HOLIDAY MANOR CARE CENTER
For profit - Limited Liability company
94 Beds
P&M MANAGEMENT
Data: November 2025
5 Immediate Jeopardy citations
Trust Grade
0/100
#1042 of 1155 in CA
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Holiday Manor Care Center has received a Trust Grade of F, indicating significant concerns about the quality of care provided. With a state rank of #1042 out of 1155 facilities in California and a county rank of #307 out of 369 in Los Angeles County, it is clear that this facility is in the bottom half of options available. The facility is showing signs of improvement, having reduced its reported issues from 27 to 17 over the past year. Staffing is average, with a turnover rate of 0%, which is a positive sign as it suggests that staff members are remaining in their positions and familiar with residents' needs. However, there are serious concerns, including critical health and safety violations such as cockroach infestations in the kitchen, which posed a risk of foodborne illnesses for all residents. Additionally, staff members failed to properly sanitize smoking aprons, potentially increasing the risk of spreading infections. Overall, while there are some strengths, the facility has significant weaknesses that families should carefully consider.
- Trust Score
- F
- In California
- #1042/1155
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ⚠ Watch
- $18,363 in fines. Higher than 81% of California facilities, suggesting repeated compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 28 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 59 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 10%
Review needed
27 → 17 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 27 issues
2025: 17 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
1-Star Overall Rating
Below California average (3.1)
Significant quality concerns identified by CMS
Federal Fines: $18,363
Below median ($33,413)
Minor penalties assessed
Chain: P&M MANAGEMENT
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 59 deficiencies on record
5 life-threatening 2 actual harm
Mar 2025
17 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 61's admission Record (face sheet), the admission record indicated that the facility originally a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 61's admission Record (face sheet), the admission record indicated that the facility originally admitted the resident on 5/13/2022, and readmitted on [DATE], with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
During a review of Resident 61's Minimum Data Set (MDS - a resident assessment tool) dated 1/31/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated that Resident 61 required staff partial/moderate assistance (helper does less than half the effort) for toileting hygiene, upper and lower body dressing, putting on/taking off footwear, and personal hygiene.
During a review of Resident 61`s Situation, Background, Assessment, Recommendation Communication Form (SBAR-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 3/3/2025, the SBAR communication form indicated that on 3/3/2025, Resident 61 was allegedly pushed by Resident 18 in the hallway. The SBAR form indicated that this incident was witnessed by Resident 53.
During a review of Resident 61`s care plan (a document outlining a detailed approach to care customized to an individual resident's need) for risk for injury related to alleged resident to resident altercation initiated on 3/3/2025, the care plan indicated a goal that the resident will have no injuries. The care plan interventions were to monitor the resident for pain and discomfort, provide safety reassurance, redirect the resident to another area away from the group of residents, and approach the resident in a calm manner.
During a review of Resident 61`s Interdisciplinary Team (IDT- a group of professionals from different disciplines who collaborate to provide comprehensive care for a patient) Conference Record-Fall Management Follow up dated 3/4/2025, the IDT follow up record indicated that Resident 61 had a fall incident on 3/3/2025, because the resident was allegedly pushed by another resident for no apparent reason and was found on the floor. The IDT follow up record indicated that Resident 61 did not sustain any injuries and X-Ray results (images of internal tissues, bones, and organs on film or digital media) were negative for any fracture.
During a review of Resident 18's admission Record (face sheet), the admission record indicated that the facility admitted the resident on 2/12/2025, with diagnoses including type two (2) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), paranoid (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly) schizophrenia (a mental illness that is characterized by disturbances in thought), and encephalopathy (a general condition characterized by impaired brain function).
During a review of Resident 18`s History and Physical (H&P) dated 2/13/2025, the H&P indicated that the resident had the capacity to understand and make decisions.
During a review of Resident 18's Minimum Data Set (MDS - a resident assessment tool) dated 2/19/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated that Resident 18 required staff partial/moderate assistance (helper does less than half the effort) for oral hygiene, toileting hygiene, lower body dressing, showering and bathing, putting on/talking off footwear, and personal hygiene. The MDS further indicated that Resident 18 exhibited behavioral symptoms not directed towards others.
During a review of Resident 61`s SBAR Communication Form dated 2/17/2025, the SBAR communication form indicated that on 2/17/2025, Resident 18 had behavioral symptoms such as throwing things and banging doors.
During a review of Resident 61`s SBAR Communication Form dated 3/3/2025, the SBAR communication form indicated that on 3/3/2025 at around 10:05 a.m., Resident 18 allegedly pushed another resident (Resident 61) without any provocation (an action or statement that is intended to make someone angry) that was witnessed by another resident (Resident 53). The SBAR form indicated that Resident 18 was immediately redirected back to his room and was placed on one-on-one supervision. The SBAR form indicated that when staff asked Resident 18 why he pushed Resident 61, Resident 18 stated that Resident 61 was making him uncomfortable and nervous. However, he (Resident 18) did not mean to hurt Resident 61, and he apologized. The SBAR form further indicated that Resident 18`s physician ordered to transfer the resident to hospital for psychological evaluation.
During a review of Resident 18`s care plan for alleged physical altercation with another resident, initiated on 3/3/2025, the care plan indicated that Resident 18 was the aggressor (the person who starts the attach first). The care plan indicated a goal that the resident`s behavior will be managed without complications and the resident will have minimized altercations with other residents. The care plan interventions were to provide one on one supervision, administer medications as ordered by the physician, assess for signs and symptoms that may trigger behaviors, redirect the resident to another area away from the group of residents, and approach the resident in a calm manner.
During a review of Resident 53's admission Record (face sheet), the admission record indicated that the facility admitted the resident on 7/31/2024, with diagnoses including paranoid schizophrenia, and anxiety disorder (a condition in which a person has excessive worry and feelings of fear).
During a review of Resident 53's MDS dated [DATE], the MDS indicated that the resident`s cognitive skills for daily decision making was moderately impaired. The MDS indicated that Resident 53 was independent (resident completes the activity by herself) for eating, oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear, and personal hygiene.
During an observation on 3/10/2025 at 9:50 a.m., Resident 61 was observed walking in the hallways. Resident 61 appeared confused and was not able to answer any questions.
During an interview on 3/10/2025 at 9:00 a.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated that on 3/3/2025 at around 10:00 a.m., she was assisting a resident inside a room when she heard a noise and commotion (a sudden, noisy, and confused activity or excitement). CNA 2 stated when she came out, she (CNA 2) Observed Resident 61 sitting on the floor in the hallway and the nurses were taking care of her. CNA 2 stated Resident 61 is confused and likes to walk in the hallways back and forth all the time.
During an Interview on 3/12/2025 at 9:30 a.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated on 3/3/2025, he was inside a resident`s room when he (LVN 3) heard commotion outside in the hallway. LVN 3 stated he (LVN 3) ran outside, and observed Resident 18 standing in the hallway and Resident 61 was sitting on the floor next to him. LVN 3 stated Resident 53 was present in the hallway as well and stated she (Resident 53) witnessed Resident 18 pushed Resident 61 causing her to fall. The LVN 3 stated when he (LVN 3) interviewed Resident 18 about the reason he (Resident 18) pushed Resident 61, Resident 18 stated that Resident 61 was making him uncomfortable and nervous, and he (Resident 18) did not mean to hurt Resident 61.
During an interview on 3/12/2025 at 10:14 a.m., Resident 53 stated that she remembers the day Resident 18 pushed Resident 61. Resident 53 stated that Resident 61 is always walking in the hallway. Resident 53 stated on 3/3/3024 in the morning in the hallway next to her room, she witnessed that Resident 61 walked towards Resident 18 and told him something. Resident 53 stated that Resident 61 always starts talking to others, but nobody understands her. Resident 53 further stated that Resident 18 pushed Resident 61 causing her to fall on the floor and hit her head against the wall. Resident 53 stated she (Resident 53) got very angry, screamed Why did you do that, and then reported this incident to the nurses.
During an interview on 3/13/2025 at 2:40 p.m., with the Director of Nursing (DON), the DON stated that the physical altercation between Resident 18 and Resident 61 was substantiated (to show something to be true, or to support a claim with facts) because it was witnessed by Resident 53. The DON stated Resident 53 reported that she witnessed Resident 18 pushed Resident 61 causing her to fall. The DON stated Resident 18 stated that he thought Resident 61 was following him, so he (Resident 18) pushed Resident 61. However, he (Resident 18) was sorry for his actions.
During an interview on 3/13/2025 at 4:17 p.m., with the Administrator (ADM), The ADM stated that the abuse allegation was substantiated because Resident 53 witnessed that Resident 18 pushed Resident 61 causing her to fall. The ADM stated this altercation is considered physical abuse. The ADM stated it is important to protect the residents by keeping the residents safe from abuse and injury.
During a review of the facility`s Policy and Procedure (P&P) titled Abuse Prevention/prohibition, last reviewed on 2/26/2025, the P&P indicated that that facility does not condone any form of resident abuse, neglect (fail to care properly), misappropriation of resident property, mistreatment, and develops facility policies, training programs, and systems in order to promote and environment free from abuse and mistreatment. The Administrator as abuse prevention coordinator is responsible for the coordination and implementation of the facility`s abuse preventions policies and training.
During a review of the facility`s Policy and Procedure (P&P) titled Resident-to Resident Altercation, last reviewed on 2/26/2025, the P&P indicated that facility staff monitor residents for aggressive/inappropriate behaviors towards other residents, family members, visitors, or to staff. Behaviors that may provoke a reaction by residents or others include physically aggressive behaviors such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, and throwing objects.
Based on interview and record review, the facility failed to:
1. Protect a resident's right to be free from verbal abuse (a type of abuse that uses language) for one of out of five sampled residents (Resident 50), when on 3/12/2025 Resident 15 yelled at Resident 50, Shut up, you fucking bitch.
This deficient practice resulted in Resident 50 being subjected to verbal abuse while under the care of the facility. Residents who are subjected to verbal abuse are at increased risk for low self-esteem (when someone lacks confidence in themselves and their abilities), anxiety (a feeling of fear, dread, and uneasiness), depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities for long periods of time) and social isolation (when someone has few or no social connections or support and lacks relationships with others).
2. Protect the resident`s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) for one of five sampled residents (Resident 61), when on 3/3/2025, Resident 18 pushed Resident 61 causing Resident 61 to fall.
As a result, Resident 61 was subjected to physical abuse by Resident 18 while under the care of the facility.
Findings:
1. During a review of Resident 50's admission Record, the admission Record indicated the facility originally admitted the resident on 1/9/2020 and readmitted the resident on 12/16/2024 with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
During a review of Resident 50's Minimum Data Set (MDS - a resident assessment tool), dated 1/7/2025, the MDS indicated the resident had intact cognition (thought processes) and was dependent on staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily).
During a review of Resident 50's Situation, Background, Assessment, and Recommendation Communication Form (SBAR - a communication tool used by healthcare workers when there is a change of condition among the residents), dated 3/12/2025, the SBAR indicated that the resident was interacting with another resident. The SBAR indicated that Resident 50 stated, He [Resident 15] was fixing the wall. I told him to stop. Then he called me a bitch.
During a review of Resident 15's admission Record, the admission Record indicated the facility originally admitted the resident on 1/24/2025 and readmitted the resident on 2/20/2025 with diagnoses including metabolic encephalopathy (a brain dysfunction resulting from a chemical imbalance in the blood, often caused by underlying systemic illnesses or organ dysfunction, rather than a primary brain injury), history of traumatic brain injury (TBI - a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head), dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thought), and psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with reality).
During a review of Resident 15's MDS, dated [DATE], the MDS indicated the resident had severely impaired cognition and required maximal assistance from staff for most ADLs.
On 3/12/2025 at 2:01 p.m., during an interview with Registered Nurse 2 (RN 2), RN 2 stated she was sitting at north nursing station when she heard a commotion. RN 2 stated she heard Resident 50 yelling but could not understand what Resident 50 was saying. RN 2 stated that, when she asked Resident 50 what happened, Resident 50 pointed at Resident 15 and stated that she was trying to tell Resident 15 to stop moving the personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) bin that was outside of his room. RN 2 stated that Resident 50 told her that Resident 15 then responded by saying, Shut up, bitch!
On 3/12/2025 at 3:54 p.m., during an interview with the Director of Staff Development (DSD), the DSD stated that, between 7:15 a.m. and 7:30 a.m., he heard Resident 50 yelling, Stop cleaning the walls, and stop moving the signs! The DSD stated he observed Resident 15 outside his room removing signs that were outside his room. The DSD stated he then heard Resident 15 shout, Shut up! to Resident 50.
On 3/13/2025 at 8:38 a.m., during an interview with Resident 50, Resident 50 stated she saw Resident 15 taking off the sign in front of his door, so she yelled for him to stop. Resident 50 stated that Resident 15 responded by yelling, Fuck you, bitch! Shut up, bitch!
On 3/13/2025 at 9:09 a.m., during an interview with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated that, between 7 a.m. to 7:15 a.m., she heard Resident 50 speaking very loudly. CNA 1 stated that, when she got to Resident 50's room, she observed Resident 50 yelling profanities at Resident 15, and she tried to tell Resident 50 to stop. CNA 1 stated that Resident 15 responded to Resident 50 by stating, Shut up, you fucking bitch.
On 3/13/2025 at 11:37 a.m., during an interview with the Administrator (ADM), the ADM stated that, at around 7:55 a.m., RN 2 notified her of the verbal resident-to-resident incident between Resident 50 and Resident 15. The ADM stated RN 2 told the ADM that Resident 50 was trying to tell Resident 15 to stop moving around the signs outside of his room. The ADM stated she was told that Resident 15 responded to Resident 50 by stating, Shut up, you fucking bitch.
On 3/13/2025 at 4:20 p.m., during an interview with the ADM, when asked if she (ADM) considered Resident 15 stating Shut up, you fucking bitch, to Resident 50 to be verbal abuse, the ADM stated that she did consider the incident as verbal abuse.
During a review of the facility's policy and procedure titled, Abuse Prevention/Prohibition, last reviewed on 2/26/2025, the policy and procedure indicated that the facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation and/or mistreatment .Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms directed to residents or their families or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop a complete and accurate baseline care plan (a document tha...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop a complete and accurate baseline care plan (a document that summarizes a resident's needs, goals, and care/treatment) within 48 hours of a resident's admission to the facility for one of two sampled residents (Resident 21) by failing to complete oxygen use, pain, safety risks, and skin risk sections in the resident's baseline care plan.
This deficient practice had the potential of Resident 21 to not receive appropriate care and treatments.
Findings:
During a review of Resident 21's admission Record, the admission Record indicated that the facility admitted the resident on 1/7/2025 with diagnoses including acute (rapid onset and relatively short duration) respiratory failure (a serious condition that makes it difficult to breathe on your own) with hypoxia (a condition where there is an inadequate supply of oxygen to the body's tissues), difficulty in walking, dementia (a progressive state of decline in mental abilities), and history of falling.
During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool) dated 1/11/2025, the MDS indicated that the resident's cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired. The MDS indicated that Resident 21 required staff partial/moderate assistance (helper does less than half the effort) for oral hygiene, showering and bathing, and personal hygiene The MDS further indicated that Resident 21 received oxygen therapy on admission and within the last 14 days.
During a review of Resident 21's Order Summary Report dated 1/7/2025, the Order Summary Report indicated an order to administer oxygen at two (2) liters per minute (LPM- unit of measurement for ozygen) via nasal canula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) as needed (PRN) for shortness of breath (SOB).
During a concurrent interview and record review on 3/13/2025 at 11:39 a.m., with the Assistant Director of Nursing (ADON), reviewed Resident 21's baseline care plan. The ADON stated that she (ADON) developed Resident 21's baseline care plan on 1/7/2025, however, the baseline care plan is missing information in multiple sections and is incomplete. The ADON stated she did not indicate that Resident 21 was receiving PRN oxygen since he was admitted to the facility on [DATE]. The ADON stated she did not complete the following sections of Resident 21's baseline care plan: pain, safety risks, and skin risk. The ADON stated this was a mistake on her part and she should have assessed the resident thoroughly. The ADON stated that residents' baseline care plans must be completed accurately reflecting all the pertinent information regarding residents within 48 hours of their admission to the facility. The ADON stated the potential outcome of not thoroughly completing a resident's baseline care plan is the inability to meet the resident's immediate care needs and lack of care.
During an interview on 3/13/2025 at 2:45 p.m., with the Director of Nursing (DON), the DON stated a resident's baseline care plan is required to be completed within 48 hours of resident's admission to the facility. The DON stated upon admission, licensed staff are required to develop a complete and thorough baseline care plan for each resident. The DON stated Resident 21's baseline care plan developed on 1/7/2025 was not completed thoroughly. The DON stated the potential outcome is the inability to meet the resident's immediate care needs and the delivery of necessary services to the resident.
During review of the facility's policy and procedure (P&P) titled, Baseline Care
Planning, last reviewed on 2/26/2025, the P&P indicated that it is the policy of the facility to develop and provide a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care that meets professional standard and quality of care. The baseline care plan must include the minimum healthcare information necessary to properly care for resident immediately upon admissions, which would address resident-specific health and safety concerns to prevent decline or injury, such as elopement or fall risk and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living as needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on interview, and record review, the facility failed to update and revise a resident's care plan (a document that summarizes a resident's needs, goals, and care/treatment) after the resident's c...
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Based on interview, and record review, the facility failed to update and revise a resident's care plan (a document that summarizes a resident's needs, goals, and care/treatment) after the resident's change of condition (a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains) on 2/17/2025, for one of two sampled residents (Resident 18).
This deficient practice had the potential to result in Resident 18 receiving inadequate care and supervision at the facility.
Findings:
During a review of Resident 18's admission Record, the admission Record indicated that the facility admitted the resident on 2/12/2025 with diagnoses including type two (2) diabetes mellitus (DM- a chronic condition that affects the way the body processes blood glucose [sugar]), paranoid schizophrenia (type of schizophrenia [a mental illness that is characterized by disturbances in thought] accompanied by paranoia [way of thinking that involves feelings of distrust and suspicion about others without a good reason]), and encephalopathy (a general condition characterized by impaired brain function).
During a review of Resident 18's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) dated 2/13/2025, the H&P indicated that the resident had the capacity to understand and make decisions.
During a review of Resident 18's Minimum Data Set (MDS - a resident assessment tool) dated 2/19/2025, the MDS indicated that the resident's cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired. The MDS indicated that Resident 18 required staff partial/moderate assistance (helper does less than half the effort) for oral hygiene, toileting hygiene, lower body dressing, showering and bathing, putting on/talking off footwear, and personal hygiene.
During a review of Resident 18's Situation, Background, Assessment, Recommendation Communication Form (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents) dated 2/17/2025, the SBAR communication form indicated that on 2/17/2025, Resident 18 had behavioral symptoms such as throwing things and banging door.
During a review of Resident 18's care plan for mood problem related to schizophrenia initiated on 2/12/2025, the care plan indicated that the resident's behavior could change from calm to hostile behavior. The care plan indicated a goal that the resident will have a happier mood, calmer appearance, and no signs and symptoms of anxiety (intense, excessive, and persistent worry and fear about everyday situations). The care plan interventions were to administer the resident's medications as ordered by the physician, provide the resident with a program of activities that is meaningful and of interest, monitor/document and report to the physician any risks for harm to self and others, signs and symptoms of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety, and sad mood.
During a review of Resident 18's care plan for behavioral symptoms related to schizophrenia initiated on 2/12/2025, the care plan indicated a goal that the resident will stay calm. The care plan interventions were to administer the resident's medications as ordered by the physician, encourage verbalization of feelings and concerns, listen attentively when resident is verbalizing concerns, and to monitor resident's interaction with another resident to prevent offensive behavior (rude, hurtful, or disrespectful conduct that is likely to upset others).
During a concurrent interview and record review on 3/12/2025 at 12:11 p.m., with Licensed Vocational Nurse 3 (LVN 3), reviewed Resident 18's SBAR form dated 2/17/2025 and care plans. LVN 3 stated that Resident 18's SBAR form dated 2/17/2025 indicated that the resident had behavioral symptoms such as throwing things and banging doors. LVN 3 stated licensed staff did not revise or update Resident 18's care plans addressing the resident's behavior and mood after this change of condition. LVN 3 stated licensed staff are required to revise a resident's care plan after a resident's change of condition to ensure the effectiveness of care plan interventions. LVN 3 stated the potential outcome of not updating/revising a resident care plan after a change of condition is the inability to provide appropriate care and monitoring to the resident.
During an interview on 3/13/2024 at 2:50 p.m., with the Director of Nursing (DON), the DON stated that residents' care plans are required to be reviewed and revised after residents' change of condition. The DON stated Resident 18's care plans were not revised or updated after Resident 18's change of condition on 2/17/2025. The DON stated the potential outcome of not updating/revising a resident's care plan is the inability to provide appropriate care and services to the resident.
During a review of the facility's policy and procedure (P&P) titled, Care Plans Comprehensive Person-Centered, last reviewed on 2/26/2025, the P&P indicated that care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Assessments of resident's are ongoing and care plans are revised as information about the residents and the residents' conditions change.
During a review of the facility's P&P titled, Change in a Resident's Condition or Status, last reviewed on 2/26/2025, the P&P indicated that the facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical, mental condition and/or status. A significant change of condition is a decline or improvement in the resident's status that requires interdisciplinary review and/or revision to the care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcers [a...
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Based on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcers [an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure]) was set correctly for one of one sampled resident (Resident 291).
This deficient practice had the potential to place Resident 291 at risk for discomfort and development of pressure ulcers/injuries.
Findings:
During a review of Resident 291's admission Record, the admission Record indicated the facility admitted the resident on 2/19/2025 with diagnoses of metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), acute respiratory failure (a condition in which your blood doesn't have enough oxygen causing shortness of breath and difficulty breathing), and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood well).
During a review of Resident 291's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) dated 1/25/2014, the H&P indicated that Resident 291 had the capacity to understand and make decisions.
During a review of Resident 291's Minimum Data Set (MDS - a resident assessment tool) dated 12/23/2025, the MDS indicated that Resident 291 had severely impaired cognition (thought process). The MDS also indicated that the resident needed supervision with eating, moderate assistance with oral and personal hygiene and was dependent on two or more helpers with bed mobility, shower transfer, dressing, and toileting.
During a review of Resident 291's Weight and Vitals Summary, the Weight and Vitals Summary indicated that Resident 291 weighed 236 pounds (lbs.- unit of measurement) on 3/4/2025.
During a review of Resident 291's Skin Observation Tool dated 2/21/2024, the Skin Observation Tool indicated Resident 291 had a pressure ulcer stage one (1) (redness of the skin that doesn't fade when pressure is applied) on sacrococcyx area (pertaining to both the sacrum [triangular bone located in the lower back] and coccyx [tailbone]).
During a review of Resident 291's care plan (a document that summarizes a resident's needs, goals, and care/treatment) dated 2/19/2025, the care plan indicated that Resident 291 had potential impairment to skin integrity related to fragile skin and incontinence (losing control of your bladder or bowels, leading to involuntary leakage of urine or feces). The care plan intervention indicated to follow facility protocol for treatment of injury.
During a concurrent observation and interview on 3/10/2025 at 9:34 a.m., with Licensed Vocational Nurse 3 (LVN 3), in Resident 291's room, observed Resident 291's LALM setting was at seven (7) for 300 lbs. LVN 3 stated Resident 291 current weight is 236 lbs. and Resident 291's physician order dated 2/20/2025 indicated for the LALM mode to be set at alternating and setting based on comfort and/or resident weight for skin management. LVN 3 stated the LALM is an intervention to promote wound healing and prevent pressure injuries.
During a concurrent record review and interview on 3/11/2025 at 2:28 p.m., with Treatment Nurse 1 (TN 1), TN 1 stated that Resident 291's stage one (1) pressure ulcer on the sacrococcyx area was resolved on 2/28/2025. TN 1 stated currently Resident 291 has intact skin and the LALM is used to prevent further injuries. TN 1 stated the correct setting on the LALM for 236 lbs. was five (5).
During an interview on 3/12/2025 at 9:12 a.m., with the Assistant Director of Nursing (ADON), the ADON stated if the LALM is not set at the correct setting then it won't be effective to prevent further pressure injuries.
During a review of the facility's policy and procedure titled, Support Surface Guidelines, dated 1/15/2025, the policy indicated, The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown.
During a review of the LALM user manual, the manual indicated, The comfort setting controls the air pressure output based on the resident's weight.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on interview, and record review, the facility failed to ensure one of one sampled resident (Resident 13) received treatment and services to prevent decrease in range of motion (ROM- full movemen...
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Based on interview, and record review, the facility failed to ensure one of one sampled resident (Resident 13) received treatment and services to prevent decrease in range of motion (ROM- full movement potential of a joint) by failing to follow Resident 13`s physician order for Restorative Nursing Assistant (RNA- nursing aide program that helps residents to maintain their function and joint mobility) exercise program.
This deficient practice had the potential to place the resident at risk for further decline in range of motion (ROM- full movement potential of a joint) decline.
Findings:
During a review of Resident 13's admission Record (face sheet), the admission Record indicated that the facility admitted the resident on 9/19/2023 and readmitted the resident on 2/10/2025, with diagnoses including metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), type 2 diabetes mellitus (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), and difficulty in walking.
During a review of Resident 13's Minimum Data Set (MDS - a resident assessment tool) dated 2/14/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 13 required maximal - to - moderate staff assistance (helper does more than half the effort) for toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear, personal hygiene and need supervision for eating.
During a review of Resident 13 History and Physical (H&P-) dated 2/11/2025, the H&P indicated that Resident 13 did not have a capacity to understand and make decision.
During a review of Resident 13's Physician Order dated 2/12/2025, the order indicated the following: RNA program for ambulation with front wheel walker (FWW - a mobility aid designed for individuals who need assistance with balance and stability while walking) as tolerate every day five (5) times a week with 2 persons assist for safety.
During a review of Resident 13's Treatment Administration Record for 02/1/2025-02/28/2025, and 03/1/2025-03/12/2025, the record did not indicate any RNA treatment entries.
During a concurrent interview and record review on 3/12/2025 at 12:02 PM, with Restorative Nursing Assistant 1 (RNA 1), RNA 1 reviewed Resident 13's restorative task flowsheet in electronic clinical record and stated that there was no order forwarded to restorative task to provide RNA program for Resident 13. RNA 1 stated she has never provided RNA exercises to Resident 13.
During a concurrent interview and record review on 2/13/2025 at 12:46 PM with the Director of Rehabilitation (DOR), Resident 13`s physician orders were reviewed. The DOR stated that Resident 13 was evaluated by the rehabilitation department and discharged to RNA program on 2/22/2025 because Resident 13 reached maximal potential with skilled services. The DOR stated the licensed staff should have followed Resident 13`s physician and provide RNA exercise program to as ambulating with 2-person assists. The DOR stated the potential outcome of not providing RNA treatment as ordered by the physician is a decline in Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily), and muscle weakness.
During a concurrent record review and interview on 3/12/2025 at 2:26 PM, the Director of Nursing reviewed Resident 13's physician orders, care plans and RNA task flowsheet. The DON stated that the Licensed Vocational Nurse who received the physician order for the RNA program for Resident 13 did not transfer the order to the RNA task flowsheet. The RNA was not able to see the order in the Electronic Health Record (EHR) until it was transferred to the task flowsheet. That is why Resident 13's RNA program was not started and the care plan for it was not created. The DON stated that it was important to create a person-centered care plan with measurable goals to monitor Resident 13's progress and prevent any potential decline in the functional ability of Resident 13.
During review of the facility's Policy and Procedure (P&P) titled, Rehabilitative Nursing Mobility Care, last reviewed 2/16/2025, the P&P indicated: The facility rehabilitative nursing care program is designed to assists each resident to achieve and maintain an optimal level of self- care and independence . Through the resident care plan, the goal of rehabilitative nursing care is reinforced in the Activities Program, therapy services.
During review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person -Centered, last reviewed 2/16/2025, the P&P indicated: A comprehensive, person -centered care plan that includes measurable objectives and timetables to meet the resident's physical. Psychosocial and functional needs is developed and implemented for each resident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure Fall Risk Evaluations were completed accurately for one of three sampled residents (Resident 16).
This deficient practice placed th...
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Based on interview and record review, the facility failed to ensure Fall Risk Evaluations were completed accurately for one of three sampled residents (Resident 16).
This deficient practice placed the resident at risk of not receiving appropriate care and services after a fall incident and had the potential to place the resident at an increased risk for falls.
Findings:
During a review of Resident 16's admission Record, the admission Record indicated the facility originally admitted the resident on 9/3/2021 and readmitted the resident on 2/1/2025 with diagnoses including metabolic encephalopathy (the loss of brain function due to a chemical imbalance in the blood), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and generalized muscle weakness.
During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool) dated 2/5/2025, the MDS indicated the resident was able to make herself understood and usually understands others. The MDS further indicated Resident 16 is dependent on staff to complete most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 16's Situation, Background, Assessment, Recommendation (SBAR- a form filled out by licensed nursing staff for the purpose of communicating information about a resident's condition or other issue to other members of the health care team, including a resident's doctor) Communication Form dated 3/11/2025, the SBAR Communication Form indicated Resident 16 was found on the floor next to her bed. The SBAR Communication Form further indicated Resident 16 stated she did not know what happened and that she was just trying to get comfortable.
During a concurrent interview and record review on 3/13/2025 at 11:20 a.m., with Treatment Nurse 1 (TN 1) and the Director of Nursing (DON), reviewed Resident 16's Fall Risk Evaluations, dated 2/1/2025 and 3/11/2025. Resident 16's Fall Risk Evaluation dated 2/1/2025 indicated the second and third sections titled Gait/Balance, and Medications were blank. TN 1 stated he (TN 1) did Resident 16's Fall Risk Evaluation dated 2/1/2025 and should have completed all sections of the evaluation. Resident 16's Fall Risk Evaluation, dated 3/11/2025, indicated Resident 16 had no falls within the past three months. The DON stated Resident 16's Fall Risk Evaluation dated 3/11/2025 was completed after Resident 16's fall on the morning of 3/11/2025 and the Fall Risk Evaluation should indicate that the resident had a fall within the past three months. The DON stated it is important to accurately complete the Fall Risk Evaluations so they know the resident's risk of falling and staff can effectively care for the resident.
During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, last revised 2/26/2025, the P&P indicated based on previous evaluations and current data, staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide trauma-informed care (an approach to delivering care that i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide trauma-informed care (an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma) to a resident with a diagnosis of post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) by failing to complete a timely trauma-informed care assessment and conduct an interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) meeting to address the resident's specific needs for one of one sampled resident (Resident 49) investigated under the care area of trauma-informed care.
This deficient practice had the potential to place the resident at increased risk of being triggered by and experiencing symptoms of their PTSD.
Findings:
During a review of Resident 49's admission Record, the admission Record indicated the facility admitted the resident on 1/31/2025 with diagnoses including PTSD.
During a review of Resident 49's Minimum Data Set (MDS - a resident assessment tool) dated 2/4/2025, the MDS indicated the resident had moderately impaired cognition (thought processes) and required moderate assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). The MDS also indicated the resident has a diagnosis of PTSD.
During a review of Resident 49's Trauma Informed Care assessment dated [DATE], the assessment indicated that Resident 49 has experienced trauma.
During a concurrent interview and record review on 3/11/2025 at 4:34 p.m., with Registered Nurse 1 (RN 1), reviewed Resident 49's IDT progress notes dated 2/4/2025 to 3/11/2025. RN 1 stated he (RN 1) could not find any IDT progress notes addressing Resident 49's PTSD.
During an interview on 3/12/2025 at 10:34 a.m., with Licensed Vocational Nurse 2 (LVN 2), LV 2 stated she (LVN 2) was from the facility's regional office and was the one who completed Resident 49's Trauma Informed Care assessment dated [DATE]. When asked what prompted her to complete Resident 49's Trauma Informed Care Assessment, LVN 2 stated that Medical Records was doing an audit and had asked her (LVN 2) to complete the assessment. LVN 2 stated it should have been done upon Resident 49's admission.
During an interview on 3/12/2025 at 11:18 a.m., with the Director of Nursing (DON), the DON stated that Social Services should be completing the Trauma Informed Care Assessment for all residents. The DON stated there should have also been an IDT meeting to discuss the specific care that a resident diagnosed with PTSD would need. The DON stated it was important to discuss the resident's specific triggers so that the facility could provide care around avoiding those triggers.
During an interview on 3/12/2025 at 11:37 a.m., with the Social Services Designee (SSD), the SSD stated that her previous director had been the one responsible for doing the Trauma Informed Care Assessments for all residents upon admission. The SSD stated she had no experience doing the assessment.
During a review of the facility's policy and procedure titled, Trauma Informed Care and Culturally Competent Care, last reviewed on 2/26/2025, the policy and procedure indicated that the purpose of the policy was to address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Develop an organizational culture that supports all Trauma-Informed and Resilience Oriented domains. These include universal and early screening and assessment, etc. Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy and procedure titled, Social Assessment, for one ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy and procedure titled, Social Assessment, for one of two sampled residents (Resident 18) by failing to conduct a social service assessment within 14 days of the resident's admission to the facility.
This deficient practice had the potential for the resident not to attain the highest practicable physical, mental, and psychosocial well-being and delay in the delivery of care and services.
Findings:
During a review of Resident 18's admission Record, the admission Record indicated that the facility admitted the resident on 2/12/2025 with diagnoses including type two (2) diabetes mellitus (DM- a chronic condition that affects the way the body processes blood glucose [sugar]), paranoid schizophrenia (type of schizophrenia [a mental illness that is characterized by disturbances in thought] accompanied by paranoia [way of thinking that involves feelings of distrust and suspicion about others without a good reason]), and encephalopathy (a general condition characterized by impaired brain function).
During a review of Resident 18's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) dated 2/13/2025, the H&P indicated that the resident had the capacity to understand and make decisions.
During a review of Resident 18's Minimum Data Set (MDS - a resident assessment tool) dated 2/19/2025, the MDS indicated that the resident's cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired. The MDS indicated that Resident 18 required staff partial/moderate assistance (helper does less than half the effort) for oral hygiene, toileting hygiene, lower body dressing, showering and bathing, putting on/talking off footwear, and personal hygiene.
During a concurrent interview and record review on 3/12/2025 at 2:36 p.m., with the Social Services Designee (SSD), reviewed Resident 18's Social Service Assessments from 2/12/2025 to 3/12/2025. The SSD stated that Resident 18 was admitted to the facility on [DATE], however, the facility did not conduct any social service assessments for Resident 18 since their admission. The SSD stated she (SSD) was not in charge of conducting social service assessments at that time, and there was another social worker in charge, however, the SSD stated that she (SSD) should have followed up and conducted the initial social service assessments for the residents missing theirs. The SSD stated the social workers are required to meet with the residents or their families upon admission and gather information necessary to conduct an initial assessment within 14 days of the resident's admission. The SSD stated that this assessment includes psychosocial history, physical, cultural and spiritual factors having impact on the resident's adjustment and wellbeing in the facility, and the determination of anticipated discharge planning. The SSD stated that this information was not gathered for Resident 18 since his admission to the facility. The SSD stated that the potential outcome of not timely assessing a resident is the delay in addressing their psychosocial issues and assisting the residents with their adjustment period in the facility.
During an interview on 3/13/2025 at 2:30 p.m., with the Director of Nursing (DON), the DON stated the social worker should visit the residents upon their admission into the facility and shall conduct a social service assessment within 14 days of the resident's admission. The DON stated staff did not conduct any social service assessments for Resident 18 and the potential outcome is the inability to address psychosocial concerns, prevent psychosocial issues, provide safe discharge, and assist residents with their adjustment period in the facility.
During review of the facility's policy and procedure (P&P) titled, Social Assessments, last reviewed on 2/26/2025, the P&P indicated that a social assessment shall be completed within 14 days of the resident's admission to the facility. A social assessment will be done to help identify the resident's personal and social situation, needs, and problems. Social services staff will obtain information during the initial interview of the family and upon the resident's admission. The purpose of obtaining this data is to identify information to help staff develop a personalized plan of care that will utilize the individual's existing strengths, try to compensate for physical and functional deficits, optimize function and quality of life, and meet the individual's needs and preferences.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to:
1. Ensure licensed nurses documented on the Medication Administrat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to:
1. Ensure licensed nurses documented on the Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) after administering as needed (PRN) tramadol (medication used for moderate to severe pain) for one of two sampled residents (Resident 29).
2. Ensure licensed nurses documented on the MAR after administering PRN oxycodone (medication used to treat moderate to severe pain) for one of two sampled residents (Resident 8).
This deficient practice had the potential to place the residents at increased risk of being given extra doses of a narcotic medication (medications used to treat moderate to severe pain) leading to an increased risk of the residents experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention).
Findings:
1. During a review of Resident 29's admission Record, the admission Record indicated the facility originally admitted the resident on 9/20/2024 and readmitted the resident on 1/24/2025 with diagnoses including polyneuropathy (a condition in which multiple peripheral nerves [nerves outside the brain and spinal cord] are damaged) and bilateral (both sides) osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the knees.
During a review of Resident 29's Minimum Data Set (MDS - a resident assessment tool) dated 12/23/2024, the MDS indicated the resident had intact cognition (thought processes) and required supervision for most activities of daily living (ADLs - activities related to personal care).
During a concurrent interview and record review on 3/11/2025 at 11:52 a.m., with Registered Nurse 2 (RN 2), reviewed Resident 29's physician orders, Resident 29's Record of Controlled Substances, and Resident 29's MAR dated 3/2025. RN 2 stated Resident 29 had an order for tramadol 50 milligrams (mg - unit of measurement) by mouth (PO) every six (6) hours as needed for chronic pain for 10 days, ordered on 2/23/2025. RN 2 stated that on 3/7/2025 at 12 p.m., the licensed nurse documented on Resident 29's Record of Controlled Substances that tramadol was taken out of the bubble pack (plastic packaging in which a medication is stored until ready for use) but did not document on Resident 29's MAR that it was administered. RN 2 stated that the Record of Controlled Substances should coincide with the MAR to ensure that the next shift nurse knows that the medication was actually administered to the resident. RN 2 stated that if it is not recorded as being given on the MAR, then there is a risk that the resident can receive a double dose of the medication.
During an interview on 3/12/2025 at 11:07 a.m., with the Director of Nursing (DON), the DON stated it was important for licensed nurses to also document when a medication was administered on the MAR so that other nurses knew whether or not a narcotic medication had been administered already.
During a review of the facility's policy and procedure titled, Administering Medications, last reviewed on 2/26/2025, the policy and procedure indicated that the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.
2. During a review of Resident 8's admission Record, the admission Record indicated the facility originally admitted the resident on 8/28/2020 and readmitted the resident on 9/9/2024 with diagnoses including idiopathic peripheral autonomic neuropathy (nerve damage in the autonomic nervous system [which controls involuntary functions]), chronic ulcer (a small open sore or wound generally found in the stomach or on the skin) on the right foot, osteoarthritis, and dorsalgia (pain in the back, specifically in the mid-back).
During a review of Resident 8's MDS dated [DATE], the MDS indicated the resident had moderately impaired cognition and was independent for most ADLs.
During a concurrent interview and record review on 3/11/2025 at 11:38 a.m., with RN 2, reviewed Resident 8's physician orders, Resident 8's Record of Controlled Substances, and Resident 8's MAR dated 3/2025. RN 2 stated Resident 8 had an order for oxycodone 30 mg PO every six (6) hours as needed for severe pain (7-9/10- numerical scale used to measure pain with 0 being no pain and 10 being the worst pain), ordered on 9/9/2024. RN 2 stated that the licensed nurse documented on Resident 8's Record of Controlled Substances that oxycodone was taken out of the bubble pack on 3/7/2025 at 12:30 p.m. and 3/8/2025 at 4 p.m., but they were not documented on Resident 8's MAR as being administered. RN 2 stated that the Record of Controlled Substances should coincide with the MAR to ensure that the next shift nurse knows that the medication was actually administered to the resident. RN 2 stated that if it is not recorded as being given on the MAR, then there is a risk that the resident can receive a double dose of the medication.
During an interview on 3/12/2025 at 11:07 a.m., with the DON, the DON stated it was important for licensed nurses to also document when a medication was administered on the MAR so that other nurses knew whether or not a narcotic medication had been administered already.
During a review of the facility's policy and procedure titled, Administering Medications, last reviewed on 2/26/2025, the policy and procedure indicated that the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure residents were free from any significant medication errors for one of five sampled residents (Resident 34) by failing t...
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Based on observation, interview and record review, the facility failed to ensure residents were free from any significant medication errors for one of five sampled residents (Resident 34) by failing to administer clozapine (medication used to treat schizophrenia [mental disorder in which people interpret reality abnormally]) as ordered.
