BROOKRIDGE COVE REHABILITATION AND CARE CENTER
For profit - Limited Liability company
96 Beds
SOUTHERN ADMINISTRATIVE SERVICES
Data: November 2025
Trust Grade
70/100
#57 of 218 in AR
Last Inspection: April 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Brookridge Cove Rehabilitation and Care Center has a Trust Grade of B, indicating it is a good option for families, though not the best available. It ranks #57 out of 218 facilities in Arkansas, placing it in the top half, and it is the only nursing home in Conway County, making it the best local choice. The facility's trend is improving, with a reduction in issues from 16 in 2023 to just 4 in 2024. Staffing is average with a turnover rate of 41%, which is better than the state average of 50%, suggesting some staff stability. Notably, there have been no fines recorded, which is a positive sign. However, there are some concerns to consider. Recent inspections revealed issues such as staff failing to wash hands properly between tasks, which could lead to foodborne illnesses for residents. Additionally, the kitchen was found in unsanitary conditions, with stained ice machines and dirty food preparation areas. While overall care quality appears solid, families should be aware of these specific incidents when researching this facility.
- Trust Score
- B
- In Arkansas
- #57/218
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 41% turnover. Near Arkansas's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Arkansas facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 24 minutes of Registered Nurse (RN) attention daily — below average for Arkansas. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 28 deficiencies on record. Higher than average. Multiple issues found across inspections.
70/100
Top 26%
No red flags
16 → 4 violations
★★★★☆
4.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 16 issues
2024: 4 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 (41%)
7 points below Arkansas average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 41%
Near Arkansas avg (46%)
Typical for the industry
Chain: SOUTHERN ADMINISTRATIVE SERVICES
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 28 deficiencies on record
Sept 2024
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe, and homelike environment as evidence...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe, and homelike environment as evidenced by not ensuring safe wall mounted railings for safety and convenience.
The findings are:
Review of a policy titled, Accidents, Hazzard Prevention, specified the frailty of some residents increases their vulnerability to hazards in the resident environment and can result in life-threatening injuries. It is important that all facility staff understand the facility's responsibility, as well as their own, to ensure the safest environment possible for residents.
On 09/03/2024 at 10:22 AM, on the 200 Hall, standing facing room [ROOM NUMBER], to the immediate right approximately 6 inches, the wall mounted handrail was not anchored, and the bracket was disconnected from the sheetrock.
On 09/03/2024 at 12:33 PM, on the 300 Hall, standing facing room [ROOM NUMBER], 5 feet on the left toward the double doors, the wall mounted handrail bracket connected to the handrest was loose.
On 09/03/2024 at 1:02 PM, the Administrator stated, Maintenance is not here, he is new and has not had time to inspect the rails. The Administrator indicated that the repairs will be made immediately.
Review of the facility's Maintenance Request Form with the Alternate Administrator on 09/04/2024 at 09:00 AM, dated 08/16/2024 through 09/02/2024, revealed no maintenance request for the handrail repairs for the 200 and 300 halls.
Apr 2024
3 deficiencies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure Resident ' s bedding was clean and in place for 1 (Resident #1) of 1 sampled residents.
The findings include:
An admission Record ind...
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Based on observation and interview, the facility failed to ensure Resident ' s bedding was clean and in place for 1 (Resident #1) of 1 sampled residents.
The findings include:
An admission Record indicated Resident #1 was admitted with diagnoses of Dementia and Multiple sclerosis.
A Care Plan indicated that Resident #1 had an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) disease process of MS (Multiple Sclerosis) and needed assistance with his/her ADL's.
On 04/22/2024 at 09:17 AM, Resident #1 had a yellowish/brown ring on the pillowcase on the pillow that was used for positioning in the reclining chair.
On 4/23/24 at 9:20 AM Resident #1 was observed with a blanket covering that was stained with yellow/brown substance and 1 pillow under the Resident's head had no slip covering.
On 04/24/2024 at 09:28 AM, Certified Nursing Assistant (CNA) #3 was observed pushing Resident #1 into his/her room and the Resident was noted to have a pillow under the right arm. The pillowcase had a yellowish- brown ring shaped stain. CNA #3 was asked what she thought the yellowish-brown ring was. CNA #3 stated She may have spilled her coffee. She was asked, how often should Resident #1 have a pillowcase on her pillow? She stated, At all times.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure an accident/hazard free environment was provided for smokers requiring a smoking apron.
The findings are:
1) Residen...
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Based on observation, interview, and record review, the facility failed to ensure an accident/hazard free environment was provided for smokers requiring a smoking apron.
The findings are:
1) Resident #13 has diagnoses of Alzheimer's, Stroke with left side paralysis, and Seizure disorder. On the Quarterly Minimum Data Set (MDS) with the assessment reference date (ARD) of April 15, 2024, the resident received a score of 15 (cognition is intact) on the brief interview for mental status (BIMS).
a) On 04/23/2024 at 11:45 PM, the Surveyor observed Residents #66, #16, and #13 outside smoking without wearing smoking aprons.
b) On 04/24/2024 at 11:50 PM, Residents #66, #16, #13 were outside smoking without wearing a smoking apron.
c) On 4/24/2024 at 3:10 PM, Surveyor asked Certified Nursing Assistant (CNA) # 1 what their procedure is when they take smokers out. CNA #1 stated they take them out together and make sure they have their cigarettes, then put their aprons on for the ones who require them. They look at a list where they get the cigarettes to see who needs aprons to prevent them from burning holes in their clothes. They make sure they have their aprons on and supervise them closely.
d) On 04/24/2024 at 03:15 PM, CNA # 2 was asked what their procedure is when they take smokers out. CNA #2 stated they take them out together at the same time and make sure they have all their cigarettes then put their aprons on for the ones who require them. They need the aprons to prevent them from burning holes in their clothes.
e) On 4/25/2024 at 09:15 AM, the Director of Nursing (DON) stated the Residents are taken out at the same time; CNAs get their cigarettes from the medication room and take them to the designated smoking area outside, then look at the smokers list to see who is supposed to have aprons.
The facility was unable to produce a smoking policy.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility failed to ensure 1 of 1 kitchen was in sanitary condition.
The findings are:
On 04/24/2024 at 09:04 AM, the ice machine had a cloth trimming under the...
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Based on observation and interview, the facility failed to ensure 1 of 1 kitchen was in sanitary condition.
The findings are:
On 04/24/2024 at 09:04 AM, the ice machine had a cloth trimming under the lid. It was wet and had brown and black stains.
On 04/24/2024 at 09:05 AM, the Dietary Manager was asked, What's the cloth material on the ice machine? She stated, I don't know what that is. It's been on there since I've been here. I've been here for 2 years.
On 04/24/2024 at 09:30 AM, the Administrator stated, We are taking the ice machine out of commission.
On 04/24/2024 at 10:22 AM, the Dietary Manager stated, A new ice machine has been ordered.
On 04/24/2024 at 11:54 AM, a thick layer of dust and lint was observed on a spice rack on the counter in the kitchen. A lid on top of a blue bin that had coffee in it was dirty. A cart with dessert on it had a grease and dirt built up.
On 04/24/2024 at 11:56 AM, the Dietary Manager was asked, Can you tell me what's on the spice rack, and the food cart? She stated, Dust on the spice rack and build up on the food cart. She was asked, How often should it be cleaned, She stated, It should be cleaned weekly.
Feb 2023
16 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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview, and record review, the facility failed to ensure a report of stolen items was reported to the Office of Long Term Care (OLTC) and other agencies in accordance with state and federa...
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Based on interview, and record review, the facility failed to ensure a report of stolen items was reported to the Office of Long Term Care (OLTC) and other agencies in accordance with state and federal law, to enable those agencies to provide any necessary oversight of the facility's investigations and protective measures for 1 (Resident #107) of 1 sampled resident whose family had reported items missing. The findings are:
1. Resident #107 had a diagnosis of Alzheimer's Disease with Late Onset.
2. The Letter dated 12/08/22 and an Invoice from Resident #107's family received by the facility for the loss or stolen items while Resident #107 was in the facility was reviewed. The Invoice documented, .Personal Property lost or stollen: Dozens of articles of clothing over a 12-year period with an average purchase price of $25 $1800.00 Two prescription glasses $800.00 Silver Wedding Ring $125.00 Total; Payable upon receipt $2725.00 .
3. Resident #107's Progress Notes contained the following documentation:
a.1/17/2022 14:51 [2:51 PM] Social Note Late Entry: Note Text: Resident't [Resident's] [family member] came to get her personal items - He took w/c [wheelchair], photo albums, a jewelry box, 2 corkboards with photos, a box of photos and cards, some jewelry Social Services .
b.1/18/2022 10:05 [10:05 AM] DC [Discharge] Summary Note Text: .Disposition of personal belongings: Family picked up W/C and pictures. Donated Clothing to facility . Nursing .
c.1/19/2022 14:50 [2:50 PM] Social Note Note Text: Called .funeral home in [City] looking for her wedding band - They will call me back if they find anything. I went through all of her personal belonging twice looking for the ring. Social Services .
4. On 02/15/23 at 8:26 AM, the Surveyor asked the Administrator when incidents are reported to OLTC. The Administrator stated, Within 2 hours of being an allegation of abuse, neglect, misappropriation of property, sexual, verbal, or physical abuse. The Surveyor asked what meets the criteria for misappropriation of property. The Administrator stated, When someone says this is missing, they are not allocating misappropriation. We treat that as a grievance and do that or reconcile that. If they are allocating that a facility employee said they got rid of it, then that is misappropriation. The Surveyor asked if the Administrator had received any notifications by letter of any items being stolen or missing. The Administrator stated, No, I have not received a letter notifying us of anything missing. Typically, if we suspected it and someone stole something or purposefully threw it away, we would report it.
5. On 02/15/23 at 9:08 AM, the Surveyor asked the Social Services Director (SSD) when she reports a resident's lost or stolen belongings. The SSD stated, It depends on how they say it. If they say it has been stolen, then I tell [Administrator]. If they say it is just missing, that is a grievance process and I document how the search was. It depends if they come at me. If it is regarding staff, then [Administrator] is the one that handles it. The Surveyor asked if Resident #107's missing ring was reported to the Administrator. The SSD stated, It should have been on the grievance form. I did a search for it. The Surveyor asked if she had any documentation of the investigation besides the entry in the Progress Notes about calling the funeral home. The SSD stated, I did not feel at that time that it was [paused], I took it that they were not angry, and I looked everywhere. The way it was said that it was missing I did not feel it was reportable. Looking back, it maybe should have been. I should have made better notes and noted the grievance. I have learned from that experience. I will learn from that error.
6. On 02/15/23 at 9:20 AM, the Surveyor asked the Administrator what should be done if it was reported to the SSD that a resident was missing items. The Administrator stated, If it is missing items, then we search for them and complete a grievance. If it is a stolen item, then we do a reportable and start and investigation. The Surveyor asked if it should be documented of what all was done to find the missing or stolen items. The Administrator stated, Yes, it should be documented on the grievance log and documented in the resident's chart. The Surveyor asked if a grievance was completed in January 2022 when R107's family reported her ring missing. The Administrator checked his computer and stated, There is not a grievance listed for [Resident #107] in January last year.
7. On 02/16/23 at 10:12 AM, the Surveyor asked if the BOM received a response from the family regarding the bill. The BOM stated she received a letter and list of items. I opened it, and I showed it to [Administrator]. I submitted the write off after the response from the family came in the mail. [Administrator] and someone at corporate has to sign it and then I do not know after that. The Surveyor asked if she had any other interaction with the family after that point. The BOM stated, No, I gave the letter and invoice to [Administrator] and I do not know what was done after that.
