SANTA FE HEIGHTS HEALTHCARE CENTER, LLC
For profit - Individual
99 Beds
CRYSTAL SOLORZANO
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
0/100
#902 of 1155 in CA
Last Inspection: February 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Santa Fe Heights Healthcare Center has received a Trust Grade of F, indicating significant concerns and a poor overall performance. It ranks #902 out of 1155 in California, placing it in the bottom half of all facilities in the state, and #237 out of 369 in Los Angeles County, meaning only a few local options are worse. The facility is worsening, with issues increasing from 36 in 2024 to 38 in 2025. Staffing is average, with a rating of 3 out of 5 stars and a turnover rate of 39%, which is close to the state average. However, they have concerning fines totaling $112,022, which is higher than 92% of California facilities, indicating ongoing compliance problems. There are serious issues related to resident safety. A critical finding revealed that the facility failed to safeguard residents' personal property, raising the risk of financial abuse. Additionally, residents have faced physical abuse incidents, including one resident being hit in the face, which resulted in a nasal fracture. While the facility does have an excellent rating in quality measures, these significant weaknesses in safety and compliance cannot be overlooked.
- Trust Score
- F
- In California
- #902/1155
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 39% turnover. Near California's 48% average. Typical for the industry.
- Penalties ⚠ Watch
- $112,022 in fines. Higher than 87% of California facilities, suggesting repeated compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 18 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 122 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 22%
Review needed
36 → 38 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 36 issues
2025: 38 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (39%)
9 points below California average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Below California average (3.1)
Below average - review inspection findings carefully
Staff Turnover: 39%
Near California avg (46%)
Typical for the industry
Federal Fines: $112,022
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: CRYSTAL SOLORZANO
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 122 deficiencies on record
1 life-threatening 3 actual harm
May 2025
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 observation, interview, and record review, the facility failed to protect resident's right to be free from physical abu...
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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 protect resident's right to be free from physical abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1), who was subjected to Resident 2's physical attack, who had diagnosis of schizophrenia (a serious mental disorder in which people interpret reality abnormally, may result in delusions and behavior that impairs daily functioning, may have grandiose delusions [strong beliefs of things that are untrue]). The facility failed to:
- Implement the facility's policy and procedure (P&P) titled, Abuse Prevention/Prohibition, dated 11/2018, which indicated the facility would understand behavioral symptoms of residents that may increase the risk of abuse including aggressive and/or catastrophic reactions of residents, outbursts, or yelling out.
- Develop a resident specific Schizophrenia care plan for Resident 2, with interventions to monitor behavior and re-evaluate for effectiveness.
-Implement the Psychosocial Well-Being Care Plan dated 3/17/2025 to listen attentively and address concerns of Resident 2, when Resident 2 had erratic mood swings for eight days and auditory hallucinations (a perception of having seen or heard something that was not there) for five days from 5/1 - 5/13/2025.
This deficient practice resulted in Resident 2 punching Resident 1 in the right eye causing bruising (traumatic injury to the skin that results in discoloration, inflammation, and pain), and swelling to the right eye. Resident 1 received pain medication, had emotional distress, stated she did not feel safe in the facility, and did not want to be alone.
Findings:
A review of Resident 2's admission Record indicated the resident was re-admitted to the facility on [DATE] with diagnoses including major depressive disorder (a mental health condition characterized by a persistent low mood), alcoholic liver disease (a range of liver injuries caused by excessive alcohol consumption), and heart failure (when the heart cannot pump enough blood to meet the body's needs). Further review of the admission Record indicated there was no diagnosis included regarding Schizophrenia.
A review of Resident 2's care plan titled, Psychosocial Well-Being (encompasses mental, emotional, social, and spiritual well-being, and its impact on overall health and functioning) dated 3/17/2025 indicated Resident 2 had the potential for alteration in psychosocial well-being related to feeling down depressed or hopeless. The care plan goal indicated to minimize episodes of behavioral symptoms for three months and the interventions indicated to listen attentively to Resident 2 and address concerns.
A review of the Residents 2's care plan titled, Mood Pattern with depression manifested by inability to sleep dated 3/17/2025, indicated interventions to monitor for increase or decrease behavior and notify medical doctor, to evaluate effectiveness of or response to medication and report to medical doctor.
A review of Resident 2's History and Physical (H&P), dated 3/18/2025 indicated the resident did not have the capacity to understand and make decisions.
A review of the Medication Administration Record (MAR) dated 3/31/2025 indicated Resident 2 was to receive Trazadone (an antidepressant medication used to treat depression and anxiety) 50 milligrams (mg, unit of measurement) at bedtime for Schizophrenia spectrum disorder (a group of mental health conditions characterized by psychosis, hallucinations, delusions and disorganized thinking).
A review of the Minimum Data Set (MDS, a resident assessment tool) dated 4/3/2025, indicated Resident 2's cognition (the ability to think, understand, and reason) was mildly impaired and the resident felt down, depressed or hopeless with a frequency of 7 - 11 days. The MDS indicated Resident 2 had an active diagnosis of a psychiatric mood disorder (depression) and was taking an antidepressant medication (used to treat mental health conditions like depression and anxiety). The MDS did not indicate Resident 2 had any behaviors of hallucinations or delusions (misconceptions or beliefs that were firmly held or contrary to reality), did not indicate Resident 2 had a diagnosis of Schizophrenia, nor received any antipsychotic medications (a class of medicines used to treat psychosis [a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality] and other mental and emotional conditions.
According to a review of the Psychiatric Evaluation Notes dated 4/12/2025, from Resident 2's Primary Physician's Office, Resident 2 had diagnoses including Schizophrenia and Mood Disorder (a mental health condition that affects a person's emotional state, causing long periods of sadness, depression, mania, or elation). The Psychiatric Evaluation Note indicated Resident 2 had episodes of being irritable, yelling and talking to herself.
A review of the Physician's Order Summary Report dated 4/14/2025, indicated Resident 2 received Depakote (a mood stabilizer medication) 250 mg three times a day for mood disorder manifested by erratic mood swings (rapid and intense moment to moment emotional changes) and received Haloperidol (Haldol, antipsychotic medication used to treat Schizophrenia symptoms like hallucinations) 5 mg three times per day for Schizophrenia manifested by auditory hallucinations (when someone perceives sounds that are not there).
A review of the Physician's Order Summary Report dated 4/14/2025, indicated Resident 2 was to be monitored for mood disorder manifested by erratic mood swings every shift and monitored for Schizophrenia manifested by hallucinations every shift.
A review of Resident 2's MAR dated 5/1/2025 indicated on 5/1, 5/4 - 5/6, 5/8, 5/9, 5/11 and 5/13/2025 (eight days) Resident 2 exhibited erratic mood swings but there was no description documented regarding the specific behavior or what was done about the behavior.
A review of Resident 2's medical record indicated there was no documentation regarding listening attentively and addressing Resident 2's concerns, per the Psychosocial Well-Being care plan.
According to a review of Resident 2's MAR, dated 5/1/2025 indicated that on dates 5/1, 5/2, 5/5, 5/9, and 5/11/2025 (five days) Resident 2 exhibited auditory hallucinations, but there was no description documented regarding the specific behavior Resident 2 exhibited or staff's interventions.
A review of the Resident 2's medical record indicated there was no care plan for the diagnosis of Schizophrenia.
A review of Resident 1's admission Record indicated the resident was readmitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), major depressive disorder (mental health condition that's characterized by a persistent low mood), and osteoporosis (a chronic condition that causes bones to gradually lose density and mass, making them more fragile and prone to fractures).
A review of the MDS dated [DATE], indicated Resident 1's cognition was moderately impaired, and the resident required substantial/maximal assistance (helper did most of the work) from staff for toileting hygiene, showers, and dressing.
A review of the Situation Background Assessment Recommendation (SBAR) form dated 5/15/2025 indicated Resident 2 had become increasingly verbally confrontational with roommate (Resident 1) and struck Resident 1 with an open hand in the face. The SBAR indicated Resident 2's diagnoses included heart failure and alcoholic liver disease. The SBAR did not indicate Resident 2's diagnosis of Schizophrenia, nor any mental status changes observed. The SBAR indicated the Behavioral Evaluation was not clinically applicable to the change in condition being reported, including danger to self or others, verbal aggression, physical aggression, or personality change. The SBAR indicated to describe other behavioral changes noted or observed but this area remained blank.
A review of Resident 1's Skin Observation Tool, dated 5/16/2025 indicated the resident had a right orbital eye swelling and discoloration.
According to a review of the Mental and Behavioral Health Treatment Progress Note dated 5/19/2025, Resident 1 was in a low mood and stated she was struck by Resident 2 for no reason. The Progress Note indicated Resident 1 stated, I was punched in my eye. I don't want to see her or have anything to do with her.
A review of the Faxed Document sent from the facility to the Department dated 5/20/2025 indicated there was a physical altercation between Resident 2 and Resident 1 that occurred at approximately 8:20 p.m. on 5/15/2025. The faxed document indicated Resident 2 hit Resident 1 in the face with an open hand, which was witnessed by a staff member (Certified Nursing Assistant, CNA 2) during a verbal argument. The faxed document indicated Resident 1 was moved to another room per her request and that the facility's Interdisciplinary Team determined, Resident 2 was physically aggressive causing to hit Resident 1 with an open hand.
A review of the MAR dated 5/20/2025 and 5/22/2025 indicated Resident 1 received Tylenol 325 mg for pain.
During an observation on 5/22/2025 at 9:47 a.m., in Resident 1's room, Resident 1 had bruising, discoloration to the right orbital eye and the top portion of the bridge of her nose.
During a concurrent interview, Resident 1 stated she and Resident 2 were both in the room they shared. Resident 1 was sitting in her wheelchair, Resident 2 came towards her, and hit her in the eye three times. Resident 1 stated, I had asked her to stop, and she put her hand over my mouth when I started to yell for help. Resident 1 stated her face was hurting after being hit. Resident 1 stated she did not feel safe in the facility, did not want to be alone, and felt that Resident 2 would come into her room when she was alone.
During an interview on 5/22/2025 at 2:10 p.m., CNA 2 stated that on 5/15/2025, Resident 1 was in her wheelchair trying to cover her face while Resident 2 was standing and hitting Resident 1. CNA 2 stated Resident 2 called her (CNA 2) a derogatory name when CNA 2 told Resident 2 to stop. Resident 1 kept saying, She hit me! She hit me! CNA 2 stated Resident 1 had redness to her nose and cheek, and that this was considered physical abuse. CNA 2 stated, Resident 2 is always cussing someone out.
During an interview on 5/22/2025 at 4 p.m., the Director of Staff Development (DSD) stated recently she had to come out of her office to see what was going on due to Resident 2's loud shouting and cursing, as it had disturbed her and some of the residents. The DSD stated observed Resident 2's erratic mood swings of outbursts and talking to herself, the DSD did not report this behavior to the RN Charge Nurse.
During an interview on 5/22/2025 at 4:33 p.m., with Registered Nurse (RN) 1 and Resident 1, in Resident 1's room, Resident 1 stated to RN 1 that she did not feel safe after being hit by Resident 2 and would feel safe if someone was in the room with her, especially at night. RN 1 stated since the incident, Resident 1 seemed sad, withdrawn, and remained in bed.
On 5/23/2025 at 9:30 a.m., during an interview in Resident 2's room, Resident 2 stated Resident 1 was talking about her (Resident 2's) mother and that Resident 2's mother was dead. Resident 2 stated, So I hit her in the face.
During an interview on 5/23/2025 at 12 p.m., the DON stated Resident 2 had a potty mouth, (using profanity or foul language) and rebelled against the structure of the facility. The DON stated Resident 2 displayed aggressive behavior towards another resident (Resident 1) and it was considered abuse. The DON stated the staff were to keep frequent visual checks on Resident 2, but there was no documentation in the medical record to confirm it was completed. The DON stated it was important to keep track and document Resident 2's whereabouts to prevent harm from reoccurring. The DON stated the physical altercation of Resident 2 hitting Resident 1 could affect Resident 1 and cause psychological harm, including being scared and withdrawn. The DON stated, We need to continue to check on Resident 1, so the psychological harm does not get worse.
During an interview on 5/23/2025 at 1:06 p.m., CNA 3 stated Resident 2 used profanity, would shout and say things such as Stupid, Shut up, and shout in the direction of residents when she walked down the hallway. CNA 3 stated Resident 2 would speak in Spanish, use derogatory language and say curse words. CNA 3 stated this behavior by Resident 2 could cause the other residents to feel badly and make the residents feel mad and disrespected. CNA 3 stated she did not report these recent behaviors from Resident 2 to a higher-level facility position.
During a concurrent interview and record review on 5/23/2025 at 4:20 p.m. with RN 2, Resident 2's MAR was reviewed. The MAR indicated from 5/1 - 5/13/2025 Resident 2 was documented to have erratic mood swings on eight days, and from 5/2 - 5/11/2025 Resident 2 was documented to have auditory hallucinations on five days, but there was no description of Resident 2's behavior. When RN 2 was asked what the facility did regarding Resident 2 exhibiting erratic mood swings and auditory hallucinations, RN 2 stated she could not find documentation in the medical record of what was done for Resident 2.
During an interview on 5/23/2025 at 4:30 p.m., RN 2 stated there was no care plan for Resident 2's diagnosis of Schizophrenia. RN 2 stated Resident 2's behaviors, such as thinking someone was speaking to her in a rude way, needed to be closely monitored for escalated behavior symptoms. RN 2 stated the Schizophrenia care plan interventions would include which non-pharmacological interventions to use and when to call the physician, so the physician could increase or decrease the resident's medications. RN 2 stated the care plan would assist the staff in identifying the aggressive behavior and knowing if the medication was working or not.
On 5/28/2025 at 9:30 a.m., during an interview, Resident 1's Responsible Party (RP) stated that he was notified about Resident 1 being hit in the face by Resident 2. The RP stated, I visited on 5/16/2025 (the day after the physical altercation), and she (Resident 1) was scared and cried about being hit. The RP stated, Resident 1 was emotional and very upset about what happened.
During a concurrent interview and record review on 5/29/2025 at 2:36 p.m., with RN 1, Resident 2's Psychiatric Evaluation Notes, dated 4/12/2025, from Resident 2's Primary Physician's Office were reviewed. RN 1 stated when Resident 2 used profanity it was not directed toward anyone in particular and it was a symptom of Resident 2's mood disorder and schizophrenia. RN 1 stated the facility should have managed Resident 2's mood behaviors with ongoing observations and document those behaviors as it was important to prevent physical abuse.
A review of the facility's P&P titled, Abuse Prevention/Prohibition, dated 11/2018, indicated the facility would understand behavioral symptoms of residents that may increase the risk of abuse. The P&P indicated symptoms include, but are not limited to, aggressive and/or catastrophic reactions of residents, outbursts, or yelling out.
A review of the facility's P&P titled, Care Planning- Interdisciplinary Team, dated 9/2013, indicated the facility's care planning/interdisciplinary team was responsible for the development of an individual comprehensive care plan for each resident. The P&P indicated the care plan was based on the resident's comprehensive assessment.
May 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
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 adequate resident supervision (oversight), and monitoring wa...
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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 adequate resident supervision (oversight), and monitoring was implemented for one of three sampled residents (Residents 1), who was at high risk for elopement (leaving the facility without permission and supervision).
This failure resulted in resident eloping the facility on 5/16/2025 and placed the resident at risk for missing scheduled medications, exposure to hot weather, accidents and other complications that can lead to severe injuries, hospitalization and death.
Findings:
During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including schizoaffective disorder (a chronic mental illness where individuals experience symptoms of both schizophrenia and a mood disorder), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and anxiety disorder (excessive and persistent fear or worry.)
During a review of Resident 1 ' s History and Physical (H&P) dated 4/21/2025, the H&P indicated Resident 1 does not have the mental capacity to understand and make medical decisions.
During a review of Residents 1 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 4/7/2025, the MDS indicated Resident 1 had moderate cognitive impairment. The MDS indicated Resident 1 required partial to moderate assistance with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene. The MDS indicates Resident 1 required supervision or touching assistance with transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side.)
During a review of Resident 1 ' s Elopement Evaluation, dated 4/7/2025 the evaluation indicated Resident 1 had history of elopement or had attempted to leave the facility without informing staff. The evaluation indicated Resident 1 had verbally expressed the desire to go home. The evaluation indicated Resident 1 wanders.
During a review of Resident 1 ' s progress notes, dated 4/17/2025 the progress notes indicated Resident 1 ' s wander guard bracelet (a bracelet monitor) was checked and Resident 1 stated, I took it out, it ' s heavy and I don't like it. Resident 1 stated, I've learned my lesson, I will not leave without telling anyone. The progress notes indicated the Interdisciplinary Team ([IDT] group of healthcare professionals, including resident/ resident representative, working together to provide residents with needed care), asked the resident if she has plan of exiting the facility and resident stated, No, I've learned my lesson. The progress notes indicated the IDT will continue with frequent visual check with the resident every shift.
During a review of Resident 1 ' s care plan titled Resident 1 ' s Wander guard applied on 4/14/2025 was removed by the resident. The resident requested not to put it back. It's heavy and the resident doesn't like it, dated 4/17/2025, one of the care plan interventions indicated frequent visual check of Resident 1 ' s whereabouts within the facility.
During an interview on 5/17/2025 at 10:31 a.m. with Resident 1, Resident 1 stated, I went to shop for fresh fruits and vegetables, went to different stores and I had lunch at Ihop restaurant. Resident 1 stated I spent the entire day shopping. Resident 1 stated I put the chair and sneaked out from the window. Resident 1 stated, I have no injuries. I am okay. Resident 1 stated, I did not tell anybody. Resident 1 stated, I called my sister to tell her about my shopping, then I came back to the facility.
During an interview on 5/17/2025 at 3:30 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated the frequent visual checks described in Resident 1 ' s care plan meant that Resident 1 needed to be checked every two hours. LVN 2 stated the care plan needs to be precise with every how many hours Resident 1 need to be visually checked. LVN 2 stated the visual check should be documented in the resident ' s clinical record. LVN 2 stated Resident 1 should always be monitored because she is at risk forelopement and injuries while outside the facility.
During a concurrent interview and record review on 5/17/2025 at 3:55 p.m. with the Director of Nursing (DON), Resident 1 ' s care plan titled Resident 1 ' s Wander guard applied on 4/14/2025 was removed by the resident. The resident requested not to put it back. It's heavy and the resident doesn't like it, dated 4/17/2025, was reviewed. The DON stated Resident 1 refused to wear the wander guard. The DON stated the care plan indicated frequent visual monitors which means Certified Nursing Assistants (CNA) and charge nurses should be monitoring Resident 1 to know where she is always at. The DON stated the care plan was not clear. The DON stated frequent visual checks should specify how often Resident 1 needed to be monitored for Resident 1 ' s safety, and to deliver high quality care. The DON stated the risk of not being specific with monitoring isResident 1 will not get the supervision she needs and can lead to another episode of elopement.
During a review of the facility ' s P&P titled Care Plans- Comprehensive, dated 9/2010, the P&P indicated an individualized care plan should include measurable objectives and timetables to meet the resident ' s medical, nursing, mental and psychological needs.
During a review of the facility ' s policy and procedure (P&P) titled, Safety and Supervision of Residents, dated 2007, the P&P indicated resident safety, supervision and assistance to prevent accidents are facility-wide priorities. The P&P indicated when accident hazards are identified, the QA&A/Safety Committee shall evaluate and analyze the cause and develop strategies to mitigate or remove the hazards to the extent possible.
Apr 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
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 a resident ' s blood pressure (the pressure of the blood in ...
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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 ' s blood pressure (the pressure of the blood in the circulatory system), and pulse rate (the number of times the heart beats within a certain time period) was assessed and documented before the administration of hydralazine and lisinopril (medications that lower blood pressure by making blood vessels widen so blood gets through more easily) as ordered by the physician and indicated in the care plan for one out of six sampled residents (Resident 1).
This failure had the potential to cause a decrease in Resident 1 ' s blood pressure and result in a medical emergency.
Findings:
During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included hypertensive heart disease (caused by unmanaged high blood pressure for a long time which could lead to heart failure or other health problems) chronic pulmonary edema (fluid accumulation in the lungs caused by heart problems), and schizophrenia (a mental illness that is characterized by disturbances in thought).
During a review of Resident 1 ' s History and Physical (H&P), dated 4/3/2025, the H&P indicated Resident 1 was able to understand and make medical decisions.
During a review of Resident 1 ' s Order Summary Report, dated 4/2025, the Order Summary Report indicated to administer hydralazine oral tablet 10 milligrams (mg- a unit of measurement) one tablet three times a day for hypertension (high blood pressure). The Order Summary Report indicated to hold the administration of hydralazine for a systolic blood pressure (SBP – top number of a blood pressure reading [normal range of 120–129]) of less than 110 millimeters of mercury ([MM HG]- unit of measurement that describes the amount of force blood uses to get through the vessels of the body) or a pulse less than 60 beats per minute (normal rate in an adult is between 60 and 100 beats per minute). The Order Summary Report indicated to administer lisinopril oral tablet 20 mg one tablet by mouth one time a day for hypertension. The Order Summary Report indicated to hold the administration of lisinopril for a SBP of less than 110 or a pulse of less than 60.
During a review of Resident 1 ' s Cardiac Distress Care Plan, initiated 4/4/2025, the Cardiac Distress Care Plan indicated to administer medications as ordered and to monitor Resident 1 ' s pulse and blood pressure as ordered.
During a concurrent interview and record review on 4/7/2025 at 12:28 p.m. with the Director of Nursing (DON), DON stated Resident 1 ' s Order Summary Report, dated 4/2025, and Electronic Medication Administration Record (eMAR), dated 4/4/2025 through 4/6/2025, and Vital Signs Summary, dated 4/4/2025 through 4/6/2025, were reviewed. The DON stated the Order Summary Report indicated there were specific parameters to hold Resident 1 ' s blood pressure medications. The DON stated Resident 1 ' s eMAR did not indicate Resident 1 ' s blood pressure or pulse were measured 30 minutes prior to the administration of the blood pressure medications on 4/4/2025 at 9 a.m., 1 p.m., and 5 p.m., 4/5/2025 at 1 p.m. and 5 p.m., and on 4/6/2025 at 1 p.m. and 5 p.m. Resident 1 ' s Vital Signs Summary indicated no vitals signs were recorded since Resident 1's admission to the facility. The DON stated it was important to ensure Resident 1 ' s vitals were assessed and documented to ensure the blood pressure medications were administered safely according to the physician ' s ordered parameters. The DON stated there was a possibility that Resident 1 could bottom out due to low blood pressure if the licensed nurses did not take the blood pressure or the pulse 30 minutes prior to the administration of Resident 1 ' s ordered doses of hydralazine and lisinopril.
During an interview with Licensed Vocational Nurse (LVN) 2 on 4/7/2025 at 3:02 p.m., LVN 2 stated he was Resident 1 ' s assigned nurse and admitted Resident 1 to the facility on 4/3/2025. LVN 2 stated he performed the medication reconciliation and entered Resident 1 ' s blood pressure medications into the electronic medical record (EMR). LVN 2 stated he forgot to the input the supplemental documentation information to allow the licensed nurses to input Resident 1 ' s blood pressure and pulse measurements into the eMAR before the administration of each blood pressure medication. LVN 2 stated this led to the lack of documentation of vital signs taken prior to the administration of Resident 1 ' s hydralazine and lisinopril on the following shifts (4/2/2025 through 4/6/2025). LVN 2 stated if Resident 1 ' s blood pressure or pulse were not assessed 30 minutes prior to the administration of blood pressure medications, there was potential Resident 1 ' s blood pressure or pulse could have been significantly lowered, which could have led to a medical emergency.
During a review of the facility ' s Policy and Procedure (P&P), titled, Care Plans, Comprehensive Person Centered, revised 12/2016, the P&P indicated the facility was to implement a comprehensive, person-centered care plan for each resident.
During a review of the facility ' s Charge Nurse Job Description (undated), the Charge Nurse Job Description indicated to coordinate nursing care through an appropriate individualized care plan. The Job Description indicated the charge nurse was to administer and document medications and treatments in compliance with facility policy.
Feb 2025
25 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the rights and dignity of residents were honor...
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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 rights and dignity of residents were honored when the facility failed to ensure the following for two out of six sampled residents (Resident 3 and Resident 4):
1. Certified Nursing Assistant (CNA) 3 did not watch television on her personal cellular phone device with earphones in each ear as she fed Resident 3 his lunch meal.
2. A bioethics committee meeting (a committee designed to support patient rights and help the resident, and the health-care team make decisions about health care) was held on the behalf of Resident 3, who was deemed unable to make medical decisions as indicated by the physician's History and Physical, dated 2/10/2025, prior to the administration of psychotropic medications (drugs that affect the brain and nervous system, altering mood, behavior, and cognitive function).
3. A public guardian (a person or organization appointed by the court to manage the care and finances of people who are unable to do so for themselves) was obtained, or a bioethics committee met on the behalf of Resident 4, who was deemed unable to make medical decisions as indicated by the physician's History and Physical, dated 8/29/2023.
These failures had the potential for Resident 3 to exhibit feelings of worthlessness and mistrust in the nursing staff for the provision of quality care. These failures resulted in the administration of psychotropic medications and changes to the plans of care for both Resident 3 and Resident 4 without the consultation of sound and reasonable decision-making parties or representatives. Cross Reference F689 and F552.
Findings:
a. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included dysphagia (difficulty swallowing), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity).
During a review of Resident 3's Minimum Data Set ([MDS], a resident assessment tool), dated 11/22/2024, the MDS indicated Resident 3's cognitive skills (ability to think and reason) for daily decision making was intact. The MDS indicated Resident 3 required substantial or maximal assistance (helper provides more than half of the effort) for eating, toileting, oral hygiene, and dressing, and when performing personal hygiene.
During a review of Resident 3's History and Physical (H&P), dated 2/10/2025, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.
During a review of Resident 3's Order Summary Report, dated 2/11/2025, the Order Summary Report indicated Resident 3 was ordered Haloperidol (an antipsychotic) tablet 5 milligrams ([mg]-a unit of measurement) one tablet orally in the morning related to schizoaffective disorder on 3/25/2024.
During a review of Resident 3's Impaired Nutrition Care Plan, initiated 2/4/2025, the care plan indicated Resident 3 was at risk for aspiration (when food, liquid, or other material accidentally enters the lungs instead of being swallowed) and the facility was to assist with and feed Resident 3 his meals, and check Resident 3's mouth after meal for pocketed food and debris.
During an observation on 2/11/2/2025 at 1:04 p.m., in Resident 3's room, Certified Nursing Assistant (CNA) 3 was observed seated in a chair with her back faced away from the entrance of the room. Resident 3's bed side table was positioned in front of her. CNA 3's personal cellular phone device and Resident 3's meal tray was positioned on top of Resident 3's bed side table. CNA 3 had both earphones in each ear. CNA 3 proceeded to scoop the contents of Resident 3's meal plate onto a spoon and feed it into Resident 3's mouth while she continued to watch her personal cellular phone device. CNA 3 continued to watch her personal cellular phone device with earphones in both ears until CNA 3 heard the State Agency Surveyor call CNA 3's attention on the third attempt.
During an interview on 2/11/2025 at 2:06 p.m. with CNA 3, CNA 3 stated she watched Tik Tok on her personal cellular phone and had both earphones in her ears while she fed Resident 3. CNA 3 stated this was not an acceptable practice because she would not have been able to see or hear if Resident 3 choked (when a person cannot speak, cough, or breathe because something is blocking the airway) and stated it was not a safe way to feed any resident. CNA 3 stated that feeding Resident 3 while watching her cellular phone did not honor Resident 3's dignity and well-being.
b. During a concurrent interview and record review on 2/11/2025 at 1:22 p.m. with the Social Services Director (SSD), Resident 3's H&P, dated 2/10/2025, was reviewed. The H&P indicated Resident 3 did not have the capacity to make medical decisions. The SSD stated she was responsible for handling the applications for public guardians and ensuring residents had a responsible party to represent the residents who did not have the decision-making capacity to guide his or her own medical care. The SSD stated if a resident did not have a responsible party or a public guardian to represent the resident, then the bioethics committee would meet to make medical decisions on the behalf of the resident. The SSD stated Resident 3 did not have a responsible party or a public guardian, and the bioethics committee should have met to guide the care of Resident 3 before any medical decisions were made and before the administration of psychotropic medications. The SSD stated Resident 3 had the right to have sound medical decisions made on his behalf, especially if the physician deemed the resident unable to make his own medical decisions.
c. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE]. Resident 4's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety (a feeling of uneasiness) disorder, and depression (a mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities).
During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive skills was severely impaired. The MDS indicated Resident 4 required partial or moderate assistance (helper provides less than half of the effort) for eating, toileting, oral hygiene, and dressing, and when performing personal hygiene.
During a review of Resident 4's Order Summary Report, dated 2/11/2025, the Order Summary Report indicated Resident 4 was ordered Risperdal (an antipsychotic) oral tablet 0.5 mg tablet by mouth in the morning for psychosis (a mental health condition characterized by a loss of contact with reality) on 12/10/2024.
During a concurrent interview and record review on 2/11/2025 at 1:22 p.m. with the SSD, Resident 4's H&P, dated 8/29/2023, was reviewed. The H&P indicated Resident 4 did not have the capacity to make medical decisions. The SSD stated Resident 4 did not have a responsible party or a public guardian, and the bioethics committee should have met to guide the care of Resident 4 before any medical decisions were made and before the administration of psychotropic medications. The SSD stated an application for public guardianship for Resident 4 should have been started in year 2023. The SSD stated she did not realize Resident 4's application for public guardianship was not started and Resident 4 was not on her list of residents that needed a public guardian. The SSD stated Resident 4 had the right to have sound medical decisions made on his behalf, especially if the physician deemed the resident unable to make his own medical decisions (in 2023).
During a review of the facility's Policy and Procedure (P&P), titled, Quality of Life- Dignity, revised 8/2009, the P&P indicated the facility was to ensure all residents were always treated with dignity and respect. The P&P indicated treated with dignity meant the resident would be assisted in maintaining and enhancing his or her self-esteem and self-worth.
During a review of the facility's P&P, titled, Psychoactive Medication Informed Consent, revised 3/2024, the P&P indicated the facility was to ensure informed consent would be obtained from the resident's representative if the resident was not capable of giving informed consent.
During a review of the facility's P&P, titled, Informed Consent - Psychotropic Medications and Restraint Devices, revised 3/2015, the P&P indicated the following:
1. The facility was to ensure informed consent would be obtained from the resident's representative if the resident was not capable of giving informed consent.
2. If the physician could not identify an appropriate surrogate decision-maker, court appointment of a conservator with medical decision-making authority or referral to the Public Guardian may be required.
3. If an agreement could not be reached about a surrogate decision-maker, and there is disagreement among potential surrogate decision-makers about the appropriate course of treatment, the physician should seek the assistance of an ethics committee and social services in the resolution of such disagreement.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure informed consent for the administration of psychotropic medi...
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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 informed consent for the administration of psychotropic medications (drugs that affect the brain and nervous system, altering mood, behavior, and cognitive function) were properly and accurately obtained for two out of six sampled residents (Resident 3 and Resident 4).
These failures resulted in the administration of psychotherapeutic medications and changes to the plans of care for both Resident 3 and Resident 4 without the consultation and knowledge of sound and reasonable decision-making parties or representatives.
Findings:
a. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included dysphagia (difficulty swallowing), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity).
During a review of Resident 3's Minimum Data Set ([MDS], a resident assessment tool), dated 11/22/2024, the MDS indicated Resident 3's cognitive skills (ability to think and reason) for daily decision making was intact. The MDS indicated Resident 3 required substantial or maximal assistance (helper provides more than half of the effort) for eating, toileting, oral hygiene, and dressing, and when performing personal hygiene.
During a review of Resident 3's History and Physical (H&P), dated 2/10/2025, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.
During a concurrent record review and interview on 2/11/2025 at 1:22 p.m. with the Social Services Director (SSD), Resident 3's H&P, dated 2/10/2025, was reviewed. The H&P indicated Resident 3 did not have the capacity to make medical decisions. The SSD stated she handled the applications for public guardians (a court-appointed person who helps people who can't care for themselves due to a medical or mental illness) and ensured residents had a responsible party (RP) to represent the residents who did not have the decision-making capacity to guide his or her own medical care. The SSD stated if a resident did not have a responsible party or a public guardian to represent the resident, then the bioethics committee would meet to make medical decisions on the behalf of the resident. The SSD stated Resident 3 did not have a responsible party or a public guardian, and the bioethics committee should have met to guide the care of Resident 3 before any medical decisions were made and before the administration of psychotherapeutic medications.
During a concurrent interview and record review on 2/11/2025 1:49 p.m. with Licensed Vocational Nurse (LVN) 3, Resident 3's Order Summary Report, dated 2/11/2025, and all of Resident 3's Informed Consents, dated 2024 and 2025, and were reviewed. The Order Summary Report indicated Resident 3 was ordered haloperidol (a psychotropic medication) tablet 5 milligrams ([mg]-a unit of measurement) one tablet orally in the morning related to schizoaffective disorder on 3/25/2024. There was no informed consent for Resident 3's daily order of haloperidol tablet 5 mg. LVN 3 stated the normal process was to obtain verification of informed consent from the resident's responsible party (RP). LVN 3 stated a new informed consent must be obtained whenever the dose of the psychotropic medication was increased or when the resident was readmitted from the General Acute Care Hospital (GACH). LVN 3 stated the informed consent for Resident 3 should have been verified with his responsible party upon readmission to the facility. LVN 3 stated the verification of informed consent was important because it ensured the RP was educated on the risks and the benefits of the psychotropic drug.
b. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE]. Resident 4's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety (a feeling of uneasiness) disorder, and depression (a mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities).