This deficient practice had the potential for the medication to not be effective or cause adverse reaction (undesired harmful effect resulting from a medication or other intervention) to Resident 34.
Findings:
During a review of Resident 34's admission Record, the admission Record indicated the facility admitted the resident on 12/18/2019 and readmitted the resident on 5/9/2024 with diagnoses that included encephalopathy (brain disease, damage, or malfunction of brain), paranoid schizophrenia (type of schizophrenia accompanied by paranoia [way of thinking that involves feelings of distrust and suspicion about others without a good reason]), and major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities of living).
During a review of Resident 34's Minimum Data Set (MDS, a resident assessment tool) dated 12/12/2024, the MDS indicated Resident 34 had mildly impaired cognition (thought processes).
During a review of History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) dated 5/9/2024, the H&P indicated that Resident 34 had capacity to understand and make decisions.
During a review of Resident 34's Order Summary Report, the Order Summary Report indicated an order for clozapine orally disintegrating tablet (ODT) 200 milligrams (mg- unit of measurement) give one tablet orally one time a day for schizophrenia paranoid type.
During a medication administration observation on 3/11/2025 at 9:48 a.m., with Licensed Vocational Nurse 1 (LVN 1), observed LVN 1 administer clozapine ODT 100 mg two tablets to Resident 34 without explaining to Resident 34 to allow the tablets to disintegrate in the mouth and swallow with saliva or chew as desired.
During an interview on 3/11/2025 at 10:00 a.m., with LVN 1, LVN 1 stated that she (LVN 1) is not sure what the abbreviation ODT meant and how to correctly administer ODT medication.
During a concurrent interview and record review on 3/11/2025 at 12:05 p.m., with the Assistant Director of Nursing (ADON), reviewed the administration manual for clozapine ODT. The ADON stated that the medication has to be dissolved in the mouth before swallowing. The ADON stated that licensed staff that are administering medication to the residents should be knowledgeable about right route of medication administration.
During an interview on 3/12/2025 at 1:14 p.m., with Pharmacist 1 (P 1), P 1 stated that ODT medication has to be disintegrated in the mouth before swallowing.
During an interview on 3/13/2025 at 3:47 p.m., with the Director of Nursing (DON), the DON stated that staff have to administer medication according to the physician order including right route of administration to enhance optimal therapeutic effect of the medication.
During a review of the facility's policy and procedure titled, Administration Medications, last reviewed 2/26/2025, the policy indicated medications are administered in a safe and timely manner including right method (route) of administration, and as prescribed to enhance optimal therapeutic effect of the medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 391's admission Record, the admission Record indicated the facility originally admitted the resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 391's admission Record, the admission Record indicated the facility originally admitted the resident on 1/30/2020 and readmitted the resident on 1/26/2025 with diagnoses including type 2 diabetes mellitus.
During a review of Resident 391's MDS dated [DATE], the MDS indicated the resident had moderately impaired cognition. The MDS also indicated Resident 391 received insulin.
During a review of Resident 391's physician orders dated 1/26/2025, the physician orders indicated an order to administer insulin glargine 100 units/milliliter, inject 20 units subcutaneously at bedtime for DM.
During a concurrent observation and interview on 3/11/2025 at 11:15 a.m., with Registered Nurse 2 (RN 2), observed Resident 391's unopened insulin glargine pen inside Medication Cart B. Observed a sticker on Resident 391's insulin pen packaging indicating to refrigerate if unopened.
During an interview on 3/12/2025 at 11:15 a.m., with the Director of Nursing (DON), the DON stated that unopened insulin should be stored in the refrigerator. The DON stated it was important to follow the manufacturer's guidelines in how to store the insulin because the temperature can affect the medication. The DON stated not refrigerating the insulin can cause it to lose efficacy, which in turn can cause it to have less of an effect for the resident.
During a review of the facility-provided insulin glargine manufacturer's guide, the manufacturer's guide indicated to keep new pens in the refrigerator between 36 to 46 degrees Fahrenheit (unit of measurement).
During a review of the facility's policy and procedure titled, Medication Labeling and Storage, last reviewed on 2/26/2025, the policy and procedure indicated that the facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location
Based on observation, interview, and record review, the facility failed to store unopened insulin (hormone that lowers the level of glucose [sugar] in the blood) pens (a medical device used to inject insulin subcutaneously [SQ - administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle]) inside the refrigerator for two of two sampled residents (Resident 80 and 391).
This deficient practice had the potential for the insulin to lose efficacy and can result in uncontrolled blood glucose.
Findings:
1. During a review of Resident 80's admission Record, the admission Record indicated the facility originally admitted the resident on 1/21/2024 and readmitted the resident on 12/16/2024 with diagnoses including type two (2) diabetes mellitus (DM - a chronic condition that affects the way the body processes blood glucose [sugar]) with ketoacidosis (a complication of diabetes in which acids build up in the blood to levels that can be life-threatening).
During a review of Resident 80's Minimum Data Set (MDS - a resident assessment tool) dated 1/16/2025, the MDS indicated Resident 80 had impaired cognition (thought processes). The MDS further indicated Resident 80 required supervision or touching assistance with most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 80's physician orders dated 12/16/2024, the physician order indicated an order to administer insulin glargine (long-acting insulin) 100 units/milliliter (U/ml- unit of measurement), inject 25 units subcutaneously at bedtime for DM.
During a concurrent observation and interview on 3/12/2025 at 11:55 p.m., with Licensed Vocational Nurse 1 (LVN 1), observed Resident 80's unopened insulin glargine pen inside Medication Cart A. Observed a sticker on Resident 80's insulin pen packaging which indicated to refrigerate unopened pens. LVN 1 stated Resident 80's insulin pen should be stored in the refrigerator. LVN 1 further stated insulin can only be out of the refrigerator for 28 days before they need to discard the medication and request a new one from the pharmacy so they can ensure the insulin works as intended.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to follow safe food handling practices when Dietary Aide 1 (DA 1) was wearing an uncovered, dangling bracelet in the kitchen.
Th...
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Based on observation, interview, and record review, the facility failed to follow safe food handling practices when Dietary Aide 1 (DA 1) was wearing an uncovered, dangling bracelet in the kitchen.
This deficient practice had the potential to place 89 out of 90 residents who receive food from the facility's kitchen at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).
Findings:
During a concurrent observation and interview on 3/12/2025 at 12:08 p.m., in the facility's kitchen with the Dietary Supervisor (DS), observed DA 1 wearing a bracelet while taking plates from the steam table and putting them into a delivery cart. Observed DA 1's bracelet not covered by the gloves DA 1 was wearing. The DS stated they do not usually wear bracelets in the kitchen.
During a concurrent interview and record review on 3/13/20254 at 9:35 a.m., with the DS, reviewed the facility's policy and procedure (P&P) titled, Dress Code for Women and Men, dated 2018. The policy indicated no excessive jewelry should be worn. The policy further indicated only wedding rings, non-dangling earrings, and a wristwatch could be worn, and wedding rings and wristwatches must be covered with gloves when handling food. The DS stated the dress code should be followed to maintain cleanliness in the kitchen.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to:
1. Implement its policy titled, Enhanced Barrier Precautions (EBP - a set of infection control practices that use personal p...
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Based on observation, interview, and record review, the facility failed to:
1. Implement its policy titled, Enhanced Barrier Precautions (EBP - a set of infection control practices that use personal protective equipment [PPE - equipment worn to reduce exposure to hazards in the workplace] to reduce the spread of multidrug-resistant organisms [MDROs - microorganisms that are resistant to multiple classes of antibiotics and antifungals] in nursing homes) by failing to ensure one of one sampled resident (Resident 57) who had a colostomy bag (a medical device that collects stool from a surgical opening in the abdomen) was placed on EBP.
This deficient practice had the potential to transmit infectious microorganisms to staff and other residents in the facility.
2. Ensure a resident's urinal (a bottle for collecting urine) was labeled with a resident identifier for one of five sampled residents (Resident 52) investigated for infection control.
This deficient practice had the potential to place the resident at increased risk of contracting an infection.
Findings:
1. During a review of Resident 57's admission Record, the admission Record indicated the facility admitted the resident on 2/7/2025 and readmitted the resident on 3/4/2025 with diagnoses including metabolic encephalopathy (condition where the brain's function is impaired due to an imbalance in the body's metabolism), urinary tract infections (UTI - an infection in the bladder/urinary tract), and colostomy status (surgical procedure that creates an opening in the abdominal wall to divert stool from the large intestine to an external bag).
During a review of Resident 57's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings), dated 3/5/2025, the H&P indicated that the resident had the capacity to understand and make decisions.
During a review of Resident 57's Minimum Data Set (MDS, a resident assessment tool) dated 3/8/2025, the MDS indicated that the resident was mildly impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated that Resident 57 required supervision (helper sets up or cleans up; resident completes activity) with eating and moderate assistance with oral hydyne and upper body dressing and was totally dependent on two or more helpers for toileting hygiene, shower and lower body dressing.
During a concurrent observation and interview on 3/10/2025 at 9:55 a.m., observed Resident 57 in her room in bed. Resident 57 stated that she has a colostomy bag. Observed no EBP signs or containers with gloves and gowns outside of Resident 57's room.
During a concurrent interview and record review on 3/12/2025 at 10:58 p.m., with the Infection Preventionist (IP), reviewed Resident 57's physician orders and care plans and stated that there was no physician order to place Resident 57 on EBP and no care plan regarding Resident 57 requiring EBP due the colostomy bag. The IP stated she was not aware that a resident who has a colostomy required EBP to be initiated. The IP stated there were no EBP signs before the entrance into Resident 57's room and no PPE outside of Resident 57's room. The IP stated it was important to follow the facility's EBP policy to prevent transmission of infectious microorganisms to the other residents.
During an interview on 3/13/2025 at 3:47 p.m., with the Director of Nursing (DON), the DON stated that it was important to put Resident 57 on EBP for infection control.
During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions, last reviewed on 2/26/2025, the policy and procedure indicated, Enhanced barrier precautions (EBP) are utilized to prevent the spread of multi-drug-resistant organisms .EBPs are indicated for residents with wounds and /or indwelling medical devices regardless of MDRO (multi-drug-resistant organisms) colonization.
2. During a review of Resident 52's admission Record, the admission Record indicated the facility admitted the resident on 6/4/2024 with diagnoses including a history of urinary tract infections (UTI - an infection in the bladder/urinary tract).
During a review of Resident 52's H&P dated 6/4/2024, the H&P indicated that the resident had the capacity to understand and make decisions.
During a concurrent observation and interview on 3/10/2025 at 9:29 a.m., with Certified Nursing Assistant 4 (CNA 4), observed an unlabeled urinal at Resident 52's bedside. CNA 4 verified by stating that the urinal was not labeled with a resident identifier.
During an interview on 3/12/2025 at 11:30 a.m., with the DON, the DON stated the facility had no specific policy addressing the labeling of urinals for infection control.
During an interview on 3/12/2025 at 12:33 p.m., with the IP, the IP stated that residents' urinals should be labeled with their last name and first initial to ensure infection control. The IP stated it was important to label urinals with a resident identifier to ensure that only one resident is using it and there is no cross contamination amongst residents.
During a review of the facility's policy and procedure titled, Infection Control Guidelines for All Nursing Procedures, last reviewed on 2/26/2025, the policy and procedure indicated that standard precautions (set of infection control practices designed to prevent the transmission of infectious diseases in healthcare settings) will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes.
During a review of the facility's policy and procedure titled, Standard Precautions, last reviewed on 2/26/2025, the policy and procedure indicated that standard precautions will be used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Handle used resident-care equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of other microorganisms to other residents and environments.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to:
1. Ensure a copy of the resident's Advance Directive (a legal docu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to:
1. Ensure a copy of the resident's Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) was readily available in the resident's medical record for one (Resident 49) out of six sampled residents investigated for Advance Directives.
2. Ensure two of six sampled residents (Resident 20 and Resident 291) were provided written information concerning the right to refuse or accept medical or surgical treatments and formulate an Advanced Directive upon admission.
These deficient practices had the potential to create confusion, which could lead to conflict with the resident's wishes regarding his/her health care.
Findings:
1. During a review of Resident 49's admission Record, the admission Record indicated the facility admitted the resident on 1/31/2025 with diagnoses including metabolic encephalopathy (a brain dysfunction resulting from a chemical imbalance in the blood, often caused by underlying systemic illnesses or organ dysfunction, rather than a primary brain injury).
During a review of Resident 49's Minimum Data Set (MDS - a resident assessment tool), dated 2/4/2025, the MDS indicated the resident had moderately impaired cognition (thought processes) and required moderate assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily).
During a concurrent interview and record review on 3/11/2025 at 1:36 p.m., with Registered Nurse 1 (RN 1), reviewed Resident 49's Advance Directive Acknowledgement form, dated 1/31/2025. RN 1 confirmed that the Advance Directive Acknowledgement form indicated that the resident had an Advance Directive. RN 1 stated he could not find a copy of the resident's Advance Directive in the resident's medical record.
During an interview on 3/11/2025 at 1:44 p.m., with Resident 49, in the presence of RN 1, Resident 49 confirmed she did have an Advance Directive.
During a concurrent interview and record review on 3/11/2025 at 1:47 p.m., with the Social Services Designee (SSD), reviewed Resident 49's Social Services progress notes. The SSD stated she did not have any documentation indicating that she followed up with either the resident or the resident's family regarding obtaining a copy of the Advance Directive.
During an interview on 3/12/2025 at 10:54 a.m., the SSD stated that the purpose of an Advance Directive was so that the resident can communicate their needs and wishes regarding their healthcare. The SSD stated it was important to have a copy of the resident's Advance Directive readily available in the medical record so that the facility was aware of and could carry out the resident's healthcare wishes. The SSD stated if they did not have a copy of the resident's Advance Directive, and an emergency came up, there was a potential that the facility will not know how to carry out the resident's wishes for their healthcare and may potentially do something that goes against their wishes. The SSD stated she should have followed up with the resident or the resident's family member immediately to obtain a copy of the resident's Advance Directive.
During a review of the facility's policy and procedure titled, Advance Directives, last reviewed on 2/26/2025, the policy and procedure indicated that Advance Directives are honored in accordance with state law and facility policy. Prior to or upon admission of a resident, the social service director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. If the resident or the residents representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff. The residents wishes are communicated to the resident's direct care staff and physician by placing the advance directive documents in a prominent, accessible location in the medical record and discussing the resident's wishes in care planning meetings.
2.a. During a review of Resident 20's admission Record (face sheet), the admission Record indicated that the facility originally admitted the resident on 2/3/2025, and readmitted on [DATE], with diagnoses including sepsis (a life-threatening blood infection), type two (2) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).
During a review of Resident 20's Minimum Data Set (MDS-a resident assessment tool) dated 3/1/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 20 was dependent to staff (helper does all the effort) for oral hygiene, toileting hygiene, personal hygiene, showering, and bathing, and upper and lower body dressing.
During a review of Resident 20's Advance Directive Acknowledgement Form (ADA-a document provided by the facility that indicates whether a resident has an AD, would like information regarding creation of an AD, or refusal to create an AD), the form in the resident`s chart was blank with no entries on it.
During a concurrent interview and record review on 3/11/2025 at 11:25 a.m., with Registered Nurse 2 (RN2), Resident 20's ADA form was reviewed. RN 2 stated that Resident 20 was readmitted to the facility on [DATE] and he has a conservator (a person appointed by the court to make decisions about personal matters for the resident, including decisions about medical care, food, clothing, where the person will live). However, the resident`s ADA form was not completed. RN 2 stated there is no evidence that Resident 20 or his responsible party was provided with written information concerning the right to refuse or formulate an advance directive.
During a concurrent interview and record review on 3/11/2025 at 11:36 a.m., with the facility`s Medical Record Director (MRD), Resident 20`s ADA form was reviewed. The MRD stated that Resident 20`s ADA form was not completed upon his admission to the facility, and it is blank. The MRD stated that the ADA form is required to be completed upon resident`s admission to the facility. MRD stated that the ADA form contains information regarding the resident`s right to be informed and to receive information on how to formulate an AD. MRD stated that the potential outcome of not completing ADA form is that the resident`s wishes may not be honored.
During review of the facility's Policy and Procedure (P&P) titled, Advance Directives, last reviewed on 2/26/2025, the P&P indicated that the resident has the right to formulate an AD, including the right to accept or refuse medical or surgical treatment. Advanced directives are honored in accordance with state law and facility policy. Prior to or upon admission of a resident the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advanced directives. The resident pr representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an AD if he or she chooses to do so. If the resident is incapacitated and unable to receive information about his or her right to formulate an AD, the information may be provided to the resident`s legal representative. Nursing staff will document in the medical record the offer to assist and the resident`s decision to accept or decline assistance.
2.b. During a review of Resident 291's admission Record, the admission Record indicated that the resident was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), acute respiratory failure (a condition in which your blood doesn't have enough oxygen causing shortness of breath and difficulty breathing, often caused by a disease or injury), and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood well).
During a review of Resident 291's History and Physical (H&P- a comprehensive assessment of a patient's health, performed by a doctor during an initial visit), dated 1/25/2014, the H&P indicated that Resident 291 had the capacity to understand and make decisions.
During a review of Resident 291's Scheduled Minimum Data Set (MDS - a standardized assessment and screening tool), dated 12/23/2025, indicated that Resident 291 had severely impaired cognition (severely damaged mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS also indicated that the resident needed supervision with eating, moderate assistance with oral and personal hygiene and was dependent on 2 or more helpers with bed mobility, shower transfer, dressing, and toileting.
During a concurrent interview and record review on 3/11/2025 at 11:48 A.M. with the Social Services Director (SSD) reviewed Resident 291's physical chart. The SSD stated that the advance directive acknowledgement form was completely blank, and she does not have any evidence that the resident was provided with written information concerning the right to refuse or formulate an advance directive if he chooses to do so. The SSD also stated that the advance directive acknowledgement form should have been signed by Resident 291 on admission.
During an interview on 3/13/2025 at 3:47 P.M., with the Director of Nursing (DON), the DON stated that it is important to have the advance directive acknowledgement form in Resident 291's clinical record because it contains information about the resident's right to accept or refuse medical treatment and the right to formulate an advanced directive. The DON stated that the facility should provide written information regarding Advanced Directives to the resident or the resident's representative at the time of admission.
During a review of the facility's policies and procedures titled Advance Directives, revised 2/26/2025, the policy indicated: Prior to or upon admission of a resident, the social services director or designee inquires of the resident , his/her family member and or his or her legal representative , about the existence of any written advance directive. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a document that ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a document that summarizes a resident's needs, goals, and care/treatment) by failing to:
1. Develop a care plan addressing a resident's diagnosis of post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) for one of one sampled resident (Resident 49) investigated for trauma-informed care.
2. Develop a care plan addressing a resident's restorative nursing assistant (RNA - an ongoing program that focuses on helping individuals, especially those in long-term care, maintain and improve their functional abilities and independence, often following rehabilitation) therapy for one of two sampled residents (Resident 47) investigated under the care area of position and mobility.
3. Resident 85's refusal of vaccination for Covid-19 (disease cause by the SARS-CoV-2 virus, that spreads throiugh respiratory droplets. Most people infected with the virus will experience mild to moderate respiratory illness) and influenza (viral infection of the nose, throat and lungs).
4. Resident 63' activities preferences.
5. Resident 21's use of oxygen.
These deficient practices had the potential to result in failure to deliver the necessary care and services.
Findings:
1. During a review of Resident 49's admission Record, the admission Record indicated the facility admitted the resident on 1/31/2025 with diagnoses including PTSD.
During a review of Resident 49's Minimum Data Set (MDS - a resident assessment tool) dated 2/4/2025, the MDS indicated the resident had moderately impaired cognition (thought processes) and required moderate assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). The MDS also indicated the resident has a diagnosis of PTSD.
During a concurrent interview and record review on 3/11/2025 at 1:56 p.m., with Registered Nurse 1 (RN 1), reviewed Resident 49's care plans dated 1/31/2025 to 3/11/2025. RN 1 stated that Resident 49 had a diagnosis of PTSD. RN 1 stated he could not find a care plan addressing Resident 49's diagnosis of PTSD.
During an interview on 3/12/2025 at 11:18 a.m., with the Director of Nursing (DON), the DON stated it was important for the interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) to determine the specific care Resident 49 would need for her PTSD. The DON stated it was important to note what triggered Resident 49 so that facility staff could avoid those triggers.
During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, last reviewed on 2/26/2025, the policy and procedure indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Services provided for or arranged by the facility and outlined in the comprehensive care plan are provided by qualified persons; culturally competent; and trauma-informed.
During a review of the facility's policy and procedure titled, Trauma Informed Care and Culturally Competent Care, last reviewed on 2/26/2025, the policy and procedure indicated to develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. Identify and decrease exposure to triggers that may re-traumatize the resident.
2. During a review of Resident 47's admission Record, the admission Record indicated the facility originally admitted the resident on 7/31/2023 and readmitted the resident on 9/10/2024 with diagnoses including difficulty in walking and muscle wasting and atrophy (the thinning or loss of muscle tissue, leading to a decrease in muscle mass and strength).
During a review of Resident 47's MDS dated [DATE], the MDS indicated the resident had severely impaired cognitive skills for daily decision making and required maximal assistance from staff for most ADLs.
During a concurrent interview and record review on 3/12/2025 at 9:54 a.m., with RN 1, reviewed Resident 47's physician's orders and Resident 47's care plans dated 9/10/2024 to 3/12/2025. RN 1 stated Resident 47 had a physician's order for RNA passive range of motion (PROM - moving a joint through its full range of motion without the resident's active muscle contraction) exercises on the bilateral upper extremities (BUE) every day five times a week or as tolerated, ordered on 12/18/2024. RN 1 stated Resident 47 also had a physician's order for RNA for ambulation (walking) with a front wheel walker (FWW) as tolerated every day for five times a week with two-person assistance for safety, ordered on 12/18/2024. RN 1 stated he could not find any care plans addressing Resident 47's RNA treatments.
During an interview on 3/12/2025 at 11:21 a.m., with the DON, the DON stated that Resident 47 should have had a care plan addressing his RNA treatments.
During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, last reviewed on 2/26/2025, the policy and procedure indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; includes the resident's stated goals upon admission and desired outcomes; builds on the resident's strengths; and reflects currently recognized standards of practice for problem areas and conditions.
5. During a review of Resident 21's admission Record (face sheet), the admission record indicated that the facility admitted the resident on 1/7/2025, with diagnoses including acute (rapid onset and relatively short duration) respiratory failure (a serious condition that makes it difficult to breathe on your own) with hypoxia (a condition where there is an inadequate supply of oxygen to the body's tissues), difficulty in walking, dementia (a progressive state of decline in mental abilities), and history of falling.
During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool) dated 1/11/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated that Resident 21 required staff partial/moderate assistance (helper does less than half the effort) for oral hygiene, showering and bathing, and personal hygiene. The MDS further indicated that Resident 21 received continuous oxygen therapy on admission and within the last 14 days.
During a review of Resident 21`s Physician Order Summary Report dated 1/7/2025, the order summary report indicated to administer oxygen at two (2) liters per minute via nasal canula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) as needed (PRN) for Shortness of Breath (SOB).
During a review of Resident 21's care plans, the care plans did not indicate an evidence of a comprehensive care plan addressing Resident 21`s oxygen use.
During a concurrent interview and record review on 3/13/2025 at 11:45 a.m., with Assistant Director of Nursing (ADON), Resident 21`s physician orders and care plans were reviewed. ADON stated that Resident 21 is using oxygen as needed. However, licensed staff did not develop a comprehensive care plan with person-centered interventions for the resident`s oxygen use. ADON stated it is required to develop a person-centered care plan with goal and interventions to monitor Resident 21`s oxygen use. ADON stated the potential outcome of not developing a care plan for a resident who uses oxygen is the lack of care and the inability to implement the specific services and monitoring that resident requires.
During an interview on 3/13/2025 at 2:36 p.m., with the Director of Nursing (DON), the DON stated licensed staff are required to develop a person-centered care plan based on the residents` needs and identified problems. The DON stated licensed staff did not develop a care plan with goal and interventions for Resident 21`s oxygen use. The DON stated that the potential outcome is providing inadequate care to the resident.
During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed on 2/26/2025, the P&P indicated that a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident`s physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive person-centered care plan is developed within seven days of completion of the required MDS assessment and no more than 21 days after admission. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident`s problem areas and their causes, and relevant clinical decision making. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents` conditions change.
3. During a review of Resident 85's admission Record, the admission Record indicated the facility admitted the resident on 12/11/2024 and readmitted her on 1/17/2025 with diagnoses including chronic obstructive pulmonary disease (COPD- long -term disease that makes it hard to breath), essential hypertension (high blood pressure), and major depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).
During a review of Resident 85's History and Physical (H&P - a comprehensive assessment that involves a healthcare provider obtaining a thorough medical history from the patient and performing a physical examination to understand their current health status and any presenting problems), dated 12/12/2024, the H&P indicated that the resident has the capacity to understand and make decisions.
During a review of Resident 85's Minimum Data Set (MDS, an assessment and care screening tool) dated 3/8/2025, the MDS indicated that the resident had an intact cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated that Resident 85 required supervision (helper sets up or cleans up; resident completes activity) with eating and moderate assistance with oral hygiene, upper body dressing and toileting hygiene, shower and lower body dressing.
During a review of Resident 85's Vaccine consent dated 12/28/2024, it indicated that Resident 85 refused Covid 19 and Influenza (viral infection of the nose, throat and lungs) vaccination.
During a concurrent interview and record review on 3/12/2025 at 10:58 p.m., the Infection Preventionist (IP) reviewed Resident 85 care plans and stated that there was no care plan created addressing Resident 85 refusal of Covid 19 and Influenza vaccination. The IP stated it was important to create care plan to address and monitor Resident 85 for possible complications secondary to vaccination refusal.
During an interview on 3/13/2025 at 3:47 p.m., the Director of Nursing (DON) stated that Resident 85 should had a care plan addressing his refusal of vaccination.
During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, last reviewed on 2/26/2025, the policy and procedure indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; includes the resident's stated goals upon admission and desired outcomes; builds on the resident's strengths; and reflects currently recognized standards of practice for problem areas and conditions.
4.During a review of Resident 63's admission Record, the admission Record indicated the facility admitted the resident on 1/3/2025 with diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly) and cellulitis (a bacterial skin infection) of left lower limb.
During a review of Resident 63's History and Physical (H&P - a comprehensive assessment that involves a healthcare provider obtaining a thorough medical history from the patient and performing a physical examination to understand their current health status and any presenting problems), dated 1/31/2025, the H&P indicated that the resident has the capacity to understand and make decisions.
During a review of Resident 63's Minimum Data Set (MDS, an assessment and care screening tool) dated 2/7/2025, the MDS indicated that the resident was mildly impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated that Resident 63 required supervision (helper sets up or cleans up; resident completes activity) with shower and personal hygiene.
During a concurrent observation and interview on 3/10/2025 at 10:00 a.m., with Restorative Nursing Assistant 1 (RNA 1), Resident 63 was observed in wheelchair in the dining room, where the television (TV) was turned off. Resident 63 stated that he would like to watch television, and he does not like that the television was turned off at that time. RNA 1 stated that the activity department was playing movies at designated times throughout the of the day while at other times the residents were encouraged residents to be involve in other activities.
During a concurrent interview and record review on 3/12/2025 at 10:58 p.m., the Activity Director (AD) reviewed Resident 63's activities initial review dated 02/01/2025 and care plans. The AD stated that according to past activities interests the resident liked to participate in watching TV. The AD stated that there was no care plan created to address Resident 63 activity preferences. The AD stated it was important to create care plan to address and monitor Resident 63 for his activity's preferences.
During an interview on 3/13/2025 at 3:47 p.m., the Director of Nursing (DON) stated that Resident 63 should had a care plan addressing his activities preferences and needs.
During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, last reviewed on 2/26/2025, the policy and procedure indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; includes the resident's stated goals upon admission and desired outcomes; builds on the resident's strengths; and reflects currently recognized standards of practice for problem areas and conditions.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure licensed nurses attempted nonpharmacological interventions (treatments or therapies that do not involve the use of medications) prio...
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Based on interview and record review, the facility failed to ensure licensed nurses attempted nonpharmacological interventions (treatments or therapies that do not involve the use of medications) prior to administering as needed (PRN) morphine sulfate (a drug used to treat moderate to severe pain) to one of one sampled resident (Resident 17) investigated under the care area of pain management.
This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention).
Findings:
During a review of Resident 17's admission Record, the admission Record indicated the facility originally admitted the resident on 10/20/2021 and readmitted the resident on 5/1/2024 for diagnoses including polyneuropathy (a condition that affects multiple peripheral nerves, which are the nerves outside the brain and spinal cord) and spinal enthesopathy in the lumbar region (a condition where the entheses [the points where tendons and ligaments attach to bone] in the lower back are affected, causing pain, stiffness, and potentially limited mobility).
During a review of Resident 17's Minimum Data Set (MDS - a resident assessment tool) dated 2/20/2025, the MDS indicated the resident had moderately impaired cognition (thought processes) and was dependent on staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily).
During a concurrent interview and record review on 3/11/2025 at 2:17 p.m., with Registered Nurse 1 (RN 1), reviewed Resident 17's physician orders and Resident 17's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 3/2025. RN 1 stated Resident 17 had an order for morphine sulfate 20 milligrams (mg - unit of measurement) per five (5) milliliters (ml - unit of measurement), give 0.25 ml sublingually (under the tongue) every two (2) hours as needed for severe pain 7 - 10 out of 10 (numerical scale used to measure pain with 0 being no pain and 10 being the worst pain) or shortness of breath (SOB), ordered on 8/9/2024. RN 1 stated Resident 17 had an order for nonpharmacological interventions, ordered on 3/2/2025. RN 1 stated Resident 17's MAR indicated the following:
- On 3/1/2025 at 2:21 a.m., Resident 17 received morphine sulfate 0.25 mg, but there is no documentation indicating that nonpharmacological interventions were attempted first.
- On 3/1/2025 at 6:32 p.m., Resident 17 received morphine sulfate 0.25 mg, but there is no documentation indicating that nonpharmacological interventions were attempted first.
- On 3/2/2025 at 6:30 p.m., Resident 17 received morphine sulfate 0.25 mg, but there is no documentation indicating that nonpharmacological interventions were attempted first.
- On 3/4/2025 at 5 p.m., Resident 17 received morphine sulfate 0.25 mg, but there is no documentation indicating that nonpharmacological interventions were attempted first.
- On 3/6/2025 at 11:09 a.m., Resident 17 received morphine sulfate 0.25 mg, but there is no documentation indicating that nonpharmacological interventions were attempted first.
- On 3/7/2025 at 8:28 p.m., Resident 17 received morphine sulfate 0.25 mg, but there is no documentation indicating that nonpharmacological interventions were attempted first.
- On 3/10/2025 at 11 a.m., Resident 17 received morphine sulfate 0.25 mg, but there is no documentation indicating that nonpharmacological interventions were attempted first.
During an interview on 3/12/2025 at 11:07 a.m., with the Director of Nursing (DON), the DON stated that licensed nurses should be attempting nonpharmacological interventions prior to administering opioid medications (medications used for moderate to severe pain) because it may possibly relieve the resident's pain, and the resident may not need the medication.
During a review of the facility's policy and procedure titled, Pain Assessment and Management, last reviewed on 2/26/2025, the policy and procedure indicated that nonpharmacological interventions may be appropriate alone or in conjunction with medications.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to:
1. Ensure licensed nurses attempted nonpharmacological interventio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to:
1. Ensure licensed nurses attempted nonpharmacological interventions (treatments or therapies that do not involve the use of medications) prior to administering as needed (PRN) lorazepam (used to treat anxiety disorder [a mental health condition characterized by persistent and excessive worry or fear that interferes with daily life]) for one of two sampled residents (Resident 29).
2 Ensure the physician's order for a resident's PRN lorazepam had a stop date (the date on which a specific medication or treatment order, as written by a physician, is scheduled to be discontinued unless the physician extends or modifies the order) for one of five sampled residents (Resident 17).
These deficient practices had the potential to place the resident at increased risk of taking an unnecessary medication and experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention).
Findings:
1. During a review of Resident 29's admission Record, the admission Record indicated the facility originally admitted the resident on 9/20/2024 and readmitted the resident on 1/24/2025 with diagnoses including anxiety disorder.
During a review of Resident 29's Minimum Data Set (MDS - a resident assessment tool) dated 12/23/2024, the MDS indicated the resident had intact cognition (thought processes) and required supervision for most activities of daily living (ADLs - activities related to personal care).
During a concurrent interview and record review on 3/11/2025 at 11:52 a.m., with Registered Nurse 2 (RN 2), reviewed Resident 29's physician orders and Resident 29's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 3/2025. RN 2 stated Resident 29 had an order for lorazepam 0.5 milligrams (mg - unit of measurement) by mouth (PO) every four (4) hours as needed for anxiety manifested by agitation leading to shortness of breath (SOB) for 14 days, ordered on 3/1/2025. RN 2 stated Resident 29's MAR dated 3/2025 indicated the following:
- On 3/1/2025 at 9 p.m., Resident 29 received lorazepam, but there is no documentation indicating that nonpharmacological interventions were attempted first.
- On 3/3/2025 at 9:06 a.m., Resident 29 received lorazepam 0.5 mg, but there is no documentation indicating that nonpharmacological interventions were attempted first.
- On 3/5/2025 at 4:37 a.m., Resident 29 received lorazepam 0.5 mg, but there is no documentation indicating that nonpharmacological interventions were attempted first.
- On 3/11/2025 at 9:15 a.m., Resident 29 received lorazepam 0.5 mg, but there is no documentation indicating that nonpharmacological interventions were attempted first.
During an interview on 3/12/2025 at 11:07 a.m., with the Director of Nursing (DON), the DON stated that nurses should be attempting nonpharmacological interventions prior to administering PRN medications because it may possibly relieve the resident's symptoms, and the resident may not need the medication.
During a review of the facility's policy and procedure titled, Psychotropic Medication Use, last reviewed on 2/26/2025, the policy and procedure indicated that nonpharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible.
2. During a review of Resident 17's admission Record, the admission Record indicated the facility originally admitted the resident on 10/20/2021 and readmitted the resident on 5/1/2024 with diagnoses including chronic obstructive pulmonary disorder (COPD - a chronic lung disease causing difficulty in breathing).
During a review of Resident 17's MDS dated [DATE], the MDS indicated the resident had moderately impaired cognition and was dependent on staff for most ADLs.
During a concurrent interview and record review on 3/11/2025 at 2:20 p.m., with Registered Nurse 1 (RN 1), reviewed Resident 17's physician orders. RN 1 stated Resident 17 had an order for lorazepam 2 mg per milliliter (ml - unit of measurement), give 0.25 ml sublingually (under the tongue) every four (4) hours as needed for anxiety manifested by verbalization of feeling anxious, ordered on 2/5/2025. RN 1 stated there was no stop date for Resident 17's lorazepam order.
During an interview on 3/12/2025 at 11:24 a.m., with the DON, the DON stated that PRN lorazepam should have a stop date after 14 days. The DON stated that, after 14 days, the physician needs to reevaluate if the resident needs to be continued on the medication.
During a review of the facility's policy and procedure titled, Psychotropic (medications capable of affecting the mind, emotions, and behavior) Medication Use, last reviewed on 2/26/2025, the policy and procedure indicated that PRN orders for psychotropic medications are limited to 14 days. For psychotropic medications that are not antipsychotics (a medication used to treat psychosis [a mental condition in which thought, and emotions are so affected that contact is lost with external reality]), if the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the time.
Dec 2024
8 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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to notify the physician and the resident's family regarding a skin discoloration on a resident's coccyx (tailbone) for one of three sampled re...
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Based on interview and record review, the facility failed to notify the physician and the resident's family regarding a skin discoloration on a resident's coccyx (tailbone) for one of three sampled residents (Resident 1).
This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted the resident on 3/28/2022 and readmitted the resident on 10/6/2022 with diagnoses that included left hip fracture (broken bone) and presence of left artificial hip joint, osteoporosis (condition in which bones become weak and brittle), and diabetes mellitus (DM, a chronic [long-term] condition that affects the way the body processes blood glucose [sugar]).
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 10/9/2022, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired. The MDS further indicated that the resident needed total assistance from staff with eating, oral hygiene, toilet hygiene, lower body dressing, bed mobility (movement), and transfer.
During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers to share information about a resident's condition to other members of the health care team, including a resident's physician) Communication Form dated 9/9/2022, the SBAR indicated that Resident 1's Certified Nursing Assistant (CNA) reported Resident 1's skin discoloration on the coccyx at 10:10 p.m., and zinc oxide (treats or prevents skin irritation like cuts, burns, or incontinent [loss of bowel or bladder control] brief rash) cream was applied and will continue to monitor resident.
During a review of Resident 1's physician order dated 9/16/2022, the physician order indicated that Resident 1 had skin excoriation (a scrape or scratch to the skin) on buttocks, and to cleanse with normal saline (NS - a saltwater solution), pat dry, and apply zinc oxide every shift for 14 days.
During a concurrent interview and record review on 12/18/2024 at 3:15 p.m., with Treatment Nurse 1 (TN 1), reviewed Resident 1's Departmental Notes (progress notes) for 9/2022, Resident 1's SBAR Communication Form dated 9/9/2022, and Resident 1's physician order dated 9/16/2022. TN 1 stated that the facility did not notify Resident 1's physician or family regarding Resident 1's skin discoloration on the coccyx noted on 9/9/2022. TN1 stated the first treatment order received on 9/16/2022 from Resident 1's physician to apply zinc oxide on Resident 1's buttocks on 9/16/2022, meant that Resident 1's physician was not notified until 9/16/2022. TN 1 stated that TN 1 was unable to locate documentation when Resident 1's family was notified regarding Resident 1's skin discoloration on the coccyx noted on 9/9/2022. TN 1 further stated that TN 1 was unsure how the facility did not notify Resident 1's physician and family regarding Resident 1's skin changes especially on the coccyx which could change to pressure ulcers (an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure) at any time. TN 1 stated that any changes of skin conditions should be notified to the residents' physician and family immediately.
During a concurrent interview and record review on 12/19/2024 at 3:50 p.m., with the Director of Nursing (DON), reviewed Resident 1's Departmental Notes for 9/2022 and Resident 1's SBAR Communication Form dated 9/9/2022. The DON stated the DON was unable to locate documentation indicating the facility staff notified Resident 1's physician or family about Resident 1's skin discoloration on the coccyx reported to the licensed nurse by the CNA on 9/9/2022. The DON stated the facility staff should notify Resident 1's physician and family about
Resident 1's skin discoloration on the coccyx on the same day, 9/9/2022.
During a review of the facility's policy and procedure titled, Changes in a Resident's Conditions or Status, last reviewed on 7/30/2024, the policy indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status The nurse will notify the resident's attending physician or physician on call when there has been a (an) . need to alter the resident's medical treatment significantly a nurse will notify the resident's representative Except in medical emergencies, notification will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a neurological assessment (evaluation of a person's nervous system [includes the brain, spinal cord, and a complex network of nerves...
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Based on interview and record review, the facility failed to ensure a neurological assessment (evaluation of a person's nervous system [includes the brain, spinal cord, and a complex network of nerves]) was completed after an unwitnessed fall for one of three sampled residents (Resident 4).
This deficient practice had the potential to result in confusion in the care and services for Resident 4, which could place the resident at risk of not receiving appropriate care due to incomplete resident medical care information.
Findings:
During a review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 12/23/2023 and readmitted the resident on 3/11/2024 with diagnoses that included encephalopathy (any brain disease that alters brain function or structure), other lack of coordination, and schizophrenia (a mental illness that is characterized by disturbances in thought).
During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 9/11/2024, the MDS indicated Resident 4's cognitive skills (thought processes) for daily decision making was moderately impaired. The MDS indicated Resident 4 was independent with eating, oral hygiene, toileting hygiene, and personal hygiene.
During a review of Resident 4's care plan (a document that summarizes a resident's needs, goals, and care/treatment) for risk for falls, initiated 9/11/2024, the care plan indicated interventions if fall occurs, initiate frequent neurological and bleeding evaluation per facility protocol.
During a review of Resident 4's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers to share information about a resident's condition to other members of the health care team, including a resident's physician) Communication Form dated 12/15/2024, the SBAR Communication Form indicated that Resident 4 was found on the floor near the dietary department.