8. On 02/16/23 at 10:17 AM, the Surveyor asked the Administrator if he remembered receiving a letter and invoice from Resident #107's family. The Administrator stated, Yes, I vaguely remember the letter but not an invoice. The Surveyor asked what steps he took after receiving the letter and invoice. The Administrator stated, We wrote off quite a few accounts in December and I believe [Resident #107] was one of them. We didn't pay it. We didn't do a grievance or anything else like that. The Surveyor asked if a reportable or investigation should have been performed. The Administrator stated, We do not do reportables when someone states an item is missing. The Surveyor showed the Administrator the letter and invoice and asked if a reportable was completed when the resident or family stated the items were stolen. The Administrator stated, Yes, if it is stated it is stolen it should have been a reportable. The Surveyor asked when the letter and invoice were received was an investigation completed. The Administrator stated, No, I do not believe one was done then because one was already done previously by [SSD].
9. On 02/16/23 at 4:30 PM, the Administrator provided Resident #107's, Resident's Personal Possessions, during her stay at the facility. A list of items signed by a family member or responsible party at or after discharge was not provided.
10. The facility policy titled, Abuse, Neglect, and Maltreatment Investigation & Reporting, provided by the Administrator on 02/13/23 at 3:10 PM documented, .The facility will endeavor to protect Resident/Elders from . the misappropriation of Resident/Elder property . 4. Reporting: All Others - 24 hour limit: If the events that cause the reasonable suspicion do not include allegations of abuse or serious bodily injury to a resident, the staff person shall report the suspicion no later than 24 hours after forming the suspicion .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for 1 (Resident #88) of 18 (Residents #2, #17, #21, #26, #31, #34, #35, ...
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Based on interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for 1 (Resident #88) of 18 (Residents #2, #17, #21, #26, #31, #34, #35, #42, #53, #55, #74, #88, #93, #94, #96, #97, #257 and #507) sampled residents whose MDS was reviewed. This failed practice had the potential to affect 107 residents who resided in the facility as documented on the Daily Census provided by the Administrator on 02/13/23. The findings are:
1. Resident #88 had diagnoses of Vascular Dementia without Behavioral Disturbance, Psychotic Disorder, and Mood Disorder with Hallucinations. The Quarterly MDS with an Assessment Reference Date (ARD) of 01/27/23 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a Brief Interview of Mental Status (BIMS) and had a Psychiatric Disorder (other than Schizophrenia).
2. The electronic records for Resident #88 contained a (State Designated Professional Associates) document dated 11/05/2021 documented, You recently submitted a Level I application . on the above client. (State Designated Professional Associates) has reviewed this application and has determined this client is a NON-PASRR [Preadmission Screening and Resident Review] client .
3. On 02/14/23 at 3:09 PM, the Surveyor asked MDS Coordinator #1, MDS Coordinator #2 and the MDS Consultant if they were able to locate the PASRR II for Resident #88. MDS Coordinator #1 stated she was a Non-PASRR client. MDS Coordinator #2 stated, Oh, on the Annual it says Bipolar. I do not know why it says that. MDS Coordinator #1 stated, We will have to do a correction and modification for 10/27/22. That explains it. The MDS Consultant stated, I want to make sure there was not a diagnosis code that was resolved. MDS Coordinator #2 stated, No, there is no resolved or struck out diagnosis. It pulled on both the Modification and the original Annual. MDS Coordinator #1 stated, Something somewhere is triggering it. We never have had one pulled like that before. It pulled on her Annual and her Quarterly. It is on all of them except the admission and the February 2022. MDS Coordinator #2 stated, May is the first one that is wrong. All since then are wrong too. MDS Coordinator #1 stated, We will get those corrected now. The Surveyor asked them who was responsible for ensuring the MDS accuracy. MDS Coordinator #1 stated, I have to close them out, but when I sign off on them an RN [Registered Nurse], I am signing that they are completed, but not completely accurate. The Surveyor asked how often the MDSs were reviewed. MDS Coordinator #1 stated, I do not think there is any RN that (paused) I don't believe there is a review done. The MDS Consultant stated, You are not signing for accuracy. MDS Coordinator #2 stated, I am the one that completed and did the May.
4. On 02/16/23 at 4:03 PM, the RN Consultant informed the Surveyor the facility did not have a policy regarding MDS assessments.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to reassess the effectiveness of interventions, and review and revise the Care Plan for 1 (Resident #74) of 4 (Residents #37, #5...
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Based on observation, record review, and interview, the facility failed to reassess the effectiveness of interventions, and review and revise the Care Plan for 1 (Resident #74) of 4 (Residents #37, #59, #63 and #74) sampled residents whose Care Plans were reviewed. This failed practice had the potential to affect all 4 residents in the Cottage who received Diabetic Nail Care as documented on the Diagnosis Report provided by the Administrator on 02/15/23 at 11:28 AM. The findings are:
1. Resident #74 had a diagnosis of Type 2 Diabetes Mellitus without Complication. The Significant Change Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 11/30/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Assessment (BIMS) and required extensive physical assistance of one person for personal hygiene and was totally dependent on two plus persons for bathing.
a. The Physician's Orders dated 12/04/21 documented, Diabetic Nail Care weekly (nurse to trim fingernails and toenails) . every day shift every Sat [Saturday] related to Type 2 Diabetes.
b. The Care Plan with a revision date of 01/11/23 documented, .Personal Hygiene: She requires extensive to total assistance with personal hygiene . prefers to do her own nail cares and likes to keep her manicure kit within reach, she refuses staff assistance for nail care. Resident has been determined safe to cut her nails and trim her cuticles independently. Remind her to keep her manicure tools zipped up in her kit when not in use .
c. On 02/13/23 at 10:41 AM, Resident #74 was lying in bed, her toenails were yellow, curled downward and extended ¼ inch beyond the tips of her toes. The Surveyor asked if she would like them to be cut. The resident answered, Yes.
d. On 02/15/23 at 9:39 AM, the Surveyor asked the Social Director when the Podiatrist was scheduled to visit the facility in the future. The Social Director could not give a date for the upcoming visit, stating, They give us a two week notice, then when they show up the Podiatrist goes room to room or sets up in one room and we bring the residents to them.
e. On 02/16/23 at 10:25 AM, the Surveyor asked the Director of Nursing (DON) who was responsible for updating the Care Plans. The DON answered, The MDS Coordinator. There are two of them, and we work together to keep them updated. The Surveyor asked the DON if a Care Plan should be updated after a significant change in the MDS. The DON answered, Yes.
f. On 02/15/23 at 9:39 AM, the Social Director provided a list dated 12/22/2022 of residents seen by the Podiatrist on the last visit. Resident #74 was not listed. The Social Director provided a list of residents selected to be seen on the next visit. Resident #74 was not listed.
g. On 02/16/23 at 4:03 PM, the Nurse Consultant reported the facility does not have a Care Plan policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to ensure Diabetic Toenail Care was provided for 1 (Resident #74) of 4 (Residents #37, #59, #63 and #74) sampled residents who w...
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Based on observation, record review, and interview, the facility failed to ensure Diabetic Toenail Care was provided for 1 (Resident #74) of 4 (Residents #37, #59, #63 and #74) sampled residents who were dependent on assistance with Diabetic Nail Care as documented on the Diagnosis Report provided by the facility Administrator on 02/15/23 at 11:28 AM. The findings are:
1. Resident #74 had a diagnosis of Morbid (Severe) Obesity due to Excess Calories, Type 2 Diabetes Mellitus without Complication, and Other Idiopathic Peripheral Autonomic Neuropathy. The Significant Change Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 11/30/2022 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Assessment (BIMS) and required extensive physical assistance of one person for personal hygiene and was totally dependent on two plus persons for bathing.
a. The Care Plan with a revision date of 12/13/22 documented, .Personal Hygiene: She requires extensive to total assistance with personal hygiene . has Diabetes Mellitus . Diabetic Toe Nail Care to be provided by Licensed Staff .
b. The February 2023 Physician Orders documented, .May see Podiatrist as needed . Order Date 03/02/2021 . Diabetic Nail Care weekly (nurse to trim fingernails and toenails) . every day shift every Sat [Saturday] related to Type 2 Diabetes . Order Date 12/14/2021 .
c. The February 2023 Treatment Administration Record (TAR) documented Diabetic Nail Care was performed on 02/04/23 by Certified Nursing Assistant (CNA) #5 and on 02/11/23 by Licensed Practical Nurse (LPN) #2.
d. On 02/13/23 at 10:41 AM, Resident #74 was lying in bed, her toenails were yellow, curled downward and extended ¼ inch beyond the tips of her toes. The toes had a reddened appearance. The Surveyor asked if she would like them to be cut. The resident answered, Yes.
e. On 02/14/23 at 10:05 AM, Resident #74 was lying in bed, her toenails were yellow, curled downward and extended ¼ inch beyond the tips of her toes. The toes had a reddened appearance.
f. On 02/15/23 at 3:25 PM, Resident #74 was lying in bed, her toenails were yellow, curled downward and extended ¼ inch beyond the tips of her toes. The toes had a reddened appearance.
g. On 02/14/23 at 2:50 PM, the Surveyor asked CNA #3 who was responsible for resident nail care. She answered, We are, unless the resident is diabetic. The Surveyor asked if Resident #74 was capable of performing her own nail care. She answered, No. She's been declining.
h. On 02/14/23 at 2:50 PM, the Surveyor asked CNA #4 what her responsibilities were. She answered, Nail care. I can file, polish, and paint them, but I can't cut diabetic's nails. The Surveyor asked who was responsible for cutting the nails of diabetic residents. She answered, We have a Podiatrist who comes around. The Surveyor asked when the last time the Podiatrist visited the facility. She answered, I don't know.
i. On 02/14/23 at 3:10 PM, Resident #74 was in the Common Room at the dining table. reclined in a Geri chair eating lunch. The surveyor asked if she was able to trim her own toenails. She answered, No.
j. On 02/15/23 at 9:00 AM, the Surveyor asked the Social Director the date of the last Podiatrist visit to the facility. She answered, It's been three to four months. The Surveyor asked the Social Director to provide a list of residents seen on the last Podiatrist visit and a list of residents to be seen on the next Podiatrist visit.
k. On 02/15/23 at 9:06 AM, the Surveyor asked LPN #2 if she performed nail care on diabetic residents in the Cottage. She answered, I can't cut nails, but I file them down as much as I can. I haven't been trained to cut diabetic nails and we don't have the right tools. The Surveyor asked if she recalled performing nail care on Resident #74 in the past week. She answered, Yes. Her nails are really thick so it's hard to file them. The Surveyor asked when the last time a Podiatrist had seen Resident #74. She answered, I'm not sure, it's been a while.
l. On 02/15/23 at 9:15 AM, the Surveyor asked the Administrator to provide a list of residents in the Cottage that were dependent or required assistance with diabetic nail care and the facility's policy on diabetic nail care.
m. On 02/15/23 at 9:39AM, the Surveyor asked the Social Director when the podiatrist was scheduled to visit the facility in the future. The Social Director could not give a date for the upcoming visit, stating, They give us a two-week notice, then when they show up the podiatrist goes room to room or sets up in one room and we bring the residents to them.
n. On 02/15/23 at 9:39 AM, the Social Director provided a list dated 12/22/2022 of residents seen by the Podiatrist on the last visit. Resident #74 was not on the list. The Social Director provided a list of residents selected to be seen on the next visit. Resident #74 was not on the list.
o. The facility policy titled, Nails, Care of (Finger and Toe, provided by the Administrator on 02/15/23 at 11:28 AM documented, .Basic Responsibility: Licensed Nurse performs the procedure on Diabetics. Nursing Assistants may perform the procedure on other residents. A Podiatrist may perform the procedure on residents per facility policy. Purpose 1. To provide cleanliness. 2. To prevent spread of infection. 3. For comfort. 4. To prevent skin problems . Procedure 1. Trim and clean nails; file smoothly. NOTE: FINGERNAILS OF DIABETIC RESIDENTS ARE TO BE CUT BY THE NURSE. NOTE: TOENAILS OF DIABETIC RESIDENTS ARE TO BE CUT BY THE PODIATRIST OR LICENSED NURSE .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0568
(Tag F0568)
Could have caused harm · This affected multiple residents
Based on interview, and record review, the facility failed to ensure residents received an individual Quarterly Financial Record Statement for 2 (Residents #58 and #74) of 13 (Residents #5, #10, #14, ...
