Review of the physician progress note dated March 2, 2024 stated reason for visit - resident got hit by a male resident and complained of shoulder pain with a recommendation for Voltaren for symptom management.
Review of the facility investigation with discover date of March 1, 2024 included that both resident #3 and #4 were interviewed. Resident #3 reported that she was sitting in the dining room at the table and a man came to her and started tugging on her wheelchair, she stated stop, don't do that and resident #3 stated he reached down trying to mess with the brakes then she reached down with her hand to stop him and when she did he leaned into her and punched her twice in the right upper arm she stated after the incident she went straight to her room. An attempt was made to interview resident #4 but revealed resident cognitively understand and continued to wander away from the interviewers. Additional review of the facility investigation revealed a witness statement dated March 1, 2024. Witness states he observed the incident from 20-25 ft. The statement details resident #4 initially circled resident #4 and became verbally loud while standing above resident #3. The witness states resident #3 became frightened and raised her voice asking resident #4 to get away from her. Resident #4 then placed his forearm in a blocking fashion against her neck and pushed. The witness states resident #3 became extremely frightened and became louder when resident #4 proceeded to cuss and 'landed 2-3 punches about resident #3 upper body. The witness states staff separated resident # 3 by removing her from the dining room and that resident #4 remained in a defensive mode for the next 15 minutes or more.
A telephonic interview was conducted on December 6, 2024 at 1:36 p.m. with registered nurse (Staff #30/RN). Staff # 30 had provided a previous interview regarding another incident in the facility. Staff # 30 stated she could not continue with the interview as she was on vacation and her family was waiting on her, but that everything is documented in my nursing note, I saw resident #4 hit resident #3 multiple times.
An interview was conducted on December 6, 2024 at 3:33 p.m. with (Staff #61/CNA). Staff #61 stated she had taken the CNA course at the facility and was a [NAME] for the facility prior to that. She stated the staff receive report every morning for any resident that needs an extra eye on them and to keep them close to us and to keep staff on the unit. Staff #61 stated she was unaware of any altercations with any of the residents currently in the dining area. Staff #61 stated she was unaware of the incident with resident #1 and #2 and they should not be left alone unsupervised. Staff #61 stated if there was an altercation with any of the residents she is to de-escalate the situation - remove the residents and report the incident. Staff #61 stated the residents #1 and #2 had been left alone approximately 20 minutes while she provided care for another resident that required the assist of two. Staff #61 stated residents who had a prior altercation require supervision and monitoring because they are a high risk- staff #61 further stated the risk of not supervising or monitoring those residents can be cause for recurrent incidents.
An interview was conducted on December 6, 2024 at 3:58 p.m. with Director of Nursing (DON/staff #43) stated staff are informed during report about resident incidents and any supervision or monitoring needed. Residents should be observed for escalation of any behaviors and remove from the situation. The DON stated the risks associated with not providing supervision is verbal or physical aggression and feel there is sufficient staff to provide these preventative measures.
Review of the facility policy titled Resident Safety: Safety and Supervision of Residents states Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.
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
Respiratory Care
(Tag F0695)
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 facility policies, the facility failed to ensure oxygen was adm...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of facility policies, the facility failed to ensure oxygen was administered as ordered by the physician for one of 3 sampled residents (#21). The deficient practice could result in residents not receiving adequate oxygen to prevent hypoxia.
Findings include:
Resident #21 was admitted on [DATE] and discharged [DATE] with diagnoses chronic obstructive pulmonary disease, unspecified, unspecified asthma, uncomplicated, dependence on supplemental oxygen, chronic respiratory failure with hypoxia, unspecified symptoms and signs involving cognitive functions and awareness, legal blindness, as defined in USA).
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating resident's cognitive status moderately impaired. Further review of the MDS revealed resident receiving oxygen therapy.
Review of the Care Plan date-initiated March 3, 2023 revealed resident receiving oxygen therapy related to Chronic Obstructive Pulmonary Disease (COPD). Interventions included when eating, oxygen must still be given to the resident but in a different manner (e.g., changing from mask to nasal cannula). Return resident to usual oxygen delivery method after the meal and monitor for signs and symptoms of respiratory distress.
A physician's order dated March 8, 2023 included an order for oxygen at 3 liters per minute as needed to keep saturation level
above 90%. every shift for Oxygen Therapy
A physician's order dated September 20, 2023 included an order for oxygen at 3 liters per minute via NC. May titrate as
needed to keep saturation lever greater than 90%. every shift for oxygen therapy.
A physician's order dated November 20, 2023 included an order for oxygen at 1-5 liters per minute as needed to keep
saturation level above 90%. every shift for oxygen therapy related to chronic obstructive pulmonary disease, unspecified (j44.9)
This order was transcribed onto the MAR (medication administration record) for November 2024 and revealed that the resident had O2 sat levels of greater than 90% at 2 liters per minute.
The nursing progress note dated November 23, 2024 revealed that CNA (Certified Nursing Assistant) was being taking resident #21 to breakfast, when stopped by another CNA due to resident being slumped over in her wheelchair and leaning to the left side. This nurse was called to the 500 hallway by CNA who informed resident did not have her oxygen on, breathing was labored and uneven. VS (vital stats) were taken, Resident #21 VS: 172/74, P-122, R-22, T-98.9, oxygen was at 57% RA. Resident's eyes were glassy and watery, resident's breathing was labored, oxygen VI simple mask was placed on resident with oxygen turned on to 10 L. Resident was noncoherent, speech was garbled and breathing continues to be labored, resident was taken to her room, assisted by two CNA's into bed, oxygen turned on and VS continued to monitor, called 911 for transport to hospital. Further review of the progress notes revealed an entry dated 11/21/2024 by the provider. The note states resident #21 was seen due to shortness of breath with exertion during therapy oxygen in use and noting last labs were done in June with noted hyponatremia, and elevated A1C- rechecking bmp.
The hospital history and physical note for visit date of November 23, 2024 included that the resident respiratory exam findings- no respiratory distress, unremarkable stable chest x-ray, Hyponatremia (chronic), hyperkalemia diagnosis, likely UTI- at baseline 2 L O2- Pt required 4 L and BiPAP-repeat chest x-ray showed pulmonary edema bilaterally. 11/24/24- Pt transferred by air to Banner Glendale.
A telephonic interview was conducted on December 6, 2024 at 1:28 p.m. with the registered nurse (RN/staff #30) who stated the certified nursing assistant (CNA) was bringing the resident out of the room approximately 20 ft from her room when she had noticed the resident was leaning and told the CNA to make sure resident has O2. Staff #30 stated the resident did not have the nasal cannula or oxygen on her, the CNA had the cannula it in her hand. Staff #30 stated she informed the CNA that the resident needed the oxygen hooked up to her now, on three liters. Staff #30 stated the resident was leaning to her left side when the CNA proceeded to take the resident to the dining room. Staff #30 state she did not see the residents face nor did she assess the resident. Staff #30 stated the resident was up at 4:45 a.m. and when she started her shift the resident was in her wheelchair, but was unsure if the resident had her oxygen on or when they got the resident up. Staff #30 stated when she asked the CNA to administer the resident oxygen that the resident's cannula was in her nose but was unhooked from the E tank with the tubing in the NA's hand. Staff #30 stated the CNA is responsible for changing out the tanks the NA was not certified at the time and was working with a CNA that was training her. Staff #30 stated the NA and resident #21 did not make it to the dining room and was observed by another nurse who asked if staff #30 had looked at the resident. Staff #30 stated when she observe the resident the resident was leaning, lethargic and mumbling when her head fell forward. Staff #30 stated she took resident #21 vital signs revealing a high blood pressure and saturation levels at 57. Resident #21 was taken back to her room and administer 5 liters of oxygen elevated head, O2 went up to 92% and called emergency services.
An interview was conducted on December 6, 2024 at 3:10 p.m. with Licensed Practical Nurse (Staff #15/LPN) who stated the signs of symptoms of hypoxia are shortness of breath, confusion, cyanotic lips and fingertips. Staff #15 stated CNA's can place the resident oxygen and tubing, but it is the responsibility of the nurse in ensuring the residents oxygen is on at the right liters per minute (LPN). Staff #15 stated CNA's are to ask the nurse what the orders are for the resident's oxygen levels. Staff #15 stated the nurse is responsible to make sure the right mask or cannula are used and that CNA's do not have the qualifications to place oxygen on a resident and would need to test for it.
An interview was conducted with Certified nursing assistant (Staff #61/CNA) on December 6, 2024 at 3:33 p.m. Staff #61 stated the responsibilities as a CNA for residents with oxygen, is to make sure tank is full, that the resident is plugged in on their concentrator, always check their vitals, switch from concentrator to the tank, check with the nurse to adjust the oxygen level and that a CNA is not allowed to change or administer oxygen to residents.
An interview was conducted with the Director of Nursing (Staff #43/DON) on December 6, 2024 at 3:58 p.m. Staff #43 stated both RN's and LPN's are responsible for administering and ensuring the correct LPN's are being administered and that the nurse should be present and assessing the resident. Staff #43 stated it is her expectation that the nurse call for services, transfer for appropriate services and that the nurse should have stopped the NA and assessed the resident and sent back to their room instead of proceeding to the dining room. The DON further stated it was inexcusable for the nurse to state that she did not see the residents face. The DON stated NA's are not allowed to administer oxygen and the risks of not administering oxygen as ordered could lead to patient decline or death.
A review of the facility's policy's titled Respiratory/Pulmonary Conditions: Oxygen Administration state;
1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.
7. Check the tubing connected to the oxygen cylinder to assure that it is free of kinks.
8. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute.
9. Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal
catheter).
10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.
11. Securely anchor the tubing so that it does not rub or irritate the resident's nose, behind the
A review of the facility's policy's titled - Medications: Administering Medications Policy Statement Medications are administered in a safe and timely manner, and as prescribed.
1. Only persons licensed or permitted by this state to prepare, administer and document the
administration of medications may do so.
Medications are administered in a safe and timely manner, and as prescribed.
Aug 2023
2 deficiencies
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
Free from Abuse/Neglect
(Tag F0600)
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 one resident (#7) was free from abuse involving resident (#33).
Findings include:
Resident #7 was admitted to the facility on [DATE] with diagnoses which included: Major Depressive disorder, recurrent; Schizophrenia and Unspecified Dementia.
The Quarterly assessment dated [DATE] revealed that the resident is severely cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 99.
An Incident note dated August 14, 2023 at 6:40 PM indicated that the nurse was notified by a Certified Nursing Assistant the the resident (#7) was on the floor in another residents room (#33). When entering the room resident #7 was lying face down on the floor with visible blood pooling under her face. Upon assessing the resident she had a gash on the bridge of her nose and a wound on the left side of her head.
A physician progress note dated August 15, 2023 at 2:03 PM noted that the resident was sent to the hospital for treatment and had suffered a nasal laceration and a broken nose.
Resident #7 was care planned for wandering behaviors.
Resident #33 was admitted to the facility on [DATE] with diagnoses which included: Major Depressive Disorder; Hallucinations; Anxiety Disorder and Unspecified Dementia with other behavioral disturbance.
The Quarterly assessment dated [DATE] revealed that the resident was cognitively intact with a BIMS (Brief Interview for Mental Status) score of 13. She also exhibited behaviors such as hitting, scratching self, pacing as well as wandering behaviors.
The resident is cared planned for behavior problems related to physical and verbal aggression towards other residents. Resident is not to be within arm's reach of other residents at anytime, initiated on April 1, 2023.
An incident progress note dated Augurs 14, 2023 at 6:40 PM documented that a resident (#7) was found on the floor in her room. The Certified Nursing Assistant who remained in the room to clean up the blood on the floor reported that resident #33 stated that she had hit the other resident in the head and tried to push her out of the room when the other resident (#7) fell out of her chair. The resident then used her call light to call for help.
The facility moved the resident (#33) to a room change on another unit to separate the resident to provide safety.
During an interview conducted on August 16, 2023 at 2:13 PM with a Licensed Practical Nurse (staff #41) he stated that the incident occurred during shift change when a Certified Nursing Assistant came to him and told him that resident #7 was on the floor of resident #33 room. He further stated that they had not had any previous episodes of aggression with resident #33 but that she was very territorial about her room. He further stated that the incident was unwitnessed as both residents were in a room.