During a concurrent interview and record review on 12/17/2024 at 4:02 p.m., with Licensed Vocational Nurse 1 (LVN 1), reviewed Resident 4's SBAR dated 12/15/2024 and Resident 4's Neurological Assessment Flow Sheet. LVN 1 stated that Resident 4 had an unwitnessed fall and was found near the dietary department. LVN 1 stated that after an unwitnessed fall licensed nurses will do a neurological assessment to monitor the resident's level of consciousness and monitor for any changes in condition (a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains). LVN 1 further stated that if there are any changes noted, licensed nurses are to inform the doctor. LVN 1 reviewed Resident 4's Neurological Assessment Flow Sheet. LVN 1 stated that Resident 4's Neurological Assessment Flow Sheet was not complete. LVN 1 stated that there is no documented evidence that a neurological assessment was done on 12/16/2024 at 4:15 p.m. LVN 1 stated that neurological assessments are important to monitor residents after an unwitnessed fall, if any changes are noted licensed nurses would be able to inform the doctor for further interventions.
During a review of the facility's policy and procedure titled, Neurological Assessment, reviewed 7/30/2024, the policy indicated the purpose of this procedure is to provide guidelines for neurological assessment: 1) upon physician order; 2) when following an unwitnessed fall; 3) subsequent to a fall with a suspected head injury; or 4) when indicated by resident condition. Under General Guidelines: 1. Neurological assessments are indicated: b. Following an unwitnessed fall. Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the procedure was performed; 2. The name and title of the individual(s) who performed the procedure; 3. All assessment data obtained during the procedure; 4. How the resident tolerated the procedure; 5. If the resident refused the procedure, the reason(s) why and the interventions taken; 6. The signature and title of the person recording the data.
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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:
1. Ensure no more than two layers of linen were use...
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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:
1. Ensure no more than two layers of linen were used with the use of a low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure injuries [an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure]) for two of three sampled residents (Resident 2 and Resident 3).
2. Ensure the LALM was set to the correct setting as ordered for two of three sampled residents (Resident 2 and Resident 3).
These deficient practices had the potential to increase the residents' risk of skin breakdown.
Findings:
a. During a review of Resident 2's admission Record, the admission Record indicated that the facility admitted the resident on 10/25/2023 with diagnoses that included gangrene (a serious medical condition where tissue dies due to a lack of blood supply) and dementia (a progressive state of decline in mental abilities).
During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 10/17/2024, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired, and the resident needed total assistance from staff with toileting hygiene, personal hygiene, and transfer, and needed moderate assistance with bed mobility (movement). The MDS further indicated that Resident 2 was at risk of developing pressure ulcers/injuries (PU/PI).
During a review of Resident 2's physician order dated 6/28/2024, the physician order indicated an order for a LALM with an alternating set mode (alternating air cells in the mattress are partially deflated and inflated, avoiding prolonged pressure on any single point) and setting based on comfort and/or of resident and check setting and functionality every shift for skin management.
During a review of Resident 2's care plan (a document that summarizes a resident's needs, goals, and care/treatment) for at risk for skin breakdown initiated 11/23/2024, the care plan indicated a goal that the resident would have skin intact and no pressure ulcers or injuries. The care plan indicated an intervention to have a LALM as ordered.
During a concurrent observation and interview on 12/17/2024 at 2:19 p.m., with Certified Nursing Assistant 1 (CNA 1), observed Resident 2 in bed on a LALM set to static mode (a setting that creates a firm surface) and lying on multiple layers consisting of one fitted sheet, one cloth incontinence (loss of bowel or bladder control) pad that is made of two different textures of linen, and wearing an adult brief. When CNA 1 was asked for the setting mode of Resident 2's LALM, CNA 1 stated that the CNAs should not touch the settings. When CNA 1 was asked about the linen use with a LALM, CNA 1 stated that only one sheet and a brief should be used, no more than that. CNA 1 stated CNA 1 forgot to remove the cloth incontinent pad that morning.
During an interview on 12/18/2024 at 11:32 a.m., with Treatment Nurse 1 (TN 1), TN 1 stated that Resident 2 had a right heel surgical wound that resolved several months ago. TN 1 stated Resident 2's LALM was being used as a preventative method for skin management and the setting should be the alternating mode. TN 1 stated the CNAs should not use more than two layers of linen with the LALM.
b. During a review of Resident 3's admission Record, the admission Record indicated that the facility originally admitted the resident on 9/3/2021 and readmitted the resident on 4/11/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing) and dementia.
During a review of Resident 3's MDS dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making was moderately impaired, and the resident needed total assistance from staff with toileting hygiene, lower body dressing, needed moderate assistance with transfer, and supervision or touching assistance with bed mobility. The MDS further indicated that Resident 3 was at risk of developing PU/PI.
During a review of Resident 3's physician order dated 6/28/2024, the physician order indicated an order to apply LALM with an alternating set mode and setting based on comfort and/or of resident and check setting and functionality every shift for skin management.
During a concurrent observation and interview on 12/17/2024 at 2:34 p.m., with CNA 2, observed Resident 3 in bed on a LALM set to static mode and lying on multiple layers of consisting of one fitted sheet, one cloth incontinence pad that is made of two different textures of linen, and wearing an adult brief. When CNA 2 was asked if the setting mode of the LALM was correct for Resident 3, CNA 2 stated that the CNAs do not touch the settings. When CNA 2 was asked about the linen use with a LALM, CNA 2 stated no more than two layers of linen should be used but forgot to remove the cloth incontinent pad and there was currently a total of four layers of linen. CNA 2 stated if more than two layers of linen are used, it was going to defeat the purpose of the LALM to prevent pressure ulcers.
During an interview on 12/18/2024 at 11:38 a.m., with TN 1, TN 1 stated that Resident 3 did not ask to set the LALM to static mode, so the LALM should be set to alternating mode. TN 1 stated the CNAs should not use more than two layers of linen with the LALM.
During a review of the facility's policy and procedure (P&P) titled, Prevention of Pressure Ulcers, last reviewed on 7/30/2024, the P&P indicated, Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin Determine if resident needs a special mattress per bed selection algorithm.
During a review of the facility's P&P titled, Support Surface Guidelines, last reviewed 7/30/2024, the P&P indicated, Element of support surfaces that are critical to pressure ulcer prevention and general safety include pressure redistribution, moisture control, shear (to cut or slide something apart by applying force in opposite directions) reduction . and life expectancy.
During a review of the facility-provided Therapy Bed Training Checklist last reviewed on 7/30/2024, indicated, Static Button: Press the Static button to enter Static mode and maintain all air cushion in the mattress at a constant pressure Linen Protocol: The above support surfaces are provided with the manufacturers loose fitting top sheet that the resident may lay on directly. These top sheets are water resistance and preventing sheering and helps to control the skin micro climate therefore the least amount of linens are suggested. Plastic chucks (Chux) or plastic briefs should never be used Avoid the multiple layers of linen under the resident. A single cotton draw sheet for turning and to absorb incontinence.
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
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure staffing information of the actual hours worked by licensed and unlicensed nursing staffing directly responsible for r...
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Based on observation, interview, and record review, the facility failed to ensure staffing information of the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift was posted daily for two of two days on 12/17/2024 and on 12/18/2024.
This deficient practice had the potential to keep residents and visitors unaware of the total number of staff and the actual hours worked by staff in the facility.
Findings:
During an observation on 12/17/2024 at 3:00 p.m., observed in the facility's lobby, a facility document titled, Posted Nursing Hours for Direct Care Staff, dated 12/17/2024.
During an interview on 12/17/2024 at 4:28 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that nursing hours posted in the lobby are projected (expected) hours.
During a concurrent observation, interview, and record review on 12/17/2024 at 5:06 p.m., with the Director of Nursing (DON), observed the facility's document titled, Posted Nursing Hours for Direct Care Staff, dated 12/17/2024, posted in the facility's lobby. The DON stated that the posted document is the facility's nursing projected hours.
During an interview on 12/18/2024 at 12:42 p.m., with Payroll 1, Payroll 1 stated that Payroll 1 is responsible for calculating the facility's actual nursing hours worked daily. Payroll 1 stated that actual nursing hours are calculated the following day for the day prior to ensure that the nursing hours are calculated accurately. Payroll 1 stated that the daily nursing hours posted in the lobby are projected nursing hours for the current day, not actual hours.
During a follow-up interview on 12/18/2024 at 1:06 p.m., with Payroll 1, Payroll 1 stated that Payroll 1 has not calculated the actual nursing hours for direct care staff for 12/17/2024 and 12/18/2024. Payroll 1 stated that 12/18/2024's actual nursing hours will be calculated tomorrow, 12/19/2024.
During an interview on 12/18/2024 at 1:09 p.m., with the DON, the DON stated that the nursing hours should be calculated daily. The DON stated that today's (12/18/2024) nursing hours will be calculated tomorrow. The DON further stated that the DON does not deal with posted nursing hours and just signs them the following day.
During a concurrent observation, interview, and record review on 12/18/2024 at 1:20 p.m., with the DON, observed the facility's document titled, Posted Nursing Hours for Direct Care Staff, dated 12/18/2024, posted in the facility's lobby. The DON stated that the posted document is the facility's nursing projected hours, not actual hours. The DON stated that it is important to post nursing hours because it will show staff, visitors, and residents that the facility is well staffed.
During a review of the facility-provided policy titled, Nurse Staffing Information, reviewed 7/30/2024, the policy indicated the facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. The information recorded on the form shall include the following: a. The name of the facility; b. The current date (the date for which the information is posted); c. The resident census at the beginning of the shift for which the information is posted; d. Twenty-four (24)-hour shift schedule operated by the facility; e. The shift for which the information is posted; e. Type (RN [Registered Nurse], LVN [Licensed Vocational Nurse], or CNA [Certified Nursing Assistant]) and category (licensed or non-licensed) of nursing staff working during that shift who are paid by the facility (including contract staff); g. the actual time worked during that shift for each category and type of nursing staff; and h. Total number of licensed and non- licensed nursing staff working for the posed shift. Within two (2) hours of the beginning of each shift, the charge nurse or designee computes the number of direct care staff and completed the Nurse Staffing Information form. The charge nurse completes the form and posts the staffing information in the location(s) designated by the administrator.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to obtain a physician's order prior to applying zinc oxide (treats or prevents skin irritation like cuts, burns, or incontinent [loss of bowel...
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Based on interview and record review, the facility failed to obtain a physician's order prior to applying zinc oxide (treats or prevents skin irritation like cuts, burns, or incontinent [loss of bowel or bladder control] brief rash) cream for one of three sampled residents (Resident 1).
This deficient practice had the potential to negatively affect the delivery of care and services.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted the resident on 3/28/2022 and readmitted the resident on 10/6/2022 with diagnoses that included left hip fracture (broken bone) and presence of left artificial hip joint, osteoporosis (condition in which bones become weak and brittle), and diabetes mellitus (DM, a chronic [long-term] condition that affects the way the body processes blood glucose [sugar]).
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 10/9/2022, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired. The MDS further indicated that the resident needed total assistance from staff with eating, oral hygiene, toilet hygiene, lower body dressing, bed mobility (movement), and transfer.
During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers to share information about a resident's condition to other members of the health care team, including a resident's physician) Communication Form dated 9/9/2022, the SBAR indicated that Resident 1's Certified Nursing Assistant (CNA) reported Resident 1's skin discoloration on the coccyx at 10:10 p.m., and zinc oxide cream was applied and will continue to monitor resident.
During a review of Resident 1's physician order dated 9/16/2022, the physician order indicated that Resident 1 had skin excoriation (a scrape or scratch to the skin) on buttocks, and to cleanse with normal saline (NS - a saltwater solution), pat dry, and apply zinc oxide every shift for 14 days.
During a concurrent interview and record review on 12/18/2024 at 4:25 p.m., with Treatment Nurse 1 (TN 1), reviewed Resident 1's SBAR Communication Form dated 9/9/2022 and physician order dated 9/16/2022 to apply zinc oxide cream to Resident 1's skin excoriation on buttocks. TN 1 stated that there was no physician's order to apply zinc oxide cream until 9/16/2022, so the staff should not apply zinc oxide cream without obtaining the physician order on 9/9/2022.
During a concurrent interview and record review on 12/19/2024 at 3:50 p.m., with the Director of Nursing (DON), reviewed Resident 1's Departmental Notes (progress notes) for 9/2022 and Resident 1's SBAR Communication Form dated 9/9/2022. The DON stated the DON was unable to locate documentation indicating the facility staff notified Resident 1's physician or family about Resident 1's skin discoloration on the coccyx reported to the licensed nurse by the CNA on 9/9/2022. The DON stated there was no physician order to apply zinc oxide cream on Resident 1's coccyx on 9/9/2022 and the nursing staff should not apply the medication without the physician's order.
During a review of the facility's policy and procedure titled, Medication and Treatment Orders, last reviewed on 7/30/2024, the policy indicated, Orders for medications and treatments will be consistent with principles of safe and effective order writing Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0777
(Tag F0777)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to promptly notify the physician of the results of a Stat (without delay, immediately) X-ray (a type of medical imaging that uses radiation to...
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Based on interview and record review, the facility failed to promptly notify the physician of the results of a Stat (without delay, immediately) X-ray (a type of medical imaging that uses radiation to take pictures of the inside of your body) for one of three sampled residents (Resident 1).
This deficient practice resulted in the delay of necessary care and services for Resident 1.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted the resident on 3/28/2022 and readmitted the resident on 10/6/2022 with diagnoses that included left hip fracture (broken bone) and presence of left artificial hip joint, osteoporosis (condition in which bones become weak and brittle), and diabetes mellitus (DM, a chronic [long-term] condition that affects the way the body processes blood glucose [sugar]).
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 10/9/2022, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired. The MDS further indicated that the resident needed total assistance from staff with eating, oral hygiene, toilet hygiene, lower body dressing, bed mobility (movement), and transfer.
During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers to share information about a resident's condition to other members of the health care team, including a resident's physician) Communication Form dated 9/29/2022, the SBAR Communication Form indicated that Resident 1's skin is intact with redness to upper leg noted after Resident 1 slid from the chair. STAT (immediately) X-ray ordered.
During a review of Resident 1's physician order dated 9/29/2022 at 7:38 p.m., the physician order indicated an order for X-ray to left hip, left femur (thigh bone) to rule out fracture.
During a review of Resident 1's document titled, Portable Service Requisition, dated 9/29/2022, the document indicated a STAT X-ray to be done for Resident 1's left hip and left femur. The document indicated under exam tracking information: Arrival date/time: 9/29/2022 at 11:22 p.m.
During a concurrent interview and record review on 12/19/2024 at 9:45 a.m., with Licensed Vocational Nurse 1 (LVN 1), reviewed Resident 1's SBAR dated 9/29/2022, Resident 1's physician's orders, and Resident 1's nursing progress notes from 9/29/2022-9/30/2022. LVN 1 stated that Resident 1 had a fall incident on 9/29/2022 and STAT X-rays were ordered. LVN 1 stated that on 9/29/2022 at 7:38 p.m., Resident 1's physician ordered a STAT X-ray of Resident 1's left hip. LVN 1 stated that on 9/30/2022 at 7:35 a.m., there is documentation that X-ray results were relayed to Resident 1's physician and Resident 1 was ordered to be transferred to the hospital for further evaluation of left hip fracture.
During a follow-up concurrent interview and record review on 12/19/2024 at 11:26 a.m., with LVN 1, reviewed the facility record titled, MediMatrix, dated 9/29/2022-9/30/2022 from the mobile diagnostic company. LVN 1 stated that the mobile diagnostic company emailed Resident 1's X-ray results on 9/30/2022 at 12:53 a.m.; called the facility, no answer on 9/30/2022 at 12:55 a.m.; called the facility, no answer on 9/30/2022 at 5:04 a.m.; called the facility, no answer on 9/30/2022 at 6:56 a.m.; called the facility, no answer on 9/30/2022 at 7:08 a.m.
During a concurrent interview and record review on 12/19/2024 at 12:46 p.m., with the Medical Records Director (MRD), reviewed the email correspondence from the mobile diagnostic company and the facility. The MRD stated that the facility received Resident 1's X-ray results via email on 9/30/2022 at 12:50 a.m. and on 9/30/2022 at 6:57 a.m. The MRD stated that the MRD does not know why the results were emailed to the Director of Nursing at that time.
During a follow-up interview on 12/19/2024 at 3:03 p.m., with LVN 1, LVN 1 stated that there should have been a better endorsement process between nursing staff from the 3 p.m.-11 p.m. and 11 p.m.-7 a.m. shift. LVN 1 continued to state that because the X-ray order was a STAT order, the 9/29/2022 11 p.m.-7 a.m. shift licensed nurses should have followed up the results of the STAT X-ray order and should have documented their attempts.
During an interview on 12/19/2024 at 4:32 p.m., with the Director of Nursing (DON), the DON stated that the incident that happened with Resident 1 was before the DON's time in the facility. The DON stated that facility staff should have followed up and called the diagnostic company for results sooner to avoid the delay of care.
During a review of the facility-provided policy and procedure titled, Lab and Diagnostic Test Results-Clinical Protocol, reviewed 7/30/2024, the policy indicated when test results are reported to the facility, a nurse will first review the results. If staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility should follow or coordinate the procedure .A nurse will identify the urgency of communicating with the Attending Physician based on physician request, the seriousness of any abnormality, and the individual's current condition .nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: a. Whether the physician has requested to be notified as soon as a result is received. b. Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic of any other factors). c. Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute (sudden) illness or condition change and is not stable or improving, or there are no previous results for comparison.
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
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was free of unnecessary psychotropic drugs (medic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was free of unnecessary psychotropic drugs (medications capable of affecting the mind, emotions, and behavior) for one of three sampled residents (Resident 1) by failing to summarize a resident's monthly behavior and side effects summary.
This deficient practice had the potential to result in the resident receiving unnecessary psychotropic drugs potentially increasing Resident 1's risk of adverse reactions (undesired harmful effect resulting from a medication or other intervention).
Findings:
During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted the resident on 3/28/2022 and readmitted the resident on 10/6/2022 with diagnoses that included left hip fracture (broken bone) and presence of left artificial hip joint, schizoaffective disorder (a mental health condition that includes features of both schizophrenia [serious mental illness that affects how a person thinks, feels, and behaves] and a mood disorder [marked disruptions in emotions]), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 10/9/2022, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired. The MDS further indicated that the resident needed total assistance from staff with eating, oral hygiene, toilet hygiene, lower body dressing, bed mobility (movement), and transfer.
During a review of Resident 1's physician orders dated 10/6/2022, the physician orders indicated the following:
- Trazodone (medication used to treat depression) 50 milligrams (mg - a unit of measurement), give one tablet by mouth daily at bedtime for depression.
- Risperdal (medication used to treat schizophrenia) 0.5 mg, give one tablet by mouth every 12 hours daily for schizoaffective disorder.
During a review of Resident 1's undated Behavior Summary Side Effects form for Trazodone 50 mg, the Behavior Summary Side Effects form was blank and did not indicate the number of episodes of verbalization of sadness for Trazodone and did not indicate the number of adverse reactions for 10/2022 and 11/2022.
During a review of Resident 1's undated Behavior Summary Side Effects form for Risperdal 0.5 mg, the Behavior Summary Side Effects form was blank and did not indicate the number of episodes of striking out at staff for Risperdal and did not indicate the number of adverse reactions for 10/2022 and 11/2022.
During a concurrent interview and record review on 12/18/2024 at 12:05 p.m., with Licensed Vocational Nurse 1 (LVN 1), reviewed Resident 1's undated Behavior Summary Side Effects form for Trazodone 50 mg and Risperdal 0.5 mg. LVN 1 stated that the facility did not summarize the monthly Behavior Summary Side Effects for both medications, Trazodone and Risperdal, for 10/2022 and 11/2022 and stated it should have been completed. LVN 1 stated the facility would not be able to compare the psychotropic medications' effectiveness or side effects that occurred from month to month without monthly summary data.
During a concurrent interview and record review on 12/19/2024 at 4:10 p.m., with the Director of Nursing (DON), reviewed Resident 1's undated Behavior Summary Side Effects form for Trazodone 50 mg and Risperdal 0.5 mg. The DON stated that the facility did not document monthly behavior data since being readmitted on [DATE]. The DON stated without a monthly summary of the behavioral or mood episodes for residents with psychotropic medications, it would be hard to proceed with a gradual dose reduction (GDR - the stepwise reducing of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) or to evaluate the effectiveness of psychotropic medications.
During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, last reviewed on 7/30/2024, the policy indicated, Residents will not receive medications that are not clinically indicated to treat a specific condition . Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes If psychotropic medications are identified as possibly causing or contributing to adverse consequences, the prescriber will determine whether the medication(s) should be continued and document the rationale for this decision.
During a review of the facility's P&P titled, Pharmaceutical Services Policy and Procedure Manual, last reviewed on 7/30/2024, the policy indicated, The facility shall utilize the data presented by the consultant pharmacist (and others) to formulate and monitor psychoactive drug use improvement plans.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of three sampled residents (Resid...
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Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of three sampled residents (Resident 1), by failing to document on a resident's Activities of Daily Living (ADL - activities related to personal care) Flow Sheet.
This deficient practice resulted in incomplete resident medical care information for Resident 1 and had the potential to result in confusion with the care and services for Resident 1 which could place the resident at risk for not receiving appropriate care.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted the resident on 3/28/2022 and readmitted the resident on 10/6/2022 with diagnoses that included left hip fracture (broken bone) and presence of left artificial hip joint, osteoporosis (condition in which bones become weak and brittle), and diabetes mellitus (DM, a chronic [long-term] condition that affects the way the body processes blood glucose [sugar]).
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 10/9/2022, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired. The MDS further indicated that the resident needed total assistance from staff with eating, oral hygiene, toilet hygiene, lower body dressing, bed mobility (movement), and transfer.
During a review of Resident 1's ADL Flow Sheet for 12/2022, the ADL Flow Sheet indicated there were no documented entries (blank) to indicate the care and services were provided or refused by Resident 1 on the following self-care areas and mobility areas as follows:
- On 12/9/2022, 7 a.m. to 3 p.m., bowel function, personal hygiene, and bathing was left blank.
- On 12/10/2022, 3 p.m. to 11 p.m., transfer and locomotion off unit (how resident moves to/return from off-unit [areas set aside for dining, activities or treatments] locations) was left blank.
- On 12/15/2022, 3 p.m. to 11 p.m., nail care needed or not, bed mobility, transfer, walk in room/corridor, locomotion on unit, dressing, eating, bladder function, and bowel function was left blank.
- On 12/16/2022, 7 a.m. to 3 p.m., locomotion on/off unit was left blank.
- On 12/21/2022, 7 a.m. to 3 p.m., nail care needed or not, bed mobility, transfer, walk in room/corridor, locomotion on/off unit, dressing, eating, meal percentage consumed for breakfast, toilet use, bladder/bowel function, personal hygiene, and bathing was left blank.
Resident 1's ADL Flow Sheet further indicated that there were no assigned Certified Nursing Assistants' (CNA) initials on 12/9/2022 7 a.m. to 3 p.m., 12/12/2022 3 p.m. to 11 p.m., 12/15/2022 3 p.m. to 11 p.m., and 12/21/2022 7 a.m. to 3 p.m.
During a concurrent interview and record review on 12/19/2024 at 9:57 a.m., with Certified Nursing Assistant 3 (CNA 3), reviewed Resident 1's ADL Flow Sheet for 12/2022. CNA 3 stated the CNAs should document at the end of their shift for the services provided to the residents and stated it was very important to document correctly. CNA 3 stated if they did not document, then they could not say what services were provided to the residents, and without the CNA's initials, they would not know who provided the services to the resident.
During a concurrent interview and record review on 12/19/2024 at 4:15 p.m., with the Director of Nursing (DON), reviewed Resident 1's ADL Flow Sheet for 12/2022. The DON stated that there were gaps on Resident 1's ADL Flow Sheet, and the CNAs did not document what services were provided to Resident 1. The DON further stated that no documentation meant no services were done, or they are unable to tell how the residents were doing with their ADLs. The DON stated that is why the CNAs should not miss their documentation on the residents' ADL Flow Sheet.
During a review of the facility's policy and procedure titled, Charting and Documentation, last reviewed on 7/30/2024, the policy indicated, All services are provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the residence medical record. The medical record should facilitate the communication between the interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) regarding the resident's condition and response to care Documentation of procedures and treatments will include care-specific details including the date and time the procedure/treatment was provided; the name and title of the individual(s) who provided the care the signature and title of the individual documenting.
Nov 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its policy and procedure for ensuring the reporting of a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its policy and procedure for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report to the State Survey Agency (SSA) an allegation of sexual abuse (any sexual activity that occurs without consent [permission]) within two (2) hours of the incident for one of four sampled residents (Resident 1).
This deficient practice resulted in a delay of an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 9/19/2022 and readmitted Resident 1 on 12/2/2023 with diagnoses that included epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures [sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain]) and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior).
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 9/20/2024, the MDS indicated that Resident 1 sometimes made self-understood and sometimes had the ability to understand others. The MDS further indicated that Resident 1's cognitive (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was moderately impaired, and Resident 1 needed moderate assistance from staff with lower body dressing, toileting hygiene, and independent with bed mobility (movement).
During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 6/8/2022 and readmitted Resident 2 on 6/28/2023 with diagnoses that included psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and mood disorder (a mental health condition that primarily affects the emotional state).
During a review of Resident 2's MDS dated [DATE], the MDS indicated that Resident 2 usually made self-understood and usually had the ability to understand others. The MDS further indicated that Resident 2's cognition was severely impaired, and Resident 2 needed maximum assistance from staff with lower body dressing, moderate assistance with toileting hygiene, and setup or clean-up assistance with bed mobility.
During a review of Resident 1's Change in Condition (COC- a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains) Evaluation dated 11/22/2024 timed at 9:08 p.m., the COC Evaluation indicated the alleged abuse was started on 11/11/2024. The COC Evaluation indicated that Certified Nursing Assistant (CNA) saw another resident (Resident 2) in her (Resident 1) room half naked from waist to knee, kneeling on the floor beside the bed, and the resident (Resident 1) was also half naked from waist to the knee. The COC Evaluation indicated Resident 1's physician and family were notified on 11/22/2024 at 8:15 p.m.
During a review of the Transaction Report (sent by the facility to the SSA) dated 11/22/2024, the Transaction Report indicated that the facility reported the alleged sexual abuse to the SSA via the facsimile (known as fax - the telephonic transmission of scanned printed material) on 11/22/2024 at 4:49 p.m.
During an interview on 11/26/2024 at 11:43 a.m., with the Infection Preventionist (IP), the IP stated on 11/22/2024 at around 2:30 p.m., Activity Assistant 1 (AA 1) approached the IP and stated AA 1 heard a rumor from other Certified Nursing Assistants (CNA) that Resident 2 was in Resident 1's room but was unsure of what had happened. The IP stated she (IP) reported it to the Director of Nursing (DON) immediately and the DON started the investigation immediately. The IP stated per the facility's investigation, Certified Nursing Assistant 1 (CNA 1) was the assigned CNA for Resident 1 and both Resident 1 and Resident 2 were found in Resident 1's room.
During an interview on 11/26/2024 at 1:15 p.m., with AA 1, AA 1 stated it was almost the end of her shift on 11/21/2024 when she (AA 1) heard two CNAs talking about Resident 1 and Resident 2 being in Resident 1's room. AA 1 stated she (AA 1) was not able to hear more about what happened and stated she (AA 1) informed the IP the following day, 11/22/2024, that she (AA 1) heard about a rumor of Resident 2 being in Resident 1's room.
During an interview on 11/26/2024 at 3:12 p.m., with CNA 1, CNA 1 stated on 11/11/2024 between 2-2:30 p.m., CNA 1 noticed Resident 1's room was almost closed, but she (CNA 1) knew that Resident 1 was in bed 30 minutes before and Resident 1's room door was open at that time. CNA 1 stated when she (CNA 1) opened the door, she (CNA 1) observed Resident 2 kneeling down with both knees on the floor next to Resident 1's bed and was half naked, not wearing pants. CNA 1 stated she (CNA 1) observed Resident 1 lying in bed half naked, not wearing pants. CNA 1 stated she (CNA 1) told Resident 2 he shouldn't be there and observed both residents putting their pants on and stated she (CNA 1) did not think anything bad happened. CNA 1 stated she (CNA 1) did not report what she saw to anyone until she (CNA 1) was called by the DON on 11/22/2024.
During an interview on 11/27/2024 at 11:30 a.m., with the DON, the DON stated the facility did not receive any reports related to the incident of Resident 1 and Resident 2 being found half naked in Resident 1's room on 11/11/2024 until 11/22/2024 around 3 p.m. when it was reported to her (DON). The DON stated CNA 1 had reported that she (CNA 1) witnessed Resident 2 in Resident 1's room and both residents were half naked and not wearing the lower parts of their clothing and CNA 1 did not report what she witnessed to anyone at the facility until 11/22/2024. The DON stated she (DON) was informed by CNA 1 that CNA 2 was also a witness to the incident between Resident 1 and Resident 2.
During an interview on 11/27/2024 at 1:27 p.m., with CNA 2, CNA 2 stated on 11/11/2024 between 2:30 p.m. and 3 p.m. she (CNA 2) was passing the hallway and saw Resident 2 and CNA 1 inside Resident 1's room and went inside to ask if they needed help. CNA 2 stated she (CNA 2) then saw Resident 2 kneeling on the floor near Resident 1's bed. CNA 2 stated she (CNA 2) saw Resident 2 with his pants off because she (CNA 2) was able to see Resident 2's buttocks and saw Resident 1 in bed and unable to recall if Resident 1 was wearing pants. CNA 2 stated she (CNA 2) asked CNA 1 if CNA 1 had reported the incident and stated that CNA 1 had told her (CNA 2) that CNA 1 had reported it. CNA 2 stated she (CNA 2) did not report it to any licensed nurse because she (CNA 2) thought the incident was already reported. CNA 2 stated if both Resident 1 and Resident 2 were found naked in the lower half of their bodies, it should have been reported.
During an interview on 11/27/2024 at 1:51 p.m., with CNA 1, CNA 1 stated she (CNA 1) should have reported the incident between Resident 1 and Resident 2 on 11/11/2024 and her responsibility was to report.
During an interview on 11/27/2024 at 3 p.m., with the DON, the DON stated she (DON) received the very first report of the incident that occurred on 11/11/2024 between Resident 1 and Resident 2 being found half naked in Resident 1's room on 11/22/2024 between 2:40 p.m. and 3 p.m. from the Director of Staff Development (DSD). The DON stated CNA 2 was another witness of the incident between Resident 1 and Resident 2. The DON stated that the facility was not able to report the incident on 11/11/2024 when it occurred because the staff that witnessed the incident did not report it to the Administrator (ADM) nor the DON. The DON further stated that staff should not judge if alleged abuses happened or not and the staff's responsibility was to report alleged abuses to the DON or the ADM, or Registered Nurse Supervisors immediately. The DON stated that staff should not assume if an incident was reported or not by another witness staff and each staff who witnessed an incident, related to any types of abuse, had the responsibility to report it immediately. The DON stated more reports are better than no reports at all. The DON stated the incident between Resident 1 and Resident 2 should have been reported immediately and within two (2) hours to initiate (start) the investigation.
During a review of the facility's policy and procedure (P&P) titled, Abuse Reporting and Investigation, last reviewed on 7/30/2024, the policy indicated, The facility will report ALL allegations of abuse as required by law and regulations to the appropriate agencies within two (2) hours. The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect (failure to provide adequate care or services), exploitation (the act of using someone or something unfairly for your own advantage), misappropriation (the act of stealing or using something in a way that is not intended by the owner) of resident property, or injuries of an unknown source when appropriate.
Oct 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to notify two of five sampled residents (Resident 2 and ...
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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 notify two of five sampled residents (Resident 2 and Resident 3) physician, when on 9/24/2024, Resident 2 and Resident 3 had changes in their skin condition. Resident 2 had dry flaky skin on both hands, itchiness, crust on both palms and Resident 3 had dry flaky skin on the right palm and itchiness.
This deficient practice resulted in a delay of medical care and treatment which could have resulted in a negative impact to Resident 2 ' s and Resident 3 ' s well-being.
Findings:
a. During a review of Resident 2 ' s admission Record indicated the facility originally admitted Resident 2 on 6/8/2022 and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems) and pruritis (medical term for itching, or the feeling on the skin that makes you want to scratch).
During a review of Resident 2 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 7/2/2024, indicated Resident 2 was usually able to make self-understood and understand others. The MDS indicated that Resident 2 was dependent on staff for showers, toileting hygiene, and oral hygiene.
During a concurrent observation and interview on 9/24/2024 at 8:37 a.m. with Treatment Nurse 1 (TN 1) and Resident 2, observed Resident 2 ' s both hands had dry flaky skin and both palms were crusted. Resident 2 stated that his (Resident 2) skin was itchy, so he was scratching. When Resident 2 was asked how long his hands were dry and flaky, Resident 2 was unable to answer the question. TN 1 stated that there are no orders in place to address and treat Resident 2 ' s dry flaky hands and crusted palms. TN 1 stated that he (TN 1) will immediately notify Resident 2 ' s physician to obtain treatment.
b. During a review of Resident 3 ' s admission Record indicated the facility originally admitted Resident 3 on 2/23/2024 and readmitted on [DATE] with diagnoses that included Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and type two diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel).
During a review of Resident 3 ' s MDS dated [DATE], indicated Resident 3 was usually able to make self-understood and understand others. The MDS indicated that Resident 3 was dependent on staff for showers, needed maximum assistance for toileting hygiene, and moderate assistance for oral hygiene.
During a concurrent observation and interview on 9/24/2024 at 8:50 a.m., with Certified Nursing Assistant 1 (CNA 1), in Resident 3 ' s room, observed Resident 3 had dry flaky skin on the right palm. Resident 3 stated that her (Resident 3 ' s) right palm was itchy. CNA 1 stated that changes in Resident 3 ' s skin condition on the right palm was reported to TN 1 about two weeks ago (unable to recall specific date).
During an interview with TN 1 on 9/25/2024 at 3:50 p.m., TN 1 stated that he (TN 1) did not receive the report from staff about Resident 3 ' s right palm until yesterday (9/24/2024). TN 1 stated he then notified Resident 3 ' s physician and obtained treatment for Resident 3 ' s right palm.
During an interview and record review with the Director of Nursing (DON) on 10/2/2024 at 1:40 p.m., the DON stated that the CNAs should have filled out the Stop and Watch form (an early warning tool that helps facility staff identify and communicate changes in a resident ' s condition) when they observed any changes including skin conditions. The DON stated that by not completing the Stop and Watch form and only notifying the licensed nurses verbally, the changes in residents ' condition could be omitted (leave unmentioned or undone) easily and not followed up. The DON further stated that she (DON) was not able to find documented evidence of the Stop and Watch form for Resident 2 and Resident 3 ' s skin conditions. The DON stated that the facility was not able to notify Resident 2 and Resident 3 ' s physician of the changes in Resident 2 and Resident 3 ' s skin condition. The DON stated that the facility did not start the care and treatment for both residents ' hands observed by the surveyor and findings confirmed by TN 1 on 9/24/2024 until after the surveyor ' s on site visit.
During a review of the facility ' s policy and procedure titled Change in a Resident ' s Condition or Status last reviewed 7/30/2024, indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident ' s medical/mental condition and/or status Need to alter the resident ' s medical treatment significantly.
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
Infection Control
(Tag F0880)
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 implement infection control practices by:
1. Failing ...
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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 implement infection control practices by:
1. Failing to store a mouthpiece (used to inhale a mist of liquid medicine that is created by a handheld nebulizer [HHN - a small, portable device that turns liquid medication into a mist that can be inhaled into the lungs]) and tubing of HHN in a bag when not used for one of five sampled residents (Resident 5).
2. Failing to report more than two suspected cases of scabies (a contagious skin condition characterized by a rash [an area of the skin that has changes in texture or color and may look inflamed or irritated] and intense itching) for two of five sampled residents (Resident 2 and Resident 3).
This deficient practice had the potential to result in the spread of cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) and scabies among staff and other residents.
Findings
1. During a review of Resident 5's admission Record indicated the facility originally admitted Resident 5 on 3/15/2023 and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks).
During a review of Resident 5's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/9/2024, indicated Resident 5's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. The MDS further indicated that Resident 5 needed supervision or touching assistance for oral hygiene, personal hygiene, and mobility (movement).
During a review of Resident 5's Physician's Order, with an order date of 8/21/2024, indicated to inhale (the process of drawing air into your lungs through your nose or mouth) Albuterol Sulfate (a medication used to prevent and treat difficulty breathing, wheezing [a symptom of a disease that obstructs the airways] and shortness of breath, coughing and chest tightness caused by lung diseases) five (5) milligrams (mg- unit of measure) 0.5% one inhalation orally via nebulizer every two hours as needed for dyspnea (difficulty breathing).
During a concurrent observation and interview on 9/24/2024 at 9:00 a.m., with Licensed Vocational Nurse 1 (LVN 1), in Resident 5's room, observed that the mouthpiece and tubing of the HHN was stored (not in a bag and undated) inside Resident 5's nightstand, undated. LVN 1 stated that staff should have stored the mouthpiece and the tubing in a bag when not used for infection control. LVN 1 then stated that he (LVN 1) will discard the mouthpiece and tubing and provide a new mouthpiece and tubing for Resident 5.
During an interview with the Director of Nursing (DON) on 9/24/2024 at 9:45 a.m., the DON stated that the mouthpiece with tubing for a HHN should be stored in a bag after labeling with the date to prevent the spread of germs. The DON further stated that not storing in a bag was against the infection prevention control program.
During a review of the facility's policy and procedure (P&P) titled, Administering Medications through a Small Volume (Handheld) Nebulizer last reviewed 7/30/2024, indicated, Rinse and disinfect the nebulizer equipment according to facility protocol, or: wash pieces with warm, soapy water When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. Change equipment and tubing every seven days, or according to facility protocol.
2. During a review of Resident 2's admission Record indicated the facility originally admitted Resident 2 on 6/8/2022 and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems) and pruritis (medical term for itching, or the feeling on the skin that makes you want to scratch).
During a review of Resident 2's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 7/2/2024, indicated Resident 2 was usually able to make self-understood and understand others. The MDS indicated that Resident 2 was dependent on staff for showers, toileting hygiene, and oral hygiene.
During a concurrent observation and interview on 9/24/2024 at 8:37 a.m. with Treatment Nurse 1 (TN 1) and Resident 2, observed Resident 2's both hands had dry flaky skin and both palms were crusted. Resident 2 stated that his (Resident 2) skin was itchy, so he was scratching. When Resident 2 was asked how long his hands were dry and flaky, Resident 2 was unable to answer the question. TN 1 stated that there are no orders in place to address and treat Resident 2's dry flaky hands and crusted palms. TN 1 stated that he (TN 1) will immediately notify Resident 2's physician to obtain treatment.
During a review of Resident 2's Physician Order dated 9/24/2024 timed 9:24 a.m., indicated, Stat (immediately) Skin scraping to rule out (r/o - a medical abbreviation that means a doctor is trying to eliminate a possible diagnosis or treatment for a resident) scabies.
During a review of Resident 3's admission Record indicated the facility originally admitted Resident 3 on 2/23/2024 and readmitted on [DATE] with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and type two diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel).
During a review of Resident 3's MDS dated [DATE], indicated Resident 3 was usually able to make self-understood and understand others. The MDS indicated that Resident 3 was dependent on staff for showers, needed maximum assistance for toileting hygiene, and moderate assistance for oral hygiene.
During a concurrent observation and interview on 9/24/2024 at 8:50 a.m., with Certified Nursing Assistant 1 (CNA 1), in Resident 3's room, observed Resident 3 had dry flaky skin on the right palm. Resident 3 stated that her (Resident 3's) right palm was itchy. CNA 1 stated that changes in Resident 3's skin condition on the right palm was reported to TN 1 about two weeks ago (unable to recall specific date).
During a review of Resident 3's Physician Order dated 9/24/2024, timed at 4:03 p.m. indicated to obtain a wound consult for Resident 3, and to administer Bactrim (used to treat a wide variety of bacterial infections) 800-160 mg one tablet by mouth two times a day for impetigo (an itchy, highly contagious skin infection).
During a review of the facility's P&P titled, Infection Control last reviewed 7/30/2024, indicated, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections Prevent, detect, investigate, and control infections in the facility .establish guidelines for implementing isolation precautions, including standard and transmission-based precautions,
During a review of the facility's P&P titled, Outbreak of Communicable Diseases last reviewed 7/30/2024, indicated, An outbreak is defined as one of the following: One case of an infection that is highly communicable or has serious health implications The administrator is responsible for communicating data about reportable diseases to the health department,
Sept 2024
2 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility (Skilled Nursing Facility 1 [SNF 1]) failed to protect the resident ' s right...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility (Skilled Nursing Facility 1 [SNF 1]) failed to protect the resident ' s right to be free from neglect (the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress) for one of three sampled residents (Resident 1), when the facility discharged Resident 1, who exhibited behaviors that made Resident 1 a danger to himself (Resident 1) and others, and who was admitted to SNF 1, a locked facility (facility that cares for residents that utilize secured perimeter fences or locked exit doors) to SNF 2, a non-locked facility (a facility that does not have secured or locked units) on [DATE] without providing safe and orderly discharge services by:
1. Failing to ensure Registered Nurse 2 (RN 2) obtained a physician order from Medical Doctor 1 (MD 1- Resident 1 ' s attending physician) to discharge Resident 1 to SNF 2 on [DATE].