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Based on interview, and record review, the facility failed to ensure residents received an individual Quarterly Financial Record Statement for 2 (Residents #58 and #74) of 13 (Residents #5, #10, #14, #17, #31, #46, #53, #55, #58, #65, #74, #81 and #83) sampled residents who had Trust Funds managed by the facility. This failed practice had the potential to affect 44 residents who had Trust Funds managed by the facility as documented on the Trust Transaction Current Account Balance received from the Business Office Manager (BOM) on 02/15/23. The findings are:
1. Resident #58 had a diagnosis of Diastolic (Congestive) Heart Failure. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/29/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview of Mental Status (BIMS).
a. On 02/14/23 at 10:22 AM, the Surveyor asked Resident #58 if the facility managed her money. Resident #58 answered, I get $40.00 per month. The Surveyor asked if she received statements from the facility. Resident #58 answered No.
2. Resident #74 had a diagnosis of Chronic Obstructive Pulmonary Disease. The Significant Change MDS with an ARD of 11/20/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS.
a. On 02/14/23 at 10:05 AM, Resident #74 reported to this Surveyor that the facility holds personal funds for her, but she does not receive quarterly statements from the facility.
3. On 02/15/23 at 10:18 AM, the Surveyor asked the BOM how often statements were provided. The BOM stated, Quarterly. The Surveyor asked the BOM how they were issued. The BOM stated, Through the mail. We do have some that we hand out here.
4. On 02/16/23 at 11:21 AM, the Surveyor requested from the BOM documentation that statements were provided to Resident #58 and Resident #74. The BOM stated, I do not have documentation. I mail them out. The Surveyor asked who they were given to. The BOM stated, If they do not have a responsible party and they are their own person then I give it to them. The Surveyor asked who received Resident #58's statements. The BOM stated, Her [family member]. He is the responsible party. The Surveyor asked of Resident #58 was competent and her own person. The BOM stated, Well, Yes. The Surveyor asked if Resident #58's [family member] was her Power of Attorney (POA). The BOM stated, I will have to look into that. The Surveyor asked if a responsible party was the same as a legal representative. The BOM stated, I think so. The Surveyor asked who received Resident #74's statements. The BOM stated, Her [family member]. She is the responsible party. The Surveyor asked if Resident #74 was competent and her own person. The BOM stated, I believe she is. The Surveyor asked if the resident is competent and their own person should the statements be sent to the responsible party of the resident/elder. The BOM stated, I will have to look into that.
5. On 02/26/23 at 11:40 AM, the Registered Nurse (RN) Consultant informed the Surveyor the facility did not have POA documentation for Resident #58 or Resident #74.
6. On 02/16/23 at 1:50 PM, the Surveyor asked the Administrator who should receive quarterly Trust Fund statements. The Administrator stated, Whoever is listed as the responsible party or to the resident if they are listed as their own person. The Surveyor asked if a responsible party was the same as a legal representative. The Administrator stated, Can be or cannot be. The Surveyor asked when POA's were active. The Administrator stated, When the resident is incapacitated or if the wording on the POA says another reason or situation. The Surveyor asked if a resident is their own person should they be receiving their statements and not the responsible party. The Administrator stated, Yes. Are they not?
7. The facility policy titled, Management of Resident and Elder Trust Accounts, provided by the RN Consultant on 02/16/23 at 3:01 PM documented, .The Resident/Elder's individual financial record is available through quarterly statements .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0574
(Tag F0574)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure contact information for the State Long-Term Care Ombudsman, the Office of Long Term Care (OLTC) Complaint Department w...
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Based on observation, interview, and record review, the facility failed to ensure contact information for the State Long-Term Care Ombudsman, the Office of Long Term Care (OLTC) Complaint Department were posted and readily accessible to all 11 residents who resided in the Cottage at the facility. The findings are:
1. On 02/13/23 at 11:00 AM, the Surveyor was unable to locate an Ombudsman or OLTC information poster in the cottage at the facility.
2. On 02/14/23 at 2:30 PM, the Surveyor asked Resident #63, the Resident Council President of the Cottage, if the Cottage had an Ombudsman poster. He answered, I have not seen one.
3. On 02/14/23 at 2:45 PM, the Surveyor asked Resident #59 if she knew where the Ombudsman poster was. She answered, We don't have a poster.
4. On 02/14/23 at 3:00 PM, the Surveyor asked Certified Nursing Assistant (CNA) #5 where the Ombudsman poster was located. CNA #5 stated, When they built the Cottage, we were told there couldn't be anything on the walls, because this is supposed to be more homelike. The Surveyor asked if the Ombudsman poster was in a binder. CNA #5 answered, They have a lot of binders, but I haven't seen one with the Ombudsman's information in it.
5. On 02/15/23 at 1:43 PM, the Surveyor asked the Administrator where the Ombudsman and OLTC Complaint information was located in the Cottage. The Administrator stated, Should be in a white binder. The Surveyor asked where the binder was kept. The Administrator stated, On a table. It's homelike, not a traditional model. It was set up that way and that's the way the training went. The Administrator stated the residents are told when they move in. The Surveyor asked who was the person that informs them. The Administrator stated, Someone should tell them. Whoever does the admission.
6. On 02/15/23 at 2:02 PM, the Surveyor asked Resident #63, the Resident Council President of the Cottage, if the Surveyors could go through the cabinets in the Main Living Area of the Cottage. Resident #63 stated, Yes, that would be fine. The Surveyor located a white binder in the back of the cabinet next to the fireplace titled, Information Binder Ombudsman Information, Resident Rights, Recent Surveys, Workers Comp, on the bottom shelf with 2 other binders on top. Included in the binder was an 8 ½ inch x 11 inch piece of paper with the Ombudsman poster copied on it and an 8 ½ inch x 11 inch piece of paper with the Resident Rights poster copied on it. The Surveyor took the binder to Resident #63 in his room and showed him the binder. Resident #63 stated he had not seen that binder before. The Surveyor took the binder to Resident #59 in her room and showed her the binder. Resident #59 stated she had not seen the binder before.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0576
(Tag F0576)
Could have caused harm · This affected multiple residents
Based on interview, and record review, the facility failed to ensure mail was provided on Saturdays to honor resident rights and prevent potential delays in receipt of mail. This failed practice had t...
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Based on interview, and record review, the facility failed to ensure mail was provided on Saturdays to honor resident rights and prevent potential delays in receipt of mail. This failed practice had the potential to affect all 107 residents who resided in the facility as documented on the Resident Census and Conditions of Residents provided by the Administrator on 02/14/23. The findings are:
1. On 02/15/23 at 10:45 AM, during a Resident Council Meeting, the Surveyor asked Residents #37, #59, #63, #70, and #71 if they received mail on Saturdays. The five residents in attendance stated they do not receive mail on Saturdays. Resident #63 and Resident #37 stated they see mail and packages delivered to the main building on Saturdays, but they don't receive mail on Saturdays.
2. On 02/15/23 at 1:38 PM, the Surveyor asked the Activities Director if she was responsible for passing out the mail to the residents. She replied, Yes, I am responsible for the mail. The Surveyor asked when it is handed out. She replied, When, every day that mail comes. Usually, every day when I am here, I pass it. The Surveyor asked who handles the mail on the weekend when she is not at the facility. She replied, It can be delivered, but since the Business Office Manager (BOM) and me do the mail and checks, then they only [pause] usually no. When I get back Monday, I have a pile from the weekend, and they get their mail.
3. On 02/15/23 at 1:43 PM, the Surveyor asked the Administrator when residents should receive their mail. The Administrator stated, When it comes in. The Surveyor asked who was responsible for obtaining the mail and passing it out to the residents. The Administrator stated, I've taken it to [Activities Director] and [BOM] and I've called staff to come over. The Surveyor asked if he obtains the mail on Saturdays. The Administrator stated, No, I do not check the mail on Saturdays. The Surveyor asked if he was aware of anyone being assigned to deliver mail on Saturdays. The Administrator stated, No, I am not aware.
4. The facility policy regarding Mail provided by the Registered Nurse Consultant on 02/16/23 at 3:01 PM documented, .Mail or other materials will be delivered to the Resident/Elder within 24 hours except when there are no regularly scheduled postal hours .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure the confidentiality of resident records were kept private by locking the computer screens when not in use. This failed...
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Based on observation, interview, and record review, the facility failed to ensure the confidentiality of resident records were kept private by locking the computer screens when not in use. This failed practice had the potential to affect 93 residents who received medication from the medication carts in the facility's main building as documented on a list provided by the Registered Nurse (RN) Consultant on 02/16/23 at 4:03 PM. The findings are:
1. On 02/14/23 at 8:19 AM, during the morning medication pass the Surveyor observed Licensed Practical Nurse (LPN) #4 walk away from the computer with it left open and visible to anyone walking by the computer. LPN #4 walked off the hall then into the medication room.
2. On 02/14/23 at 8:26 AM, the Surveyor asked LPN #4 if she was aware that she had walked away from the computer with the medical record visible during medication pass. She stated, That is when I went to the Medication Room to find those updrafts. The Surveyor asked what could happen if a computer was left open with a resident's information on it visible to anyone. LPN #4 stated, Somebody can see something they aren't supposed to see. The Surveyor asked what would that be called. She stated, HIPPA [Health Insurance Portability and Accountability Act].
3. On 02/14/23 at 3:30 PM, the Surveyor observed LPN #5 with
3 other staff standing in front of a room on the 300 Hall talking. The Surveyor noted the computer with approximately a dozen residents' names and information in boxes on the screen sitting on the medication cart, approximately 15 feet from the staff talking. The Surveyor watched and waited by the medication cart. LPN#5 returned to the medication cart four minutes later and the Surveyor asked her if she saw an issue. LPN #5 stated, Yes, I left the computer on. I had to go stop a staff from going in a room. The Surveyor asked her about the conversation for the next few minutes following her stopping the staff. LPN #5 stated, No, I should have come back to the computer right away. Sorry, I am new and still getting all this down. The Surveyor asked her what the concern was with leaving the computer on. LPN #5 stated, The information that is left up on the screen.
4. On 02/15/23 at 10:25 AM, the 300 Hall medication cart computer was left opened with a resident ' s medical record visible for anyone to see. There was no nurse in sight. The Social Director walked by and closed out the computer and stated, They have been told to lock out of their computer if they walk away.
5. On 02/15/23 at 10:39 AM, the Surveyor asked LPN #3 if she realized that she had left the computer opened. LPN #3 looked down at the computer and said, I was told that I could just lower the top of the computer and that it would be ok. The Surveyor asked what could happen if the computer was left open and the residents medical record was visible. LPN #3 stated, Someone could read it and a HIPPA violation could happen, and someone could get information.
6. On 02/16/23 at 3:38 PM, the Surveyor asked the Director of Nursing (DON) if the computer should be left open with resident information visible for anyone to see. She stated, No. The Surveyor asked what could happen. The DON stated, HIPPA, their picture, and medical record is open for whoever goes by.