During an interview conducted on August 16, 2023 at 2:27 PM with a Certified Nursing Assistant (staff #56), he stated that he did not witness the incident but was called to the room by the nurse to help getting resident #7 off the floor. He stated that after resident #7 was removed from the room, he remained in the room which was when resident #33 told him that resident #7 had entered her room and they began to argue and that she struck resident #7 on the side of her head and then tried to push resident #7 out of her room when she fell out of her chair.
During an interview conducted on August 16, 2023 at 3:50 PM with resident #7, she was unable to state what had happened. Her comments were just that her nose itched.
During an interview conducted on August 16, 2023 at 4:15 PM with resident #33, she was lying in her bed, but would not answer any questions.
Review of the facility's Abuse Policy revealed that Haven Health facilities strive to prevent the abuse of all their residents. Our objective is to provide a safe haven for our residents through preventative measures that protect every resident's right to freedom from abuse.
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
Accident Prevention
(Tag F0689)
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...
Read full inspector narrative →
**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 that two residents (#7 and #33) were provided adequate supervision to prevent wandering behaviors leading to abuse.
Findings include:
Resident #7 was admitted to the facility on [DATE] with diagnoses which included: Major Depressive disorder, recurrent; Schizophrenia and Unspecified Dementia.
The Quarterly assessment dated [DATE] revealed that the resident is severely cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 99.
Resident #7 was care planned for wandering behaviors and was known to wander into other resident's rooms.
An Incident note dated August 14, 2023 at 6:40 PM indicated that the nurse was notified by a Certified Nursing Assistant the the resident (#7) was on the floor in another residents room (#33). When entering the room resident #7 was lying face down on the floor with visible blood pooling under her face. Upon assessing the resident she had a gash on the bridge of her nose and a wound on the left side of her head.
Resident #33 was admitted to the facility on [DATE] with diagnoses which included: Major Depressive Disorder; Hallucinations; Anxiety Disorder and Unspecified Dementia with other behavioral disturbance.
The Quarterly assessment dated [DATE] revealed that the resident was cognitively intact with a BIMS (Brief Interview for Mental Status) score of 13. She also exhibited behaviors such as hitting, scratching self, pacing as well as wandering behaviors.
An incident progress note dated Augurs 14, 2023 at 6:40 PM documented that a resident (#7) was found on the floor in her room. The Certified Nursing Assistant who remained in the room to clean up the blood on the floor reported that resident #33 stated that she had hit the other resident in the head and tried to push her out of the room when the other resident (#7) fell out of her chair. The resident then used her call light to call for help.
During an interview conducted on August 16, 2023 at 2:13 PM with a Licensed Practical Nurse (staff #41) he stated that the incident occurred during shift change when a Certified Nursing Assistant came to him and told him that resident #7 was on the floor of resident #33 room. He further stated that they had not had any previous episodes of aggression with resident #33 but that she was very territorial about her room. He further stated that the incident was unwitnessed as both residents were in a room.
During an interview conducted on August 16, 2023 at 2:27 PM with a Certified Nursing Assistant (staff #56), he stated that he did not witness the incident but was called to the room by the nurse to help getting resident #7 off the floor. He stated that after resident #7 was removed from the room, he remained in the room which was when resident #33 told him that resident #7 had entered her room and they began to argue and that she struck resident #7 on the side of her head and then tried to push resident #7 out of her room when she fell out of her chair.
During an interview conducted on August 16, 2023 at 3:50 PM with resident #7, she was unable to state what had happened. Her comments were just that her nose itched.
During an interview conducted on August 16, 2023 at 4:15 PM with resident #33, she was lying in her bed, but would not answer any questions.
Review of the facility's Abuse Policy revealed that Haven Health facilities strive to prevent the abuse of all their residents. Our objective is to provide a safe haven for our residents through preventative measures that protect every resident's right to freedom from abuse.
May 2023
1 deficiency
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and review of policy, the facility failed to ensure a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and review of policy, the facility failed to ensure a physician order for an X-ray was carried out timely for one resident (#46) and failed to ensure physician was notified regarding a change in condition for one resident (#76). The sample size was 18. The deficient practice may increase the risk for residents to sustain complications including hospitalization and/or death.
Findings include:
-Resident #46 admitted on [DATE] with diagnoses of primary hypertension, unspecified osteoarthritis and chronic pain.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating severe cognitive impairment. The MDS also included that the resident required extensive one-person physical assistance for most activities of daily living, had no falls since admission and/or the prior assessment and had displayed rejection of care on 1-3 days out of the 7-day look-back period.
A Fall Risk Evaluation dated February 22, 2023 revealed the resident sustained 1-2 falls within the prior 6 months and was assessed to be at high risk for further falls.
An Interdisciplinary Team (IDT) Fall Review dated March 3, 2023 at 6:16 p.m. included the resident had sustained a fall with no injury at 6:06 p.m.; and that, the resident was found sitting upright on the floor. Per the documentation, there were no clutter or spills noted in the area; and that, the resident attempted a self-transfer without success. New intervention included the resident's bed was placed next to the wall. According to the investigation, no abuse or neglect was suspected; and that, the resident was placed on alert charting, fall risk assessment was completed and the care plan was updated. Further, the documentation included that the Medical Doctor (MD)/Practitioner, responsible party, and case manager were notified.
An Alert Charting Change of Condition Summary dated March 3, 2023 revealed that the resident's neurological checks remained within baseline with no decline in status. The note indicated that the resident had complaints of pain in her right knee; however, there were no swelling, redness, abrasion or bruising was noted. Per the documentation, the nurse practitioner (NP) was notified and an order for a right knee x-ray (2 views) was received. Further, the noted included that the administrator on call and transportation were also notified.
An electronic MAR (eMAR) note dated March 4, 2023 revealed that a call to transportation was made to see when they were going to take the resident to the hospital for x-rays of the right knee. According to the documentation, the transportation driver (staff #71) stated that if the order was not STAT, that they would not see the resident. Further, the documentation included that the resident was checked and there was no redness or swelling, and scrapes to the left or right knee.
An Alert Charting Change of Condition Summary dated March 4, 2023 included the resident was status post fall with no visible signs or symptoms of injury. The documentation included the resident had complaints of pain and had refused pain medication.
Despite the resident's complain of pain to the right knee and staff knowledge that transportation would not pick up the resident for X-ray unless the order was a STAT order, the clinical record revealed no evidence that the provider was informed or asked to modify the order to address the resident's issue.
A health status note dated March 5, 2023 revealed nurse received a report from night shift that the resident had sustained a fall on March 3, 2023 and had right knee pain with an x-ray pending. According to the documentation, the resident had complained of pain with any movement of the right lower extremity; and, had severe pain when the right hip was palpated, with no internal or external rotation or shortening identified. The note included that the NP was notified and an order for a STAT right hip and right knee X-ray was received.
A health status note dated March 5, 2023 included that X-ray report showed displaced right hip fracture and an order to send the resident to the emergency room for evaluation and treatment was received.
A Discharge summary dated [DATE] revealed the resident was transferred to the hospital via ambulance. Per the documentation, the resident had a fall and had increased pain.
A fall care plan initiated on March 5, 2023 revealed the resident had a right hip fracture related to fall. Interventions included to follow physician orders for weight bearing status.
A hospital History and Physical dated March 5, 2023 included that the resident was sent to the hospital in order to get an imaging study done and was noted to have a hip fracture. According to the documentation, the resident was incredibly reactive and agitated at times with her history of dementia and that she was refusing a physical exam.
An admission evaluation noted dated March 7, 2023 revealed the resident was readmitted to the facility.
An interview was conducted on May 18, 2023 at 11:58 a.m. with a Licensed Practical Nurse (LPN/staff #118). She stated that if a resident had an unwitnessed fall she would complete a head to toe assessment, including whether or not the resident had an altered mental status, broken bones, skin tears, pain with range of motion or any injury. She stated that a resident with a broken hip would wince, scream, holler in pain or give non-verbal signs of pain. The LPN said that if the resident complained of pain, she would have therapy look at them; and that, if there is actual or suspicion of injury, she would call the doctor and ask for a STAT order. She stated that when a resident fall, it will be documented in the progress notes. Regarding resident #46, the LPN stated she would have called the provider, called 911 and send the resident sent out in the morning the resident complained of pain. She stated that she thinks the care that resident #46 received the day and after the fall would not have met her expectations. She stated that after an order for an x-ray had been received they should have done it immediately. Further, the LPN stated that resident #46 had to deal with the pain for a couple of days with the risk of throwing a blood clot before the resident was sent out to the hospital.
An interview was conducted on 05/18/23 at 2:01 p.m. with the Director of Nursing (DON/staff #25) who stated that they try to have continuity of care on the dementia unit so that the nurses could recognize when a resident has a change in status. She stated that after a fall, she expected the staff to follow the fall protocol which included a head to toe assessment, notify all the appropriate parties and to start neuro checks. She stated she would anticipate the resident to be on 72-hour alert charting, which includes assessing the resident every shift. The DON stated that residents with dementia express pain with facial grimacing, abnormal movements, redness, swelling, and pain during repositioning. Regarding resident #46, the DON stated that when the resident's pain was noted, nursing staff called the NP and obtained an order for x-ray. However, she stated that the x-ray had not been completed by 5:00 p.m. the following day which did not meet her expectation. The DON stated that the x-ray should have only taken a couple of hours to complete. She stated that it did not meet her expectation that resident #46 waited so long to go to the hospital for and x-ray and treatment. She stated that after the incident with resident #46, a new process began that include that if a resident fall and an x-ray was ordered, the resident will be to send to the hospital through 911.
-Resident #76 admitted on [DATE] with diagnoses of unspecified kidney failure, acute cystitis with hematuria and type 2 diabetes mellitus without complications.
A care plan initiated on December 2, 2022 included the resident had hypertension related to lifestyle. The goal was that the resident will remain free of complications related to hypertension. Interventions included to give antihypertensive medications as ordered and to monitor for side effects such as orthostatic hypertension, increased heart rate and effectiveness.
A physician history and physical note dated December 5, 2022 included an assessment of hypertension. Plan was to continue amlodipine (antihypertensive), carvedilol (antihypertensive), Lasix (furosemide/diuretic) and potassium (supplement). Further, the plan included to monitor vitals and notify of abnormal trends.
The admission MDS (minimum data set) assessment dated [DATE] revealed a BIMS score of 12 indicating resident had moderately impaired cognition. The assessment also included resident required extensive one to two-person physical assistance for most activities of daily living.
A physician order dated December 13, 2022 revealed the following orders:
-Amlodipine besylate 10 milligrams (mg) one time a day for hypertension;
-Lisinopril 40 mg one time a day for hypertension; and,
-Furosemide 40 mg one time a day for edema related to hypertension.
A physician order dated December 14, 2022 included an order for Carvedilol 25 mg, 1 tablet two times a day for hypertension and to give it with meals.
These orders were transcribed onto the MAR (medication administration record) for December 2022, January and February 2023. Per the documentation in the MAR, these medications were administered as ordered.
Review of the blood pressure (BP) summary for January and February 2023 revealed there were multiple dates that the systolic blood pressure (SBP) was recorded to be less than 110.
The NP note dated February 26, 2023 included the resident had increased back pain, required 1:1 assistance with feeding, no longer wished for interventional treatment, was electing for palliative care and refused to allow blood draws or invasive procedures.
Further review of the BP summary for February 2023 revealed that the following information:
-February 27 at 6:43 a.m., the SBP was recorded as 91/54 millimeters of mercury (mmHg); and,
-February 28, at 7:10 a.m., the SBP was recorded as 85/47.
Review of the MAR for February 2023 included that carvedilol, amlodipine and furosemide were administered as ordered. In the space provided for nursing documentation related to the 8:00 a.m. administration of lisinopril, a code 9 was documented - indicating Other/See Nurse Note; and that, the medication was held.
Despite documentation of low BP readings, the clinical record revealed no evidence the provider was notified.
The health status note dated February 28, 2023 at 9:34 a.m. revealed that the resident's oxygen (O2) saturation levels was 89%; and that, oxygen was applied at 2 liters via nasal cannula and the O2 saturation increased to 94%. Per the documentation, the resident had increased wheezing, weakness and confusion; and that, hospice was contacted and will be admitting the resident to their services for diagnosis of protein calorie malnutrition.
The health status note dated February 28, 2023 at 6:16 p.m. revealed the resident had absent of vital signs which was verified by two nurses.
The late entry Discharge summary dated [DATE] included that the resident had an expected decline with natural death that occurred on February 28, 2023 at 6:16 p.m.