During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive skills was severely impaired. The MDS indicated Resident 4 required partial or moderate assistance (helper provides less than half of the effort) for eating, toileting, oral hygiene, and dressing, and when performing personal hygiene.
During a concurrent interview and record review on 2/11/2025 at 1:22 p.m. with the SSD, Resident 4's H&P, dated 8/29/2023, was reviewed. The H&P indicated Resident 4 did not have the capacity to make medical decisions. The SSD stated Resident 4 did not have a responsible party or a public guardian, and the bioethics committee should have met to guide the care of Resident 4 before any medical decisions were made and before the administration of psychotherapeutic medications.
During a concurrent interview and record review on 2/11/2025 1:49 p.m. with LVN 3, Resident 4's Informed Consent form, dated 8/30/2023, and H&P, dated 8/29/2023, were reviewed. The Informed Consent form was left incomplete for Resident 4's order of Risperdal 0.5mg tablet by mouth for psychosis. The section allotted to indicate whom the informed consent was obtained from was left blank. LVN 3 stated the informed consent form was not accurately and properly completed. LVN 3 stated all informed consent forms should be completed accurately to ensure the resident or the resident's RP were explained the risks and the benefits of all prescribed psychotropic medications. LVN 3 stated Resident 4 had the right to have the risks and benefits of his prescribed psychotropics medications explained to an RP to ensure sound medical decisions were made for Resident 4.
During a concurrent interview and record review on 2/13/2025 at 8:20 a.m. with LVN 4, Resident 4's Physician Order, dated 9/24/2024, Informed Consent form, dated 9/24/2024. and H&P, dated 8/29/2023, were reviewed. The Physician Order indicated Resident 4 was ordered haloperidol 5mg intramuscular ([IM]- administered in the muscle) every eight hours as needed for agitation. The Informed Consent form indicated verification of informed consent was obtained from Resident 4 (the resident, himself) for the order of haloperidol 5 mg IM every eight hours as needed for agitation (a state of restlessness, unease, and distress that can manifest as physical and emotional symptoms). LVN 4 stated she transcribed and carried out the physician's order for the administration of haloperidol 5 mg IM and obtained verification of informed consent incorrectly. LVN 4 stated the H&P indicated he was not able to make his own medical decisions and Resident 4 was not able to obtain consent on his own.
During a review of the facility's P&P, titled, Psychoactive Medication Informed Consent, revised 3/2024, the P&P indicated the facility was to ensure informed consent would be obtained from the resident's representative if the resident was not capable of giving informed consent.
During a review of the facility's P&P, titled, Informed Consent - Psychotherapeutic Medications and Restraint Devices, revised 3/2015, the P&P indicated the following:
1. The facility was to ensure informed consent would be obtained from the resident's representative if the resident was not capable of giving informed consent.
2. If the physician could not identify an appropriate surrogate decision-maker, court appointment of a conservator with medical decision-making authority or referral to the Public Guardian may be required.
3. If an agreement could not be reached about a surrogate decision-maker, and there is disagreement among potential surrogate decision-makers about the appropriate course of treatment, the physician should seek the assistance of an ethics committee and social services in the resolution of such disagreement.
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 the call light was within reach for two of eig...
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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 call light was within reach for two of eight sampled residents (Resident 72 and 86).
This deficient practice had the potential to result in a delay or an inability for the residents to obtain necessary care and services as needed.
Findings:
a. During a review of Resident 72's admission Record, dated 2/13/2024, the admission record indicated Resident 72 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses which included type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic kidney disease (CKD - a longstanding disease in which the kidneys are damaged and cannot filter blood as well as they should), muscle wasting (weakening, shrinking, and loss of muscle), and difficulty walking.
During a review of Resident 72's History and Physical (H&P), dated 12/5/2024, the H&P indicated Resident 72 had a fluctuating capacity to understand and make decisions.
During a review of Resident 72's Minimum Data Set (MDS - a resident assessment tool), dated 1/30/2025, the MDS indicated Resident 72's cognition (ability to think, remember, and reason) was moderately impaired. The MDS indicated Resident 72 required moderate assistance (helper does less than half the effort) with bathing, toileting and personal hygiene. The MDS indicated Resident 72 required moderate assistance to walk 10 feet and utilized a wheelchair or walker to assist with mobility (the ability to move freely).
During a review of Resident 72's Care Plan titled Risk for Falls, initiated on 7/23/2024, the care plan indicated Resident 72's fall risk was related to an abnormal gait (walk), mobility, and cognitive impairment. The care plan indicated Resident 72's goal was to be free of falls. The care plan interventions indicated to ensure Resident 72's call light was available and to utilize devices as appropriate to ensure Resident 72's safety.
During a review of Resident 72's Care Plan titled Resident at Risk for Falls, initiated on 10/28/2024, the care plan indicated Resident 72's fall risk was related to psychoactive (affects how the brain works) drug use, weakness, and fatigue (tiredness and lack of energy). The care plan goals indicated Resident 72 would be free of falls and not sustain serious injury for 90 days. The care plan interventions indicated to ensure Resident 72's call light was within reach, encourage the use of the call light for assistance as needed, and ensure prompt responses to all requests for assistance.
During an observation on 2/10/2025 at 10:55 a.m., in Resident 72's room, observed Resident 72 in bed with the call light hanging from the bedside nightstand. Resident 72 wore a yellow Fall Precaution bracelet on her left wrist.
During an observation on 2/11/2025 at 2:15 p.m., in Resident 72's room, observed Resident 72 in bed. Observed Resident 72's call light device was not within reach, and hanging from the drawer of the bedside nightstand.
During a concurrent observation and interview on 2/11/2025 at 2:20 p.m. with Certified Nursing Assistant (CNA) 1, Resident 72 was observed lying in bed with the call light device hanging from the nightstand drawer. CNA 1 stated the call light should not be on the nightstand because Resident 72 could not reach it. CNA 1 stated the call light should be on the bed next to Resident 72. CNA1 stated it was important to have the call light close to Resident 72 in order to call out for water, medications, or during an emergency.
During an interview on 2/11/2025 at 2:28 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 72's call light should have been within the resident's reach. LVN 3 stated the call light needed to be within reach in order for Resident 72 to call out for assistance and to prevent falls.
During an interview on 2/13/2025 at 9:40 a.m., with the Director of Nursing (DON), the DON stated the nursing staff must ensure the call lights are within reach for the residents at all times.
b. During an observation on 2/10/2025 at 8:57 a.m., in Resident 86's room, observed Resident 86 lying in bed. Resident 86's call light was observed on the floor behind Resident 86's bed. Resident 86's call light was not within reach.
During a review of Resident 86's admission Record, the admission record indicated Resident 86 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), muscle wasting (weakening, shrinking, and loss of muscle), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
During a review of Resident 86's MDS, dated [DATE], the MDS indicated Resident 86's cognitive skills for daily living was severely impaired. The MDS indicated Resident 86 required maximal (helper does more than half the effort) assistance from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 86 required maximal assistance from staff for chair/bed-to-chair transfer (the ability to transfer to and from bed to chair and/or wheelchair).
During a review of Resident 86's care plan with a focus of Resident at risk for decline in cognition, date initiated 1/6/2025, the care plan intervention indicated the facility would anticipate Resident 86's care needs, meet them, and provide the call light within reach.
During an observation on 2/10/2025 at 2:00 p.m., in Resident 86's room, observed Resident 86's lying in bed supine position. Resident 86's call light was observed on the floor behind Resident 86's bed. Resident 86's call light was not within reach.
During a concurrent observation and interview on 2/11/2025 at 2:50 p.m., with CNA 2, in Resident 86's room, Resident 86 was observed lying in bed in a semi-Fowler's position (lying on the back with head and upper body raised), CNA 2 stated while Resident 86 was lying in bed, td the call light was observed on the floor behind the resident's bed, not within reach. CNA 2 stated Resident 86's call light should have been attached to the resident's bed and within reach. CNA 2 stated it was important the resident was able to reach and use the call light when needed and for an emergency.
During an interview on 2/12/2025 at 10:45 a.m., LVN 1, LVN 1 stated the call light should be placed within resident reach and the near the resident's bedside. LVN 1 stated the call light was important for resident's to be able to communicate with the staff. LVN 1 stated the facility's licensed staff were responsible for checking the residents' call light and placing it within resident reach at the bedside. LVN 1 stated if the call light not within the resident's reach, the residents would not be able to use the call light and would not be able to call for help and assistance when needed. LVN 1 stated the call light not within reach was a resident safety issue, and placed residents at risk for falls and injury.
During a review of the facility's job duties and responsibilities titled, Certified Nursing Assistant, not dated, the job duties and responsibilities for CNAs indicated CNAs were responsible for keeping the nurses' call system within easy reach of the resident.
During a review of the facility's policy and procedures (P&P) titled, Answering the Call Light, revised August 2022, the P&P indicated when a resident is in the bed or confined to a chair, the call light must be within easy reach of the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician of a resident's low blood level concentration ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician of a resident's low blood level concentration of phenobarbital (a drug used to control seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) for one out of six sampled residents (Resident 10).
This failure increased the potential for Resident 10 to suffer from a bodily injury due to a seizure. Cross reference F656.
Findings:
During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 10's diagnoses included epilepsy (a chronic brain disorder characterized by recurrent seizures), status epilepticus (a life-threatening medical emergency that can occur in people with epilepsy), history of falling, schizophrenia (a mental illness that is characterized by disturbances in thought), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and abnormalities of gait and mobility.
During a review of Resident 10's Minimum Data Set ([MDS], a resident assessment tool), dated 4/28/2024, the MDS indicated Resident 10's cognitive skills (ability to think and reason) for daily decision making were severely impaired. The MDS indicated Resident 10 required set up or clean up assistance (helper sets up or cleans up) for eating, toileting, oral hygiene, and dressing, and when performing personal hygiene.
During a review of Resident 10's Seizure Care Plan, dated 9/20/2024, the care interventions indicated the facility was to monitor and report any subtherapeutic (a drug level too low to produce the intended medical effect) or toxic (poisonous or harmful to the body) results to the physician.
During a review of Resident 10's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Note, dated 2/11/2025, the SBAR Note indicated on 2/11/2025, Resident 10 exhibited a seizure in his room. The SBAR Note indicated Resident 10 exhibited stiff jerking movements and was difficult to arouse. The SBAR Note indicated seizure precautions were initiated, and oxygen was applied via a non-rebreather mask (a device that delivers oxygen to patients who need more than what they can get on their own) with 15 liters ([L]- a unit of measurement) per minute of oxygen. The SBAR Note indicated 911 was called. The SBAR Note indicated Resident 10 suffered two seizures, two minutes apart, the first seizure lasted for three minutes and the second seizure lasted two minutes.
During a review of Resident 10's Order Summary, dated 2/13/2025, the Order Summary indicated Resident 10 was ordered phenobarbital tablet 32.4 milligrams ([mg]- a unit of measurement) one tablet three times a day related to epilepsy. The Order Summary also indicated Resident 10 was to have his phenobarbital level drawn every three months.
During a concurrent interview and record review on 2/12/2025 at 2:53 p.m. with Registered Nurse (RN) 1, Resident 10's Phenobarbital Laboratory Results, dated 10/11/2024, and Nursing Progress Notes, dated 10/2024, were reviewed. The Laboratory Results indicated Resident 10 had a lowered blood level concentration reading of eight (8) micrograms per milliliter ([ug/mL]- a unit of measurement) (normal range of 14-40 ug/mL) for phenobarbital. The Nursing Progress Notes did not indicate Resident 10's physician was made aware of Resident 10's low blood level concentration of phenobarbital. RN 1 stated Resident 10's blood level concentration of phenobarbital was abnormally low. RN 1 stated the low blood level concentration of phenobarbital indicated Resident 10 was more likely to exhibit a seizure. RN 1 stated RN 1 usually reviewed all laboratory results, and Resident 10's laboratory results may have been missed. RN 1 stated Resident 10's physician should have been made aware of Resident 10's low blood level concentration of phenobarbital on 10/11/2024. RN 1 stated there was a possibility that Resident 10's phenobarbital blood levels continued to remain subtherapeutic when Resident10 suffered a seizure on 2/11/2025.
During an interview on 2/12/2025 at 2:20 p.m. with the Director of Nurses (DON), the DON stated the licensed nurses were expected to monitor and report any subtherapeutic laboratory results to the physician. The DON stated the physician should have been made aware of Resident 10's low blood concentration of phenobarbital (on 10/11/2024) in his system so the physician could have adjusted Resident 10's dose. The DON stated there was a possibility Resident 10 could have exhibited a seizure on 2/11/2025 due to the possibility that Resident 10's blood level concentrations of phenobarbital were low.
During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, revised 11/2017, the P&P indicated the facility was to promptly notify the attending physician changes in the resident's medical/mental condition and/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
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 ensure residents were free from physical and verbal abuse for one o...
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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 residents were free from physical and verbal abuse for one of six sampled residents (Resident 69).
This deficient practice resulted in Resident 69 being verbally and physically abused by Resident 73, and had the potential for Resident 69 to have physical and/or psychological distress.
Findings:
a. During a review of Resident 69's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 69 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness or paralysis on one side of the body), schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 69's Minimum Data Set ([MDS] - a resident assessment tool), dated 1/23/2025, the MDS indicated Resident 69's cognitive (the ability to think and process information) skills for daily living was severely impaired. The MDS indicated Resident 69 required maximal (helper does more than half the effort) assistance form staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).
During a review of Resident 69's situation, background, assessment, recommendation ([SBAR]-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 2/2/2025, the SBAR indicated Resident 69 had a room change for better roommate compatibility.
During an interview on 2/10/2025 at 9:30 a.m., with Resident 69, on the patio, Resident 69 stated a few days prior (was not able to recall the date), his roommate (Resident 73) yelled at him, called him a bad (curse) word, and threw water at him. Resident 69 stated he felt scared and sad.
b. During a review of Resident 73's Face Sheet, the Face Sheet indicated Resident 73 was admitted to the facility on [DATE] with diagnoses which included DM, dysphagia (difficulty swallowing), and hypertension (HTN- high blood pressure).
During a review of Resident 73's MDS, dated [DATE], the MDS indicated Resident 73's cognitive skills for daily living was intact. The MDS indicated Resident 73's required moderate (helper does less than half the effort) assistance from staff for ADLs.
During a review of Resident 73's History and Physical (H&P), dated 12/1/2024, the H&P indicated Resident 73 had the capacity to understand and make decisions.
During an interview on 2/10/2025 at 10:31 a.m., with Resident 73, in Resident 73's room. Resident 73 stated on 2/2/2025 in the early evening hours (was not able to recall the time), he had a verbal, and physical altercation with his roommate (Resident 69). Resident 73 stated he was upset and angry because Resident 69 was eating his (Resident 73) snacks. Resident 73 stated he throw water at Resident 69 and called Resident 69 a Motherf---er.
During a concurrent interview and record review on 2/12/2025 at 11:00 a.m., with the Director of Nursing (DON), Resident 73's SBAR dated 2/2/2025 was reviewed. The DON stated the SBAR indicated Resident 73 yelled curse words and threw a water pitcher towards his roommate (Resident 69). The DON stated the SBAR indicated Resident 73 was yelling at Resident 69, I'm going to hit him in the face because he (Resident 69) ate my snacks. The DON stated Resident 73's action toward Resident 69 was resident to resident verbal and physical abuse. The DON stated residents at the facility shall be free from verbal, and physical abuse.
During a telephone interview on 2/12/2025 at 12:00 p.m., with Licensed Vocational Nurse (LVN 6), LVN 6 stated in the evening of 2/2/2025, she was at the nurses' station and heard yelling and screaming coming from Residents 69 and 73's room. LVN 6 stated she walked into the room and observed Resident 73 yelling curse words and throwing a water pitcher towards Resident 69. LVN 6 stated Resident 73 was upset and angry because Resident 69 was eating his snacks. LVN 6 stated Resident 73's action towards Resident 69 was physical and verbal abuse.
During a review of the facility's policy and procedure (P&P) titled Preventing Resident Abuse, revised 12/2013, the P&P indicated the facility would not condone any form of resident abuse. The P&P indicated the facility would maintain an abuse-free environment.
During a review of the facility's P&P titled Resident Rights, revised 12/2016, the P&P indicated residents at the facility shall be free from abuse.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 report an allegation of physical and verbal abuse for one two of si...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of physical and verbal abuse for one two of six sampled residents (Resident 69 and Resident 73), by failing to:
1. Ensure facility staff report no later than two hours, the alleged resident to resident physical and verbal abuse to the California Department of Public Health (CDPH).
2. Ensure the facility report the results of the investigation within five (5) working days.
These deficient practices resulted in a delay of an onsite investigation by CDPH and had the potential to place all residents in the facility at risk for further abuse.
Findings:
a. During a review of Resident 69's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 69 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness or paralysis on one side of the body), schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 69's Minimum Data Set ([MDS] - a resident assessment tool), dated 1/23/2025, the MDS indicated Resident 69's cognitive (the ability to think and process information) skills for daily living was severely impaired. The MDS indicated Resident 69 required maximal (helper does more than half the effort) assistance form staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).
During a review of Resident 69's situation, background, assessment, recommendation ([SBAR]-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 2/2/2025, the SBAR indicated Resident 69 had a room change for better roommate compatibility.
During an interview on 2/10/2025 at 9:30 a.m., with Resident 69, on the facility's patio, Resident 69 stated a few days prior (was not able to recall the date), his roommate (Resident 73) yelled at him, called him a bad (curse) word and threw water at him. Resident 69 stated he felt scared and sad.
b. During a review of Resident 73's Face Sheet, the Face Sheet indicated Resident 73 was admitted to the facility on [DATE] with diagnoses which included DM, dysphagia (difficulty swallowing), and hypertension (HTN- high blood pressure).
During a review of Resident 73's MDS, dated [DATE], the MDS indicated Resident 73's cognitive skills for daily living was intact. The MDS indicated Resident 73's required moderate (helper does less than half the effort) assistance from staff for ADLs.
During a review of Resident 73's History and Physical (H&P), dated 12/1/2024, the H&P indicated Resident 73 had the capacity to understand and make decisions.
During an interview on 2/10/2025 at 10:31 a.m., with Resident 73, in Resident 73's room, Resident 73 stated on 2/2/2025 in the early evening hours (was not able to recall the time), he had a verbal, and physical altercation with his roommate (Resident 69). Resident 73 stated he was upset and angry because Resident 69 was eating his (Resident 73) snacks. Resident 73 stated he threw water at Resident 69 and called Resident 69 a Motherf---er.
During a concurrent interview and record review on 2/12/2025 at 11:00 a.m., with the Director of Nursing (DON), Resident 73's SBAR dated 2/2/2025 was reviewed. The DON stated the SBAR indicated Resident 73 curse words and threw a water pitcher towards his roommate (Resident 69). The DON stated the SBAR indicated Resident 73 was yelling at Resident 69 I'm going to hit him in the face because he (Resident 69) ate my snacks. The DON stated Resident 73's action toward Resident 69 was resident to resident verbal and physical abuse. The DON stated, the staff should have reported to her (DON) and/or Administrator (ADM).
During a telephone interview on 2/12/2025 at 12:00 p.m., with Licensed Vocational Nurse (LVN 6), LVN 6 stated in the evening of 2/2/2025, she was at the nurses' station and heard yelling and screaming coming from Residents 69, and 73's room. LVN 6 stated she walked into the room and observed Resident 73 yelling curse words and throwing a water pitcher towards Resident 69. LVN 6 stated Resident 73 was upset and angry because Resident 69 was eating his snacks. LVN 6 stated Resident 73's action towards Resident 69 was a physical and verbal abuse. LVN 6 stated she did not report the resident to resident physical and verbal abuse to the DON, ADM, and/or the CDPH. LVN 6 stated it was important to report a verbal and physical abuse to the DON, ADM, and/or the CDPH immediately, to investigate the allegations, and to prevent the risk of Resident 69 and other residents in the facility from being abused.
During a review of the facility's policy and procedure (P&P) titled Recognizing Signs and Symptoms of Abuse/Neglect, revised 1/2011, the P&P indicated all personnel would report any signs and symptoms of abuse to their supervisor and/or to the Director of Nursing (DON) immediately.
During a review of the facility's P&P titled Abuse Investigation, revised 4/2014, the P&P indicated should an incident or suspected incident of resident abuse should be reported to the Administrator (ADM), or his/her designee.
During a review of the P&P titled Abuse Reporting and Investigation, dated 11/2018, the P&P indicated:
1. The facility would report all allegations of abuse as required by law and regulations to the appropriate agencies within two (2) hours.
2. The facility would provide a written report of the results of the abuse investigation and appropriate action taken to the CDPH Licensing and Certification within five (5) working days of the reported allegation.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to implement its policy and procedure (P&P) by failing to investigate...
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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 (P&P) by failing to investigate a resident-to-resident physical and verbal abuse between two of six sampled residents (Resident 69 and Resident 73).
This deficient practice resulted in unidentified abuse in the facility to Resident 69 and failed to protect other residents from abuse.
Findings:
a. During a review of Resident 69's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 69 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness or paralysis on one side of the body), schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 69's Minimum Data Set ([MDS] - a resident assessment tool), dated 1/23/2025, the MDS indicated Resident 69's cognitive (the ability to think and process information) skills for daily living was severely impaired. The MDS indicated Resident 69 required maximal (helper does more than half the effort) assistance from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).
During an interview on 2/10/2025 at 9:30 a.m., with Resident 69, on the facility's patio, Resident 69 stated a few days prior (was not able to recall the date), his roommate (Resident 73) yelled at him, called him a curse word, and threw water at him. Resident 69 stated he felt scared and sad.
b. During a review of Resident 73's Face Sheet, the Face Sheet indicated Resident 73 was admitted to the facility on [DATE] with diagnoses which included DM, dysphagia (difficulty swallowing), and hypertension (HTN- high blood pressure).
During a review of Resident 73's MDS, dated [DATE], the MDS indicated Resident 73's cognitive skills for daily living was intact. The MDS indicated Resident 73's required moderate (helper does less than half the effort) assistance from staff for ADLs.
During a review of Resident 73's History and Physical (H&P), dated 12/1/2024, the H&P indicated Resident 73 had the capacity to understand and make decisions.
During an interview on 2/10/2025 at 10:31 a.m., with Resident 73, in Resident 73's room, Resident 73 stated on 2/2/2025 in the early evening hours (was not able to recall the time), he had a verbal and physical altercation with his roommate (Resident 69). Resident 73 stated he was upset and angry because Resident 69 was eating his (Resident 73) snacks. Resident 73 stated he throw water at Resident 69 and called Resident 69 a Motherf---er.
During a concurrent interview and record review on 2/12/2025 at 11:00 a.m., with the Director of Nursing (DON), Resident 73's SBAR dated 2/2/2025 was reviewed. The DON stated the SBAR indicated Resident 73 used curse words and threw a water pitcher towards Resident 69. The DON stated the SBAR indicated Resident 73 was yelling at Resident 69 I'm going to hit him in the face because he (Resident 69) ate my snacks. The DON stated Resident 73's action toward Resident 69 was resident to resident verbal and physical abuse, and the staff should have investigated the abuse allegations immediately (no later than two hours) per the facility's policy.
During a telephone interview on 2/12/2025 at 12:00 p.m., with Licensed Vocational Nurse (LVN 6), LVN 6 stated in the evening of 2/2/2025, while at the nurses' station she heard yelling and screaming coming from Residents 69, and 73's room. LVN 6 stated she walked into the room and observed Resident 73 yelling curse words and throwing a water pitcher towards Resident 69. LVN 6 stated she should have immediately reported what occurred between Resident 69 and Resident 73 to the DON so the DON could have started an investigation immediately and prevent the risk of Resident 69 and other residents in the facility from being abused.
During a review of the facility's P&P titled Abuse Investigation, revised 4/2014, the P&P indicated all reports of resident abuse shall be thoroughly and promptly investigated by the facility management.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
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 Minimum Data Set ([MDS] - a resident asses...
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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 Minimum Data Set ([MDS] - a resident assessment tool), for one of eight sampled residents (Resident 48) was accurately coded to reflect Resident 48's oral and/or dental status.
This deficient practice resulted in incorrect data transmitted to the Centers for Medicare and Medicaid Services (CMS) regarding Resident 48's dentures (oral appliances that replace missing teeth) and had the potential to negatively affect Resident 48's care plan and delivery of necessary care and services.
Findings:
During a review of Resident 48's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 48 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease ([COPD]- a chronic lung disease causing difficulty in breathing), diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing), depression (loss of interest in activities), and anxiety (feeling of fear).
During a review of Resident 48's Minimum Data Set ([MDS]- a resident assessment tool), dated 11/29/2024, the MDS indicated Resident 48's cognitive (the ability to think and process information) skills for daily decision making was intact. The MDS indicated Resident 48 required moderate (helper does less than half the effort) assistance from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 48 was assessed as not having any oral and/or dental issues.
During a concurrent observation and interview on 2/11/2025 at 3:35 p.m., in Resident 48's room, with Minimum Data Set Nurse (MDSN 1), Resident 48 was observed sitting on the bed. MDSN 1 stated Resident 48 did not have her upper and bottom teeth. MDSN 1 stated Resident 48's dentures were placed on the top of Resident 48's bedside table.
During a concurrent interview and record review on 2/11/2025 at 4:00 p.m., with MDSN 1, Resident 48's MDS, dated [DATE] section L was reviewed. MDSN 1 stated Resident 48's MDS section L (oral/dental status) was coded incorrectly as it did not reflect the resident's actual oral and/or dental status. MDSN 1 stated because of Resident 48's use of dentures, the MDS should have been coded. MDSN 1 stated accuracy of the MDS assessment was important for, quality measures tools that help quality and measure healthcare process, outcomes, and resident perceptions, and care for the resident. MDSN 1 stated inaccuracy of the MDS assessment had the potential to result in not meeting the resident's care needs and services.
During a review of the facility's policy and procedure (P&P) titled Certifying Accuracy of the Resident Assessment, revised 11/2019, the P&P indicated qualified professionals who have completed the MDS resident assessment are to certify the accuracy of the section they have completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
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 accurately complete the Preadmission Screening and Resident Review ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete the Preadmission Screening and Resident Review ([PASARR] - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Level I screening by omitting a diagnoses of depression (a mental health condition characterized by loss of interest in activities that interfere with daily functioning) and anxiety (feeling of fear) for one of six sampled residents (Resident 80).
This deficient practice had the potential for Resident 80 to not receive the necessary and appropriate care, treatment and services, and increased risk for a decline in the resident's health and well-being.
Findings:
During a review of Resident 80's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 80 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included depression, anxiety, hypertension (HTN-high blood pressure), dementia (a progressive state of decline in mental abilities), and diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 80's Minimum Data Set ([MDS] - a resident assessment tool), dated 1/8/2025, the MDS indicated Resident 80's cognitive (the ability to think and process information) skills for daily decision making was intact. The MDS indicated Resident 80 required setup or clean up (helper sets up or cleans up; resident completes activity) assistance from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated anxiety and depression were currently Resident 80's active diagnoses.
During a concurrent interview and record review on 2/11/2025 at 2:30 p.m., with the Director of Nursing (DON), Resident 80's PASARR Level I, dated 4/1/2024 was reviewed. The DON stated Resident 80's PASARR Level I, dated 4/1/2024, indicated Resident 80 did not have a serious mental illness (such as depression, and anxiety). The DON stated the facility failed to accurately complete the PASARR Level I screening for Resident 80. The DON stated Resident 80 currently had depression and anxiety diagnoses which were indicated in the clinical records. The DON stated an accurate PASARR was important to identify whether the resident needed special services based on mental illness. The DON stated Resident 80's inaccurate PASARR Level I increased the risk the resident would not receive needed specialized care and services based on the diagnoses and potentially lead to a decline in health and well-being.
During a review of the facility's policy and procedure (P&P) titled Pre-admission Screening Resident Review, undated, the P&P indicated the facility would coordinate assessments and the pre-admission screening and resident review (PASARR). The P&P indicated the facility would refer residents with serious mental disorder for Level II resident review upon assessment.
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 develop and implement the care plan for three of 18 s...
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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 develop and implement the care plan for three of 18 sampled residents (Residents 48, 10, and 242) by failing to:
1. Develop and implement a comprehensive care plan for Resident 48's use of dentures (oral appliances that replace missing teeth).
2. Ensure Resident 10's care plan for seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) was implemented when the facility failed to notify Resident 10's physician of Resident 10's low blood level concentration of Phenobarbital (a medication used to control seizures).
3. Develop and implement a comprehensive, person-centered care plan for Resident 242's oxygen administration.
These deficient practices had the potential to negatively affect Residents 48, 10, and 242's physical well-being, increased Resident 10's risk for a seizure which could lead to bodily injury, and delay necessary monitoring and safety interventions related to Resident 242's oxygen administration.
Findings:
a. During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease ([COPD]- a chronic lung disease causing difficulty in breathing) and depression (loss of interest in activities).
During a review of Resident 48's Minimum Data Set ([MDS]- a resident assessment tool), dated 11/29/2024, the MDS indicated Resident 48's cognitive (the ability to think and process information) skills for daily decision making was intact. The MDS indicated Resident 48 required moderate (helper does less than half the effort) assistance from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 48 was assessed as not having any oral and/or dental issues.
During a concurrent observation and interview on 2/11/2025 at 3:35 p.m., in Resident 48's room, with Minimum Data Set Nurse (MDSN 1), observed Resident 48 seated on the bed. MDSN 1 stated Resident 48 did not have her upper and bottom teeth. MDSN 1 stated Resident 48's dentures placed on the top of Resident 48's bedside table.
During a concurrent interview and record review on 2/11/2025 at 4:00 p.m., with MDSN 1, Resident 48's electronic medical record (eMAR), was reviewed. MDSN 1 was not able to locate a care plan for Resident 48's use of dentures. MDSN 1 stated there was no care plan for the use of dentures and there should have been a care plan initiated upon Resident 48's admission to the facility. MDSN 1 stated care planning served as a communication tool among facility staff who provided care to the residents. MDSN 1 stated if there was no care plan, the facility staff would not be able to provide quality of care to residents.
c. During a review of Resident 242's admission Record, the admission Record indicated Resident 242 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission record indicated the following diagnoses which included COPD, respiratory failure (a serious lung condition that makes it difficult to breathe on your own), dependence on supplemental oxygen, type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and chronic kidney disease (CKD - a longstanding disease in which the kidneys are damaged and cannot filter blood as well as they should).
During a review of Resident 242's H&P, dated 2/5/2025, the H&P indicated Resident 242 had the capacity to understand and make decisions.
During a review of Resident 242's MDS, dated [DATE], the MDS indicated Resident 242's cognition was moderately impaired. The MDS indicated Resident 242 required set-up and clean up assistance (helper sets up or cleans up) for eating and was dependent (helper does all of the effort) with bathing and toileting.
During a review of Resident 242's Order Summary Report dated 2/5/2025, the order summary report indicated Resident 242 had an active order on 1/8/2025 for oxygen at 2 liters per minute (LPM) via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) every day as needed to keep oxygen above 93 percent (%) related to aspiration (when food, drink or objects enter the lungs) precautions.
During an observation on 2/10/2025 at 4:07 p.m., observed Resident 242 lying in bed receiving oxygen at 2 LPM via nasal cannula.
During a concurrent interview and record review on 2/12/2025 at 12:37 p.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 reviewed Resident 242's care plans. LVN 4 stated Resident 242 did not have an oxygen care plan. LVN 4 stated Resident 242 should have had an oxygen care plan because the resident was receiving oxygen. LVN 4 stated an oxygen care plan was important in order to follow interventions regarding Resident 242's oxygen parameters and oxygen safety.
During an interview on 2/13/2025 at 9:47 a.m., with the Director of Nursing (DON), the DON stated all residents receiving oxygen should have a care plan. The DON stated the MDS Coordinator or any licensed nurse care assigned to the resident was responsible for initiating a care plan once a resident was placed on oxygen.
During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive [NAME]-Centered, revised March 2022, the P&P indicated a comprehensive, person-centered care plan would includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs would be developed and implemented for each resident. The P&P indicated the comprehensive, person-centered care plan would be developed within seven days of the completion of the MDS assessment and no more than 21 days after admission.
b. During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 10's diagnoses included epilepsy (a chronic brain disorder characterized by recurrent seizures), status epilepticus (a life-threatening medical emergency that can occur in people with epilepsy), history of falling, schizophrenia (a mental illness that is characterized by disturbances in thought), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and abnormalities of gait and mobility.
During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 10 required set up or clean up assistance (helper sets up or cleans up) for eating, toileting, oral hygiene, and dressing, and when performing personal hygiene.
During a review of Resident 10's Seizure Care Plan, dated 9/20/2024, the interventions indicated the facility was to monitor and report any subtherapeutic (a drug level too low to produce the intended medical effect) or toxic (poisonous or harmful to the body) results to the physician.
During a review of Resident 10's Phenobarbital Laboratory Results, dated 10/11/2025, the Phenobarbital Laboratory Results indicated Resident 10 had a lowered blood level phenobarbital reading of eight (8) micrograms per milliliter ([ug/mL]- a unit of measurement) (normal range of 14-40 ug/mL).
During a review of Resident 10's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 2/11/2025, the SBAR indicated on 2/11/2025, Resident 10 exhibited a seizure in his room. The SBAR Note indicated Resident 10 exhibited stiff jerking movements and was difficult to arouse. The SBAR note indicated seizure precautions were initiated, and oxygen was applied via a non-rebreather mask (a device that delivers oxygen to patients who need more than what they can get on their own) with 15 liters ([L]- a unit of measurement) of oxygen per minute. The SBAR note indicated 911 was called. The SBAR note indicated Resident 10 suffered two seizures, two minutes apart. The SBAR note indicated the first seizure lasted for three minutes and the second seizure lasted two minutes.