7. The facility policy titled, Confidentiality of Social and Medical Record Information, provided by the RN Consultant on 02/16/23 at 3:01 PM documented, .Privacy and Confidentiality . Residents/Elders' personal and medical records are protected to assure confidentiality .
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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
Based on interview, and record review, the facility failed to ensure a report of stolen and/or missing items was thoroughly investigated and documented to determine if misappropriation of the resident...
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Based on interview, and record review, the facility failed to ensure a report of stolen and/or missing items was thoroughly investigated and documented to determine if misappropriation of the resident's property occurred for 1 (Resident #107) of 1 sampled resident whose family had reported items missing. The findings are:
1. Resident #107 had a diagnosis of Alzheimer's Disease with Late Onset.
2. The Letter dated 12/08/22 and an Invoice from Resident #107's family received by the facility for the loss or stolen items while Resident #107 was in the facility was reviewed. The Invoice documented, .Personal Property lost or stollen: Dozens of articles of clothing over a 12-year period with an average purchase price of $25 $1800.00 Two prescription glasses $800.00 Silver Wedding Ring $125.00 Total; Payable upon receipt $2725.00 .
3. Resident #107's Progress Notes contained the following documentation:
a.1/17/2022 14:51 [2:51 PM] Social Note Late Entry: Note Text: Resident't [Resident's] [family member] came to get her personal items - He took w/c [wheelchair], photo albums, a jewelry box, 2 corkboards with photos, a box of photos and cards, some jewelry Social Services .
b.1/18/2022 10:05 [10:05 AM] DC [Discharge] Summary Note Text: .Disposition of personal belongings: Family picked up W/C and pictures. Donated Clothing to facility . Nursing .
c.1/19/2022 14:50 [2:50 PM] Social Note Note Text: Called .funeral home in [City] looking for her wedding band - They will call me back if they find anything. I went through all of her personal belongings twice looking for the ring. Social Services .
4. On 02/15/23 at 8:26 AM, the Surveyor asked the Administrator when incidents are reported to OLTC. The Administrator stated, Within 2 hours of being an allegation of abuse, neglect, misappropriation of property, sexual, verbal, or physical abuse. The Surveyor asked what meets the criteria for misappropriation of property. The Administrator stated, When someone says this is missing, they are not alleging misappropriation. We treat that as a grievance and do that or reconcile that. If they are alleging that a facility employee said they got rid of it, then that is misappropriation. The Surveyor asked if the Administrator had received any notifications by letter of any items being stolen or missing. The Administrator stated, No, I have not received a letter notifying us of anything missing. Typically, if we suspected it and someone stole something or purposefully threw it away, we would report it.
5. On 02/15/23 at 9:08 AM, the Surveyor asked the Social Services Director (SSD) when she reports a resident's lost or stolen belongings. The SSD stated, It depends on how they say it. If they say it has been stolen, then I tell [Administrator]. If they say it is just missing, that is a grievance process and I document how the search was. It depends if they come at me. If it is regarding staff, then [Administrator] is the one that handles it. The Surveyor asked if Resident #107's missing ring was reported to the Administrator. The SSD stated, It should have been on the grievance form. I did a search for it. The Surveyor asked if she had any documentation of the investigation besides the entry in the Progress Notes about calling the funeral home. The SSD stated, I did not feel at that time that it was [paused], I took it that they were not angry, and I looked everywhere. The way it was said that it was missing I did not feel it was reportable. Looking back, it maybe should have been. I should have made better notes and noted the grievance. I have learned from that experience. I will learn from that error.
6. On 02/15/23 at 9:20 AM, the Surveyor asked the Administrator what should be done if it was reported to the SSD that a resident was missing items. The Administrator stated, If it is missing items, then we search for them and complete a grievance. If it is a stolen item, then we do a reportable and start and investigation. The Surveyor asked if it should be documented of what all was done to find the missing or stolen items. The Administrator stated, Yes, it should be documented on the grievance log and documented in the resident's chart. The Surveyor asked if a grievance was completed in January 2022 when Resident #107's family reported her ring missing. The Administrator checked his computer and stated, There is not a grievance listed for [Resident #107] in January last year.
7. On 02/16/23 at 10:12 AM, the Surveyor asked if the BOM received a response from the family regarding the bill. The BOM stated she received a letter and list of items. I opened it, and I showed it to [Administrator]. I submitted the write off after the response from the family came in the mail. [Administrator] and someone at corporate has to sign it and then I do not know after that. The Surveyor asked if she had any other interaction with the family after that point. The BOM stated, No, I gave the letter and invoice to [Administrator] and I do not know what was done after that. On 12/08/22, a letter and invoice from Resident #107 ' s family was received by the facility for the loss items while she was in the facility.
8. On 02/16/23 at 10:17 AM, the Surveyor asked the Administrator if he remembered receiving a letter and invoice from Resident #107's family on 12/08/22. The Administrator stated, Yes, I vaguely remember the letter but not an invoice. The Surveyor asked what steps he took after receiving the letter and invoice. The Administrator stated, We wrote off quite a few accounts in December and I believe [Resident #107] was one of them. We didn't pay it. We didn't do a grievance or anything else like that. The Surveyor asked if a reportable or investigation should have been performed. The Administrator stated, We do not do reportables when someone states an item is missing. The Surveyor showed the Administrator the letter and invoice and asked if a reportable was completed when the resident or family stated the items were stolen. The Administrator stated, Yes, if it is stated it is stolen it should have been a reportable. The Surveyor asked when the letter and invoice were received was an investigation completed. The Administrator stated, No, I do not believe one was done then because one was already done previously by [SSD].
9. On 02/16/23 at 4:30 PM, the Administrator provided Resident #107's, Resident's Personal Possessions, during her stay at the facility, A list of items signed by a family member or responsible party at or after discharge was not provided.
10. The facility policy titled, Abuse, Neglect, and Maltreatment Investigation & Reporting provided by the Administrator on 02/13/23 at 3:10 PM documented, .The facility will endeavor to protect Resident/Elders from . the misappropriation of Resident/Elder property . 3. Identification and Investigation . The Administrator or Administrator's designee will conduct an immediate investigation of all alleged or actual incidents of abuse, neglect, or misappropriation of property .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to ensure bathing services were regularly provided and chin hairs were removed to maintain good hygiene for 1 (Resident #93) of ...
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Based on observation, record review, and interview, the facility failed to ensure bathing services were regularly provided and chin hairs were removed to maintain good hygiene for 1 (Resident #93) of 30 (Residents #5, #10, #14, #16, #17, #18, #31, #35, #37, #42, #44, #50, #58, #59, #63, #65 #66, #70, #71, #83, #88, #93, #96, #96, #97, #99, #100, #104, #157, #457 and #507 sampled residents who required assistance with bathing and/or grooming. This failed practice had the potential to affect 74 residents who required assistance from staff for bathing/showers according to a list provided by the Registered Nurse (RN) Nursing Consultant on 02/16/23 at 4:03 pm. The findings are:
1. Resident #93 had diagnoses of Chronic Kidney Disease, Stage 4 (Severe) Dementia, Moderate with Anxiety, Alzheimer's Disease with Late Onset, Nondisplaced Intertrochanteric Fracture of Right Femur, Subsequent Encounter for closed Fracture with Routine Healing and Nondisplaced Lateral Mass Fracture of First Cervical Vertebra. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/22 documented the resident scored 12 (8-12 indicates moderately cognitively impaired) on a Brief Interview of Mental Status (BIMS) and required limited physical assistance of one person for personal hygiene and bathing.
a. The Care Plan with a revision date of 12/27/22 documented, .has an ADL [Activities of Daily Living] ADL self-care performance deficit . Bathing: Requires extensive assistance with bathing . Dressing: Requires extensive assistance with dressing . Personal Hygiene/oral care: She requires extensive assist [assistance] of x [times] 1 staff for personal hygiene and oral care. She frequently refuses nail cares, continue to offer, and encourage, but respect her choice .
b. The February 2023 Bathing Self Performance sheet provided by the Director of Nursing (DON) on 02/16/23 at 12:06 pm documented, .Resident Refused . with check mark on 02/08/23 at 23:36 [11:36 pm] and 02/11/23 at 03:34 [3:34 am] . and Not Applicable .with check marks on every day except for 02/08/23 at 23:36 and 02/11/23 at 03:34 . Upon observation of the Bathing Self Performance sheet, the surveyor asked the DON what Not Applicable (n/a) means. She stated, That's not a shower day.
c. On 02/13/23 at 12:13 pm, Resident #93 was lying in bed and stated, I have not had a bath or shower since being here, and have not been shaved. I look horrid. She had facial hair on her chin and left upper side of her lip, that was thick and approximately 1/4 long.
d. On 02/15/23 at 10:15 am, Resident #93 was in her room sitting in a wheelchair (w/c). She was wearing the same dress she had on two days before. The Surveyor asked if she had been given a shower yet. She stated, No, I haven't had one since I've been moved from that Cottage and look (rubbing her chin hair with her fingers), I need all this hair off my chin.
e. On 02/16/23 at 1:50 pm, Resident #93 was in her room sitting in her w/c. She was wearing a different dress, her hair was pulled back in ponytail and her chin hair had been removed. The Surveyor asked if she had her shower. She stated, Yes, I had a shower and I feel so much better.
f. On 02/17/23 at 9:16 am, the Surveyor asked Certified Nursing Assistant (CNA) #10, How often are residents supposed to get showers? She stated, Twice a week unless care planned. The Surveyor asked, On the Bathing Self Performance sheet, what does n/a mean? CNA #10 stated, Showers are assigned for certain days by hall and room number. When residents get moved to another room/hall for different reasons, it may show that it is not their designated shower day. I'm on the shower team so the only reason I would check n/a is because it isn't their scheduled day. The Surveyor asked, Can residents get showers when it isn't their scheduled day? CNA #10 stated, Yes. The Surveyor asked, Who shaves the residents? CNA #10 stated, They usually get shaved during showers unless they refuse. The Surveyor asked, Can all CNAs shave residents? CNA #10 stated, Yes.
g. On 02/17/23 at 9:35 am, the Surveyor asked CNA #11, How often are residents supposed to get showers? She stated, Twice weekly unless they ask to have more. The Surveyor asked if she was familiar with Resident #93. She stated, Yes. The Surveyor asked how often Resident #93 was scheduled to receive showers. She stated, Twice weekly on the 3-11 [3:00 pm to 11:00 pm] shift. The Surveyor asked, On the Bathing Self Performance sheet, what does n/a mean? CNA #11 stated, You check that when you don't give showers for any reason. The Surveyor asked, Can residents get a shower when it isn't their scheduled day? CNA #11 stated, Yes, we try to get the residents who are scheduled for that day first, but they are worked in. The Surveyor asked, What do you do when a resident complains of not getting a shower? She stated, I try to figure out why she hasn't had one, then give them a shower as soon as I can.
h. On 02/17/23 at 9:40 am, the Surveyor asked License Practical Nurse (LPN) #3, How often are residents supposed to get showers/bathing? She stated, Twice a week, but they can have more if they want. The Surveyor asked, What does n/a mean on the bathing sheet? She stated, It means maybe they were not here, maybe they refused, or Hospice did their bathing. The CNAs tell me when a resident refuses a scheduled bath. The Surveyor asked, Who is responsible for shaving faces, and can all CNAs perform it? She stated, Nursing and CNAs are responsible. As long as the CNAs are certified and have been checked off on that. We have a shower team and shaving should be an option at that moment. The Surveyor asked, What would you do if a resident complained that they didn't get a shower? She stated, I would make sure the resident got a shower or bed bath even if I had to give it myself.
i. On 02/16/23 at 4:03 pm, the RN Consultant stated, The facility does not have a policy/procedure on showering and facial shaving.
j. On 12/22/20 at 11:05 am, during a telephone interview with the DON, the Surveyor asked, Who is responsible for giving the resident showers? The DON stated, The CNAs. The Surveyor asked, Is there a shower team? The DON stated, No team now, we used to have one, but we've had several people quit, so the shower CNAs now have to work the floor. The Surveyor asked, Is the facility short staffed at this time? The DON stated, Yes, we've been short for about 2 weeks now. The Surveyor asked, Who fills in and takes care of the residents since you have been short staffed? The DON stated, The nurses, the DON, the ADON [Assistant Director of Nursing]. Last weekend we had someone come in designated to do showers. The Surveyor asked, When is nailcare performed? The DON stated, With the showers.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure the metal bolts securing toilet seats were cut to a safe length to prevent potential accidents and injury to residents...