An interview was conducted on May 18, 2023 at 8:22 a.m. with an LPN (staff #3) who stated that if a resident's blood pressure was extremely low or high, he would notify the physician. He stated that if the resident's blood pressure was in the 90's (systolic) over 50's (diastolic) he would hold the antihypertensives and call the doctor. He stated that it was part of his assessment as a nurse to see if the medication was safe to give. The LPN also said that giving antihypertensive medications to residents with low blood pressure would not be appropriate and might increase the risk that the resident might die.
In an interview with another LPN (staff #129) conducted on May 18, 2023 at 8:30 a.m. the LPN stated that residents' blood pressures are checked/reviewed before giving their antihypertensive medications. She stated that if a medication does not have a parameter, she would still check the blood pressure and pulse; and that, if the systolic blood pressure were less than 100 and/or the pulse was less than 60, she would check with the physician before giving the medications. She stated that if the resident's blood pressure was frequently 110 or less, she would check with the doctor to see if they wanted to adjust the medication; and, would definitely contact the physician.
During an interview conducted with the DON (staff #25) on May 18, 2023 at 8:44 a.m., the DON stated that when physician orders do not have parameters on them, she would not expect the nurse to assess the blood pressure. The DON said she would expect the nurse to ask the resident questions such as whether or not they were dizzy or lethargic, and just to talk to the resident. She stated that if the medication did not have parameters, it would be at the nurses' discretion whether or not to give the medication. She stated that they do not always take the resident's blood pressure; and, if nothing triggered they would not know if a change of condition had happened. She stated that if the resident's blood pressures were 91/54 or 85/47 mmHg she hopes that the nurse would hold the medication, call the provider and follow orders. However, the DON said that if the nurse did not take the blood pressure she would not know to hold the med. She stated that when nurses consult with the provider, it was her expectation that the nurse would document the conversation/notification. She stated that risks associated with administering antihypertensive medications to a resident with low blood pressure readings would include an altered level of consciousness, lethargy and potentially death.
The facility's policy on Conformity with Laws and Professional Standards policy, revised April 2007, included that the facility operates and provides services in compliance with current federal, state and local laws, regulations, codes and professional standards of practice that apply to the facility and types of services provided. The facility's policies, procedures and operational practices are developed and maintained in accordance with current accepted professional standards and principles as well as current commonly accepted health standards established by national organizations, boards and councils.
The facility policy on Change in Resident's Condition or Status included that regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments.
The Nurse Management of Change of Condition policy/procedure, dated 2018, included that residents in our facilities depend on us to provide quality care and to ensure their safety. This includes monitoring residents for change of conditions (COC). According to the American Medical Directors Association (AMDA) (2005 p. 22) the definition for an acute change of condition is a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral or functional domains . that without intervention, may result in complications or death. According to the policy, what constituted a COC included a fall with or without injury, increased or unrelieved pain and blood pressure out of normal range. Per the policy anything out of the normal limits and baseline for the resident constituted COC. They can be related to an acute condition or chronic condition that is getting worse such as changes in vital signs i.e., blood pressure out of normal range. It also included that when COC is identified, the information regarding the COC and any orders received must be communicated to other members of the health care team; and that, notifications need to be documented in the resident's chart.
May 2022
13 deficiencies
2 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #40 was admitted to the facility on [DATE] with diagnoses of paraplegia, cystitis, and neuromuscular dysfunction of th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #40 was admitted to the facility on [DATE] with diagnoses of paraplegia, cystitis, and neuromuscular dysfunction of the bladder.
A Health Status Note dated April 5, 2022 included Multiple limb contractures noted, which have obvious effects on gross & fine motor function.
A Weekly Skin Check dated April 5, 2022 included a left-hand middle digit wound that measured 1 cm x 1.5 cm x .5 cm.
A Physician's Order dated April 5, 2022 included left hand- middle finger- cleanse with wound cleanser and apply Band-Aid every day shift for the open wound.
Review of the TAR for April 2022 revealed the treatment was provided as ordered.
A Care Plan initiated on April 5, 2022 and revised on May 5, 2022 revealed the resident had a potential impairment to skin integrity related to paraplegia, decreased mobility and had an actual impairment to skin integrity related to the right heel deep tissue injury and ring finger and middle finger pressure ulcer. Interventions stated to monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to the physician and follow facility protocols for treatment of injury.
A Physician History and Physical Note dated April 7, 2022 included Early contractures of legs, and severe Left arm, Ltd movement of R arm.
An admission MDS assessment dated [DATE] revealed the resident had a BIMS score of 8 which indicated moderate cognitive impairment. This assessment also included the resident had one unstageable pressure injury that was present on admission.
A Pressure Ulcer Documentation and assessment dated [DATE] included a left-hand middle digit stage 2 pressure wound that measured 1 cm x 1.5 cm x 0.5 cm. This document stated On initial exam I believed that the patients wound on her finger was an injury sustained by force prior to admission but after further assessment of patients lack of mobility and natural laying position I believe it is a pressure injury from the position her hand lays in. This PU was present upon admission. Order placed to tx and float when in bed.
However, a review of the clinical record revealed no order for floating the resident's hand or that the physician was informed that the wound was determined to be a pressure ulcer until May 7, 2022.
A Pressure Ulcer Documentation and assessment dated [DATE] revealed this resident had a left-hand middle finger stage 2 pressure wound that measured 1.5 cm x 2 cm x 0.2 cm with 100% red/open/granulation and a left-hand ring finger stage 2 pressure wound that measured 1 cm x 1.2 cm x 0.2 cm with 100% red/open/granulation.
A review of the clinical record revealed no evidence that the physician was informed of this new pressure ulcer on the left-hand ring finger until May 7, 2022.
A physician's order dated May 7, 2022 included left hand middle and ring finger - cleanse with wound cleanser and pat dry. Weave xeroform between fingers and pad so that the fingers are separated. Wrap with kerlix between fingers and around hand followed by an ace wrap to keep in place every day shift for the open wound.
A Weekly Skin Check and Wound assessment dated [DATE] included that this resident had a left-hand middle finger wound that measured 1 cm x 1.4 cm x UTD (unable to determine) and a left-hand ring finger wound that measured 1.1 cm x 1.2 cm x UTD.
A wound observation was conducted on May 12, 2022 at 12:52 PM with the Wound RN (staff #79). The RN sanitized her hands, put on gloves and spoke with the resident about the procedure. She then removed the wrap from the resident's hand and disposed of it. The RN then cut the kerlix off of the resident's hand with scissors and asked the resident to tell her if it hurt. This RN said that the way the resident's hand is curled up, they have an order to float the hand when possible. She said that the wound is full thickness and that last week she could see the wound bed. She said that the wounds have no odor. She measured the ring finger wound to be 1 cm x 1 cm and stated that she was unable to determine the depth due to eschar. She measured the middle finger wound to be 1.2 cm x 1.2 cm and stated that she was unable to determine the depth, and said that the wound was improving because before it had a foul odor and that she feels the xeroform has caused it to have gotten much better. The RN said that she does a weekly wound report to track whether a wound is declining or improving and that she tracks the significant wounds. She also stated that she has been the wound nurse at this facility since mid-March.
During an interview conducted on March 13, 2022 at 9:49 AM with the Wound RN (staff #79), she said that heel protectors and frequent positioning were some of the interventions required for a pressure ulcer. She said that she was not sure of the facility protocols for a pressure wound. She reviewed this resident electronic record and said that the order to float the resident's hands should be in there, but that she did not see it. Staff #79 stated the physician should be informed right away of new wounds and worsening wounds. She said that she had been informing the DON right away about the wounds and that she believed that the DON had spoken to a provider about the wounds. The RN said that improvement and decline are components of the wound report that goes out weekly and that the nutritionist is on the list to receive the report but that she did not see that the physician was on the list. She said that since she had performed the wound care on May 12, she had spoken to a provider about the resident's heel but she had not spoken to the provider about the resident's finger pressure wounds. This staff said that eschar is a downgrade from granulation.
An interview was conducted on March 13, 2022 at 10:26 AM with the DON (staff #127), who said that any staff can notify the physician and that the Wound Nurse should be working closely with the physician. She said that the Wound Nurse should be notifying the physician about downgrades in wounds. She said that she did not notify the physician on May 3 or 4 about the new pressure wound on this resident's finger but that she believed the Wound Nurse had notified him. The DON said the Wound Nurse should be talking to the physician about all wounds.
A facility policy titled Wound Management program revealed that it is the goal of the facility that all residents with wounds receive treatment and services consistent with the resident's goals of treatment. The Wound Management Program is structured and implemented using processes founded on accepted standards of practice, research driven clinical guidelines and interdisciplinary involvement.
A facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol revealed the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). The physician will help identify factors contributing or predisposing residents to skin breakdown; for example, medical comorbidities such as diabetes or congestive heart failure, overall medical instability, cancer or sepsis causing a catabolic state, and macerated or friable skin. This document included that the physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents.
A facility policy titled Change in a Resident's Condition or Status revealed that this facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. This policy included the nurse will notify the resident's Attending Physician or physician on call when there has been a need to alter the resident's medical treatment significantly or specific instruction to notify the physician of changes in the resident's condition.
Based on clinical record reviews, observations, staff interviews, facility documentation, and policy and procedures, the facility failed to ensure that 2 out of 3 sampled residents (#57 and #40) received care and services, consistent with professional standards of practice, to prevent, treat, and/or heal pressure ulcers. The deficient practice could result in residents developing pressure ulcers or worsening of pressure ulcers.
Findings include:
-Resident #57 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, other intervertebral disc degeneration, lumbar region, and unilateral primary osteoarthritis, unspecified hip.
A risk for pressure ulcer development care plan dated 03/25/15 related to multiple sclerosis, incontinence and immobility had a goal for intact skin, free of redness and discoloration. Interventions included following the facility policies/protocols for the prevention/treatment of skin breakdown.
Physician's orders included elevating the resident's legs off the bed as tolerated dated 09/05/21, and frequent repositioning every 2 hours during the day at a minimum, and an alternating low air-loss mattress dated 12/11/21.
Review of the Pressure Ulcer Documentation and assessment dated [DATE] revealed a facility acquired unstageable pressure ulcer to the left ischium measuring 3.5 centimeters (cm) x 4.0 cm. The progress note stated that the wound was found on 12/23/21 during a brief change. According to the documentation, the etiology of the wound was likely poor positioning of the resident and the wheelchair cushion in the resident's chair.
Review of the clinical record revealed thorough pressure ulcer assessments were completed on 01/08/22 and 01/15/22.
Review of the Treatment Administration Record (TAR) dated January 2022 revealed treatments and repositioning were provided daily as ordered, with the exception of 01/17, when there was no documentation to indicate whether or not the resident received treatment on that date.
Review of the Pressure Ulcer Documentation and assessment dated [DATE] included clarification that the left ischial pressure ulcer was to the sacrum.
A Pressure Ulcer Documentation and Assessment was completed on 02/04/22.
The Pressure Ulcer Documentation and assessment dated [DATE] revealed the sacral wound was a stage 4 pressure ulcer which measured 12.0 cm x 10.0 cm x 9.0 cm, with a large amount of drainage (no description), no odor, and a wound base of 30% yellow slough, 70% red. The treatment included Dakin's (dilute sodium hypochlorite) solution.
Review of the clinical record included Pressure Ulcer Documentation and Assessment on 02/18/22 and 02/25/22.
A physician order dated 02/26/22 stated to cleanse the sacral pressure ulcer with wound cleanser, apply skin prep to the peri wound, window pane with opsite (antibacterial/absorbent), apply wound vac foam into the base of the wound and secure with opsite, attach a wound vac and place it on continuous suction at 125 millimeters of mercury (mmHg) continuously every day shift on Monday, Wednesday, and Friday.
Per the February 2022 TAR treatments to the sacrum were provided in accordance with the physician orders.
Review of the clinical record revealed Pressure Ulcer Documentation and Assessments for 03/05/22, 03/11/22 and 03/17/22.
A physician order dated 03/21/22 included cleansing the sacral wound with wound cleanser and application of skin prep to the peri wound; window pane with opsite (antibacterial/absorbent), apply wound vac foam into base of wound and secure with opsite, attach a wound vac and place on continuous suction at 125 millimeters of mercury (mmHg) continuous every day shift every other day.