During a review of Resident 10's Order Summary, dated 2/13/2025, the Order Summary indicated Resident 10 was ordered Phenobarbital Tablet 32.4 milligrams ([mg]- a unit of measurement) one tablet three times a day related to epilepsy. The Order Summary also indicated Resident 10 was to have his phenobarbital level drawn every three months (February, May, August and November).
During a concurrent record review and interview on 2/12/2025 at 2:53 p.m. with Registered Nurse (RN) 1, Resident 10's Phenobarbital Laboratory Results, dated 10/11/2024, and Nursing Progress Notes, dated 10/2024, were reviewed. The Laboratory Results indicated Resident 10 had a phenobarbital blood level reading of 8 ug/mL. The Nursing Progress Notes did not indicate Resident 10's physician was made aware of Resident 10's low blood level of phenobarbital. RN 1 stated Resident 10's blood level of phenobarbital was abnormally low.
RN 1 stated the low blood level concentration of phenobarbital indicated Resident 10 was more likely to exhibit a seizure. RN 1 stated RN 1 usually reviewed all laboratory results, and Resident 10's laboratory results may have been missed. RN 1 stated Resident 10's physician should have been made aware of Resident 10's low blood levels of phenobarbital. RN 1 stated there was a possibility that Resident 10's phenobarbital blood levels continued to remain subtherapeutic when Resident 10 suffered a seizure on 2/11/2025.
During a concurrent record review and interview on 2/13/2025 at 11:25 a.m., with Quality Assurance Nurse (QA 1), Resident 10's Seizure Care Plan interventions, dated, 9/20/2024, was reviewed. The Seizure Care Plan interventions indicated the facility was to monitor and report any subtherapeutic or toxic results to the physician. QA 1 stated the licensed nurses did not follow Resident 10's seizure care plan and there was a lack of documentation to indicate the physician was made aware. QA 1 stated the physician would have been able to adjust Resident 10's dose of phenobarbital if the physician was made aware. QA 1 stated the lack of physician notification increased the likelihood of Resident 10 to exhibit a seizure or a fall due to a seizure.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care and services to maintain good grooming a...
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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 care and services to maintain good grooming and personal hygiene for one of eight sampled residents (Residents 86) by failing to keep Resident 86's fingernails clean and neat.
This failure had the potential to result in a negative impact on Resident 86's quality of life and self-esteem and had the potential for the development of an infection.
Findings:
During a concurrent observation and interview on 2/10/2025 at 8:57 a.m., with Resident 86, in Resident 86's room, observed Resident 86's fingernails long with black substance underneath her fingernails. Resident 86 stated she did not remember the last time her fingernails were cleaned or cut. Resident 86 stated her fingernails looked long and that she would like to have her fingernails cut and cleaned.
During a review of Resident 86's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 86 was admitted to the facility on [DATE] with diagnoses which included dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), muscle wasting (weakening, shrinking, and loss of muscle), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
During a review of Resident 86's Minimum Data Set ([MDS] - a resident assessment tool), dated 1/8/2025, the MDS indicated Resident 86's cognitive (the ability to think and process information) skills for daily living was severely impaired. The MDS indicated Resident 86 required maximal (helper does more than half the effort) assistance from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).
During a review of Resident 86's care plan with a focus of Resident has an ADL self-care deficit related to impaired cognitive skills, date initiated 1/4/2025, the care plan interventions indicated the facility would assist Resident 86 with ADLs as needed.
During an observation on 2/10/2025 at 2:00 p.m., in Resident 86's room, Resident 86 had long fingernails and black substance underneath her fingernails.
During a concurrent observation and interview on 2/11/2025 at 2:50 p.m., with Certified Nursing Assistant (CNA 2), in Resident 86's room, Resident 86 was observed with long fingernails with black substance underneath. CNA 2 stated Resident 86's fingernails were long and dirty. CNA 2 stated CNAs were responsible for cleaning the residents' fingernails daily and trimming as needed. CNA 2 stated it was important to keep Resident 86's fingernails clean and trimmed to prevent the growth of bacteria (infection). CNA 2 stated long, dirty fingernails had the potential for the resident to scratch her skin and if Resident 86 scratched herself hard enough, it could create an open wound and increased risk of infection. CNA 2 stated having dirty fingernails was not sanitary because the resident will use her hands to hold utensils when eating and any bacteria could transfer into the body.
During an interview on 2/13/2025 at 10:43 a.m., with the Director of Staff Development (DSD), the DSD stated it was the CNAs' responsibility to make sure the residents' fingernails were cleaned daily and trimmed as needed. The DSD stated residents should be provided with care and services necessary to maintain good personal hygiene.
During a review of the facility's policy and procedure (P&P) titled Fingernails/Toenails, Care, revised 2/2018, the P&P indicated the facility would clean residents' fingernails daily to prevent infections. The P&P indicated the facility would trim resident's fingernails regularly to prevent the resident from scratching and injuring his or her skin.
During a review of the facility's P&P titled Job Description Certified Nursing Assistant (CNA), undated, the P&P indicated the CNAs would assist residents with nails care (i.e., clipping, trimming, and cleaning the fingernails).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
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, with severe, painful bilateral (pe...
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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, with severe, painful bilateral (pertaining to both sides) hand contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) was provided the application of hand splints (used to support and position the hand and wrist to help reduce pain and swelling, and to prevent further contractures) for four to five hours, as ordered by the physician, for one out of six sampled residents (Resident 3).
This failure had the potential for Resident 3 to develop worsening pain, experience more frequent episodes of bleeding on Resident 3's inner palm (where his ring finger met the face of his palm), and worsen the condition of Resident 3's bilateral hand contractures.
Findings:
During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included dysphagia (difficulty swallowing), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity).
During a review of Resident 3's Minimum Data Set ([MDS], a resident assessment tool), dated 11/22/2024, the MDS indicated Resident 3's cognitive skills (ability to think and reason) for daily decision making was intact. The MDS indicated Resident 3 required substantial or maximal assistance (helper provides more than half of the effort) for eating, toileting, oral hygiene, and dressing, and when performing personal hygiene. The MDS indicated Resident 3 had functional limitations in both upper extremities.
During a review of Resident 3's Order Summary Report, dated 2/11/2025, the Order Summary Report indicated Resident 3 was ordered the application of bilateral hand rolls (splints) for four to five hours every day five days a week.
During a concurrent observation and interview on 2/10/2025 at 12:45 p.m., with Resident 3, in Resident 3's room, Resident 3's hands were observed. Resident 3's hands were tightly curled into a fist, and Resident 3's inner palm had redness and a deep indentation where his ring fingernail met his palm. Resident 3 stated his inner palm (where his ring finger met his palm) would bleed on occasion. Resident 3 stated his contractures caused him pain, and he did not receive services to splint his hands or exercises to improve his range of motion in his arms or his legs.
During observations made on 2/11/2025 at 7:45 a.m., 9:51 a.m., 11:28 a.m., 12:15 p.m., 1:04 p.m., 2:16 p.m., and 3:05 p.m., Resident 3 did not have hand splints applied.
During an interview on 2/12/25 at 9:58 a.m., with Resident 3, Resident 3 stated the Restorative Nurse Aids (RNAs) did not apply hand splints on him for the entire day yesterday (2/11/2025).
During a concurrent interview and record review on 2/12/2025 at 10:35 a.m. with RNA 1, Resident 3's RNA Flow Sheet, dated 2/2025, and RNA 1's timecard, dated 2/11/22025, were reviewed. The RNA Flow Sheet indicated Resident 3 received 240 minutes of the application of bilateral hand splints on 2/11/2025. The timecard indicated RNA 1 worked on 2/11/2025, from 7:17 a.m. to 3:35 p.m. RNA 1 stated she was the assigned RNA for Resident 3. RNA 1 stated she did not apply Resident 3's bilateral hand splints because she did not have enough time to complete the task, and she did not chart accurately in Resident 3's RNA Flow Sheet. RNA 1 stated RNAs were only scheduled to work on weekdays, and if Resident 3 did not get his splinting done on 2/11/2025, then Resident 3 did not receive services to splint his hands for the entire five days, as ordered. RNA 1 stated there was a possibility for Resident 3's bilateral hand contractures to worsen if his bilateral hand splints were not applied for four to five hours as ordered.
During an interview on 2/12/2025 at 11:30 a.m. with Certified Occupational Therapy Assistant (COTA) 1, COTA 1 stated the application of hand splints were beneficial for residents with hand contractures to ease the pain associated with hand contractures and to prevent gradual worsening of the hand contractures. COTA 1 stated there was a potential for decline or the worsening of hand contractures if the resident did not receive the application of the hand splints as ordered.
During a review of the facility's Policy and Procedure (P&P), titled, Restorative Nursing Services, revised 7/2017, the P&P indicated the facility was to ensure residents will receive restorative nursing care as needed to help promote optimal safety and independence.
During a review of the facility's P&P, titled, Health Information Record Manual, revised 1/2025, the P&P indicated the facility was to ensure charting for RNA programs must agree with the physician orders or the nursing plan of care.
CONCERN
(D)
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** c. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnoses included dysphagia (difficulty swallowing), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity).
During a review of Resident 3's MSD, dated 11/22/2024, the MDS indicated Resident 3's cognitive skills for daily decision making was intact. The MDS indicated Resident 3 required substantial or maximal assistance (helper provides more than half of the effort) for eating, toileting, oral hygiene, and dressing, and when performing personal hygiene.
During a review of Resident 3's Physician Orders, dated 7/2024, the Physician Orders indicated Resident 3 was ordered a pureed (food that has been ground, pressed, blended or served to the consistency of paste or liquid) diet.
During an observation on 2/11/2/2025 at 1:04 p.m. in Resident 3's room, observed Certified Nursing Assistant (CNA) 3 seated in a chair with her back facing away from the entrance of the room. Resident 3's bed side table was positioned in front of CNA 3. CNA 3's personal cellular phone device and Resident 3's meal tray was positioned on top of Resident 3's bed side table. CNA 3 had both earphones in each ear. CNA 3 proceeded to scoop the contents of Resident 3's meal plate onto a spoon and feed it into Resident 3's mouth while she continued to watch her personal cellular phone device. CNA 3 continued to watch her personal cellular phone device with earphones in both ears until CNA 3 heard the State Agency Surveyor call CNA 3's attention on the third attempt.
During an interview on 2/11/2025 at 2:06 p.m. with CNA 3, CNA 3 stated she watched Tik Tok on her personal cellular phone and had both earphones in her ears while feeding Resident 3. CNA 3 stated it was not an acceptable practice because she would not have been able to see or hear if Resident 3 choked as it was not a safe way to feed any resident.
During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, revised July 2017, the P&P indicated, Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P&P indicated employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accidents hazards and try to prevent avoidable accidents.
During a review of the facility's P&P titled, Falls and Fall Risk, Managing, revised March 2018, the P&P indicated the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. The P&P indicated obstacles in the footpath as a fall risk factor. The P&P indicated the staff would monitor and document each resident's response to intervention intended to reduce falling or the risks of falling.
During a review of the facility's P&P titled, Answering the Call Light, revised August 2022, the P&P indicated when a resident is in the bed or confined to a chair, the call light must be within easy reach of the resident.
Based on observation, interview, and record review, the facility failed to ensure residents' environment remains as free of accident hazards as possible for three out of 15 sampled residents (Residents 72, 80, and 3), by failing to:
1. Ensure nursing staff followed the facility's policy and procedure (P&P) on fall prevention for Resident 72 by ensuring a footpath free of obstacles and the call light device was within reach at all times.
2. Ensure the leaking bathroom sink and drainpipe was repaired in Resident 80's bathroom.
3. Certified Nursing Assistant (CNA 3) did not watch television on her personal cellular phone device with earphones in each ear while she fed Resident 3 his meal.
These deficient practices increased Residents 72 and 80's risk for falls and leading to injury, and had the potential for Resident 3 to exhibit an unwitnessed episode of choking (when a person cannot speak, cough, or breath because something is blocking the airway) or undetected signs and symptoms of choking while being fed.
Findings:
a. During a review of Resident 72's admission Record, the admission record indicated Resident 72 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses which included type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic kidney disease (CKD - a longstanding disease in which the kidneys are damaged and cannot filter blood as well as they should), muscle wasting (weakening, shrinking, and loss of muscle), and difficulty walking.
During a review of Resident 72's History and Physical (H&P), dated 12/5/2024, the H&P indicated Resident 72 had a fluctuating capacity to understand and make decisions.
During a review of Resident 72's Minimum Data Set (MDS - a resident assessment tool), dated 1/30/2025, the MDS indicated Resident 72's cognition (ability to think, remember, and reason) was moderately impaired. The MDS indicated Resident 72 required moderate assistance (helper does less than half the effort) with bathing, toileting and personal hygiene. The MDS indicated Resident 72 required moderate assistance to walk 10 feet and utilized a wheelchair or walker to assist with mobility (the ability to move freely).
During a review of Resident 72's Fall Risk Evaluation, dated 1/20/2025, the fall risk evaluation indicated Resident 72 was at high risk for falls. The fall risk evaluation indicated Resident 72 had decreased muscular coordination, balance problems while walking and standing, and required the use of assistive devices.
During a review of Resident 72's Care Plan titled Risk for Falls, initiated on 7/23/2024, the care plan indicated Resident 72's fall risk was related to an abnormal gait (walk), mobility, and cognitive impairment. The care plan indicated Resident 72's goal was to be free of falls. The care plan interventions indicated to evaluate Resident 72's environment to identify factors known to increase the risk of falls. The care plan interventions also indicated if Resident 72 was a fall risk, to initiate fall risk precautions, ensure Resident 72's call light was available, and utilize devices as appropriate to ensure Resident 72's safety.
During a review of Resident 72's Care Plan titled Resident at Risk for Falls, initiated on 10/28/2024, the care plan indicated Resident 72's fall risk was related to psychoactive (affects how the brain works) drug use, weakness, and fatigue (tiredness and lack of energy). The care plan goals indicated Resident 72 would be free of falls and not sustain serious injury for 90 days. The care plan interventions indicated Resident 72 needed a safe environment with even floors that were free from spills and clutter, a working and reachable call light, and a bed in low position. The care plan interventions also indicated Resident 72 required prompt responses to all requests for assistance.
During an observation on 2/10/2025 at 10:55 a.m., in Resident 72's room, observed Resident 72 lying in bed with her call light device not within reach hanging from the drawer handle of her nightstand table. Resident 72 wore a yellow Fall Precaution bracelet on her left wrist. Resident 72 had cords and wires along with several pairs of shoes on the floor next to her bed.
During an observation on 2/11/2025 at 2:15 p.m., in Resident 72's room, observed Resident 72 in bed. Observed Resident 72's call light device not within reach hanging from the drawer of her nightstand. Wires and shoes were observed on the floor next to Resident 72's bed.
During a concurrent observation and interview on 2/11/2025 at 2:20 p.m. with Certified Nursing Assistant (CNA) 1, in Resident 72's room, Resident 72 was observed lying in bed with the call light device hanging from the nightstand drawer along with wires, cords and shoes on the floor next to the bed. CNA 1 stated the call light should not be on the nightstand because Resident 72 could not reach it, and the resident could fall if she attempted to retrieve the call light hanging from the nightstand. CNA 1 stated the call light should be on the bed next to Resident 72. CNA 1 stated the wires, cords and shoes on the floor could cause Resident 72 to fall if she (Resident 72) attempted to get out of bed. CNA 1 stated the wires and cords should be removed from the floor and Resident 72's shoes belonged inside of the cabinet and not on the floor next to the bed.
During an interview on 2/11/2025 at 2:28 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 72's call light device should have been within reach. LVN 3 stated the call light device needed to be within reach in order for Resident 72 to call out for assistance and to prevent falls. LVN 3 stated the shoes and wires around the bed should not have been there. LVN 3 stated everything should be in place in Resident 72's room to prevent the resident from falling. LVN 3 stated Resident 72 should not have had items in the area where she had to walk.
During an interview on 2/13/2025 at 9:40 a.m., with the Director of Nursing (DON), the DON stated the nursing staff must ensure the call lights are within reach for the residents at all times. The DON stated cords and shoes on the floor was a tripping hazard for the resident and should not have been there.
b. During an observation on 2/10/2025 at 9:45 a.m., in Resident 80's bathroom, observed leaking from the bathroom sink and drainpipe. Water was observed on the bathroom floor. A plastic container was placed under the sink drainpipe.
During a review of Resident 80's admission Record, the admission record indicated Resident 80 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included depression (a mental health condition characterized by loss of interest in activities that interfere with daily functioning), anxiety (feeling of fear), hypertension (HTN- high blood pressure), dementia (a progressive state of decline in mental abilities), and DM.
During a review of Resident 80's MDS, dated [DATE], the MDS indicated Resident 80's cognitive skills for daily decision making was intact. The MDS indicated Resident 80 required setup or clean up (helper sets up or cleans up; resident completes activity) assistance from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 80 required a walker (a device used to help with balance while walking) for mobility.
During a review of Resident 80's Fall Risk Evaluation (a standardized tool used to evaluate a resident's risk of fall), dated 1/8/2025, the Fall Risk Evaluation indicated Resident 80 was at high-risk for falls, related to gait (walking) and/or balance (to be steady) problem while walking and required the use of a assistive device (walker).
During a review of Resident 80's care plan with a focus of Resident had impaired cognitive function and had the potential for fall, date initiated 9/19/2024, the care plan indicated the interventions included to provide Resident 80 with a safe environment.
During an observation on 2/11/2025 at 9:10 a.m., in Resident 80's bathroom, observed leaking water from the bathroom sink and drainpipe. Observed water on the bathroom floor.
During a concurrent observation and interview on 2/11/2025 at 2:10 p.m., in Resident 80's bathroom, with Resident 80, observed Resident 80 standing by the bathroom sink. Resident 80's bathroom sink was leaking. Water was observed on the floor under the bathroom sink with a plastic container placed under the leaking sink drainpipe. Resident 80 stated the sink and the drainpipe had been leaking for one week. Resident 80 stated he notified the nurse (unidentified) of the leaking sink and drainpipe a few days prior. Resident 80 stated the staff did not come to check and/or fix the leak. Resident 80 stated he was worried he would slip and fall because the water was all over the bathroom floor. Resident 80 stated he placed the plastic container under the sink to prevent the water from leaking onto the bathroom floor.
During a concurrent observation and interview on 2/11/2025 at 2:30 p.m., with CNA 2, in Resident 80's bathroom, observed the leaking water from the sink and drainpipe. Water was observed on the floor. CNA 2 stated water on the bathroom floor created an unsafe environment for the resident and had the potential to place Resident 80 at risk for fall and injury.
During a concurrent observation and interview on 2/11/2025 at 3:05 p.m., with the Maintenance Supervisor (MS), in Resident 80's bathroom, observed water on the bathroom floor. A plastic container with water was observed under the leaking bathroom sink drainpipe. The MS stated the leaking sink and drainpipe and water on the floor was unsafe and dangerous for Resident 80. The MS stated Resident 80 could slip on the wet floor and fall. The MS stated the plastic container under the sink's drainpipe should not be on the floor and/or in the resident's bathroom because Resident 80 could trip and/or try to use the water which was unsafe and unsanitary.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to place oxygen signage at the doorway indicating oxygen...
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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 place oxygen signage at the doorway indicating oxygen was in use for one of eight sampled residents (Resident 242) receiving oxygen therapy.
This deficient practice had the potential to place all residents' and staff's safety at risk.
Findings:
During a review of Resident 242's admission Record, dated 2/13/2024, the admission record indicated Resident 242 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission record indicated the following diagnoses which included, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), respiratory failure (a serious lung condition that makes it difficult to breathe on your own), dependence on supplemental oxygen, type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and chronic kidney disease (CKD - a longstanding disease in which the kidneys are damaged and cannot filter blood as well as they should).
During a review of Resident 242's History and Physical (H&P), dated 2/5/2025, the H&P indicated Resident 242 had the capacity to understand and make decisions.
During a review of Resident 242's Minimum Data Set (MDS - a resident assessment tool), dated 2/10/2025, the MDS indicated Resident 242's cognition (ability to think, remember, and reason) was moderately impaired. The MDS indicated Resident 242 required set-up and clean up assistance (helper sets up or cleans up) for eating and was dependent (helper does all of the effort) with bathing and toileting.
During a review of Resident 242's Order Summary Report dated 2/5/2025, the order summary report indicated Resident 242 had an active order on 1/8/2025 for oxygen at two liters (unit of volume) per minute (LPM) via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) every day as needed to keep oxygen saturation (O2 sat - a measurement of how much oxygen the blood is carrying as a percentage) above 93 percent (%) (normal O2 sat - 95% to 100%) related to aspiration (when food, drink or objects enter the lungs) precautions.
During an observation on 2/10/2025 at 4:07 p.m., observed Resident 242 lying in bed receiving oxygen at two LPM via nasal cannula. Observed Resident 242 did not have oxygen signage placed outside of the doorway or in the room.
During a concurrent observation and interview on 2/11/2025 at 2:40 a.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 observed Resident 242 lying in bed on two LPM oxygen via nasal cannula. LVN 3 stated Resident 242 did not have oxygen signage placed outside of the door. LVN 3 stated there should be an oxygen sign on Resident 242's door because the resident was receiving oxygen. LVN 3 stated it was important to have oxygen signage on the door of residents receiving oxygen in case of a fire or other safety precautions.
During an interview on 2/23/2025 at 9:47 a.m., with the Director of Nursing (DON), the DON stated as soon as the nursing staff were aware Resident 242 was receiving oxygen, the oxygen signage should have gone up. The DON stated the nursing staff do not have to wait on the environmental services department to place the oxygen signage on the door but should place the oxygen signage on the door as soon as the resident was placed on oxygen.
During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, revised on October 2010, the P&P indicated the following guidelines for safe oxygen administration:
1. Place an Oxygen in Use sign on the outside of the room entrance door and place an Oxygen in Use sign in a designated place on or over the resident's bed.
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 observation, interview, and record review, the facility failed to:
1. Administer medications as per physician's orders ...
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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. Administer medications as per physician's orders and/or manufacturer specifications for two of eight sampled residents (Resident 50 and Resident 69) by failing to:
a. Ensure Resident 50's Aspirin (a medication used to prevent heart attack [flow of blood and oxygen is blocked] and stroke [loss of blood flow to a part of the brain]) chewable tablet was administered as chewable during medication administration.
b. Ensure Resident 69's Quetiapine (a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought] and major depressive disorder (depression) with bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs]) order was entered with accurate scheduled administration times and clarified with the physician before it was administered, when physician order indicating Quetiapine 25 milligrams (mg - a unit of measurement for mass), give 1 tablet orally three times a day related to schizophrenia, order date 12/30/2024, and medication card / bubble pack indicating Quetiapine 25 mg, take one-half (0.5) tablet by mouth (12.5mg) every 8 hours for agitation, did not match.
2. Clarify Resident 30's order for Polyethylene Glycol (a medication used to treat constipation) 3350 oral powder 17 gram (gm - a unit of measurement for mass) per scoop, give 17 gm orally as needed for constipation mix 17 gm with 8 ounce (oz - a unit of measurement for volume) of water or juice and take by mouth, order date 2/18/2024, start date 7/1/2024, to ensure the order had a frequency of administration.
These failures of not administering medications to Residents 30, 50 and 69 in accordance with the physician orders or professional standards of practice had the potential to result in hospitalization due to adverse effects such as heart attack, stroke, diarrhea and behavioral disturbances.
Findings:
1a. During a review of Resident 50's admission Record (a document containing demographic and diagnostic information), dated 2/10/2025, the admission record indicated, Resident 50 was originally admitted to facility on 3/2/2018 and readmitted on [DATE] with diagnoses including but not limited to atherosclerosis (a medical condition with buildup of fat and calcium) of aorta (the main blood vessel through which oxygen and nutrients travel from the heart to organs throughout the body), and Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood glucose level) and hyperlipidemia (a condition with high levels of fat particles [lipids] in the blood).
During a review of Resident 50's History and Physical (H&P), dated 1/14/2025, the document indicated, Resident 50 did not have the capacity to understand and make decisions.
During a review of Resident 50's Minimum Data Set (MDS - a resident assessment tool), dated 12/23/2024, the MDS indicated, Resident 50's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was moderately impaired. The MDS indicated Resident 50 required supervision level assistance from the facility staff in performing activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as eating, upper and lower body dressing, putting on/taking off footwear, and moderate assistance for oral hygiene, toileting and showering.
During an observation on 2/10/2025 between 9:27 a.m. and 9:43 a.m., Licensed Vocational Nurse (LVN) 3 prepared and administered ten medications for Resident 50 that included one tablet of aspirin 81 mg chewable tablet from a manufacturer's bottle. LVN 3 failed to instruct Resident 50 to chew the aspirin tablet. Resident 50 was observed swallowing all medications including the aspirin 81 mg chewable tablet.
During a review of Resident 50's Order Summary Report (a document containing a summary of all active physician orders), dated 2/10/2025 and 1/19/2025, the order summary report indicated but not limited to the following physician order:
Aspirin tab delayed release 81 mg, give 1 tablet orally in the morning for cerebrovascular accident ([CVA] - loss of blood flow to part of the brain, which damages brain tissue) prophylaxis (PPX - prevention), order date 4/22/2024, start date 7/1/2024.
During an interview on 2/10/2025 at 12:32 p.m. with LVN 3, LVN 3 stated aspirin 81 mg for Resident 50 was a chewable tablet and was supposed to be chewed before swallowing. LVN 3 stated Resident 50 did not chew the tablet per manufacturer specifications, which would increase the possibility that aspirin could be ineffective and could increase the resident's potential risk for stroke, heart attack or hospitalization.
1b. During a review of Resident 69's admission record, dated 2/11/2025, the admission record indicated, Resident 69 was admitted to facility on 10/18/2021 with diagnoses including but not limited to schizophrenia and major depressive disorder, recurrent and severe with psychotic symptoms.
During a review of Resident 69's history and physical (H&P), dated 10/24/2024, the H&P indicated Resident 69 had fluctuating capacity to understand and make decisions.
During a review of Resident 69's MDS, dated [DATE], the MDS indicated Resident 69 had severe cognitive impairment. The MDS indicated Resident 69 required supervision level assistance from the facility staff for ADLs such as eating, moderate assistance for oral hygiene, and maximal assistance for toileting, showering, upper and lower body dressing, putting on/taking off footwear and personal hygiene.
During an observation of a medication administration on 2/11/2025 at 1:22 p.m., LVN 1 prepared and administered one-half (0.5) tablet (12.5 mg) of quetiapine fumarate 25 mg to Resident 69 from medication card / bubble pack.
During a medication reconciliation review on 2/11/2025 at 2:20 p.m. Resident 69's order summary report and observed administered medication details were reviewed. The order summary report, dated 2/12/2025 indicated, but not limited to the following physician orders:
Quetiapine fumarate tab 25 mg, give 1 tablet orally three times a day related to schizophrenia, unspecified, manifested by (m/b) constantly trying to throw/slide himself out of bed. Informed consent obtained by MD after explanation of risks and benefits to the resident, order date 12/30/2024, start date 12/30/2024.
Quetiapine fumarate oral tablet, give 12.5 mg by mouth three times a day for schizophrenia, unspecified, m/b constantly trying to throw/slide himself out of bed. Informed consent obtained by MD after explanation of risks and benefits to the resident, order date 2/11/2025, start date 2/11/2025.
Quetiapine fumarate oral tablet, give 12.5 mg by mouth three times a day for schizophrenia, unspecified m/b constantly trying to throw/slide himself out of bed. Informed consent obtained by MD after explanation of risks and benefits to the resident, order date 2/11/2025, start date 2/11/2025.
The order summary report, dated 1/19/2025 indicated, but not limited to the following physician order:
Quetiapine fumarate tab 25 mg, give 1 tablet orally three times a day related to schizophrenia, unspecified, manifested by (m/b) constantly trying to throw/slide himself out of bed. Informed consent obtained by MD after explanation of risks and benefits to the resident, order date 12/30/2024, start date 12/30/2024.
During a review of Resident 69's electronic medication administration record (eMAR) order details, dated 2/11/2025, for quetiapine 25 mg, order date 12/30/2024, the order details indicated facility time code was entered as 9:00 a.m., 1:00 p.m. and 5:00 p.m., and specific times were shown as 9:00 a.m., 2:00 p.m. and 9:00 p.m.
During a review of Resident 69's Medication Administration Record ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 12/30/2024 to 12/31/2024, 1/1/2025 to 1/31/2025 and 2/1/2025 to 2/11/2025, the MAR indicated quetiapine 25 mg was administered for a total of 129 times as give 1 tablet orally three times a day related to schizophrenia with start date 12/30/2024.
During a concurrent interview and record review on 2/11/2025 at 3:02 p.m. with LVN 1, Resident 69's administered order of quetiapine during medication pass observation on 2/11/2025, medication card / bubble pack dated 1/14/2025 and eMAR for quetiapine fumarate tab 25 mg dated 2/13/2025, were reviewed. LVN 1 stated the medication card / bubble pack indicated, quetiapine fum 25 mg, take 0.5 tablet by mouth (12.5 mg) every 8 hours for agitation, whereas the eMAR indicated, quetiapine fumarate tab 25 mg, give 1 tablet orally three times a day related to schizophrenia, order date: 12/30/2024, order status: active. LVN 1 stated the medication card for Resident 69's quetiapine did not match with eMAR order details for quetiapine. LVN 1 stated Resident 69 did not receive quetiapine as ordered by physician and she would call physician to clarify quetiapine order. LVN 1 stated Resident 69 did not receive appropriate dose of quetiapine which possibly failed to manage symptoms and increased risk for behavioral disturbances and hospitalization.
2. During a review of Resident 30's admission record, dated 2/11/2025, the admission record indicated Resident 30 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including but not limited to chronic pain.
During a review of Resident 30's H&P dated 2/19/2024, the H&P indicated Resident 30 had fluctuating capacity to understand and make decisions.
During a review of Resident 30's MDS, dated [DATE], the MDS indicated Resident 30's cognition was moderately impaired. The MDS indicated Resident 30 needed supervision level assistance from the facility staff for ADLs such as eating, moderate assistance for oral hygiene, and maximal assistance for toileting, showering, upper and lower body dressing, putting on/taking off footwear and personal hygiene.
During a medication reconciliation review on 2/11/2025 at 2:05 p.m. following medication administration observation on 2/11/2025 at 12:05 p.m. with LVN 1, Resident 30's order summary report dated 2/12/2025 and 1/19/2025 were reviewed. The order summary report dated 2/12/2025 indicated, but not limited to the following physician orders:
Polyethylene Glycol 3350 oral powder 17 gm/scoop, give 17 grams orally as needed for constipation, mix 17 g with 8 oz of water and juice and take by mouth (PO), order date 2/18/2024, start date 7/1/2024.
Polyethylene Glycol 3350 oral powder 17 gm/scoop, give 17 grams orally every 24 hours as needed for constipation, mix 17 g with 8 oz of water or juice and take PO, order date 2/11/2025, start date 2/11/2025.
The order summary report dated 1/19/2025 indicated, but not limited to the following physician order:
Polyethylene Glycol 3350 oral powder 17 gm/scoop, give 17 grams orally as needed for constipation, mix 17 g with 8 oz of water and juice and take by mouth (PO), order date 2/18/2024, start date 7/1/2024.
During a concurrent interview and record review on 2/11/2025 at 4:49 p.m. with LVN 1, Resident 30's eMAR for polyethylene glycol 3350 oral powder dated 2/13/2025 was reviewed. LVN 1 stated polyethylene glycol order did not have a frequency of administration and needed to be clarified with physician. LVN 1 stated polyethylene glycol was last administered to Resident 30 on 10/7/2024 at 6:48 p.m. LVN 1 stated there was a risk of causing diarrhea, fluid loss and dehydration if polyethylene glycol was given in excess than what Resident 30 needed. LVN 1 stated it was not safe or effective to have a medication order without a clear dosing frequency.
During an interview on 2/12/2025 at 3:50 p.m. with the Director of Nursing (DON), the DON stated Resident 50's chewable aspirin 81 mg should have been administered as a chewable tablet per manufacturer specifications to prevent stroke and clotting. The DON stated if the chewable aspirin was swallowed without chewing, it might not get absorbed completely or timely which could increase the risk for thrombosis (a medical term used when blood clots block blood vessels obstructing blood blow). The DON stated the aspirin 81 mg order should have been clarified with the physician because it was entered in eMAR as a capsule but given as a chewable aspirin tablet where the LVN did not instruct resident to chew the tablet. The DON stated medication orders should have a dosing frequency. The DON stated polyethylene glycol order with only as needed without a frequency could have caused Resident 30 to receive more or lesser amount of medication than needed, increasing resident's risk for diarrhea, dehydration and depending on how the resident reacted to the medication it could cause more harm. The DON stated regarding Resident 69's quetiapine order, during recap, there was an error with quetiapine order, and physician and pharmacy were called for clarification. The DON stated facility should have compared eMAR, the chart and medication card to ensure there were no discrepancies in the orders. The DON stated, resident was doing very well on quetiapine 12.5 mg dose, otherwise there could have been a medication error. The DON stated the nurse who entered the order no longer worked at the facility, but orders should have been entered accurately for the scheduled times of administration according to physician orders.
During a review of the facility's policy and procedure (P&P) titled, Medication Orders, dated 11/2014, the P&P indicated, 1. Medication Orders - When recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered .example: Dilantin .per day. 2. PRN Medication Orders - When recording PRN medication orders, specify the type, route, dosage, frequency, strength and the reason for administration. Example Tylenol 101F.