2. Failing to ensure that the facility staff at SNF 1 provided SNF 2 with the discharge summary and recapitulation of stay (a summary of a resident course of treatment and stay at a facility) for Resident 1 when Resident 1 was discharged to SNF 2 on [DATE]. SNF 2 was only provided the Order Summary Report (a list of the physician orders for a resident, while the resident was admitted to a facility).
3. Failing to ensure facility staff from SNF 1 conducted a hand off communication (the transfer of resident medical information from the licensed nurse of the discharging facility to the licensed nurse of the receiving facility for continuity of care) to SNF 2 in preparation of receiving and admitting Resident 1 on [DATE].
4. Failing to ensure facility staff established or specified the specific care that Resident 1 needed that SNF 1, a locked unit was unable to provide, that required Resident 1 to be discharged to SNF 2, an unlocked and less secure unit.
5. Failing to ensure the facility staff at SNF 1 utilized medical transport when discharging Resident 1 to SNF 2 on [DATE], after the facility identified that Resident 1 was a danger to self and to others.
These deficient practices resulted in Resident 1 being discharged from SNF 1 to SNF 2 on [DATE] using a non-medical transport after Resident 1 was identified as being a danger to himself (Resident 1) and to others; and placed Resident 1 at increased risk for injury, medication errors, and worsening of unresolved medical conditions.
On [DATE] at approximately 3:30 a.m., Resident 1 expired at SNF 2, less than nine hours after arriving at SNF 2.
On [DATE] at 5:16 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM), Director of Nursing (DON) and Social Service Director (SSD) due to the facility ' s failure to ensure Resident 1 was free from neglect when the facility discharged Resident 1 to SNF 2 without providing safe and orderly discharge.
On [DATE] at 3:45 p.m. the ADM provided an IJ Removal Plan which included the following summarized actions:
1. On [DATE], Resident 1 was discharged to SNF 2 and is no longer a resident of the facility (SNF 1).
2. On [DATE], the DON in-serviced RN 2 to enter physician orders for discharge on ly after speaking to the physician.
3. On [DATE], the DON in-serviced the facility Marketer 1 (MTR 1) to no longer arrange resident transportation.
4. On [DATE], the DON in-serviced RN 2 regarding giving report to the nurse at the receiving facility of SNF 2.
5. On [DATE], Medical Director Medical Doctor 1 (MDMD 1) in-serviced the ADM, DON, Assistant Director of Nursing (ADON), SSD, and all other Department Heads regarding ensuring all residents are free of neglect related to discharge services to ensure resident ' s safety and promote their (resident) highest well-being from the time residents enter the facility to the time residents leave the facility.
6. On [DATE], the DON continued providing in-services to admissions office staff, nursing staff, and social services staff regarding the facility ' s current policies and procedures for the prevention of Neglect related to Discharge/Transfer services.
On [DATE] at 4:00 p.m. while onsite and after verifying the facility ' s full implementation of the accepted IJ Removal Plan, the SSA removed the IJ situation in the presence of the ADM, DON, and Minimum Data Set Nurse (MDSN).
Findings:
1. During a review of Resident 1's admission Record indicated the facility admitted Resident 1 on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD- a common lung disease that causes breathing problems by restricting airflow), type two (2) diabetes mellitus (a long-term medical condition in which the body has trouble controlling blood sugar and using it for energy), schizoaffective (a mental illness that can affect a person ' s thoughts, mood and behavior) disorder and psychosis (a severe mental condition in which thought and emotions are affected that contact is lost with external reality).
During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated [DATE], indicated that Resident 1 had memory problems and difficulty in making decisions regarding tasks of daily life.
During a review of Resident 1 ' s admission summary dated [DATE] timed at 4:00 p.m. indicated Resident 1 was incontinent (unable to voluntarily control the excretion of urine or the contents of the bowels) of bladder (a sac- shaped muscular organ that stores urine) and bowel (a long, tube-shaped organ in the abdomen that is part of the digestive system) function, had unsteady gait (pattern of walking), was confused (refers to the inability to think clearly or quickly), and agitated (a condition in which a person is unable to relax and be still) towards others. The admission Summary further indicated that Resident 1 had a preference of sitting and crawling on the floor requiring one to one (1:1- where a staff member is assigned to monitor the resident at all times) supervision.
During a review of Resident 1 ' s Physician Discharge summary dated [DATE] indicated Resident 1 ' s discharge was necessary for the health and safety of individuals in the facility that would be endangered due to Resident 1 ' s clinical (medical) or behavioral status.
During a review of Resident 1 ' s Notice of Transfer/Discharge, with a notification date of [DATE] and effective date of [DATE], indicated that the notice was to inform Resident1 that the discharge to SNF 2 was necessary for the safety of individuals in the facility that would be endangered due to Resident 1 ' s clinical or behavioral status.
During a review of Resident 1`s Physician`s Order dated [DATE], timed at 2:20 p.m., indicated that MD 1 provided a verbal order to discharge Resident 1 to SNF 2. The Physician ' s Order was documented by RN 2 and signed by MD 1.
During a review of Resident 1 ' s Recapitulation of Stay dated [DATE], timed at 5:00 p.m. indicated Resident 1 ' s reason for discharge to SNF 2 was because of behavior (not specified). Resident 1 ' s Recapitulation of Stay indicated Resident 1 needed skilled care and nursing services and required assistance with physical functioning such as bathing, bed mobility, dressing, toilet use, locomotion (ability to move from one place to another) and walking.
During a review of Resident 1 ' s Health Status Note dated [DATE] timed at 5:10 p.m. indicated Resident 1 was discharged to SNF 2 via a non-medical transport.
During a review of Resident 1 ' s SNF 2 Record of Death, dated [DATE], the Record of Death indicated that Resident 1 expired in SNF 2 on [DATE] at 3:30 a.m.
During a concurrent interview and record review on [DATE] at 11:30 a.m. with RN 2, Resident 1 ' s Physician ' s Order dated [DATE], timed at 2:20 p.m. that indicated that MD 1 gave a verbal order to discharge Resident 1 to SNF 2 and was documented by RN 2 was reviewed. RN 2 stated that on [DATE], RN 2 had not spoken with MD 1 to obtain the verbal order for Resident 1 ' s discharge, either in person or by phone before inputting the order to discharge Resident 1 to SNF 2. RN 2 stated that RN 2 entered the physician order to discharged Resident 1 to SNF 2 on [DATE] and indicated that the order was received verbally by MD 1 because RN 2 was told by SSD that Resident 1 needed a physician order for discharge. RN 2 stated that when the SSD informs the licensed nurses of the facility that a resident is to be discharged , a licensed nurse will enter a verbal order for discharged into the resident ' s physician order record on behalf of the physician.
During a concurrent interview and record review on [DATE] at 11:50 a.m. with MD 1, MD 1 reviewed Resident 1 ' s Physician ' s Order dated [DATE] to discharge Resident 1 to SNF 2. MD 1 stated that MD 1 was not in the facility on [DATE]. When MD 1 was asked how come MD 1 signed the physician order to discharge Resident 1 to SNF 2 on [DATE] when RN 2 had stated that RN 2 had not spoken with MD 1 to obtain the verbal order for Resident 1 ' s discharge, either in person or by phone, MD 1 stated that this is what is normally done in the facility. MD 1 further stated that Resident 1 ' s physician order to discharge to SNF 2 dated [DATE] did not include the reason for the discharge.
During an interview with RN 2 on [DATE] at 4:02 p.m., RN 2 stated that only physicians, nurse practitioners and physician assistant can give an order to discharge a resident. RN 2 stated that on [DATE], RN 2 should have, but did not communicate with MD 1 concerning Resident 1 ' s discharge. RN 2 stated that by entering the order to discharge Resident 1 to SNF 2 on [DATE], RN 2 deprived Resident 1 of a safe discharge to SNF 2, which is required for a safe and orderly discharge.
During a concurrent interview and record review on [DATE] at 4:07 p.m. with the DON, Resident 1 ' s Physician ' s Order dated [DATE], timed at 2:20 p.m. that indicated that MD 1 gave a verbal order to discharge Resident 1 to SNF 2 and was documented by RN 2 was reviewed. The DON stated that RN 2 ' s actions of entering the order to discharge Resident 1 to SNF 2 on [DATE] without communicating to MD 1 was neglectful and the RN 2 should have acted based on her scope of practice.
2. During an interview with Registered Nurse 4 (RN 4) on [DATE] at 3:12 p.m., RN 4 stated RN 4 worked at SNF 2. RN 4 stated that on [DATE] at approximately 6:40 p.m. Resident 1 arrived at SNF 2 with only a summary of Resident 1 ' s Physician Orders dated [DATE] from SNF 1. RN 4 stated that RN 4 attempted to call SNF 1 several times to attempt to speak with a licensed nurse from SNF 1 and obtain additional discharge information. RN 4 stated SNF 1 did not answer the phone. RN 4 stated that RN 4 had no prior knowledge that Resident 1 would be arriving to be admitted into SNF 2.
During an interview with Licensed Vocational Nurse 3 (LVN 3) on [DATE] at 4:15 p.m., LVN 3 stated that LVN 3 works at SNF 2. LVN 3 stated that on [DATE], Resident 1 had suddenly arrived at SNF 2. LVN 3 stated that LVN 3 had no prior knowledge that Resident 1 was arriving to SNF 2 for admission. LVN 3 stated that Resident 1 arrived with no Discharge Summary, and Recapitulation of Stay from SNF 1. LVN 3 stated that Resident 1 arrived with only Resident 1 ' s Physician Order Summary Report (totaling to four pages) from SNF 1.
During an interview with RN 2 on [DATE] at 4:02 p.m., RN 2 stated that on [DATE], the only discharge paperwork that RN 2 completed for Resident 1 was writing Resident 1 ' s physician order for discharge. RN 2 stated that RN 2 endorsed Resident 1 ' s discharge to the oncoming shift nurse, Registered Nurse 3 (RN 3). RN 2 stated that RN 3 was to finish Resident 1 ' s discharge on [DATE].
During a concurrent interview and record review on [DATE] at 4:21 p.m. with Medical Records Director 1 (MRD 1), Resident 1 ' s discharge forms, clinical and discharge documentations from [DATE] to [DATE] were reviewed. MRD 1 stated that there was no documented evidence found that a Discharge Care Plan, and a Medication Reconciliation (process of identifying the most accurate list of all medications that the resident is taking) form was completed, and copies of the Discharge Summary and Recapitulation of Stay from SNF 1 were sent with Resident 1 to SNF 2.
During an interview with the DON on [DATE] at 4:24 p.m., the DON stated that there was no documented evidence found that copies of Resident 1 ' s Discharge Summary and Recapitulation of Stay from SNF 1 were sent with Resident 1 to SNF 2. The DON stated that this was a neglectful deficient practice because the Discharge Summary and Recapitulation of Stay for Resident 1 should have been provided to Resident 1 as part of the safe and orderly discharge services.
During an interview with RN 3 on [DATE] at 5:03 p.m., RN 3 stated that on [DATE] RN 3 completed Resident 1 ' s discharge packet which included Resident 1 ' s Discharge Summary and Recapitulation of Stay. RN 3 stated that RN 3 did not fax the discharge packet of Resident 1 to SNF 2.
During a follow-up interview with MRD 1 on [DATE] at 5:58 p.m., MRD 1 stated that the nursing staff involved in Resident 1 ' s discharge on [DATE], that included RN 3, should have but did not send Resident 1 ' s discharge documentation including a Discharge Summary, a Recapitulation of Stay to SNF 2.
3. During an interview with RN 2 on [DATE] at 4:02 p.m., RN 2 stated that RN 2 did not, by phone, in person, or in writing, communicate with any staff from SNF 2 of Resident 1 ' s discharge on [DATE].
During an interview with the DON on [DATE] at 4:17 p.m., the DON stated that to the DON ' s best knowledge, no nursing staff from SNF 1 gave a hand off communication report to a licensed nurse at SNF 2 as part of safe and orderly discharge services. The DON stated that this was a neglectful deficient practice because the nursing staff from SNF 1 should have conducted a hand off communication report to the licensed nurses at SNF 2. The DON stated that SNF 2 should be informed of the most current and pertinent nursing and medical information concerning Resident 1 in order to provide the necessary care and services to Resident 1.
During an interview with the DON on [DATE] at 4:00 p.m., the DON stated that licensed nurses of SNF 1 did not follow the facility ' s policy and procedure for a safe and orderly discharge, when on [DATE], the facility staff of SNF 1 did not provide a hand off communication regarding Resident 1 ' s pertinent nursing and medical information to SNF 2.
During an interview with RN 3 on [DATE] at 5:03 p.m., RN 3 stated that RN 3 did not give a hand off communication report to any staff at SNF 2.
During an interview with MRD 1 on [DATE] at 5:38 p.m., MRD 1 stated that no nursing staff from SNF 1 documented in Resident 1 ' s medical record that a hand off communication was conducted with SNF 2 regarding Resident 1 ' s discharge on [DATE].
4. A review of the facility ' s Facility Assessment Data Collection Tool, dated 2/2024 through 7/2024, indicated that the facility had admitted and treated other residents with psychosis and other mental disorders, impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life). The facility ' s Facility Assessment Data Collection Tool further indicated that the facility had admitted and treated residents in need of behavioral support, behavioral healthcare needs dementia care .and other mental disorders.
During a concurrent interview and record review on [DATE] at 3:20 p.m. with the DON, the facility ' s Facility Assessment Data Collection Tool dated 2/2024 through 7/2024 was reviewed. The DON stated that the facility was capable of and had been providing care for residents with same diagnoses and behavior that Resident 1 had. The DON stated she was not aware of any services that Resident 1 needed that the facility could not provide that SNF 2 could provide other than that SNF 2 was not a locked facility.
During a review of Resident 1 ' s Interdisciplinary Team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of their residents) Conference Notes, dated [DATE], indicated the facility ' s IDT met to discuss Resident 1 ' s condition as of [DATE], two days after the facility admitted Resident 1 from General Acute Care Hospital 2 (GACH 2) on [DATE]. The document indicated the IDT specifically discussed Resident 1 ' s fall incidents, Resident 1 ' s nutritional status and weight, Resident 1 ' s need for reminders to participate in group activities and a one to one staff assignment to ensure resident is safe. The document also indicated, Unable to determine discharge plan at this time.
During a review of Resident 1 ' s Health Status Note, dated [DATE], 2:43 p.m., the health status note indicated that Resident 1 was unsteady on his feet and needed a one-to-one supervision (a nurse or health care support worker who provides care to a single resident for a period of time) to ensure his (Resident 1) safety related to falls prevention.
During a review of Resident 1 ' s care plan dated [DATE] indicated that Resident 1 was at risk for wandering (a resident ' s aimless, repetitive movement from one area to another that puts them at risk of harm).
During an interview with MTR 1 on [DATE] at 11:32 a.m., MTR 1 stated that MTR 1 did not know the specific reason why the facility wanted to discharge Resident 1 to SNF 2 or what services Resident 1 needed that SNF 1 could not provide but SNF 2 could.
During an interview with the DON on [DATE] at 3:29 p.m., the DON stated that Resident 1 had medical conditions and needs such that Resident 1 required the level of care that a locked unit can provide. The DON stated specifically, Resident 1 needed one-to-one supervision to prevent falls. The DON further stated that Resident 1 was at risk for elopement (to leave a skilled nursing facility without notice or permission), from the facility related to Resident 1 ' s wandering behavior. The DON stated that there was nothing required in Resident 1 ' s plan of care that SNF 1 could not provide.
During a concurrent interview and record review on [DATE] at 3:35 p.m. with the DON, reviewed Resident 1 ' s IDT Conference Note dated [DATE]. The DON stated that on [DATE], the IDT Team was unable to determine discharge plans for Resident 1. The DON stated that Resident 1 required one-to-one supervision to ensure Resident 1 ' s safety. The DON stated that Resident 1 had episodes of aggressive behaviors towards staff however the IDT Conference Note dated [DATE] did not indicate what specific behaviors were observed, what specific interventions could have been implemented to address the aggressive behaviors or other behaviors related to Resident 1 ' s mental illness. The DON stated there was no documentation found of the facility ' s attempts to meet the resident ' s needs or what services the new receiving facility (SNF 2) had in order to meet the resident ' s needs.
During an interview with the ADM on [DATE], 3:59 p.m., ADM stated that ADM was not aware of any specific services that Resident 1 needed that SNF 1 could not provide but that SNF 2 could provide.
5. During an interview with RN 4 on [DATE] at 3:12 p.m., RN 4 stated RN 4 worked at SNF 2. RN 4 stated that on [DATE], at approximately 6:40 p.m. the driver (Driver 1) of a private non-medical vehicle arrived at SNF 2 and informed RN 4 that he (Driver 1) was instructed to drop off Resident 1. RN 4 stated that Driver 1 helped bring Resident 1 inside SNF 2.
During an interview with the DON on [DATE] at 4:26 p.m., the DON stated that the facility did not ensure that Resident 1 was provided with a safe and appropriate (medical) form of transportation when the facility utilized a ride share company (a company that uses independent contractors with no training regarding medical safety, to transport people between various places) to discharge Resident 1 to SNF 2. The DON stated that SNF 1 had knowledge of Resident 1 ' s medical condition and history of aggressive behavior. The DON stated that Resident 1 ' s medical conditions included mental illness, and therefore the facility should have provided Resident 1 with professional medical transportation services to ensure Resident 1 ' s safety as part of safe and orderly discharge services. The DON stated that utilizing a non-medical transportation to transport Resident 1 from SNF 1 to SNF 2 was neglectful because the facility should have provided Resident 1 with professional medical transportation services as part of safe and orderly discharge services but did not do so.
During a concurrent interview and record review on [DATE] at 3:40 p.m., with the DON, the facility ' s policy titled, Resident Rights, last reviewed by the facility on [DATE], was reviewed. The policy indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to . to be free from . neglect . The DON stated that Resident 1 had a right to safe and orderly discharge services as defined by federal regulations and the facilities policies regarding discharge services. The DON stated that the facility did not follow its policy regarding resident ' s right to be free of neglect when the facility failed to provide Resident 1 with safe and orderly discharge services on [DATE].
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0624
(Tag F0624)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility (Skilled Nursing Facility 1 [SNF 1]) failed to ensure a safe and orderly disc...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility (Skilled Nursing Facility 1 [SNF 1]) failed to ensure a safe and orderly discharge was provided to one of three sampled residents (Resident 1), who exhibited behaviors that made Resident 1 a danger to himself (Resident 1) and others, and who was admitted to SNF 1, a locked facility (facility that cares for residents that utilize secured perimeter fences or locked exit doors) to Skilled Nursing Facility 2 (SNF 2), a non-locked facility (a facility that does not have secured or locked units) on [DATE] by:
1. Failing to ensure Registered Nurse 2 (RN 2) obtained a physician order from Medical Doctor 1 (MD 1- Resident 1 ' s attending physician) to discharge Resident 1 to SNF 2 on [DATE].
2. Failing to ensure that the facility staff at SNF 1 provided SNF 2 with the discharge summary and recapitulation of stay (a summary of a resident course of treatment and stay at a facility) for Resident 1 when Resident 1 was discharged to SNF 2 on [DATE]. SNF 2 was only provided the Order Summary Report (a list of the physician orders for a resident, while the resident was admitted to a facility).
3. Failing to ensure facility staff from SNF 1 conducted a hand off communication (the transfer of resident medical information from the licensed nurse of the discharging facility to the licensed nurse of the receiving facility for continuity of care) to SNF 2 in preparation of receiving and admitting Resident 1 on [DATE].
4. Failing to ensure facility staff established or specified the specific care that Resident 1 needed that SNF 1, a locked unit was unable to provide, that required Resident 1 to be discharged to SNF 2, an unlocked and less secure unit.
5. Failing to ensure the facility staff at SNF 1 utilized medical transport when discharging Resident 1 to SNF 2 on [DATE], after the facility identified that Resident 1 was a danger to self and to others.
These deficient practices resulted in Resident 1 being discharged from SNF 1 to SNF 2 on [DATE] using a non-medical transport after Resident 1 was identified as being a danger to himself (Resident 1) and to others; and placed Resident 1 at increased risk for injury, medication errors, and worsening of unresolved medical conditions.
On [DATE] at approximately 3:30 a.m., Resident 1 expired at SNF 2, less than nine hours after arriving at SNF 2.
On [DATE] at 5:16 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM), Director of Nursing (DON) and Social Service Director (SSD) due to the facility ' s failure to ensure Resident 1 was provided a safe and orderly discharge when the facility discharged Resident 1 to SNF 2 using a non-medical transport, and without conducting a hand off communication to ensure continuity of care in order to minimize the risk of medical errors, and ensure all necessary medical information of Resident 1 from SNF 1 was given to SNF 2 in order to allow for a seamless transition of care upon discharge.
On [DATE] at 3:45 p.m. the ADM provided an IJ Removal Plan which included the following summarized actions:
1. On [DATE], Resident 1 was discharged to SNF 2 and is no longer a resident of the facility (SNF 1).
2. On [DATE], the DON in-serviced RN 2 to enter physician orders for discharge on ly after speaking to the physician.
3. On [DATE], the DON in-serviced the facility Marketer 1 (MTR 1) to no longer arrange resident transportation.
4. On [DATE], the DON in-serviced RN 2 regarding giving report to the nurse at the receiving facility of SNF 2.
5. On [DATE], Medical Director Medical Doctor 1 (MDMD 1) in-serviced the ADM, DON, Assistant Director of Nursing (ADON), SSD, regarding ensuring all residents receive all discharge services (providing and completed needed discharge documentations and conducting hand off report to receiving facility) needed to ensure the resident ' s safety and promote the resident ' s highest wellbeing from the time of discharge.
On [DATE] at 4:00 p.m. while onsite and after verifying the facility ' s full implementation of the accepted IJ Removal Plan, the SSA removed the IJ situation in the presence of the ADM, DON, and Minimum Data Set Nurse (MDSN).
Findings:
1. During a review of Resident 1's admission Record indicated the facility admitted Resident 1 on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD- a common lung disease that causes breathing problems by restricting airflow), type two (2) diabetes mellitus (a long-term medical condition in which the body has trouble controlling blood sugar and using it for energy), schizoaffective (a mental illness that can affect a person ' s thoughts, mood and behavior) disorder and psychosis (a severe mental condition in which thought and emotions are affected that contact is lost with external reality).
During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated [DATE], indicated that Resident 1 had memory problems and difficulty in making decisions regarding tasks of daily life.
During a review of Resident 1 ' s admission summary dated [DATE] timed at 4:00 p.m. indicated Resident 1 was incontinent (unable to voluntarily control the excretion of urine or the contents of the bowels) of bladder and bowel function, had unsteady gait (pattern of walking), has confusion (refers to the inability to think clearly or quickly), and agitated (a condition in which a person is unable to relax and be still) towards others. The admission Summary further indicated that Resident 1 has a preference of sitting and crawling on the floor requiring one to one (1:1- where a staff member is assigned to monitor the resident at all times) supervision.
During a review of Resident 1 ' s Physician Discharge summary dated [DATE] indicated Resident 1 ' s discharge was necessary for the health and safety of individuals in the facility that would be endangered due to Resident 1 ' s clinical (medical) or behavioral status.
During a review of Resident 1 ' s Notice of Transfer/Discharge, with a notification date of [DATE] and effective date of [DATE], indicated that the notice was to inform Resident1 that the discharge to SNF 2 was necessary for the safety of individuals in the facility that would be endangered due to Resident 1 ' s clinical or behavioral status.
During a review of Resident 1`s Physician`s Orders dated [DATE], timed at 2:20 p.m., indicated that MD 1 provided a verbal order to discharge Resident 1 to SNF 2. The order was documented by RN 2 and signed by MD 1.
During a review of Resident 1 ' s Recapitulation of Stay dated [DATE], timed at 5:00 p.m. indicated Resident 1 ' s reason for discharge to SNF 2 was because of behavior (not specified). Resident 1 ' s Recapitulation of Stay indicated Resident 1 needed skilled care and nursing services and required assistance with physical functioning such as bathing, bed mobility, dressing, toilet use, locomotion (ability to move from one place to another) and walking.
During a review of Resident 1 ' s Health Status Note dated [DATE] timed at 5:10 p.m. indicated Resident 1 was discharged to SNF 2 via a non-medical transport.
During a review of Resident 1 ' s SNF 2 Record of Death, dated [DATE], the Record of Death indicated that Resident 1 expired in SNF 2 on [DATE] at 3:30 a.m.
During a concurrent interview and record review on [DATE] at 11:30 a.m. with RN 2, Resident 1 ' s Physician ' s Order dated [DATE], timed at 2:20 p.m. that indicated that MD 1 gave a verbal order to discharge Resident 1 to SNF 2 and was documented by RN 2 was reviewed. RN 2 stated that on [DATE], RN 2 had not spoken with MD 1 to obtain the verbal order for Resident 1 ' s discharge, either in person or by phone before inputting the order to discharge Resident 1 to SNF 2. RN 2 stated that RN 2 entered the physician order to discharged Resident 1 to SNF 2 on [DATE] and indicated that the order was received verbally by MD 1 because RN 2 was told by SSD that Resident 1 needed a physician order for discharge. RN 2 stated that when the SSD informs the licensed nurses of the facility that a resident is to be discharged , a licensed nurse will enter a verbal order for discharged into the resident ' s physician order record on behalf of the physician.
During a concurrent interview and record review on [DATE] at 11:50 a.m. with MD 1, MD 1 reviewed Resident 1 ' s Physician ' s Order dated [DATE] to discharge Resident 1 to SNF 2. MD 1 stated that MD 1 was not in the facility on [DATE]. When MD 1 was asked how come MD 1 signed the physician order to discharge Resident 1 to SNF 2 on [DATE] when RN 2 had stated that RN 2 had not spoken with MD 1 to obtain the verbal order for Resident 1 ' s discharge, either in person or by phone, MD 1 stated that this is what is normally done in the facility. MD 1 further stated that Resident 1 ' s physician order to discharge to SNF 2 dated [DATE] did not include the reason for the discharge.
During an interview with RN 2 on [DATE] at 4:02 p.m., RN 2 stated that only physicians, nurse practitioners and physician assistant can give an order to discharge a resident. RN 2 stated that on [DATE], RN 2 should have, but did not communicate with MD 1 concerning Resident 1 ' s discharge. RN 2 stated that by entering the order to discharge Resident 1 to SNF 2 on [DATE], RN 2 deprived Resident 1 of a safe discharge to SNF 2, which is required for a safe and orderly discharge.
2. During an interview with Registered Nurse 4 (RN 4) on [DATE] at 3:12 p.m., RN 4 stated RN 4 worked at SNF 2. RN 4 stated that on [DATE] at approximately 6:40 p.m. Resident 1 arrived at SNF 2 with only a summary of Resident 1 ' s Physician Orders dated [DATE] from SNF 1. RN 4 stated that RN 4 attempted to call SNF 1 several times to attempt to speak with a licensed nurse from SNF 1 and obtain additional discharge information. RN 4 stated SNF 1 did not answer the phone. RN 4 stated that RN 4 had no prior knowledge that Resident 1 would be arriving to be admitted into SNF 2.
During an interview with Licensed Vocational Nurse 3 (LVN 3) on [DATE] at 4:15 p.m., LVN 3 stated that LVN 3 works at SNF 2. LVN 3 stated that on [DATE], Resident 1 had suddenly arrived at SNF 2. LVN 3 stated that LVN 3 had no prior knowledge that Resident 1 was arriving to SNF 2 for admission. LVN 3 stated that Resident 1 arrived with no discharge summary, and recapitulation of stay from SNF 1. LVN 3 stated that Resident 1 arrived with only Resident 1 ' s Physician Order Summary Report (totaling to four pages) from SNF 1.
During an interview with RN 2 on [DATE] at 4:02 p.m., RN 2 stated that on [DATE], the only discharge paperwork that RN 2 completed for Resident 1 was writing Resident 1 ' s physician order for discharge. RN 2 stated that RN 2 endorsed Resident 1 ' s discharge to the oncoming shift nurse, Registered Nurse 3 (RN 3). RN 2 stated that RN 3 was to finish Resident 1 ' s discharge on [DATE].
During an interview with RN 3 on [DATE] at 5:03 p.m., RN 3 stated that on [DATE] RN 3 completed Resident 1 ' s discharge packet which included Resident 1 ' s Discharge Summary and Recapitulation of Stay. RN 3 stated that RN 3 did not fax the discharge packet of Resident 1 to SNF 2.
During an interview with Medical Records Director 1 (MRD 1) on [DATE] at 5:58 p.m., MRD 1 stated that the nursing staff involved in Resident 1 ' s discharge on [DATE], that included RN 3, should have but did not send Resident 1 ' s discharge documentation including a Discharge Summary, a Recapitulation of Stay to SNF 2.
3. During an interview with RN 2 on [DATE] at 4:02 p.m., RN 2 stated that RN 2 did not, by phone, in person, or in writing, communicate with any staff from SNF 2 of Resident 1 ' s discharge on [DATE].
During an interview with the DON on [DATE] at 4:17 p.m., the DON stated that to the DON ' s best knowledge, no nursing staff from SNF 1 gave a hand off communication report to a licensed nurse at SNF 2 as part of safe and orderly discharge services. DON stated that since the nursing staff from SNF 1 did not give a hand off communication report to the licensed nurses at SNF 2, SNF 2 would not know the most current and pertinent nursing and medical information concerning Resident 1.
During an interview with the DON on [DATE] at 4:00 p.m., the DON stated that licensed nurses of SNF 1 did not follow the facility ' s policy and procedure for a safe and orderly discharge, when on [DATE], the facility staff of SNF 1 did not provide a hand off communication regarding Resident 1 ' s pertinent nursing and medical information to SNF 2.
During an interview with RN 3 on [DATE] at 5:03 p.m., RN 3 stated that RN 3 did not give a hand off communication report to any staff at SNF 2.
During an interview with MRD 1 on [DATE] at 5:38 p.m., MRD 1 stated that no nursing staff from SNF 1 documented in Resident 1 ' s medical record that a hand off communication was conducted with SNF 2 regarding Resident 1 ' s discharge on [DATE].
4. During a review of Resident 1 ' s Interdisciplinary Team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of their residents) Conference Notes, dated [DATE], indicated the facility ' s IDT met to discuss Resident 1 ' s condition as of [DATE], two days after the facility admitted Resident 1 from General Acute Care Hospital 2 (GACH 2) on [DATE]. The document indicated the IDT specifically discussed Resident 1 ' s fall incidents, Resident 1 ' s nutritional status and weight, Resident 1 ' s need for reminders to participate in group activities and a one to one staff assignment to ensure resident is safe. The document also indicated, Unable to determine discharge plan at this time.
During a review of Resident 1 ' s Health Status Note, dated [DATE], 2:43 p.m., the health status note indicated that Resident 1 was unsteady on his feet and needed a one-to-one supervision (a nurse or health care support worker who provides care to a single resident for a period of time) to ensure his (Resident 1) safety related to falls prevention.
During a review of Resident 1 ' s care plan dated [DATE] indicated that Resident 1 was at risk for wandering (a resident ' s aimless, repetitive movement from one area to another that puts them at risk of harm).
During an interview with MTR 1 on [DATE] at 11:32 a.m., MTR 1 stated that MTR 1 did not know the specific reason why the facility wanted to discharge Resident 1 to SNF 2 or what services Resident 1 needed that SNF 1 could not provide but SNF 2 could.
During an interview with the DON on [DATE] at 3:29 p.m., the DON stated that Resident 1 had medical conditions and needs such that Resident 1 required the level of care that a locked unit can provide. The DON stated specifically, Resident 1 needed one-to-one supervision to prevent falls. The DON further stated that Resident 1 was at risk for elopement (to leave a skilled nursing facility without notice or permission), from the facility related to Resident 1 ' s wandering behavior. The DON stated that there was nothing required in Resident 1 ' s plan of care that SNF 1 could not provide.
During a concurrent interview and record review on [DATE] at 3:35 p.m. with the DON, reviewed Resident 1 ' s IDT Conference Note dated [DATE]. The DON stated that on [DATE], the IDT Team was unable to determine discharge plans for Resident 1. The DON stated that Resident 1 required one-to-one supervision to ensure Resident 1 ' s safety. The DON stated that Resident 1 had episodes of aggressive behaviors towards staff however the IDT Conference Note dated [DATE] did not indicate what specific behaviors were observed, what specific interventions could have been implemented to address the aggressive behaviors or other behaviors related to Resident 1 ' s mental illness. The DON stated there was no documentation found of the facility ' s attempts to meet the resident ' s needs or what services the new receiving facility (SNF 2) had in order to meet the resident ' s needs.
During an interview with the ADM on [DATE], 3:59 p.m., ADM stated that ADM 1 was not aware of any specific services that Resident 1 needed that SNF 1 could not provide but that SNF 2 could provide.
5. During an interview with RN 4 on [DATE] at 3:12 p.m., RN 4 stated RN 4 worked at SNF 2. RN 4 stated that on [DATE], at approximately 6:40 p.m. the driver (Driver 1) of a private non-medical vehicle arrived at SNF 2 and informed RN 4 that he (Driver 1) was instructed to drop off Resident 1. RN 4 stated that Driver 1 helped bring Resident 1 inside SNF 2.
During an interview with the DON on [DATE] at 4:26 p.m., the DON stated that the facility did not ensure that Resident 1 was provided with a safe and appropriate form of transportation when the facility utilized a ride share company (a company that uses independent contractors with no training regarding medical safety, to transport people between various places) to discharge Resident 1 to SNF 2. The DON stated that SNF 1 had knowledge of Resident 1 ' s medical condition and history of aggressive behavior. The DON stated that Resident 1 ' s medical conditions included mental illness, and therefore the facility should have provided Resident 1 with professional medical transportation services to ensure Resident 1 ' s safety as part of safe and orderly discharge services.
During a review of the facility ' s policy and procedure titled Discharging the Resident, last reviewed [DATE], indicated that if a resident is being discharged to another facility, the facility is to ensure a transfer summary is completed and telephone report is called to the receiving facility.
During a review of the facility ' s policy and procedure titled Transfer of Discharge Documentation, last reviewed on [DATE], indicated that documentation from the Care Planning Team concerning all transfers or discharges must include, as a minimum
a. The reason(s) for the transfer or discharge
f. A summary of the resident's overall medical, physical, and mental condition
h. Disposition of medications .
Should the resident be transferred or discharged for the following reasons, the basis for the transfer or discharge must be documented in the resident's clinical record by the resident's Attending Physician:
a. The transfer or discharge is necessary for the resident's welfare, and the resident's needs cannot be met in the facility; or . Should the resident be transferred or discharged because health of individuals in the facility would otherwise be endangered, the basis for the transfer or discharge must be documented in the resident's clinical record by a physician.
Jun 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the needed care and services that were resident centered fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the needed care and services that were resident centered for one of three sampled residents (Resident 1) when on 6/15/2024, Licensed Vocational Nurse 2 (LVN 2) did not endorse (to inform) to Licensed Vocational Nurse 1 (LVN 1) or Registered Nurse Supervisor 1 (RNS 1) that Resident 1 had sustained a fall.
This deficient practice placed Resident 1 at risk for a delay in needed care and services.
Findings:
A review of Resident 1 ' s admission record dated 5/28/2024, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic inflammatory lung disease that causes obstructed airflow from the lungs), chronic kidney disease (when kidneys are damaged and can't filter blood the way they should), anxiety disorder (characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), lack of coordination (loss of muscle control in their arms and legs) and major depressive disorder (characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).
A review of the Resident 1 history and physical dated 5/28/2024, indicated Resident 1 has capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 6/1/2024, indicated Resident 1 had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS further indicated that Resident 1 require supervision with activities of daily living (ADL- are activities related to personal care, they include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating).A review of Resident 1 ' s Fall Risk Assessment (an evaluation tool used to determine a resident ' s likelihood that the resident with sustain a fall) dated 5/28/2024, indicated that Resident 1 was not considered a high risk for falls.
A review of Resident 1 ' s Situation-Background-Assessment-Recommendation (SBAR- a structured communication tool that can help share information about the condition of a resident) dated 6/15/2024 at 7:30 a.m., indicated that at around 7:30 a.m., Resident 1 complained of pain of six out of 10 (a pain rating scale from zero to ten where ten is the worst possible pain) to the left leg to Certified Nursing Assistant 1 (CNA 1) . The SBAR indicated that according to Resident 1, Resident 1 informed CNA 1 that Resident 1 had fallen from his (Resident 1) bed earlier that morning on 6/15/2024.The SBAR indicated that Resident 1 ' s primary physician was made aware of the incident and provided orders for a stat (immediately) bilateral (both) hip with pelvis (lower part of the abdomen, located between the hip bones) x-ray (type of imaging test that creates or generates images of tissues and structures inside the body) and left femur (leg bone) x-ray.
A review of Resident 1 ' s Nursing Progress note dated 6/15/2024 at 12:05 p.m., indicated that the results of Resident 1 ' s x-ray of the left femur showed that Resident 1 sustained an acute minimally displaced intertrochanteric fracture (a break in the bone located near the top of the leg or hip area) of the left femur. The note further indicated that Resident 1 ' s attending physician ordered for Resident 1 to be transferred to the General Acute Care Hospital (GACH).
During an interview with Licensed Vocational Nurse 1 (LVN 1) on 6/18/2024 at 1:58 p.m., LVN 1 stated that on 6/15/2024 at approximately 7:00 a.m., CNA 1 had informed him (LVN 1) that Resident 1 was complaining of feeling weak and having pain to the left leg. LVN 1 stated that after assessing Resident 1, Resident 1 informed LVN 1 that Resident 1 had rolled out of bed earlier that same day. LVN 1 stated Resident 1 ' s physician was notified and ordered for Resident 1 to be transferred to the GACH after it was confirmed by ordered x-rays that Resident 1 sustained a fracture to the left leg.
During an interview with Licensed Vocational Nurse 2 (LVN 2) on 6/20/2024 at 1:15 p.m. LVN 2 stated that he (LVN 2) was assigned to provide care to Resident 1 during the night shift from 11p.m. to 7a.m. beginning on 6/14/2024. LVN 2 stated that on 6/15/2024 sometime around 7:00 a.m., LVN 2 was informed by CNA 2 that Resident 1 was found on the floor next to the resident ' s bed. LVN 2 stated that he (LVN 2) immediately went to Resident 1 ' s room and found the resident on the floor. LVN 2 stated that he (LVN 2) along with CNA 2 assisted Resident 1 back to bed. LVN 2 stated that he did not notify Registered Nurse Supervisor 1 (RNS 1) regarding Resident 1 being found on the floor. LVN 2 stated that he (LVN 2) did not endorse to LVN 1 regarding finding Resident 1 on the floor. LVN 2 stated that he was very busy but that he (LVN 2) should have endorsed Resident 1 ' s change of condition of having sustained a fall to LVN 1.
During an interview with RNS 1 on 6/21/2024 at 9:40 a.m., RNS 1 stated that LVN 2 should have completed the change of condition (when there is a change in a resident's health condition) form for Resident 1, informed Resident 1's physician and endorsed the change of condition of Resident 1 to LVN 1.
During an interview with the Administrator on 7/9/2024 at 7:45 p.m., the Administrator stated that the facility does not have a specific policy related to quality of care.
May 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one of three sampled resident (Resident 1) was provided with activities of daily living (ADL).
This deficient practice resulted in a...
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Based on interview and record review, the facility failed to ensure one of three sampled resident (Resident 1) was provided with activities of daily living (ADL).
This deficient practice resulted in a delay in delivering the necessary care and services to Resident 1.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 1/18/2024 with diagnoses that included atrial fibrillation (irregular and often very rapid heart rhythm) and heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs).
A review of Resident 1 ' s History and Physical Exam, dated 1/18/2024, indicated Resident 1 has the capacity to understand and make decisions.
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 4/19/2024 indicated that Resident 1 had the ability to make self understood and had the ability to understand others. The MDS further indicated Resident 1 required setup or clean-up assistance for eating, oral hygiene, toileting hygiene, shower or bathing self, upper and lower body dressing, personal hygiene, and mobility (movement).