The Pressure Ulcer Documentation and assessment dated [DATE] revealed for a stage 4 sacral pressure ulcer which measured 12.0 x 10.0 x 8.7 cm, with no tunneling. A large amount of brown/green drainage was noted in the wound vac, with no odor identified. The wound bed was described as 100% red/pink.
Review of the March 2022 TAR revealed that sacral treatments were provided as ordered, with the exception of 03/16, 03/21, and 03/23.
Review of the clinical record did not reveal evidence to indicate whether or not the resident received treatment on those dates, and/or the rationale for why the treatments were not provided.
Pressure Ulcer Documentation and Assessment was completed on 04/01 and 04/05.
A Wound Clinic progress note dated 04/06/22 included the wound appeared better than at the last visit and that the resident was to continue wound vac therapy.
A physician order dated 04/13/22 instructed that when the wound vac was unavailable, to cleanse the wound with wound cleanser and apply wet-to-dry dressing every day shift.
The Pressure Ulcer Documentation and assessment dated [DATE] revealed that wet-to-dry dressings to the sacral wound would be implemented temporarily while the wound vac was being shipped.
An additional Pressure Ulcer Documentation and Assessment was completed on 04/19.
Review of the April 2022 TAR revealed that wound treatments to the sacrum were not provided on 04/12, 04/14, 04/15, 04/16, 04/17, 04/18, 04/19, 04/21, and 04/25.
Review of the clinical record revealed no evidence to provide a rationale for why the resident did not receive wound care.
The quarterly Minimum Data Set Assessment (MDS) assessment dated [DATE] revealed the resident scored 14 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. The resident exhibited no behaviors, including rejection of care and required extensive 2-person physical assistance for most activities of daily living. Per the assessment, the resident had one stage 3 pressure ulcer, one stage 4 pressure ulcer, and 8 unstageable pressure ulcers.
A change of condition summary dated 04/27/22 at 7:55 p.m. revealed the resident was sent to the emergency room for a high temperature. The resident returned on 04/29/22.
Review of a nurse practitioner progress note dated 05/01/22 revealed the resident had a stage 4 decubitus ulcer and a large plantar ulcer at the posterior calcaneus that were suspicious for osteomyelitis. The resident returned to the facility with sepsis due to stage 4 decubitus ulcers and that the resident had refused therapy at the medical center.
A Pressure Ulcer Documentation and Assessment was done on 05/02/22. Per the documentation, no signs or symptoms of infection were noted.
Review of the physician's orders dated 05/02/22 included ciprofloxacin HCl (antibiotic) 500 milligrams (mg) twice daily for wound infection, and clindamycin HCl (antibiotic) 300 mg 2 capsules two times a day for wound infection.
The Wound Clinic progress note dated 05/04/22 revealed that a sharp debridement of the sacrum, dressings, and education had been provided that day. The Director of Nursing (DON/staff #127) had initialed the document and written Noted next to her initials. The note also included the wound vac was changed out and should be changed every other day or 3 times a week.
Review of the May 2022 TAR revealed that pressure ulcer care and treatment with the wound vac had not been provided on 05/06. The documentation included 9 which meant other/see nurse notes.
Review of the nurse notes did not reveal an entry for 05/06/22.
A nurse practitioner (NP) progress note dated 05/08/22 at 9:21 p.m. indicated that the reason for the visit was related to no wound vac canister. The note included that the resident reported that the wound vac canister was full with drainage, but there was no canister in the facility to change. The note revealed that the NP discussed this with a Registered Nurse (RN/staff #67). The note stated that dressings were to be changed daily and as needed due to full drainage in the canister of the vac to reduce potential of infection.
Review of the TAR for May 2022 revealed the treatment was provided to the sacrum on 05/09/22.
On 05/10/22 at 2:49 p.m., the resident was observed lying in the bed. A wound vac, with a canister that appeared to be almost completely filled with drainage, was observed on the bed beside the resident.
A wound care observation was conducted on 05/11/22 at 9:00 a.m. with the wound Registered Nurse (RN/staff #79) who was assisted by a RN (staff #67). The wound nurse removed the old dressing and described the wound as a full-thickness stage 4 pressure ulcer. She stated that the wound had moderate serosanguinous drainage with foul odor. She said the wound bed was 40% necrotic/black tissue and 60% red, with wound borders denuded, and moisture-associated skin damage to the perimeter. After cleansing the wound with normal saline, she stated that the wound measured 10.0 cm x 11.0 cm x 3.5 cm with tunneling at 2 o'clock which measured 4.5 cm.
On 05/11/22 at 9:34 a.m., the wound vac was observed laying on a chair at the foot of the resident's bed. Rotted, clotted-looking debris was noted in the canister. The resident stated that he did not know how often the canister was changed.
An interview was conducted on 05/11/22 at 9:51 a.m. with the wound RN (staff #79). She stated that if the resident had agreed to have the wound vac on that she would use the one that was sitting on the resident's chair. She stated the resident would get a new canister whenever the one on the wound vac got filled up. She stated that she did not think that there was a record of when the canister was replaced. The RN stated that she had never read up on it, but she thought that placing a wound vac onto a wound with a canister that was filled with debris might pose a risk for infection to the resident.
On 05/12/22 at 11:13 a.m., an interview was conducted with an RN (staff #67). She stated that the resident's dressings are changed twice per day and that the wound vac is changed on the night shift. She stated that the resident absolutely wears the wound vac every day on the day shift. She stated that the wound vac is supposed to be on every day. She stated that the canister is changed every 24 hours, whenever it is needed, or when it is full. The RN stated that she thought that the resident's sacrum had been infected since March. She stated that placing a wound vac over necrotic tissue was acceptable because the wound nurse does it. She stated that she would assume that someone would tell her if it was not appropriate. She said the resident's sacral wound was debrided on 05/04/22 and that the sacrum was not necrotic until towards the end of that week. She stated that when the resident's sacral wound became necrotic she did not notify the physician. The RN stated that she would not necessarily have noticed when the wound became necrotic because the wound vac was on. She stated that the change in wound status would be considered a change of condition. She stated that she was not sure when the provider was notified. She stated that the resident does not refuse wound care from her. The RN said that dressing changes should be provided daily or it should be documented that the resident refused. She stated that she had not really heard anything about the resident refusing.
An interview was conducted on 05/12/22 at 1:06 p.m. with the Director of Nursing (DON/staff #127). She stated that it would not meet her expectation for a full canister to be utilized on the resident's wound. She stated that if the resident had gone to the wound clinic to have the wound debrided on 05/04/22 she would question the wound nurse's definition of necrosis. She stated that the wound nurse is an RN and that she is qualified to assess wounds. But, she stated, she was not sure that the wound nurse had received sufficient training to be able to identify necrotic tissue. She stated that she could not say whether or not the wound nurse was qualified to assess wounds. The DON reviewed the resident's clinical record and stated that she could not identify when the resident's sacral wound became necrotic. She stated that she did not see a progress note indicating that the wound had a change in status or that the provider had been notified. She stated that this did not meet her expectations. The DON stated that she understood that it did not meet professional standards to place a wound vac on a necrotic wound, that the policy stated such, and that the manufacturer's instructions said the same thing. She reviewed the resident's record and indicated that incomplete documentation in the TAR, not completing dressing changes as ordered, and/or not documenting when the resident refused treatment did not meet her expectations.
On 05/13/22 at 9:28 a.m., an interview was conducted with the wound nurse (staff #79). She stated that wound assessments are required to be completed weekly. She stated that she documents the assessments on the Pressure Ulcer Documentation and Assessment. She stated that pressure ulcer assessments include wound measurements, description of the wound bed and perimeter of the wound, signs and symptoms of infection, type and amount of drainage, and whether or not there is odor. She stated that when she identifies symptoms of infection she will speak to the provider about it in person. She stated that she will note symptoms of infection on the weekly wound report and pressure ulcer documentation. Staff #79 stated that she was not sure that she had documented the conversations in the clinical record, but if there was a change in the wound she would note that. She stated that the necrosis on the sacral wound was a new change that occurred between 05/05 and 05/11. She stated that she spoke with the physician regarding the changes to the wound. She stated that she did not document the conversation. The RN stated that she put the wound vac on hold on 05/12/22 with the authorization of the physician. She stated that she completes wound assessments and dressing changes for the resident on Mondays. She said that on Monday, 05/09/22, she did note that the wound had become necrotic but did not include that in her documentation. She stated that she had not notified the provider until yesterday. The wound nurse stated that she would consider it to be a change of condition/status of the wound. She stated that she did not feel like it was an immediate danger because she had placed a wet-to-dry dressing on the sacral wound. She said she thought she had placed a hold on the wound vac then (05/09), but she had not. The RN stated that it did not meet the standard of professional practice to place a wound vac on a necrotic wound and that she thought the risks might include sepsis.
The facility policy titled Negative Pressure Wound Therapy included that the purpose of the procedure was to provide guidelines for establishing and maintaining negative pressure wound therapy (NPWT). The general guidelines included that NPWT was contraindicated in residents who have wounds with necrotic tissue with eschar, untreated osteomyelitis, non-enteric fistula or malignancy in the wound. Reporting included marked changes in the wound from baseline or previous dressing change.
The V.A.C. Therapy System Safety Information included that V.A.C. therapy is contraindicated for wounds that included untreated osteomyelitis and necrotic tissue with eschar present.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Incontinence Care
(Tag F0690)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and policy reviews, the facility failed to ensure one sampled r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and policy reviews, the facility failed to ensure one sampled resident (#40) with an indwelling urinary catheter was provided care and services to prevent skin impairment. The deficient practice could result in residents with indwelling urinary catheters having skin breakdown issues.
Findings include:
Resident #40 was admitted to the facility on [DATE] with diagnoses of paraplegia, cystitis, and neuromuscular dysfunction of the bladder.
A physician's order dated April 5, 2022 included a Foley catheter size 16 French with a 10 cc (cubic centimeter) balloon, a different size may be inserted if the size ordered cannot be reinserted.
Review of a care plan initiated on April 5, 2022 revealed the resident had an indwelling suprapubic catheter. The goal was that the resident would be/remain free from catheter-related trauma. Interventions stated to change the catheter every 4 weeks and to monitor/document for pain/discomfort due to the catheter.
Review of another care plan initiated on April 5, 2022 revealed the resident had potential for impairment to skin integrity related to paraplegia, decreased mobility. The goal was that the resident would have no complications related to skin injury. Interventions stated to keep body parts from excessive moisture, educate resident/family/caregivers of causative factors and measures to prevent skin injury, keep skin clean and dry, report abnormalities, maceration etc. to the physician, and turn and reposition the resident frequently while sitting in a chair or lying in bed.
An admission Minimum Data Set (MDS) assessment dated [DATE] included that this resident had a Brief Interview for Mental Status (BIMS) score of 8 which indicated moderate cognitive impairment. This assessment also included this resident had an indwelling catheter and required total dependence with 2+ person physical assistance for toilet use.
A physician's order dated April 12, 2022 revealed for catheter care with soap and water or wipes every shift for catheter care. The order did not include applying a split gauze.
The suprapubic catheter care plan was revised on April 13, 2022 and included positioning the catheter bag and tubing below the level of the bladder and away from the entrance door.
Review of the Treatment Administration Record (TAR) dated April 2022 revealed catheter care was performed as ordered.
Review of the TAR for May 2022 revealed catheter care was provided as ordered. The TAR included the suprapubic drainage bag was changed on May 4 and the suprapubic catheter was changed May 6.
Review of the clinical record revealed Weekly Skin Check and Wound Assessments were completed from April 5, 2022 through May 10, 2022.
The Skin Observation Tasks dated May 8, 9, and 10, 2022 indicated this resident had a skin issue of an open area that was not on the arms, leg, back, buttocks, heels.
An observation was conducted on May 12, 2022 at 9:17 AM with a Certified Nursing Assistant (CNA/staff #112) who spoke with the resident, then raised the bed. This staff removed the resident's brief, and wiped around the urinary catheter which was surrounded by a sanguineous exudate. A Unit Manager who was assisting stated that the resident had some irritation and that she would have the wound nurse assess the resident. The CNA left the room and spoke with the Licensed Practical Nurse (LPN/Staff #45) at the desk who said that the resident has had bloody drainage for a while, it was normal. Observations revealed no method of securing this catheter and no gauze or other dressing was observed around the catheter site. The CNA returned to the room and continued to perform the catheter care, measured the output, cleaned the area and repositioned the resident.
However, review of the clinical record revealed no evidence regarding this skin issue or that the skin issued had been assessed.