During a review of the facility's P&P titled, Administering Medications, dated 4/2019, the P&P indicated, Medications are administered in a safe and timely manner and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. The P&P indicated, If a dosage is believed to be inappropriate or excessive for a resident .the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns. The P&P indicated, The individual administering the medication checks the label three (3) times to verify the right resident .right dosage .right method (route) of administration before giving the medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
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 maintain a medication error rate of less than 5 perce...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5 percent (%) during medication pass for two of eight sampled residents (Residents 50 and 69) by failing to:
a. Ensure Resident 50's Aspirin (a medication used to prevent heart attack [flow of blood and oxygen is blocked] and stroke [loss of blood flow to a part of the brain]) chewable tablet was administered as chewable during medication administration.
b. Ensure Resident 69's Quetiapine (a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought] and major depressive disorder (depression) with bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs]) order was clarified with physician before it was administered, when physician order indicating Quetiapine 25 milligrams (mg - a unit of measurement for mass), give 1 tablet orally three times a day related to schizophrenia, order date 12/30/2024, and medication card / bubble pack indicating Quetiapine 25 mg, take one-half (0.5) tablet by mouth (12.5mg) every 8 hours for agitation, did not match.
These deficient practices of medication administration error rate of 8 percent (%) exceeded the five (5) percent (%) threshold.
Findings:
a. During a review of Resident 50's admission Record (a document containing demographic and diagnostic information), dated 2/10/2025, the admission record indicated, Resident 50 was originally admitted to facility on 3/2/2018 and readmitted on [DATE] with diagnoses including but not limited to atherosclerosis (a medical condition with buildup of fat and calcium) of aorta (the main blood vessel through which oxygen and nutrients travel from the heart to organs throughout the body), and Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood glucose level) and hyperlipidemia (a condition with high levels of fat particles [lipids] in the blood).
During a review of Resident 50's History and Physical (H&P), dated 1/14/2025, the document indicated, Resident 50 did not have the capacity to understand and make decisions.
During a review of Resident 50's Minimum Data Set (MDS - a resident assessment tool), dated 12/23/2024, the MDS indicated Resident 50's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was moderately impaired. The MDS indicated Resident 50 required supervision level assistance from the facility staff in performing activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as eating, upper and lower body dressing, putting on/taking off footwear and moderate assistance for oral hygiene, toileting and showering.
During an observation on 2/10/2025 between 9:27 a.m. and 9:43 a.m., Licensed Vocational Nurse (LVN) 3 prepared and administered the following ten medications for Resident 50 that included one tablet of aspirin 81 mg chewable tablet from a manufacturer's bottle. LVN 3 failed to instruct Resident 50 to chew the aspirin tablet. Resident 50 was observed swallowing all of the following medications including aspirin 81 mg chewable tablet:
1. One tablet of amlodipine (a medication used to treat high blood pressure) 5 mg.
2. One tablet of chewable aspirin 81 mg.
3. One tablet of buspirone (a medication used to treat anxiety) 5 mg.
4. One tablet of divalproex (a medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and manic episodes related to bipolar disorder) sodium delayed release 500 mg.
5. One tablet of glyburide (a medication used to treat high blood glucose level) 2.5 mg.
6. One tablet of lisinopril (a medication used to treat high blood pressure) 10 mg.
7. One tablet of megestrol (a medication used to stimulate appetite) 40 mg.
8. One tablet of multivitamin with minerals.
9. One tablet of risperidone (a medication used to treat schizophrenia) 2 mg.
10. One tablet of metformin (a medication used to treat high blood glucose level) 500 mg.
During a review of Resident 50's Order Summary Report (a document containing a summary of all active physician orders), dated 1/19/2025 and 2/10/2025, the order summary report indicated but not limited to the following physician order:
Aspirin tab delayed release 81 mg, give 1 tablet orally in the morning for cerebrovascular accident ([CVA] - loss of blood flow to part of the brain, which damages brain tissue) prophylaxis (PPX - prevention), order date 4/22/2024, start date 7/1/2024.
During an interview on 2/10/2025 at 12:32 p.m. with LVN 3, LVN 3 stated aspirin 81 mg for Resident 50 was a chewable tablet and was supposed to be chewed before swallowing. LVN 3 stated Resident 50 did not chew the tablet per manufacturer specifications, which would increase the possibility that aspirin could be ineffective and could increase resident's potential risk for stroke, heart attack or hospitalization.
b. During a review of Resident 69's admission record, dated 2/11/2025, the admission record indicated, Resident 69 was admitted to facility on 10/18/2021 with diagnoses including but not limited to schizophrenia and major depressive disorder, recurrent and severe with psychotic symptoms.
During a review of Resident 69's H&P, dated 10/24/2024, the H&P indicated Resident 69 had fluctuating capacity to understand and make decisions.
During a review of Resident 69's MDS, dated [DATE], the MDS indicated Resident 69 had severe cognitive impairment. The MDS indicated Resident 69 required supervision level assistance from the facility staff for ADLs such as eating, moderate assistance for oral hygiene, and maximal assistance for toileting, showering, upper and lower body dressing, putting on/taking off footwear and personal hygiene.
During an observation of a medication administration on 2/11/2025 at 1:22 p.m., LVN 1 prepared and administered one-half (0.5) tablet (12.5 mg) of quetiapine fumarate 25 mg to Resident 69 from medication card / bubble pack.
During a medication reconciliation review on 2/11/2025 at 2:20 p.m. Resident 69's order summary report and observed administered medication details were reviewed. The order summary report, dated 2/12/2025 indicated, but not limited to the following physician orders:
Quetiapine fumarate tab 25 mg, give 1 tablet orally three times a day related to schizophrenia, unspecified, manifested by (m/b) constantly trying to throw/slide himself out of bed. Informed consent obtained by MD after explanation of risks and benefits to the resident, order date 12/30/2024, start date 12/30/2024.
Quetiapine fumarate oral tablet, give 12.5 mg by mouth three times a day for schizophrenia, unspecified, m/b constantly trying to throw/slide himself out of bed. Informed consent obtained by MD after explanation of risks and benefits to the resident, order date 2/11/2025, start date 2/11/2025.
Quetiapine fumarate oral tablet, give 12.5 mg by mouth three times a day for schizophrenia, unspecified m/b constantly trying to throw/slide himself out of bed. Informed consent obtained by MD after explanation of risks and benefits to the resident, order date 2/11/2025, start date 2/11/2025.
The order summary report, dated 1/19/2025 indicated, but not limited to the following physician order:
Quetiapine fumarate tab 25 mg, give 1 tablet orally three times a day related to schizophrenia, unspecified, manifested by (m/b) constantly trying to throw/slide himself out of bed. Informed consent obtained by MD after explanation of risks and benefits to the resident, order date 12/30/2024, start date 12/30/2024.
During a review of Resident 69's electronic medication administration record (eMAR) order details, dated 2/11/2025, for quetiapine 25 mg, order date 12/30/2024, the order details indicated facility time code was entered as 9:00 a.m., 1:00 p.m. and 5:00 p.m., and specific times were shown as 9:00 a.m., 2:00 p.m. and 9:00 p.m.
During a review of Resident 69's Medication Administration Record ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 12/30/2024 to 12/31/2024, 1/1/2025 to 1/31/2025 and 2/1/2025 to 2/11/2025, the MAR indicated quetiapine 25 mg was administered for a total of 129 times as give 1 tablet orally three times a day related to schizophrenia with start date 12/30/2024.
During a concurrent interview and record review on 2/11/2025 at 3:02 p.m. with LVN 1,
Resident 69's administered order of quetiapine during medication pass observation on 2/11/2025, medication card / bubble pack dated 1/14/2025 and eMAR for quetiapine fumarate tab 25 mg dated 2/13/2025, were reviewed. LVN 1 stated the medication card / bubble pack indicated, quetiapine fum 25 mg, take 0.5 tablet by mouth (12.5 mg) every 8 hours for agitation, whereas the eMAR indicated, quetiapine fumarate tab 25 mg, give 1 tablet orally three times a day related to schizophrenia, order date: 12/30/2024, order status: active. LVN 1 stated the medication card for Resident 69's quetiapine did not match with eMAR order details for quetiapine. LVN 1 stated Resident 69 did not receive quetiapine as ordered by physician and she would call physician to clarify quetiapine order. LVN 1 stated Resident 69 did not receive appropriate dose of quetiapine which possibly failed to manage symptoms and increased risk for behavioral disturbances and hospitalization.
During an interview on 2/12/2025 at 3:50 p.m. with the Director of Nursing (DON), the DON stated Resident 50's chewable aspirin 81 mg should have been administered as a chewable tablet per manufacturer specifications to prevent stroke and clotting. The DON stated if the chewable aspirin was swallowed without chewing, it might not get absorbed completely or timely which could increase the risk for thrombosis (a medical term used when blood clots block blood vessels obstructing blood blow). The DON stated the aspirin 81 mg order should have been clarified with the physician because it was entered in eMAR as a capsule but given as a chewable aspirin tablet where the LVN did not instruct resident to chew the tablet. The DON stated regarding Resident 69's quetiapine order, during recap, there was an error with quetiapine order, and physician and pharmacy were called for clarification. The DON stated facility should have compared eMAR, the chart and medication card to ensure there were no discrepancies in the orders. The DON stated, resident was doing very well on quetiapine 12.5 mg dose, otherwise there could have been a medication error. The DON stated the nurse who entered the order no longer worked at the facility, but orders should have been entered accurately for the scheduled times of administration according to physician orders.
During a review of the facility's policy and procedure (P&P) titled, Medication Orders, dated 11/2014, the P&P indicated, 1. Medication Orders - When recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered .example: Dilantin .per day. 2. PRN Medication Orders - When recording PRN medication orders, specify the type, route, dosage, frequency, strength and the reason for administration. Example Tylenol 101F.
During a review of the facility's P&P titled, Administering Medications, dated 4/2019, the P&P indicated, Medications are administered in a safe and timely manner and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. The P&P indicated, If a dosage is believed to be inappropriate or excessive for a resident .the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns. The P&P indicated, The individual administering the medication checks the label three (3) times to verify the right resident .right dosage .right method (route) of administration before giving the medication.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:
1. Ensure medications were stored separately from fo...
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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 medications were stored separately from food items (Sriracha [a brand of spicy sauce] bottle) in one of one inspected medication room (Station A Medication Room).
2. Ensure removal of expired niacin (a vitamin B supplement to treat low level of vitamin B) tablets from one of one inspected medication room (Station A Medication Room).
3. Ensure medication storage area did not have an unidentified and/or unapproved container noted to be utilized during medication administration to measure water volume for G-tube flushes in one of two inspected medication carts (Medication Cart B).
4. Ensure storage, labeling and/or removal of expired and/or discontinued medications that included vitamin B12 (a vitamin supplement to treat low level of vitamin B12) tablets, latanoprost ophthalmic solution (a medication in form of eye drops used to treat high pressure in the eyes), insulin glargine (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) prefilled pen, metoclopramide (a medication used to treat heartburn, stomach discomfort and increase gastrointestinal motility) oral solution, cranberry tablets and vitamin D3 (a vitamin supplement to treat low level of vitamin D3) tablets, in accordance with manufacturer requirements, affecting three residents (Residents 58, 83, 36) in two of two inspected medication carts (Medication Cart B, Middle Medication Cart 2).
5. Ensure 15 controlled medications (medications that the use and possession of are controlled by the federal government) that were for discharged residents and/or discontinued orders, were removed from medication cart, and the physical inventory for 15 controlled medications was documented daily in controlled medication accountability record, affecting nine residents (Residents 342, 26, 343, 19, 90, 344, 78 and 29) in one of two inspected medication carts (Medication Cart B). The medications included one or more medication cards (bubble packs) of clonazepam (a medication used to treat panic disorder and seizure [a medical term used to describe sudden, uncontrolled burst of electrical activity in the brain]), lorazepam (a medication used to treat anxiety and insomnia [trouble falling asleep or staying asleep]), temazepam (a medication used to treat insomnia), hydrocodone-acetaminophen (a combination medication used to treat pain), zolpidem (a medication used to treat sleep disorder), tramadol (a medication used to treat pain) and diphenoxylate-atropine (a combination medication used to treat diarrhea).
These failures increased the risk that Residents 58, 83, 36, 342, 26, 343, 19, 90, 344, 78, 29 and other facility residents could have received medications that had become ineffective or toxic due to improper storage, labeling and/or expiration, possibly leading to abnormal blood glucose levels, other health complications, hospitalization, and increased risk for inadvertent medication administration, medication errors, misuse, drug loss, diversion, and accidental exposure to controlled substances to residents and staff.
Findings:
1. During a concurrent inspection and interview on 2/10/2025 at 1:45 p.m. with Licensed Vocational Nurse (LVN) 3 of the Station A Medication Room, there was a bottle of Sriracha sauce (food item) placed on shelf along with medications. LVN 3 stated Sriracha bottle should not have been there along with medications because that posed a risk for cross contamination.
During an interview on 2/12/2025 at 2:55 p.m. with the Director of Nursing (DON), the DON stated facility staff should not be storing food items or water or a bottle of Sriracha sauce next to medications because that increased the risk for contamination.
2. During a concurrent inspection and interview on 2/10/2025 at 1:45 p.m. with LVN 3 of the Station A Medication Room, the following product was expired:
a. One sealed bottle of niacin 100 milligram (mg - a unit of measurement for mass), quantity of 100 tablets, with an expiration date of 8/2024.
LVN 3 stated the expired niacin bottle was expired and should have been removed from medication stock. LVN 3 stated the expired product would not be safe or effective to administer and could cause the residents to have side effects or reactions if administered.
During an interview on 2/12/2025 at 2:55 p.m. with the DON, the DON stated expired medications would have a different chemical breakdown and would not be effective or safe to be administered to residents.
3. During a concurrent inspection and interview on 2/10/2025 at 2:20 p.m. with LVN 4 of the Medication Cart B, there was an empty, white container with some measurements on the outside with a blue lid in the medication cart. The container label was not in English language except the words, Drink Saver 800ml. The container indicated handwritten words Gtube (gastrostomy, [G-tube] a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) flushes in black ink on the lid and on the side. LVN 4 stated she would not take the container with her inside resident's room, but she used the container to measure water whenever she had to perform a G-tube administration and would use same container to measure water volume for G-tube flushes.
During an interview on 2/12/2025 at 02:55 p.m. with the DON, the DON stated there should not have been a random bottle or container in medication cart to measure water volume for any purposes. The DON stated the container was not approved by facility to be used and all facility staff should follow a standard process to measure volume of water for G-tube administration to prevent medication errors.
4a. During a concurrent inspection and interview on 2/10/2025 at 2:20 p.m. with LVN 4 of the Medication Cart B, the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications:
1. One open bottle of vitamin B12 100 microgram (mcg - a unit of measurement for mass) with an expiration date of 12/2024.
2. One bottle of sealed latanoprost ophthalmic solution 0.005 percent (%) for Resident 58 with no opened date.
According to the manufacturer's product labeling, unopened bottle(s) should be stored under refrigeration at 2-to-8 degree Celsius [(°C) is a unit of temperature] (36-to-46 degree Fahrenheit [(°F) is a unit of temperature]) and open or in-use bottle should be stored at room temperature up to 25°C (77°F) for six weeks.
LVN 4 stated the latanoprost eye drops would help Resident 58 to treat glaucoma so if it was not properly stored according to manufacturer specifications, the medication should not be administered because it would not be safe or effective and could have side effects. LVN 4 stated, I don't know what those side effects would be.
3. One prefilled pen of insulin glargine-yfgn 100 units (a unit of measurement for insulin) / milliliters ([mL] - a unit of measurement for volume) for Resident 83 with no opened date.
According to the manufacturer's product labeling, in-use (opened) pen and not in-use (unopened) pen if stored at room temperature (up to 30°C [86°F]) should be used within 28 days or be discarded.
LVN 4 stated insulin glargine for Resident 83 did not have an opened date and placed the resident at risk for side effects if administered.
4. In-use bottle of metoclopramide oral solution 5 mg/5 mL for Resident 36 with the pharmacy label that indicated, Take 1 mL by mouth (1 mg) three times daily for antiemetic (to treat nausea) for 3 days (therapy ends 12/10/24).
LVN 4 stated she would need to clarify with pharmacy because the order was not matching in the computer system. LVN 4 stated the pharmacy label indicated the medication administration should have ended on 12/10/2024. LVN 4 stated the physician order in electronic medication administration record (eMAR) and the pharmacy label were contradicting and could cause a medication error due to inadvertent administration of a discontinued order. LVN 4 stated metoclopramide for Resident 36 was for peptic ulcer disease, so if medication was not properly given, it would not protect resident's stomach lining and could cause ulcer (a small open sore or wound generally found in the stomach or on the skin) and lead to hospitalization.
4b. During a concurrent inspection and interview on 2/11/2025 at 3:56 p.m. with LVN 5 of the Middle Medication Cart 2, the following medications were found expired:
1. One opened bottle of cranberry 450 mg with an expiration date of 12/2023.
2. One opened bottle of vitamin D3 25 mcg with an expiration date of 4/2023.
LVN 5 stated it would be unsafe to give expired meds to residents because they could have a bad reaction. LVN 5 stated cranberry was a supplement and if given to residents as expired, it could cause adverse reactions such as nausea and vomiting and would not be a proper dose either. LVN 5 stated the expired vitamin D would not treat deficiency and could be harmful if administered.
5. During a concurrent inspection and interview on 2/10/2025 at 2:20 p.m. with LVN 4 of the Medication Cart B, the following 15 controlled medications were found in the locked section. The pharmacy medication card / bubble pack and drug accountability record indicated the following medications and remaining quantities:
1. Temazepam 15 mg for Resident 342, quantity of 15 capsules, date on medication card 12/10/2024.
2. Clonazepam 1 mg for Resident 342, quantity of 11 tablets, date on medication card 1/2/2025, last dispensed date on controlled drug record 1/14/2025.
3. Temazepam 15 mg for Resident 342, quantity of 15 capsules, date on medication card 1/9/2025.
4. Temazepam 15 mg for Resident 342, quantity of four capsules, date on medication card 11/13/2024, last dispensed date on controlled drug record 1/13/2025.
5. Hydrocodone-Acetaminophen 5-325 mg for Resident 26, quantity of 22 tablets, date on medication card 11/27/2024, last dispensed date on controlled drug record 1/26/2025.
6. Zolpidem 5 mg for Resident 343, quantity of 13 tablets, date on medication card 1/11/2025, last dispensed date on controlled drug record 1/17/2025.
7. Clonazepam 0.5 mg for Resident 343, quantity of nine tablets, date on medication card 12/16/2024, last dispensed date on controlled drug record 1/11/2025.
8. Clonazepam 0.5 mg for Resident 343, quantity of 16 tablets, date on medication card 1/11/2025, last dispensed date on controlled drug record 1/18/2025.
9. Lorazepam 0.5 mg for Resident 19, quantity of 28 tablets, date on medication card 12/23/2024, last dispensed date on controlled drug record 1/15/2025.
10. Tramadol 50 mg for Resident 19, quantity of 30 tablets, date on medication card 12/23/2024.
11. Temazepam 15 mg for Resident 90, quantity of one capsule, date on medication card 10/10/2024, last dispensed date on controlled drug record 11/1/2024.
12. Diphenoxylate-Atropine 2.5 mg-0.025 mg for Resident 344, quantity of 18 tablets (two tablets in each bubble pack for nine bubbles), date on medication card 12/21/2024.
13. Lorazepam 0.5 mg for Resident 78, quantity of 21 tablets, date on medication card 11/4/2024, last dispensed date on controlled drug record 11/25/2024.
14. Clonazepam 0.5 mg for Resident 29, quantity of one-half 29 tablets, date on medication card 12/6/2024, last dispensed date on controlled drug record 12/11/2024.
15. Lorazepam 1 mg for Resident 29, quantity of 18 tablets, date on medication card 12/6/2024, last dispensed date on controlled drug record 1/8/2025.
LVN 4 stated these controlled medications medication cards were stored separately in locked cabinet of medication cart because they were discontinued orders or for discharged residents. LVN 4 stated discontinued controlled medications or for discharged residents should have been given to the DON as soon as possible but she did not have a chance to do so. LVN 4 stated there was a risk of medication diversion or misuse but they were locked in medication cart. LVN 4 stated she did not know the policy on when the controlled medications should be given to the DON after they were discontinued.
During a review of Resident 342's admission Record (a document containing demographic and diagnostic information), dated 2/12/2025, the admission record indicated, Resident 342 was originally admitted to the facility on [DATE], readmitted on [DATE] and discharged on 1/15/2025.
During a review of Resident 343's admission record, dated 2/13/2025, the admission record indicated, Resident 342 was admitted to the facility on [DATE] and discharged on 1/25/2025.
During a review of Resident 19's admission record, dated 2/12/2025, the admission record indicated Resident 19 was originally admitted to the facility on [DATE], readmitted on [DATE] and discharged on 2/9/2025.
During a review of Resident 90's admission record, dated 2/12/2025, the admission record indicated Resident 90 was admitted to the facility on [DATE] and discharged on 12/20/2024.
During a review of Resident 344's admission record, dated 2/11/2025, Resident 344 was admitted to the facility on [DATE] and discharged on 1/15/2025.
During a review of Resident 78's clinical physician orders, dated 2/13/2025, the Ativan (generic name - lorazepam) 0.5 mg order indicated end date to be 11/18/2024.
During an interview on 2/12/2025 at 02:55 p.m. with the DON, the DON stated the facility nurse should bring controlled medications to the DON as soon as the medication was discontinued, changed or when the residents were discharged or deceased . The DON stated nurse should have brought medication as soon as they could, but it would not always happen. The DON stated she was not sure of the specific timeframe when the facility nurse should have brought the controlled medications to her after being discontinued. The DON stated the facility nurses should bring discontinued controlled medications to the DON in timely manner for their accountability because of their risk for addiction and misuse. The DON stated, But all the quantities matched right? there was no diversion!
During an interview on 2/12/2025 at 02:55 p.m. with the DON, the DON stated the facility staff should be checking medication carts and medication rooms to ensure removal of expired and soon to be expiring medications. The DON stated the expired medications would not be effective or safe to be given to residents. The DON stated resident could have an adverse reaction or would not be effective if the latanoprost eye drops were not stored in refrigerator or not labeled with opened date. The DON stated the insulin with no opened date could have been used beyond the expiration rate and would not be effective in controlling blood glucose. The DON stated there would be a risk for hyperglycemia (high blood glucose), hypoglycemia (low blood glucose), ketoacidosis (extremely high serum and urine concentrations of ketones) or even hospitalization. The DON stated metoclopramide oral solution pharmacy label indicated it ended on 12/10/2024 and should have been removed from medication cart. The DON stated metoclopramide could have been expired and would not be effective to treat resident's nausea or infection.
During a review of the facility's policy and procedure (P&P) titled, Alliance Pharmacy Pharmaceutical Services Policy and Procedure Manual - Discontinued Medications - Disposal, dated 2/2019, the P&P indicated, Medications shall be removed from the medication cart immediately upon receipt of an order to discontinue in order to avoid inadvertent administration. Medications shall then be sequestered in a secure place within the facility, mutually acceptable .Pharmacy, Inc.
During a review of the facility's P&P titled, Alliance Pharmacy Pharmaceutical Services Policy and Procedure Manual - Controlled Medications - Disposal, dated 2/2019, the P&P indicated, Schedule II, III, IV, and V medications remaining in the facility after a resident has been discharged , or the order discontinued, are disposed of in the facility by the director of nursing and consultant pharmacist jointly, by returning .as directed by state laws, regulations, and/or the DEA.
During a review of the facility's P&P titled, Alliance Pharmacy Pharmaceutical Services Policy and Procedure Manual - Storage of Medications, dated 11/2020, the P&P indicated, Medications and biologicals hall be stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The P&P indicated, Medications requiring refrigeration or temperatures between 2°C (36°F) and 8°C (46°F) shall be kept in a refrigerator with a thermometer .monitoring. The P&P indicated, Unopened refrigerated items such as multi-dose insulin vials may be stored in refrigerator up to the expiration date on the pharmacy label or manufacturer expiration date whichever is earlier. If the refrigerated .expiration date. Once a refrigerated item such as multi-dose insulin vials are opened, the nurses will write down the open date and it must be discarded after 30 days from the date open. If the refrigerated item is a unit dose . from the date opened. The P&P indicated, outdated, contaminated, or deteriorated medications . shall be immediately removed from stock medication disposal. The P&P indicated, Medication storage areas shall be kept clean, well-lit and free of clutter temperatures.
During a review of the facility's P&P titled, Storage of Medications, dated 11/2020, the P&P indicated, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. The P&P indicated, Medications are stored separately from food and are labeled accordingly.
During a review of the facility's P&P titled, Alliance Pharmacy Pharmaceutical Services Policy and Procedure Manual - Controlled Medication Storage, dated 11/2020, the P&P indicated, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the facility in accordance with federal, state and other applicable laws and regulations. The P&P indicated, At each shift change, a physical inventory of all controlled medications shall be conducted by two licensed nurses and is documented on the controlled substances accountability record.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when staff were:
a. Unable to verbalize the a...
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Based on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when staff were:
a. Unable to verbalize the acceptable temperature for low temperature dishmachine and the correct chlorine concentration range.
b. Unable to verbalize the process of checking quaternary ammonium compound (QUAT, a chemical that disinfect) sanitizer concentration testing for the red buckets and three compartment sink's (sink for dishwashing that have wash, rinse and sanitize compartments) use.
These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 87 of 88 medically compromised residents who received food and ice from the kitchen.
Findings:
a. During a concurrent demonstration and interview on 2/11/2025 at 2:44 p.m. of the dishwashing machine process with Dietary Aide 1 (DA 1), DA 1 stated the temperature range for the low temperature dishmachine was 110 to 120 degrees (°) Fahrenheit (F, measurement of temperature). DA 1 stated staff also checked the concentration of the sanitizer in the dishmachine and the acceptable range was at 50-100 parts per million ([ppm], describes the concentration of the solution).
During a concurrent demonstration and interview on 2/13/2025 at 9:14 a.m. of the dishwashing process with Dietary Aide 2 (DA 2), DA 2 stated the acceptable temperature of the low temperature dishmachine was 110 to 120°F. DA 2 stated she read the low temperature dismachine poster and the acceptable temperature was at 120°F and not 110°F like she previously stated. DA 2 stated staff also check the chlorine concentration of the dishmachine using a test strip. Observed DA 2 retrieve a Hydrion test strip and dip it in the chlorine solution and counted 1.2.3.4.5. DA 2 stated the test strip was reading 100 ppm but she did not know the range for acceptable chlorine solution concentration. DA 2 stated it was important to know the acceptable range of concentration of the chlorine solution because if it is too low, it would not clean the dishes.
During a review of the facility's policies and procedures (P&P) titled Dishwashing, dated 2023, the P&P indicated, POLICY: All dishes will be properly sanitized through the dishwasher. The dishwasher will be kept clean and in good working order. (8) A temperature log (a chlorine log for low-temperature machines) will be kept and maintain by the dishwashers to assure that the dishmachine is working correctly. This log will be completed each meal prior to any dishwashing. Please check for manufacturer's recommendations which should be posted on your machine and insert the temperature of the above posted on the line. Low temperature machine: If you do not have manufacturer's recommendations, use the machine at a range of 120°F to 140°F. The chlorine should read 50-100 ppm on dish surface in final rinse.
During a review of the facility's poster titled Individual Low Temperature Dishmachine Procedure, undated, the poster indicated, Cycle machine and check for proper temperature 120°F.
During a review of Food Code 2022, the Food Code 2022 indicated, 4-501.110 Mechanical Warewashing Equipment Wash Solution Temperature (B) The temperature of the wash solution in spray-type warewashers that use chemicals to sanitize may not be less than 120°F.
During a review of Food Code 2022, the Food Code 2022 indicated, 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration. Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device.
b. During a concurrent demonstration and interview on 2/11/2025 at 3:12 p.m. of the QUAT sanitizer used to sanitize surfaces with DA 1 and the DS, observed DA 1 pull a test strip from the container and dip it in the premix QUAT sanitizer solution. DA 1 stated the acceptable range for the QUAT sanitizer concentration was 100-400 ppm. DS 1 stated staff always got 200 ppm and had to check the water temperature which should be around 75°F and above for it to have an accurate reading. DS 1 stated the current water temperature was at 71.6°F. DS 1 stated DA 1 did not follow manufacturers guidelines in checking the water temperature and following the acceptable range of 150-400 ppm for sanitizer concentration. DS 1 stated it was important to follow manufacturer's guidelines to ensure the sanitizer is sanitizing and cleaning the dishes well. DA 1 stated, they were not following the manufacturer's guidelines because their log is 70°F and not more than 75°F, the sanitizer concentration might not be accurate. DS 1 stated this could cause food borne illnesses as a potential outcome.
During a concurrent demonstration and interview on 2/13/2024 at 9:14 a.m. of the QUAT sanitizer used to sanitize surfaces with DA 2, DA 2 stated staff also monitor the QUAT sanitizer solution, but she did not know the acceptable concentration of the QUAT sanitizer. DA 2 stated staff needed to monitor the temperature when testing the sanitizing solution which should be at 70°F. DA 2 stated the poster posted indicated the temperature when testing sanitizing solution was 75°F. DA 2 stated staff were doing it wrong, and the sanitizing solution might not be in their proper concentration reading. DA 2 stated unsanitized dishes would be the potential outcome for not correctly checking the concentration of the QUAT sanitizer.
During a review of the facility's poster titled Individual Sanitizer Testing Procedure, undated, the poster indicated, 1. Use lukewarm water (room temperature) water, fill sink or container to proper level. 2. Wait for foam to dissipate 3. Test paper should be clean and dry. Immerse test paper for 10 seconds, do not move or shake the test paper. 3. Remove and match the color of the test paper to the chart on the test paper label. Range 150-400 ppm.
During a review of the facility's test strip manufacturer's guidelines titled QAC QR test strips, undated, the guidelines indicated, 1. Immerse pad in solution and remove immediately. 2. Hold strip level for 5 seconds. Shake off excess water from pad. Compare pad to color chart above. Note: Sample must be at room temperature (above 75°F)
During a review of the facility's log titled Quaternary Ammonium Log with Temperature Reading, dated 2/2025, the log indicated, solution temperature for testing is from 69-71°F, not following manufacturer's guidelines.
During a review of the facility's job description titled Job Description: Dietary Aide dated and signed by DA 1, on 1/19/2024 the document indicated Duties and responsibilities included dishwashing.
During a review of the facility's competency checklist titled Dietary Aide Competency Evaluation and Performance Satisfactory Completion, dated 1/4/2024, the checklist indicated, DA 1 was competent to operate kitchen equipment. The checklist did not indicate competency verification for dishmachine temperatures, checking chlorine and Quat sanitizer concentration.
During a review of the facility's competency checklist titled Dietary Aide Competency Evaluation and Performance Satisfactory Completion, dated 1/12/2024, the checklist indicated, DA 2 was competent to operate kitchen equipment. The checklist did not indicate competency verification for dishmachine temperatures, checking chlorine and Quat sanitizer concentration.
During a review of Food Code 2022, the Food Code 2022 indicated, 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration. Concentration of the sanitizing solution shall be accurately determined by using test kit or other device.
During a review of Food Code 2022, the Food Code 2022 indicated, 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitation- Temperature, pH, Concentration, and Hardness. A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times specified under 4-703.11 (C) shall meet criteria specified under 7-204.11 Sanitizers, criteria shall be used in accordance with the EPA-registered label use instructions, and shall be used as follows: (C) A quaternary ammonium compound solution shall (1) Have a minimum temperature of 24°C (75°F), (2) Have a concentration as specified under 7-204.11 and as indicated by the manufacturer's use directions included in the labeling.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
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 follow the menu and did not meet nutritional needs of...
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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 follow the menu and did not meet nutritional needs of:
a. Seventy five (75) of 88 residents on regular texture diet who received 1/3 cup (c., a household measurement) instead of ½ c of sweet corn salad.
b. Four (4) of six (6) residents on renal diet received less portion instead of ½ c when staff used a regular serving scoop instead of using a perforated spoodle (kitchen utensils with holes that is part spoon and part ladle used to scoop and serve precise portions of food).
These failures had the potential to result in a decrease in food and nutrient intake resulting in unintended (not planned) weight loss.
Findings:
a. During a review of the facility's menu spreadsheet (a sheet containing kind and amount of food each diet would receive) titled Winter Menus, dated 2/10/2025, the spreadsheet indicated residents on regular texture diets would receive ½ c. sweet corn salad on the tray.
During an observation on 12/10/2025 at 11:03 a.m., of [NAME] 2 portioning the sweet corn salad, observed [NAME] 2 use a green scoop (1/3 c.) when portioning sweet corn salad from the container to the individual Styrofoam bowl.
During an interview on 12/10/2025 at 11:08 a.m. with [NAME] 2, [NAME] 2 stated she used the green scoop which was number 12 scoop when portioning the sweet corn salad for all the residents.
During a concurrent interview and record review on 2/10/2025 at 2:27 p.m. with [NAME] 2 and the Dietary Supervisor (DS), the Winter Menu spreadsheet was reviewed. The Winter menu indicated, residents on regular texture diet would get ½ c of sweet corn salad. The DS stated green scoop is #12 scoop which is 1/3 c in portions. The DS stated [NAME] 2 should have used a grey scoop which was number 8 scoop or ½ c. [NAME] 2 stated she accidentally used an incorrect scoop which was small in portions because she read the spreadsheet as number 12 scoop instead of ½ a c. [NAME] 2 stated residents would not be getting the full nourishment that they need, and they could lose weight as a potential outcome. The DS stated giving small portions to the residents could cause them not to get the right amount of nutrients they needed.