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Based on observation, interview, and record review, the facility failed to ensure the metal bolts securing toilet seats were cut to a safe length to prevent potential accidents and injury to residents on the Secure Unit for 1 (Resident #96) of 7 (Residents #18, #65, #66, #88, #96, #99 and #100) sampled residents who were able to stand and move on their own. The failed practice had the potential to affect 18 residents on the Secure Unit who were able to stand and move on their own as documented on a list provided by the Registered Nurse (RN) Consultant on 02/17/23. The findings are:
1. Resident #96 had a diagnosis of Alzheimer's Disease. The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 01/20/23 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview of Mental Status (BIMS) and required extensive physical assistance of one person with transfers and toilet use and was not steady and only able to stabilize with staff assistance when moving from seated to standing position, on and off the toilet and from surface to surface transfer and has had two falls since admission.
a. On 02/13/23 at 12:15 PM, Resident #96's family member informed the Surveyor she had concerns regarding the screw sticking up from the toilet bottom since he [Resident #96] has fallen in the bathroom. She stated he does not understand that he should not get up on his own.
b. The Care Plan with a revision date of 01/03/23 documented, . is at risk for falls . 10/14/2022-fell in bathroom, he is to wear non-skid socks to bed .
c. The 01/01/23 to 01/31/23 and 02/01/23 to 02/13/23 Incident and Accident lists provided by the Administrator on 02/13/23 at 1:13 PM documented, . Fall Un-Witnessed Incidents . [Resident #96] . 2/12/23 7:30 AM . 1/3/23 1:15 AM . 1/13/23 11:15 PM .
d. On 02/13/23 at 2:00 PM, the Surveyor accompanied the Maintenance Supervisor to the Secure Unit. The Surveyor entered Resident #96's room and asked the Maintenance Supervisor if he was responsible for repair to the toilets. He stated he was. The Surveyor pointed to the screw sticking approximately 3 inches up from the nut on the screw and asked the Maintenance Supervisor what could happen if a resident fell while in the bathroom. The Maintenance supervisor stated, They could get a scratch, or they could get really hurt. The Surveyor accompanied the Maintenance Supervisor to 7 of the 12 resident occupied rooms on the Secure Unit and found all had screws sticking up approximately 3 inches past the nut. The Maintenance Supervisor stated, I can get them cut down. I never thought of it as a problem. I guess they could get hurt.
e. On 02/13/23 at 2:30 PM, the Surveyor asked the Administrator if he was aware of the screws sticking up from the base of the toilets in the Secure Unit. The Administrator stated he was not. The Surveyor asked if the Administrator felt the screws could be a safety issue. He stated, I have done this for 13 years and have never had anyone get hurt on a toilet screw.
f. The facility policy titled, Accident Hazards Prevention, provided by the Registered Nurse (RN) Consultant on 02/17/23 at 8:39 AM documented, .Resident Environment. The environment will be free from accident hazards as is possible . An effective way for the facility to avoid accidents is to develop a culture of safety and commit to implementing systems that address resident risk and environmental hazards to minimize the likelihood of accidents. A facility with a commitment to safety: .6. Demonstrates a commitment to safety at all levels of the organization .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to ensure a residents Continuous Positive Airway Pressure (CPAP) mask was properly stored when not in use to prevent potential c...
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Based on observation, record review, and interview, the facility failed to ensure a residents Continuous Positive Airway Pressure (CPAP) mask was properly stored when not in use to prevent potential contamination that could result in respiratory infection and failed to ensure a malfunctioning CPAP machine was reported and replaced in a timely manner consistent with professional standards of practice and to prevent possible respiratory complications for 1 (Resident #34) of 2 (Residents #34 and #507) sampled residents who had Physician Orders for CPAP. The findings are:
1.Resident #34 had a diagnosis of Obstructive Sleep Apnea. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/20/22 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS) did not receive oxygen therapy.
a. The Clinical Physician Orders in the Facility Computer Software documented, .Apply CPAP at (bedtime) . On Hold 8/15/2022 . CPAP to be cleaned weekly . On Hold . 10/15/2022 . The February 2023 Physician Orders did not contain an order for CPAP usage/care.
b. The Care Plan with a revision date of 12/27/22 did not address CPAP usage and/or care.
c. On 02/13/23 at 01:11 PM, Resident #34 was lying in bed. A CPAP mask was lying on the bedside table, not in a bag. The mask appeared to have intermittent coating of a white and yellow colored substance throughout the inside of the mask.
d. On 02/14/23 at 08:56 AM, Resident #34 was lying in bed. A CPAP mask was lying on the bedside table, not in a bag. The Surveyor asked Resident #34 if the CPAP was used every night. Resident #34 stated No, it doesn't work. The Surveyor asked how long it had not been working. Resident #34 stated, I don't know.
e. On 02/15/23 at 10:44 AM, the Surveyor asked the Director of Nursing (DON) if she was aware of Resident #34's CPAP machine not functioning. The DON said she had not heard about that and asked the Treatment Nurse about it, who stated it was on the 24 hour report.
f. The 24 Hour Report dated 02/15/23 provided by the Assistant Director of Nursing (ADON) on 02/15/23 at 11:02 AM, documented at the bottom of the page, Notes: [Resident # 34] - CPAP not working correctly, system fault error 001 phone number listed . The ADON said she had called the phone number at the bottom of the form today. They said the CPAP had to be replaced. The Surveyor requested the original 24 hour report that documented the first date the CPAP was not working.
g. The 24 Hour Report dated 01/28/23 provided by the ADON on 02/15/23 at 11:40 AM documented at the bottom of the page, .Resident #34] CPAP not working correctly system fault error 001 handwritten with phone number at bottom of the form .
h. The February 2023 Treatment Administration Record (TAR) documented, .Apply CPAP at (bedtime) at bedtime - Start Date - 08/15/2022 2000 [8:00 PM] . CPAP to be cleaned weekly - must take apart and clean reservoir. In the morning every Sat [Saturday] - Start Date - 10/15/2022 0700 [7:00 AM] . The TAR was checked off as the CPAP being applied every day starting on 02/01/23 through 02/14/23 and as the CPAP being cleaned on 02/04/23 and 02/11/23.
2. The facility policy titled, Respiratory Care, provided by the Administrator on 02/16/23 at 8:30 AM documented, .Policy. The facility will ensure residents that need respiratory care, including tracheostomy care and suctioning, will be provided consistent with professional standards of care . The policy did not address CPAP usage/care.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served in accordance with the planned, written menu to meet the nutritional needs of the resid...
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Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served in accordance with the planned, written menu to meet the nutritional needs of the residents for 1of 2 meals observed. This failed practice had the potential to affect 6 residents who received pureed diets and 32 residents who received mechanical soft diets, 59 residents who received regular diets, in the Main Building and the residents on pureed diets were to receive a #8 scoop of pureed 4 Layer Delight according to a list provided by Dietary Supervisor on 02/14/23 at 2:27 PM. The findings are:
1. The facility menu for the lunch meal provided by the Dietary Supervisor documented the residents who received regular diets and mechanical soft diets were to receive 1/2 cup of Chopped Lettuce with Tomatoes and residents on pureed diets were to receive a #8 scoop of pureed 4 Layer Delight.
2. On 02/13/23 at 12:39 PM, the following observations were made during the noon meal service in the kitchen:
a. Dietary Employee (DE) #2 used a tong to portion a pinch of Shredded Lettuce with Diced Tomatoes onto the residents' plates.
3. On 02/13/23 at 1:21 PM, the following observations were made during the noon meal service:
a. On 02/13/23 at 12:55 PM, the residents who received meal trays in the Unit were served a pinch of Salad. Licensed Practical Nurse #1 was asked, How much Salad do the residents receive? She stated, That doesn't look like a half cup. It was a pinch.
b. Residents on regular diets and residents on mechanical soft diets were served a pinch of Shredded Lettuce with Diced Tomatoes, instead of ½ cup as specified on the menu.
c. The residents on pureed diets were served Pudding, instead of 4 Layer Delight.
d. On 02/13/23 at 1:38 PM, DE #1 and DE #2 were asked, How much Shredded and/or Chopped Lettuce and Tomatoes should the residents have? They both stated, I thought we were supposed to give a pinch of it like garnishing. At 1:46 PM, DE #2 was asked the reason the residents on pureed diets did not receive pureed 4 Layer Delight. She stated, We ran out of 4 Layer Delight, and we gave Pudding to the residents on pureed diets.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, and interview, the facility failed to ensure staff washed their hands between dirty and clean tasks and before handling clean dishes or food items to prevent the potential for fo...
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Based on observation, and interview, the facility failed to ensure staff washed their hands between dirty and clean tasks and before handling clean dishes or food items to prevent the potential for food borne illness for residents who received meals from 1 of 2 kitchens; failed to ensure dairy products were maintained at or below a temperature of 41 degrees Fahrenheit; failed to ensure expired food items were promptly removed/discarded by the expiration or use by dates to prevent the potential for food borne illness for residents who received meals from 2 of 2 kitchens. These failed practices had the potential to affect 85 residents who received meals from the Main Kitchen and 11 residents who received meals from the Cottage (total census:107), as documented on the list provided by Dietary Supervisor on 02/14/23 at 2:27 PM. The findings are
1. On 02/13/23 at 10:15 AM, Dietary Employee (DE) #1 turned the hand washing sink faucet and washed her hands. She turned off the faucet with her bare hands, contaminating her hands. Without washing her hands, she picked up clean dishes and placed them on a rack with her fingers touching the interior surfaces of the dishes
2. On 02/13/23 at 10: 25 AM, the following items were in a milk crate on a cart in the walk-in refrigerator:
a. 21 cartons of whole milk.
b. 25 carons of sugar free Vanilla Mighty Shakes.
c. One half gallon of Chocolate Milk.
d. One half-gallon of cultured Bulgarian Style Buttermilk.
All the dairy products were warm to the touch. The Dietary Supervisor stated, They were left over from breakfast.
3. The Surveyor asked the Dietary Supervisor to check the internal temperature of the milk. The temperatures were as follows:
a. Whole Milk - 46 degrees Fahrenheit.
b. Mighty Shake - 50 degrees Fahrenheit. The manufacture specification on the carton stated, Store frozen, thaw at low 40 degrees Fahrenheit. Use product within 14 days and keep refrigerated.
c. Cultured Bulgarian Style Buttermilk - 53 degrees Fahrenheit.
d. Chocolate Milk - 47 degrees Fahrenheit.
4. On 02/13/23 at 10:34 AM, DE #1 turned on the hand washing sink faucet and washed her hands. She turned off the faucet and without washing her hands, she picked up tomatoes, placed them on the cutting board and diced them. She then picked up the diced tomatoes and placed them in a container to be served to the residents for the lunch meal.
5. On 02/13/23 at 10:44 AM, one 5-pound container of cottage cheese with an expiration date of 2/4/2023 was stored on a shelf in the walk-in refrigerator.