An observation was conducted on May 12, 2022 at 12:52 with the Wound Registered Nurse (RN/staff #79) who sanitized her hands, changed her gloves, and then used gauze with wound cleanser to clean the sanguineous drainage from around the catheter and folds. The RN said that she saw some skin breakdown and bright red bloody discharge. She said that she had not been informed of the wound prior to being asked to measure it by the surveyor. The RN measured the area and said that it was 0.5 centimeters (cm) x 1.5 cm with a bright red wound bed. This nurse would not state the depth. She said that the area was possibly shearing. She told the resident that she would speak with the physician. The RN stated the red area was towards 9 o'clock where the urinary catheter tube was laying. The wound was observed to be full thickness with a beefy red wound bed and had moderate sanguineous exudate. The wound was observed in the groove where the catheter had been left on the skin approximately 2 cm from the catheter insertion site.
An interview was conducted on May 13, 2022 with a [NAME] (staff #93) who said she did not think that it was bloody yesterday but that she was moved around the facility a lot. She said that she was surprised that the resident did not have a split gauze around the catheter site and that she would let the nurse know so he could place one.
An interview was conducted on May 13, 2022 at 8:33 AM with an LPN (staff #45), who said that this resident has had a bloody discharge and that he noticed it last week on Friday. He said that he had put a split gauze around the catheter on that Friday. He said that he was having trouble getting the split gauze because the facility is having such issues with their supply because the person who does central supply also does transportation. He said that the facility has leg bands to secure catheters and that they were talking about getting clamps because the leg bands tend to migrate down. When asked when he had informed the physician, he looked nervous and said that he told the doctor. He reviewed the progress notes and the orders and then retracted and said that the bloody discharge was discovered yesterday during the catheter care performed by staff #112.
An interview was conducted on May 13, 2022 at 9:49 AM with the Wound RN (staff #79) who said that this wound was irritation from the catheter rubbing there, not sitting there. She said that she does not know if there should be a drainage sponge or gauze cover around the catheter or if the catheter should be secured because the nursing staff cares for that. She said that she put in a treatment after speaking with the physician. She said that she could see that having a cover around the catheter could help. She said that the physician should be informed of new wounds right away.
An interview was conducted on May 13, 2022 at 10:26 AM with the Director of Nursing (DON/staff #127), who said that her expectation for suprapubic catheters is to follow the physician's orders. She said that orders are built into the system and that she was not sure what standards were used to produce them. She said that if the catheter was not a new placement then there may not be an order for them. She said that catheters were protected by having briefs or clothing over them. She said that they need to be better with securing them.
A facility policy titled Suprapubic Catheter Care included that the purpose of this procedure is to prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract. This policy included that staff should notify their supervisor immediately in the event of hemorrhage and to include a drainage sponge if ordered by a physician.
A policy titled Urinary Catheter Care revealed that the staff should ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, clinical record review, and policy review, the facility failed to ensure t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, clinical record review, and policy review, the facility failed to ensure that dignity was maintained for one sampled resident (#27). The deficient practice could result in residents not being treated in a dignified manner.
Findings include:
Resident #27 was admitted to the facility on [DATE] with diagnoses that included displaced fracture of base of neck of right femur, subsequent encounter for closed fracture with routine healing, and unspecified muscle weakness.
Review of a care plan dated March 12, 2022 stated the resident had ADLs (Activity of Daily Living) self-performance deficit related to limited mobility related to hip fracture status post THA (total hip arthroplasty), and weakness. The interventions revealed the resident required one staff participation with personal hygiene and dressing.
Further care plan review revealed no refusal related to wearing street clothes.
Review of admission MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 12, which indicated the resident had moderate impaired cognition. The assessment also revealed the resident needed extensive assistance with bed mobility, transfer, locomotion on/off unit, dressing, and toilet use.
Review of the progress notes revealed no documentation of refusal to wear street clothes.
An observation was made on May 9, 2022 at 12:25 p.m. in the main dining room. Resident #27 was eating lunch at the restorative dining table with other residents. All residents in the dining room, including those who were not sitting at the restorative dining table, were wearing street clothes except resident #27. Resident #27 was wearing a green/blue printed hospital gown partially fastened, and a pair of yellow non-skid socks, and no shoes.
Another observation was conducted on May 11, 2022 at 11:32 a.m. The resident was observed being transferred by a CNA (certified nursing assistant) from the bed into a wheelchair. The resident was wearing a green gown with blue printed leaves, and a pair of yellow non-skid socks, and no shoes. Resident #27 stated she was getting ready to go to the dining room.
On May 11, 2022 at 11:35 a.m., resident #27 entered the dining room wearing only a green gown with blue printed leaves, and a pair of yellow non-skid socks, and no shoes. Resident #27 was seated at the restorative dining table with other residents who were wearing street clothes. It was also observed that all the other residents who attended dining that was not a part of restorative dining, were all wearing street clothes.
Immediately following this observation, an interview was conducted with resident #27, who stated she wears a hospital gown when she goes to bed, but would like to wear regular clothes daily. Resident #27 stated the staff were all so nice but they were so busy and always left her wearing a hospital gown. Resident #27 stated the staff today did not offer different types of clothes.
Another observation was conducted on May 12, 2022 at 9:55 a.m. of the resident. Resident #27 was observed sitting in the wheelchair wearing a green hospital gown with blue leaves, a red/black [NAME]/[NAME] mouse printed pajama bottom, and a pair of yellow non-skid socks.
Following the observation, an interview was conducted with resident #27, who stated she would wear regular clothes. The resident stated a family member had brought her clothes and they are in the second drawer. The resident stated she would wear them because she was always so cold when wearing the hospital gown, but the staff does not offer those clothes. Resident #27 stated the staff was so busy in the morning, they always put a hospital gown on her. She said she felt like she was homeless. She said she told staff that she wants to wear regular clothes but they keep her in a gown because she lays back down in bed after meals due to a bad back. The resident also stated she has a pair of shoes in the duffle bag.
An observation of the blue duffle bag revealed a brand-new pair of navy-blue house slippers. The second drawer of the chest had 3 pairs of jogging pants in different colors and 3 long sleeve shirts, and a couple short sleeve blouses in various colors.
An interview was conducted on May 12, 2022 at 10:30 a.m. with a resident relation manager (staff #49). Staff #49 stated she saw the resident yesterday, and that the resident was smoking outside wearing only a hospital gown. Staff #49 stated she offered street clothes to the resident, but the resident refused.
An interview was conducted on May 13, 2022 at 9:05 a.m. with an LPN (licensed practical nurse/staff #103) unit manager. Staff #103 stated she was very familiar with resident #27, and that the resident is very outgoing, alert and oriented X 4 (alert to name, time, place, and situation). Staff #103 stated that resident #27 has not refused any ADLs. She stated that she had observed the resident in the dining room one time wearing a hospital gown, and she told a CNA to offer clothes to the resident, and that the resident agreed to be changed. Staff #103 stated if a resident is not dressed, the resident would feel bad about themselves because their dignity is affected.
An interview was conducted on May 13, 2022 at 9:42 a.m. with a CNA (certified nursing assistant/staff #99). Staff #99 stated she has worked in the facility for 3 years as a float CNA and that she is very familiar with resident #27. Staff #99 stated resident #27 needs limited assistance with dressing and that the resident likes to wear street clothes. She also stated the resident has personal clothing in the drawer. Staff #99 stated she always offered street clothing to the residents because when a resident wears street clothing it boost the resident's morale, [NAME], and makes them feel better. Staff #99 stated there has not been a time when resident #27 refused ADLs or street clothing, and that the resident is always pleasant and cooperative with the staff.
An interview was conducted on May 13, 2022 at 10:08 a.m. with the DON (director of nurses/staff #127). The DON stated her expectation for dignity included providing privacy, respect, kindness to residents and following resident rights. The DON stated dignity included appearance, washing the resident's face, comb hair, and making sure the resident is wearing their street clothes when they are out of the room unless they choose to wear a gown. The DON stated her expectation is that the resident should at least be covered in the dining room.
A facility policy titled, Resident Rights, stated the facility promotes and protects the rights of residents. The policy stated the right to a dignified life included a homelike environment, and the use of personal belongings when possible.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
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 facility policy, the facility failed to ensure the representati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of facility policy, the facility failed to ensure the representative of one of five sampled residents (#52) was informed in advance of the risks and benefits of proposed treatment with psychotropic medications. The deficient practice could result in residents or their representative not being informed prior to receiving treatment with high risk medications without education, their knowledge, or consent.
Findings include:
Resident #52 was readmitted to the facility on [DATE] with diagnoses that included urinary tract infection, Dementia in other diseases classified elsewhere with behavioral disturbance, and altered mental status.
A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a score of 3 on the Brief Interview for Mental Status which indicated the resident had severe cognitive impairment.
A physician order dated March 8, 2022 stated Risperidone (antipsychotic) 1 milligram tablet by mouth at bedtime for Dementia with aggressive behavior related to Dementia in other diseases classified elsewhere with Behavioral Disturbance.
Review of the informed consent for Risperdal revealed the statement resident unable to sign but agreeable to treatment on the signature line for resident #52 and the date March 8, 2022. Below the line was the signature of two nurses.
Continued review of the clinical record revealed no evidence that the nurses reached out to the resident's family/representative or the physician regarding the administration of this medication for resident #52 who had cognitive deficits.
Review of the physician order dated March 10, 2022 revealed the resident needed a Power of Attorney (POA).
A review of the Medication Administration Record (MAR) dated March 2022 revealed Risperdal was administered as ordered.
Review of the quarterly MDS assessment dated [DATE] revealed the resident had moderate impaired cognitive skills for daily decision making. The assessment also revealed the resident received antipsychotic medications 7 days of the 7-day lookback period.
Review of the care plan dated April 22, 2022 revealed the resident was receiving the antipsychotic medication, Risperidone related to dementia with behaviors and to treat the behaviors of hallucinations. The goal was to remain free of drug related complications. Interventions included administering medications as ordered.
The MAR for April 2022 and May 2022 revealed Risperdal was administered as ordered.
An interview was conducted on May 13, 2022 at 9:05 AM with a Licensed Practical Nurse (LPN/staff #45). The LPN stated prior to administering an antipsychotic drug, the nurses should review the targeted behavior and the order. Further, the nurse stated prior to administering the medication the nurse should ensure that an informed consent was obtained and if it was not, obtain a consent. The LPN stated that to obtain an informed consent the nurse should meet with the resident or their representative and explain the risks, side effects, and benefits of the medication and then have them sign for consent to the treatment. Additionally, the nurse explained that if the resident had a cognitive deficit with a BIMS score of 3 that would indicate the resident should not sign an informed consent. The LPN stated that no resident with a cognitive deficit should sign informed consent because they do not understand what they are signing and they could not properly be being informed. Staff #45 stated that in that case, the process is to reach out to a POA or a family representative. Further, the LPN stated that if he could not reach them then the medication should be held until the proper consent could be obtained. Additionally, the LPN stated that anytime you attempt to reach out to a representative that would be documented in the resident's record. Further, the nurse explained that the medical provider should be notified of the situation.
An interview was conducted on May 13, 2022 at 9:34 AM with the Director of Nursing (DON/staff #127). The DON stated that prior to administering any psychotropic medication nurses should talk to the resident and the family and educate them and get their consent for the medication. Further, she explained that the consent is an informed consent notifying the resident or their representative that a physician has prescribed a psychotropic medication and there are risks related to side effects and benefits to treat targeted behaviors. The DON stated that with any order for psychotropic medication staff should also implement behavior monitoring, side effect monitoring, and a care plan. She further stated that the nurses, Assistant Director of Nursing (ADON), and herself are responsible for obtaining informed consent for psychotropic medications. The DON also stated that if the resident has a cognitive deficit, then the family should be notified so they can act as representative for the choices of the resident. She explained, if staff cannot get a hold of family and family is listed, then they should wait to give the medication. She stated all attempts to reach out to the family should be documented in the progress notes in the resident's record. The DON stated that she is familiar with resident #52 and sometimes the resident can respond meaningfully and sometimes the resident is in Viet Nam. She stated this resident should not be administered this medication without notifying the resident's family and educating them properly, and obtaining informed consent.
The facility policy titled Psychotropic Medication Use revised November 16, 2016 stated the facility should involve the resident or the resident's representative(s) in the discussion of potential non-drug and medication interventions to address the management of behaviors and the involvement should be documented in the resident's medical record. Facility staff should inform the resident and/or the resident representative of the initiation, reason for use, and the risks associated with the use of psychotropic medications, per facility policy or applicable state regulations.