During a review of the facility's recipe titled Recipe: Sweet Corn Salad, undated, the recipe indicated portion size of sweet corn salad was ½ c.
b. During a review of the facility's menu spreadsheet titled Winter Menus, dated 2/11/2025, the spreadsheet indicated residents on renal diet (diet that includes food low in salt, potassium [mineral found in banana, potatoes and tomatoes] and phosphorus [mineral found in milk, lentils, and nuts) would receive ½ c wheat pasta with margarine on the tray.
During an observation on 2/11/2025 at 12:14 p.m., of the trayline (an area where foods were assembled from the steamtable to the resident's tray), observed [NAME] 1 was using a regular perforated serving spoon instead of a spoodle.
During a concurrent observation and interview on 2/11/2025 at 12:24 p.m. of [NAME] 1 portioning the wheat pasta with the DS, observed [NAME] 1 using a regular spoon. The DS stated [NAME] 1 should be using ½ cup or number 8 scoop for the wheat pasta for renal diets. The DS stated she needed to get the correct utensils for [NAME] 1.
During an interview on 2/11/2025 at 12:30 p.m. with the DS, the DS stated using a regular serving spoon would not give enough pasta to residents on renal diet hence the residents would get lesser calories. The DS stated residents on renal diet could lose weight loss and their nutritional status would go down for getting lesser calories.
During an interview on 2/12/2025 at 2:01 p.m. with the Registered Dietitian (RD), the RD stated scoop number 8 was a bigger portion than scoop number 12 and it was important to use the correct scoops and utensils to ensure staff were giving the correct portion sizes to prevent potential weight loss for the residents.
During a review of the facility's recipe titled Recipe: Parsley & Herb Penne, undated, the recipe indicated portion size of parsley & penne was ½ c.
During a review of the facility's policy and procedure (P&P) titled Portion Control, dated 2023, the P&P indicated, POLICY: To provide specific portion control information. Procedure: To be sure portions served equal portion sizes listed on the menu, portion control equipment must be used. A variety of portion control equipment should be available and utilized by employees portioning food. The P&P further indicated, (1) Scoops are sized by number (the number of scoopfuls needed to equal one quart). The smaller the number, the larger the size. Scoop numbers and amounts are listed within the menus, recipe [NAME] and menu spreadsheet. (2) Ladles are sized according to their capacity.
During a review of the facility's P&P titled Menus Planning, dated 2024, the P&P indicated, (4) Menus are planned to meet nutritional needs of residents in accordance with established national guidelines, physician's orders and, to the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences. Menus are to be approved by the facility Registered Dietitian prior to the beginning of each quarterly menu cycle.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
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 prepare food by methods that conserved flavor, appear...
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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 prepare food by methods that conserved flavor, appearance, and appetizing temperature when:
a. Sweet corn salad was at 62 degrees Fahrenheit (°F, a scale of temperature) and the lettuce was wilted.
b. Broccoli did not have seasoning and flavor and was overcooked and mushy.
These failures had a potential to result in 75 of 88 residents on regular texture (no restriction) on 2/10/2025 and 89 of 89 residents on 2/11/2025 facility residents getting food from the kitchen, including Resident 70 and 34 at risk of unplanned weight loss, a consequence of poor food intake.
Findings:
During a review of Resident 34's admission Record, the admission Record indicated the facility initially admitted Resident 34 on 1/23/2020 and re-admitted on [DATE] with diagnoses including polyneuropathy (malfunction of peripheral nerves throughout the body), chronic obstructive pulmonary disease (COPD, a condition caused by damage to the airways or other parts of the lung), unspecified protein-calorie malnutrition (a disorder caused by lack of proper nutrition or inability to absorb nutrients from food) and chronic kidney disease (when kidney becomes damaged overtime and have a hard time doing its function).
During a review of Resident 34's Minimum Data Set (MDS- a resident assessment tool), dated 1/22/2025, the MDS indicated Resident 34 usually made self understood and usually understand others. The MDS further indicated Resident 34 required no assistance when eating while a resident of the facility and within the last seven days.
During a review of Resident 34's Order Summary Report, dated 7/1/2024, the Order Summary Report indicated a physician's order for regular, thin consistency diet.
During an interview on 2/10/2025 at 10:10 a.m. with Resident 34, Resident 34 stated the food absolutely sucks and did not taste good. Resident 34 stated nothing tastes good and the food did not even look good.
During a review of Resident 70's admission Record, the admission Record indicated the facility initially admitted Resident 70 on 8/17/2021 and re-admitted on [DATE] with diagnoses including acute pyelonephritis (a bacterial infection causing inflammation of the kidneys), unspecified protein-calorie malnutrition, and COPD.
During a review of Resident 70's MDS, dated [DATE], the MDS indicated Resident 70 made self understood and understand others. The MDS further indicated Resident 70 required set up and clean up assistance with eating while a resident of the facility and within the last seven days.
During a review of Resident 70's Order Summary Report, dated 7/7/2024, the Order Summary Report indicated a physician's order for regular, thin consistency, fortified diet (food with extra nutrients added to it).
During an interview on 2/10/2025 at 2:22 p.m. with Resident 70, Resident 70 stated the food sucks, tastes bad and looks bad.
a. During a review of the facility's menu spreadsheet (a list food of what would each diet get including the amount) titled Winter Menus, dated 2/10/2025, the spreadsheet indicated residents on regular diet texture would include the following foods in the tray:
1. Fish fillet with tarragon sauce 3 ounces (oz, a unit of measurement) / 1 oz.
2. Tartar sauce 1 tablespoon (Tbsp, a household measurement).
3. Cajun County [NAME] number 12 scoop (1/3 cup [c, a household measurement).
4. Creamed spinach ½ c.
5. Parsley garnish.
6. Sweet corn salad ½ c.
7. Fruit Bavarian cream 1 pc (3x2 ½ inches).
8. Milk 4 oz.
During an observation on 2/10/2025 at 11:03 a.m., observed [NAME] 2 dish up (to put food into a dish) the sweet corn salad in a Styrofoam bowl.
During an observation on 2/10/2025 at 11:40 a.m., observed staff dishing out bowls of corn salad from the refrigerator to the resident's tray inside the carts.
During an observation on 2/10/2025 at 12:22 p.m. of the corn salad temperature, observed corn salad temperature was at 62.1°F.
During a concurrent observation and interview on 2/10/2025 at 1:06 p.m. with the Dietary Supervisor (DS), observed corn salad temperature was at 15°F coming out from the refrigerator. The DS stated there was not a reason why staff plated the salad from the refrigerator to the trays at 11:40 a.m. The DS stated the corn salad would be warm, not fresh, and it was at 62°F. The DS stated the residents would not eat it as the salad leaves were wilted because it was initially frozen and did not look appetizing. The DS stated this would result to resident's decline of meal intake leading to weight changes and weight loss as a potential outcome.
During an interview on 2/12/2025 at 2:12 p.m. with the Registered Dietitian (RD), the RD stated the corn salad was plated in a Styrofoam and would not hold temperature. The RD stated salad at 15°F would freeze and if it would sit out for an hour, the temperature would be warm. The RD stated the acceptability and the quality of the salad would go down. The RD stated residents would not eat the salad which could potentially cause weight loss.
During a review of the facility's policies and procedure (P&P) titled Meal Service, dated 2023, the P&P indicated, The food will be served on trayline at the recommended temperatures indicated below and recorded on the daily therapeutic menu in the temperature column of the regular food and next to the food item under the therapeutic diet column of each food served. The temperature of the foods should be periodically monitored throughout the meal service to ensure proper hot or cold holding temperature. Milk, puddings, salads and juice service temperature at 41°F or less. (4) Cold food items will be placed on the trays as close to the serving time as possible to assure the temperature is below 41°F. To accomplish this, all cold foods will be pre-poured and kept in the refrigerator or freezer and pulled out in small quantities at a time. (7) Temperature of the food when the resident receives it is based on palatability. The goal is to serve cold food cold and hot food hot. See table below for suggested temperatures. Cold entrée less than or equal to 50°F, salads less than or equal to 45°F.
b. During a review of the facility's menu spreadsheet titled Winter Menus, dated 2/11/2025, the spreadsheet indicated residents on regular diet texture would include the following foods in the tray:
1. Italian Lasagna (3x3 1/3= 1 square).
2. Seasoned broccoli ½ c.
3. Parsley garnish.
4. Garlic bread 1 slice.
5. Peanut Butter cup pudding number 12 scoop (1/3 c).
6. Milk 4 oz.
During an observation on 2/11/2025 at 12:07 a.m., of the trayline (an area where foods are assembled from the steamtable to the resident's plate), observed the broccoli mushy and olive green, brown in color.
During a concurrent observation and interview on 2/11/2025 at 12:38 p.m. of the broccoli with the DS, the DS stated the broccoli was a little mushy as it was overcooked. The DS stated when vegetables are overcooked, it loses its nutritional content. The DS stated the broccoli did not taste like it had any seasoning. The DS stated overcooked vegetables influence flavor and presentation, and residents would not eat the food causing them to lose weight as a potential outcome.
During an interview on 2/12/2025 at 2:15 p.m., with the RD, the RD stated overcooked vegetables would lose their vitamins and would breakdown its fiber content. The RD stated vitamin deficiency and constipation would be the potential outcome for residents for overcooking the vegetables. The RD stated overcooked vegetables would not be an acceptable presentation and residents would not eat it because of the way it looked. The RD stated broccoli with no flavor could cause dissatisfaction for residents as it would not match the menu and residents' food intake would be low as a potential outcome.
During a review of the facility's recipe titled Recipe: Seasoned Broccoli, dated 2024, the recipe indicated, ingredients: broccoli fresh or frozen broccoli, margarine, salt.
During a review of the facility's P&P titled Food Preparation, dated 2023, the P&P indicated, Policy: Food shall be prepared by methods that conserve nutritive value, flavor and appearance. (3) Prepared foods will be sampled. The Food and Nutrition Services employee who prepares the food will sample it to be sure the food has a satisfactory flavor and consistency. Use a clean spoon or put a small portion of the food in a dish and taste from the dish. (4) Poorly prepared food will not be served- such food is to either be improved, prepared again, or replaced with an appropriate substitution. (6). Process raw and uncooked foods in batches. Remove from refrigeration only the amount of product that can be processed within a 30-minute period. Preparation of vegetables:
1. [NAME] vegetables in small amount of water for a short of time.
2. Add variety of seasonings to vegetables to arity their taste and appeal.
3. Serve vegetables promptly. Do not hold on the steamtable for long periods of time.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to prepare foods in a form designed to meet individual needs when puree Cajun country rice was sticky, did not pass the spoon ti...
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Based on observation, interview, and record review, the facility failed to prepare foods in a form designed to meet individual needs when puree Cajun country rice was sticky, did not pass the spoon tilt test (a test used to determine the stickiness of the food and the ability of the food to hold together), and did not hold its shape on the plate for residents on puree diet (foods that are smooth with pudding like consistency) /International Dysphagia Diet Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) level four (4).
These failures had the potential to result in difficulty in swallowing, chewing, decreased in food intake and nutrient intake to 8 of 88 residents on puree diet, resulting to unintended (not planned) weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs).
Findings:
During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled Winter Menus, dated 2/10/2025, the spreadsheet indicated residents on pureed IDDSI level 4 diet would include the following foods on the tray:
1. Pureed fish fillet number 8 scoop (1/2 cup, [c] a household measurement).
2. Puree tartar sauce 1 tablespoon (Tbsp, a household measurement).
3. Puree Cajun country rice 1/3 c.
4. Puree creamed spinach 1/3 c .
5. Parsley flakes.
6. Puree sweet corn salad 1/3 c.
7. Puree fruit Bavarian cream 1/3 c.
During an observation on 2/10/2025 at 12:25 p.m. of the trayline (an area where foods were assembled from the steamtable to resident's plate), observed that the puree Cajun country rice did not hold its shape on the plate.
During a concurrent observation and interview of the test tray (a process of tasting, temping, and evaluating the quality of food) of the puree diet on 2/10/2025 at 12:30 p.m. with the Dietary Supervisor (DS), the DS stated the puree diet had to be a pudding-like consistency, no chunks, smooth in consistency and able to hold its shape. The DS stated the puree Cajun country rice did not hold its shape on the plate. The DS stated puree diet was used for residents who had swallowing and chewing difficulties. The DS stated the winter menus started on 12/2/2024 with the IDDSI menu and the facility was in the process of training staff and did not have a diet manual definition for IDDSI. The DS stated she was not familiar with the spoon tilt test.
During a concurrent interview and IDDSI website review on 2/10/2025 at 12:45 p.m. with the DS, the IDDSI website titled IDDSI dated 7/2019 was reviewed. The website indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and Fork drip test. (IDDSI, July 2019, The IDDSI Framework section). The DS stated the puree Cajun country rice did not fall off during the spoon tilt test.
During a concurrent interview and record review on 2/10/2025 at 1:01 p.m., with the DS, the facility's recipe titled, Recipe: Pureed (IDDSI Level 4) Starch (Rice, Pasta, Polenta, Potatoes), dated 2024 was reviewed. The recipe indicated, (5) The finished puree item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, or should not weep. The finished puree item must pass IDDSI level 4 testing requirements (i.e. the fork drip, fork pressure and spoon tilt test). The DS stated the Cajun county rice did not fall off the spoon tilt test and residents could have a hard time swallowing the food.
During an interview on 2/12/2025 at 2:08 p.m. with the Registered Dietitian (RD), the RD stated the IDDSI diets were not implemented. The RD stated the DS was told to attend the training, but the DS did not go. The RD stated if the staff did not get the training about IDDSI diets the food would not be at the right consistency and residents could choke and aspirate (when something enters your airway or lungs) as a potential outcome. The RD stated she provided an IDDSI training 2/10/2025.
During a review of the facility's policies and procedures (P&P) titled Food Preparation, dated 2023, the P&P indicated, PROCEDURE: The facility will use approved recipes, standardized to meet the resident census. This count is to be kept so that an accurate amount of food is prepared. Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide.
During a review of the facility's P&P titled Nutritional Care Management, dated 2023, the P&P indicated, POLICY: The facility will have an approved diet manual in the Food and Nutrition Services Department and at each Nurses' station. This is the primary source of therapeutic diet information. Its contents should be frequently reviewed by all Food and Nutrition Services personnel, especially FNS Director and Cooks.
During a review of the facility's diet manual titled Regular Pureed Diet/IDDSI Level 4, dated 2024, the P&P indicated, Description: The pureed diet is a regular diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture of the prepared puree food items included on this diet should be smooth, free of lumps, hold their shape, while not being too firm or sticky and should not weep.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
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 safe and sanitary food storage and food prepar...
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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 safe and sanitary food storage and food preparation practices in the kitchen when:
1. Kitchen equipment and kitchen areas were not cleaned and sanitized:
a. Reach in freezer vents had dust buildup by the exit door.
b. Reach in freezer bottom shelves had dirt debris.
c. Three kitchen vents had dust buildup.
d. Kitchen hood had dust and dirt buildup.
e. Ice machine had brown and white dirt buildup.
2. Pans were stacked wet at the storage area.
3. Two (2) dented cans were stored with non-dented cans.
4. Staff did not perform handwashing:
a. Staff touched the trash lid then held sandwiches without washing her hands.
b. Staff [NAME] a plastic lid on the floor then proceeded handling clean coffee mugs on the resident's tray without washing hands.
c. Staff did not wash hands when touching the dirty trays then touched the clean domes.
5. Dirty potholder touching the lip of the pans with food.
6. Equipment and utensils were not smooth and easy to clean:
a. Can opener blade had chips and metal was coming off.
b. Two storage racks had paint coming off and had cracks.
c. Ten (10) cracked resident's tray.
d. Scoop storage was rusted.
7. Freezer temperature was not monitored and checked.
8. Resident's refrigerator temperature range was not in an acceptable temperature of below 41 degrees Fahrenheit ([°F], a scale of temperature).
9. Emergency water storage floor had a lot of trash (gloves, empty soda cans, dirty and paper) and it was not six (6) inches elevated from the floor.
These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 87 of 88 medically compromised residents who received food and ice from the kitchen.
Findings:
1a. During an observation on 2/10/2025 at 9:12 a.m., of the reach in freezer by the exit door, observed four (4) vents had dust build up.
b. During an observation on 2/10/2025 at 9:16 a.m., of the reach-in freezer, observed dirt debris at the bottom shelves.
During a concurrent observation and interview on 2/10/2025 at 9:25 a.m. with the Dietary Supervisor (DS), the DS stated staff cleaned the freezer on 2/3/2025 and 2/7/2025 but there was dust buildup on the vents and debris from the boxes on the bottom shelves. The DS stated it was important to keep the freezer clean to prevent bacterial growth as residents could get sick, throw up, develop diarrhea from the food, and cross-contamination.
During a review of the facility's policies and procedures (P&P) titled Refrigerator and Freezer, dated 2023, the P&P indicated, Maintaining a clean refrigerator and freezer can improve the safety and quality of your foods.
1. For the best cleaning results, always refer to your owner's manual.
2. Remove all items and clean shelves. Wipe with sanitizer.
During a review of the facility's P&P titled Sanitation, dated 2023, the P&P indicated, Vents must be free of dust and dirt.
c. During an observation on 2/10/2025 at 9:21 a.m. of the vents in the trayline area (an area where foods are assembled from the steamtable to the resident's plate), observed three (3) vents had dust buildup.
d. During an observation on 2/10/2025 at 9:23 a.m. of the kitchen hood, where Cooks prepare and cook foods under, observed the kitchen hood had dust buildup.
During a concurrent observation and interview on 2/10/2025 at 9:31 a.m. of the kitchen vents and hoods with the DS, the DS stated the maintenance staff cleans the vents, and an outside vendor cleans the kitchen hood. The DS stated the hood was last cleaned on 9/2024 and she did not know as to when the maintenance staff cleaned the vent. The DS stated there was a dust buildup on the vents and hood where dirt could fall directly into the spinach that was being cooked under it. The DS stated dust going to the food could cause food poisoning to the residents.
During a review of the facility's P&P titled Hoods, Filters and Vents, dated 2023, the P&P indicated, Hoods must be cleaned every two weeks and must be free from dust.
e. During a concurrent observation and interview on 2/11/2025 at 10:48 a.m. of the ice machine with the DS, observed a dirt build up in the ice machine. The DS stated the maintenance staff cleaned the ice machine on 2/5/2025 but the brown, white, and yellowish buildup was from the hardness of the water.
During an interview on 2/11/2025 at 10:56 a.m. with the DS, the DS stated it was not acceptable for the ice machine to have dirt buildup though it was not touching the ice, the particles could drop in the ice residents consume. The DS stated the dirt would contaminate the ice resulting to food borne illness as a potential outcome for the residents.
During an interview on 2/11/2025 at 2:39 p.m. with the Maintenance Director (MD) and the DS, the MD stated they cleaned the ice machine 2-3 weeks prior to make sure there was no corrosion. The MD stated the pipes and the vents were cleaned so residents would not get sick from the corrosion. The MD stated the dirt from the ice machine was corrosion. The DS stated the dirt in the ice machine was from the metals from the filter and calcium build up and it was not okay due to cross-contamination.
During a review of the facility's P&P titled Ice Machine Cleaning Procedures dated 2023, the P&P indicated, The ice machine needs to be cleaned and sanitized monthly. The internal components cleaned monthly or per manufacturer's recommendations, and the date recorded when cleaned. The maintenance supervisor can keep this record, or it can be posted on the ice machine. (3) Clean inside of ice machine with a sanitizing agent per the manufacturer's instructions. Add instructions to your policies or use manufacturer's procedures to clean and sanitize the machine.
During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or storing a food temperature measuring device, and (5) At the time during the operation when contamination may have occurred.
During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.
During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-602.12 Cooking and Baking Equipment. (A) The food contact surfaces of cooking and baking equipment shall be cleaned at least every 24 hours. This section does not apply to hot oil cooking and filtering equipment if it is cleaned as specified subparagraph 4-602.11 (D)(6).
2. During an initial kitchen tour observation on 2/10/2025 at 9:15
a.m. in the pots and pans storage area, observed pans were stacked wet.
During a concurrent observation and interview on 2/10/2025 at 9:36 a.m. with the DS, the DS stated all the pots and pans went through the dishmachine and staff air-dried it in the clean area then store it by the preparation area. The DS stated the pans were not dry all the way and it was supposed to be dry before storing. The DS stated she needed to look up the reason why the pans could not be stored and stacked wet.
During an interview on 2/11/2025 at 8:52 a.m. with the DS, the DS stated they could not stack wet pans because it could grow bacteria that could cause cross-contamination to food.
During a review of the facility's P&P titled Three Compartment Procedure for Manual Dishwashing, dated 2023, the P&P indicated, Step 6: All items are air-dried, which means no water droplets are present.
During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-901.11 Equipment and Utensils, air-drying required. After cleaning and sanitizing equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food and; (B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry.
3. During a concurrent observation and interview on 2/10/2025 at
9:41 a.m., in the dry storage area with the DS, observed one (1) dented can and 1 bulging can stored with the non-dented cans. The DS stated kitchen staff always separated dented cans because they do not use dented cans. The DS stated residents could get sick as the metal particles could go in the food which was not good.
During a review of the facility's P&P titled Food Storage-Dented Cans, dated 2023, the P&P indicated, Policy: Food in unlabeled, rusty, leaking, broken containers or cans with side seam dents, rim dents, or swells shall not be retained or used by the facility. Procedure: All dented cans (defined as side seam or rim dents) and rusty cans are to be separated from remaining stock and placed in a specified labeled area for return to purveyor for refund. All leaking cans are to be disposed of immediately.
During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of §3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and
actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard.
4a. During an observation on 2/10/2025 at 11:17 a.m. of the food preparation, observed Dietary Aide 1 (DA 1), throw her gloves in the trashcan while holding the trash lid, and then got a sandwich without washing her hands.
b. During an observation on 2/10/2025 at 11:59 a.m. in the
preparation area, observed [NAME] 2 throw away a plastic lid that was on the floor while touching the trash lid, and then proceeded placing coffee mugs on the resident's trays.
During an interview on 2/10/2025 at 1:15 p.m. with the DS, the DS stated the staff needed to wash their hands after they come back from break, after using the bathroom, after they touched their hair, clothes and every time they touched something dirty before going back to work. The DS stated if the staff touched something dirty like the lid of the garbage there can be cross-contamination during food preparation and could cause foodborne illness to the residents.
During an review of the facility's P&P titled Sanitation, dated 2023, the P&P indicated, 17. All Food and Nutrition Services staff shall know the proper hand washing technique. The FNS Director is responsible for the proper training of this.
c. During an observation on 2/11/2025 at 9:13 a.m. of the dishwashing area, observed Dietary Aide 3 (DA 3) loading the soiled dishes in the dirty area then started putting away clean dishes without washing his hands.
During a concurrent observation and interview on 2/11/2025 at 9:19 a.m. of the dishwashing process with the DS, the DS stated DA 3 went from the clean area then touched the soiled dishes then went back and touched the clean dishes without washing his hands. The DS stated DA 3 only rinsed his hands and he needed to tell DA 3 to wash his hands before he touches the clean dishes. The DS stated it was important to wash hands as it could contaminate the clean dishes and could potentially cause food borne illnesses for the residents.
During a review of the facility's P&P titled, Handwashing Procedure, dated 2023, the P&P indicated Hand washing is important to prevent the spread of infection. When hands need to be washed:
1. After handling soiled dishes and utensils
2. Touching trash can or lid.
During a review of the facility's P&P titled, Sanitation, dated 2023, the P&P indicated, (18) A minimum of two employees will be used when dishes are machine washed. One will handle the soiled area, and one will handle the clean side. If an employee does need to go from soiled end to clean end, a strict hand washing routine must be followed.
During a review of Food Code 2022, the Food Code 2022 indicated 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; P (B) After using the toilet room; P (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); P (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; P (E) After handling soiled EQUIPMENT or UTENSILS; P (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; P (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands.
5. During an observation on 2/10/2025 at 11:59 a.m. of [NAME] 1's food
preparation, observed [NAME] 1 use a soiled potholder to touch the lip of the pan that contained food.
During a concurrent observation and interview on 2/10/2025 at 2:32 p.m. of the potholder, the DS stated the potholder was replaced three (3) weeks ago, but it was dirty, and it should not touch the lip of the pans with food as it would cause cross-contamination. The DS stated residents could have foodborne illnesses as a potential outcome of cross-contamination.
During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301-3-306.
6a. During an observation on 2/11/2025 at 8:49 a.m., of the can
opener, observed the can opener blade had a chip.
During a concurrent observation and interview on 2/11/2025 at 8:53 a.m. of the can opener with the DS, the DS stated the can opener blade had a chip, and it was not okay due to physical contamination.
b. During a concurrent observation and interview on 2/11/2025 at 9:00 a.m. of the two storage racks for the pots and pans, observed the paint of the storage racks were chipped. The DS stated it was not okay that the paint of the racks came off because it could be physical contamination to food. The DS stated bacteria could grow to the surfaces that were not smooth.
c. During a concurrent observation and interview on 2/11/2025 at 9:02 a.m. of the resident's tray with the DS, observed ten (10) resident's trays with cracks. The DS stated if tray surfaces are not smooth, it could grow bacteria on the cracks and could cause cross-contamination to food. The DS stated cracked surfaces were also hard to clean causing bacterial growth.
d. During a concurrent observation and interview on 2/11/2025 at 9:04 a.m. of the scoop drawer with the DS, observed the scoop drawer was lined with aluminum foil and the drawer was rusted. The DS stated the scoop drawer was cleaned every two (2) weeks, and the staff lined it with aluminum foil because the drawer was old and its rusted needing replacement. The DS stated it was not acceptable to store scoops in a rusted container due to cross-contamination. The DS stated she needed to talk to his boss to change the whole kitchen.
During an interview on 2/12/2025 at 1:56 p.m. with the Registered Dietitian (RD), the RD stated she conducts rounds and a kitchen inspection monthly for food safety and sanitation. The RD stated she conducted the last kitchen inspection on 1/31/2024 and she had no significant findings other than one food product missing a label. The RD stated the DS told her about the rusty scoop drawer and it was not acceptable because the paint could chip off and contaminate food causing the residents to get sick due to food bacterial growth. The RD stated residents could get food poisoning as a potential outcome.
During a review of the facility's P&P titled Sanitation, dated 2023, the P&P indicated, All equipment shall be maintained as necessary and kept in working order. (11) All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas. (12) Plastic ware, china, and glassware that becomes unsightly, unsanitary, or hazardous because of chips, cracks, or loss of glaze shall be discarded. (19) Cracked or chipped dishes and glasses will be disposed of.
During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints.
7. During an observation on 2/11/2025 at 10:51 a.m. of the resident's
freezer, observed that there was no thermometer in the freezer for temperature monitoring.
During a concurrent observation and interview on 2/11/2025 at 11:26 a.m., with the Quality Assurance Registered Nurse (QA RN), observed the freezer had no thermometer. The QA RN stated there was no thermometer in the freezer and she did not know the acceptable temperature range for the freezer. The QA RN stated the acceptable range for the freezer is 0°F to -18°F for frozen food storage after looking it up from the internet. The QA RN stated it was her fault for not monitoring the freezer temperature because she was not sure if they needed to monitor it however the QA RN stated it was important to monitor the freezer temperature to prevent food to spoil causing residents to get sick of tummy pain as a potential outcome.
During a review of the facility's P&P titled, Sanitation dated 2023, the P&P indicated, 21. Correct temperatures for the storage and handlings of food are used. Thermometers will be used to check temperatures, freezers and food storeroom.
During a review of the facility's P&P titled Cold Storage Temperature, dated 2023, the P&P indicated, Freezer temperature standards are 0°F or below.
During a review of Food Code 2022, dated 1/18/2023, the Food Code indicated 4-204.112 Temperature Measuring Devices. (A) In a mechanically refrigerated or hot FOOD storage unit, the sensor of a TEMPERATURE MEASURING DEVICE shall be located to measure the air temperature or a simulated product temperature in the warmest part of a mechanically refrigerated unit and in the coolest part of a hot FOOD storage unit. (B) Except as specified in (C) of this section, cold or hot holding EQUIPMENT used for TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be designed to include and shall be equipped with at least one integral or permanently affixed TEMPERATURE MEASURING DEVICE that is located to allow easy viewing of the device's temperature display.
8. During a concurrent observation and interview on 2/11/2025 at
11:20 p.m. of the resident's refrigerator with the QA RN, observed the temperature log acceptable range was 36°F to 46°F. The QA RN stated the acceptable range for the refrigerator for food storage is 36°F to 46°F and there was a policy for it. The QA RN stated it was important the monitor the refrigerator with an acceptable temperature range to ensure food would not spoil and bacteria would not grow in the food. The QA RN stated she needed to check the food code for the proper refrigerator food storage acceptable temperature range.
During a review of the facility's P&P titled Cold Storage Temperature Monitoring and Record Keeping, dated 2023, the P&P indicated, Policy: Food and Nutrition Services staff shall review and record temperatures of all refrigerators and freezers to ensure they are at the correct temperature for food storage and handling. (3) Refrigerator temperature standards are at least to 41°F. The goal is to keep the temperature at 34°F to 39°F. This will allow for a 2° rise in temperature when the door is opened throughout the day. This will also keep the food at less than 41°F.
During a review of Food Code 2022, the Food Code 2022 indicated, 3-501.16 Time/Temperature for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as a public health control as specified under 3-501.19, and except as specified under (B) and in (C) of this section, Time/Temperature Control for safety food shall be maintained: (2) At 5°C (41°F) or less.
9. During a concurrent observation and interview on 2/11/2025 at
2:34 p.m., of the disaster water supply storage area with the MD and the DS, observed the floor with empty soda can, paper, and trash and the storage racks were not six (6) inches from the ground. The MD stated he did not know what to expect when it comes to the storage of water and food however there was a lot of trash on the floor where the emergency water supplies were stored. The MD stated it was important to keep the water storage clean to prevent the water getting dirty and to prevent residents to get diseases and infection. The MD stated the storage rack was four (4) inches from the floor after measuring it with the tape measure. The DS stated the storage racks should be 6 inches and above from the floor to provide access for them to clean and sweep under it to prevent rodents in the area.
During a review of the facility's P&P titled, Storeroom, dated 2024, the P&P indicated, The general cleanliness and care of the storeroom and supplies are important to ensure safe wholesome food. (1) The floor, walls, ceiling, lights, shelves, and equipment must be kept clean by setting up, maintaining, and monitoring a regular cleaning schedule. Routine inspection must be made to ensure cleanliness and high standards and sanitation.
During a review of the facility's P&P titled. Storage of Food and Supplies, dated 2023, the P&P indicated, 4. All shelves and storage racks or platforms should be in accordance with state and federal regulations to facilitate air circulation and promote easy and regular cleaning. Shelves and cupboards will not be lined with shelf paper or other lines. All food and food containers are to be stored 6 inches off the floor and on clean surfaces in a manner that protects it from contamination. Store food and supplies at least 18 inches below the fire sprinkler head deflectors.
During a review of Food Code 2022 dated 1/16/2024 the Food Code 2022 indicated 3-305.11 Food Storage (A) Except as specified in (B) and (C) of this section, food shall be protected from contamination by storing the food: (3) at least 15 cm (6 inches) above the floor.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to ensure two of two staff were able to verbalize the policy regarding the use and storage of food brought to residents by family...
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Based on observation, interview, and record review the facility failed to ensure two of two staff were able to verbalize the policy regarding the use and storage of food brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.
This failure had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 88 of 88 medically compromised residents who store food in the resident's refrigerator.
Findings:
During a review of the facility's Policies and Procedures (P&P), titled Food for Residents from Outside Sources, dated 2023, the P&P indicated Policy: Food brought in from outside the facility kitchen for resident's consumption will be monitored. This is done to measure effectiveness of this intervention in residents with low food intake; to be sure the food is within the guidelines of the diet order, and to better assess nutrient intake. Nursing and/or admissions will provide the family or new admits with the information sheet, Bringing in Food for a resident (Section 6, page 6.24). Procedure: The following is to be done to ensure the above is accomplished:
1. Non-perishable foods such as cookies, cake, crackers, fruit, etc. (do not require time and temperature holding), can be stored in the resident's room or at the nurses' station with the resident's name and date of storage. If unopened, refer to the Dry Storage Guide. If opened, the food must be sealed, dated to the date opened and disposed by the best by date or 30 days, whichever comes first.
2. Prepared foods, beverages, or perishable food that requires refrigeration, can be stored for the resident in the facility kitchen, the refrigerator with the nurses' station, or in the resident's personal refrigerator. In the Food and Nutrition Services Department, the policy of food storage will apply. Otherwise, if unopened, refrigerated or frozen items will be disposed of by the expiration date on the container. If opened, the food must be sealed, dated to the date opened and disposed of in 2 days after opening. Frozen items, such as ice cream, will be disposed of in 30 days.
During an interview with the Dietary Supervisor (DS) on 2/11/20 at 10:40 p.m., the DS stated the facility did not have a refrigerator designated for resident's food from home in the kitchen, but the facility had a little refrigerator in the utility room in Nurse Station A.
During an interview with the DS on 2/11/2025 at 10:57 a.m., in the utility room, the DS stated she did not maintain the resident's refrigerator. The DS stated housekeeping maintained the resident's refrigerator.
During an interview on 2/11/2025 at 11:09 a.m. with Licensed Vocational Nurse 1 (LVN1 ), LVN 1 stated she was usually assigned in Station 1. LVN 1 stated she was not familiar with the food from the outside source policy but recalled having an in-service that they could not store food in the kitchen.
During an interview on 2/11/2025 at 11:18 a.m. with the Director of Nursing (DON), the DON stated the refrigerator in the utility room was designated for resident's food from the outside.