6. On 02/13/23 at 11:04 AM, DE #2 turned on the hand washing sink faucet and washed her hands. She turned off the faucet and without washing her hands she picked glasses by their rims and placed them on a tray to be used in serving beverages to the residents for the lunch meal. The Surveyor asked, What should you have done after touching dirty objects and before handling clean objects? She stated, Washed my hands.
7. On 02/13/23 at 11:57 AM, DE #1 turned on the 3-compartment sink and rinsed the inside of a pan. DE #1 picked up a spray bottle and sprayed inside the pan. Without washing her hands, she pushed the blade down that was attached on the base of the blender and continued to puree chili to be served to the residents on pureed diets. At 11:58 AM, DE #1 placed 7 servings of shredded cheese on top of the chili and pureed.
8. On 02/13/23 at 12:12 PM, DE #3 removed a bottle of grape jelly, a container of pimento cheese, and a container of peanut butter and placed them on the counter. He picked up a bag of bread from the bread rack and placed it on the counter. He turned on the hand washing sink and washed his hands. He turned off the faucet with his bare hands contaminating his hands. He removed gloves from the glove box and placed them on his hands, contaminating the gloves. At 12:18 PM, he removed a ziplock bag that contained slices of cheese and a ziplock bag that contained slices of ham from the walk-in refrigerator and placed them on the counter and untied the bag of bread. At 12:20 PM, when he was ready to remove slices of bread from the bread bag. The Surveyor immediately stopped him and asked, What should you have done after touching dirty objects and before handling clean objects? He stated, Rewash my hands and put on new gloves.
9. On 02/14/23 at 4:53 PM, in the Cottage, Certified Nursing Assistant (CNA) #1 turned on the hand washing sink, she washed the blender bowl and the blade with hot water and soap. She placed them in the dish washing machine. She washed her hands and then turned off the faucet with her bare hands. Without washing her hands, she picked up a clean blade from the dish washing machine and attached it to the base of the blender to be used in grounding food items for a resident on a mechanical soft diet. The Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, Washed my hands.
10. On 02/14/23 at 5:12 PM, in the Cottage, CNA #1 pushed a cart towards the ice machine, contaminating her hands. Without washing her hands, she picked up glasses with her fingers inside the glasses and placed them on the cart to be used in serving beverages to the residents for supper meal. The Surveyor immediately asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, Washed my hands.
11. The facility policy titled, Handwashing and Glove Usage in Food Service, provided by the Dietary Supervisor on 02/14/23 at 2:27 PM documented, .Food handlers must wash their hands: After touching anything else such as dirty equipment, work surfaces or cloths. After leaving and returning to the kitchen/prep area .
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0565
(Tag F0565)
Minor procedural issue · This affected multiple residents
Based on interview, and record review, the facility failed to ensure the residents residing in the Cottage at the facility were allowed to hold Resident Council meetings without staff present. The fin...
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Based on interview, and record review, the facility failed to ensure the residents residing in the Cottage at the facility were allowed to hold Resident Council meetings without staff present. The findings are:
1. On 02/14/23 at 2:45 PM, the Surveyor asked Resident #59 if the Cottage residents were allowed to have Resident Council meetings without a staff member present. She answered, No. I was the council president, and I called a meeting. They didn't like it that I called a meeting without a staff member present, so I resigned.
2. On 02/15/23 at 10:45 AM, during a Resident Council meeting the Surveyor asked Residents #37, #59, #63, #70 and #71 if they were allowed to hold Resident Council Meetings without staff present. Resident #59 stated, We were told we did have to have staff present. Resident #63 stated, We were told we could not have a meeting without them. Resident #70 stated, We haven't had that many meetings because of that. Resident #37 stated, I have never been to one that was just residents. Resident #59 stated, We don't even know there is going to be a meeting until they are here. Resident #59 stated, They talk about things that they are gonna do and don't ask us if there are any concerns. Resident #63 stated, It is her meeting not our meeting. Resident #70 stated, We have very little rights. Resident #59 stated, It feels like I'm in jail. Resident #63 stated, This must be what a concentration camp feels like. Resident #37 stated, We don't go to their staff meetings, so they should not come to ours. The Surveyor asked who told them they could not have one without staff. Resident #63 and Resident #59 stated (Administrator) told them. Resident #70 and Resident#37 stated (Activity Director) told them.
3. On 02/15/23 at 1:38 PM, the Surveyor asked the Activity Director if the Resident Council could meet without staff. The Activity Director stated, Usually since I have been working here, no. I let them know what is going on. The Surveyor asked what the Resident Council was for. The Activity Director stated, It is for updating activities from the month before and the next month and we decide on the meal of the month and what activities for the next month we come up with and we go over 2 rights each time and then if they have any complaints or issues. I will bring the grievance forms and they have to fill those out, and I do not put any of them on the Resident Council report. The Surveyor asked her to clarify that she fills out the form that states what happens in the Resident Council meeting. The Activity Director stated, Yes, I will fill it out.
4. On 02/15/23 at 1:43 PM, the Surveyor asked the Administrator if the Resident Council was allowed to meet without staff present. The Administrator stated, Yes, but we prefer to have them meet with us present to ensure it is completed. The Surveyor asked what the purpose of Resident Council was. The Administrator stated, To talk about the good things going on, any concerns, and vote on the meal of the month. The point of the resident council is to have a voice, so, we prefer to be there so all have a voice. I told them that they could have their meetings, but we prefer we have the Resident Council meetings, so all have a voice. The Surveyor asked if concerns voiced should be documented on the Resident Council meeting reports. The Administrator stated, Yes. The Surveyor asked if having grievance forms filled out instead of voicing concerns on the Resident Council meeting reports was how things were supposed to work. The Administrator stated, That is absolutely not true.
5. On 02/15/23 at 7:20 PM, the Surveyor reviewed the Resident Council meeting minutes dated 11/28/22, 12/27/22, and 01/30/23 provided by the Administrator on 02/13/23. The minutes for all the meetings had the word discussions circled in the section labeled Floor Open for Suggestions / Discussions / Complaints:.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0888
(Tag F0888)
Minor procedural issue · This affected most or all residents
Based on interview, and record review, the facility failed to ensure all staff received complete primary COVID-19 vaccinations, had an approved or pending medical or religious exemption, or a temporar...
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Based on interview, and record review, the facility failed to ensure all staff received complete primary COVID-19 vaccinations, had an approved or pending medical or religious exemption, or a temporary delay per the Center for Disease Control (CDC) per the Centers for Medicare and Medicaid Services (CMS) COVID-19 Health Care Staff Vaccination Regulations Quality Service and Oversight (QSO) and staff vaccination tracking records were updated timely. The findings are:
1. On 02/13/23 at 9:58 AM, the Administrator informed the Surveyor the facility currently had 16 COVID-19 positive residents.
2. The Community Transmission Level provided by the Administrator on 02/13/23 at 3:10 PM documented level was High for 02/02/23 and Substantial for 02/08/23.
3. The Staff COVID-19 Vaccination List provided by the Administrator on 02/13/23 at 3:10 PM documented 4 employees were listed as not fully vaccinated and 2 employees were COVID Vac [Vaccination] Exempt.
4. On 02/15/23 at 3:38 PM, the Surveyor asked the Human Resource (HR) Coordinator if she was responsible for tracking the COVID-19 vaccinations of the staff. The HR Coordinator stated she was. The Surveyor asked about Certified Nursing Assistant (CNA) #6's blank record. The HR Coordinator stated, Oh woah, I must have typed that wrong. The HR Coordinator looked in a file cabinet and stated Oh, I did not do hers. It is wrong. I need to correct that. It is not accurate. The Surveyor asked her about Nursing Assistant (NA) #1's exemption. The HR Coordinator provided an unsigned medical exemption. The Surveyor asked if a medical exemption was valid without a signature. The HR Coordinator stated, I do not have a signed one. I thought she gave me a signed one. The Surveyor asked if a physician's note required a signature to be valid. The HR Coordinator stated, I did not know a signature was needed. The Surveyor asked when NA #1 started working at the facility. The HR Coordinator stated, 1/12/23. The Surveyor asked about CNA #7's exemption. She provided a signed medical exemption. The Surveyor asked if records should be kept up to date. The HR Coordinator stated, Yes. The Surveyor asked about CNA #2's single vaccination. The HR Coordinator stated, She only has one Moderna on 10/13/22. The Surveyor asked if CNA #2 should have been allowed to work after 11/12/22. The HR Coordinator stated, No, she shouldn't have been allowed to work. The Surveyor asked about CNA #8's and CNA #9's blank record. The HR Coordinator stated, I don't know why I have not updated those. The Surveyor asked how often the vaccinations were updated. The HR Coordinator stated, Monthly. Well, I try to do that as much as I can, but I see I need to go back and check it again. The Surveyor requested the time sheets for CNA #2 and NA #1. The Surveyor asked if CNA #2 and NA #1 should have been working without an exemption, primary vaccinations, or temporary delay. The HR Coordinator stated, They should not be working if they do not have any of those. The Surveyor asked if she was aware they were working. The HR Coordinator stated, No, I am not aware. The timesheet for CNA #2 documented she had worked 35 days and NA #1 had worked 16 days.
5. On 02/15/23 at 3:50 PM, the Surveyor asked the Administrator if he was aware of staff working without an exemption, primary vaccinations, or temporary delay. The Administrator stated he was not aware anyone was working without vaccinations, exemptions, or without a delay. The Surveyor asked the Administrator if staff should be working if they did not have one of those. The Administrator stated, They should not be working. The Surveyor asked how often HR should be updating the list. The Administrator stated, Every thirty days. HR should be checking that.
6. The Resident COVID-19 Positive List provided by the Administrator on 02/13/23 at 3:10 PM documented Resident #40 and Resident #84 were COVID Positive and were hospitalized with respiratory issues.
a. Resident #40 tested positive for COVID-19 on 02/70/23 and on 02/11/23 at .14:00 .Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: .Respiratory Status Evaluation: Labored or rapid breathing .Nursing observations, evaluation, and recommendations are: Resident is laboring to breath even with the addition of oxygen. Resident recently diagnosed with COVID. Decreased LOC [level of consciousness], hypertensive .Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: .Recommendations: Send to ER [Emergency Room] for eval [evaluation] and tx [treatment] as indicated. On 2/11/23 Resident was sent to the emergency room and was admitted . Resident currently continues to be hospitalized . Prior to COVID-19 diagnosis Resident #40 was not receiving Oxygen.
b. Resident #84 tested positive for COVID-19 on 02/03/23 and on 02/11/23 at .09:56 [AM] Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Respiratory Status Evaluation: Labored or rapid breathing .Nursing observations, evaluation, and recommendations are: Resident is laboring to breath even with the addition of oxygen. Resident recently diagnosed with COVID. Decreased LOC, hypertensive .Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: .A. Recommendations: Send to ER for eval and tx as indicated .C. New Intervention Orders: .Oxygen (if available) .
7. The facility policy titled, COVID-19 Vaccination Policy, provided by the Administrator on 02/13/23 at 3:10 PM documented, .All staff working at the Facility as of February 13, 2022, must have received their first dose of a two-shot series or a single dose of a one-shot COVID-19 vaccine (except those staff who have been granted exceptions from the COVID-19 vaccine or have a pending exemption . All staff working in the facility as of March 15, 2022 must have received all necessary doses top complete the vaccine series, including their second dose of a two-shot series or a single dose of the one-shot COVID-19 vaccine, unless they have been granted an exemption pursuant to federal law or due to a temporary delay in vaccination as recommended by the CDC . Beginning March 15, 2022, and thereafter, so long as this policy is in effect, all new hires must have at a minimum, have received their first dose of a two-dose COVID-19 vaccine or a one-dose COVID-19 vaccine prior to providing any care, treatment, or other services for the facility unless approved for an exemption pursuant to federal law .