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 resident and staff interviews, clinical record review, facility documentation, and policy and procedure, the facility f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, clinical record review, facility documentation, and policy and procedure, the facility failed to ensure that one sampled resident's (#17) representative was notified after the resident had a significant change in condition. The deficient practice may result in resident representatives not being notified when residents experience a change in condition.
Findings include:
Resident #17 admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease of native coronary artery without angina pectoris, type 2 diabetes mellitus without complication, and primary hypertension.
A physician progress note dated 02/24/22 at 5:22 p.m. included that the resident's medications had been reviewed and that the resident was alert and oriented x 3 (person, place, and time), with no deficits noted.
Review of the hospital History and Physical dated 02/24/22, with no time specified, revealed that the resident had presented to the emergency department due to acute onset seizure. The documentation included that the seizure was witnessed by staff at the skilled nursing facility and the duration was approximately 4 minutes before resolving.
However, review of the clinical record did not include a recorded summary of seizure activity, including where or when the incident occurred, whether or not the physician had been notified, a physician's order for transfer, or the time when the resident had been transported to the hospital for emergency services. In addition, there was no evidence to indicate that the resident's representative had been notified of the transfer.
A Change of Condition Summary note dated 02/25/22 at 4:29 p.m. indicated that the resident returned from the ER (emergency room) visit related to seizure-type of activity, and that the resident had returned with a diagnosis of atrial fibrillation. The note included that the physician and the nurse practitioner were notified of the resident's return and a new medication order. However, the note did not state that the resident's representative had been notified of the resident's change in status.
The quarterly Minimum Data Set assessment dated [DATE] revealed the resident scored 15 on the Brief Interview for Mental Status which indicated intact cognition, required supervision for most activities of daily living, and that the resident had a seizure disorder/epilepsy.
A seizure disorder care plan was not initiated until 03/07/22 and had a goal the resident would remain free from injury related to seizure activity. Interventions included giving medications as ordered and monitoring/documentation for effectiveness and side effects.
During an interview conducted with the resident on 05/09/22 at 1:53 p.m., the resident stated that he had a grand mal seizure a couple of months ago and that the facility did not call his family to notify them. The resident stated that they had no idea that he had been hospitalized . The resident stated that this was very upsetting to him.
At 3:24 p.m. on 05/12/22, an interview was conducted with the Resident Relations Manager (staff #49). She stated that nursing will typically report to the resident's family when the resident is sent to the ER, not social services. She identified other documented instances when the resident's representative/family had been notified of other incidents, but stated that she did not identify an entry on 02/24/22.
An interview was conducted on 05/13/22 at 8:19 a.m. with a Licensed Practical Nurse (LPN/staff #45). He stated that the nurse is supposed to notify the resident's family/representative when the resident is sent to the emergency room. He stated that the purpose is just to let the family know that the resident has had a change of condition. The LPN stated that it would not be acceptable for the resident's family not to have been notified of the resident's hospitalization.
On 05/13/22 at 8:30 a.m., an interview was conducted with the Director of Nursing (DON/staff #127). She stated that her expectation is to follow the resident's wishes when the resident is sent out to the ER. She stated that if the resident was alert and oriented, and was their own responsible party, the facility may not notify the family if something happened because the family would be aware of the resident's history and what was going on with the resident. The DON stated that should the dynamic change, she would expect nursing to notify the contact person. The DON stated that she thought that nursing had just missed the call to the resident's family.
The facility policy titled Change in a Resident's Condition or Status revealed the facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) The nurse will notify the resident's attending physician or the physician on call for instances which include when there has been a significant change in the resident's physical/emotional/mental condition and when there is a need to transfer the resident to the hospital/treatment center. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.
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** Based on clinical record review, staff interview, and review of policies and procedures, the facility failed to ensure the compr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and review of policies and procedures, the facility failed to ensure the comprehensive care plan was revised to include changes in wound status for one resident (#57). The sample size was 21. The deficient practice could result in inaccurate/incomplete plans of care for residents.
Findings include:
Resident #57 admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, other intervertebral disc degeneration, lumbar region, and unilateral primary osteoarthritis, unspecified hip.
A risk for pressure ulcer development care plan dated 03/25/15 related to multiple sclerosis, incontinence and immobility had a goal for intact skin, free of redness and discoloration. Interventions included following facility policies/protocols for the prevention/treatment of skin breakdown.
A physician order dated 09/05/21 revealed to elevate the resident's legs off the bed as tolerated.
Other physician's orders dated 12/11/21 included frequent repositioning every 2 hours during the day at a minimum and an alternating low air-loss mattress.
Review of the Pressure Ulcer Documentation and assessment dated [DATE] revealed a facility acquired unstageable pressure ulcer to the left ischium measuring 3.5 centimeters (cm) x 4.0 cm. The progress note stated that the wound was found on 12/23/21 during a brief change. According to the documentation, the etiology of the wound was likely poor positioning of the resident and wheelchair cushion in the resident's chair. Interventions included a wheelchair cushion, low air-loss mattress, and nutritional interventions. The document indicated that the resident's care plan had been reviewed and updated.
However, review of the physician's orders did not reveal a wheelchair cushion or nutritional interventions. In addition, review of the resident's care plan did not include updates or revisions to care.
The Pressure Ulcer Documentation and assessment dated [DATE] included for the stage 2 left ischial pressure ulcer, which measured 3.5 cm x 5.0 cm x 0.2 cm and an additional blister to the resident's right heel that measured 5.5 cm x 5.0 cm. The progress note included that the wounds continued to improve and that the care plan had not been reviewed or updated.
The Pressure Ulcer Documentation and assessment dated [DATE] revealed wound assessments for two facility acquired pressure ulcers. The documentation stated that the care plan had not been reviewed or updated.
Review of the Pressure Ulcer Documentation and assessment dated [DATE] revealed clarification that the left ischial pressure ulcer was sacral. In addition to the unstageable pressure ulcer to the sacrum and right heel, new unstageable pressure ulcers were listed to the resident's right lateral foot and right lateral ankle. The documentation indicated that the care plan had been reviewed and updated.
However, review of the resident's care plan did not include an update or revision to the care plan.
An intervention to obtain and monitor lab/diagnostic work as ordered, report results to the medical provider, and to follow up as indicated was added to the resident plan of care on 02/01/22.
Per the Pressure Ulcer Documentation and assessment dated [DATE], the sacral pressure ulcer was unstageable measuring 12.0 cm x 10.0 cm x unable to determine (UTD) depth, and the wound bed was noted with 50% yellow slough, 50% red. The documentation also included assessments to the pressure ulcer of the right heel, right lateral foot, and right lateral ankle. The documentation indicated that the resident's care plan had been reviewed and updated.
However, review of the resident's care plan did not include an update or revision to include for the change in wound status.
Review of the clinical record included for Pressure Ulcer Documentation and Assessments on 02/11/22 and 02/18/22.
The Pressure Ulcer Documentation and assessment dated [DATE] included a stage 4 pressure ulcer to the resident's sacrum which measured 10.0 cm x 10.0 cm x 7.0 cm. The wound bed was described as 100% red. Additional pressure ulcers noted and assessed in the documentation included the right heel, right lateral foot, right lateral ankle, left lateral mid foot, and left lateral distal foot. The documentation indicated that the resident's care plan had been reviewed and updated.
However, no update to the care plan was identified.
The quarterly Minimum Data Set assessment dated [DATE] revealed the resident scored 14 on the Brief Interview for Mental Status, indicating intact cognition. The resident exhibited no behaviors, including rejection of care. The resident required extensive 1-2-person physical assistance for most activities of daily living. The assessment also revealed the resident had 1 stage 3 pressure ulcer, 1 stage 4 pressure ulcer, and 8 unstageable pressure ulcers.
An interview was conducted on 05/13/22 at 11:12 a.m. with the Director of Nursing (DON/staff #127). She stated that the resident's care plan should reflect updates weekly. She stated that the wound nurse should have updated the resident's care plan upon identification of necrosis to the sacrum and infection to the left ankle to ensure that changes were identified and goals applied. The DON stated that it did not meet her expectations.
The facility policy titled Care Plans, Comprehensive Person-Centered revealed a comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Assessment of residents is ongoing and care plans are revised as information about the resident and the resident's condition change. The IDT must review and update the care plan when there has been a significant change in the resident's condition, when the desired outcome is not met, and at least quarterly, in conjunction with the required quarterly MDS assessment.
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 observations, clinical record review, resident and staff interviews, and facility documentation, the facility failed to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident and staff interviews, and facility documentation, the facility failed to provide treatment and care in accordance with professional standards of practice for one sampled resident (#16) with bilateral lower extremity edema. The deficient practice could result in residents not receiving proper treatment for bilateral lower extremities edema.
Findings include:
Resident #16 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure and type 2 diabetes mellitus.
Review of the care plan dated June 22, 2021 stated the resident has congestive heart failure. The goal stated the resident will be free of complications. The care plan interventions included monitoring for signs and symptoms of congestive heart failure such as dependent edema of the legs and feet.
Review of the physician order dated January 14, 2022 revealed an order for Furosemide 20 milligrams orally daily for unspecified systolic congestive heart failure.
Review of a nurse practitioner (NP) progress note dated February 6, 2022 at 4:34 p.m., stated the resident was seen and examined on this date for bilateral lower extremity edema with mild erythema. The progress notes included TED hose will be provided, elevate legs, and encourage ambulation with assistance.
A NP progress note dated February 20, 2022 at 4:12 p.m., stated the resident uses all extremities, 3+ edema present bilaterally. The assessment and plan included bilateral lower extremity edema: Lasix, potassium, and TED hose.
However, further review of the clinical record revealed no order for TED hose, and review of nursing progress notes revealed no evidence of interventions related to bilateral lower extremities edema.
A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a BIMS score (Brief Interview of Mental Status) of 7 which indicated the resident had severe impaired cognition. The MDS assessment stated the resident needed limited assistance with transfer, dressing, and personal hygiene. The primary medical condition included heart failure, coronary artery disease, and diabetes mellitus.
An observation was conducted of the resident on May 9, 2022 at 12:04 p.m. Resident #16 was observed in the dining room, sitting in a wheelchair without a foot rest. The resident was wearing a black long sleeve blouse, and a multi-colored orange/blue/white printed skirt. The resident legs were exposed, and were observed to have edema. The resident's feet had a pair of blue non-skid socks and a pair of black tennis shoes on them. The tennis shoes were observed to be tight and too small for the resident's feet because of the edema. The back of the tennis shoes was folded under the resident's heels.
A second observation was conducted on May 10, 2022 at 2:52 p.m. in the secured unit. Resident #16 was observed sitting in the wheelchair propelling the wheelchair using her hands and feet towards the resident's room. Her hands had a package of chocolate snacks in them. The resident was wearing an olive colored dress with long sleeves. The resident's lower legs were exposed, and had visible edema in both lower extremities. The resident's legs were not elevated, and the resident's feet had light blue non-skid socks on them that were tight around the ankles. The resident was wearing a pair of tightly fitted, dark colored tennis shoes, and the back of the shoes was folded under the resident's heels. The resident reached towards the left ankle and pulled down the blue non-skid socks, there were visible skin indentations marks on the resident's ankles.
Following this observation, an interview was conducted with the resident who stated her feet hurt sometimes because the socks are too tight. The resident stated she wears the tennis shoes even if they do not fit because she has no other pair of shoes. The resident stated she cannot put her entire feet in the shoes because her feet are swollen and the nurses know about it because they help her get dressed and put her shoes on every day.
Observations conducted on May 11, 2022 at 7:50 a.m., and May 12, 2022 at 2:42 p.m. revealed the resident was wearing the same olive colored dress, blue non-skid socks, and dark colored tennis shoes that were too small for the resident's swollen feet. The resident was not observed to be wearing TED hose and no foot rest was observed on the wheelchair.
A follow up interview was conducted with the resident on May 12, 2022 at 2:49 p.m. in the secured dining room. The resident stated she likes wearing the olive dress all the time because it is comfortable and has a v-shaped neckline that makes it more comfortable. The resident stated that the staff put on her shoes and socks every day, and that she is wearing the same socks because there are no other pairs of socks. The resident stated the socks hurt, are too tight, and are cutting on her legs, that it hurts because they are too tight.