A review of Resident 1 ' s Care Plan dated 1/19/2024 indicated Resident 1 had ADL deficit related to eating, personal hygiene, mobility, dressing, toilet use, bathing, transfer, walking and locomotion (movement or ability to move from one place to another) on and off unit. The goal was for Resident 1 ' s ADL needs to be met daily. The approaches included to assist with ADL as needed, monitor the resident for ADL needs and keep clean and dry.
A review of Resident 1 ' s Certified Nurse Assistant (CNA) Functional Abilities Flowsheet dated 4/2024 indicated there were no documented evidence found (blank) that on 4/6/2024 during the day shift (7:00 a.m. to 3:00 p.m.) Resident 1 was assisted and provided with ADL such as eating, oral hygiene, toileting hygiene, shower or bathing, upper and lower body dressing, and personal hygiene.
During a concurrent interview and record review, on 5/1/2024 at 11:01 a.m., with the Director of Staff Development (DSD), the DSD stated that CNA ' s must document on the CNA Functional Abilities Flowsheet after assisting or providing the ADL task to the resident. The DSD further stated the importance of documenting to ensure care or services has been provided and to notify licensed nurses for any changes in resident ' s needs. The DSD stated that if the CNA Functional Abilities Flowsheet was blank and there were no documentations found if care was provided it means it was not done.
A review of the facility's policy and procedure titled, Activities of Daily Living (ADLs), Supporting, last revised on 3/2018 indicated residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).
Mar 2024
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity by failing to ensure the certified nursing assistant sat at eye level w...
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Based on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity by failing to ensure the certified nursing assistant sat at eye level while providing feeding assistance for one of four sampled residents (Resident 59) investigated under the Dining Observation Task.
This deficient practice had the potential to affect a resident's self-worth and self- esteem.
Findings:
A review of Resident 59's Face Sheet (admission record) indicated the facility admitted the resident on 12/30/2020 and readmitted the resident on 7/5/2021 with diagnoses that included chronic obstructive pulmonary disease (COPD, progressive lung disease), unspecified dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with behavioral disturbance, and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves).
A review of Resident 59's Minimum Data Set (MDS - an assessment and screening too) dated 1/1/2024, indicated the resident usually had the ability to understand others and sometimes had the ability to make herself understood. The MDS further indicated the resident required substantial / maximal assistance (the helper does more than half the effort) from staff with eating and was dependent on staff for toileting, dressing, personal hygiene, transfers, and mobility.
During an observation on 3/18/2024 at 12:32 p.m., observed Resident 59 sitting up in bed with Certified Nursing Assistant 1 (CNA 1) standing beside Resident 59's bed while providing feeding assistance to Resident 59. Observed CNA 1 not at eye level with the resident while providing feeding assistance.
During an interview on 3/18/2024 at 12:40 p.m., with CNA 1, CNA 1 stated he did not sit down with Resident 59 to provide feeding assistance. CNA 1 stated he should always sit and make eye contact with the resident while providing feeding assistance.
During an interview on 3/18/2024 at 12:48 p.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated CNAs are trained to sit while providing feeding assistance to residents for dignity purposes. LVN 2 stated he was not aware of any reason to not provide feeding assistance while seated to Resident 59.
During a concurrent interview and record review on 3/19/2024 at 4:20 p.m., with the Director of Nursing (DON), reviewed the facility's policies and procedures titled, Assistance with Meals and Dignity, last reviewed 2/28/2024. The DON stated for dignity and comfort, during feeding assistance staff must sit at a level so the resident can see and interact with them. The DON stated standing is seen as a commanding presence. The DON stated the facility's policies were not followed because it was not acceptable to stand during feeding assistance for Resident 59.
A review of the facility's policy and procedure titled, Assistance with Meals, last reviewed 2/28/2024, indicated residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example, not standing over residents while assisting them with meals.
A review of the facility's policy and procedure titled, Resident Rights, last reviewed 2/28/2024, indicated employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to: a dignified existence and to be treated with respect, kindness, and dignity.
A review of the facility's policy and procedure titled, Dignity, last reviewed 2/28/2024, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are always treated with dignity and respect. When assisting with care, residents are supported in exercising their rights. For example, residents are provided with a dignified dining experience.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's call light device (device used by...
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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 ensure a resident's call light device (device used by residents that when pressed informs facility staff that assistance is being requested) was within reach for two of two sampled residents (Resident 13 and Resident 44).
This deficient practice had the potential to delay the provision of services and residents' needs not being met.
Findings:
a. A review of Resident 13's Face Sheet (admission record) indicated the facility admitted the resident on 12/28/2023, with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) with dyskinesia (uncontrolled, involuntary muscle movement), muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), and anxiety disorder (persistent and excessive worry that interferes with daily activities).
A review of Resident 13's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 1/2/2024, indicated Resident 13 had moderately impaired cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses).
A review of Resident 13's Care Plan titled, Activity of Daily Living (ADLs - activities related to personal care) dated 12/29/2023, indicated an intervention to have call light within reach and staff to answer promptly.
During a concurrent observation and interview on 3/18/2024 at 9:38 a.m., observed Resident 13 in bed with their call light device placed on the floor near the right side of the headboard and not within reach. Resident 13 stated he was not able to get his call light device. Resident 13 stated he just wanted a cup of ice water.
During an interview on 3/18/2024 at 9:50 a.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated the call light should have been placed on Resident 13's bed for easy reach, so that the resident was able to get services in a timely manner.
b. A review of Resident 44's admission Record indicated the facility admitted the resident on 6/9/2022 and readmitted the resident on 9/14/2023 with diagnoses that included primary generalized (osteo) arthritis (degenerative [progressive, often irreversible deterioration] disorder of the joint resulting in pain) unspecified dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) with psychotic disturbance (severe mental disorders that cause abnormal thinking and perceptions), and anxiety disorder.
A review of Resident 44's MDS dated [DATE], indicated Resident 44 had severely impaired cognition.
A review of Resident 44's Care Plan titled, ADL, initiated on 9/14/2023, indicated an intervention to have call light within reach and staff to answer promptly.
During a concurrent observation and interview on 3/18/2024 at 9:58 a.m., observed Resident 44 in bed with their call light device placed on the floor near the right side of the headboard and not within reach. Resident 44 stated she was not able to find her call light device. Resident 44 stated she wanted her sandwich.
During an interview on 3/18/2024 at 10:08 a.m., with CNA 1, CNA 1 stated the call light should have been placed close to Resident 44's bed for easy reach, so that the resident was able to get services in a timely manner. CNA 1 also stated this Resident 44 can be prevented from falls and injury.
A review of the facility's policy and procedure titled, Call System, Resident, last reviewed 2/28/2024, indicated each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bating facilities and from the floor. The purpose of the call system is to provide with a means to call staff for assistance through a communicate system that directly calls a staff member or a centralized workstation.
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 interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a form where licensed nurses can summarize a person's health conditions, s...
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Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a form where licensed nurses can summarize a person's health conditions, specific care needs, and current treatments) for medication refusal for approximately three months for one of five sampled residents (Resident 87) investigated for unnecessary medications.
This deficient practice had the potential to negatively affect the delivery of care and services to Resident 87.
Findings:
A review of Resident 87's Face Sheet indicated the facility admitted the resident on 12/21/2023 with diagnoses that included dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).
A review of Resident 87's Minimum Data Set (MDS, an assessment and care screening tool) dated 12/27/2023 indicated the resident was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated that Resident 87 was independent with walking, eating, and oral hygiene.
A review of Resident 87's physician's orders indicated the following:
- Escitalopram (a medication to treat depression [feelings of sadness]) 10 milligrams (mg, a unit of measure) by mouth daily for depression manifested by verbalization of feeling depressed, dated 1/1/2024.
- Losartan potassium (a medication to treat hypertension [high blood pressure]) 50 mg tablet, give one tablet by mouth once a day for hypertension, hold if systolic blood pressure (SBP - the first number in a blood pressure reading, which measures the pressure in the arteries [pathway that carries blood away from the heart] when the heart beats) less than 110 millimeters of mercury (mmHg, a unit of measure) or heart rate is less than 60 beats per minute (bpm, normal reference range 60 - 100 bpm), dated 1/21/2024.
- Hydrochlorothiazide (a diuretic [medication to cause the kidneys to produce more urine]) 12.5 mg, give one capsule by mouth once a day for hypertension, hold if SBP is less than 110 mmHg or heart rate is less than 60 bpm, dated 1/21/2024.
- Atorvastatin calcium (a medication given to lower cholesterol levels) 40 mg, give one tablet by mouth at bedtime for hyperlipidemia (high cholesterol), dated 12/21/2023.
- Abilify five (5) (brand name for a medication to treat depression) manifested by persistent anger with others without provocation, give one tablet by mouth at hours of sleep for major depressive disorder, dated 1/1/2024.
A review of Resident 87's Medication Administration Records (MAR-a flow sheet where nursing documents medications provided to a resident daily) for the months of 1/2024, 2/2024, and 3/2024 indicated the following 63 medication refusals:
- On 1/4/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 1/4/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 1/8/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 1/8/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 1/8/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 1/9/2024 at 9 p.m., Resident 87 refused atorvastatin 40 mg.
- On 1/9/2024 at 9 p.m., Resident 87 refused Abilify 5 mg.
- On 1/13/2024 at 9 p.m., Resident 87 refused atorvastatin 40 mg.
- On 1/13/2024 at 9 p.m., Resident 87 refused Abilify 5 mg.
- On 1/22/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 1/22/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 1/22/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 1/23/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 1/23/2024 at 9 p.m., Resident 87 refused atorvastatin 40 mg.
- On 1/23/2024 at 9 p.m., Resident 87 refused Abilify 5 mg.
- On 1/29/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 1/29/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 1/29/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 1/30/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 1/30/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 1/30/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 2/5/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 2/5/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 2/5/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 2/6/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 2/6/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 2/6/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 2/7/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 2/7/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 2/7/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 2/10/2024 at 9 p.m., Resident 87 refused atorvastatin 40 mg.
- On 2/10/2024 at 9 p.m., Resident 87 refused Abilify 5 mg.
- On 2/13/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 2/13/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 2/13/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 2/14/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 2/14/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 2/14/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 2/19/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 2/19/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 2/19/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 2/20/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 2/20/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 2/20/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 2/21/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 2/21/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 2/21/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 2/24/2024 at 9 p.m., Resident 87 refused atorvastatin 40 mg.
- On 2/24/2024 at 9 p.m., Resident 87 refused Abilify 5 mg.
- On 2/27/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 2/27/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 2/27/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 2/27/2024 at 9 p.m., Resident 87 refused atorvastatin 40 mg.
- On 2/27/2024 at 9 p.m., Resident 87 refused Abilify 5 mg.
- On 3/4/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 3/4/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 3/4/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 3/6/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 3/6/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 3/6/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 3/12/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 3/12/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 3/12/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
During a concurrent interview and record review on 3/22/2024 at 1:23 p.m., with the Director of Nursing (DON), reviewed Resident 87's MAR dated 1/2024, 2/2024, and 3/2024 and MAR Detailed Reports. The DON stated LVN 1 was the licensed nurse who documented Resident 87's medication refusals for the months of 1/2024, 2/2024, and 3/2024. The DON stated if a resident refuses to take medication, the licensed nurse should come back to offer the medication and if the resident refuses, the licensed nurse should then notify the resident's physician. The DON stated the licensed nurses should have made a care plan for the refusal and conduct an interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) meeting.
A review of the facility's policy and procedure titled, Refusal of Treatment, last reviewed 2/28/2024, indicated treatment is defined as care provided for purposes of maintaining/restoring health, improving functional level, or relieving symptoms. The policy and procedure indicated the following:
If a resident refuses treatment, the charge nurse or DON will interview the resident to determine what and why the resident is refusing in order to try to address the resident's concerns and explain the consequences.
The Care Plan Team will assess the resident's needs and offer the resident alternative treatments, if available and pertinent.
Should the resident refuse to accept treatment, detailed information relating to the refusal must be entered into the resident's medical record including the date and time the staff tried to give a medication, the medication refused, the resident's response and reason for refusal, and the date and time the physician was notified as well as the physician's response.
A review of the facility's policy and procedure titled, Goals and Objectives, Care Plans, last reviewed 2/28/2024, indicated the following:
Care plan goals and objectives are defined as the desired outcome for a specific resident problem.
When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established.
Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medication and biologicals were stored with cur...
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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 ensure medication and biologicals were stored with currently accepted professional standards for one of two medication carts (Medication Cart 1) investigated during the Medication Storage and Labeling task by failing to:
1. Ensure two opened bottles of glucometer (medical device for determining the approximate concentration of glucose [sugar] in the blood) control solution (solutions used to test the glucometer for proper function) were labeled with the open date.
2. Ensure Medication Cart 1 refrigerated emergency medication kit (e-kit- basic emergency medical kit that includes common emergency drugs) was secured after opening and there was documentation indicating what was removed.
These deficient practices had the potential to result in inaccurate blood sugar readings, mismanagement of diabetes (a chronic condition that affects the way the body processes blood glucose [sugar]) in residents, and delay in care and services.
Findings:
During a medication storage observation of Medication Cart 1 and Medication room [ROOM NUMBER], and concurrent interview on [DATE] at 3:47 p.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 observed and confirmed by stating the following:
1. In Medication Cart 1 there were two opened glucometer control solution bottles not labeled with the opened date. LVN 2 stated the bottles and box containing the bottles should have been labeled with the discard date because the solution expires 90 days after opening. LVN 2 stated if glucometer control solutions are used past the expiration date, the reading of the glucometer may not be accurate. LVN 2 stated the glucometer readings must be accurate because insulin (hormone that lowers the level of glucose in the blood) dosage depends on the reading and insulin controls the residents' blood sugar.
2. In Medication room [ROOM NUMBER] refrigerator there was an e-kit with two cut green zip ties placed on the e-kit. LVN 2 stated when an e-kit it opened the green zip ties are cut, medication is removed, documentation is completed to indicate what was removed, red zip ties are placed to secure it closed, and pharmacy is called to replace the e-kit.
During a concurrent interview and record review on [DATE] at 4:20 p.m., with the Director of Nursing (DON), reviewed the facility's policy and procedures titled, Emergency Medications, last reviewed [DATE] and the AgaMatrix (brand name for control solutions) Control Solutions manufacture guidelines. The DON stated the facility follows the manufacture guidelines and the control solutions should be labeled with the date and thrown out after the expiration to make sure the viability is not compromised. The DON stated when the control solutions are compromised it could potentially lead to the wrong outcome of a control solution test. The DON stated when a test is wrong then it may lead to inaccurate blood sugar values. The DON stated Medication room [ROOM NUMBER] refrigerated e-kit had cut green zip ties and appeared to be missing a Humulin N (a type of intermediate-acting insulin) vial. The DON stated when nursing staff needs a medication in an e-kit, they cut the zip ties, remove the medication, and complete the pharmacy log. The DON stated the manifest includes the drug name, the date and time removed, and what resident it was used for. The DON stated once an e-kit is opened the pharmacy is called to replace it. The DON stated the facility's policy and procedure was not followed because an opened e-kit was in the refrigerator.
During an interview on [DATE] at 12:10 p.m., with the DON, the DON stated she did not know what happened with the refrigerator e-kit because there was no documentation. The DON stated it was important to follow the facility's process and have a track record of the e-kit medication and who it was used for to make sure the medication is used for a particular resident needing the medication. The DON stated it was important to place red zip ties after opening because it secures the e-kit. The DON stated it was important to call the pharmacy once the e-kit is opened to make sure the medications are resupplied and available for residents who need them.
A review of the facility's policy and procedure titled, Emergency Medications, last reviewed [DATE], indicated the facility shall maintain a supply of medications typically used in emergencies. Each nurse's station will store emergency medication in the drug room. The contents of each emergency medication kit will be clearly listed. Required documentation after dispensing an emergency medication is the same as for any other medication. Any medication that is removed from the emergency kit must be documented on the emergency medication administration log. Medications and supplies used from the emergency medication kit must be replaced upon the next routine drug order.
A review of the facility-provided AgaMatrix Normal / High Control Solution manufacture guidelines, dated 2016, indicated the control solutions contain a known amount of glucose that reacts with an AgaMatrix Test Strip in combination with the AgaMatrix Blood Glucose Meter to make sure they are working properly together. The test results should fall within the appropriate target range. Control solution tests should be performed in order to ensure accurate test results. Out of range results may be due to expired control solution. Discard any unused control solution 90 days after first opening.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices by failing to:
1. Ensure ...
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Based on observation, interview, and record review, the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices by failing to:
1. Ensure Licensed Vocational Nurse 1 (LVN 1) did not willfully falsify entries in Resident 17's Medication Administration Record (MAR-a flow sheet where nursing documents medications provided to a resident daily) for one of two sampled residents (Resident 17) investigated for medication storage and labeling by documenting the administration of Ambien (a medication used to aid sleep), gabapentin (a medication used to treat nerve pain), and simvastatin (a medication used to treat hyperlipidemia (high cholesterol [a waxy substance that can build up in the blood resulting in stroke or heart issues]) on 3/14/2024.
This resulted in inaccurate documentation in Resident 17's medical chart indicating the resident received Ambien, gabapentin, and simvastatin.
2. Ensure LVN 1 did not willfully falsify entries in the MAR for one of four sampled residents (Resident 18) investigated for medication administration by documenting a heart rate (HR, the number of times the heart beats per minute [bpm]) of 75 bpm on 3/19/2024 that LVN 1 stated she documented after giving a medication and not before, as indicated in the physician's order.
This resulted in inaccurate documentation in Resident 18's medical chart indicating the resident's HR was measured prior to the administration of metoprolol (a medication to treat high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) with a physician's ordered parameter (a set of defined limits) to hold (do not give) if the HR was less than 60 bpm.
Findings:
a. A review of Resident 17's Face Sheet (admission record) indicated the facility admitted the resident on 9/3/2021 and readmitted the resident on 1/8/2024 with diagnoses that included polyneuropathy (disease or dysfunction of one or more peripheral nerves [nerves located outside of the brain and spinal cord], typically causing numbness or weakness), hyperlipidemia, chronic pain, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one's daily functioning), and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).
A review of Resident 17's Minimum Data Set (MDS, an assessment and care screening tool) dated 1/12/2024 indicated the resident usually was able to understand others and usually was able to make herself understood. The MDS further indicated the resident required substantial / maximal assistance from staff for movement and dressing and was dependent on staff for toileting and bathing.
A review of Resident 17's physician's orders indicated orders for the following:
-Ambien 10 milligram (mg, a unit of measurement) tablet, give one tablet by mouth before bedtime (QHS) for insomnia (persistent problems falling and staying asleep) manifested by inability to sleep, dated 1/8/2024.
-Gabapentin 300 mg capsule, give one capsule by mouth at bedtime for neuropathy (nerve pain), dated 1/8/2024.
- Simvastatin 20 mg tablet, give one tablet by mouth at bedtime, dated 1/8/2024.
A review of Resident 17's Care Plan titled, Disturbance in Sleep Pattern related to Insomnia, initiated 1/9/2024 indicated to administer medication as ordered.
During a concurrent interview and record review on 3/18/2024 at 3:47 p.m., with Licensed Vocational Nurse 2 (LVN 2), reviewed Resident 17's Record of Controlled Substances (RCS) form for Ambien and MAR dated 3/2024. LVN 2 stated Ambien was a controlled substance (medication that have an accepted medical use, have a potential for abuse, and may also lead to physical or psychological [related to the mental and emotional state of a person] dependence) and kept in a locked drawer in the medication cart because controlled substances have a potential for abuse and there is a risk they may be stolen. LVN 2 stated the RCS form is completed when the medication is removed from the bubble pack (a package that contains multiple sealed compartments with medication/s) and the MAR is used to document administration of the medication. LVN 2 noted the following:
1. Resident 17's RCS for Ambien indicated Ambien was not removed on 3/14/2024. LVN 2 stated the amount of medication remaining in the bubble pack matched the amount remaining on the RCS form and indicated the medication was not removed on 3/14/2024.
2. Resident 17's MAR indicated Ambien was administered on 3/14/2024 at 9 p.m. by LVN 1.
LVN 2 stated if the MAR indicated the medication was administered it should have been documented as removed on the RCS, but it was not.
During a concurrent interview and record review on 3/19/2024 at 3 p.m., with LVN 1, reviewed Resident 17's RCS form for Ambien and MAR dated 3/2024. LVN 1 stated the process for removing and administering Ambien was to remove the medication bubble pack from the locked narcotic drawer, remove the medication from the bubble pack, count the amount of Ambien remaining in the bubble pack, complete the RCS form, administer the medication, and then sign the MAR. LVN 1 reviewed Resident 17's MAR dated 3/2024 and the RCS for Ambien and stated she did not administer Resident 17's Ambien, but documented in the MAR that it was administered. LVN 1 stated on 3/14/2024 she was called in to work to administer medications and arrived around 9 p.m. LVN 1 stated she assumed Resident 17 already received the 9 p.m. medications because Resident 17 told her they were already given. LVN 1 reviewed the MAR and stated the following:
1. On 3/14/2024 at 9 p.m., LVN 1 documented Ambien was administered, but LVN 1 did not administer the medication to Resident 17.
2. On 3/14/2024 at 9 p.m., LVN 1 documented gabapentin was administered, but LVN 1 did not administer the medication to Resident 17.
3. On 3/14/2024 at 9 p.m., LVN 1 documented simvastatin was administered, but LVN 1 did not administer the medication to Resident 17.
LVN 1 stated Resident 17's MAR was not accurate because she documented medication was administered that she did not give.
During a concurrent interview and record review on 3/19/2024 at 4:20 p.m., with the Director of Nursing (DON), the DON reviewed the facility's policy and procedure titled, Medication Administration, last reviewed 2/28/2024. The DON stated Resident 17 has periods of confusion and LVN 1 should not sign the MAR for medications that she assumed were administered by someone else. The DON stated nurses do not sign the MAR for medications they do not personally administer because it could lead to inaccurate documentation indicating a medication was given and it was not. The DON stated the facility's policy and procedure was not followed because the resident did not receive the medications and they were documented as administered.
During a concurrent interview and record review on 3/20/2024 at 12:10 p.m., with the DON, reviewed the facility's policy and procedure titled, Charting and Documentation, last reviewed 2/28/2024. The DON stated LVN 1 falsified (the act of deliberately misrepresenting something) Resident 17's MAR. The DON stated the facility's policy and procedure was not followed for accuracy of documentation. The DON stated the importance of accurate documentation is for the residents' well-being.
b. A review of Resident 18's Face Sheet indicated the facility admitted the resident on 1/10/2023 and readmitted the resident on 1/1/2024 with diagnoses that included hypertensive heart disease with heart failure (refers to heart problems that occur because of high blood pressure that is present over a long time, and results in heart failure in which the heart does not pump blood to the body effectively).
A review of Resident 18's Minimum Data Set (MDS, an assessment and care screening tool) dated 1/5/2024 indicated the resident was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated that Resident 18 was dependent on staff for oral, personal, and toileting hygiene.
A review of Resident 18's physician's orders indicated an order for metoprolol (medication used for high blood pressure) 25 milligrams (mg, a unit of measurement) one tab by gastrostomy tube (G-Tube, a plastic tube inserted into a resident's stomach to administer medications for one who is unable to swallow) twice a day, hold if systolic blood pressure (SBP - the first number in a blood pressure reading, which measures the pressure in the arteries [pathway that carries blood away from the heart] when the heart beats) less than 110 millimeters of mercury (mmHg-a unit of measure) or HR less than 60 bpm, dated 1/1/2024.
During an observation on 3/19/2024 at 8:02 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 prepared Resident 18's medications to be given through the G-Tube. LVN 1 entered Resident 18's room with a manual blood pressure cuff (device used to measure blood pressure) and stethoscope (device used to assist in measuring BP and HR). LVN 1 measured Resident 18's BP. LVN 1 then administered the medications, including metoprolol 25 mg, to Resident 18. LVN 1 was observed not taking Resident 18's heart rate.
A review of Resident 18's Medication Administration Record (MAR-a flow sheet where nursing documents medications provided to a resident daily) dated 3/2024 indicated Resident 18's heart rate was 75 BPM.
During an interview and concurrent record review on 3/19/2024 at 2:10 p.m., with LVN 1 and the Director of Nursing (DON), reviewed Resident 18's MAR dated 3/2024. LVN 1 stated she overlooked taking the heart rate and went back and took Resident 18's heart rate after giving the metoprolol and documented that. LVN 1 stated she did not see the order indicating a heart rate was needed until she clicked review and sign when documenting the medication. LVN 1 stated she did not add any note indicating this heart rate was taken after the metoprolol was given. LVN 1 stated by not checking the heat rate, it put Resident 18 at risk for having an abnormally low heart rate.
During an interview on 3/20/2024 at 12:18 p.m., with the DON, the DON stated LVN 1 documented inaccurately by not indicating the heart rate was taken before the metoprolol was given which is falsification (the act of deliberately misrepresenting something) of a resident's record. The DON stated the action was intentional, but she may not have understood the gravity of her actions. The DON stated Resident 18 could be at risk for low heart rate, which can result in dizziness and fall. The DON stated the importance of accurate documentation is for the residents' well-being.
A review of the facility's policy and procedure titled, Medication Administration, last reviewed 2/28/2024, indicated medications are administered in a safe and timely manner, and as prescribed. Only persons licensed by the state to prepare, administer, and document the administration of medications may do so.
A review of the facility's policy and procedure titled, Charting and Documentation, last reviewed 2/28/2024, indicated all services provided to the resident shall be documented in the resident's medical record. The medical record shall facilitate communication between the interdisciplinary team (IDT, a group of disciplines such as nursing, dietary, and social services that meet to discuss a resident's plan of care) regarding the resident's condition and response to care. Information regarding medications administered is to be documented in the resident medical record. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure that both the top and bottom small dryers (Dryer Unit 2) inside the laundry room were maintained in good working condi...
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Based on observation, interview, and record review, the facility failed to ensure that both the top and bottom small dryers (Dryer Unit 2) inside the laundry room were maintained in good working condition when the thermometer (tool that measures temperature) for each dryer was observed not working on 3/22/2024.
This deficient practice had the potential to lead to contamination of resident clothes and may cause a spread of infection.
Findings:
During a concurrent observation and interview on 3/22/2024 at 8:30 a.m., with the Housekeeping Supervisor (HKS) inside the laundry room, observed the thermometer for both the top and bottom dryer units of Dryer Unit 2 with a temperature reading of 120 degrees Fahrenheit (F-unit of measure). The HKS stated that each dryer should maintain a temperature of 180 degrees F.
During a concurrent interview and record review on 3/22/2024 at 8:50 a.m., with the HKS, reviewed the facility's water and dryer temperature log for 3/22/2024. The HKS stated the temperature for both the top and bottom dryer units of Dryer Unit 2 was noted to be 180 degrees F at 5:40 a.m. The HKS stated the thermometers for the top and bottom dryer units of Dryer Unit 2 needed to be repaired immediately.
During an interview on 3/22/2024 at 9:19 a.m., with the Maintenance Director (MD), the MD stated that the thermometers for both the top and bottom dryer units of Dryer Unit 2 needed to be repaired. The MD stated that he would call the manufacturer's maintenance department for the needed replacement placement parts for repair.
A review of the facility's policy and procedure titled, Laundry and Bedding, Soiled, last reviewed 2/28/2024, indicated laundry equipment is used and maintained according to the manufacturer's instructions for use to prevent microbial (germs) contamination of the system.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure the physician was notified of medication refusals for approximately three months for one of five sampled residents (Resident 87) inv...
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Based on interview and record review, the facility failed to ensure the physician was notified of medication refusals for approximately three months for one of five sampled residents (Resident 87) investigated for unnecessary medications.
This deficient practice had the potential to result in the adverse effects (undesired harmful effect resulting from a medication or other intervention) of hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), have increased depression (feelings of sadness), and to have increased cholesterol (a waxy, fat-like substance that in high amounts in the body can cause heart disease) levels in the body.
Findings:
A review of Resident 87's Face Sheet indicated the facility admitted the resident on 12/21/2023 with diagnoses that included dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).
A review of Resident 87's Minimum Data Set (MDS, an assessment and care screening tool) dated 12/27/2023 indicated the resident was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated that Resident 87 was independent with walking, eating, and oral hygiene.
A review of Resident 87's physician's orders indicated the following:
- Escitalopram (a medication to treat depression [feelings of sadness]) 10 milligrams (mg, a unit of measure) by mouth daily for depression manifested by verbalization of feeling depressed, dated 1/1/2024.
- Losartan potassium (a medication to treat hypertension [high blood pressure]) 50 mg tablet, give one tablet by mouth once a day for hypertension, hold if systolic blood pressure (SBP - the first number in a blood pressure reading, which measures the pressure in the arteries [pathway that carries blood away from the heart] when the heart beats) less than 110 millimeters of mercury (mmHg, a unit of measure) or heart rate is less than 60 beats per minute (bpm, normal reference range 60 - 100 bpm), dated 1/21/2024.
- Hydrochlorothiazide (a diuretic [medication to cause the kidneys to produce more urine]) 12.5 mg, give one capsule by mouth once a day for hypertension, hold if SBP is less than 110 mmHg or heart rate is less than 60 bpm, dated 1/21/2024.
- Atorvastatin calcium (a medication given to lower cholesterol levels) 40 mg, give one tablet by mouth at bedtime for hyperlipidemia (high cholesterol), dated 12/21/2023.
- Abilify five (5) mg (brand name for a medication to treat depression) manifested by persistent anger with others without provocation, give one tablet by mouth at hours of sleep for major depressive disorder, dated 1/1/2024.
A review of Resident 87's Care Plan for Hyperlipidemia and Hypertension, initiated 12/27/2023, indicated Resident 87 is at risk for hypertension, heart problems, and elevated lipid panel (blood test to assess cholesterol levels in the body). The care plain indicated a goal that Resident 87's systolic blood pressure will stay below 130 mmHg and the lipid panel will be within normal range.
A review of Resident 87's Medication Administration Records (MAR-a flow sheet where nursing documents medications provided to a resident daily) for the months of 1/2024, 2/2024, and 3/2024 indicated the following 63 medication refusals:
- On 1/4/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 1/4/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 1/8/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 1/8/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 1/8/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 1/9/2024 at 9 p.m., Resident 87 refused atorvastatin 40 mg.
- On 1/9/2024 at 9 p.m., Resident 87 refused Abilify 5 mg.
- On 1/13/2024 at 9 p.m., Resident 87 refused atorvastatin 40 mg.
- On 1/13/2024 at 9 p.m., Resident 87 refused Abilify 5 mg.
- On 1/22/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 1/22/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 1/22/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 1/23/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 1/23/2024 at 9 p.m., Resident 87 refused atorvastatin 40 mg.
- On 1/23/2024 at 9 p.m., Resident 87 refused Abilify 5 mg.
- On 1/29/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 1/29/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 1/29/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 1/30/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 1/30/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 1/30/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 2/5/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 2/5/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 2/5/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 2/6/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 2/6/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 2/6/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 2/7/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 2/7/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 2/7/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 2/10/2024 at 9 p.m., Resident 87 refused atorvastatin 40 mg.
- On 2/10/2024 at 9 p.m., Resident 87 refused Abilify 5 mg.
- On 2/13/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 2/13/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 2/13/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 2/14/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 2/14/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 2/14/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 2/19/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 2/19/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 2/19/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 2/20/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 2/20/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 2/20/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 2/21/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 2/21/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 2/21/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 2/24/2024 at 9 p.m., Resident 87 refused atorvastatin 40 mg.
- On 2/24/2024 at 9 p.m., Resident 87 refused Abilify 5 mg.
- On 2/27/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 2/27/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 2/27/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 2/27/2024 at 9 p.m., Resident 87 refused atorvastatin 40 mg.
- On 2/27/2024 at 9 p.m., Resident 87 refused Abilify 5 mg.
- On 3/4/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 3/4/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 3/4/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 3/6/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 3/6/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 3/6/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
- On 3/12/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg.
- On 3/12/2024 at 9 a.m., Resident 87 refused losartan 50 mg.
- On 3/12/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg.
A review of Resident 87's MAR Detail Report for 1/2024, 2/2024, and 3/2024 indicated Resident 87 refused medications. There was no indication that Licensed Vocational Nurse 1 (LVN 1) documented attempts to offer medications again, documented reason for refusal, or notified Resident 87's physician of the medication refusal.
During a concurrent interview and record review on 3/22/2024 at 1:23 p.m., with the Director of Nursing (DON), reviewed Resident 87's MAR dated 1/2024, 2/2024, and 3/2024 and MAR Detailed Reports. The DON stated LVN 1 was the licensed nurse who documented Resident 87's medication refusals for the months of 1/2024, 2/2024, and 3/2024. The DON stated if a resident refuses to take medication, the licensed nurse should come back to offer the medication and if the resident refuses, the licensed nurse should then notify the resident's physician. The DON stated the licensed nurse should document so that the other licensed nurses are made aware of the medication refusal. The DON stated the licensed nurses should have made a care plan for the refusal and conduct an interdisciplinary team (IDT, a group of disciplines such as nursing, dietary, and social services that meet to discuss a resident's plan of care) meeting.
A review of the facility's policy and procedure titled, Refusal of Treatment, last reviewed 2/28/2024, indicated treatment is defined as care provided for purposes of maintaining/restoring health, improving functional level, or relieving symptoms.
If a resident refuses treatment, the charge nurse or DON will interview the resident to determine what and why the resident is refusing in order to try to address the resident's concerns and explain the consequences.
The Care Plan Team will assess the resident's needs and offer the resident alternative treatments, if available and pertinent.
Should the resident refuse to accept treatment, detailed information relating to the refusal must be entered into the resident's medical record including the date and time the staff tried to give a medication, the medication refused, the resident's response and reason for refusal, and the date and time the physician was notified as well as the physician's response.
A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, last reviewed 2/28/2024, indicated the nurse supervisor/charge nurse will notify the resident's attending physician when there has been a refusal of treatment or medications (i.e., two (2) or more consecutive times. The policy and procedure indicated, prior to notifying the physician, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Situation, Background, Assessment, and Recommendation Communication Form (SBAR, a structured communication framework that can help teams share information about the condition of a resident).
CONCERN
(E)
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 ensure residents were provided a comfortable and home...
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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 ensure residents were provided a comfortable and homelike environment for seven of 17 sampled residents (Resident 194, 3, 10, 47, 52, 62, and 79) by failing to provide communal dining.
This deficient practice had the potential to result in decreased social interactions, decreased psychosocial wellbeing, and weight loss in residents.
Findings:
a.1 A review of Resident 3's Face Sheet (admission record) indicated the facility admitted the resident on 9/29/2023 and readmitted the resident on 11/20/2023, with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and depression (mood disorder that causes a persistent feeling of sadness and loss of interest).
A review of Resident 3's History and Physical (H&P - a formal assessment of a patient and their problem) dated 11/20/2023, indicated Resident 3 had capacity to understand and make decisions.
A review of Resident 3's Minimum Data Set (MDS - an assessment and screening tool), dated 1/3/2024, indicated Resident 3 does not require supervision (oversight, encouragement, or cueing) with eating.
During an interview on 3/19/2024 at 10:36 a.m., during the resident council meeting, Resident 3 stated he wanted communal dinning in the dining areas. Resident 3 stated there was no communal dinning since the last COVID-19 outbreak at the facility ended in 1/2024.
a.2. A review of Resident 10's Face Sheet indicated the facility admitted the resident on 8/20/2020 and readmitted the resident on 1/29/2024 with diagnoses that included schizophrenia and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations).
A review of Resident 10's H&P, dated 1/29/2024, indicated Resident 10 had capacity to understand and make decisions.
A review of Resident 10's MDS, dated [DATE], indicated Resident 10 does not require supervision with eating.
During an interview on 3/19/2024 at 10:39 a.m., during the resident council meeting, Resident 10 stated she wanted communal dinning in the dining areas. Resident 10 stated that is the time and place where she can meet up with her friends in the facility. Resident 10 stated there was no communal dinning since the last COVID-19 outbreak at the facility ended in 1/2024.
a.3. A review of Resident 47's Face Sheet indicated the facility admitted the resident on 12/23/2020 and readmitted the resident on 3/11/2024 with diagnoses that included schizophrenia and psychosis (a mental disorder characterized by a disconnection from reality).
A review of Resident 47's H&P, dated 3/11/2024, indicated Resident 47 had the capacity to understand and make decisions.
A review of Resident 47's MDS, dated [DATE], indicated Resident 47 had capacity to understand and make decisions and does not require supervision with eating.
During an interview on 3/19/2024 at 10:41 a.m., during the resident council meeting, Resident 47 stated she always wants to eat her meals in the dining room and she would spend most of her time in the dining room to talk to her friends and other residents. Resident 47 stated there was no communal dinning since the last COVID-19 outbreak at the facility ended in 1/2024.
a.4. A review of Resident 52's Face Sheet indicated the facility admitted the resident on 3/20/2023 with diagnoses that included dementia disorder (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and depression.
A review of Resident 52's H&P, dated 3/20/2023, indicated Resident 52 had the capacity to understand and make decisions.
A review of Resident 52's MDS, dated [DATE], indicated Resident 52 does not require supervision with eating.
During an interview on 3/19/2024 at 10:51 a.m., during the resident council meeting, Resident 52 stated he wanted communal dinning in the dining areas with other residents. Resident 52 stated he hates to eat inside his room because he feels lonely eating by himself inside his room. Resident 52 stated there was no communal dinning since the last COVID-19 outbreak at the facility ended in 1/2024.
a.5. A review of Resident 62's Face Sheet indicated the facility admitted the resident on 1/11/2024 and readmitted the resident on 2/12/2024 with diagnoses that included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood) and pneumonia (an infection that affects one or both lungs).
A review of Resident 62's H&P, dated 2/13/2024, indicated Resident 62 had the capacity to understand and make decisions.
A review of Resident 62's MDS, dated [DATE], indicated Resident 62 does not require supervision with eating.
During an interview on 3/19/2024 at 10:51 a.m., during the resident council meeting, Resident 62 stated he wanted communal dinning in the dining areas with other residents. Resident 62 stated there was no communal dinning since the last COVID-19 outbreak at the facility ended in 1/2024.
a.6. A review of Resident 79's Face Sheet indicated the facility admitted the resident on 5/10/2023 with diagnoses that included major depressive disorder, dementia disorder, and anxiety disorder.
A review of Resident 79's H&P, dated 5/10/2023, indicated Resident 79 had the capacity to understand and make decisions.
A review of Resident 79's MDS, dated [DATE], indicated Resident 79 does not require supervision with eating.
During an interview on 3/19/2024 at 10:51 a.m., during the resident council meeting, Resident 79 stated she wanted communal dinning in the dining areas with her friends and other residents. Resident 79 stated she feels happy to eat her meals together with other friends and residents. Resident 79 stated there was no communal dinning since the last COVID-19 outbreak at the facility ended in 1/2024.
A review of the facility-provided COVID-19 Outbreak (more cases of disease in time or place than expected) Clearance Letter, dated 1/16/2024, indicated the Department (Public Health) determined the outbreak at the facility had ended and all related requirements and restrictions were removed.
During an interview on 3/20/2024 at 12:10 p.m., with the Director of Nursing (DON), the DON stated during the COVID-19 outbreak the public health nurse had the facility close the communal dining room. The DON stated the outbreak was closed in 1/2024 and they have slowly begun group activities again but had not yet offered communal dining. The DON stated communal dining is offered to residents who are alert and oriented and want to be in the dining room to eat meals. The DON stated it was part of a homelike environment to offer communal dining and any resident who wants to be a part of lunch or dinner looks forward to it. The DON stated when communal dining is not provided then it may result in increased depression, increased anxiety levels, and weight loss could develop as a result.
A review of the facility's policy and procedure titled, Assistance with Meals, last reviewed 2/28/2024, indicated residents shall receive assistance with meals in a manner that meets the individual needs of each resident. All residents will be encouraged to eat in the dining room.
b. A review of Resident 194's Face Sheet (admission record) indicated the facility admitted the resident on 2/20/2024 and readmitted the resident on 3/6/2024 with diagnoses that included encephalopathy, muscle wasting (loss of muscle tissue), and hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time, and results in heart failure in which the heart does not pump blood to the body effectively).
A review of Resident 194's MDS dated [DATE], indicated the resident had the ability to understand others and had the ability to make herself-understood. The MDS further indicated the resident required supervision with eating.
A review of Resident 194's Care Plan titled, Activity / Psychosocial Wellbeing, initiated 3/7/2024, indicated to assess the resident for activity preference, allow the resident to make choices, and provide social group.
A review of the facility-provided Coronavirus disease-2019 [COVID-19, a highly contagious viral infection that can trigger respiratory tract infection] Outbreak (more cases of disease in time or place than expected) Clearance Letter, dated 1/16/2024, indicated the Department (Public Health) determined the outbreak at the facility had ended and all related requirements and restrictions were removed.