Aug 2021
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure the comprehensive plan of care addressed the assessments, care and monitoring required related to the use of psychotropic medication...
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Based on record review and interview, the facility failed to ensure the comprehensive plan of care addressed the assessments, care and monitoring required related to the use of psychotropic medications for 1 (Resident #35) of 1 (Resident #35) sampled resident who had a physician order for as-needed (PRN) Lorazepam and for 1 (Resident #42) of 2 (Residents #28 and #42) sampled residents who had physician's orders for Seroquel. The findings are:
1. Resident #35 had a diagnosis of Dementia. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/09/21 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status and did not receive antianxiety medication during the 7-day look-back period.
a. Physician's orders dated 06/30/21 documented, Lorazepam Solution 2 MG [milligrams] / ML [milliliter]. Give 0.25 ml by mouth every 3 hours as needed for anxiety . Lorazepam Solution 2 MG/ML, Give 0.5 ml by mouth every 3 hours as needed for Anxiety .
b. A Lorazepam package insert documented a black box warning, The FDA [Food and Drug Administration] has found that benzodiazepine drugs, such as lorazepam, when used in combination with opioid medications or other sedating medications can result in serious adverse reactions including slowed or difficult breathing and death .
c. As of 8/19/21, the Care Plan dated 06/24/21 did not address the PRN use of Lorazepam or the black box warning for this medication.
d. On 08/19/21 at 09:18 AM, the MDS Coordinator was asked if Lorazepam and the black box warning were addressed in the resident's care plan. She replied, No. She was asked if these items should be addressed in the care plan? She replied, Yes.
2. Resident #42 had diagnoses of Delusional Disorder and Mood Affective Disorder. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/17/21 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and received an antipsychotic on 7 of the past 7 days.
a. The physician's order dated 03/24/21 documented, QUEtiapine Fumarate Tablet 25 MG [milligrams]. Give 1 tablet by mouth at bedtime .
b. Physician's orders dated 07/22/21 documented, SEROquel Tablet 50 MG (QUEtiapine Fumarate). Give 1 tablet by mouth at bedtime . SEROquel Tablet 25 MG (QUEtiapine Fumarate). Give 1 tablet by mouth in the afternoon .
c. A Seroquel package insert documented a black box warning, .WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS; and SUICIDAL THOUGHTS AND BEHAVIORS . Increased Mortality in Elderly Patients with Dementia-Related Psychosis . Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death .
d. As of 8/19/21, the Care Plan dated 06/29/21 did not address the use of Seroquel (Quetiapine Fumarate), the black box warning for this medication, or interventions related to the corresponding diagnosis.
e. On 08/19/21 at 09:15 AM, the MDS Coordinator was asked to review Resident #42's care plan. She was asked if the care plan addressed the resident's use of Seroquel, the black box warning for this medication, or interventions relating to the corresponding diagnosis. She replied, He does have a care plan for a psychotropic drug, but it's an antidepressant. She was asked if the care plan should address this. She replied, Yes. She was asked why it is important for person-centered comprehensive care plans to be completed. She replied, To make sure that we provide the most comprehensive, holistic care for the residents and address all of their needs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview, the facility failed to ensure a resident's hair was regularly washed to maintain good hygiene for 1 (Resident #35) of 18 (Residents #5, #17, #24, #28...
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Based on observation, record review and interview, the facility failed to ensure a resident's hair was regularly washed to maintain good hygiene for 1 (Resident #35) of 18 (Residents #5, #17, #24, #28, #31, #32, #35, #37, #38, #39, #42, #43, #44, #51, #56, #64, #316, #365) sampled residents who required assistance with personal hygiene; and failed to ensure fingernails were trimmed to maintain good grooming for 1 (Resident #316) of 18 (Residents #5, #17, #24, #28, #31, #32, #35, #37, #38, #39, #42, #43, #44, #51, #56, #64, #316, #365) sampled residents who required assistance with nail care. The findings are:
1. Resident #35 had diagnoses of Dementia and Chronic Obstructive Pulmonary Disease (COPD). A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/09/21 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status and required extensive assistance with all activities of daily living.
a. The Care Plan dated 06/11/21 documented, .has an ADL [activities of daily living] self-care performance deficit r/t [related to] dementia, COPD . Bathing: Extensive assistance of 1-2 with bathing/showering .
b. On 08/16/21 at 10:28 AM, 08/17/21 at 08:56 AM, and 08/18/21 at 10:52 AM, the resident was resting in bed in her room. Her hair on the left side had an area that was matted and had a white substance in it.
c. On 08/18/21 at 10:52 AM, Certified Nursing Assistant (CNA) #4 was asked to describe what she saw in the resident's hair. She stated, It looks like it might be dry saliva or maybe phlegm. She was asked, How often should residents get a bath? She stated, Typically 2-3 times a week, unless they prefer daily baths. She was asked, Do residents get their baths as scheduled? She replied, Yes, unless they refuse.
d. On 08/18/21 at 11:03 AM, Licensed Practical Nurse (LPN) #4 was asked to describe what she saw in the resident's hair. She replied, Matted hair with secretions in part of her hair. She was asked how often the residents were supposed to get a shower or bath. She stated, They are supposed to get one 3 times a week. She was asked if the residents were getting their scheduled showers. She replied, On day shift, yes, we make sure they get them, but I can't speak for the other shifts.
e. On 08/18/21 at 01:45 PM, CNA #5 was asked if she gave Resident #35 a bath on Monday, August 16th. She replied, Yes. She was asked if the resident refused any part of her bath. She replied, No. She was asked if the resident had any type of behaviors during her bath on Monday. She replied, No. She was asked if she attempted to wash the resident's hair on Monday. She replied, No.
f. On 08/19/21 at 09:00 AM, the Director of Nursing was asked how often residents should get a bath. She replied, Our standard is at least two times a week, unless they refuse. Then they will try to at least wash them off if they will let them. She was asked if the resident's hair should be washed on bath days. She replied, Not all of them do that, but most of the time, some of them choose to have it done once a week. If it is visibly soiled, we would recommend that.
2. Resident #316 had diagnoses of Weakness and Paralysis of the Dominant Right Side. An admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/06/21 documented the resident scored 02 (0-7 indicates severe impairment) on a Brief Interview for Mental Status; required limited assistance with bed mobility and transfers and supervision for personal hygiene.
a. The Care Plan with a completion date of 06/10/21 documented, .resident has an ADL [activities of daily living] self-care performance deficit . Personal Hygiene: The resident requires limited assistance with personal hygiene .
b. On 08/16/21 at 09:52 AM, the resident was sitting up on the side of her bed. Her fingernails were approximately 1 inch long. The resident was asked if she liked her nails long. She replied in nonsensical phrases.
c. On 08/17/21 at 09:05 AM, the resident was sitting up on the side of her bed. Her fingernails remained approximately 1 inch long.
d. On 08/18/21 at 12:50 PM, the resident was resting in bed. Her fingernails remained long.
e. On 08/18/21 at 2:51 PM, Registered Nurse #1 was asked to look at the resident's fingernails and describe what she saw. She replied, They are long. She was asked about how long she thought they were. She stated, An inch probably.
f. On 08/19/21 at 09:03 AM, the Director of Nursing was asked how often nail care should be provided for residents who require assistance. She replied, As needed, but weekly we have our nurses do nail care. Sunday is our standard day. She was asked if a resident's fingernails should be short unless they were care planned for long fingernails, based on preference. She replied, Whatever the resident's preference is. She was asked what if the resident is not able to communicate a preference and stated, Then they should be kept fairly short. She was asked, Why is it important to keep resident's fingernails trimmed? She replied, To keep them from scratching themselves or causing skin tears.
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
Based on observation, interview and record review, the facility failed to ensure an assessment was conducted and documented initially and at least weekly for skin tears to enable nursing staff to trac...
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Based on observation, interview and record review, the facility failed to ensure an assessment was conducted and documented initially and at least weekly for skin tears to enable nursing staff to track healing progress, failed to obtain physician orders for skin tear treatments to facilitate continuity of care, and failed to ensure skin tear dressings were dated in accordance with accepted standards of nursing practice for 1 (Resident #52) of 1 sampled resident who was reviewed for skin tear treatments. The findings are:
Resident #52 had diagnoses of Type 2 Diabetes Mellitus, Vascular Dementia with Behavioral Disturbance, and Peripheral Vascular Disease. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/7/21 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, required extensive assistance of one person for transferring and toileting, and had no skin tears.
a. An Incident and Accident (I&A) form dated 7/31/21 documented, .7-31-21 Incident . fall . Immediate action taken, Description: c/o [complained of] right hip/leg pain sent to [hospital] ER [emergency room] for eval [evaluation] and treatment. Skin tear x [times] 3 to LUE [left upper extremity] cleansed and covered with xeroform .
b. On 8/17/21 at 03:08 PM the Surveyor observed 2 clear dressings on the resident's left arm. There was not a date on the dressings. The Surveyor asked the Licensed Practical Nurse (LPN) Treatment Nurse what happened. The LPN stated the resident had fallen and had skin tears on her arm. The LPN was unsure of the date of the incident. The Surveyor asked to see the orders for the treatment to the skin tears. The LPN was unable to find them in the computer and said, I don't see any active order for them. The LPN removed the dressings. The surveyor asked, How long have the 2 dressings been on there? A while? She said, Yes. She was asked, How long do you think it's been on there? The LPN said, I am not really sure.
c. On 08/18/21 at 09:35 AM, LPN #3 was asked how often skin audits were done. She said Weekly. The Surveyor asked the LPN, Do you see any orders for the wound care to the resident's left arm? She said, No. The Surveyor asked the LPN, What was the date of the last skin audit? The LPN stated, It shows 8/12/21, and it does not show any skin tear or anything. The LPN said, I worked 8/11/21, and I remember seeing the dressing that you are talking about and the order said to check dressing placement.
d. On 08/18/21 at 12:25 PM, the Surveyor asked the Director of Nursing (DON) how often body audits were to be done. The DON replied Weekly.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
Based on observation, record review and interview, the facility failed to ensure the physician reviewed and documented a rationale for PRN (as needed) psychotropic medications every 14 days or discont...
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Based on observation, record review and interview, the facility failed to ensure the physician reviewed and documented a rationale for PRN (as needed) psychotropic medications every 14 days or discontinued the medications after 14 days to minimize the potential for adverse drug effects for 1 (Resident #35) of 1 (Resident #35) sampled resident who had physician's orders for PRN Lorazepam. The findings are:
Resident #35 had a diagnosis of Dementia. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/09/21 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status.
a. The physician's orders dated 06/30/21 documented, LORazepam Solution 2 mg [milligrams] / mL [milliliter], Give 0.25 ml by mouth every 3 hours as needed for anxiety . LORazepam Solution 2 mg/mL, Give 0.5 mL by mouth every 3 hours as needed for Anxiety .
b. As of 8/18/21, the July and August 2021 Medication Administration Records (MARs) documented the resident received a total of 12 doses of PRN Lorazepam during the month of July and 1 dose thus far, during the month of August 2021.
c. On 08/18/21 at 09:06 AM, the Director of Nursing was asked how long a PRN order for a psychotropic medication could be continued before a physician must document a rationale for continuing the medication. She replied, Supposed to be 14 days. She was asked why it is important for the physician to review the order every 14 days. She replied, To ensure the resident needs the medication.
d. As of 8/18/21, there was no documentation in the resident's clinical record of a physician's documented rationale for continuing the Lorazepam PRN orders.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, record review and interview, the facility failed to ensure medications and biologicals were stored in a secure location (locked medication room or medication / treatment cart) to...