An interview was conducted on May 12, 2022 at 2:53 a.m. with an LPN (licensed practical nurse/staff #103) manager. Staff #103 stated the process for managing congestive heart failure included monitoring for weight gain, oxygen saturation, vital signs, and symptoms of fluid overloads. Staff #103 stated treatment for bilateral lower extremities (BLE) edema included nursing elevating both legs, TED hose for compression, monitoring intake/output, and medications as ordered by the physician. Staff #103 stated if a physician orders a diuretic, such as Lasix, she would check the output and the pitting edema to BLE. Staff #103 stated if the pitting edema is present, she would notify the physician and document the event in the nurses' notes.
Immediately following the interview, staff #103 assessed the resident's BLE. Staff #103 stated the resident's legs are definitely swollen, and has 4+ pitting edema. Staff #103 also stated the blue socks were cutting on the resident's legs, and that the shoes were too small because of the edema. Staff #103 stated, as a nurse, she would encourage the resident to go to bed and elevate her legs, put TED hose on, and get bigger shoes and socks. She also stated she would call the physician.
An interview was conducted on May 12, 2022 at 3:05 p.m. with a CNA (certified nursing assistant/staff #17), who stated if the resident has swelling in their legs, she would let the nurse know. She also stated she would encourage the resident to lay down and elevate the resident's legs to help with the swelling. Staff #17 stated that if a resident did not want to lay down, she would get an elevating footrest to elevate the resident's legs while in the wheelchair. Staff #17 stated that if the shoes were too tight she would not put them on because it can also cut circulation. She said she would just put on a bigger pair of non-skid socks.
An interview was conducted on May 13, 2022 at 10:08 a.m. with the DON (director of nurses/staff #127). Staff #127 stated the CHF (congestive heart failure) protocol included assessments, looking at the medications, and that if a resident's legs were swollen she would keep them elevated. Staff #127 stated she would notify the physician and review the medications. Staff #127 stated if a physician wrote a progress note regarding the edema management, the process included the physician notifying a nurse to write an order for the TED hose. Staff #127 also stated that the nursing staff reads the progress notes for the recommendations for follow up. The DON stated there are interventions a nurse can do to manage the BLE edema without a physician order which includes elevating the legs and following the care plan for CHF management.
Review of the facility clinical protocol, Heart Failure, included the nursing assessment of vital signs, general physical assessment, all current medications, and all active diagnoses.
However, the clinical protocol did not include edema management.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on observations, staff interviews, and policy review, the facility failed to ensure the area around the dumpsters was free of refuse/garbage. The deficient practice could result in an unsanitary...
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Based on observations, staff interviews, and policy review, the facility failed to ensure the area around the dumpsters was free of refuse/garbage. The deficient practice could result in an unsanitary condition and the harborage of pests and insects.
Findings include:
An observation of the facility's main kitchen was conducted with the kitchen manager (staff #85) on 05/09/22 at 9:40 AM. During the observation, a cardboard food container, cigarette butts and several small plastic cups and napkins were observed in back of the dumpsters.
A second observation was conducted on 05/11/22 at 11:51 PM. Soiled napkins and old cigarette butts were observed around the dumpsters.
An interview was conducted with the kitchen manager (staff #85) on 05/11/22 at 12:49 PM. Staff #85 stated that the garbage dumpsters are checked twice weekly. She added that they probably should be checked daily. Staff #85 stated the dumpsters are also often blown open by the wind and that may be how the boxes and garbage near the fence got there, but they should have been cleaned up by the second check.
During an interview conducted with the Director of Nursing (DON/staff #127) on 05/11/22 at 1:39 PM. The DON stated that the area around the dumpsters should always be clean and the dumpster lids locked down. The DON stated it is her expectation that the garbage dumpsters area be clean, free of refuse and checked regularly.
Review of the facility policy titled Waste Disposal stated that the dumpster will be inspected for debris and the lid closed when trash is disposed of by service staff. Maintenance and service staff are also responsible to ensure the dumpster lid is closed and the area is free of accumulated debris.
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, staff interviews, and policy review, the facility failed to ensure that one sampled resident (#...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that one sampled resident (#41) received specialized rehabilitation services as ordered. The deficient practice could result in the resident experiencing decline in activities of daily living and range of motion.
Findings include:
Resident #41 was admitted to the facility on [DATE], discharged on 3/29/22 and readmitted on [DATE], with diagnoses that included sepsis, anemia, heart failure and depressive disorder.
Review of a care plan initiated on 10/23/21 revealed that the resident has a problem with gait and balance. The goal was to have no serious injuries with interventions that included anticipation of needs, ensuring the call light is within reach, prompt responses to calls for assistance, and PT (physical therapy) to evaluate and treat as ordered or as needed.
Review of the physician's orders dated 3/28/22 revealed the resident was to have physical therapy for 8 weeks.
Review of the Physical Therapy Treatment and Encounters notes dated 3/29/22, revealed the resident was seen for risk of falls. Therapeutic exercises were performed to enhance balance and standing.
Review of the resident's progress notes revealed the resident was discharged to the hospital on 3/29/22 and was readmitted on [DATE].
However, there was no clinical record documentation that physical therapy was reevaluated to resume.
An interview was conducted with the Director of Therapy (staff #35) on 05/12/22 at 10:13 AM. Staff #35 stated that the resident was discharged the day after therapy started and should have been reevaluated and resumed when the resident returned to the facility. He stated that he does not know why it was not done. He added that the resident should be receiving therapy so that the resident can improve and return home.
An interview was conducted with the Director of Nursing (DON/staff #127) on 05/12/22 at 11:37 AM. The DON stated that it is her expectation that when a resident is readmitted , all therapies be resumed according to their policy. The DON stated if a resident is needing therapy to achieve their needs and does not obtain it, the resident has not been set up properly for discharge. She added that it is her expectation that the therapist director obtains the necessary orders to re-evaluate as needed.
Review of the facility policy titled Scheduling of Therapy (revised July 2013) stated that a therapist is to interview a resident on admission and consult with the attending physician as to the type of treatment to be administered.
Review of the facility policy titled Requests for Therapy Services (revised July 2013) stated that an order for therapy services must be obtained.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
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 policy and procedures, the facility failed to ensure that a physician ord...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure that a physician order for advance directive was obtained for one of two sampled residents (#370). The deficient practice could result in residents' medical records not having orders for advance directives.
Findings include:
Resident #370 was admitted to the facility on [DATE] with diagnoses that included traumatic subdural hemorrhage without loss of consciousness, traumatic hemorrhage of the cerebrum, multiple fractures of the ribs, and aphasia following unspecified cerebrovascular disease.
Review of the clinical record revealed the resident's advanced directive dated [DATE]. The advance directive stated the resident wished to have nutrition, hydration, and blood transfusions but did not wish to be resuscitated.
However, further review of the clinical record revealed no physician order for the resident's advanced directive.
An interview was conducted on [DATE] at 9:52 a.m., with an LPN (licensed practical nurse/staff #103) who stated the process for obtaining a resident's code status included obtaining a signed advance directive from the resident or guardian, then a physician order is obtained according to the advanced directives. Staff #103 stated that the resident's code status is found in the chart, on the main body of the E-MAR (electronic medication administration record). Staff #103 stated if a resident did not have a physician order for code status the resident would be considered a full code, in which CPR (cardio-pulmonary resuscitation) would be provided. The LPN further stated, it is better to do CPR than to find out they are a full code and the staff did not attempt to save the resident. During the interview, staff #103 accessed the resident's medical record. Staff #103 stated that there was no code status on the body of the resident's E-MAR, and that there was no physician order for the resident not to be resuscitated.
An interview was conducted on [DATE] at 10:21 a.m. with the DON (director of nurses/staff #127). Staff #127 stated the code status DNR (do not resuscitate) and full code must have a physician order.
Review of the facility policy, Advance Directives, stated the advance directives will be respected in accordance with stated law and facility policy. The policy interpretation and implementation included the DON or designee will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and facility policy, the facility failed to ensure that appropr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and facility policy, the facility failed to ensure that appropriate infection prevention practices were followed during wound care for one of three sampled residents (#40). The deficient practice could result in the spread of infection.
Findings include:
Resident #40 was admitted to the facility on [DATE] with diagnoses of paraplegia, cystitis, and neuromuscular dysfunction of bladder.
A Physician's Order dated May 7, 2022 included left hand middle and ring finger - cleanse with wound cleanser and pat dry. Weave xeroform between fingers and pad so that the fingers are separated. Wrap with kerlix between fingers and around hand followed by an ace wrap to keep in place every day shift for the open wound.
A wound treatment observation was conducted May 12, 2022 at 12:52 PM with a Wound Registered Nurse (RN/staff #79). The RN sanitized her hands, put on gloves and spoke with the resident about the procedure. She then removed the wrap from the resident's hand and disposed of it. The RN then removed the kerlix from the resident's hand by cutting it with scissors and asked the resident to tell her if it hurt. The RN said that the wound has full thickness and no odor, and that last week she could see the wound bed. She measured the ring finger wound to be 1.0 cm (centimeter) x 1 cm and she stated she was unable to determine the depth. She measured the middle finger wound to be 1.2 cm x 1.2 cm and stated she was unable to determine the depth and that the wound was improving because before it had a foul odor and she feels the xeroform has caused the wound to get much better. The RN was not observed to sanitize her hands before applying the gauze padding between the resident's fingers. She then removed her gloves and sanitized her hands, reapplied gloves, applied tape strips, then wrapped the wound in kerlix. She then sanitized her hands, checked the resident's feet, sanitized and changed gloves, cleaned and assessed a wound near the resident's stoma. She cleaned up, washed her hands, placed the tape in her pocket, and scissors in her pants loop, and removed the hand sanitizer and placed it on the wound cart.
An interview was conducted on March 13, 2022 at 9:49 AM with the Wound RN (staff #79) who said that she should sanitize her hands as often as she feels like they are dirty, after taking the old dressing off and putting on the new one.
An interview was conducted on March 13, 2022 at 10:26 AM with the Director of Nursing (DON/staff #127) who said that her expectations would be that staff would wash hands, clean the field, educate the patient, perform the procedure then wash the scissors. She said that she would want the staff to wash their hands between clean and dirty areas of the procedure, and that the staff should sanitize hands between changing gloves. This DON said that she did not know what standards of practice were used and that they followed facility policy.
A facility policy titled Wound Management program revealed that it is the goal of the facility that all residents with wounds receive treatment and services consistent with the resident's goals of treatment. The Wound Management Program is structured and implemented using processes founded on accepted standards of practice, research driven clinical guidelines and interdisciplinary involvement.
A facility policy titled Infection Control Program revealed that it is the policy of the facility to maintain an active infection control program with the focus of providing a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #69 was admitted to the facility on [DATE] and discharged briefly on March 29, 2022 then readmitted to the facility on...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #69 was admitted to the facility on [DATE] and discharged briefly on March 29, 2022 then readmitted to the facility on [DATE] with diagnoses that included sepsis, unspecified part of neck of the left femur, and pressure ulcers on multiple locations which included left and right heel, left ankle, and right buttock. The resident was later discharged on May 11, 2022.
Review of the clinical record revealed a physician's order dated January 6, 2022 for
an opioid pain medication, Hydrocodone-Acetaminophen tablet 5-325 mg one tablet by mouth every 6 hours as needed for pain 7-10 out of 10 related to a fracture of an unspecified part of the neck of the left femur.
Review of the MAR for January 2022 revealed that the resident was administered Hydrocodone-Acetaminophen on the following dates:
January 10th for pain reported 6
January 12th for pain reported 6
January 13th for pain reported 6.
Review of the care plan initiated on January 17, 2022 revealed the resident had acute pain related to a femur fracture and took Hydrocodone-acetaminophen and/or Tylenol as needed. The goal was that the resident would verbalize adequate relief of pain or ability to cope with incompletely relieved pain. Interventions included administering analgesia medication as per orders.
Further review of the physician orders revealed an order dated February 28, 2022 for Tylenol (Acetaminophen) 325 mg, 2 tablets by mouth every 4 hours as needed for pain scale 1-6/10 not to exceed 3 grams (gm) in a 24-hour period.
Review of the MAR for February 2022 revealed that the resident was administered Hydrocodone-Acetaminophen on February 28, 2022 for a pain reported as 5.