During a concurrent observation and interview on 3/18/2024 at 9:15 a.m., with Resident 194, the resident sat on her bed and stated she had been in the facility for a month or so and she was bored. Resident 194 stated she just eats in her room.
During an observation on 3/18/2024 at 12:01 p.m., observed the facility dining room with the lights off and no staff or residents present.
During an interview on 3/18/2024 at 12:13 p.m., with the Administrator (ADM), the ADM stated the facility had not had communal dining since before their last COVID-19 outbreak. The ADM stated residents have been dining in their rooms since the outbreak, but there are group activities in the dining area.
During an interview on 3/18/2024 at 4:14 p.m., with Resident 194, Resident 194 stated she would enjoy dining with other residents very much, but it was not offered.
During an observation on 3/19/2024 at 12:03 p.m., observed the communal dining room with the lights off and no staff or residents present.
During a concurrent interview and record review on 3/20/2024 at 7:50 a.m., with the Social Services Director (SSD), reviewed the facility's policy titled, Assistance with Meals, last reviewed 2/28/2024. The SSD stated the facility had not offered communal dining the entire time she had been working there since 11/2023. The SSD stated for the past few weeks they have been discussing opening the communal dining room, but she does not know why it has not yet been opened. The SSD stated communal dining is for socialization and when it is not provided it affects resident socialization. The SSD stated socialization is important, so residents don't feel isolated and alone. The SSD stated when communal dining is provided it is more of a homelike environment with a dining room and tables. The SSD stated the facility's policy indicates that all residents should be encouraged to eat in the dining room, but they do not offer it.
During an interview on 3/20/2024 at 12:10 p.m., with the Director of Nursing (DON), the DON stated during the COVID-19 outbreak the public health nurse had the facility close the communal dining room. The DON stated the outbreak was closed in 1/2024 and they have slowly begun group activities again but had not yet offered communal dining. The DON stated communal dining is offered to residents who are alert and oriented and want to be in the dining room to eat meals. The DON stated it was part of a homelike environment to offer communal dining and any resident who wants to be a part of lunch or dinner looks forward to it. The DON stated when communal dining is not provided then it may result in increased depression, increased anxiety levels, and weight loss could develop as a result.
A review of the facility's policy and procedure titled, Assistance with Meals, last reviewed 2/28/2024, indicated residents shall receive assistance with meals in a manner that meets the individual needs of each resident. All residents will be encouraged to eat in the dining room.
A review of the facility's policy and procedure titled, Homelike Environment, last reviewed 2/28/2024, indicated residents are provided with a safe, clean, comfortable, and homelike environment. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. The facility staff and management minimize, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure a resident's orthostatic blood pressure (taking a blood pressure [BP- the pressure of circulating blood against the wal...
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Based on observation, interview and record review, the facility failed to ensure a resident's orthostatic blood pressure (taking a blood pressure [BP- the pressure of circulating blood against the walls of blood vessels] lying down, sitting up, and standing up) was taken correctly for one of five sampled residents (Resident 87) investigated for unnecessary medications.
This deficient practice had the potential to place Resident 87 at risk for developing symptoms of orthostatic hypotension (a form of low blood pressure [the force of the blood pushing on the blood vessel walls is too low] that happens when standing after sitting or lying down which can cause dizziness or lightheadedness and possibly fainting).
Findings:
A review of Resident 87's Face Sheet (admission record) indicated the facility admitted the resident on 12/21/2023 with diagnoses that included dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities).
A review of Resident 87's Minimum Data Set (MDS, an assessment and care screening tool) dated 12/27/2023 indicated the resident was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated that Resident 87 was independent with walking, eating, and oral hygiene.
A review of Resident 87's physician's orders indicated the following:
- Monitor blood pressure for orthostatic hypotension while lying and sitting every Sunday during the 3-11 p.m. shift, ordered 1/1/2024.
- Monitor orthostatic blood pressure on Saturdays during the 3-11 p.m. shift, ordered 1/27/2024.
- Abilify (medication used to treat major depressive disorder [mood disorder that causes a persistent feeling of sadness and loss of interest]) manifested by persistent anger with others without provocation, give one tablet by mouth at hours of sleep for major depressive disorder, dated 1/1/2024.
A review of Resident 87's Care Plan for Orthostatic Hypotension, initiated 1/1/2024, indicated Resident 87 has the potential for fluctuations in blood pressure. The care plan, indicated a goal that the systolic blood pressure (SBP - the first number in a blood pressure reading, which measures the pressure in the arteries [pathway that carries blood away from the heart] when the heart beats) will not be lower than 100 millimeters of mercury (mmHg, a unit of measure for blood pressure) and/or diastolic blood pressure (DBP- the second number in a blood pressure reading, which measures the pressure in the arteries when the heart rests between beats) will not be lower than 60 mmHg when checked for 90 days. The care plan indicated an intervention to check blood pressure as ordered.
A review of Resident 87's Medication Administration Records (MAR-a flow sheet where nursing documents medications provided to a resident daily) for 1/2024, 2/2024, and 3/2024 indicated the following:
- On 1/7/2024, Resident 87's BP while lying was 125/76 mmHg and while sitting was 128/72 mmHg.
- On 1/14/2024, Resident 87's BP while lying was 120/80 mmHg and while sitting was 128/79 mmHg.
- On 1/21/2024, Resident 87's BP while lying was 130/78 mmHg and while sitting was 132/76 mmHg.
- On 1/27/2024, Resident 87's BP while lying was 116/76 mmHg and while standing was 117/72 mmHg.
- On 1/28/2024, Resident 87's BP while lying was 132/78 mmHg and while sitting was 130/72 mmHg.
- On 2/3/2024, Resident 87's BP while lying was 118/76 mmHg and while standing was 122/80 mmHg.
- On 2/4/2024, Resident 87's BP while lying was 120/70 mmHg and while sitting was 126/70 mmHg.
- On 2/10/2024, Resident 87's BP while lying was 122/67 mmHg and while standing was 132/77 mmHg.
- On 2/11/2024, Resident 87's BP while lying was 130/78 mmHg and while sitting was 136/75 mmHg.
- On 2/17/2024, Resident 87's BP while lying was 125/76 mmHg and while standing was 122/78 mmHg.
- On 2/18/2024, Resident 87's BP while lying was 124/72 mmHg and while sitting was 127/60 mmHg.
- On 2/24/2024, Resident 87's BP while lying was 133/78 mmHg and while standing was 138/86 mmHg.
- On 2/25/2024, Resident 87's BP while lying was 118/80 mmHg and while sitting was 120/85 mmHg.
- On 3/2/2024, Resident 87's BP while lying was 122/76 mmHg and while standing was 119/78 mmHg.
- On 3/3/2024, Resident 87's BP while lying was 130/78 mmHg and while sitting was 132/80 mmHg.
- On 3/9/2024, Resident 87's BP while lying was 128/84 mmHg and while standing was 124/78 mmHg.
- On 3/10/2024, Resident 87's BP while lying was 132/80 mmHg and while sitting was 130/74 mmHg.
- On 3/16/2024, Resident 87's BP while lying was 127/86 mmHg and while standing was 130/86 mmHg.
- On 3/17/2024, Resident 87's BP while lying was 125/76 mmHg and while sitting was 122/78 mmHg.
During a concurrent interview and record review on 3/20/2024 at 5:01 p.m., with Licensed Vocational Nurse 4 (LVN 4), reviewed Resident 87's MAR dated 3/2024. LVN 4 stated he followed what is on the electronic MAR for 3/16/2024, which are two options for taking blood pressure, while lying and standing. LVN 4 stated orthostatic blood pressure should include taking blood pressures lying, sitting, and standing. LVN 4 stated the importance of this is to obtain an accurate orthostatic blood pressure. LVN 4 stated Resident 87 could have been at risk for low blood pressure, potentially resulting in dizziness and falling.
During a concurrent interview and record review on 3/20/2024 at 5:09 p.m., with LVN 5, reviewed Resident 87's MARs dated 1/2024, 2/2024 and 3/2024. LVN 5 stated on the electronic MAR, there is an option for orthostatic blood pressures while lying and standing but not for sitting. LVN 5 acknowledged she takes Resident 87's orthostatic blood pressure. LVN 5 stated she takes the orthostatic blood pressure for Resident 87 for lying, sitting, and standing position, but was unable to state what the sitting blood pressure readings were for those dates on the MARs dated 1/2024, 2/2024 and 3/2024. LVN 5 stated she should document all three blood pressure position readings. LVN 5 stated Resident 5 could be at risk for dizziness.
During a concurrent interview and record review on 3/22/2024 at 1:23 p.m., with the Director of Nursing (DON), reviewed Resident 87's MARs dated 1/2024, 2/2024, and 3/2024. The DON stated the orthostatic blood pressure should including lying, sitting, and standing positions. The DON stated this is important so that there is an accurate indicator of Resident 87's blood pressure and to ensure Resident 87 does not have orthostatic hypotension.
A review of the facility's policy and procedure titled, Psychotropic Medication (medications capable of affecting the mind, emotions, and behavior) Use, last reviewed 2/28/2024, indicated residents receiving psychotropic medications are monitored for adverse consequences (undesired harmful effect resulting from a medication or other intervention) including orthostatic hypotension.
A review of the facility's policy and procedure titled, Blood Pressure, Measuring, last reviewed 2/28/2024, indicated orthostatic (postural) hypotension is defined as a 20 mm Hg (or greater) decline in systolic blood pressure or a 10 mm Hg (or greater) decline in diastolic blood pressure upon standing. The policy and procedure indicated the procedure to measure orthostatic blood pressure, take the blood pressure after helping the resident to a standing position and to note the changes in both systolic and diastolic measurements compared to the reading taken while the resident was in a seated position.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administ...
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Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of one of two sampled residents (Resident 17) investigated during the Medication Storage and Labeling task by failing to:
1. Ensure Licensed Vocational Nurse 1 (LVN 1) administered Resident 17's Ambien (medication used to aid sleep), gabapentin (a medication used to treat nerve pain), and simvastatin (a medication used to treat hyperlipidemia (high cholesterol [a waxy substance that can build up in the blood resulting in stroke or heart issues]) per the physician's orders on 3/14/2024.
2. Ensure the Record of Controlled Substances form (a form completed to document removal of a controlled substance [substances that have an accepted medical use, have a potential for abuse, and may also lead to physical or psychological (related to the mental and emotional state of a person) dependence]) from a bubble pack [packaging in which medications are organized and sealed between a cardboard backing and clear plastic cover] for Ambien accurately reflected Resident 17's Medication Administration Record (MAR-a flow sheet where nursing documents medications provided to a resident daily).
3. Ensure licensed nursing staff completed documentation indicating reconciliation (a system of recordkeeping that ensures an accurate inventory of medications by accounting for controlled medications that have been received, dispensed, and administered) of controlled medications for three of 53 shift opportunities.
These deficient practices had the potential for inaccurate reconciliation of controlled medication and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications and the potential to result in ineffective treatment of Resident 17's insomnia (inability to sleep), pain, and hyperlipidemia.
Findings:
a. A review of Resident 17's Face Sheet (admission record) indicated the facility admitted the resident on 9/3/2021 and readmitted the resident on 1/8/2024 with diagnoses that included polyneuropathy (disease or dysfunction of one or more peripheral nerves [nerves located outside of the brain and spinal cord], typically causing numbness or weakness), hyperlipidemia, chronic pain, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one's daily functioning), and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).
A review of Resident 17's Minimum Data Set (MDS, an assessment and care screening tool) dated 1/12/2024 indicated the resident usually was able to understand others and usually was able to make herself understood. The MDS further indicated the resident required substantial / maximal assistance from staff for movement and dressing and was dependent on staff for toileting and bathing.
A review of Resident 17's physician's orders indicated orders for the following:
-Ambien 10 milligram (mg, a unit of measurement) tablet, give one tablet by mouth before bedtime (QHS) for insomnia manifested by inability to sleep, dated 1/8/2024.
-Gabapentin 300 mg capsule, give one capsule by mouth at bedtime for neuropathy, dated 1/8/2024.
- Simvastatin 20 mg tablet, give one tablet by mouth at bedtime, dated 1/8/2024.
A review of Resident 17's Care Plan titled, Disturbance in Sleep Pattern related to Insomnia, initiated 1/9/2024 indicated to administer medication as ordered.
During a concurrent interview and record review on 3/18/2024 at 3:47 p.m., with Licensed Vocational Nurse 2 (LVN 2), reviewed Resident 17's Record of Controlled Substances (RCS) form for Ambien and MAR dated 3/2024. LVN 2 stated Ambien was a controlled substance (medication that have an accepted medical use, have a potential for abuse, and may also lead to physical or psychological [related to the mental and emotional state of a person] dependence) and kept in a locked drawer in the medication cart because controlled substances have a potential for abuse and there is a risk they may be stolen. LVN 2 stated the RCS form is completed when the medication is removed from the bubble pack and the MAR is used to document administration of the medication. LVN 2 noted the following:
- Resident 17's RCS form for Ambien indicated Ambien was not removed on 3/14/2024. LVN 2 stated the amount of medication remaining in the bubble pack matched the amount remaining on the RCS form and indicated the medication was not removed on 3/14/2024.
- Resident 17's MAR indicated Ambien was administered on 3/14/2024 at 9 p.m. by LVN 1.
LVN 2 stated if the MAR indicated the medication was administered it should have been documented as removed, but it was not.
During a concurrent interview and record review on 3/19/2024 at 3 p.m., with LVN 1, reviewed Resident 17's RCS form for Ambien and MAR dated 3/2024. LVN 1 stated the process for removing and administering Ambien was to remove the medication bubble pack from the locked narcotic drawer, remove the medication from the bubble pack, count the amount of Ambien remaining in the bubble pack, complete the RCS form, administer the medication, and then sign the MAR. LVN 1 reviewed Resident 17's MAR dated 3/2024 and the RCS for Ambien and stated she did not administer Resident 17's Ambien, but documented in the MAR that it was administered. LVN 1 stated on 3/14/2024 she was called in to work to administer medications and arrived around 9 p.m. LVN 1 stated she assumed Resident 17 already received the 9 p.m. medications because Resident 17 told her they were already given. LVN 1 reviewed the MAR and stated the following:
1. On 3/14/2024 at 9 p.m., LVN 1 documented Ambien was administered, but LVN 1 did not administer the medication to Resident 17.
2. On 3/14/2024 at 9 p.m., LVN 1 documented gabapentin was administered, but LVN 1 did not administer the medication to Resident 17.
3. On 3/14/2024 at 9 p.m., LVN 1 documented simvastatin was administered, but LVN 1 did not administer the medication to Resident 17.
LVN 1 stated Resident 17's MAR dated 3/2024 was not accurate because she documented medication was administered that she did not give.
During a concurrent interview and record review on 3/19/2024 at 4:20 p.m., with the Director of Nursing (DON), the DON reviewed the facility's policy and procedure titled, Medication Administration, last reviewed 2/28/2024. The DON stated Resident 17 has periods of confusion and LVN 1 should not sign the MAR for medications that she assumed were administered by someone else. The DON stated nurses do not sign the MAR for medications they do not personally administer because it could lead to inaccurate documentation indicating a medication was given and it was not. The DON stated if Resident 17 was not administered gabapentin it could lead to pain as an outcome. The DON stated if Resident 17 was not administered simvastatin it could lead to higher cholesterol levels. The DON stated if Resident 17 was not administered Ambien it could lead to insomnia. The DON stated the facility's policy and procedure was not followed because the resident did not receive the medications and they were documented as administered.
A review of the facility's policy and procedure titled, Medication Administration, last reviewed 2/28/2024, indicated medications are administered in a safe and timely manner, and as prescribed. Only persons licensed by the state to prepare, administer, and document the administration of medications may do so. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication the individual administering the medication records in the resident's medical record the date and time the medication was administered and the signature and title of the person administering the drug.
A review of the facility's policy and procedure titled, Documentation of Medication Administration, last reviewed 2/28/2024, indicated medication administration record is used to document all medications administered. A nurse documents all medications administered to each resident on the resident's MAR immediately after it is given.
b. During a concurrent interview and record review on 3/18/2024 at 3:47 p.m., with LVN 2, reviewed Medication Cart 1 8-Hour Controlled Drugs - Count Record dated 3/2024. LVN 2 stated controlled substance are kept in a locked drawer in the med cart because controlled substances have a potential for abuse and may be stolen and thus not available for the residents. LVN 2 stated the 8-Hour Controlled Drugs - Count Record is completed by two licensed nurses at the beginning and end of each shift to ensure all narcotics are accounted for. LVN 2 stated the narcotics record is signed by the two nurses at the same time indicating the narcotic count was done together. LVN 2 reviewed the 8-Hour Controlled Drugs - Count Record dated 3/2024 and noted the following:
1. On 3/2/2024, missing the 11 p.m. to 7 a.m. incoming nurse's signature.
2. On 3/3/2024, missing the 11 p.m. to 7 a.m. outgoing nurse's signature.
3. On 3/13/2024, missing the 11 p.m. to 7 a.m. incoming nurse's signature.
During a concurrent interview and record review on 3/19/2024 at 4:20 p.m., with the DON, reviewed the 8-Hour Controlled Drugs - Count Record dated 3/2024. The DON stated the 8-Hour Controlled Drugs - Count Record is completed at the change of every shift when the narcotics are counted and endorsed to the oncoming nurse. The DON stated if the 8-Hour Controlled Drugs - Count Record was not signed then it was not done at that date and time. The DON stated licensed nurses must sign together to make sure there is no diversion of controlled substances. The DON stated if there is a count discrepancy, it must be investigated immediately.
A review of the facility's policy and procedure titled, Controlled Substances, last reviewed 2/28/2024, indicated the facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Only authorized licensed nursing and/or pharmacy personnel have access to controlled drugs maintained on premises. Access to controlled medications remains locked at all times and access is recorded. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. Controlled medications are counted at the end of each shift. The nurse coming on duty and nurse going off duty determine the count together. Any discrepancies in the controlled substance count are documented and reported to DON immediately.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR, a monthly thorough evalu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR, a monthly thorough evaluation by the consulting pharmacist of a resident's medication regimen, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) was acted upon for four of five sampled residents (Resident 19, 87, 57, and 7) investigated for unnecessary medications by:
1. Failing to conduct an MRR for Resident 19 and 87.
2. Ensure the physician's response to the pharmacy recommendations were carried out for a gradual dose reduction (GDR, tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose) of mirtazapine for resident 57.
3. Ensure the physician's response to the pharmacy recommendations were clarified and carried out regarding orders for antidepressants (medication used for depression [a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one's daily functioning]) and antipsychotic medications (medications used to treat psychosis [a mental condition in which thought, and emotions are so affected that contact is lost with external reality]) for Resident 7.
These deficient practices had the potential to result in adverse reaction (undesired harmful effect resulting from a medication or other intervention) from the continued use of these medications.
Findings:
1.a. A review of Resident 19's Face Sheet (admission record) indicated the facility admitted the resident on 10/20/2021 and readmitted the resident on 8/25/2023 with diagnoses that included major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), schizoaffective disorder (a mental health condition that includes features of both schizophrenia [serious mental illness that affects how a person thinks, feels, and behaves] and a mood disorder [marked disruptions in emotions]) bipolar type (mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations).
A review of Resident 19's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 1/18/2024, indicated Resident 19 had severe impairment of cognitive (the process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making. The MDS indicated Resident 19 required extensive assistance with two or more persons physical assist for toilet use and personal hygiene. The MDS also indicated Resident 19 was receiving antipsychotic medications.
A review of Resident 19's physician's orders, dated 8/25/2023, indicated the following orders:
- Duloxetine hydrochloride (medication used to treat depression and anxiety) delayed-release 30 milligrams (mg, a unit of measure) for depression for verbalization of sadness.
- Klonopin (medication used to treat anxiety disorder) one mg by mouth daily for anxiety.
- Risperidone (medication used to treat schizophrenia and bipolar disorder) one mg for schizoaffective bipolar type for extreme mood swings that cause distress and danger to self.
A review of Resident 19's Care Plan for Psychotropic Medication, initiated 8/26/2023, indicated the resident requires the use of psychoactive medications and included an intervention to pharmacy audit of medication monthly.
During a concurrent interview and record review on 3/21/2024 at 10:41 a.m., with the Medical Record Director (MDR), review Resident 19's MRR for 12/2023. The MDR confirmed by stating Resident 19 did not have a MRR completed for the month of 12/2023.
During a concurrent interview and record review on 3/21/2024 at 12:01 p.m., with the Registered Nurse 1 (RN 1), reviewed Resident 19's MRR for 12/2023. RN 1 confirmed by stating Resident 19 did not have a MRR completed for the month of 12/2023. RN 1 stated there was no documentation that there was communication between the facility and the facility's consultant pharmacist for the missing 12/2023 MRR report for Resident 19. RN 1 stated Resident 19 could be overdosed on the psychotropic medications (medications capable of affecting the mind, emotions, and behavior) if the pharmacist did not perform a monthly review of Resident 19's medications.
During an interview on 3/22/2024 at 2:55 pm, with the Director of Nursing (DON), the DON confirmed by stating there was no MRR for Resident 19 for 12/2023. The DON stated it is RN 1's responsibility to follow up with the facility's consultant pharmacist for the monthly MRR reports.
A review of the facility's policy and procedure titled, Medication Regimen Reviews, last reviewed 2/28/2024, indicated the consultant pharmacist reviews the medication regimen of each resident at least monthly. MRR are done upon admission and at least monthly thereafter, or more frequently if indicated. The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication.
2. A review of Resident 57's Face Sheet (admission record) indicated the facility admitted the resident on 12/28/2022 and readmitted the resident on 10/21/2023 with diagnoses that included polyneuropathy (disease or dysfunction of one or more peripheral nerves [nerves located outside of the brain and spinal cord], typically causing numbness or weakness), difficulty walking, major depressive disorder, schizoaffective disorder (a mental health condition that includes features of both schizophrenia [serious mental illness that affects how a person thinks, feels, and behaves] and a mood disorder [marked disruptions in emotions]), and unspecified dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with agitation.
A review of Resident 57's Minimum Data Set (MDS - an assessment and screening too) dated 1/28/2024, indicated the resident usually had the ability to understand others and usually had the ability to make self-understood. The MDS further indicated the resident was taking antipsychotics and antidepressants.
A review of Resident 57's physician's orders indicated an order for the following:
-Risperidone (an antipsychotic medication) one (1) milligram (mg, a unit of measurement) tablet: give one tablet three times a day (TID) for schizoaffective disorder manifested by (m/b) screaming and yelling for no apparent reason, dated 10/21/2023.
-Remeron (mirtazapine, an antidepressant medication) 15 mg tablet, give one tablet by mouth for depression m/b verbalization of feeling sad, dated 10/21/2023.
-Depakote delayed-release (divalproex, a medication to treat bipolar disorder [causes extreme mood swings]) 250 mg tablet, give one tablet by mouth at bedtime (QHS) for mood disorder m/b sudden outburst of anger as evidenced by striking out at staff, dated 11/13/2023
A review of Resident 57's Note to Attending Physician / Prescriber dated 1/12/2024, indicated the resident was currently on risperidone 1 mg TID, mirtazapine 15 mg QHS, and divalproex 250 mg QHS. The note indicated a GDR be attempted in two separate quarters within the first year in which a resident is admitted on psychopharmacologic medication (medications treating mental disorders).
During a concurrent interview and record review on 3/21/2024 at 12:26 p.m., with Registered Nurse 1 (RN 1), reviewed Resident 57's Note to Attending Physician / Prescriber form dated 1/12/2024 and physician orders. RN 1 stated the facility's consultant pharmacist reviews the resident's medication monthly and may make a recommendation to the primary care provider. RN 1 stated the resident's primary care provider assesses the resident and responds to the pharmacist's recommendations. RN 1 stated she is responsible for reviewing the primary care provider's response to the pharmacy recommendations and clarify any new or changes to orders. RN 1 reviewed and noted the following:
1.Resident 57's Note to Attending Physician / Prescriber form, dated 1/12/2024, indicated the primary care provider responded to the pharmacist's recommendation to decrease the mirtazapine dosage to 7.5 mg.
2. Resident 57's physician's orders indicated an active order for mirtazapine dosage 15 mg.
During a concurrent interview and record review on 3/21/2024 at 1 p.m., with the Director of Nursing (DON), the DON reviewed the facility's policies and procedures titled, Medication Regimen Reviews (MRR) and Psychotropic Medication Use, last reviewed 2/28/2024, and Resident 57's Note to Attending Physician / Prescriber form dated 1/12/2024. The DON stated it was a constant process to try to gradually reduce the dosage of psychotropic medications because there was a high risk for adverse side effects. The DON stated the primary care provider responded to the pharmacy recommendation to reduce Resident 57's mirtazapine dosage to 7.5 mg, but it was not carried out. The DON stated the dosage should have been lowered, but it was not. The DON stated the facility's policy and procedure was not followed when the primary care provider's response was not carried out and could have potentially resulted in excessive psychotropic medications being administered resulting in adverse side effects like extrapyramidal symptoms (drug-induced movement disorders), lethargy (diminished energy) leading to residents becoming more dependent on staff to perform activities of daily living, and falls resulting in broken bones.
A review of the facility's policy and procedure titled, Medication Regimen Reviews (MRR), last reviewed 2/28/2024, indicated the consultant pharmacist reviews the medication regimen of every resident at least monthly. The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medications. The MRR involves a thorough review of the resident's medications to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example: medications ordered in excessive doses and duplicative therapies. Within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physicians for each resident identified as having a non-life-threatening medication irregularity. The report contains the pharmacist's recommendation. The attending physician documents in the medical record the irregularity has been reviewed and what (if any) action was taken to address it.
A review of the facility's policy and procedure titled, Psychotropic Medication Use, last reviewed 2/28/2024, indicated residents will not receive medications that are not clinically indicated to treat a specific condition. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: anti-psychotics, anti-depressants, anti-anxiety medications, and hypnotics (sleep-inducing drug). Residents on psychotropic medications receive GDR (coupled with non-pharmacological interventions), unless clinically contraindicated, in an effort to discontinue these medications.
3. A review of Resident 7's Face Sheet indicated the facility admitted the resident on 7/4/2023 and readmitted the resident on 12/13/2023 with diagnoses that included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), major depressive disorder, schizoaffective disorder, bipolar type, anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear).
A review of Resident 7's MDS dated [DATE], indicated the resident had the ability to understand others and had the ability to make himself understood. The MDS further indicated the resident was taking antipsychotics and antidepressants.
A review of Resident 7's physician's orders indicated an order for the following:
-Risperidone four (4) mg tablet, give one tablet twice a day for schizoaffective disorder, bipolar type m/b sudden aggressive behavior in danger to others, dated 12/26/2023.
-Olanzapine (an antipsychotic medication) 15 mg tablet, give one tablet by mouth at bedtime for schizoaffective disorder, bipolar type m/b unprovoked angry outburst, dated 12/13/2023.
-Trazadone (an antidepressant medication) 50 mg tablet, give one tablet by mouth at bedtime for depression m/b inability to sleep, dated 12/26/2023.
-Sertraline hydrochloride (an antidepressant medication) 50 mg tablet, give one tablet by mouth once a day for depression m/b feeling of hopelessness as evidenced by diminished interest of selfcare, dated 12/26/2023.
A review of Resident 7's Note to Attending Physician / Prescriber forms dated 1/10/2024, indicated the following:
1.Resident is currently receiving the following antidepressants: trazadone 50 mg and sertraline 50 mg. There is concern of increased side effects with two or more similar agents being used for the same condition.
2. Resident is currently receiving the following antipsychotics: olanzapine 15 mg and risperidone 4 mg. There is concern of increased side effects with two or more similar agents being used for the same condition.
During a concurrent interview and record review on 3/21/2024 at 12:26 p.m., with RN 1, reviewed Resident 7's Note to Attending Physician / Prescriber forms dated 1/10/2024 and physician orders. RN 1 stated the pharmacy reviews the resident's medication monthly and may make a recommendation to the primary care provider. RN 1 stated the resident's primary care provider assesses the resident and responds to the pharmacy recommendations. RN 1 stated she is responsible for reviewing the primary care provider's response to the pharmacy recommendations and clarify any new or changes to orders. RN 1 reviewed and noted the following:
1.Resident 7's Note to Attending Physician / Prescriber forms, dated 1/10/2024, indicated the primary care provider responded agree to the pharmacy recommendations regarding the concern of increased side effects with two or more similar antipsychotics and two or more antidepressants being used for the same conditions.
2. Resident 7's physician's orders indicated active orders for risperidone 4 mg, olanzapine 15 mg, trazadone 50 mg, and sertraline HCL 50 mg.
RN 1 stated when the primary care provider indicated agree it meant they wanted to discontinue one of the duplicate antidepressants and one of the duplicate antipsychotics, but none of the medications were discontinued. RN 1 stated she should have clarified with the primary care provider what medications were to be discontinued, but she did not. RN 1 stated the primary care providers response was not clarified or carried out because the medications are still being administered. RN 1 stated it was important to clarify and follow up for resident safety due to possible overdose (too much of a drug taken or given at one time) with side effects of dry mouth, organ failure, drowsiness, or falls.
During a concurrent interview and record review on 3/21/2024 at 1 p.m., with the DON, reviewed the facility's policies and procedures titled, Medication Regimen Reviews (MRR) and Psychotropic Medication Use, last reviewed 2/28/2024, and Resident 7's Note to Attending Physician / Prescriber forms dated 1/10/2024. The DON stated it was a constant process to try to gradually reduce the dosage of psychotropic medications because there was a high risk for adverse side effects. The DON stated the forms indicated the physician agreed with the pharmacist's recommendations to discontinue one of the duplicate antipsychotics and one of the duplicate antidepressants for Resident 7, but the form did not indicate which medication to discontinue. The DON stated it was the responsibility of the reviewing nurse to clarify with the physician because the form was confusing. The DON stated the response of the physician to the pharmacist's recommendation was not clarified or carried out, but it should have been. The DON stated the facility's policy and procedure was not followed when the physician's response was not carried out and could have potentially resulted in excessive psychotropic medications being administered resulting in adverse side effects like extrapyramidal symptoms, lethargy leading to residents becoming more dependent on staff to perform activities of daily living, and falls resulting in broken bones.
A review of the facility's policy and procedure titled, Medication Regimen Reviews (MRR), last reviewed 2/28/2024, indicated the consultant pharmacist reviews the medication regimen of every resident at least monthly. The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medications. The MRR involves a thorough review of the resident's medical to prevent, identify, report, and resolve medication related problems, medication errors and other irregularities, for example: medications ordered in excessive doses and duplicative therapies. Within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physicians for each resident identified as having a non-life-threatening medication irregularity. The report contains the pharmacist's recommendation. The attending physician documents in the medical record the irregularity has been reviewed and what (if any) action was taken to address it.
A review of the facility's policy and procedure titled, Psychotropic Medication Use, last reviewed 2/28/2024, indicated residents will not receive medications that are not clinically indicated to treat a specific condition. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: anti-psychotics, anti-depressants, anti-anxiety medications, and hypnotics. Residents on psychotropic medications receive GDR (coupled with non-pharmacological interventions), unless clinically contraindicated, in an effort to discontinue these medications.
1.b. A review of Resident 87's Face Sheet indicated the facility admitted the resident on 12/21/2023 with diagnoses that included dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).
A review of Resident 87's MDS dated [DATE], indicated the resident was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated that Resident 87 was independent with walking, eating, and oral hygiene.
During an interview on 3/22/24 at 12:44 p.m., with the Director of Nursing (DON), the DON, the DON stated each resident in the facility should have their medications reviewed monthly by the consultant pharmacist. The DON was unable to provide documented evidence that Resident 87 had an MRR completed for 2/2024.
A review of the facility's policy and procedure titled, Medication Regimen Reviews, last reviewed 2/28/2024, indicated the consultant pharmacist reviews the medication regimen of each resident at least monthly. MRR are done upon admission and at least monthly thereafter, or more frequently if indicated. The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication.
Mar 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Social Security Act by failing to report an allegation of abuse that occurred on 2/27/2024 for two of two sampled residents (Resident 1 and Resident 2) within two hours of being made aware of the allegation to the State Survey Agency (SSA).
This deficient practice had the potential to result in unidentified abuse in the facility and placed residents at risk from further abuse.
Findings:
A review of Resident 1's admission Record dated 1/26/2024, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included, metabolic encephalopathy (brain dysfunctions due to problems with your metabolism), type 2 diabetes (a disease that occurs when your blood glucose [blood sugar] is too high), chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems), epilepsy (a disorder of the brain characterized by repeated seizures [a sudden alteration of behavior due to a change in the electrical functioning of the brain]), and history of malignant neoplasm of large intestine (cancer of the large intestine).
A review of Resident 1's History and Physical Examination, dated 1/30/2024 indicated Resident 1 does not have the capacity to understand and make decisions.
A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 1/31/2024, indicated Resident 1 has severe cognitive impairment (has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS further indicated Resident 1 normally used wheelchair as a mobility (movement) device.
A review of Resident 2's admission Record dated 1/4/2024, indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, COPD, anemia (a condition in which the body does not have enough health red blood cells [RBC - provides oxygen to body tissues]), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment).
A review of Resident 2's History and Physical Examination dated 1/5/2024, indicated resident has fluctuating capacity to understand and make decisions.
A review of Resident 2's MDS, dated [DATE], indicated Resident 2, has severe cognitive impartment. The MDS further indicated Resident 2 required supervision from staff with eating and partial moderate assistance with oral hygiene toileting, shower/bathing, upper body dressing, lower body dressing and putting on taking off footwear.
A review of Resident 1's Situation, Background, Assessment and Recommendation (SBAR - a communication tool that help healthcare professionals share information about the condition of a resident) Form completed by Registered Nurse Supervisor 1 (RNS 1) dated 2/27/2024 indicated at around 9:30 a.m. Activities Staff 1 (AS 1) notified RNS 1 that there was screaming and yelling in Resident 1 and Resident 2's room about the room not being big enough. Resident 2 (Bed A) was near the door and Resident 1 (Bed B) was in bed.
During an interview on 3/12/2024 at 11:11 a.m. with Dietary Supervisor 1 (DS 1), DS 1 stated that on 2/27/2024 at around 9:30 a.m. DS 1 was walking down the hallway and heard Resident 2 yelling bad words in Farsi (the modern Persian language) to Resident 1. DS 1 stated she explained to Resident 2 that he could not use bad words and Resident 2 stated that he had no room to move around because Resident 1's personal belongings were in his way.
During an interview on 3/12/2024 at 1:00 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that on 2/27/2024 he was assigned as a charge nurse and was informed by AS 1 that Resident 1 and Resident 2 were yelling at each other. LVN 1 stated that when there is an abuse allegation, the Administrator (ADM), who is the Abuse Coordinator should be notified immediately. LVN 1 stated that he thought RNS 1 notified the Abuse Coordinator following the incident.
During an interview on 3/13/2024 at 12:58 p.m. with the ADM, the ADM stated that she was informed of the abuse allegation between Resident 1 and Resident 2 on 2/27/2024 at around 3:30 p.m. (six hours after) when she met with Resident 1 and Resident 1's wife because Resident 1 wanted to leave the facility against medical advice (AMA - a resident chooses to leave the facility before the physician recommends discharge). The ADM further stated Resident 1 informed her that Resident 2 tried swinging a chair at him earlier in the day. The ADM stated she was not informed of the verbal exchange between Resident 1 and Resident 2 in the morning of 2/27/2024 at around 9:30 a.m. until she started conducting the investigation. The ADM stated RNS 1 should have notified her as soon as possible of the alleged abuse between Resident 1 and Resident 2 so notifications to the SSA, Long Term Care (LTC) Ombudsman (representatives that serve as an advocate to resident in long term care facilities with issues related to day-to-day care, health, safety and personal preferences), Local Law Enforcement (LLE) can be made, and abuse investigations can be conducted immediately.
A review of the facility Job Description for Nurse Supervisor, dated 3/19/2023, indicated the purpose of the of the job is to supervise the day-to-day clinical activities of the facility to ensure that the highest quality of care is maintained at all times. Such supervisor must be in compliance with all current federal, state, and local laws, rules, regulations, and guidelines .Complies with abuse prevention & reporting policies and procedures.
A review of the facility's policy and procedure (P&P) titled Abuse Prevention and Prohibition undated, indicated the facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation and/or mistreatment, and develops facility policies, procedures, training programs, and systems in order to promote an environment free from abuse and mistreatment. The Administrator as Abuse Prevention Coordinator is responsible for the coordination and implementation of the facility's abuse prevention polices and training.
A review of the facility's P&P titled Abuse Investigation and Reporting dated 2/2023 indicated all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies and thoroughly invested by facility management An alleged violation of abuse will be reported immediately but not later that two hours if the alleged violation involves abuse or has resulted in serious bodily injury.
Nov 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (delibe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) by:
1. Resident 2 for one of five sampled residents (Resident 1), when on 11/1/2023, Resident 2 punched Resident 1 in the stomach.
2. Resident 4 for one of five sampled residents (Resident 3), when on 11/11/2023, Resident 4 punched Resident 3 in the face.
These deficient practices resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility, and Resident 3 being subjected to physical abuse by Resident 4 while under the care of the facility. Resident 3 sustained a bloody nose (bleeding from inside the nostrils caused by the physical impact of being hit on the nose).
Based on the reasonable person concept (hypothetical [suggested], average person's reaction to the actual circumstances) due to Resident 1's severely impaired cognition (ability to think and make decisions) and Resident 3's moderately impaired cognition, an individual subjected to physical abuse has lifetime physical pain and psychological (mental or emotional) effects including feelings of embarrassment and humiliation.
Findings:
1. A review of Resident 1's admission Record, indicated Resident 1 was originally admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out simple tasks).
A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 8/15/2023, indicated Resident 1 had the ability to sometimes make self understood (limited ability to making requests) and had the ability to sometimes understand others (responds adequately to simple, direct communication only).
A review of Resident 1's Situation-Background-Assessment-Recommendation Communication Form (SBAR, a form that provides communication between health care team members about a resident 's condition) dated 11/1/2023, and timed at 11:32 a.m., indicated that on 11/1/2023 at around 10:45 a.m., Certified Nurse Assistant 1 (CNA 1) and Licensed Vocational Nurse 1 (LVN 1) immediately separated Resident 1 and Resident 2, and that Resident 1 had stated that Resident 2 had hit Resident 1 in the stomach.
A review of Resident 2's admission Record, indicated Resident 2 was originally admitted to the facility on [DATE] then readmitted on [DATE] with diagnoses that included schizoaffective disorder, (mental illness that can affect your thoughts, mood and behavior) bipolar type (symptoms of a mental disorder including mania [condition of abnormally heightened and extreme changes in mood or emotions and energy level], depression [mental disorder including persistent sadness or lack of interest], and psychosis [collection of symptoms that affect the mind]) and borderline personality disorder (mental illness that severely impacts a person's ability to manage their emotions)
A review of Resident 2's MDS dated [DATE], indicated Resident 2 had the ability to sometimes make self understood and had the ability to sometimes understand others.
A review of Resident 2's SBAR Communication Form dated 11/1/2023 timed at 10:45 a.m. indicated that on 11/1/2023 at around 10:45 a.m., Resident 2 hit Resident 1 with a closed fist using her right hand in the abdominal (stomach) area. The SBAR further indicated that Resident 2 stated she hit Resident 1 because Resident 1 was standing next to Resident 2.
During an interview on 11/15/2023 at 9:45 a.m. with Resident 1, Resident 1 stated that she was unable to recall the incident between Resident 2 that had occurred on 11/1/2023.
During an interview on 11/15/2023 at 11:50 a.m. with CNA 1, CNA 1 stated that on 11/1/2023 at close to lunch time (approximately 10:45 a.m.), CNA 1 saw Resident 2 sitting in her wheelchair near the nursing station. CNA 1 stated that Resident 1 walked over and stood next to Resident 2. CNA 1 stated she saw Resident 2 appear to be irritated and that Resident 2 suddenly reached out with her right hand in a closed fist and hit Resident 1 in stomach area with the backside of Resident 2's fist. When asked how CNA 1 knew that Resident 2 was irritated, CNA 1 stated that she heard Resident 2 state move, you're too close to me as she hit Resident 1. CNA 1 stated that the incident was not an accident and that Resident 2 looked irritated as she hit Resident 1. CNA 1 stated that she then saw Resident 1 holding her stomach with both hands immediately after being hit by Resident 2.
During an interview on 11/15/2023 at 2:50 p.m. with LVN 1, LVN 1 stated that on 11/1/2023 he was in the nursing station charting (documenting in medical records) when CNA 1 reported that Resident 2 had hit Resident 1. LVN 1 stated that according to Resident 2, Resident 2 hit Resident 1 because Resident 1 was next to Resident 2.