During an interview on 2/11/2025 at 11:20 a.m. with the Quality Assurance Nurse (QA RN), the QA RN stated the refrigerator in the utility room in Station 1 was for resident's outside food. QA RN stated she was the one monitoring the resident's refrigerator for food safety and she checked for the labeling and dating of expired food for disposal. QA RN stated it was important that the staff know of the facility's policy on food brought from home because food could spoil, and bacteria could grow in the food and could cause stomach pain.
During an interview on 2/12/2025 at 10:59 a.m. with Licensed Vocational Nurse 2 (LVN 2), who is a treatment nurse, LVN 2 stated he was not too keen about the food storage policy; however, he was aware staff could not store food because it could spoil. LVN 2 stated the facility only had a medication refrigerator at Nurse Station 2. LVN 2 stated he went to Nurse Station 1 and checked that the refrigerator there was for residents. LVN 2 stated the facility did not store any food for more than 24 hours. LVN 2 stated it was important to know the policy on food brought from home for the resident's food safety so food would not spoil.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure standard infection control practices were foll...
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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 standard infection control practices were followed when:
1. Housekeeping personnel failed to perform hand hygiene after cleaning a resident's room.
2. Nursing staff failed to perform hand hygiene after coming in contact with a resident's body fluids.
3. Nursing staff failed to sanitize a high traffic surface area contaminated with body fluids.
4. Nursing staff failed to ensure Resident 56's nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs), nebulizer mask (a face mask over the nose and mouth to deliver medication into the lungs), and tubing was not touching the floor, was dated, and stored properly.
These deficient practices had the potential to expose Resident 56, other residents, staff, and visitors to infection.
Findings:
a. During an observation on 2/10/2025 at 10:24 a.m., while in the hallway, observed Housekeeper (HK) 1 inside of a resident's room collecting trash from the floor with her gloved hands and placing the trash inside of a trash bag. Observed HK 1 remove her gloves and exit the resident's room without washing or sanitizing her hands. HK 1 then proceeded down the hallway with her cart. HK 1 was then observed lifting the lid of another trash can in the hallway without gloves and without washing her hands before touching the trash can lid.
During an interview on 2/10/2025 at 10:26 a.m. with HK 1, HK 1 stated she should have washed her hands when she left the resident's room. HK 1 stated she usually washes her hands, but she had forgotten on this occasion. HK 1 stated handwashing was important when entering and leaving a resident's room to prevent the spread of an infection from one resident to another resident.
During an observation on 2/11/2025 at 10:28 a.m., while at the nursing station, observed an unknown resident approaching the nursing station with large amounts of mucus (a thin, slippery fluid that lines your nose, throat, and other passages) dripping from his nose. The resident's mucus dripped onto the nursing station's counter. Licensed Vocational Nurse (LVN) 3 approached the resident and placed a paper towel over the mucus on the counter. LVN 3 then picked up the paper towel from the counter and gave it to the resident to cover his nose. LVN 3 walked away from the nursing station with the resident.
During an interview on 2/11/2025 at 11:22 a.m. with LVN 3, LVN 3 stated due to infection control she should have disinfected the counter at the nursing station and washed her hands before leaving with the resident. LVN 3 stated the resident left his body fluids in an area where other people could have come into contact with the bodily fluids. LVN 3 stated other residents and visitors could have become ill after exposure to the resident's bodily fluids.
During an interview on 2/11/2025 at 1:25 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated the housekeeper should have washed her hands before leaving the resident's room. The IPN stated when a staff member enters a room, they must wash their hands before leaving the room. The IPN stated staff must make it a habit to wash their hands before entering and leaving a resident's room even if they do not come in contact with the resident. The IPN stated the nurse should have also wiped down the counter at the nursing station, washed her hands and called housekeeping staff to sanitize the surface area immediately after the resident left body fluids on the counter. The IPN stated the counter was contaminated and if touched could have passed an infection to staff or residents.
During an interview on 2/13/2025 at 9:44 a.m., with the Director of Nursing (DON), the DON stated that all high touched areas should be cleaned frequently and immediately if bodily fluid was present.
During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Environmental Surfaces, revised June 2009, the P&P indicated housekeeping surfaces such as floors and tabletops will be cleaned on a regular basis, when spills occur and when these surfaces are visibly soiled. The P&P indicated spills of blood and other potentially infectious materials will promptly be cleaned and decontaminated.
During a review of the facility's P&P titled, Infection Control Guidelines for All Nursing Procedures, revised August 2012, the P&P indicated employees must wash their hands for ten to fifteen seconds using antimicrobial or non-antimicrobial soap and water under the following conditions:
1. Before and after direct contact with residents
2. When hands are visibly dirty or soiled with blood and other body fluids
3. After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin
4. After removing gloves
5. After handling items potentially contaminated with blood, body fluids or secretions.
b. During an observation on 2/10/2025 at 10:17 a.m., in Resident 56's room, Resident 56's nebulizer machine and the mask (a face mask over the nose and mouth to deliver medication into the lungs) were observed on the floor behind Resident 56's bed. The tubing was undated.
During a review of Resident 56's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 56 was originally admitted to the facility on [DATE] and re admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease ([COPD]- a chronic lung disease causing difficulty in breathing), diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
During a review of Resident 56's Minimum Data Set ([MDS] - a resident assessment tool), dated 1/17/2025, the MDS indicated Resident 56's cognitive (the ability to think and process information) skills for daily living was intact. The MDS indicated Resident 56 required moderate (helper does less than half the effort) assistance from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).
During a review of Resident 56's Order Summary Report dated 3/24/2024, the order summary report indicated Levalbuterol HCL nebulizer solution (medication used to treat wheezing [a high-pitched sound during breathing]) 0.63 milligram per (/) 3 milliliters (mg/ml- metric unit of measurement, used for medication dosage and/or amount). The order summary report indicated Resident 56 would receive Levalbuterol HCL 3 ml nebulizer solution every eight (8) hours as needed for wheezing related to COPD.
During a concurrent observation and interview on 2/11/2025 at 10:28 a.m., in Resident 56's room, with LVN 1, Resident 56's nebulizer machine, mask, and tubing was observed on the floor. LVN 1 stated Resident 56's nebulizer machine was touching the floor, and it was unsanitary. LVN 1 stated the nebulizer machine should have been placed on the top of the table by Resident 56's bed. LVN 1 stated the tubing and mask were on the floor and undated. LVN 1 stated the nebulizer tubing and mask should be changed and dated every seven days and stored in the plastic bag next to the resident's bed. LVN 1 stated nebulizer tubing and mask might accumulate dirt and dust and placed Resident 56 at risk for respiratory infection.
During an interview on 2/13/2025 at 11:25 a.m., with the IPN, the IPN stated the nebulizer tubing and mask should be changed every seven days, dated, and stored in the bag next to the resident's bed when resident not using it. The IPN stated it was important that the respiratory equipment was dated and labeled for staff to know when it was last changed. The IPN stated it was important to store the nebulizer tubing and mask in the bag to prevent contamination, and respiratory infection. The IPN stated the purpose of changing the nebulizer tubing and mask every seven days was for infection control and it was the facility's policy.
During a review of the facility's P&P titled Administering Medications through a Small Volume (Handheld) Nebulizer, revised October 2010, the P&P indicated facility would provide aerosolized (a liquid drug that can be inhaled) safely and aseptically (free from infection). The P&P indicated facility would change nebulizer equipment every seven days. The P&P indicated facility would store nebulizer equipment in a plastic bag with the resident's name and date.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
Based on observation, interview, and record review, the facility failed to provide 80 square feet ([sq. ft.]- a unit of measurement) of room space per resident for 22 rooms out of 40 rooms.
This defic...
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Based on observation, interview, and record review, the facility failed to provide 80 square feet ([sq. ft.]- a unit of measurement) of room space per resident for 22 rooms out of 40 rooms.
This deficient practice had the potential for inadequate space for each resident's privacy and safe nursing care.
Findings:
During a review of the facility's Room Waiver Request letter, dated 2/11/2025, the letter indicated the following two-person rooms did not meet the 80 square feet per resident requirement: Rooms 11, 12, 14, 15, 17, 18, 21, 22,23, 24,25,26,27, 28,29, 30, 31, 32, 33, 34, 35, and 36. The letter indicated the room waiver did not adversely affect the health and safety of the residents or impede the ability of any resident from attaining his or her highest practicable well-being.
During an interview on 2/12/2025 3:39 p.m. with the Administrator (ADM), the ADM stated the impact to resident care was minimal and the facility would continue to ensure patient care and safety would not be compromised or effected. The ADM stated all 22 rooms had sufficient space for Hoyer lifts (an electronically operated patient lift for the safe lifting of heavier patients), wheelchairs, and gurneys (a wheeled bed used to transport patients who need medical care) to enter the rooms.
During observations made throughout the course of the survey, from 2/10/2025 to 2/13/2025, there were no adverse effects that pertained to the residents' care provided by facility staff, residents' privacy, health, and safety related to the provided living space of less than 80 sq. ft. per resident.
During a review of the facility's Policy and Procedure (P&P), titled, Quality of Life- Homelike Environment, revised 4/2014, the P&P indicated the facility was to ensure residents were provided with a safe, clean, comfortable and homelike environment.
Feb 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 interview and record review, the facility failed to notify the physician for one out of three sampled residents having ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician for one out of three sampled residents having a change of condition (Resident 2) by failing to:
1) Ensure the physician was made aware of Resident 2's wandering (aimlessly going from one location to another) behaviors on 12/30/2024, 1/1/2025, and 1/4/2025.
2) Ensure the Interdisciplinary Team (IDT) meeting assessed Resident 2's risk for wandering after resident 2 exhibited a change of condition, as indicated in the facility's Elopement Wandering policy.
Findings:
a. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included dementia (a progressive state of decline in mental abilities) with other behavioral disturbances, lack of coordination, difficulty in walking, and 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 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 2 required substantial or maximal assistance for toileting, oral hygiene, and dressing, and required clean-up assistance when performing personal hygiene, and was entirely dependent (helper does all the effort) on staff when walking ten feet (ft- a unit of measurement).
During a concurrent interview and record review 2/6/2025 at 3:24p.m. with Licensed Vocational Nurse (LVN) 3, Resident 2's Nursing Progress Notes, dated 12/30/2024, 1/1/2025, and 1/4/2025, were reviewed. The progress notes indicated Resident 2 wandered at night. LVN 3 stated she wrote the note and did not make the physician aware of Resident 2's wandering behaviors because she forgot.
During a concurrent interview and record review on 2/6/2025 at 3:33 p.m. with the Minimum Data Set Nurse Coordinator (MDSNC), all of Resident 2's IDT Meeting Notes, dated 2024 to 2025 were reviewed. There was no documentation to indicate Resident 2's risk for wandering was assessed by the IDT. The MDSNC stated the team should have assessed Resident 2's risk upon admission, upon every readmission, and when Resident 2 exhibited changes of condition. The MDSNC stated the IDT should have met to properly assess and address Resident 2's wandering behaviors to ensure proper interventions were in place.
During a concurrent interview record review on 2/5/2025 at 4:45 p.m. with the Director of Nursing (DON), Resident 2's IDT Meeting Notes, dated 2025, were reviewed. The DON stated IDT meetings were important because different disciplines within the facility were able to meet with the resident to formulate a plan of care and ensure [the resident's] psychosocial needs were met. The DON stated there should have been an IDT meeting to modify Resident 2's plan of care for wandering.
During a review of the facility's Policy and Procedure (P&P), titled, Change in Resident's Condition or Status, revised 11/2015, the P&P indicated the charge nurse would notify the attending physician when the following has occurred:
1. There has been an incident involving the resident.
2. A significant change in the resident's physical, emotional, and mental condition.
3. A need to alter the resident's medical treatment significantly.
The P&P also indicated a significant change of condition is a decline or improvement in the resident's status that requires an interdisciplinary review (IDT).
During a review of the facility's P&P, titled, Wandering and Elopement, revised 11/2018, the P&P indicated the facility was to assess the resident upon, admission, readmission, and upon identification of significant change of condition.
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 prevent physical abuse for two out of three sampled residents (Resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent physical abuse for two out of three sampled residents (Resident 2 and Resident 3) when the facility failed to:
1) Ensure Resident 1 ' s physicians ' order on 12/3/2024 to send out to the General Acute Center Hospital (GACH) for a psychiatric evaluation (the diagnosis, treatment, and prevention of mental health conditions) if Resident 1 displayed any further behaviors of physical aggression was written and carried out.
2) Ensure the physician was notified after Resident 1 displayed episodes of physical aggression on 12/4/2024 and 12/5/2024 with staff.
These failures resulted in Resident 1 pushing Resident 3 down in the hallway, unprovoked, on 1/21/2025, Resident 1 hitting Resident 2 on the head multiple times in Resident 1 ' s room on 1/23/2025 which led to a delay in care for Resident 1 and placed other residents at risk of further abuse by Resident 1.
Findings:
a. During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), Human Immunodeficiency Virus disease (HIV - a virus that attacks the body's immune system), anxiety disorder (feelings of uneasiness), unspecific psychosis (a mental health condition characterized by a loss of contact with reality).
During a review of Resident 1 ' s Minimum Data Set ([MDS], a resident assessment tool), dated 11/26/2024, the MDS indicated Resident 1 ' s cognitive skills (ability to think and reason) for daily decision making was severely impaired. The MDS indicated Resident 1 required substantial or maximal assistance (helper provides more than half of the effort) for toileting, oral hygiene, and dressing, and required clean-up assistance when performing personal hygiene.
During a review of Resident 1 ' s SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 1/21/2025, the SBAR indicated Resident 1 shoved Resident 3 in front of a medication cart, in the hallway.
During a review of Resident 1 ' s SBAR, dated 1/23/2025, the SBAR indicated Resident 2 wandered into Resident 1 ' s room, and Resident 1struck Resident 2 in the head multiple times. The SBAR indicated Resident 2 sustained a scratch on the left arm and thumb.
During an interview on 2/5/2025 at 1:30p.m. with Registered Nurse (RN) 1, RN 1 stated the licensed nurses should have notified the physician on 12/4/2024 and 12/5/2024 when Resident 1 displayed episodes of aggression. RN 1 stated this should have been done to prevent any abuse and minimize the chance of another altercation.
During a concurrent interview and record review on 2/5/2025 at 1:19 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s SBAR, dated 12/3/2024, was reviewed. The SBAR indicated Resident 1 hit CNA ' s arm as she attempted to make Resident 1 ' s bed. The SBAR indicated the physician ordered to send out Resident 1 to the GACH for further psychiatric evaluation if Resident 1 displayed another episode of physical aggression. LVN 1 stated it was important to write and carry out physician orders because the orders provided guidance on how to provide care for a resident. LVN 1 stated she should have written and carried out the physician ' s order and placed the order into the Electronic Medical Record (EMR). LVN 1 stated she did not transcribe the order or relay the information to the oncoming shift LVN.
During a concurrent interview and record review on 2/5/2025 at 1:19 p.m. with LVN 1, Resident 1 ' s Nursing Progress Note dated 12/4/2024 was reviewed. The Nursing Progress Note indicated Resident 1 had become physically aggressive towards a CNA after the CNA attempted to assist Resident 1 to pull up his pants. The Nursing Progress Note indicated Resident 1 threw a lunch tray out of his room. LVN 1 stated there was no documentation to indicate the physician was made aware. LVN 1 stated it was important to notify the physician of any changes of condition and altercations, especially when residents became physically aggressive. LVN 1 stated she should have notified the physician when Resident 1 had displayed the episode of aggression on 12/4/2024. LVN 1 stated she assumed that the physician had already been made aware and that she was a new nurse.
During a concurrent interview and record review on 2/5/2025 at 4:45 p.m. with the Director of Nursing (DON), Resident 1 ' s SBAR Note dated 12/3/2024 and Nursing Progress Notes, dated 12/3/2024 and 12/5/2024, were reviewed. The DON stated she expected the licensed nurses to write and carry out orders once the orders were received from the physician. The DON stated LVN 1 should have written the physician ' s order to send Resident 1 out to the GACH if he displayed another act of aggression. The DON stated Resident 1 should have been sent out to the GACH on 12/4/2024 or 12/5/2024 to prevent further instances of physical aggression, physical altercations, or physical abuse.
During a concurrent interview and record review on 2/6/2025 at 3:55 p.m. with LVN 2, Resident 1 ' s Nursing Progress Note, dated 12/5/2024 was reviewed. The Nursing Progress Note indicated Resident 1 had become physically aggressive after staff had attempted to transfer Resident 1 to another room. There was no documentation to indicate the physician was made aware. LVN 2 stated Resident 1 started to lunge towards staff and attempted to attack them. LVN 2 stated she should have called the physician, but did not think of doing so at the time. LVN 2 stated she was not made aware of the physician ' s previous order to send out Resident 1 if he (Resident 1) displayed continued acts of aggression. LVN 1 stated if she had known, she would have sent Resident 1 to the GACH to receive the care he needed.
b. During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 ' s diagnoses included dementia (a progressive state of decline in mental abilities) with other behavioral disturbances, lack of coordination, difficulty in walking, and 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 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 ' s cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 2 required substantial or maximal assistance for toileting, oral hygiene, and dressing, and required clean-up assistance when performing personal hygiene, and was entirely dependent (helper does all the effort) on staff when walking ten feet (ft- a unit of measurement).
c. During a review of Resident 3 ' s admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3 ' s diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and difficulty in walking.
During a review of Resident 3 ' s MDS, dated [DATE], the MDS indicated Resident 3 ' s cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 3 required partial or moderate assistance (helper provides less than half of the effort) for toileting, oral hygiene, and dressing, and required clean-up assistance when performing personal hygiene.
During an interview on 2/5/2025 at 4:45 p.m. with the DON, the DON stated the licensed nurses should have sent Resident 1 out to the GACH for a psychiatric evaluation on 12/4/2024. The DON stated, This led to repeated episodes of altercations, further acts of aggression towards staff, and residents. The DON stated this could have led to the physical abuse incidents on 1/21/2025 and 1/23/2025 to Resident 2 and Resident 3 by Resident 1.
During a review of the facility ' s Policy and Procedure (P&P), titled, Abuse Prevention and Prohibition, revised 11/2018, the policy indicated the facility was to understand behavioral symptoms of residents that would increase the risk of abuse. The P&P indicated aggressive and, or catastrophic reactions of residents and wandering behaviors were symptoms that would increase the risk of abuse. The P&P indicated the facility involved qualified psychiatrists and other mental health professionals to help facility staff manage difficult of aggressive residents.
During a review of the facility ' s P&P, titled, Medication and Treatment Orders, revised 4/2014, the P&P indicated the licensed nurses were to record verbal orders immediately in the resident ' s chart by the person receiving the order.
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
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 interview and record review, the facility failed to ensure a care plan was initiated and implemented to address a resid...
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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 care plan was initiated and implemented to address a resident's known wandering behaviors before the resident wandered into Resident 1's room and caused a physical altercation (on 1/23/2025) for one out of three sampled residents (Resident 2).
Findings:
a. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included dementia (a progressive state of decline in mental abilities) with other behavioral disturbances, lack of coordination, difficulty in walking, and 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 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 2 required substantial or maximal assistance for toileting, oral hygiene, and dressing, and required clean-up assistance when performing personal hygiene, and was entirely dependent (helper does all the effort) on staff when walking ten feet (ft- a unit of measurement).
During a concurrent interview and record review 2/6/2025 at 3:24p.m. with Licensed Vocational Nurse (LVN) 3, Resident 2's Nursing Progress Notes, dated 12/30/2024, 1/1/2025, and 1/4/2025, and all of Resident 2's care plans, dated 2024 to 2025, were reviewed. The progress notes indicated Resident 2 wandered at night. LVN 3 stated there was no care plan initiated to address Resident 2's wandering behaviors. LVN 3 stated she wrote the note and forgot to initiate a care plan. LVN 3 stated she should have immediately created a care plan for Resident 2's wandering behaviors so that interventions could have been in place to keep Resident 2 safe, to prevent physical altercations, physical abuse, and injury.
During an interview on 2/5/2025 at 4:45 p.m. with the Director of Nursing (DON), the DON stated if there had been a care plan in place (for Resident 2), interventions would have been put into place.
b. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), Human Immunodeficiency Virus disease (HIV - a virus that attacks the body's immune system), anxiety disorder (feelings of uneasiness), unspecific psychosis (a mental health condition characterized by a loss of contact with reality).
During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 11/26/2024, the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making was severely impaired. The MDS indicated Resident 1 required substantial or maximal assistance (helper provides more than half of the effort) for toileting, oral hygiene, and dressing, and required clean-up assistance when performing personal hygiene.
During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 1/23/2025, the SBAR indicated Resident 2 wandered into Resident 1's room, and Resident 1struck Resident 2 in the head multiple times. The SBAR indicated Resident 2 sustained a scratch on the left arm and thumb.
During a review of the facility's P&P, titled, Care Plans Comprehensive, revised 9/2010, the P&P indicated the facility was to develop and maintain a comprehensive care plan for the resident that identifies the highest level of functioning the resident may be expected to attain.
During a review of the facility's P&P, titled, Safety and Supervision of Residents, revised 7/2070, the P&P indicated the facility was to address safety and accident hazards and implement interventions to reduce accident risks and hazards.
Jan 2025
3 deficiencies
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 ensure two of ten residents (Resident 6 and Resident 7) were free f...
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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 two of ten residents (Resident 6 and Resident 7) were free from physical abuse (intentional bodily injury) when:
a. Resident 1 struck Resident 7 in the face unprovoked at Station A's hallway on 1/18/2025.
b. Resident 5 slapped Resident 6 on the right side of the face near the vending machines because Resident 6 would not light Resident 5's cigarette on 1/7/2025.
As a result of these failures, Resident 7 sustained an acute (severe and sudden in onset) depressed nasal bone fracture (a break in the nasal [relating to or having to do with the nose] bone that pushed the bone inward toward the maxilla [the bones that formed the upper part of the jaw, the roof of the mouth, and parts of the eye socket and nose] usually caused by a direct blow to the nose), and Resident 6 was physically abused by Resident 5.
Findings:
1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included metabolic encephalopathy (a brain disorder that occurred when there's an imbalance of chemicals in the blood), dementia (a progressive state of decline in mental abilities), psychosis (a severe mental condition in which thought, and emotions were so affected that contact was lost with reality), and anxiety (a feeling of fear, dread, and uneasiness).
During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 11/22/2024, the MDS indicated Resident 1 had severely impaired cognitive skills for daily decision making (ability to think and reason). The MDS indicated Resident 1 was independent (resident completed the activity by herself without assistance from a helper) with eating and personal hygiene, and required supervision with oral hygiene, toileting hygiene, and showering/bathing self.
During a review of Resident 1's Order Summary Report, dated 10/18/2024, the report indicated to monitor Resident 1's behavior of sudden shifts in mood from pleasant to extreme anger and striking out staff or peers every shift.
During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there was a change of condition among the residents), dated 1/7/2025 and untimed, the report indicated on 1/7/2025, Resident 1 slapped the hat off, of a resident (Resident 2).
During a review of Resident 1's care plan titled Altercation resident to resident verbal altercation resulting to physical assault to another resident, initiated on 1/7/2025, the interventions indicated nursing staff were to distract and redirect Resident 1 by engaging the resident in alternative activities to divert attention away from triggers.
During a review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR), dated 1/18/2025 and untimed, the SBAR indicated on 1/18/2025 Resident 1 exhibited physical aggression towards another resident (Resident 7).
During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was admitted to the facility on [DATE]. Resident 7's diagnoses included difficulty in walking, metabolic encephalopathy, diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia.
During a review of Resident 7's History and Physical (H&P), dated 11/24/2024, the H&P indicated Resident 7 did not have the capacity to understand and make decisions.
During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 7 required partial assistance (helper did less than half the effort) with eating and substantial assistance (helper did more than half the effort) with oral hygiene, toileting hygiene, showering/ bathing self, and personal hygiene. The MDS indicated Resident 1 required supervision in walking and used a wheelchair for mobility.
During a review of Resident 7's SBAR, dated 1/18/2025, the SBAR indicated on 1/18/2025, Dietary Aid (DA 1) witnessed Resident 1 grab Resident 7 by the shoulder and with a closed fist and hit Resident 7 in the nose. The SBAR indicated on 1/18/2025, Resident 7 did not have pain nor changes in the skin observed.
During a review of Resident 7's X-ray (a type of electromagnetic radiation that produced images of the inside of the body, used to diagnose and treat diseases and injuries) report, dated 1/19/2025, the report indicated Resident 7 had an acute depressed fracture involving the nasal bone.
During a review of Resident 7's Interdisciplinary Team (IDT, a group of healthcare professionals who worked together to provide care for residents in a nursing home) Conference Record, dated 1/19/2025, the IDT record indicated on 1/18/2025, DA 1 witnessed Resident 1 unprovokedly punched Resident 7 on the nose in the Station A hallway, and the facility abuse protocol was initiated. The IDT record indicated Resident 7 had no pain, no facial discoloration or swelling, nor had any chronic (a condition that lasted for a long time and requires ongoing medical care) or acute (something was severe and sudden, or immediate) changes noted. The IDT record indicated Resident 7 continued to enjoy his daily routines.
During an interview on 1/22/2025 at 10:35 am with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on the morning of 1/18/2025 (could not recall the time), she was informed by DA 1 that Resident 1 unprovokedly punched Resident 7 on the nose in the Station A hallway when they walked past each other. LVN 1 stated Resident 1 was calm and unable to indicate why he punched Resident 7 in the nose.
During a telephone interview on 1/22/2025 at 11:23 a.m. with DA 1, DA 1 stated on the morning of 1/18/2025 (could not recall the time), DA 1 saw Resident 1 was using his left hand to hold Resident 7 by the shoulder and punched Resident 7 on the nose with his right fist in Station A's hallway. DA 1 stated Resident 7 was trying to push Resident 1 away but was too weak to do so. DA 1 stated he tried to separate Resident 1 and Resident 7, but DA 1 did not get to the residents on time. DA 1 stated he called LVN 2 over to check on Resident 7.
During a telephone interview on 1/22/2025 at 12:29 p.m. with LVN 2, LVN 2 stated on the morning of 1/18/2025 (could not recall the time), she was informed by DA 1 that Resident 1 unprovokedly punched Resident 7 on the nose on. LVN 2 stated on 1/18/2025(could not recall the time), there was no visible injury to Resident 7's face. LVN 2 stated Resident 7 was unable to provide information on what happened.
2. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE]. Resident 5's diagnoses included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), schizoaffective disorder (a mental illness that could affect thoughts, mood, and behavior), bipolar disorder (sometimes called manic-depressive disorder; mood swings that ranged from the lows of depression to elevated periods of emotional highs), and restlessness (a state of unable to stay still or quiet, or feeling worried or bored) and agitation (a state of extreme arousal, restlessness, or tension that could make it hard to relax).
During a review of Resident 5's H&P, dated 12/21/2024, the H&P indicated Resident 5 did not have the capacity to understand and make decisions.
During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5 had mildly impaired cognitive skills for daily decision making. The MDS indicated Resident 5 was independent with eating, oral hygiene, toileting hygiene, showering/ bathing self, and personal hygiene. The MDS indicated Resident 5 had hallucinations (a false perception of a sight, sound, smell, taste, or touch that seems real but was not).
During a review of Resident 5's Order Summary Report, dated 12/20/2024, the report indicated to monitor Resident 5 for auditory (hearing) and visual hallucinations.
During a review of Resident 5's Order Summary Report, dated 12/30/2024, the report indicated to monitor Resident 5 for behavior of sudden angry outburst.
During a review of Resident 5's care plan titled Resident has a behavioral pattern, initiated on 1/6/2025, the care plan indicated interventions included one-to-one (1:1, a situation where a dedicated healthcare professional constantly observed and attended to a single resident, maintaining close proximity [the state of being close to something or someone in space] at all times to ensure their safety and intervene as needed) supervision.
During a review of Resident 5's SBAR, dated 1/8/2025, the SBAR indicated on 1/7/2025 around 11:05 p.m. Resident 5 slapped Resident 6 near the vending machines. The SBAR indicated Resident 5 stated she slapped Resident 6 because Resident 6 drank all her (Resident 5) soda and did not want to light her cigarette.
During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE]. Resident 6's diagnoses included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), hyperlipidemia (a medical condition where there were abnormally high levels of fats in the blood), schizoaffective disorder, and bipolar disorder.
During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 had mildly impaired cognitive skills for daily decision making. The MDS indicated Resident 6 required supervision with eating and partial assistance with oral hygiene, toileting hygiene, shower/ bathe self, and personal hygiene. The MDS indicated Resident 5 used a wheelchair for mobility.
During a review of Resident 6's incident report, dated 1/7/2025, the report indicated on 1/7/2025 around 11:05 p.m., Activities Aide (AA) 1 witnessed Resident 5 slap Resident 6 on the side of the head in the patio. The report indicated Resident 6 stated he was walking out and Resident 5 smacked him.
During a review of Resident 6's IDT record, dated 1/8/2025, the IDT record indicated during the wee hours (the early hours of the morning) of 1/8/2025, Resident 6 stated Resident 5 slapped him on the right side of face when Resident 5 asked for a lighter and Resident 6 stated he did not have one. The IDT record indicated the mandated abuse reporting guideline had been completed and Resident 6 pressed charges (to take legal action against someone) against Resident 5.
During an interview on 1/22/2025 at 10:06 a.m. with Resident 6, Resident 6 stated on the night of 1/7/2025, Resident 5 punched him with a closed fist and hit him (Resident 6) on the right side of the cheek near the vending machines, after he told Resident 5 to light her own cigarette. Resident 6 stated there was no staff present when it happened. Resident 6 stated being slapped by Resident 5 made him feel weird because he thought Resident 5 was his friend.
During an interview on 1/22/2025 at 11:35 a.m., with AA 1, AA 1 stated on the night of 1/7/2025 at 11 p.m., she was supervising Resident 5 and walked with Resident 5 to the vending machine area. AA 1 stated she left Resident 5 alone for about five minutes with Resident 6 to inform the charge nurse that she needed to leave work and go home. AA 1 stated on 1/7/2025 at 11:05 p.m., she witnessed Resident 5 slap Resident 6 across the face when she returned to the vending machine area.
During a review of the facility's Policy and Procedure (P&P) tilted Abuse Prevention and Prohibition, dated 11/2018, the P&P indicated the facility did not condone any form of resident abuse. The P&P indicated the facility promoted an environment free from abuse and mistreatment. The P&P also indicated physical abuse was defined as hitting, slapping, pinching, and or kicking.
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 interview and record review, the facility failed to provide adequate supervision for one of ten residents (Resident 5),...
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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 adequate supervision for one of ten residents (Resident 5), who was on one-to-one (1:1, a situation where a dedicated healthcare professional constantly observed and attended to a single resident, maintaining close proximity at all times to ensure their safety and intervene as needed) supervision, slapped Resident 6 on the right side of Resident 6's face on 1/7/2025 near the vending machines because Resident 6 would not light Resident 5's cigarettes.
This deficient practice had the potential to negatively affect Resident 6's physical, mental, and psychosocial well-being.
Findings:
During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE]. Resident 5's diagnoses included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), schizoaffective disorder (a mental illness that could affect thoughts, mood, and behavior), bipolar disorder (sometimes called manic-depressive disorder; mood swings that ranged from the lows of depression to elevated periods of emotional highs), and restlessness (a state of unable to stay still or quiet, or feeling worried or bored) and agitation (a state of extreme arousal, restlessness, or tension that could make it hard to relax).
During a review of Resident 5's History and Physical (H&P), dated 12/21/2024, the H&P indicated Resident 5 did not have the capacity to understand and make decisions.
During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool), dated 12/30/2024, the MDS indicated Resident 5 had mildly impaired cognitive skills for daily decision making (ability to think, remember and reason). The MDS indicated Resident 5 was independent (resident completed the activity by herself without assistance from a helper) with eating, oral hygiene, toileting hygiene, showering/bathing self, and personal hygiene. The MDS indicated Resident 5 required supervision with toileting hygiene and personal hygiene. The MDS indicated Resident 5 had hallucinations (a false perception of a sight, sound, smell, taste, or touch that seems real but was not).
During a review of Resident 5's care plan titled Resident has a behavioral pattern, initiated on 1/6/2025, the staff interventions indicated 1:1 supervision.
During a review of Resident 5's Situation, Background, Assessment, Recommendation (SBAR- a communication tool used by healthcare workers when there was a change of condition among the residents), dated 1/8/2025, the SBAR indicated Resident 5 slapped Resident 6 near the vending machines on 1/7/2025 around 11:05 p.m. The SBAR indicated Resident 5 stated she slapped Resident 6 was because Resident 6 drank all of her soda and did not want to light her cigarette.
During a review of Resident 5's Order Summary Report, dated 12/30/2024, the report indicated to monitor Resident 5 for behavior of sudden angry outbursts.
During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE]. Resident 6's diagnoses included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), hyperlipidemia (a medical condition where there were abnormally high levels of fats in the blood), schizoaffective disorder, and bipolar disorder.
During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 had mildly impaired cognitive skills for daily decision making. The MDS indicated Resident 6 required supervision with eating and partial assistance (helper did less than half the effort) with oral hygiene, toileting hygiene, showering/bathing self, and personal hygiene. The MDS indicated Resident 5 used a wheelchair for mobility.
During a review of Resident 6's Incident Report, dated 1/7/2025, the report indicated on 11/7/2025 around 11:05 p.m., Activities Aide (AA) 1 witnessed Resident 5 slap Resident 6 on the side of the head in the patio. The report indicated Resident 6 stated he was walking out from the patio and Resident 5 smacked him.
During an interview on 1/22/2025 at 10:06 a.m. with Resident 6, in Resident 6's room, Resident 6 stated Resident 5 punched him with closed fit and hit him (Resident 6) on right side of the cheek on 1/7/2025 near the vending machines after telling Resident 5 to light her own cigarettes. Resident 6 stated there was no staff present when it happened. Resident 6 stated it made him feel weird because he thought Resident 5 was his friend.