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Based on observation, record review and interview, the facility failed to ensure medications and biologicals were stored in a secure location (locked medication room or medication / treatment cart) to prevent potential tampering for residents who resided on 2 (300 and 400 Halls) of 4 (100, 200, 300 and 400 Halls) halls. The findings are:
1. On 08/17/21 at 09:02 AM, the treatment cart on the 400-hall secure unit was left unlocked and unattended by staff. The treatment cart was accessible to the residents and contained 2 bottles of Dakin's solution, acetone, wound cleanser, hydrogen peroxide, scissors, and other wound supplies. Licensed Practical Nurse (LPN) #2 was asked if the treatment cart should be left unlocked and stated, No, but I was just down the hall and was coming right back. The Surveyor asked what could happen. The LPN stated, The residents could get in it and hurt themselves.
08/18/21 10:35 AM the surveyor asked the Director of Nursing (DON) should the Treatment cart be locked? The DON said, Yes if It is not in sight. The Surveyor asked, why should it be locked? The DON said, For safety of the Residents.
2. On 8/16/21 at 10:17 a.m., there was a bottle of Ketotifen Fumara ophthalmic solution on a table at the end of Resident #5's bed. On 08/19/21 at 09:11 AM, the Director of Nursing was asked if medication should be left in a resident's room. She replied, No. She was asked why not and stated, Because another resident could get it.
3. On 8/19/21 at 10:40 AM, LPN #5 provided a copy of the facility's, Medication Storage in the Facility Policy, which documented, .Medications and biologicals are stored safely, securely, and properly . The medication supply is accessible only to licensed Nursing Personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to ensure meals / foods were served at temperatures that were acceptable to the residents to improve palatability and encourage ...
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Based on observation, record review, and interview, the facility failed to ensure meals / foods were served at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 3 of 3 meals observed. The failed practices had the potential to affect 11 residents who received meal trays in their rooms on 200 Hall, 17 residents who received trays in their rooms on the 300 Hall and 13 residents who received meal trays in their rooms on 400 Hall, as documented on a list provided by the Dietary Supervisor on 8/18/2021. The findings are:
1. On 08/17/21 at 10:49 AM, Resident #5 was asked about the food served by the facility and stated, The food isn't always good and sometimes it's cold.
2. On 08/17/21 at 12:31 PM, Resident #42 stated, The food is terrible and sometimes it's cold.
3. On 8/17/2021 at 1:12 p.m., an unheated tray cart that contained 15 trays for the lunch meal was delivered to the 400 Hall (unit) by Dietary Employee #1. At 1:29 p.m., immediately after the last resident received a tray in their room on the 400 Hall, the temperatures of the food items on a test tray from the cart were checked and read by the Social Worker with the following results:
a. Milk 55 degrees Fahrenheit
b. Pureed meat loaf 101 degrees Fahrenheit.
c. Pureed cut green beans 103. 6 degrees Fahrenheit.
d. Ground meat loaf 105 degrees Fahrenheit.
e. Regular meat loaf 93.7 degrees Fahrenheit.
f. Great northern beans 95 degrees Fahrenheit
g. Regular cut green beans 98.8 degrees Fahrenheit.
h. regular mashed potatoes 112.1 degrees Fahrenheit.
i. Super mashed potatoes 96 degrees Fahrenheit.
j. Vegetable blend 88 degrees Fahrenheit.
4. On 8/17/21 at 1:26 p.m., an unheated tray cart that contained 14 trays for the lunch meal was delivered to 300 Hall by Certified Nursing Assistant #1. At 1:43 p.m., immediately after the last resident received a tray in their room on the 300 Hall, the temperatures of the food items on a test tray from the cart were checked and read by the Social Worker with the following results:
a. Milk 54.8 degrees Fahrenheit.
5. On 8/17/21 at 1:39 p.m., an unheated tray cart that contained 11 trays for the lunch meal was delivered to the 200 Hall by Certified Nursing Assistant #2. At 1:49 p.m., immediately after the last resident received a tray in their room on 200 Hall, the temperatures of the food items on a test tray from the cart were checked and read by the Social Worker with the following results:
a. Milk 54.4 degrees Fahrenheit.
b. Cut green beans 102.2 degrees Fahrenheit.
6. On 8/17/2021 at 1:51 p.m., Certified Nursing Assistant (CNA) #2 was asked, how many of you were passing trays? Certified Nursing Assistant #2 stated, I was the only one passing trays.
7. On 8/18/21 at 7:40 a.m., an unheated tray cart that contained 13 trays for the breakfast meal was delivered to the 400 Hall (unit) At 8:05 a.m., immediately after the last resident received a tray in their room on 400 Hall, the temperatures of the food items on a test tray from the cart were checked and read by the Dietary Supervisor with the following results:
a. Milk 57 degrees Fahrenheit.
b. Ground sausage with gravy 84 degrees Fahrenheit.
c. Scrambled eggs 84.2 degrees Fahrenheit.
d. Sausage links 84.4 degrees Fahrenheit.
e. Super cereal 102 degrees Fahrenheit, degrees Fahrenheit.
8. On 8/18/2021 at 7:48 a.m., the Dietary Supervisor was asked about the temperatures of the food items served to the residents for the breakfast meal. Dietary Supervisor stated, I wish it would be warmer.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items to decrease the potential for foodborne illness for res...
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Based on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items to decrease the potential for foodborne illness for residents who received food from 1 of 1 kitchen. The failed practice had the potential to affect 66 residents who received meals from the kitchen, as documented on a list provided by the Food Service Supervisor on 8/18/21. The findings are:
1. On 8/17/2021 at 11:16 a.m. Dietary Employee #1 took a pan of Oreo cookie delight from the walk -in refrigerator and placed it on the counter. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents who required pureed diets.
2. On 8/17/21 at 11:55 a.m., Dietary Employee #1 lifted the trash can lid and threw away a paper towel with her fingers touching the lid, contaminating her hands. She then pushed a cart towards a rack where trays that contained clean glasses were stored. Without washing her hands, she picked up glasses by their rims and placed them on the trays.
3. On 08/17/21 at 12:10 PM, Dietary Employee #1 washed her hands and dried her hands with paper towels. She lifted the trash can lid and threw the paper towels away, with her fingers touching the lid. Again, she picked up glasses by their rims and placed them on trays to be used in serving beverages to the residents at the supper meal.
4. On 8/17/21 at 12:22 p.m., Dietary Employee #2 touched the menu and without washing her hands, picked up a clean blade and attached it to the base of the blender to be used in pureeing food items.
5. On 8/17/21 at 12:52 p.m., Dietary Employee #2 picked up a bag of bread from the bread rack and placed it on the counter. Without washing her hands, she picked up a blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents who received pureed diets. At 12:54 p.m., she was asked what she should have done after touching dirty objects, before handling clean equipment. She stated, I should have washed my hands.
6. The facility's handwashing policy, provided by the Dietary Supervisor on 8/18/2021 at 8:45 a.m., documented, .Handwashing is the most important part of personal hygiene . You must train your food handlers to wash their hands, and then you must monitor them. After drying hands with paper towel you are to use foot pedal on trash can to open it. Do not use hands to open trash can at all .
MINOR
(B)
Minor Issue - procedural, no safety impact
Assessment Accuracy
(Tag F0641)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accura...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate and complete to facilitate the ability to plan and provide necessary care and services for 2 (Residents #39 and #42) of 18 (Residents #5, #17, #24, #28, #31, #32, #35, #37, #38, #39, #42, #43, #44, #51, #56, #64, #316, #365) sampled residents whose MDS assessments were reviewed. The findings are:
1. Resident #39 had diagnoses of Atrial Fibrillation, Vascular Dementia without Behavioral Disturbance, and Essential Hypertension.
a. The Comprehensive Plan of Care documented, I have elected Hospice Services . Date Initiated: 06/14/2021 .
b. A physician order dated 6/14/21 documented, Admit to hospice .
c. The admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 6/18/21 documented the resident scored 3 (0-7 indicates severe impairment) on a Brief Interview for Mental Status, received 1 insulin injection during the 7 day look back period, and did not receive hospice care while a resident.
d. The June 2021 Medication Administration Record did not document the resident received an insulin injection during the 7-day look-back period.
e. On 08/19/21 at 1:52 PM, the MDS Coordinator was asked to look at Resident #39's admission MDS assessment dated [DATE], sections N and O. As she looked, she stated, I see; I will correct it. She was asked if the resident was receiving hospice services. She stated, Yes. She was asked if the resident had received insulin during the look-back period of the assessment, as documented in section N. She stated, I didn't find where she did.
2. Resident #42 had a diagnosis of Peripheral Venous Insufficiency.
a. A physician's order dated 9/12/20 documented, Clopidogrel Bisulfate Tablet 75 MG [milligrams]. Give 1 tablet by mouth one time a day for blood clot prevention.
b. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/17/21 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and received an anticoagulant medication on 7 of the past 7 days.
c. On 08/19/21 at 09:25 AM, the MDS Coordinator was asked, What is the medication classification for Clopidogrel? She replied, Anticoagulant. She was asked, Can you tell me how you answered question N04010E on his most recent MDS? She replied, That he was on an anticoagulant. That was an error. I'm correcting that right now.
d. The Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, October 2019, documented for MDS Item N0410E Anticoagulant Use, .Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period . Do not code antiplatelet medications such as . clopidogrel here .
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 major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Arkansas facilities.
- • 41% turnover. Below Arkansas's 48% average. Good staff retention means consistent care.
Concerns
- • 28 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 70/100. Visit in person and ask pointed questions.
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About This Facility
What is Brookridge Cove Rehabilitation And Care Center's CMS Rating?
CMS assigns BROOKRIDGE COVE REHABILITATION AND CARE CENTER an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Arkansas, 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 Brookridge Cove Rehabilitation And Care Center Staffed?
CMS rates BROOKRIDGE COVE REHABILITATION AND CARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 41%, compared to the Arkansas average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Brookridge Cove Rehabilitation And Care Center?
State health inspectors documented 28 deficiencies at BROOKRIDGE COVE REHABILITATION AND CARE CENTER during 2021 to 2024. These included: 25 with potential for harm and 3 minor or isolated issues.
Who Owns and Operates Brookridge Cove Rehabilitation And Care Center?
BROOKRIDGE COVE REHABILITATION AND CARE CENTER 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 SOUTHERN ADMINISTRATIVE SERVICES, a chain that manages multiple nursing homes. With 96 certified beds and approximately 106 residents (about 110% occupancy), it is a smaller facility located in MORRILTON, Arkansas.
How Does Brookridge Cove Rehabilitation And Care Center Compare to Other Arkansas Nursing Homes?
Compared to the 100 nursing homes in Arkansas, BROOKRIDGE COVE REHABILITATION AND CARE CENTER's overall rating (4 stars) is above the state average of 3.1, staff turnover (41%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Brookridge Cove Rehabilitation And Care Center?
Based on this facility's data, families visiting should ask: "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?"
Is Brookridge Cove Rehabilitation And Care Center Safe?
Based on CMS inspection data, BROOKRIDGE COVE REHABILITATION AND CARE CENTER 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 Arkansas. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Brookridge Cove Rehabilitation And Care Center Stick Around?
BROOKRIDGE COVE REHABILITATION AND CARE CENTER has a staff turnover rate of 41%, which is about average for Arkansas 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 Brookridge Cove Rehabilitation And Care Center Ever Fined?
BROOKRIDGE COVE REHABILITATION AND CARE CENTER 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 Brookridge Cove Rehabilitation And Care Center on Any Federal Watch List?
BROOKRIDGE COVE REHABILITATION AND CARE CENTER 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.