During an interview on 11/15/2023 at 5:55 p.m. with the Administrator (ADM), ADM stated that as the facility's abuse coordinator (person designated to investigate abuse allegations) she investigated the incident that occurred on 11/1/2023 at approximately 10:45 a.m. between Resident 1 and Resident 2. ADM stated that Resident 1 was found to have been hit in the stomach by Resident 2 with a closed fist. When asked if Resident 1 was free from abuse while under the care of the facility, ADM stated no.
2. A review of Resident 3's admission Record, indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included unspecified dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and schizoaffective disorder.
A review of Resident 3's MDS, dated [DATE], indicated Resident 3 had the ability to usually make self understood and ability to usually understand others.
A review of Resident 3's SBAR Communication Form, dated 11/1/2023 timed at 7:15 p.m., indicated on 11/11/2023 at around 7:45 p.m. Resident 3 was found by Certified Nursing Assistant 3 (CNA 3) having a fist fight (a fight in which people hit each other using their tightly closed hands) with Resident 4. The SBAR Communication Form further indicated that as a result of the fist fight, Resident 3 sustained a bloody nose and torn shirt.
A review of Resident 4's admission Record, indicated Resident 4 was originally admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder and anxiety disorder (persistent and excessive worry that interferes with daily activities).
A review of Resident 4's MDS dated [DATE], indicated Resident 4 had the ability to make self understood and ability to understand others.
A review of Resident 4's SBAR Communication Form dated 11/11/2023 timed at 8:49 p.m., indicated that on 11/11/2023 at around 7:15 p.m. Resident 4 was found by CNA 3 having a fist fight with Resident 3. The form indicated that Local Law Enforcement (LLE) were notified to investigate the incident. The form indicated that Resident 4 was then transferred to the General Acute Care Hospital (GACH) on 11/11/2023 at 11:00 p.m. for further evaluation.
During an interview on 11/15/2023 at 10:10 a.m. with Resident 3, Resident 3 stated that he was unable to recall the incident with Resident 4 that had occurred on 11/11/2023.
During an interview on 11/15/2023 at 2:05 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated that on 11/11/2023 at around 7:30 p.m., he saw Resident 3 and Resident 4 hitting each other. CNA 2 stated that he saw the two residents were both seated in their own wheelchairs and were both hitting each other with closed fists. CNA 2 stated that he saw Resident 3 with blood on the resident's face at the time he separated Resident 3 and Resident 4.
During an interview on 11/15/2023 at 2:29 p.m. with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated that on 11/11/2023 around 7:00 p.m., CNA 3 observed Resident 3 and Resident 4 sitting in their own wheelchairs close by each other. CNA 3 stated that Resident 3 and Resident 4 were seen talking to each other at first, then both residents started to scream at one another. CNA 3 stated that as she tried to separate the two residents, Resident 3 and Resident 4 held onto each other's wheelchairs. CNA 3 stated that she then saw Resident 4 hit Resident 3 first in the face. CNA 3 stated she was unable to recall if Resident 3 had hit Resident 4. CNA 3 stated that she saw Resident 3 bleeding from his nose.
During an interview on 11/15/2023 at 3:05 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated that on 11/11/2023, LVN 2 was notified by CNA 3 of a fist fight between Resident 3 and Resident 4. LVN 2 stated that when she went and saw Resident 3, Resident 3 had blood dripping from both nostrils that covered the resident's upper lip. LVN 2 stated that Resident 3 was observed with his shirt ripped apart on the right chest and shoulder area.
During an interview on 11/15/2023 at 5:55 p.m. with the ADM, ADM stated that as the facility's abuse coordinator she investigated the incident between Resident 3 and Resident 4. ADM stated that Resident 3 and Resident 4 were in a physical altercation which resulted in Resident 3 having a bloody nose. When asked if Resident 3 was free from abuse while under the care of the facility, ADM stated no.
A review of the facility's Policies and Procedures titled, Abuse Prevention, undated, indicated the facility does not condone any form of resident abuse. Physical Abuse is defined as hitting, slapping, pinching, and/or kicking. The P&P further indicated that the facility would promote an environment free from abuse and mistreatment.
Oct 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (delibe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of five sampled residents (Resident 1) on 9/23/2023 when Resident 2 hit and scratched Resident 1 on the face.
This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. Resident 1 sustained a skin tear (a wound that happens when the layers of skin separate or peel back) on the left cheek of his face and redness (red discoloration to the skin) on right cheek of his face, left cheek of his face, and left lower jaw. Based on the reasonable person concept (hypothetical [suggested], average person's reaction to the actual circumstances of alleged illegal activities) due to Resident 1's severely impaired cognition (ability to think and make decisions), an individual subjected to physical abuse has lifetime physical pain and psychological (mental or emotional) effects including feelings of embarrassment and humiliation.
Findings:
A review of Resident 1's admission Record, indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of chronic kidney disease (the gradual loss of kidney function).
A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 8/16/2023, indicated Resident 1 had severely impaired cognition and required total assistance from staff with activities of daily living such as bed mobility, transfers, eating, toilet use, personal hygiene, and bathing.
A review of Resident 1's Situation - Background - Assessment - Recommendation (SBAR) Communication Form (a form used to facilitate prompt communication regarding a change in a resident's health condition), dated 9/23/2023 timed at 9:50 a.m., indicated on 9/23/2023 at around 7:25 a.m. Certified Nurse Assistant 1 (CNA 1) found Resident 1 being hit and scratched by Resident 2. The SBAR further indicated that Resident 1 was noted with open skin and active bleeding on the face requiring
pressure to be applied to the open skin to stop the bleeding.
A review of Resident 1's Wound Assessment Report dated 9/23/2023, indicated Resident 1 sustained a skin tear on the left cheek with a length of 1.0 centimeters (cm- a unit of measurement) and a width of 1.0 cm, edges are not well approximated (not a clear cut edge on the skin) with presence of torn skin flaps (skin removed from area of the face), and redness on the left cheek measuring 2.0 cm by 3.0 cm. Further review of the Wound Assessment Report dated 9/23/2023, indicated that upon assessment of Resident 1's right cheek, the resident sustained redness measuring 2.5 cm by 3.5 cm and redness measuring 0.5 cm by 0.2 cm to the left lower jaw.
A review of Resident 1's Physician Order dated 9/23/2023 indicated to apply steri-strips (thin adhesive bandages or strips of tape applied across a cut to keep the edges of the wound together as it heals) on the left cheek until it falls off and to monitor for any signs and symptoms of infection. Further review of Resident 1's Physician Order dated 9/23/2023 indicated to monitor Resident 1's right cheek, left cheek and left lower jaw for discoloration (change in natural skin color) and for adverse reaction such as pain, discomfort, or further skin breakdown daily for 30 days.
A review of Resident 2's admission Record, indicated Resident 2 was originally admitted to the facility on [DATE] then readmitted on [DATE] with diagnoses that included hydrocephalus (a brain disorder with too much fluid built up inside the brain that causes pressure on the brain's tissues), generalized anxiety (feeling of worry, nervousness, or unease) disorder and mood disorder.
A review of Resident 2's MDS dated [DATE], indicated Resident 2 had moderately impaired cognition.
A review of Resident 2's SBAR Communication Form dated 9/23/2023 timed at 8:09 a.m. indicated on 9/23/2023 at around 7:25 a.m. Resident 2 went inside Resident 1's room and started hitting and scratching Resident 1. The SBAR Communication Form further indicated Resident 2 was observed with disruptive behavior (any behavior or conduct that interferes with safe resident care) by hitting, grabbing, scratching, and threatening Resident 1.
A review of Resident 3's admission Record, indicated Resident 3 was originally admitted to the facility on [DATE] then readmitted on [DATE] with a diagnosis of Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements such as shaking).
A review of Resident 3's MDS dated [DATE], indicated Resident 3 had intact cognition.
During an interview on 10/12/2023 at 2:20 p.m. with Resident 3, Resident 3 stated that on 9/23/2023, unable to recall the time, Resident 3 witnessed the physical altercation (a dispute between two residents in which one sustain bodily injury as a result) between Resident 1 and Resident 2. Resident 3 stated that he shares a room with Resident 1. Resident 3 stated he was in his bed when he saw Resident 2 standing on the right side of Resident 1 as Resident 1 was lying in bed. Resident 3 stated that he saw Resident 2 then hit Resident 1 with what appeared to be a rolled-up towel. Resident 3 stated that he then saw Resident 2 with both hands clenched into a fist. Resident 3 stated he witnessed Resident 2 repeatedly hit Resident 1's face. Resident 3 stated that he then saw Resident 1 bleeding from the face. Resident 3 stated it appeared as if Resident 1 was unable to defend himself as he was being attacked by Resident 2.
During an interview on 10/12/2023 at 3:15 p.m. with Resident 2, Resident 2 was unable to recall the incident with Resident 1 on 9/23/2023.
During an interview on 10/12/2023 at 6:30 p.m. with CNA 1, CNA 1 stated that on 9/23/2023 at around 7:25 a.m., CNA 1 heard Resident 3 calling CNA 1's name to his room stating that someone was fighting in the room (referring to Resident 1 and Resident 3's room). CNA 1 stated she ran in to the room to find Resident 2 standing on the right side of Resident 1. CNA 1 stated she saw Resident 2 had his left hand on Resident 1's bed for support while using his (Resident 2) right hand in a closed fist to hit Resident 1 on the face. CNA 1 stated she told Resident 2 to stop and had to hold him back. CNA 1 stated she saw Resident 1 bleeding from the face.
During an interview on 10/13/2023 at 3:05 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated that on 9/23/2023 at around 7:25 a.m., LVN 2 heard CNA 1 screamed from Resident 1's room. LVN 2 stated that she ran over and saw CNA 1 redirecting Resident 2 away from Resident 1's room. LVN 2 stated that Resident 1's left cheek had open skin and was bleeding from the face. LVN 2 stated that after tending to the residents she reported the incident immediately to the Director of Nursing (DON) that Resident 2 was found physically abusing Resident 1. LVN 2 further stated Resident 1 was later transferred to a General Acute Care Hospital 1 (GACH 1) not related to the incident with Resident 2.
During an interview on 10/13/2023 at 5:10 p.m. with the Administrator (ADM), the ADM stated that she is the abuse coordinator (the person that investigates allegations of abuse in the facility). ADM stated she was notified by the DON regarding the incident between Resident 1 and Resident 2 that occurred on 9/23/2023. ADM stated that her investigation of the incident between Resident 1 and Resident 2 was physical abuse, with Resident 1 having sustained physical injuries.
A review of the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting, dated 2/2023, indicated that it is the right of the resident to be free from abuse.
A review of the facility's P&P titled, Abuse Prevention, undated, indicated the facility does not condone any form of resident abuse. Physical Abuse is defined as hitting, slapping, pinching, and/or kicking. The P&P further indicated that the facility would promote an environment free from abuse and mistreatment.
Jul 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to protect resident ' s right to be free from physical abuse (deliber...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to protect resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) by Resident 1 for one of five sampled residents (Resident 2). On 7/10/2023, Resident 1 punched Resident 2 in the face.
This deficient practice had the potential for Resident 2 to experience fear from further abuse and resulted in Resident 2 experiencing mild pain (noticeable discomfort).
Findings:
A review of Resident 1's admission Record indicated the facility admitted the resident on 7/04/2023 with diagnoses that included schizoaffective disorder (a combination of symptoms of schizophrenia [a mental condition in which one sees or hears people or things that do not exist] and a mood disorder, such as depression [feelings of sadness] or bipolar disorder [feelings of depression alternating with episodes of high energy and excitement]) and anxiety (feelings of uneasiness).
A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/10/2023, indicated Resident 1 had intact cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS indicated Resident 1 required one-person limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with bed mobility, dressing, walking, and personal hygiene.
A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR- a tool used by medical professionals to communicate with one another regarding a resident's medical condition) form, dated 7/10/2023, indicated that on 7/10/2023 at approximately 2:30 p.m., Resident 1 punched Resident 2 in the face and the incident was witnessed by Dietary Supervisor (DS). The SBAR indicated Resident 1 ' s physician was notified resulting in Resident 1 being transferred to the General Acute Care Hospital (GACH) by 5150 (the code which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric [relating to mental illness or its treatment] hospitalization when evaluated to be a danger to others, or to himself) for behavioral evaluation.
A review of Resident 1 ' s Nursing Progress Notes, dated 7/11/2023, indicated at approximately 11:25 p.m. on 7/10/2023, Resident 1 was taken to the GACH for behavioral evaluation.
A review of Resident 2's admission Record indicated the facility admitted the resident on 2/22/2023 and re-admitted on [DATE] with schizoaffective disorder.
A review of Resident 2's MDS dated [DATE], indicated Resident 2 had intact cognition with skills required for daily decision making. The MDS indicated Resident 2 required one-person supervision (oversight, encouragement, or cueing) with transfer, walking and eating.
A review of Resident 2 ' s Physician ' s Orders, dated 6/21/2023, indicated an order to administer Acetaminophen (a medication used to relieve mild to moderate pain) 325 milligrams (mg, a unit of measure) two tablets by mouth, every six hours, as needed for mild to moderate pain.
A review of Resident 2 ' s Medication Administration Record (MAR) for July 2023 indicated on 7/10/2023 at 2:35 p.m., Resident 2 received Acetaminophen 325 mg two tablets for pain.
A review of Resident 2's SBAR, dated 7/10/2023, indicated, on 7/10/2023 at approximately 2:30 p.m., Resident 1 punched Resident 2 on his right temple area (on the side of the head behind the eye between the forehead and the ear). The SBAR indicated staff assessed Resident 2 who reported three (3) out of 10 pain (a pain scale of zero to 10, where zero represents no pain and 10 represents the worst pain possible). The form further indicated that Resident 2 was administered a prescribed pain medication as ordered, an ice pack was provided, and the physician ordered an X-ray (an imaging study that takes pictures of bones and soft tissues) of the right temple.
During an interview with DS on 7/19/2023 at 12:52 p.m., DS indicated that she witnessed Resident 1 punch Resident 2 on the right side of his face, near the ear, with a fist. The DS stated this incident was not an accident, and that Resident 1 intended to hit Resident 2.
During an attempted interview with Resident 2 on 7/20/2023 at 12:45 p.m. and again at 2:52 p.m., Resident 2 refused to answer questions.
During an interview with the Director of Nurses (DON) on 7/24/2023 at 2:15 p.m., she stated she was notified that the DS observed Resident 1 hitting Resident 2. The DON stated Resident 1 ' s action was deliberate and intentional. The DON stated Resident 1 hitting Resident 2 was a form of physical abuse. The DON stated residents should not be subject to abuse because it can lead to physical injury and psychological injury such as low self-esteem and distrust of others.
A review of the facility ' s policy and procedure titled, Abuse Prevention Program, reviewed 6/28/2023, indicated the residents have the right to be free from abuse which includes physical abuse. The policy and procedure indicated, as part of resident abuse prevention, the administration will protect the resident from abuse by anyone including facility staff and other residents.
May 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide supervision in order to ensure elopement (to l...
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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 provide supervision in order to ensure elopement (to leave a secured institution without notice or permission) prevention for one of three sampled residents (Resident 1) from a locked facility (when a skilled nursing home has restricted and secured doors to prevent confused residents from exiting the facility).
This deficient practice resulted in Resident 1 eloping from the locked facility on 5/9/2023 at approximately 10:30 a.m., Resident 1 was returned to the facility after staff observed the resident in the street, outside the facility.
Findings:
A review of Resident 1 ' s Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (a mental disorder in which a person experiences symptoms such as hallucinations [hearing, seeing things that are not there] or delusions [a fixed, false belief in something that is not real or does not exist]) and mood disorder symptoms such as depression [feelings of sadness] or mania [extreme high energy or mood]), and dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment).
A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/09/2023 indicated Resident 1 had severely impaired cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS indicated Resident 1 required one-person, limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs) with walking, dressing, and personal hygiene.
A review of Resident 1 ' s General Acute Care Hospital (GACH) dated 3/20/23, indicated Resident 1 has a history of dementia and had previously eloped from their primary residence.
A review of Resident 1 ' s Situation-Background-Assessment-Recommendation Communication Form (SBAR, a form that provides communication between health care team members about a resident ' s condition), dated 5/09/2023, indicated that on 5/09/2023 at 10:30 a.m., Resident 1 had a wandering episode and was safely brought back to the facility.
A review of Resident 1 ' s Social Services Progress Note, dated 5/09/2023, indicated that a staff from the facility saw Resident 1 outside of the facility in the street. The note indicated that staff then re-directed Resident 1 back to the facility.
During an interview with Licensed Vocational Nurse 1 (LVN 1) on 5/10/2023 at 1:45 p.m., LVN 1 stated that on 5/9/2023 at approximately 10:30 a.m., he was notified by the Central Supply Director (CSD) that Resident 1 was seen outside of the facility. LVN 1 stated that the CSD remained with Resident 1 until LVN 1 arrived on site to pick up Resident 1. LVN 1 stated he was not sure how Resident 1 left the facility without staff knowing because the facility is a secured locked unit. LVN 1 stated that if a secured door was opened, an alarm would have made a sound alerting staff that someone had opened the door.
During an interview with the CSD on 5/10/2023 at 3:22 p.m., the CSD stated that on 5/9/2023 he observed Resident 1 outside of the facility in the street as he was driving. The CDS stated he called the facility to notify staff that he saw Resident 1 on the street. The CSD stated that he followed Resident 1 until licensed nurses arrived to bring the resident back to the facility.
During an interview with Licensed Vocational Nurse 1 (LVN 1) on 5/11/2023 at 1:57 p.m., LVN 1 stated that staff did not know Resident 1 was missing on 5/9/2023 until they were notified by phone by the CSD. LVN 1 stated that, he and the facility staff looked for Resident 1 inside the facility but was unable to locate the resident. LVN 1 stated that he then drove to the street to bring Resident 1 back to the facility.
During an interview on 5/11/2023 at 2:50 p.m., the Director of Nursing (DON) stated that Resident 1 should have been supervised more closely by facility staff to prevent elopement. The DON stated Resident 1 should not have been able to leave the facility unsupervised since the facility is a locked facility.
A review of the policy and procedure titled, Nursing - Wandering and Elopement, reviewed 4/26/2023, indicated elopement is considered when a resident who does not have capacity, leaves the facility premises unaccompanied. The policy and procedure indicated that the facility is to identify residents at risk for elopement and to enhance the safety of residents in the facility.
May 2021
11 deficiencies
3 IJ (3 facility-wide)
CRITICAL
(L)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Food Safety
(Tag F0812)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
Based on observation, interview, and record review, the facility failed to maintain the kitchen in a clean, safe and sanitary condition when did not ensure food was stored, prepared and served in acco...
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Based on observation, interview, and record review, the facility failed to maintain the kitchen in a clean, safe and sanitary condition when did not ensure food was stored, prepared and served in accordance with professional standards of food service safety by:
1. Having cockroaches (small insects that carry and spread infectious diseases) in the kitchen and harborage conditions (locations and conditions where pests can live, thrive, reproduce, and feed).
2. Having one of one ice maker machine, located in the kitchen, with buildup matter inside the ice collection bin and throughout the areas in contact with water and ice.
The above deficient practices placed all 75 of 75 residents residing in the facility and who consumed food including iced water, prepared in the kitchen at risk of developing food-borne illness (eating live microorganisms, food containing toxins from bacteria), water-borne illnesses (from drinking contaminated ice and water) and vector-borne diseases (diseases that result from an infection transmitted to human by insects such as cockroaches) that could lead to life-threatening complications and death.
On 5/17/2021 at 12:10 p.m., an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death of a resident or residents) was declared in the presence of the Administrator and Director of Nursing (DON).
On 5/20/2021 at 3:19 p.m., IJ situation was abated (removed) in the presence of the Administrator, DON, and the Administrator Designee, after on-site verification of the implementation of the written Plan of Action (POA, interventions to immediately correct the deficient practice) through observation, interview and record review. The acceptable POA included the following:
a. MS inspected structural problems to repair and clean.
b. Pest control service was provided immediately
c. DS procured food and water from sister facility, while the kitchen was closed for pest elimination.
d. All non-sealed food items were disposed of immediately.
e. The ice machine and ice storage containers including hard to reach areas was drained, sanitized, and deep cleaned (disassembling the ice machine and bin, removing mineral deposits from areas or surfaces that are in direct contact with water, cleaning the exterior panels and around the ice machine) per manufacturers instruction.
f. All residents were assessed by licensed nurses for any potential signs and symptoms of food-borne illness each shift for 72 hours.
g. Staff were provided with training in kitchen sanitation and infection control.
Cross Reference F880 and F925
Findings:
1. On 5/17/2021 at 8:30 a.m., during a kitchen observation with the Dietary Supervisor (DS), there was one cockroach on the floor. The DS stated cockroaches showed up occasionally, one at a time. One more cockroach was on the floor and then three more were between the dishwasher counter and a wall. There were five live German cockroaches (a small species of cockroach that can access food items and carry serious diseases) and fecal (bowel movement) spotting in the dishwashing area between the counter and the wall.
On 5/17/2021 at 8:58 a.m., during an observation with DS, there were 30 live nymph (baby) cockroaches behind the stove. There were structural cracks and crevices in the walls, around plumbing, and peeling paint on the walls and ceilings.
On 5/17/2021 at 10:15 a.m., during an interview with Maintenance Supervisor (MS) and a concurrent review of the most recent pest control company Service Inspection Report dated 4/17/2021, the report indicated no pest was found in the kitchen, dishwashing areas, cookline and dry storage area. The Conditions/Observations section indicated there were cracks and holes along the walls and floorboard and loose wall coverings at the dishwashing area. The Actions section indicated to seal any cracks and holes and repair loose was coverings. The General Comments/Instructions indicated follow-up with possible treatment scheduled on 4/19/2021. There was no report for 4/19/2021. MS stated the pest control technician came monthly and on 4/17/2021, the technician recommended to come on 4/19/2021 but it did not happen. MS stated he did not know why the second visit did not take place.
The State Agency (The Department) notified the Los Angeles County Department of Environmental Health (LAC DEH, the agency that approves operation of kitchens [licensing] and conduct periodic kitchen inspections [restaurants, health facilities, any public venue that serves food]) of the facility's kitchen condition.
The Environmental Health Specialist (EHS - inspector) report titled, Official Inspection Report, dated 5/17/2021, and timed at 3:30 p.m., indicated the EHS observed live cockroaches under the ware wash machine drain boards and in the wall that is soaked with water from the ware wash machine (dish washing area). EHS also observed over 10 live baby cockroaches on the floor coming from behind the wet wall at the ware wash machine area and one live medium cockroach running on the wall behind the three-compartment sink near the hanging pots and pans. The EHS closed the facility's kitchen on 5/17/2021 at 4:00 p.m. The EHS report also indicated that cockroaches also spread different forms of gastroenteritis [food poisoning, diarrhea, and other illnesses], plus they carry a number of allergens which may cause people to exhibit skin rashes, watery eyes, sneezing, congestion of nasal passages, and asthma (a respiratory condition in which a person's airways become inflamed which makes it difficult to breathe).
A review of the EHS's report titled, Retail Food Service Inspection Report, indicated inspection date of 5/17/2021 indicated EHS observed a total of 29 live adult and nymph German cockroaches. EHS also observed six ootheca casings (egg sacs of cockroaches).
On 5/18/2021 at 9:05 a.m., during an observation of the structural condition of the kitchen and concurrent interviews with DS and Registered Dietitian (RD) Consultant, DS stated cracks and crevices in dishwashing and stove areas were repaired.
On 5/18/2021 at 9:33 a.m., Kitchen Staff 1 (KS 1) stated she had observed a cockroach or two recently (did not recall dates) and would kill them and had reported to DS.
On 5/19/2021 at 12:04 p.m., during a kitchen observation with DS present, there was one medium live cockroach behind the stove and one dead juvenile (young) cockroach in front of stove. DS confirmed seen the two cockroaches.
A review of article from the Los Angeles County Department of Public Health (LAC DPH) titled, Effective Management of Cockroach Infestation, retrieved on 5/25/2021, indicated the cockroaches may become pests in any structure that has food preparation or storage areas. They contaminate food and eating utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high enough numbers. When cockroaches that live outdoors come into contact with human excrement in sewers or with pet droppings, they have the potential to transmit bacteria that cause food poisoning if they enter into structures.
A review of the Centers for Disease Control and Prevention (CDC), Guidelines for Environmental Infection Control in Health Care Facilities, updated on 7/23/2019, indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. Pest Control included cockroaches found in health-care facilities that can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector (carrier that transfers an infectious organism from one host to another).
A review of the facility's policy and procedure titled, Pest Control, revised on 05/2008, indicated the facility maintains an ongoing pest control program to ensure the building is kept free of insects and rodents. The Maintenance services assist in providing pest control services.
A review of facility's contract with the Pest Management Company, dated 1/6/2016, indicated ongoing service for pest night service for kitchen. In the terms and conditions section, the agreement indicated that moisture conditions in and around structures can be conducive to a variety of pests and wood destroying insects.
A review of the facility's undated policy and procedure titled, Sanitation Audit, indicated the RD and/or DS will conduct audit a minimum of once per month or more often if deemed necessary. A form would be competed as specific as possible with comments then review findings with staff and administrator as appropriate. Develop a plan of correction for any problems and follow up within one to two weeks.
2. On 5/17/2021 at 8:43 a.m., during an observation of the ice machine and concurrent interview with DS, there was dark substance underneath the running water and the collection bin had buildup matter of light-yellow color. Upon interview, DS stated maintenance staff cleaned the ice machine monthly. DS stated kitchen staff did not have the manufacturer's guidelines for cleaning and disinfecting the ice machine and they did not open the upper compartment to clean the inner components or the lower bin. DS stated the ice machine was used to provide ice to the residents in the water pitcher at bedside and iced water or drinks with or between meals. DS was not sure who was responsible to ensure the ice machine was in sanitary condition to prevent contamination of the ice and subsequent risk for the resident to develop water-borne illness.
On 5/17/2021 at 10:15 a.m., during an interview, Maintenance Supervisor (MS) stated the contracted pest control technician came monthly and last month the technician recommended to come twice a month to treat the cockroach infestation, but this was not implemented. MS also stated he cleaned the ice machine once a month with the last cleaning on 4/22/2021. MS stated he saw a video from the manufacturer on how to clean the ice machine and the process included emptying all the ice from the machine, using a cleaning product, then a disinfectant to run through in the machine's cleaning load, and remove the front panel to put it in the dishwasher. MS stated he did not follow the manufacturer's cleaning and sanitizing recommendations.
On 5/17/2021 at 2:56 p.m., during an observation and concurrent interview, MS opened the ice machine upper compartment and removed the stainless-steel cover. There was thick and dark substance buildup on the inner cover (water curtain), lower and upper plastic where ice was produced, and on the water trough. There was black, brown, and pink residue buildup, heavy black substance buildup inside the crevices of the lower section towards the back. MS stated he had never gone that far back into the machine because he could not reach that far and did not know it had to be done. MS stated monthly cleaning was not enough and he could not be sure if it was 100% clean after running the machine with cleaner and sanitizer because he could not see the back section. MS stated he thought it was normal to have buildup and did not know there were professional cleaning services for ice machines. MS stated he had not followed the manufacturer's recommendations for cleaning and disinfecting.
On 5/18/2021 at 9:18 a.m., a concurrent interview with RD consultant and a review of a kitchen report dated 9/8/2020 and 4/2/2021 indicated the ice machine was clean. The RD consultant stated the report did not specify an inspection of the ice machine internal components was conducted to ensure cleanliness. The RD Monthly Kitchen Rounds Checklist forms dated 2/17/2021, 3/10/2021, and 4/23/2021, were reviewed with RD consultant.
RD consultant verified the checklist form did not include an inspection of the ice machine condition. RD consultant stated she was responsible to ensure staff followed the ice machine manufacturer's cleaning and sanitizing guidelines to prevent ice contamination.
A review of the ice machine manufacturer's manual titled Maintenance, indicated cleaning and sanitizing of ice machine procedure must be performed a minimum of once every six months . machine and bin must be disassembled, cleaned, and sanitized. The procedure states to clean all components in the water flow path. All ice produced must be discarded and mineral deposits should be removed from areas or surfaces that are in direct contact with water. Removing the ice machine top cover may allow easier access. Use a soft bristle nylon brush, sponge, or cloth to carefully clean the parts, soak for 5 minutes, then rinse with clean water. While components soaking, use nylon brush or cloth to thoroughly clean the following ice machine areas including side walls, base (area above water trough), evaporator plastic parts(top, bottom, and sides), bin or dispenser and rinse all thoroughly with clean water. Spray a mix of sanitizer and water on all the components and areas without rinsing after. After waiting 20 minutes, the ice machine could be used again.
CRITICAL
(L)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Infection Control
(Tag F0880)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
4. On 5/20/2021 at 1:15 p.m., Resident 479 was observed wearing a protective apron and smoking in the smoking patio, in the designated Yellow Zone (area reserved for newly admitted resident and reside...
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4. On 5/20/2021 at 1:15 p.m., Resident 479 was observed wearing a protective apron and smoking in the smoking patio, in the designated Yellow Zone (area reserved for newly admitted resident and residents who have been exposed to or have symptoms of COVID-19). Activity Assistant 1 (AA 1) was supervising Resident 479. When Resident 479 finished smoking, AA 1 hung the apron on a wall within the patio without disinfected it.
On 5/20/2021 at 1:21 p.m., during an interview, AA 1 stated the smoking apron are not sanitized before and after each use but in the morning, in the afternoon between 2-3 p.m., and at the end of the day. AA 1 stated each resident had their own apron with their names written on the apron ties. Upon observation, the aprons did not have names written on the ties. AA 1 explained that the names could not be read due to being washed in laundry.
On 5/20/2021 at 3:56 p.m., during an interview, Licensed Vocational Nurse 4 (LVN 4) stated the smoking aprons were sanitized before and after each use since the aprons are not dedicated but shared among all Yellow Zone residents.
On 5/21/2021 at 10:38 a.m., during an interview, DON stated smoking aprons are shared among Yellow Zone residents and should be sanitized with a disinfectant between each use. DON further stated there was potential risk of spread of infection if the aprons were not disinfected.
On 5/21/2021 at 12:38 p.m., during an interview, DON clarified that aprons are dedicated for each smoking resident instead of being shared and the resident's name should be on a label and stapled on the ties of the apron. Upon closer observation of four aprons in the Yellow Zone smoking patio, DON confirmed there were no names written anywhere on all four aprons. Three of the gowns were observed hung together and touching each other.
A review of the facility's policy and procedures titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 10/2018, indicated, reusable items are cleaned and disinfected or sterilized between residents.
Based on observation, interview, and record review, the facility failed to ensure an effective infection prevention and control program, led by the Infection Preventionist [IP] Nurse, to provide a safe and sanitary environment by:
1. Having cockroaches (small insects that carry and spread infectious diseases) in the kitchen and harborage conditions (locations and conditions where pests can live, thrive, reproduce, and feed).
2. Having one of one ice maker machine, located in the kitchen, with buildup matter inside the ice collection bin and throughout the areas in contact with water and ice.
The above deficient practices placed all 75 of 75 residents residing in the facility and who consumed food including iced water, prepared in the kitchen at risk of developing food-borne illness (eating live microorganisms, food containing toxins from bacteria), water-borne illnesses (from drinking contaminated ice and water) and vector-borne diseases (diseases that result from an infection transmitted to human by insects such as cockroaches) that could lead to life-threatening complications and death.
On 5/17/2021 at 12:10 p.m., an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death of a resident or residents) was declare in the presence of the facility's Administrator and Director of Nursing (DON) of the findings.
On 5/20/2021 at 3:19 p.m., the SA removed the IJ in the presence of the Administrator, DON, and the Administrator Designee after on-site verification of the implementation of the written Plan of Action (POA, interventions to immediately correct the deficient practice) through observation, interview and record review. The acceptable POA included the following:
a. MS inspected structural problems to repair and clean.
b. Pest control service was provided immediately
c. DS procured food and water from sister facility, while the kitchen was closed for pest elimination.
d. All non-sealed food items were disposed of immediately.
e. The ice machine and ice storage containers including hard to reach areas was drained, sanitized, and deep cleaned (disassembling the ice machine and bin, removing mineral deposits from areas or surfaces that are in direct contact with water, cleaning the exterior panels and around the ice machine) per manufacturers instruction.
f. All residents were assessed by licensed nurses for any potential signs and symptoms of food-borne illness each shift for 72 hours.
g. Staff were provided with training in kitchen sanitation and infection control.
In addition, the facility failed to ensure infection control prevention practices were implemented by:
3. One Certified Nursing Assistant (CNA 6) out of 117 staff and visitors listed on 5/19/2021, not completing the screening questionnaire for signs and symptoms of Coronavirus Disease 2019 (COVID-19, a highly contagious infection transmitted from person to person and affects the respiratory track) before starting the shift. If CNA 6 was symptomatic (with possible COVID-19 infection), residents and staff were at risk of getting infected.
4. Allowing the share use of four smoking aprons that were to be used by designated residents with potential COVID-19 infection, and not disinfecting the aprons between use, which could result on transmission of COVID-19 infection.
5. Not re-directing Resident 2, who was confused and incontinent (unable to control urination and bowel movement), to prevent her from laying down on Resident 77's bed. If Resident 2 had an episode of incontinence, it was likely to she would soil Resident 77's bed placing the resident at risk of cross contamination.
Cross Reference F812 and F925
Findings:
1. On 5/17/2021 at 8:30 a.m., during a kitchen observation with the Dietary Supervisor (DS), there was one cockroach on the floor. The DS stated cockroaches showed up occasionally, one at a time. One more cockroach was on the floor and then three more were between the dishwasher counter and a wall. There were five live German cockroaches (a small species of cockroach that can access food items and carry serious diseases) and fecal (bowel movement) spotting in the dishwashing area between the counter and the wall.
On 5/17/2021 at 8:58 a.m., during an observation with DS, there were 30 live nymph (baby) cockroaches behind the stove. There were structural cracks and crevices in the walls, around plumbing, and peeling paint on the walls and ceilings.
On 5/17/2021 at 10:15 a.m., during an interview with Maintenance Supervisor (MS) and a concurrent review of the most recent pest control company Service Inspection Report dated 4/17/2021, the report indicated no pest was found in the kitchen, dishwashing areas, cookline and dry storage area. The Conditions/Observations section indicated there were cracks and holes along the walls and floorboard and loose wall coverings at the dishwashing area. The Actions section indicated to seal any cracks and holes and repair loose was coverings. The General Comments/Instructions indicated follow-up with possible treatment scheduled on 4/19/2021. There was no report for 4/19/2021. MS stated the pest control technician came monthly and on 4/17/2021, the technician recommended to come on 4/19/2021 but it did not happen. MS stated he did not know why the second visit did not take place.
The State Agency (The Department) notified the Los Angeles County Department of Environmental Health (LAC DEH, the agency that approves operation of kitchens [licensing] and conduct periodic kitchen inspections [restaurants, health facilities, any public venue that serves food]) of the facility's kitchen condition.
The Environmental Health Specialist (EHS - inspector) report titled, Official Inspection Report, dated 5/17/2021, and timed at 3:30 p.m., indicated the EHS observed live cockroaches under the ware wash machine drain boards and in the wall that is soaked with water from the ware wash machine (dish washing area). EHS also observed over 10 live baby cockroaches on the floor coming from behind the wet wall at the ware wash machine area and one live medium cockroach running on the wall behind the three-compartment sink near the hanging pots and pans. The EHS closed the facility's kitchen on 5/17/2021 at 4:00 p.m. The EHS report also indicated that cockroaches also spread different forms of gastroenteritis [food poisoning, diarrhea, and other illnesses], plus they carry a number of allergens which may cause people to exhibit skin rashes, watery eyes, sneezing, congestion of nasal passages, and asthma (a respiratory condition in which a person's airways become inflamed which makes it difficult to breathe).
A review of the EHS's report titled, Retail Food Service Inspection Report, indicated inspection date of 5/17/2021 indicated EHS observed a total of 29 live adult and nymph German cockroaches. EHS also observed six ootheca casings (egg sacs of cockroaches).
On 5/18/2021 at 9:05 a.m., during an observation of the structural condition of the kitchen and concurrent interviews with DS and Registered Dietitian (RD) Consultant, DS stated cracks and crevices in dishwashing and stove areas were repaired.
On 5/18/2021 at 9:33 a.m., Kitchen Staff 1 (KS 1) stated she had observed a cockroach or two recently (did not recall dates) and would kill them and had reported to DS.
On 5/19/2021 at 12:04 p.m., during a kitchen observation with DS present, there was one medium live cockroach behind the stove and one dead juvenile (young) cockroach in front of stove. DS confirmed seen the two cockroaches.
A review of article from the Los Angeles County Department of Public Health (LAC DPH) titled, Effective Management of Cockroach Infestation, retrieved on 5/25/2021, indicated the cockroaches may become pests in any structure that has food preparation or storage areas. They contaminate food and eating utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high enough numbers. When cockroaches that live outdoors come into contact with human excrement in sewers or with pet droppings, they have the potential to transmit bacteria that cause food poisoning if they enter into structures.
A review of the Centers for Disease Control and Prevention (CDC), Guidelines for Environmental Infection Control in Health Care Facilities, updated on 7/23/2019, indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. Pest Control included cockroaches found in health-care facilities that can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector (carrier that transfers an infectious organism from one host to another).
A review of the facility's policy and procedure titled, Pest Control, revised on 05/2008, indicated the facility maintains an ongoing pest control program to ensure the building is kept free of insects and rodents. The Maintenance services assist in providing pest control services.
A review of facility's contract with the Pest Management Company, dated 1/6/2016, indicated ongoing service for pest night service for kitchen. In the terms and conditions section, the agreement indicated that moisture conditions in and around structures can be conducive to a variety of pests and wood destroying insects.
A review of the facility's undated policy and procedure titled, Sanitation Audit, indicated the RD and/or DS will conduct audit a minimum of once per month or more often if deemed necessary. A form would be competed as specific as possible with comments then review findings with staff and administrator as appropriate. Develop a plan of correction for any problems and follow up within one to two weeks.
2. On 5/17/2021 at 8:43 a.m., during an observation of the ice machine and concurrent interview with DS, there was dark substance underneath the running water and the collection bin had buildup matter of light-yellow color. Upon interview, DS stated maintenance staff cleaned the ice machine monthly. DS stated kitchen staff did not have the manufacturer's guidelines for cleaning and disinfecting the ice machine and they did not open the upper compartment to clean the inner components or the lower bin. DS stated the ice machine was used to provide ice to the residents in the water pitcher at bedside and iced water or drinks with or between meals. DS was not sure who was responsible to ensure the ice machine was in sanitary condition to prevent contamination of the ice and subsequent risk for the resident to develop water-borne illness.
On 5/17/2021 at 10:15 a.m., during an interview, Maintenance Supervisor (MS) stated the contracted pest control technician came monthly and last month the technician recommended to come twice a month to treat the cockroach infestation, but this was not implemented. MS also stated he cleaned the ice machine once a month with the last cleaning on 4/22/2021. MS stated he saw a video from the manufacturer on how to clean the ice machine and the process included emptying all the ice from the machine, using a cleaning product, then a disinfectant to run through in the machine's cleaning load, and remove the front panel to put it in the dishwasher. MS stated he did not follow the manufacturer's cleaning and sanitizing recommendations.
On 5/17/2021 at 2:56 p.m., during an observation and concurrent interview, MS opened the ice machine upper compartment and removed the stainless-steel cover. There was thick and dark substance buildup on the inner cover (water curtain), lower and upper plastic where ice was produced, and on the water trough. There was black, brown, and pink residue buildup, heavy black substance buildup inside the crevices of the lower section towards the back. MS stated he had never gone that far back into the machine because he could not reach that far and did not know it had to be done. MS stated monthly cleaning was not enough and he could not be sure if it was 100% clean after running the machine with cleaner and sanitizer because he could not see the back section. MS stated he thought it was normal to have buildup and did not know there were professional cleaning services for ice machines. MS stated he had not followed the manufacturer's recommendations for cleaning and disinfecting.
On 5/18/2021 at 9:18 a.m., a concurrent interview with RD consultant and a review of a kitchen report dated 9/8/2020 and 4/2/2021 indicated the ice machine was clean. The RD consultant stated the report did not specify an inspection of the ice machine internal components was conducted to ensure cleanliness. The RD Monthly Kitchen Rounds Checklist forms dated 2/17/2021, 3/10/2021, and 4/23/2021, were reviewed with RD consultant. RD consultant verified the checklist form did not include an inspection of the ice machine condition. RD consultant stated she was responsible to ensure staff followed the ice machine manufacturer's cleaning and sanitizing guidelines to prevent ice contamination.