During an interview on 1/22/2025 at 11:35 a.m., with AA 1, AA 1 stated she was supervising Resident 5 on 1/7/2025 and walked with Resident 5 to the vending machine area around 11 p.m. AA 1 stated she left Resident 5 alone with Resident 6 to inform the charge nurse that she needed to leave work and go home. AA 1 stated there was no other staff supervising Resident 5 at that time. AA 1 stated she witnessed Resident 5 slap Resident 6 across the face on 1/7/2025 at 11:05 p.m. when she returned to the vending machine area. AA 1 stated staff providing 1:1 supervision was not supposed to leave Resident 5 alone because an abuse incident could occur.
During an interview on 1/22/2025 at 11:45 a.m. with the Director of Staff Development (DSD), the DSD stated staff providing 1:1 supervision should supervise residents at all times, and residents should not leave the staff's sight at any time. The DSD stated staff providing 1:1 supervision had to have someone to relive them when going on breaks because the resident might have another behavioral episode when left alone. The DSD stated it was not acceptable to leave residents alone when they were on 1:1 supervision.
During an interview on 1/22/2025 at 2:21 p.m. with the Director of Nursing (DON), the DON stated staff was expected to have the residents within their visual field at all times when residents were on 1:1 supervision, so staff could redirect the residents as needed. The DON stated AA 1 should have brought Resident 5 along to notify the charge nurse that she needed to leave. The DON stated it was not acceptable to have no staff present when Resident 5 and Resident 6 were in the vending machine area, as there was lack of supervision.
During a review of the facility's P&P, titled Safety and supervision of residents, revised in 7/2017, the P&P indicated The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices . Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
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 meet professional standards of quality of care for seven out of ten...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to meet professional standards of quality of care for seven out of ten residents (Resident 1,2,4,5,7,8, and 9) by failing to:
1. Ensure the facility documented the findings related to a change of condition (COC) that on 1/8/2025 Resident 1 slapped the hat off Resident 2, for Resident 1 on 1/8/2025 and 1/9/2025 3 p.m. -11 p.m. (evening) shifts nor on 1/9/2025 7 a.m. - 3 p.m. (morning) shift.
2. Ensure the facility completed documentation of nursing interventions for resident care on Resident 2's Medication Administration Record (MAR) on 1/1/2025, 1/9/2025, 1/10/2025, and 1/14/2025 evening shifts.
3. Ensure the facility documented the findings related to a COC that on the morning of 1/7/2025 Resident 2 alleged Resident 1 went into his (Resident 2) room and hit him (Resident 2) in the head for Resident 2, on 1/7/2025, 1/9/2025 evening shifts and 1/8/2025, 1/9/2025 morning shifts.
4. Ensure the facility completed documentation of nursing interventions for resident care on Resident 4's MAR on 1/1/2025, 1/9/2025, 1/10/2025, and 1/14/2025 evening shifts.
5. Ensure the facility documented the findings related to a COC that on 1/5/2025, Resident 5 allegedly hit Resident 4 across the face, for Resident 5 on 1/6/2025 and 1/7/2025 evening shifts.
6. Ensure the facility documented the findings related to a COC that on 1/18/2025 Resident 1 struck Resident 7 in the face unprovoked at Station A's hallway, for Resident 7 on 1/18/2025 and 1/19/2025 evening shifts.
7. Ensure the facility completed documentation of nursing interventions for resident care on Resident 8's MAR on 1/1/2025, 1/9/2025, 1/10/2025, and 1/14/2025 evening shifts.
8. Ensure the facility documented the findings related to a COC that on 1/19/2025, Resident 8 reported that Resident 9 spat on his left arm unprovokedly (something was done without a clear reason or justification), for Resident 8 on 1/19/2025 and 1/21/2025 evening shifts.
9. Ensure the facility completed documentation of nursing interventions for resident care on Resident 9's MAR on 1/1/2025 evening shift.
10. Ensure the facility documented the findings related to a COC that on 1/19/2025, Resident 9 spat on Resident 8's left arm unprovokedly, for Resident 9 on 1/19/2025 and 1/21/2025 evening shifts.
These deficient practices could have potentially delayed necessary medical and behavioral care for Resident 1,2,4,5,7,8, and 9, and increased the risk of another episode of resident-to-resident altercation.
Findings:
1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included metabolic encephalopathy (a brain disorder that occurred when there's an imbalance of chemicals in the blood), dementia (a progressive state of decline in mental abilities), psychosis (a severe mental condition in which thought, and emotions were so affected that contact was lost with reality), and anxiety (a feeling of fear, dread, and uneasiness).
During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 11/22/2024, the MDS indicated Resident 1 had severely impaired cognitive skills for daily decision making (ability to think, remember and reason). The MDS indicated Resident 1 was independent (resident completed the activity by herself without assistance from a helper) with eating and personal hygiene, and required supervision with oral hygiene, toileting hygiene, shower/ bathe self, and walking.
During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there was a change of condition among the residents), dated 1/7/2025, the report indicated on 1/7/2025, Resident 1 had behavior changes and Resident 1 slapped the hat off Resident 2.
During a concurrent interview and record review on 1/22/2025 at 1:30 p.m. with Registered Nurse (RN 1), Resident 1's nursing progress notes, dated 1/22/2025, were reviewed. RN 1 stated there was no documentation on the nursing progress notes regarding on 1/7/2025, Resident 1's behavior changes that Resident 1 slapped the hat off Resident 2, on 1/8/2025 and 1/9/2025 evening shifts nor on 1/9/2025 morning shift.
2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), anxiety disorder (a mental health condition that involved excessive and persistent feelings of fear and worry), and schizoaffective disorder (a mental illness that could affect thoughts, mood, and behavior).
During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had contact cognitive skills for daily decision making. The MDS indicated Resident 2 used walker and wheelchair for mobility devices. The MDS indicated Resident 2 was independent with eating; required supervision with oral hygiene and personal hygiene; and required partial assistance (helper did less than half the effort) with toileting hygiene and shower/bathe self.
During a review of Resident 2's Incident Report (IR), dated 1/7/2025, the IR indicated Resident 2 stated Resident 1 went into his room and hit him in the head on 1/7/2025.
During a review of Resident 2's care plan titled Resident engaged in an altercation with another resident (Resident 1), initiated on 1/5/2025, the care plan indicated interventions included be alert for sign and changes in behavior by observing presence of yelling, anger, restlessness, repetitive pacing, talking to self, and to assess for injury and/ or pain.
During a review of Resident 2's History and Physical (H&P), dated 1/12/2025, the H&P indicated Resident 2 was alert and oriented x 3 (a person was awake, aware, and understands who they were, where they were, and what time it was) and required specialized nursing interventions for the sustained management of chronic health conditions.
During a concurrent interview and record review on 1/22/2025 at 1:30 p.m. with RN 1, Resident 2's MAR, dated 1/17/2025 at 12:22 p.m. was reviewed. RN 1 stated there was no documentation on 1/1/2025, 1/9/2025, 1/10/2025, and 1/14/2025 evening shifts for the following orders:
a) Monitor adverse side effects (ASE, an undesired effect of a drug) of antidepressant (a type of medicine used to treat depression [a constant feeling of sadness and loss of interest] every (Q) shift
b) Monitor behavior of bipolar disorder (mood swings [a sudden or intense change in a person's emotional state] that ranged from the lows of depression to elevated periods of emotional highs) m/b (manifested by) sudden mood swings Q shift.
c) Monitor behavior of verbalization of feeling of helplessness on medical condition Q shift.
d) Monitor for skin breakdown (tissue damage caused by friction, shear, moisture or pressure and was limited to the top layer of skin) posterior (the back side of things head) Q shift for 7 days.
e) Monitor signs/symptoms (S/S) of psychosocial behavior Q shift.
f) Monitor ASE of antipsychotics (A type of drug used to treat symptoms of psychosis) Q shift.
g) Pain assessment Q shift.
During a concurrent interview and record review on 1/22/2025 at 1:30 p.m. with RN 1, Resident 2's nursing progress notes, dated 1/22/2025, were reviewed. RN 1stated there was no documentation on the nursing progress notes regarding Resident 2's altercation with Resident 1 happened on 1/7/2025 on 1/7/2025 and 1/9/2025 evening shifts, nor on 1/8/2025 and 1/9/2025 morning shift.
3. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4's diagnoses included COPD, anxiety, bipolar disorder, and schizophrenia (a mental illness that was characterized by disturbances in thought).
During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 had mildly impaired cognitive skills for daily decision making. The MDS indicated Resident 4 required supervision with eating and partial assistance with oral hygiene, toileting hygiene, and shower/ bathe self.
During a review of Resident 4's H&P, dated 1/14/2025, the H&P indicated Resident 4 did not have the capacity to understand and make decisions.
During a review of Resident 4's psychiatric note, dated 12/5/2024, the psychiatric note indicated Resident 4 had episodes of paranoia (a mental disorder in which a person had an extreme fear and distrust of others), angry outburst, poor PO (oral) intake, moods swings, and delusions (having false or unrealistic beliefs).
During a review of Resident 4's IR, dated 1/5/2025, the IR indicated Resident 4 was crying and stated Resident 5 hit her on 1/5/2025.
During a review of Resident 4's care plan titled Resident engaged in an altercation with Roommate (Resident 5), initiated on 1/5/2025, the care plan indicated interventions included Be alert for sign and changes in behavior by observing presence of yelling, anger, restlessness, repetitive pacing, talking to self.
During a concurrent interview and record review on 1/17/2025 at 12:21 p.m. with RN 1, Resident 4's MAR, dated 1/17/2025 at 9:57 a.m., was reviewed. RN 1 stated there was no documentation on 1/1/2025, 1/9/2025, 1/10/2025, and 1/14/2025 evening shifts for the following orders:
a) Covid-19 (Coronavirus disease, an infectious disease caused by the SARS-CoV-2 virus) monitoring to be completed every shift: monitor for S/S of respiratory infection. Check temperature and oxygen saturation (the amount of oxygen you had circulating in your blood) Q shift.
b) Keep HOB (head of bed) elevated 30-40 degrees due to SOB (shortness of breath) while lying flat in bed related to COPD Q shift.
c) Monitor ASE of antidepressant Q shift.
d) Monitor ASE of mood stabilizer (a medication that helped treat mood swings) Q shift.
e) Monitor behavior episodes of depression m/b poor PO intake Q shift.
f) Monitor behavior for anxiety m/b continuous purposeless pacing (to walk with regular steps in one direction and then back again) in hallway Q shift.
g) Monitor behavior for mood swing m/b sudden mood changes Q shift.
h) Monitor behavior of schizophrenia m/b paranoia thinking she was being poisoned Q shift.
i) Monitor for further skin breakdown of left eye Q shift for 7 days.
j) Monitor new onset of pain Q shift for 7 days.
h) Monitor ASE of antipsychotics Q shift.
i) Monitor ASE of anxiolytics (A drug used to treat symptoms of anxiety) Q shift.
j) Monitor S/S of melena (black, tarry stools that indicated bleeding in the upper gastrointestinal [GI] tract), bruising, and hematuria (blood in the urine) Q shift.
k) Monitor S/S of psychosocial behavior Q shift.
l) Pain assessment Q shift.
4. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE]. Resident 5's diagnoses included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), schizoaffective disorder, bipolar disorder, and restlessness (a state of unable to stay still or quiet or feeling worried or bored) and agitation (a state of extreme arousal, restlessness, or tension that could make it hard to relax).
During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5 had mildly impaired cognitive skills for daily decision making. The MDS indicated Resident 5 was independent with eating, oral hygiene, toileting hygiene, shower/ bathe self, and personal hygiene. The MDS indicated Resident 5 had hallucinations (a false perception of a sight, sound, smell, taste, or touch that seems real but was not).
During a review of Resident 5's H&P, dated 12/21/2024, the H&P indicated Resident 5 did not have the capacity to understand and make decisions.
During a review of Resident 5's care plan titled Residents roommate (Resident 4) alleges she (Resident 5) hit her on face 1/5/2025, initiated on 1/5/2025, the care plan indicated interventions included 72 hours monitoring after incident.
During a review of Resident 5's SBAR, dated 1/5/2025, the SBAR indicated Resident 5 allegedly hit Resident 4 across the face on 1/5/2025.
During a review of the facility's follow-up report, dated 1/8/2025, the report indicated the allegation of Resident 5 hitting Resident 4 on the left side of face and eye on 1/5/2025 was found to be valid (based on truth or reason, or legally acceptable).
During a review of Resident 5's SBAR, dated 1/8/2025, the SBAR indicated Resident 5 slapped Resident 6 near the vending machines on 1/7/2025 around 11:05 p.m. The SBAR indicated Resident 5 stated she slapped Resident 6 was because Resident 6 drank her soda and did not want to light her cigarette.
During a concurrent interview and record review on 1/22/2025 at 1:30 p.m. with RN 1, Resident 5's nursing progress notes, dated 1/22/2025, were reviewed. RN 1 stated there were no documentation on the nursing progress notes regarding Resident 5's altercation with Resident 6 happened on 1/7/2025, on 1/6/2025 and 1/7/2025 evening shifts.
5. During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was admitted to the facility on [DATE]. Resident 7's diagnoses included difficulty in walking, metabolic encephalopathy, Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia.
During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 7 required partial assistance with eating and substantial assistance (helper did more than half the effort) with oral hygiene, toileting hygiene, shower/ bathe self, and personal hygiene. The MDS indicated Resident 1 required supervision in walking and used wheelchair for mobility.
During a review of Resident 7's H&P, dated 11/24/2024, the H&P indicated Resident 7 did not have the capacity to understand and make decisions.
During a review of Resident 7's SBAR, dated 1/18/2025, the report indicated kitchen staff (Dietary Aid- DA) witnessed Resident 1 grabbed Resident 7 by the shoulder and with closed fist hit Resident 7 in the nose.
During a review of Resident 7's X-ray (a type of electromagnetic radiation that produced images of the inside of the body. X-rays were used to diagnose and treat diseases and injuries) report, dated 1/19/2025, the report indicated Resident 7 had acute depressed fracture involving nasal bone.
During a concurrent interview and record review on 1/22/2025 at 1:30 p.m. with RN 1, Resident 7's nursing progress notes, dated 1/22/2025, were reviewed. RN 1 stated there was no documentation on the nursing progress notes regarding Resident 7's altercation with Resident 1 happened on 1/182025, on 1/18/2025 and 1/19/2025 evening shifts.
6. During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 8's diagnoses included DM, COPD, schizoaffective disorder, bipolar disorder, and anxiety.
During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8 had intact cognitive skills for daily decision making. The MDS indicated Resident 8 had verbal behavioral symptoms (threatening others, screaming at others, cursing at others) directed toward others. The MDS indicated Resident 8 had impairment on upper extremity and used wheelchair for mobility device. The MDS indicated Resident 8 was independent with eating; required supervision in oral hygiene; and required partial assistance with toileting hygiene, shower/ bathe self, and personal hygiene.
During a review of Resident 8's H&P, dated 12/7/2024, the H&P indicated Resident 8 had fluctuating capacity (when a person's ability to make decisions changed over time) to understand and make decisions.
During a review of Resident 8's SBAR, dated 1/19/2025, the report indicated Resident 8 reported that Resident 9 spat on his left arm unprovokedly (something was done without a clear reason or justification) on 1/19/2025.
During a review of Resident 8's care plan titled Resident to Resident Altercation: Resident alleges another resident (Resident 9) without provocation, spit on him, initiated on 1/19/2025, the care plan indicated interventions which included 72 hours monitoring after incident.
During a concurrent interview and record review on 1/22/2025 at 1:30 p.m. with RN 1, Resident 8's MAR, dated 1/22/2025 at 12:50 p.m., was reviewed. RN 1 stated there was no documentation on 1/1/2025, 1/9/2025, 1/10/2025, and 1/14/2025 on the evening shifts for the following orders:
a) Monitor behavior for erratic (inconsistent and unpredictable) mood swings Q shift.
b) Monitor behavior of anxiety AEB (as evident by) verbalization of feeling anxious Q shift.
c) Monitor behavior of schizophrenia m/b angry outbursts towards staff or other residents Q shift.
d) Monitor for anxiolytic side effects Q shift.
g) Pain assessment Q shift.
During a concurrent interview and record review on 1/22/2025 at 1:30 p.m. with RN 1, Resident 8's nursing progress notes, dated 1/22/2025, were reviewed. RN 1 stated there was no documentation on the nursing progress notes regarding Resident 8's altercation with Resident 9 happened on 1/18/2025, on 1/19/2025 and 1/21/2025 evening shifts.
7. During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was admitted to the facility on [DATE]. Resident 9's diagnoses included intractable absence epileptic syndrome (a type of epilepsy where absence seizures [brief, sudden lapses in consciousness characterized by staring blankly into space and a lack of awareness of surroundings] were not controlled by medication), schizophrenia, dementia, and anxiety.
During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9 had mildly impaired cognitive skills for daily decision making. The MDS indicated Resident 9 had verbal behavioral symptoms directed toward others. The MDS indicated Resident 9 was independent with eating and oral hygiene, and required supervision with toileting hygiene, shower/ bathe self, and personal hygiene. The MDS indicated Resident 9 used walker and wheelchair for mobility devices.
During a review of Resident 9's SBAR, dated 1/19/2025, the report indicated Resident 9 spat on Resident 8's left arm unprovokedly on 1/19/2025.
During a review of Resident 9's care plan titled Resident to Resident Altercation: Resident alleges spat on another male resident's (Resident 9) left arm unprovoked, initiated on 1/19/2025, the care plan indicated interventions included 72 hours monitoring.
During a concurrent interview and record review on 1/22/2025 at 1:30 p.m. with RN 1, Resident 9's MAR, dated 1/22/2025 at 12:48 p.m., was reviewed. RN 1 stated licensed nurse should complete documentation on MARs by the end of shift before leaving. RN 1 stated the expectation was for the responsible licensed nurse of the shift to complete the MAR at the end of the shift. RN 1 stated if not documented meant it did not happen. RN 1stated document was to prove it was done. RN 1 stated the potential risk was resident's unmanaged behaviors, which could be addressed before the behavior and/or situation escalated, and it could possibly delay necessary care for residents. RN 1 stated there was no documentation on 1/1/2025 evening shift for the following orders:
a) Monitor for episodes of seizure Q shift.
b) Monitor for pain Q shift.
c) Monitor for psychosis m/b striking out at staff during care Q shift.
d) Monitor for the following behaviors: Striking out, inconsolable screaming, rapid mood cycling (swing) mania (mental state of an extreme highs or depressive lows) Q shift.
e) Monitor for ASE of antipsychotic Q shift.
f) Monitor for ASE of anxiolytics Q shift.
During a concurrent interview and record review on 1/22/2025 at 1:30 p.m. with RN 1, Resident 9's nursing progress notes, dated 1/22/2025, were reviewed. RN 1 stated there was no documentation on the nursing progress notes regarding Resident 9's altercation with Resident 8 happened on 1/18/2025, on 1/19/2025 and 1/21/2025 evening shifts. RN 1 stated the licensed nurse needed to document on progress note for residents on 72 hours monitoring on each shift. RN 1 stated the purpose of the documentation was for staff to see residents' response to the incident, residents' psychical and emotion states, and the continuity of care staff provided. RN 1 stated residents might be at risk of unmanaged pain and mood, and with the potential of striking again and harming self.
During an interview on 1/22/2025 at 2:21 p.m. with the Director of Nursing (DON), the DON stated the licensed nurse was expected to complete all documentation on residents' MARs before leaving the shift. The DON stated no documentation meant interventions were not being done, and staff could possibly miss the changes in residents' condition. The DON stated the purpose of monitoring residents for 72 hours after incident was for license nurses to prevent another resident-to-resident altercation as much as possible. The DON stated if there were changes in residents' behavior, the licensed nurse was expected to be aware of and contact physician to provide interventions. The DON stated the licensed nurse should document Q shift on progress note. The DON stated staff could miss addressable (able to be addressed/changed, directly accessible) changes in residents which could probably lead to another incident and possible delay necessary care.
During a review of facility's Charge Nurse (CN)-RN/LVN (Licensed Vocational Nurse) Job Description, undated, the job description indicated the CN needed to complete daily charting as assigned and ensured documentation was complete and legible at all times.
During a review of facility's Policy and Procedure (P&P) titled Charting and Documentation, revised on 4/2008, the P&P indicated All observations, medications administered, services performed, etc., must be documented in the resident's clinical records.
Jan 2025
4 deficiencies
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
Notification of Changes
(Tag F0580)
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 implement its policy and procedure (P&P) titled, Change in a Reside...
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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 (P&P) titled, Change in a Resident's Condition, which indicated the facility will notify a resident's physician when there was a significant change (major decline or improvement in the resident's status that could not normally resolve itself without intervention by the staff) in the resident's condition by failing to notify a physician timely, for one of seven sampled residents (Resident 2) when:
a. Resident 2 had a change of condition of a decreased oxygen saturation (the percentage [%] of oxygen in a person's blood, normal oxygen saturation level between 95 and 100 %] rate oxygen of 84 %. Resident 2's oxygen saturation did not reach the normal oxygen saturation level of 95 to 100% after administering 5 liters per minute (LPM, unit of measurement) of oxygen, 10 LPM, and 15 LPM of oxygen via an oxygen mask (device used to deliver supplemental oxygen [treatment in which a storage tank of oxygen or a machine called a compressor is used to give oxygen to people with breathing problems]).
b. Resident 2 refused the 72-Hour Neurological check (series of tests over a 72-hour period to assess for changes in neurological function [the ability of the nervous system to send and receive signals throughout the body, allowing for movement, sensation, and other bodily functions]) and Body Check Assessment after an unwitnessed fall on [DATE].
c. Resident 2 refused Skin Check Assessments during activities of daily living ([ADLs], activities such as bathing, dressing, and toileting a person performs daily).
These failures resulted in Resident 2 being hypoxic (absence of oxygen in the tissues to sustain bodily functions) with labored breathing (breathing that requires more effort than normal, or an increased amount of energy) and only responsive to tactile stimuli (any form or touch or physical contact perceived by the skin), and a one hour delay in transferring the resident to a general acute care hospital (GACH) for timely evaluation and treatment. These failures also had the potential to result in the ability of Resident 2's nervous system (a complex network of nerve tissue that sends signals between the brain and the body) to send and receive signals throughout the body, allowing for movement, sensation, and other bodily functions. These failures resulted in Resident 2's covered skin area (back and buttocks) not being assessed for skin breakdown and impaired skin integrity.
Findings:
a. During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included cellulitis (a skin infection that causes swelling and redness) of the right and left lower limb (leg), acute embolism (a blood clot that enters the blood stream and blocks blood flow) and thrombosis (a blood clot that forms in a blood vessel, partially or completely blocking blood flow) of the left calf muscular vein (part of the deep vein system that drains blood from the calf muscles back to the heart), and peripheral vascular disease ([PVD], a slow progressive narrowing of the blood flow to the arm and legs).
During a review of Resident 2's Minimum Data Set ([MDS], a resident assessment tool), dated [DATE], the MDS indicated Resident 2's cognition (process of thinking) was severely impaired. The MDS indicated Resident 2 required moderate assistance with oral hygiene, toileting, bathing, and dressing. The MDS indicated Resident 2 had four venous ulcers (an open sore on the leg that occurs when blood does not circulate properly in the leg veins) and an infection of the foot.
During a review of Resident 2's Change in Condition (COC), dated [DATE], the COC indicated on [DATE] at 3:08 a.m., Resident 2 was observed with discoloration and swelling of his right first toe and bleeding from the right, lower extremity (leg). The COC indicated Resident 2 had abnormal vital signs (measurements of the body's most basic functions) and altered mental status (a change in how well your brain is working). The COC indicated 9-1-1 was called at 4:09 a.m., and Resident 2 was transferred to the GACH at 4:40 a.m., 92 minutes after Resident 2's initial change of condition.
During a review of Resident 2's Progress Notes, dated [DATE], the Progress Notes indicated on [DATE] at 3:08 a.m., Licensed Vocational Nurse (LVN) 1 assessed Resident 2's discoloration and swelling on his right first toe. The Progress Notes indicated Resident 2 appeared confused. The Progress Notes indicated the following vital signs and assessments:
1. At 3:10 a.m., Resident 2's vital signs were the following: Blood pressure (BP, force of blood used to get through the vessels of the body) was 106/64 (normal range of 120-129 [top number] and 80-84 [bottom number) millimeters of mercury ([mm Hg], unit of measurement), respiratory rate (RR, breathing) of 21 breaths per minute (normal RR 12 to 20 bpm), heart rate (HR) was 66 beats per minute ([BPM], normal range 60 to 100 BPM), temperature of 98.8 degrees Fahrenheit ([F], a unit of measurement, normal temperature range 97 to 99 F), and oxygen saturation of 84% on room air. The Progress Note indicated supplemental oxygen was initiated at 5 LPM via an oxygen mask.
2. At 3:40 a.m., the Progress Note indicated Resident 2 had no changes from the assessment done at 3:10 a.m. The Progress Note indicated Resident 2 was making noises. Resident 2's vital signs were the following: BP was 94/84 mmHg, RR was 21 bmp, HR was 87 BPM, temperature was 98.9 F, and oxygen saturation was 87% while receiving 10 LPM of oxygen via an oxygen mask.
3. At 3:55 a.m., Resident 2's vital signs were the following: BP was 104/48 mmHg, RR was 22 bpm, HR was 87 BPM, temperature was 98.9 F, and oxygen saturation was 84% while receiving 15 LPM via an oxygen mask.
4. At 4:07 a.m., Resident 2 was observed with his eyes closed, with labored breathing, and with his (unspecified) upper extremity cold to the touch. Resident 2 was unable to respond verbally but would awake to tactile stimuli (any form or touch or physical contact perceived by the skin). Resident 2's vital signs were the following: BP was 104/52 mmHg, RR was 22 bpm, HR was 116 BPM, temperature was 99.1 F, and oxygen saturation was 87% while receiving 15 LPM of oxygen via a non-rebreather mask (oxygen mask that delivers high concentrations of oxygen).
The Progress Notes dated [DATE], indicated 9-1-1 was called at 4:09 a.m. and the emergency medical services (EMS) arrived at the facility at 4:13 a.m. The Progress Notes indicated on [DATE], Resident 2 was transferred to the GACH at 4:40 a.m., 92 minutes after Resident 2's initial change of condition.
During a review of Resident 2's GACH Emergency Department (ED) Note, dated [DATE] and timed at 5:10 a.m., the GACH ED Note indicated upon arrival to the ED, Resident 2's vital signs were the following: BP was 64/43 mmHg, RR was 22 bpm, HR was 98 BPM, temperature was 104.9 F, and oxygen saturation was 87% on 15 LMP of oxygen via an oxygen mask. The GACH ED Note indicated Resident 2 was brought to the GACH via ambulance for worsening cellulitis to the bilateral (affecting both sides) lower extremities. The GACH ED Note indicated Resident 2's legs were initially wrapped in gauze and plastic bags and when removed the legs were noted to be extremely pungent malodorous (a strong, sharp, unpleasant odor). The GACH ED Note indicated Resident 2's lactic acid level (a blood test used to help diagnose sepsis [a life-threatening blood infection]) was elevated at 3.46 millimoles per liter ([mmol/L, unit of measurement], normal value of 0.7 to 1.9 mmol/L). The GACH ED Note indicated Resident 2's white blood cell count ([WBC], a blood test that indicate the presence of inflammation or infection) was elevated at 16 microliters ([X10^3/Ul]- a unit of measurement, normal WBC count 4.5 to 11). The GACH ED Note indicated Resident 2 was diagnosed with septic shock (a life-threatening condition that occurs when an infection causes a dangerously low blood pressure and organ failure), acute renal failure (condition where kidneys suddenly lose their function), and cellulitis.
During a review of Resident 2's GACH History and Physical (H&P), dated [DATE] and timed at 7:57 a.m., the H&P indicated Resident 2 had worsening right, lower extremity cellulitis. The GACH H&P indicated Resident 2 remained hypotensive (low blood pressure) despite fluid resuscitation (a medical procedure that involves replacing fluids lost by the body) and received norepinephrine (a vasopressor [drug used to make blood vessels constrict or become narrow to raise blood pressure]), vasopressin (a vasopressor), and phenylephrine (vasopressor). The H&P indicated the general surgeon was consulted and a decision was made for Resident 2 to have an emergent right, below the knee amputation.
During a review of Resident 2's GACH Nursing Progress Notes, dated [DATE] and timed at 10 a.m., Resident 2 arrived in the Intensive Care Unit (ICU, a hospital ward that provides specialized care for patients who are very ill or injured) at 9:00 a.m. and was intubated (a procedure that involves the insertion of a tube to facilitate breathing) at 10:30 a.m. The notes indicated Resident 2 underwent right and left below the knee amputations (removal of a limb) and was required to be placed on maximum continuous doses of norepinephrine (a vasopressor), vasopressin, and phenylephrine.
During a review of Resident 2's GACH Clinical Notes, dated [DATE] and timed at 6:21 p.m., the Clinical Note indicated Resident 2 continued to receive Levophed (used to treat life-threatening low blood pressure) and phenylephrine despite the right, lower extremity amputation and continued fluid resuscitation. The Clinical Note indicated Resident 2's left lower extremity appeared worse than at admission ([DATE]), with new ischemic changes (when the part of the body does not get enough blood or oxygen) to the soft tissue (the body's supporting tissues such as fat, skin, and muscle). The Clinical Note indicated the care team will proceed with an emergent left below the knee amputation.
During a review of Resident 2's GACH Amputation Below Knee Procedure Notes, dated [DATE], the notes indicated Resident 2 underwent bilateral below the knee amputations.
During a review of Resident 2's GACH Rapid Response Note, dated [DATE] and timed at 11:54 a.m., the note indicated Resident 2 became pulseless (no heartbeat), required chest compressions, and expired at 11:57 a.m. from cardiac arrest (occurs when the heart suddenly stops beating).
During an interview on [DATE] at 12:52 p.m., with LVN 1, LVN 1 stated on [DATE], at approximately 3 a.m., he noticed Resident 2 looked off. LVN 1 stated Resident 2 had blood on his right lower extremity and his right toe had a dark purple discoloration. LVN 1 stated at the beginning of the shift at 11 p.m., Resident 2 did not have any bleeding or dark purple discoloration on his right toe. LVN 1 stated he began to check Resident 2's vital signs and observed the resident's oxygen saturation was low, at 84%. LVN 1 stated he initiated supplemental oxygen and had to increase the amount of oxygen to Resident 2, however, the Resident 2's oxygen saturation did not improve and fluctuated between 84 to 87%. LVN 1 stated due to Resident 2's condition, wound care was not provided to Resident 2's legs and instead was wrapped with additional gauze and a plastic bag. LVN 1 stated he attempted to notify Resident 2's physician towards the end of his shift at approximately 7 a.m., (four hours after Resident 2's initial change of condition). LVN 1 stated Resident 2's physician was not notified when Resident 2's initial change of condition was noted at 3:10 a.m. LVN 1 stated he went with his nursing judgement and acted to treat Resident 2's desaturation (decrease in oxygen saturation) instead of calling Resident 2's physician and waiting for orders. LVN 1 stated he should have notified Resident 2's physician of the resident's status and initial desaturation of 84% for guidance on how to proceed with Resident 2's care. LVN 1 stated if he notified Resident 2's physician sooner, he may have been directed to call 9-1-1 sooner.
During an interview on [DATE] at 2:20 p.m., with Registered Nurse (RN) 1, RN 1 stated Resident 2 did not have any respiratory issues and never required supplemental oxygen. RN 1 stated if a resident required 10 LPM of oxygen, regardless of improvement, he would have to immediately call 9-1-1. RN 1 stated Resident 2 requiring supplemental oxygen was a change of condition and his physician should have been notified immediately. RN 1 stated notifying the physician would provide a line of communication where the physician may give orders on how to proceed with treatment. RN 1 stated the physician may request to call 9-1-1 due to the need of a higher level of care for prompt assessment and treatment. RN 1 stated Resident 2 was hypoxic (having too little oxygen) for over an hour and could have been hypoxic long before LVN 1 assessed him. RN 1 stated the lack of physician notification resulted in a delay in care.
During an interview on [DATE] at 3:56 p.m., with the Director of Nursing (DON), the DON stated Resident 2 should have been sent to the GACH sooner. The DON stated Resident 2 had a change in oxygenation and mental status. The DON stated Resident 2's physician should have been notified of Resident 2's initial change of condition. The DON stated Resident 2 should not have been allowed to decline to the degree of being responsive only to tactile stimuli. The DON stated Resident 2 was hypoxic for over an hour, which meant he was not getting oxygen to his vital organs. The DON stated Resident 2 suffered a delay in care.
During a review of the facility's Policy and Procedure (P&P) titled, Transfer or Discharge, Emergency, revised 9/2012, the P&P indicated when it was necessary to make an emergency transfer to the hospital, the facility would notify the resident's physician.
During a review of the facility's P&P titled, Change in a Resident's Condition or Status, revised 2/2021, the P&P indicated the nurse would notify the resident's physician when there was a significant change (major decline or improvement in the resident's status that could not normally resolve itself without intervention by the staff) in the resident's condition and the resident needed to be transferred to the GACH.
b. During a review of Resident 2's COC, dated [DATE], the COC indicated on [DATE] at 9:20 a.m., Resident 2 had an unwitnessed fall and was found in a sitting position on the floor by his bed. The COC indicated Resident 2's 72-Hour Neurological Check (series of tests over a 72-hour period to assess for changes in neurological function [the ability of the nervous system to send and receive signals throughout the body, allowing for movement, sensation, and other bodily functions]) was initiated.