Review of the MAR for March 2022 revealed that the resident was administered Hydrocodone-Acetaminophen on March 9th for pain reported at a 4 and then later again on March 9, 2022 for a pain reported at a 6. The resident also received the opioid on March 28th for pain reported as a 5.
Further review of the MAR for March 2022 revealed that the resident received Tylenol on March 17, 2022 for pain reported as 0.
The 5-day modified Minimal Data Set (MDS) assessment dated [DATE] revealed the BIMS score was a 7 which indicated that the resident had moderate cognitive deficits.
Review of the MAR for April 2022 revealed the resident received the Hydrocodone-acetaminophen on April 23, 2022 for pain reported as 5 and again on the same day at a later time for pain reported as 6.
An interview was conducted on May 13, 2022 at 9:05 AM with an LPN (staff #75). The LPN stated that pain assessment includes asking the resident about the type of pain, the location of the pain, onset of pain, and asking the resident to rate the pain on a scale of 1-10. She stated if a resident reported 10 that is the highest level of pain and 0 is the lowest and means the resident is not in any pain at all. Additionally, the LPN stated she usually is able to consult with the resident and see if the resident would try non-medication interventions like ice or heat or redirection. The LPN stated that if a resident had physician orders for multiple prn pain medications, nurses should administer the medication that has the correlating pain scale on the order. Staff #75 stated it would not be appropriate to administer an opioid pain medication for pain reported anything outside of the physician's pain scale parameter listed on the order. The nurse stated that there are increased risks with opioid pain medication such as constipation and lowered blood pressure. The nurse reviewed the MAR for January 2022 and stated Hydrocodone-acetaminophen had been administered outside of the physician order pain parameters. Further the LPN stated that unless there were progress notes why it was administered, then that should not have happened.
An interview was conducted on May 13, 2022 at 9:24 AM with the DON (staff #127). The DON stated that if a pain medication was administered outside of the physician's order parameters, the nurse should document what occurred, who was notified and why it was approved. The DON stated that she would expect that after the physician was notified she would expect the nurse to update the ordered pain parameters. The DON stated that if the resident reports pain of 0 that would indicate on the pain scale that there is no pain and therefore no medication is needed. The DON also stated that if a resident had a prn (as needed) pain medication for Acetaminophen and another medication such as Hydrocodone, she would expect the nurses to review the pain scale on each order and then determine which medication coincides with the resident's reported pain number. Additionally, she stated that there are increased risks related to opioid pain medication such as constipation, fall risk, decrease in blood pressure and respirations as well as dizziness. The DON stated that if the pain med was given outside of the ordered parameters then the medication could have been given unnecessarily. The DON reviewed the MAR for resident #69 and stated administering the pain medication outside of the orders pain scale did not meet her expectations.
The facility policy titled Administering Medications reviewed December 2012 stated medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame.
The facility policy titled Pain Medication revised October 2010 stated the purpose is to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medication. Administer pain medication as ordered.
Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure that 2 out of 5 sampled residents (#62 and #69) were administered medications according to the parameters as ordered by the physician. The deficient practice could result in residents receiving unnecessary drugs.
Findings include:
-Resident #62 was admitted to the facility on [DATE] with diagnoses that included nondisplaced fracture of lateral malleolus of left fibula, subsequent encounter for closed fracture with routine healing, and other chronic pain.
An acute pain care plan dated 04/20/22 related to opioid and non-opioid analgesics had a goal for adequate relief of pain or ability to cope with incompletely relieved pain. Interventions included administering analgesia medication as per orders.
The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 14 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. The assessment included the resident frequently experienced pain of 10 out of 10 on a pain scale. In addition, the resident received opioid pain medication for 6 out of 7 days in the lookback period.
Review of a physician's order dated 04/28/22 included dronabinol (cannabinoid) 5 milligrams (mg) every 6 hours as needed for pain of 8-10.
However, review of the April 2022 Medication Administration Record (MAR) revealed the resident received dronabinol on 4 occasions when the resident reported pain levels less than 8, twice on 04/29 for a pain level of 7 and twice on 04/30 for a pain level of 7.
Review of the May 2022 MAR revealed the resident received dronabinol May 1 - 6, up to two times daily, for pain levels of 6 and 7.
An interview was conducted on 05/12/22 at 10:39 a.m. with a Licensed Practical Nurse (LPN/staff #103). She stated her process for administering as needed (PRN) pain medications is to first ask the resident to rate their pain, and then she will look to see when the last time the resident received the medication. She stated that the correct thing to do when the resident requests a specific medication outside of the parameters would be to notify the physician prior to giving the medication. The LPN stated that she would consider the administrations to be medication errors and that the resident had received the medications unnecessarily.
On 05/12/22 at 12:56 p.m., an interview was conducted with the Director of Nursing (DON/staff #127). She stated that her expectation is for nursing to educate the resident in regard to the physician's orders. She stated that if the resident is adamant about receiving the specific medication, she would expect the nurse to give the appropriate pain medication (i.e. acetaminophen) and then to notify the physician of the resident's concerns. The DON stated that nurses are expected to give the appropriate pain medication according to the parameters, notify the physician, and then document the conversation.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on concerns identified during the survey, the Facility Assessment, staff interviews, and policy review, the Quality Assura...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on concerns identified during the survey, the Facility Assessment, staff interviews, and policy review, the Quality Assurance and Performance Improvement (QAPI) committee failed to ensure a plan of action was developed and implemented that corrected identified quality care concerns related to skin breakdown. The deficient practice could result in other quality concerns not being corrected.
Findings include:
During the survey, concerns were identified regarding delayed identification of new and existing skin wounds, treatments not consistently being provided, the physician not being notified timely of changes in wounds and new wounds, preventative measures not consistently being implemented, and delays in obtaining and/or providing wound treatments.
Review of the facility's assessment dated [DATE] revealed the purpose was to determine what resources were necessary to care for residents competently during both day to day operations and emergencies. The assessment stated the type of care provided by the facility included pressure injury prevention and care, skin care, wound care (surgical, other skin wounds); and intermittent or indwelling or other urinary catheter. The assessment identified the type of staff members needed to provide support and care for residents. The staffing plan included licensed nurses and licensed nursing assistants or certified nursing assistants (CNAs) providing direct care and for wound care one Licensed Practical Nurse full time. Staff education and training included pressure ulcer care and prevention. Also included in the assessment was the question What opportunities exist for quality initiatives (QAPI) as a result of what we learned from the Facility Assessment to improve our facility's services and resources? QAPI Initiatives/Performance Improvement Projects (PIP) action to be taken/already taken this year included wounds.
An interview was conducted with the Executive Director (ED/staff #71) on May 13, 2022 at 10:44 AM. The ED stated the QAPI committee meets at least quarterly and that they plan to meet monthly. He stated that they have identified pressure ulcers as an area of concern and that a PIP was started in 2021.
An interview was conducted with the Director of Nursing (DON/staff #127) on May 13, 2022 at 11:16 AM, who stated the PIP for pressure ulcers was created before September 12, 2021. The DON stated that the performance in the facility has improved. The DON stated that the committee has started meeting every month and that she would provide the QAPI plan/PIP.
Review of the facility's PIP for pressure ulcers revealed a start date of September 12, 2021 with a target end date of December 11, 2021. The PIP included that the problem was an increase in facility acquired pressure ulcers. A root cause analysis revealed that nurses required increased education on pressure ulcer prevention. The PIP included the following meeting minutes:
-September 20, 2021, the facility indicated they would continue to educate nurses on wounds one on one.
-November 10, 2021, the facility indicated that facility acquired pressure ulcers had decreased.
-November 27, 2021, the facility noted that new admission skin conditions were being checked by two nurses. This was helping to decrease facility acquired pressure ulcers.
-December 7, 2021, new admissions continued to be reviewed and the Assistant Director of Nursing (ADON)/nursing staff were educated to put in treatment orders as soon as there is skin impairment noted.
-December 19, 2021, a new wound nurse had started working and was learning the wound process.
-December 28, 2021 and January 9, 2022, new facility acquired pressure ulcers were found. The facility indicated that the ADON would no longer oversee wounds and a new charge nurse would be taking on the wound program and is currently in transition/training to do so.
-January 17, 2022 and January 24, 2022, the charge nurse would continue to oversee wound care and skin checks after admissions.
-February 2, 2022, the charge nurse changed career paths and the DON would assume wound care and oversee wounds until another nurse is trained on wound care.
-February 16, 2022, wound care was being completed daily by the floor nurses and weekly by the DON and the facility was in process of looking for a skilled wound nurse.
-February 27, 2022, there were more facility acquired pressure ulcers noted and it was in part from having new Temporary Nursing Assistants (TNAs), CNAs and new nurses. Education was given one on one and more education was being given to all staff one on one by the DON, ADON, and staffing coordinator.
-March 7, 2022, education given one on one and more education being given to all staff via DON, ADON, and staffing coordinator. More pressure ulcers were being noted on skin assessments within 24 hours of admission.
-The QAPI meeting dated March 8, 2022 stated a full-time wound nurse would help capture incoming pressure wounds.
-March 20, 2022, the facility noted that facility acquired pressure ulcers were now being overseen by a new wound care nurse.
-March 26, 2022 and April 8, 2022, the wound nurse was giving one on one education to staff as a situation in need of education presented itself.
-April 17, 2022, the facility indicated that facility acquired pressure ulcers had decreased.
-May 8, 2022, the wound nurse along with newly educated nurses found new pressure ulcers on admission within 24 hours.
However, review of the information provided did not include evidence of tracking, auditing, monitoring, or that the plan of action was revised to ensure correction was achieved and sustained.
During the survey it was revealed one resident developed a facility acquired unstageable pressure ulcer to the left ischium/sacral that was found on December 23, 2021 during a brief change, and had a wound vac applied to the pressure ulcer that had necrotic tissue in May 2022. Another resident developed a facility acquired stage 2 pressure ulcer to the left-hand ring finger on May 5, 2022 and developed a facility acquired wound related to an indwelling urinary catheter May 2022.
In an interview conducted with a wound Registered Nurse (RN/staff #59) on May 12, 2022 at 12:52 PM, the RN stated that she has been the wound nurse at the facility since mid-March and that she graduated from nursing school in January.
Review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI) Committee (April 2014) revealed the primary goals of the QAPI committee included helping identifying actual and potential negative outcomes relative to resident care and resolving them appropriately; supporting the use of root cause analysis to help identify where patterns of negative outcomes point to underlying systemic problems; coordinating the development, implementation, monitoring, and evaluation of performance improvement projects to achieve specific goals; and helping departments, consultants and ancillary services implement system to correct potential and actual issues in quality of care. The QAPI committee shall help various departments/committees/disciplines/individuals develop and implement a plan of correction and monitoring approaches. These plans and approaches should include specific time frames for implementation and follow-up. The committee shall track the progress of any active plans of correction. The administration shall be advised of the need for policy or procedural changes and, as appropriate, monitor to ensure that such changes are implemented.
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
- "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.
- • 44% turnover. Below Arizona's 48% average. Good staff retention means consistent care.
Concerns
- • 24 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
Bottom line: Mixed indicators with Trust Score of 60/100. Visit in person and ask pointed questions.
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About This Facility
What is Haven Of Globe's CMS Rating?
CMS assigns HAVEN OF GLOBE an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Arizona, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Haven Of Globe Staffed?
CMS rates HAVEN OF GLOBE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 44%, compared to the Arizona average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Haven Of Globe?
State health inspectors documented 24 deficiencies at HAVEN OF GLOBE during 2022 to 2025. These included: 2 that caused actual resident harm and 22 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Haven Of Globe?
HAVEN OF GLOBE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by HAVEN HEALTH, a chain that manages multiple nursing homes. With 104 certified beds and approximately 73 residents (about 70% occupancy), it is a mid-sized facility located in GLOBE, Arizona.
How Does Haven Of Globe Compare to Other Arizona Nursing Homes?
Compared to the 100 nursing homes in Arizona, HAVEN OF GLOBE's overall rating (4 stars) is above the state average of 3.3, staff turnover (44%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Haven Of Globe?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "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 below-average staffing rating.
Is Haven Of Globe Safe?
Based on CMS inspection data, HAVEN OF GLOBE 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 4-star overall rating and ranks #1 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 Haven Of Globe Stick Around?
HAVEN OF GLOBE has a staff turnover rate of 44%, which is about average for Arizona nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Haven Of Globe Ever Fined?
HAVEN OF GLOBE 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 Haven Of Globe on Any Federal Watch List?
HAVEN OF GLOBE 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.