A review of the ice machine manufacturer's manual titled Maintenance, indicated cleaning and sanitizing of ice machine procedure must be performed a minimum of once every six months . machine and bin must be disassembled, cleaned, and sanitized. The procedure states to clean all components in the water flow path. All ice produced must be discarded and mineral deposits should be removed from areas or surfaces that are in direct contact with water. Removing the ice machine top cover may allow easier access. Use a soft bristle nylon brush, sponge, or cloth to carefully clean the parts, soak for 5 minutes, then rinse with clean water. While components soaking, use nylon brush or cloth to thoroughly clean the following ice machine areas including side walls, base (area above water trough), evaporator plastic parts(top, bottom, and sides), bin or dispenser and rinse all thoroughly with clean water. Spray a mix of sanitizer and water on all the components and areas without rinsing after. After waiting 20 minutes, the ice machine could be used again.
5. During an observation on 5/18/2021, at 12:35 p.m., Resident 2 was wandering through the hallway while Resident 77 was sitting in a wheelchair outside her room. Resident 2 was observed entering Resident 77's room and laid down on Resident 77's bed for 10 minutes. At 12:45 p.m., LVN 1 redirected the resident back to her room.
During an interview on 5/18/2021, at 12:51 p.m., CNA 1 stated Resident 2 was incontinent (inability to control urination or bowel movement) and could soil other resident's bed. CNA 1 stated Resident 2 should have been redirected to her room upon entering Resident 77's room or use 'STOP' sign barrier across the door as a reminder.
During an interview on 5/18/2021 at 12:57 p.m., LVN 1 verified Resident 2 was laying on Resident 77's bed and stated it should have not occurred. LVN 1 stated it was important to prevent cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another).
A review of the facility's policy and procedures titled, Policies and Practices- Infection Control, revised on 7/2014, indicated, the policy was intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. The objectives were to prevent, detect, investigate, and control infection in the facility and maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public.
A review of the facility's policy and procedure titled, Wandering (moving aimlessly from place to place) and Elopements (leaving the facility without staff noticing and without permission due to safety needs), revised in 3/2019, indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintain the least restrictive environment for residents.
3. On 5/21/2021, at 9:38 a.m. during an interview with the IP Nurse and concurrent review of the Staff/Visitor Screening Log, IP Nurse stated on 5/19/2021, Certified Nursing Assistant 6 (CNA 6) did not completely fill out the screening questionnaire (left blank responses regarding the presence of COVID-19 symptoms). IP Nurse explained that prior to the employees' shift they get their temperature checked and indicate on the screening log if they have any signs and symptoms of COVID-19. IP Nurse stated the form should have been filled out entirely because the purpose is to determine if a staff member has any signs and symptoms prior to starting their work assignment.
On 5/21/2021, at 9:47 a.m. during an interview, DON stated the importance of screening staff prior to the start of their shift is to protect the residents because they were vulnerable.
A review of the facility's policy and procedure titled, Policy for Emergent Infectious Diseases for Skilled Nursing Care Centers, revised 3/17/2021, indicated the following:
-Screen all visitors and staff who enter facility:
-Must sign entrance with date and time
-Must take temporal reading for temperature
-Free of shortness of breath
-Free of persistent cough
-Free of diarrhea, nausea, & vomiting
-Free of fever, sore throat, chills or other respiratory symptoms
-Free of loss of taste and smell
-Free of headache or confusion
-Free of muscle pain or joint pain
-International travel within the last 14 days to restricted countries
-Contact with someone who is confirmed or under investigation for COVID-19
A review of the County of Los Angeles Public Health Guidelines for Preventing and Managing COVID-19 in Skilled Nursing Facilities, updated 4/11/2021, indicated, All persons, regardless of vaccination status, should be screened for signs and symptoms of COVID-19 infection, including a temperature check. Additionally, all persons who are not fully vaccinated should be screen for any recent travel in the past 14 days. Persons requiring symptoms and travel screening includes facility staff, essential visitors, and general visitors. Symptoms include but are not limited to the following: fever, chills, cough, shortness of breath, new loss of taste or smell, muscle or body aches, headache, sore throat, congestion or runny nose, nausea or vomiting, diarrhea, or not feeling well. All staff should be checked for symptoms and fever at least once per shift, including at the beginning of shifts.
CRITICAL
(L)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0925
(Tag F0925)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
Based on observation, interview, and record review, the facility failed to conduct an ongoing monitoring of the kitchen environment and effectiveness of the pest control service to prevent and eradica...
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Based on observation, interview, and record review, the facility failed to conduct an ongoing monitoring of the kitchen environment and effectiveness of the pest control service to prevent and eradicate (destroy/kill) cockroach infestation (presence of an unusually large number of cockroaches [small insects that carry and spread infectious diseases]) and eliminate harborage conditions in the kitchen for 75 of 75 residents residing in the facility and who ate food prepared in the kitchen. The kitchen had live cockroaches on the floor, between the dishwasher counter and a wall, in the dishwashing area between the counter and the wall, and live nymph (baby) cockroaches behind the stove. The kitchen had structural cracks and crevices (narrow opening) in the walls, around the plumbing, peeling paint on walls and ceilings, holes and gaps in the walls under the dishwashing machine, cockroach fecal matter in the dishwashing area between the counter and the wall which provided both food and places for harborage of pests and the warm kitchen conditions necessary to encourage the cockroaches to thrive.
These deficient practices placed the total of 75 residents at risk of food-borne illness (eating live microorganisms, food containing toxins from bacteria) and vector-borne diseases (diseases that result from an infection transmitted to human by insects such as cockroaches) that could lead to life-threatening complications and death.
On 5/17/2021 at 12:10 p.m., an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death of a resident or residents) was declared in the presence of the Administrator and Director of Nursing (DON).
On 5/20/2021 at 3:19 p.m., IJ situation was abated (removed) in the presence of the Administrator, DON, and the Administrator Designee, after on-site verification of the implementation of the written Plan of Action (POA, interventions to immediately correct the deficient practice) through observation, interview and record review. The acceptable POA included the following:
a. MS inspected structural problems to repair and clean.
b. Pest control service was provided immediately
c. DS procured food and water from sister facility, while the kitchen was closed for pest elimination.
d. All non-sealed food items were disposed of immediately.
e. All residents were assessed by licensed nurses for any potential signs and symptoms of food-borne illness each shift for 72 hours.
f. Staff were provided with training in kitchen sanitation and infection control.
Cross Reference F880 and F812
Findings:
On 5/17/2021 at 8:30 a.m., during a kitchen observation with the Dietary Supervisor (DS), there was one cockroach on the floor. The DS stated cockroaches showed up occasionally, one at a time. One more cockroach was on the floor and then three more were between the dishwasher counter and a wall. There were five live German cockroaches (a small species of cockroach that can access food items and carry serious diseases) and fecal (bowel movement) spotting in the dishwashing area between the counter and the wall.
On 5/17/2021 at 8:58 a.m., during an observation with DS, there were 30 live nymph (baby) cockroaches behind the stove. There were structural cracks and crevices in the walls, around plumbing, and peeling paint on the walls and ceilings.
On 5/17/2021 at 10:15 a.m., during an interview with Maintenance Supervisor (MS) and a concurrent review of the most recent pest control company Service Inspection Report dated 4/17/2021, the report indicated no pest was found in the kitchen, dishwashing areas, cookline and dry storage area. The Conditions/Observations section indicated there were cracks and holes along the walls and floorboard and loose wall coverings at the dishwashing area. The Actions section indicated to seal any cracks and holes and repair loose was coverings. The General Comments/Instructions indicated follow-up with possible treatment scheduled on 4/19/2021. There was no report for 4/19/2021. MS stated the pest control technician came monthly and on 4/17/2021, the technician recommended to come on 4/19/2021 but it did not happen. MS stated he did not know why the second visit did not take place.
The State Agency (The Department) notified the Los Angeles County Department of Environmental Health (LAC DEH, the agency that approves operation of kitchens [licensing] and conduct periodic kitchen inspections [restaurants, health facilities, any public venue that serves food]) of the facility's kitchen condition.
The Environmental Health Specialist (EHS - inspector) report titled, Official Inspection Report, dated 5/17/2021, and timed at 3:30 p.m., indicated the EHS observed live cockroaches under the ware wash machine drain boards and in the wall that is soaked with water from the ware wash machine (dish washing area). EHS also observed over 10 live baby cockroaches on the floor coming from behind the wet wall at the ware wash machine area and one live medium cockroach running on the wall behind the three-compartment sink near the hanging pots and pans. The EHS closed the facility's kitchen on 5/17/2021 at 4:00 p.m. The EHS report also indicated that cockroaches also spread different forms of gastroenteritis [food poisoning, diarrhea, and other illnesses], plus they carry a number of allergens which may cause people to exhibit skin rashes, watery eyes, sneezing, congestion of nasal passages, and asthma (a respiratory condition in which a person's airways become inflamed which makes it difficult to breathe).
A review of the EHS's report titled, Retail Food Service Inspection Report, indicated inspection date of 5/17/2021 indicated EHS observed a total of 29 live adult and nymph German cockroaches. EHS also observed six ootheca casings (egg sacs of cockroaches).
On 5/18/2021 at 9:05 a.m., during an observation of the structural condition of the kitchen and concurrent interviews with DS and Registered Dietitian (RD) Consultant, DS stated cracks and crevices in dishwashing and stove areas were repaired.
On 5/19/2021 at 12:04 p.m., during a kitchen observation with DS present, there was one medium live cockroach behind the stove and one dead juvenile (young) cockroach in front of stove. DS confirmed seen the two cockroaches.
A review of article from the Los Angeles County Department of Public Health (LAC DPH) titled, Effective Management of Cockroach Infestation, retrieved on 5/25/2021, indicated the cockroaches may become pests in any structure that has food preparation or storage areas. They contaminate food and eating utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high enough numbers. When cockroaches that live outdoors come into contact with human excrement in sewers or with pet droppings, they have the potential to transmit bacteria that cause food poisoning if they enter into structures.
A review of the Centers for Disease Control and Prevention (CDC), Guidelines for Environmental Infection Control in Health Care Facilities, updated on 7/23/2019, indicated cockroaches found in health-care facilities can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector (carrier that transfers an infectious organism from one host to another).
A review of the facility's policy and procedure titled, Pest Control, revised on 05/2008, indicated the facility maintains an ongoing pest control program to ensure the building is kept free of insects and rodents. The Maintenance services assist in providing pest control services.
A review of facility's contract with the Pest Management Company, dated 1/6/2016, indicated ongoing service for pest night service for kitchen. In the terms and conditions section, the agreement indicated that moisture conditions in and around structures can be conducive to a variety of pests and wood destroying insects.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure residents' rights were honored as evidenced by:
1. Failure to obtain informed consent (permission granted by a resident or resident ...
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Based on interview and record review, the facility failed to ensure residents' rights were honored as evidenced by:
1. Failure to obtain informed consent (permission granted by a resident or resident representative to proceed with treatment after the physician had fully explained the benefits and possible risks or consequences) prior to increasing the frequency of Seroquel (medication that changes brain function and results in alterations in perception, mood, consciousness or behavior) was given for one out of one resident (Resident 74) reviewed for informed consent.
2. Failure to develop and implement residents' rights policies and procedures, in accordance to state laws and regulations, related to psychotherapeutic (used to treat psychosis, which refers to a group of mental disorders such as depression, schizophrenia, and manic-depressive disorders, that affect mood and behavior) informed consent, for one of two sampled residents (Resident 17).
These deficient practices violated the residents' rights to make an informed decision regarding the use of medications.
Findings:
A review of Resident 74's Face Sheet (admission record) indicated the facility admitted the resident on 12/23/2020, with diagnoses including dementia (group of symptoms affecting memory, language, problem-solving, and other thinking abilities) and schizophrenia (chronic and severe mental disorder that affects how a person thinks, feels, and behaves).
A review of Resident 74's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 4/16/2021, indicated the resident had the ability to make self understood and the ability to understand others.
A review of Resident 74's physician's orders, indicated a discontinued order to administer Seroquel 100 milligrams (mg) 1 tablet by mouth twice a day for schizophrenia manifested by angry outburst without provocation, ordered on 12/23/2020.
A review of Resident 74's physician's orders, indicated an order to administer Seroquel 100 mg 1 tab by mouth three times a day for schizophrenia manifested by angry outburst without provocation with fabrication of stories as evidenced by verbalizing other resident trying to hit her, ordered on 5/17/2021.
During a concurrent interview and record review on 5/19/2021, at 2:33 p.m., with the Assistant Director of Nursing (ADON), the ADON reviewed Resident 74's chart and confirmed there was no informed consent for Seroquel 100 mg by mouth three times a day ordered on 5/17/2021. The ADON stated they have a consent for Seroquel 100mg by mouth two times a day, however was unable to provide documented evidence that a new consent was completed for the increase in frequency of the medication.
During a concurrent interview and record review, on 5/19/2021 at 2:38 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 reviewed Resident 74's chart and verified that the informed consent was not in the chart. LVN 1 stated the licensed nurses are required to obtain informed consent prior to carrying out an order from physician for any antipsychotic medication (medication used to manage abnormal condition of the mind described as involving a loss of contact with reality). LVN 1 stated that a consent will be obtained for the recent order for Seroquel placed on 5/17/2021.
During an interview, on 5/21/2021 at 11:41 a.m., with the Director of Nursing (DON), the DON stated that a consent needs to be obtained from psychiatrist prior to starting a resident on an antipsychotic medication. The DON also confirmed that a new consent is required to be obtained any time there is an increase in dosage or frequency of antipsychotic medications.
A review of the facility's undated policy and procedure titled, Psychotherapeutic Drug Policies, indicated the following procedure:
Prior to initiation of psychotherapeutic drug therapy, perform a comprehensive assessment of the resident. Documentation by the Interdisciplinary Team and Physician of the following:
The appropriateness of the clinical approach
Previous attempts to use less restrictive measures
Behavior and environmental interventions
Refer to the attached recommendations for documentation of psychotherapeutic drug use
Prepare the informed consent
Confirm the appropriate diagnosis and dose
2. During an interview, on 12/3/2018, at 2:32 p.m., the DON, regarding a request for the facility's written resident rights policy and procedures related to psychotherapeutic (medications used to treat psychosis, which refers to a group of mental disorders for example depression, schizophrenia, manic-depressive disorders, and anxiety disorders), stated, We don't have a residents' rights policy.
A review of the Resident 17's Interdisciplinary Team Meeting Conference Record, dated 1/21/2020, under Resident/Responsible Party Participation, had check mark in Resident check box and Resident 17's signature on Attended the Conference (signature) line. In the Restraints section, indicated an entry for, Haloperidol 5 mg 1 tablet by mouth two times a day for psychosis manifested by physical behavior symptoms, aggressiveness directed towards other like hitting.
A review of Resident 17's Face Sheet, indicated blank spaces for Responsible Party, Second Contact, and Third Contact
Regarding the request for patients rights policies and procedures related psychotherapeutic informed consent, the facility produced Use of Restraints, revised 2/2007, and corporate, Policy: Informed Consent, effective date 3/1/1989, both of which did not specifically address psychotherapeutic medications.
During in interview, on 3/20/2021 at 2:27 p.m., the Administrator's Designee, regarding the absence of the patients rights policies and procedures related psychotherapeutic informed consent, offered to provide another policy, but it was the same Policy: Informed Consent.
A review of the facility's policy and procedures, titled, Informed Consent, date not listed, did not indicate an entry for a residents' rights policy and procedures related to psychotherapeutic informed consent.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide documented evidence that advance directives (written statem...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide documented evidence that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed for two of three sampled residents (Resident 11 and 479).
These deficient practices had the potential to violate the resident's rights and/or representative's right to be fully informed of the option to formulate their advance directives.
Findings:
a. A review of Resident 11's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included, but not limited to, schizophrenia (chronic and severe mental disorder that affects how a person thinks, feels, and behaves) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest).
A review of Resident 11's Minimum Data Set (MDS - an assessment and care screening tool), dated 2/7/2021, indicated the resident has the ability to usually make self-understood and the ability to usually understand others.
During a concurrent interview and record review, on 5/20/2021 at 9:37 a.m., with the Social Service Director (SSD), the SSD reviewed Resident 11's medical record and was unable to find any documented evidence that advance directives were discussed with the resident or responsible party. The SSD stated he attempts to inform residents of their right to formulate an advance directive within the first five days of admission into the facility if the resident does not have one in place. If the resident refuses to execute an advance directive, the SSD stated he would review and complete the advance directive acknowledgement form with the resident. The advance directive acknowledgement form in the resident's chart only had the resident's name, date of admission, and name of facility and was otherwise blank. The SSD confirmed the advance directive acknowledgement form in Resident 11's medical record was not complete. The SSD stated he will review and complete the acknowledgement form with the resident right now.
A review of the facility's policy and procedure titled, Advance Directives, dated December 2016, indicated, Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. The policy further stated, information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.
b. A review of Resident 479's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] with diagnoses that included, but not limited to, schizophrenia (mental illness that affects how a person thinks, feels and behaves) and anxiety (an intense, excessive, and persistent worry or fear about everyday situations).
A review of Resident 479's History and Physical Exam, dated 5/13/21, indicated the resident has the capacity to understand and make decisions.
During a concurrent interview and record review, on 5/20/2021 at 9:53 a.m., with the Social Service Director (SSD), the SSD reviewed Resident 479's medical record and was unable to find any documented evidence that advance directives were discussed with the resident or responsible party. The SSD verified Resident 479's advance directive acknowledgement form only contained the physician's signature but did not indicate if the resident received information regarding formulating an advance directive or not.
During an interview, on 5/20/2021 at 11:50 a.m., with the SSD, the SSD stated he was unable to find any documented evidence that advance directives were discussed with Resident 479. SSD further stated he went ahead and spoke with the resident regarding formulating an advance directive and completed the acknowledgment form.
A review of the facility's policy and procedure titled, Advance Directives, dated December 2016, indicated, Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. The policy further stated, information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the development and/or implementation of a com...
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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 ensure the development and/or implementation of a comprehensive person-centered care plan (written guide that organizes information about the resident's care) on wandering behavior with measurable objectives, time frames, and person-centered interventions for one out of 18 residents (Resident 2).
This deficient practice had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services for Resident 2.
Findings:
A review of Resident 2's Face Sheet (admission record) indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses that included schizophrenia (chronic and severe mental disorder that affects how a person thinks, feels, and behaves) and unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning) with behavioral disturbance.
A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 4/23/2021, indicated the resident had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for decision-making. The MDS also indicated the resident needed limited to extensive assistance with activities of daily living (ADLs - routine activities people do every day).
A review of Resident 2's Care Plan (written guide that organizes information about the resident's care) titled, Wandering Behavior, dated 11/11/2020, indicated Resident 2 was at risk for injuries secondary to wandering behavior, leading to elopement. The goal indicated, the resident will not wander out of facility unassisted and the resident will have no injuries for 90 days. The care plan interventions included to monitor behavior and mood patterns every shift.
During an observation on 5/18/2021, at 12:35 p.m., Resident 2 was observed wandering through the hallway while Resident 77 was sitting on her wheelchair outside the room. Resident 2 was observed entering Resident 77's room and laid on Resident 77's bed for 10 minutes.
During an interview on 5/21/2021, at 10:50 a.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated he had seen Resident 2 going to other residents' room and laying on their bed multiple times, since 1/2021. CNA 2 also stated, Resident 2 has had her room changed multiple times since other residents were angry at her for using their bed.
During a concurrent interview and record review, on 5/21/2021, at 11:03 a.m., with Licensed Vocational Nurse (LVN3), Resident 2's medical chart was reviewed. LVN 3 verified there was no documented evidence on monitoring resident's behavior and mood patterns every shift as indicated in the care plan. LVN 3 stated, the licensed nurses and CNAs should have monitored resident's wandering behavior and charge nurses should have documented the behavior every shift. It was important for the safety of Resident 2 and other residents in the facility. LVN 3 also confirmed there was no specific plan mentioned in the care plan related to resident's behavior of going to other residents' room. LVN 3 stated, the resident's care plan on wandering behavior was not patient-centered and updated. LVN 3 stated, the care plan should be patient-centered and specific for the problem because the care plans are the guide for resident's care.
During a concurrent interview and record review on 5/21/2021, at 12:20 p.m., with the Director of Nursing (DON), Resident 2's care plans were reviewed. The DON stated the licensed nurses were responsible to monitor and document on Resident 2's wandering behavior in the progress notes every shift. The DON stated the importance of monitoring was to identify and prevent potential harm for Resident 2 and other residents in the facility. The DON also stated the care plan was not patient-centered and did not reflect the resident's specific behavior. The care plan can help to provide the appropriate care to the resident by identifying the problem, setting up goals to resolve the problem, and provide appropriate interventions. The DON stated care plans are guide for care givers to manage the identified problem.
A review of the facility's policy and procedure titled, Care Plans, - Comprehensive Person - Centered, revised in12/2016, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive person-centered care plan will include measurable objectives and timeframes; describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; incorporate identified problem areas; and incorporate risk factors associated with identified problems. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process.
A review of the facility's policy and procedure titled, Wandering and Elopements, revised in 3/2019, indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintain the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 7) received treatme...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 7) received treatment and care in accordance with professional standards of practice by failing to document a SBAR (Situation, Background, Assessment, Recommendation- a form used for communication with doctors) and hold an Interdisciplinary Team Meeting (IDT) regarding reopening of arterial ulcers (an ulcer that develops due to poor blood supply to lower legs and feet).
This deficient practice had the potential to result in a delay to healing of arterial ulcers.
Findings:
A review of resident 7's admission record (face sheet) indicated resident was admitted [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes mellitus (DM- High blood sugar) , disorder of arteries (blood vessel that delivers oxygen rich blood from the heart to the tissues of the body), and anemia (blood has lower than normal number of red blood cells).
A review of the Resident 7's Minimum Data Set (MDS- A standardized assessment and care screening tool), dated 4/23/21, indicated resident is rarely/never able to make self understood or able to understand others. The MDS indicated Resident 7 required total dependence on staff in all activities of daily living. The MDS also indicated Resident 7 was at risk for pressure ulcers/injury with two arterial ulcers present.
A review of Resident 7's Physician Orders, indicated for cleaning and dressing of left fifth toe and left lateral foot arterial ulcers for 30 days was ordered on 3/19/21.
A review of Resident 7's Wound Assessment Notes, dated 3/22/21, indicated wound doctor assessed resident for left first toe arterial ulcer and reopened left fifth toe arterial ulcer.
A review of the Resident 7's Wound Assessment Report dated 3/26/21, indicated the left fifth toe arterial ulcer was identified on 3/19/21.
During an interview on 5/20/21 at 10:57 a.m., with the DON, the DON stated there was no documented evidence SBAR or Change of Condition was done. The DON stated when a wound is reopened after it was healed, there should be a SBAR on change of condition reopening of Resident 7's left fifth toe arterial ulcer and there should be follow- up because the potential outcome would be no treatment for that issue.
During an interview on 5/20/21 at 11:22 a.m., with the Treatment Nurse (TN), the TN stated Resident 7's arterial ulcer first started in 7/22/19 and reopened on 3/19/21 on the left fifth toe and left lateral foot. TN stated the wound specialist comes to the facility every Friday.
During concurrent interview and record review on 5/20/21 at 11:40 a.m., with the Director of Nursing (DON), the DON reviewed Resident 7's medical chart. The DON stated the latest IDT about the left fifth toe arterial ulcer was on 12/9/20, but there was no documented evidence of IDT in Resident 7's record for the reopening of left fifth toe and left lateral foot arterial ulcers that occurred on 3/19/21. The DON stated the IDT meet weekly to identify changes in skin conditions and evaluate whether the plan is working with social worker and dietician. The DON stated the potential negative outcome IDT not done is the resident not being attended to accordingly.
A review of facility policy titled change in a Resident's Condition or Status, revised 11/2015, indicated a significant change of condition is a decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions; impacts more than one area of the resident's health status; and requires interdisciplinary review and/or revision to the care plan. The policy also indicated that prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the SBAR Communication Form.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure that two medications were administered to a resident, one (1) resident out of four (4) residents observed during medic...
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Based on observation, interview, and record review, the facility failed to ensure that two medications were administered to a resident, one (1) resident out of four (4) residents observed during medication administration (med pass) (Resident 56).
This deficient practice had the potential for harm to the resident due to not receiving medications indicated for the promotion of bone and eye health.
Findings:
1a. During an observation, at Station North, on 5/17/2021 from 9:01 a.m. to 9:29 a.m., of Resident 56's morning medication administration (med pass), at Station North Medication Cart, the licensed vocation nurse (LVN 1) did not administer the morning dose of Vitamin D (promotes calcium absorption in the gut and maintains adequate serum calcium and phosphate concentrations to enable normal bone mineralization) 1000 U (strength in units) one (1) tablet of by mouth.
A review of Resident 56's Face Sheet (document that gives a patient's information at a quick glance. Face sheets can include contact details, a brief medical history and the patient's level of functioning, along with patient preferences and wishes), dated 1/22/2019, indicated diagnoses of primary generalized osteoarthritis (degeneration of joint cartilage and the underlying bone, most common from middle age onward. It causes pain and stiffness, especially in the hip, knee, and thumb joints).
A review of Resident 56's Physician Orders for May 2021 indicated an order date of 11/16/2020, and an order for Vitamin D 1000 U Tab by mouth three times a day.
During an interview, on 5/17/2021, at 2:12 p.m., LVN 1 stated that the order did not show on the e-MAR (an electronic version of the medication administration record, the report that serves as a record of the drugs administered to a patient by a health care professional. The MAR is a part of a patient's permanent record on their medical chart), and that the ADM (admission) code was entered instead of MED (medication). LVN 1 stated did not see this medication as it was in a different section of the e-MAR. LVN 1 stated that the licensed nurse processing the admission orders into the e-MAR made the computer inputting error.
1b. During an observation, at Station North, on 5/17/2021 from 9:01 a.m. to 9:29 a.m., of Resident 56's morning medication administration (med pass), at Station North Medication Cart, the licensed vocation nurse (LVN 1) did not administer the morning dose of Ocuvite with Lutein (a vitamin supplement used to support eye health) one (1) tablet by mouth.
During an interview, on 5/17/2021, at 2:02 p.m., LVN 1 stated she could not find Ocuvite with Lutein in the stockroom (Central Supply over-the-counter medication room), and it was not reordered by the charge nurses prior to running out. LVN 1 reordered it from pharmacy just now.
A review of Resident 56's Physician Orders May 2021, order date 1/22/2019, indicated order for Ocuvite with Lutein Tablet, one (1) tablet by mouth daily for supplement, 9 a.m.
A review of the facility's policy and procedures, titled, Administering Medications, revised December 2012, indicated, Policy Statement .Medications shall be administered .as prescribed.
A review of the facility's policy and procedures, titled, Charting and Documentation, revised 4/2008, indicated, Policy Interpretation and Implementation .To ensure consistency in charting and documentation of the resident's clinical record, only facility approved abbreviations and symbols may be used when recording entries in the resident's clinical records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document specific indications for the use of Seroquel (antipsychoti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document specific indications for the use of Seroquel (antipsychotic medication [medication used to manage abnormal condition of the mind described as involved a loss of contact with reality]) for one of six sampled residents (Resident 478).
This deficient practice placed the resident at risk for receiving unnecessary medication and had the potential to result in inconsistent monitoring of behaviors.
A review of Resident 478's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] with diagnoses that included, but not limited to, dementia (group of symptoms affecting memory, language, problem-solving, and other thinking abilities) with behavioral disturbance and schizophrenia (chronic and severe mental disorder that affects how a person thinks, feels, and behaves).
A review of Resident 478's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 4/20/2021, indicated the resident has the ability to usually make self-understood and the ability to usually understand others.
A review of Resident 478's physician's order, dated 4/16/2021, indicated to give Seroquel 100 milligrams (mg) one tablet by mouth three times daily for bipolar disorder (mental illness that causes extreme high and low moods and changes in sleep, energy, thinking, and behavior) manifested by disorganized behavior.
During an interview, on 5/20/2021 at 3:10 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 478 is resistant to care sometimes and will not allow staff provide care. LVN 1 further stated resident exhibits mood swings on and off but has been calm throughout her shift for today.
During an interview, on 5/20/21 at 3:15 p.m., with Certified Nursing Assistant 5 (CNA 5), CNA 5 stated Resident 478 gets agitated when providing incontinent care for the resident. CNA 5 further stated Resident 478 would get stiff and not allow staff to change him. In severe cases, Resident 478 would try to hit staff with his hands and legs.
During a concurrent interview and record review, on 5/21/2021 at 11:54 a.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 reviewed the physician's order for Seroquel ordered on 4/16/2021 and confirmed that the description of disorganized behavior provided as the behavioral indication for the medication was not specific enough. LVN 4 agreed licensed nurses would not know what is meant by disorganized behavior as well as the specific behaviors to monitor for.
During an interview, on 5/21/2021 at 12:18 p.m., with the Director of Nursing (DON), the DON stated that the description of disorganized behavior provided as the behavioral indication for the medication was too general and not specific. The DON agreed there may inconsistencies in how staff interpret disorganized behavior and stated Resident 478's order for Seroquel should have a specific behavioral indication for why the resident is on the medication.
A review of the facility's undated policy and procedure titled, Psychotherapeutic Drug Policies, indicated to include the specific behavior in objective and measurable terms under section Procedure for Taking and Writing Psychotherapeutic Drug Orders.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure that the medication error rate of less than five (5) percent, due to two (2) medication administration errors involvin...
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Based on observation, interview, and record review, the facility failed to ensure that the medication error rate of less than five (5) percent, due to two (2) medication administration errors involving one (1) residents out of four (4) residents observed during medication administration (med pass).
This deficient practice of a medication administration error rate of seven and four-tenths percent (7.4%) exceeded the five (5) percent threshold.
Findings:
1a. During an observation, at Station North, on 5/17/2021 from 9:01 a.m. to 9:29 a.m., of Resident 56's morning medication administration (med pass), at Station North Medication Cart, the Licensed Vocational Nurse (LVN 1) did not administer the morning dose of Vitamin D (promotes calcium absorption in the gut and maintains adequate serum calcium and phosphate concentrations to enable normal bone mineralization ) 1000 U (strength in units) one (1) tablet by mouth.
A review of Resident 56's Face Sheet (admission record), dated 1/22/2019, indicated diagnoses of primary generalized osteoarthritis (degeneration of joint cartilage and the underlying bone, most common from middle age onward. It causes pain and stiffness, especially in the hip, knee, and thumb joints).
A review of Resident 56's Physician Orders, dated 5/2021 indicated an order date of 11/16/2020, and an order for Vitamin D 1000 U Tab by mouth three times a day.
During an interview, on 5/17/2021, at 2:12 p.m., LVN 1 stated that the order did not show on the e-MAR (an electronic version of the medication administration record, the report that serves as a record of the drugs administered to a patient by a health care professional. The MAR is a part of a patient's permanent record on their medical chart), and that the ADM (admission) code was entered instead of MED (medication). LVN 1 stated did not see this medication as it was in a different section of the e-MAR. LVN 1 stated that the licensed nurse processing the admission orders into the e-MAR made the computer inputting error.
1b. During an observation, at Station North, on 5/17/2021 from 9:01 a.m. to 9:29 a.m., of Resident 56's morning medication administration (med pass), at Station North Medication Cart, LVN 1 did not administer the morning dose of Ocuvite with Lutein (a vitamin supplement used to support eye health) one (1) tablet of by mouth.
During an interview, on 5/17/2021, at 2:02 p.m., LVN 1 stated she could not find Ocuvite with Lutein in the stockroom (Central Supply over-the-counter medication room), and it was not reordered by the charge nurses prior to running out.
A review of Resident 56's Physician Orders 5/2021, order date 1/22/2019, indicated order for Ocuvite with Lutein Tablet, one (1) tablet by mouth daily for supplement, 9 a.m.
A review of the facility's policy, titled, Administering Medications, revised 12/2012, indicated Policy Statement .Medications shall be administered .as prescribed.
A review of the facility's policy, titled, Charting and Documentation, revised 4/2008, indicated Policy Interpretation and Implementation .To ensure consistency in charting and documentation of the resident's clinical record, only facility approved abbreviations and symbols may be used when recording entries in the resident's clinical records.
The medication error rate was calculated as two (2) medication errors divided by twenty-seven (27) opportunities and missed opportunities, multiplied by one-hundred (100), which resulted in the medication error rate of seven and four tenths percent (7.4 %), exceeding the five percent (5%) threshold.
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 observations, interviews, and record reviews, the facility failed to:
1. Ensure that hazardous materials were stored separately from the medications, in one (1) out of two (2) medication cart...
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Based on observations, interviews, and record reviews, the facility failed to:
1. Ensure that hazardous materials were stored separately from the medications, in one (1) out of two (2) medication carts, out of two (2) total medication carts at the facility.
2. Ensure that refrigerator temperatures in two medication storage rooms were within the temperature ranges specified for refrigerated medications, in two (2) out of two (2) sampled medication storage rooms, out of three (3) total medication storage rooms at the facility.
3. Ensure that the room temperature and refrigerator temperature monitoring records were not missing the times for the room temperature and refrigerator readings, for medications requiring routine room temperature and refrigerator temperature monitoring, in one (1) out of two (2) sampled medication storage rooms, out of three (3) total medication storage rooms at the facility.
4. Ensure that the refrigerator temperature monitoring records did not have the incorrect printed temperature range, in one (1) sampled medication storage rooms, out of three (3) total medication storage rooms at the facility.
These deficient practices had the potential for harm to residents due to the potential loss of strength of the medications, and the potential for the residents to receive ineffective medication dosages.
Findings:
1. During an observation, on 5/18/2021 at 11:38 a.m., during the South Station Medication Cart inspection with the Licensed Vocation Nurse (LVN 2), indicated that one (1) container of Microdot Bleach (a chemical irritating to the skin, lungs, and eyes) Wipes was co-located and was in direct contact with one bottle of Pro-Stat Sugar Free (dietary supplement), 30 fluid ounces (fl. oz.), and one bottle of Geri-Tussin (Guaifenesin, a medication that breaks up mucus and relieves cough) Oral Solution, 16 fl. oz.
During an interview, on 5/18/2021 at 11:47 a.m., the Licensed Vocational Nurse (LVN 2) acknowledged the co-location and direct contact of a container of bleach disinfectant with a bottle of dietary supplement and a bottle of cough syrup. LVN 2 removed the disinfectant container and relocated it. LVN 2, regarding the two affected bottles, stated, I will replace them.
A review of the facility's policy, titled, Storage of Medications, dated 4/2019, indicated Procedures .Potentially harmful substances such as .disinfectants .shall be clearly identified and stored in a locked area separately from medications.
2. During an observation, on 5/18/2021 at 1:43 p.m., in the Central Supply Medication Room, the refrigerator thermometer indicated a temperature of 34 degrees F (Fahrenheit). The refrigerator was empty.
During an interview, on 5/18/2021 at 1:43 p.m., LVN 2 confirmed the refrigerator thermometer reading of 34 degrees F, and stated, Let me adjust it (thermostat).
During an observation, on 5/18/2021 at 8:19 a.m., in the South Station Medication Room, the refrigerator thermometer temperature reading was 34 degrees F. The refrigerator temperature log indicated dates but no times. The refrigerator contained medications.
During an interview, on 5/18/2021, at 8:20 a.m., the Registered Nurse (RN 1) confirmed the refrigerator thermometer reading of 34 degrees F. RN 1 stated, It is too low, should be 36 (degrees F)
During an interview, on 5/18/2021, at 9:04 a.m., the Director of Nursing (DON) acknowledged that the random refrigerator temperature reading was 34 degrees F, below the 36 degree threshold. The DON stated, I will adjust the temperature (dial) now.
During an interview, on 5/18/2021, at 11:04 a.m., the DON, regarding the temperature excursion to 34 degrees F, stated We will replace (refrigerated medications).
A review of the facility's policy, titled, Storage of Medications, dated 4/2019, indicated Procedures .medications requiring 'refrigeration' or temperatures between 2 degrees C (36 degrees F) to 8 degrees C (46 degrees F) shall be kept in a refrigerator with a thermometer to allow temperature monitoring .medication storage areas are kept .free of .extreme temperatures .medication storage conditions are monitored on a monthly basis and corrective action taken if problems are identified.
3. During an observation, on 5/18/2021 at 8:17 a.m., in the South Station Medication Room, the room thermometer temperature reading was 76 degrees F.
During an interview, on 5/18/2021, at 8:18 a.m., RN 1 confirmed the room thermometer reading of 76 degrees F. RN 1 confirmed the room temperature log entries indicated dates but no times.
During an observation, on 5/18/2021 at 8:19 a.m., in the South Station Medication Room, the refrigerator temperature log indicated dates, but no times.
A review of the Refrigerator Temperature Log 2020 and Refrigerator Temperature Log 2021 indicated dates, but no times. One or two temperature readings were recorded in the spaces for the dates, but without the times.
During an interview, on 5/18/2021 at 8:36 a.m., RN 1 confirmed that the refrigerator temperature logs had dates but no times for either one or two daily temperature readings, and acknowledged that the temperature readings did not indicate times of temperature fluctuations throughout the day. RN 1 stated, We will change the form to include times
During an interview, on 5/18/2021 at 9:04 a.m., the DON acknowledged that there were dates but no times on the refrigerator temperature log, as well as the room temperature log. The DON stated, We will change the form. The DON acknowledged, after adjusting temperature dial, that the facility will document the times to identify the potential temperature fluctuations.
A review of the facility's policy, titled, Storage of Medications, dated 4/2019, indicated Procedures .medications requiring storage at 'room temperature' shall be kept at temperatures ranging from 15 degrees C (59 degrees F) to 30 degrees C (86 degrees F) .medications requiring 'refrigeration' or temperatures between 2 degrees C (36 degrees F) to 8 degrees C (46 degrees F) shall be kept in a refrigerator with a thermometer to allow temperature monitoring .medication storage areas are kept .free of .extreme temperatures .medication storage conditions are monitored on a monthly basis and corrective action taken if problems are identified.
4. During an observation, on 5/18/2021 at 8:19 a.m., in the South Station Medication Room, the refrigerator thermometer temperature reading was 34 degrees F.
During an interview, on 5/18/2021, at 8:20 a.m., RN 1 confirmed the refrigerator thermometer reading of 34 degrees F. RN 1 stated, It is too low, should be 36 (degrees F)
A review of the, Refrigerator Temperature Log indicated, Acceptable Temperature Range 35 F to 46 F (2C-8C). The refrigerator temperature log indicated an incorrect printed temperature of 35 degrees F, instead of 36 degrees F.
During an interview, on 5/18/2021, at 9:04 a.m., the DON acknowledged that the facility's pharmacy policy and procedure, titled, Storage of Medications, effective date 04/2019, indicated the refrigerator temperature range of 36 degrees F to 46 degrees F, and that the facility's refrigerator temperature log erroneously indicated 35 degrees F to 46 degrees F. DON stated, We will change the form.
A review of the facility's policy, titled, Storage of Medications, dated 4/2019, indicated Procedures .medications requiring 'refrigeration' or temperatures between 2 degrees C (36 degrees F) to 8 degrees C (46 degrees F) shall be kept in a refrigerator with a thermometer to allow temperature monitoring .medication storage areas are kept .free of .extreme temperatures .medication storage conditions are monitored on a monthly basis and corrective action taken if problems are identified.
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
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 5 life-threatening violation(s), 2 harm violation(s). Review inspection reports carefully.
- • 59 deficiencies on record, including 5 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $18,363 in fines. Above average for California. Some compliance problems on record.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Holiday Manor's CMS Rating?
CMS assigns HOLIDAY MANOR CARE CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within California, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Holiday Manor Staffed?
CMS rates HOLIDAY MANOR CARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes.
What Have Inspectors Found at Holiday Manor?
State health inspectors documented 59 deficiencies at HOLIDAY MANOR CARE CENTER during 2021 to 2025. These included: 5 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, and 52 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Holiday Manor?
HOLIDAY MANOR 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 P&M MANAGEMENT, a chain that manages multiple nursing homes. With 94 certified beds and approximately 89 residents (about 95% occupancy), it is a smaller facility located in CANOGA PARK, California.
How Does Holiday Manor Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, HOLIDAY MANOR CARE CENTER's overall rating (1 stars) is below the state average of 3.1 and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Holiday Manor?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the substantiated abuse finding on record.
Is Holiday Manor Safe?
Based on CMS inspection data, HOLIDAY MANOR CARE CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 5 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in California. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Holiday Manor Stick Around?
HOLIDAY MANOR CARE CENTER has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Holiday Manor Ever Fined?
HOLIDAY MANOR CARE CENTER has been fined $18,363 across 2 penalty actions. This is below the California average of $33,262. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Holiday Manor on Any Federal Watch List?
HOLIDAY MANOR 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.