During a concurrent interview and record review on [DATE], with RN 1, Resident 2's 72-Hours Neuro Checklist, dated [DATE], was reviewed. RN 1 stated the 72-Hour Neuro Checklist indicated Resident 1's neurological assessment was initiated on [DATE] at 9:30 a.m. RN 1 stated the 72-Hour Neuro Checklist indicated assessment was to be completed twice every 30 minutes, then three times every hour, then two times every two hours, then four times every four hours, and finally six times every eight hours. RN 1 stated the 72-Hours Neuro Checklist dated [DATE], indicated:
a. At 9:30 a.m., BP of 108/64 mmHg, temperature 97.8 F, HR of 80 BPM, RR of 18 bpm, alert, pupils equal and responsive, and left- and right-hand grip firm.
b. At 10 a.m., Resident 2 refused assessment.
c. At 1 p.m., Resident 2 refused assessment.
d. At 4 p.m., Resident 2 refused assessment.
e. At 7 p.m., Resident 2 refused assessment.
f. At 10 p.m., Resident 2 refused assessment.
RN 1 stated Resident 2 refused the neurological assessments on [DATE]. RN 1 stated the licensed nurses did not complete the 72-Hours Neuro Checklist for the full 72 hours. RN 1 stated the 72-Hours Neuro Checklist was only completed for 12 hours. RN 1 stated although Resident 2 refused the neurological assessments; the licensed nurse should have continued to try to assess Resident 2 for neurological deficits. RN 1 stated conducting the neurological assessments would help detect any changes in Resident 2's mental status and ensure his brain was functioning at its baseline. RN 1 stated not attempting to complete Resident 2's 72-Hours Neuro Checklist put the resident at risk for undetected symptoms from a brain bleed. RN 1 stated Resident 2's physician should have been notified of his refusal of the neurological assessments. RN 1 stated notifying Resident 2's physician would allow the physician to be aware of Resident 2's status, and further treatment.
During a review of the facility's P&P titled, Neurological Assessment, revised 10/2010, the P&P indicated, The purpose of this procedure is to provide guidelines for a neurological assessment upon physician order, when following an unwitnessed fall, subsequent to a fall with a suspected head injury, or when indicated by resident condition. The P&P indicated, Notify the physician of any changes in a resident's neurological status. Notify the supervisor if the resident refuses the procedure. Report other information accordance with facility policy and professional standards of practice.
c. During a review of Resident 2's Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal of a resident) Fall Management Follow-Up, dated [DATE], the IDT Fall Management Follow-Up indicated Resident 2 was placed on Neuro Checks and Post-Fall Monitoring. The IDT Fall Management Follow-Up indicated other interventions implemented for Resident 2 included to check the resident's vital signs, pain assessment, and body/skin check. The IDT Fall Management Follow-Up indicated an X-ray (procedure to take pictures of the inside of the body) of Resident 2's hips were ordered. The IDT Fall Management Follow-Up indicated Resident 2 did not want the licensed nurse to perform any assessments and to leave him alone.
During an interview on [DATE] at 1:10 p.m., with the Quality Assurance (QA) Nurse, the QA Nurse stated after a fall, Resident 2's vital signs and exposed skin, such as arms, legs, and head were assessed. The QA Nurse stated when Resident 2 had an unwitnessed fall on [DATE] but refused to have a full body and skin assessment done. The QA Nurse stated Resident 2 was found on his buttocks and it was important to assess the area for any redness or bruising. The QA Nurse stated Resident 2's physician was not notified the resident refused the skin assessment after the fall. The QA Nurse stated she was unsure why Resident 2's physician was not notified of his refusal for a skin assessment. The QA Nurse stated Resident 2's physician should have been notified for orders to monitor Resident 2 for skin changes and any treatment, if needed.
d. During a review of Resident 2's Skin Observation document, dated [DATE] through [DATE], the Skin Observation document indicated Resident 2 refused the skin observation on [DATE], [DATE], [DATE], and [DATE].
During a review of Resident 2's Wound Scan Photos, dated [DATE] and timed at 8:44 a.m., the Wound Scan Photos indicated Resident 2 had redness to the bilateral buttocks, a dark brown spot on his lower back, and a red/brown spot on his left lower back.
During a review of Resident 2's GACH Nursing Note, dated [DATE] and timed at 10 a.m., the Nursing Note indicated Resident 2 had many wounds on his back and hip area indicating that he is unable to turn on his own.
During an interview on [DATE] at 11:26 a.m., with the Treatment Nurse (TN), the TN stated the CNAs see the residents' skin more often than the licensed nurses. The TN stated the licensed nurses depended on the CNAs to report any skin changes immediately. The TN stated if a resident refused a shower or skin assessment, the CNA would have to inform the licensed nurse. The TN stated he was unaware of any wounds on Resident 2's buttocks and backside. The TN stated a facility-wide skin sweep would be conducted monthly and Resident 2 was set to have a full body skin assessment if he was not sent to the GACH.
During an interview on [DATE] at 11:13 a.m., with CNA 7, CNA 7 stated she was assigned to Resident 2 and was familiar with the resident. CNA 7 stated Resident 2 would not allow her to touch him or allow her to assist with his ADLs or other parts of his care. CNA 7 stated Resident 2 would ask for towels and take wet wipes into the restroom to wipe himself down. CNA 7 stated Resident 2 would close the door on her and would not allow CNA 7 to observe his back side and buttocks. CNA 7 stated Resident 2 was very independent and ambulatory (ability to walk). CNA 7 stated she informed the licensed nurse of Resident 2's skin check refusals.
During an interview on [DATE] at 11:44 a.m., with the DON, the DON stated the licensed nurses conduct a monthly skin sweep for each resident, and CNAs would perform a daily skin observation when providing care to a resident. The DON stated the CNAs would note any skin changes and inform the licensed nurses. The DON stated Resident 2 did not allow the CNAs or licensed nurses to assist with his care and demanded they leave his room. The DON stated Resident 2's physician was not notified the resident refused his skin assessments. The DON stated the physician should have been notified for interventions to better care for Resident 2 and prevent the resident's condition from getting worse. The DON stated notifying Resident 2's physician could have allowed for better assessment of Resident 2's skin and to identify any changes in his skin and treat accordingly.
During a review of the facility's P&P titled, Refusal of Care and Treatment, revised 2017, the P&P indicated, The Attending Physician must be notified of refusal or treatment, in a time frame determined by the resident's condition and potential serious consequences of the refusal.
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 F0657
(Tag F0657)
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 revise the person-centered care plan (document that helps nurses an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise the person-centered care plan (document that helps nurses and other team care members organize aspect of resident care) for one of seven sampled residents (Resident 2), who refused skin check assessments during activities of daily living ([ADLs], activities such as bathing, dressing, and toileting a person performs daily).
This failure had the potential to result in the mismanagement of Resident 2 ' s care by not having a guideline to follow for assessing and managing Resident 2 ' s skin integrity.
Findings:
During a review of Resident 2 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included cellulitis (a skin infection that causes swelling and redness) of the right and left lower limb, acute embolism (a blood clot that enters the blood stream and blocks blood flow) and thrombosis (a blood clot that forms in a blood vessel, partially or completely blocking blood flow) of the left calf muscular vein, and peripheral vascular disease ([PVD], a slow progressive narrowing of the blood flow to the arm and legs).
During a review of Resident 2 ' s Minimum Data Set ([MDS], a resident assessment tool), dated 11/27/2024, the MDS indicated Resident 2 ' s cognition (process of thinking) was severely impaired. The MDS indicated Resident 2 required moderate assistance with oral hygiene, toileting, bathing, and dressing. The MDS indicated Resident 2 had four venous ulcers (an open sore on the leg that occurs when blood does not circulate properly in the leg veins) present. The MDS indicated Resident 2 had an infection of the foot.
During a review of Resident 2 ' s Skin Observation record, dated 11/24/2024 through 11/28/2024, the Skin Observation record indicated Resident 2 refused the skin observation on 11/28/2024, 12/2/2024, 12/4/2024, and 12/11/2024.
During an interview on 1/2/2025 at 11:11 a.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated when the residents were showered, the CNAs would do a skin inspection and report any out of the ordinary findings to the licensed nurse. CNA 3 stated if a resident refused a shower or refused the skin inspection, the licensed nurse would be notified.
During an interview on 1/3/2025 at 11:13 a.m., with CNA 7, CNA 7 stated she was assigned to Resident 2 and was familiar with the resident. CNA 7 stated Resident 2 would not allow her to touch him (Resident 2) or allow her (CNA 7) to assist with his ADLs or other parts of his care. CNA 7 stated Resident 2 would ask for towels and take wet wipes into the restroom to wipe himself down. CNA 7 stated Resident 2 would close the door on her and would not allow her to see his back side and buttocks. CNA 7 stated Resident 2 was very independent and ambulatory (ability to walk). CNA 7 stated she would inform the licensed nurse of Resident 2 ' s skin check refusals.
During an interview on 1/6/2025 at 11:44 a.m., with the Director of Nursing (DON), the DON stated the licensed nurses conduct a monthly skin sweep for each resident, however, the CNAs would do a skin observation daily when they provided care to a resident. The DON stated the CNAs would note any skin changes and inform the licensed nurses. The DON stated Resident 2 did not allow the CNAs or licensed nurses to assist with his care and would demand them to leave his room. The DON stated Resident 2 ' s care plan of refusing skin assessments should have been revised. The DON stated Resident 2 refused a skin assessment upon admission, however, the care plan should have been revised to communicate the ongoing problem. The DON stated revising the care plan would ensure the nurses and the physician were aware of the ongoing problem and to develop and implement further interventions to prevent skin breakdown and to promote skin healing.
During a review of the facility ' s policy and procedure (P&P) titled, Care Plans- Comprehensive, revised 9/2010, the P&P indicated, Assessments of residents are ongoing and care plans are revised as information about the resident and the resident ' s condition change.
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 ordered wound care treatments on 12/7/2024 and 12/28/2024, ...
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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 ordered wound care treatments on 12/7/2024 and 12/28/2024, for one of seven sampled residents (Resident 2).
This failure had the potential to result in the development of an infection and the potential for Resident 2 ' s wounds to worsen.
Findings:
During a review of Resident 2 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included cellulitis (a skin infection that causes swelling and redness) of the right and left lower limb, acute embolism (a blood clot that enters the blood stream and blocks blood flow) and thrombosis (a blood clot that forms in a blood vessel, partially or completely blocking blood flow) of the left calf muscular vein, and peripheral vascular disease ([PVD], a slow progressive narrowing of the blood flow to the arm and legs).
During a review of Resident 2 ' s Minimum Data Set ([MDS], a resident assessment tool), dated 11/27/2024, the MDS indicated Resident 2 ' s cognition (process of thinking) was severely impaired. The MDS indicated Resident 2 required moderate assistance with oral hygiene, toileting, bathing, and dressing. The MDS indicated Resident 2 had four venous ulcers (an open sore on the leg that occurs when blood does not circulate properly in the leg veins) present. The MDS indicated Resident 2 had an infection of the left foot.
During a review of Resident 2 ' s Order Recap Report, dated 11/1/2024 through 1/31/2025, the Order Recap Report indicated the following orders:
a. Cleanse Resident 2 ' s left, dorsal (top side) foot venous wound with normal saline (solution of water and salt used to clean wounds) and pat dry. Apply silvadene cream (medicated cream used to prevent and treat wound infections) and zinc oxide cream (cream used to treat and prevent skin irritation). Cover with absorbent dressing and wrap with kerlix (dressing used to secure and prevent movement of primary dressing), once a day.
b. Cleanse Resident 2 ' s left, lower extremity (leg) venous wound with normal saline and pat dry. Apply Silvadene cream and zinc oxide cream. Cover with absorbent dressing and wrap with kerlix, once a day.
c. Cleanse Resident 2 ' s right, dorsal foot venous wound with normal saline and pat dry. Apply Silvadene cream and zinc oxide cream. Cover with absorbent dressing and wrap with kerlix, once a day
d. Cleanse Resident 2 ' s right, lower extremity venous wound with normal saline and pat dry. Apply Silvadene cream and zinc oxide cream. Cover with absorbent dressing and wrap with kerlix, once a day.
During a review of Resident 2 ' s Skin Observation Tool, dated 12/18/2024, the Skin Observation Tool indicated the following measurements for Resident 2 ' s venous wounds:
a. Right, dorsal foot venous wound measured 11 centimeters (cm, unit of measurement) in length, 4 cm in width, and 0.7 cm in depth.
b. Right, lower leg venous wound measured 23 cm in length, 40 cm in width, and 3 cm in depth.
c. Left, lower leg venous wound measured 35 cm in length, 30 cm in width, and 1.2 cm in depth.
d. Left, dorsal foot venous wound measured 6 cm in length, 3 cm in width, and 0.3 cm in depth.
The Skin Observation Tool indicated Resident 2 ' s wounds had heavy serous (clear or slightly yellow, thin, watery fluid that seeps from a wound during healing) drainage and edema (swelling).
During an interview on 1/2/2025 at 11:29 a.m., with the Treatment Nurse (TN), the TN stated Resident 2 was admitted to the facility with venous ulcers to both lower legs and both dorsal feet. The TN stated there were times Resident 2 refused wound care treatment. The TN stated he would inform Resident 2 ' s physician of his refusal. The TN stated he was the only dedicated wound care nurse for the facility, however, the other licensed nurses could administer the treatment when he was not there. The TN stated Resident 2 ' s wound treatments was ordered once a day and unless Resident 2 refused the treatments, Resident 2 should have received the treatments even if he was not scheduled to work that day.
During a concurrent interview and record review on 1/2/2024 at 11:35 a.m., with the TN, Resident 2 ' s Treatment Administration Record (TAR), dated 12/1/2024 through 12/31/2024 was reviewed. The TAR indicated Resident 2 did not receive the ordered wound care treatments for his left dorsal foot, left lower extremity, right dorsal foot, and right lower extremity on 12/7/2024 and 12/28/2024. The TN stated the empty boxes on Resident 2 ' s TAR signified that Resident 2 did not receive the ordered treatments on 12/7/2024 and 12/28/2024. The TN stated Resident 2 had extensive wounds on both his legs and feet and providing the wound care treatment everyday was important to heal those wounds. The TN stated Resident 2 ' s wounds had heavy drainage, which made it very important to change his wound dressings every day. The TN stated not providing the ordered wound care treatment and changing soiled dressings could cause Resident 2 ' s wounds to worsen.
During an interview on 1/2/2025 at 2:17 p.m., with Registered Nurse (RN) 1, RN 1 stated the days the TN did not work, the residents ' wound care treatments would need to be completed by the licensed nurse assigned. RN 1 stated there was no reason for missed treatment unless the resident refused or was not in the facility. RN 1 stated providing wound care to Resident 2 was very important due to the size and nature of the wounds. RN 1 stated not providing wound treatments to Resident 2 had the potential to result in the wounds getting worse.
During a review of the facility ' s policy and procedure (P&P) titled, Wound Care, revised 10/2010, the P&P indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Verify that there is a physician ' s order. The P&P indicated after performing wound care to document on the resident ' s medical record the type of wound care given, the date and time the wound care was given, the name of the individual performing wound care, and if the resident refused the treatment.
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 interview and record review, the facility failed to ensure residents were free of accidents and hazards for two of seve...
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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 residents were free of accidents and hazards for two of seven sampled residents (Residents 1 and 2) by failing to:
1. Ensure Certified Nursing Assistant (CNA) 1 reported Resident 1 ' s unwitnessed fall to the licensed nurses.
2. Ensure CNA 1 and CNA 2 followed the facility ' s procedure of not moving Resident 1, who fell, prior to being assessed by a licensed nurse.
3. Ensure Resident 1 did not experience a 2-hour delay in physical assessment, 72-Hour Neurological Check (serious of tests over a 72-hour period to assess for changes in neurological function) initiation, and care.
4. Complete Resident 1 ' s post-fall Fall Risk Evaluation.
5. Correctly complete Resident 2 ' s 72-Hour Neurological Check.
These failures resulted in Resident 1 ' s licensed nurses being unaware of Resident 1 ' s fall, which resulted in a delay in assessment and interventions. These failures also resulted in Resident 2 not being assessed timely for neurological deficits.
Findings:
a. During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses the included ataxia (loss of muscle control and coordination) following nontraumatic subarachnoid hemorrhage (neurosurgical emergency that occurs when blood pools in the space that covers the brain), epilepsy (chronic brain condition that causes seizures, which are brief episodes of abnormal electrical activity in the brain), dementia (a progressive state of decline in mental abilities), and acute myocardial infarction (heart attack).
During a review of Resident 1 ' s Minimum Data Set ([MDS], a resident assessment tool), dated 10/17/2024, the MDS indicated Resident 1 ' s cognition (process of thinking) was moderately impaired. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) with oral hygiene, toileting, bathing, dressing, and personal hygiene.
During a review of Resident 1 ' s History and Physical (H&P), dated 9/5/2024, the H&P indicated Resident 1 had fluctuating (changing) capacity to understand and make decisions.
During a review of Resident 1 ' s Fall Risk Evaluation, dated 10/17/2024, the Fall Risk Evaluation indicated Resident 1 was at high risk for falls.
During a review of Resident 1 ' s Change of Condition (COC), dated 12/15/2024, the COC indicated on 12/15/2024 at 4 p.m., Licensed Vocational Nurse (LVN) 2 noticed Resident 1 had red color in his spit and Resident 1 stated he fell on his face two hours prior. The COC indicated the 72-Hour Neurological Check was initiated and Resident 1 was assessed with slight swelling and discoloration to the left side of his face and under the eye.
During a review of Resident 1 ' s Statement, dated 12/15/2024 at 4 p.m., the Statement indicated Resident 1 fell two hours prior and was assisted by two nurses who helped him into bed and then left the room.
During a review of Resident 1 ' s 72 Hours Neuro Checklist, dated 12/15/2025 through 12/18/2024, the 72 Hours Neuro Checklist indicated Resident 1 ' s Neurological Assessment started on 12/15/2024 at 4 p.m.
During an interview on 12/31/2024 at 9:50 a.m., with Resident 1, Resident 1 stated he fell when he tried to throw trash into the trashcan near his bed. Resident 1 stated the trash did not make it into the trashcan and when he tried to pick it up, he fell onto the floor. Resident 1 stated two CNAs helped him back into bed. Resident 1 stated he told the oncoming LVN he fell.
During an interview on 12/31/2024 at 10:16 a.m., with CNA 1, CNA 1 stated towards the end of her shift on 12/15/2024, she did her rounds on residents and saw CNA 2 and CNA 5 waving her over to Resident 1 ' s room. CNA 1 stated when she entered Resident 1 ' s room, Resident 1 was on the floor. CNA 1 stated she and CNA 2 picked Resident 1 off the floor and assisted him back to his bed. CNA 1 stated she observed Resident 1 ' s face and did not see any bruising or visual bumps. CNA 1 stated once Resident 1 was back in bed, she changed his diaper and went to look for the LVN on duty. CNA 1 stated she could not locate the LVN assigned to Resident 1 and went to assist another resident. CNA 1 stated by the end of her shift, she forgot to report Resident 1 ' s fall to the assigned LVN. CNA 1 stated she could have reported Resident 1 ' s fall to the other licensed nurses on duty that day. CNA 1 stated there were two other CNAs assisting her and she could have delegated one to get the LVN. CNA 1 stated when a resident fell, she was supposed to get a licensed nurse to come to the room to assess the resident for any injuries. CNA 1 stated reporting to the licensed nurse immediately after Resident 1 ' s fall was important to ensure Resident 1 was assessed for injuries.
During an interview on 12/31/2024 at 10:27 a.m., with CNA 2, CNA 2 stated she saw Resident 1 sitting on the floor and informed CNA 1 because she was the assigned CNA to Resident 1. CNA 2 stated she did not inform the licensed nurses about Resident 1 ' s unwitnessed fall because she was not assigned to Resident 1 and thought CNA 1 would report it. CNA 2 stated Resident 1 had an unwitnessed fall, she and CNA 1 should not have moved him before he was assessed by the licensed nurse. CNA 2 stated waiting for the licensed nurse to assess Resident 1 was essential just in case Resident 1 had a broken bone or other kind of injury.
During an interview on 12/31/2024 at 11:27 a.m., with the Director of Staff Development (DSD), the DSD stated the expectations of the CNAs if they found a resident on the floor was to call the licensed nurse for assistance and to not move the resident. The DSD stated after a resident falls, the resident could sustain an unseen injury or could be injured when moved. The DSD stated informing the licensed nurse would allow them to conduct an assessment and to determine if the resident was safe to move. The DSD stated the licensed nurse would then report the fall to the physician who would give further orders on how to care for the resident.
During an interview on 11:53 a.m., with Registered Nurse (RN) 1, RN 1 stated he was not informed on 12/15/2024 that Resident 1 fell. RN 1 stated Resident 1 told LVN 2, who reported to the physician and began Resident 1 ' s assessments. RN 1 stated CNA 1 should have reported to the licensed nurse immediately after she found Resident 1 on the floor. RN 1 stated immediate reporting to the licensed nurse would allow for Resident 1 to be assessed for injury. RN 1 stated due to the delay in reporting, Resident 1 ' s 72-Hour Neurological Check initiated two hours after Resident 1 ' s fall. RN 1 stated the 72-Hour Neurological Check should have been initiated immediately after knowledge of Resident 1's fall to ensure Resident 1 ' s neurological status was assessed timely. RN 1 stated initiating the 72-Hour Neurological Check immediately was crucial to detect any changes in Resident 1 ' s mental status, which could mean injury to the brain. RN 1 stated if Resident 1 did not inform LVN 2 of his fall and neither CNA 1 nor CNA 2 notified a licensed nurse, Resident 1 may not have received the care and assessments needed. RN 1 stated CNA 1 should not have assisted Resident 1 back to bed before Resident 1 was assessed for injuries. RN 1 stated CNAs were not trained to assess for injuries or use the appropriate interventions. RN 1 stated after a fall, the resident would be assessed for visible injuries, changes in range of motion, any swelling, discoloration, or bleeding.
During a concurrent interview and record review on 12/31/2024 at 12:01 p.m., with RN 1, Resident 1 ' s Fall Risk Evaluations were reviewed. RN 1 stated Resident 1 did not have a Fall Risk Evaluation completed after his fall on 12/15/2024. RN 1 stated the purpose of the Fall Risk Evaluation after a fall allowed the nurses to reevaluate and determine if the resident was at further risk for falls and what interventions to implement to prevent further falls. RN 1 stated because a Fall Risk Evaluation was not completed after Resident 1 fell, the nurses may not initiate and implement the appropriate interventions specific to prevent Resident 1 from falling in the future.
During an interview on 12/31/2024 at 1:30 p.m., with the Director of Nursing (DON), the DON stated the CNAs were expected to report to the licensed nurse on duty when a resident falls and to not move them. The DON stated based on the assessment and if the resident was stable, the resident would be assisted back into the bed or wheelchair. The DON stated a 72-Hour Neurological Check would be initiated if the resident stated or if there was suspicion that they hit their head. The DON stated immediate reporting of the CNA to the licensed nurse would allow the licensed nurse to address any acute issues present and to provide the appropriate care to the resident. The DON stated a delay in initiating Resident 1 ' s 72-Hour Neurological Check put him at risk for undetected neurological decline and potential for delay in interventions. The DON stated Fall Risk Evaluations were completed upon admission to the facility, quarterly, and after a fall. The DON stated completing the Fall Risk Evaluation after a fall would inform the nurses whether the resident was at a higher risk for falls and what measures to be put into place to prevent or decrease the chance of injury.
During a review of the facility ' s policy and procedure (P&P) titled, Falls and Fall Risk, Managing, revised 3/2018, the P&P indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.
During a review of the facility ' s CNA Job Description, undated, the CNA Job Description indicated the duties and responsibilities of the CNA were to report all changes in the resident ' s condition to the Nurse Supervisor/Charge Nurse as soon as practical [and to] report all accidents and incidents you observe on the shift that they occur.
During a review of the facility ' s In-Service Lesson Plan titled, Fall Risk & Prevention, undated, the In-Service Lesson Plan indicated not to move a resident who falls onto the floor and a head trauma is suspected.
b. During a review of Resident 2 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included cellulitis (a skin infection that causes swelling and redness) of the right and left lower limb, acute embolism (a blood clot that enters the blood stream and blocks blood flow) and thrombosis (a blood clot that forms in a blood vessel, partially or completely blocking blood flow) of left calf muscular vein, and peripheral vascular disease ([PVD], a slow progressive narrowing of the blood flow to the arm and legs).
During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 ' s cognition was severely impaired. The MDS indicated Resident 2 required moderate assistance with oral hygiene, toileting, bathing, and dressing. The MDS indicated Resident 2 had four venous ulcers (an open sore on the leg that occurs when blood does not circulate properly in the leg veins) present. The MDS indicated Resident 2 had an infection of the foot.
During a review of Resident 2 ' s Fall Risk Evaluation, dated 11/25/2024, the Fall Risk Evaluation indicated Resident 2 was at risk for falls.
During a review of Resident 2 ' s COC, dated 12/27/2024, the COC indicated on 12/27/2024 at 9:20 a.m., Resident 2 was found in a sitting position on the floor by his bed side. The COC indicated Resident 2 ' s 72-Hour Neurological Check was initiated.
During a concurrent interview and record review on 1/2/2025, with RN 1, Resident 2 ' s 72 Hours Neuro Checklist, dated 12/27/2024, was reviewed. The 72 Hours Neuro Checklist indicated Resident 1 ' s neurological assessment was initiated on 12/27/2024 at 9:30 a.m. The 72 Hours Neuro Checklist indicated assessment was to be completed twice every 30 minutes, then three times every hour, then two times every two hours, then four times every four hours, and finally six times every eight hours. The 72 Hours Neuro Checklist indicated the following:
a. 12/27/2024 at 9:30 a.m., Blood pressure of 108/64 millimeters of mercury ([mmHg], unit of measurement that describes the amount of force blood uses to get through the vessels of the body), Temperature 97.8 Fahrenheit ([F], a unit of measurement), Heart Rate of 80 beats per minute, Respiratory (breathing) Rate of 18 breaths per minute, alert, pupils were equal and responsive, and left- and right-hand grip were firm.
b. 12/27/2024 at 10 a.m., Resident 2 refused assessment.
c. 12/27/2024 at 1 p.m., Resident 2 refused assessment.
d. 12/27/2024 at 4 p.m., Resident 2 refused assessment.
e. 12/27/2024 at 7 p.m., Resident 2 refused assessment.
f. 12/27/2024 at 10 p.m., Resident 2 refused assessment.
RN 1 stated Resident 2 refused the neurological assessments. RN 1 stated the licensed nurse who attempted the neurological assessment on Resident 2 did not follow the timing. RN 1 stated instead of assessing Resident 2 every hour for three hours, the licensed nurse attempted the neurological assessment every three hours over a nine-hour period. RN 1 stated this was incorrect because the first few hours after a suspected head injury, neurological symptoms could present themselves and would only be detected with timely assessment. RN 1 stated the licensed nurses did not complete the 72 Hours Neuro Checklist for the full 72 hours and was only completed for 12 hours. RN 1 stated Resident 2 refused the neurological assessment; however, the licensed nurse should continue to try to assess Resident for neurological deficits. RN 1 stated conducting the neurological assessments would help detect any changes in Resident 2 ' s mental status and to ensure his brain was functioning at its baseline. RN 1 stated not attempting to complete Resident 2 ' s 72 Hours Neuro Checklist put him at risk of undetected symptoms from a brain bleed.
During an interview on 1/2/2025 at 3:49 p.m., with the DON, the DON stated the 72 Hours Neurological Checks were done to identify any change in a resident ' s mental status and to allow for timely interventions. The DON stated the 72 Hours Neurological Checklist had to be completed, or at least attempted, so they could see a trend or pinpoint when a negative change in the resident ' s mental status occurred.
During a review of the facility ' s P&P titled, Neurological Assessment, revised 10/2010, the P&P indicated, Neurological assessments are indicated upon physician order, following an unwitnessed fall, following a fall or other accident/injury involving head trauma, or when indicated by resident ' s condition.
Dec 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
Medical Records
(Tag F0842)
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 four sampled residents' (Resident 4), psychiatry not...
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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 four sampled residents' (Resident 4), psychiatry note was readily available in resident's physical chart.
This deficient practice had the potential to delay communication between the healthcare team involved in Resident 4's care and can affect the treament plan Resident 4 need.
Findings:
During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE]. Resident 4 ' s diagnoses including schizophrenia (a mental illness that can affect thoughts, mood, and behavior), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs).
During a review of Resident 4 ' s Minimum Data Set ([MDS]- a resident assessment tool), dated 11/8/2024, the MDS indicated Resident 4 had severe cognitive impairment (ability to reason, understand, remember, judge, and learn).
During a review of Resident 4 ' s Order Summary Report, dated 12/2/24, the order summary report indicated Resident 4 may have a psychiatry (a medical specialty that focuses on diagnosing, treating, and preventing mental, emotional, and behavioral disorders) evaluation and follow up treatment as indicated.
During a review of Resident 4 ' s clinical records, the clinical records had no notes of a psychiatry evaluation conducted.
During an interview on 12/3/2024 at 2:09 PM, the Medical Records Director (MDR) stated all doctor ' s notes were kept in the resident ' s physical chart. The MDR checked Resident 4 ' s clinical records. The MDR stated Resident 4's clinical records did not have the psychiatrist's notes. The MDR stated the psychiatry team will be notified and have the notes sent to the facility.
During an interview on 12/4/2024 at 9:48 AM, the Registered Nurse (RN) 2 stated Resident 4 ' s psychiatry team would type their notes and email it to medical records to be placed in the resident ' s chart. RN 2 further stated if a resident ' s doctors notes is not in the chart, it could affect the care Resident 4 would need, if another staff member or doctor needed the psychiatrist's evaluation of Resident 4.
During an interview on 12/4/2024 at 10:20 AM, the MDR stated if the doctor ' s type their notes, the notes will be emailed to the medical records. The MDR stated, the medical records will print the notes and place in the resident ' s physical chart. The MDR stated she does not know how it was missed that Resident 4 didn ' t have any of their psychiatry notes in the chart.
Nov 2024
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
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 the Minimal Data Set ([MDS]- a resident assessment tool), wa...
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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 Minimal Data Set ([MDS]- a resident assessment tool), was coded correctly for one of four sampled residents (Resident 1).
This deficient practice resulted in incorrect data transmitted to the Center for Medicare and Medicaid Services (CMS) regarding Resident 1 ' s behavior (how person ' s mental health affects their actions), hallucinations (perceptual experiences in the absence of real external sensory stimuli), and verbal behavioral (e.g., screaming) (yelling) directed toward others.
Findings:
During a review of Resident 1 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), anxiety disorder (feeling of fear, dread, and uneasiness) , and diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 1 ' s quarterly (cycle once every three months) Minimum Data Set ([MDS] - a resident assessment tool), dated 9/24/2024, the MDS section C (cognitive patterns) indicated Resident 1 ' s cognitive skills (the ability to think and process information) for daily decisions making was intact.
During a review of Resident 1 ' s physician order, dated 7/1/2024, the order indicated monitor for schizoaffective disorder manifested by (m/b) auditory hallucinations every shift.
During a concurrent interview and record review on 11/18/2024 at 1:45 p.m., with Minimum Data Set Nurse (MDSN 1), Resident 1 ' s care plan titled Behavior problem, initiated 9/19/2024 and revised 10/17/2024 was reviewed. MDSN 1 stated Resident 1 ' s care plan indicated Resident 1 had a behavior problem auditory hallucination related to (r/t) schizoaffective disorder. MDSN 1 stated Resident 1 ' s care titled problems/needs date initiated 9/12/2024, indicated Resident 1 was yelling at the staff. MDSN 1 stated Resident 1 ' s behavior should have been coded on Resident 1 ' s MDS under section E (behavior).
During a concurrent interview and record review on 11/18/2024 at 1:56 p.m., with MDSN 1, Resident 1 ' s MDS, dated [DATE] section E (behavior) was reviewed. MDSN 1 stated Resident 1 ' s MDS section E behavior hallucinations were coded as None of the Above, and verbal behavioral directed toward others was encoded 0 (behavior not exhibited). MDSN 1 stated Resident 1 ' s behaviors it should have been coded. MDSN 1 stated she does not know how she missed that.
During a review of the facility ' s policy and procedure (P&P) tilted Resident Assessment, revised 3/2022, the P&P indicated resident assessment coordinator was responsible for ensuring appropriate resident assessments. The P&P indicated person who have completed MDS resident assessment form would sign the document attesting to the accuracy of such information.
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
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 interview and record review, the facility failed to initiate and implement a comprehensive care plan for two of four sa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to initiate and implement a comprehensive care plan for two of four sampled residents (Resident 1 and 3) by failing to:
1. Initiate a care plan with individualized approaches addressing Resident 1 ' s behavior (how person ' s mental health affects their actions) pacing (walking back and forth) in the hallway.
2. Initiate a care plan to address Resident 1 ' s medication administration and side effects of buspirone (medication to treat anxiety disorder).
3. Initiate a care plan to address Resident 3 ' s Restorative Nurse Aide (RNA) services.
Findings:
a)During a review of Resident 1 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), anxiety disorder (feeling of fear, dread, and uneasiness) , and diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 1 ' s Minimum Data Set ([MDS] - a resident assessment tool), dated 9/24/2024, the MDS indicated Resident 1 ' s cognitive skills (the ability to think and process information) for daily decisions making was intact.
During a review of Resident 1 ' s progress note, dated 10/9/2024, the progress note indicated Resident 1 was observed pacing down the hallway multiple times. The progress note indicated Resident 1 ignored staff and refused care.
During a concurrent interview and record review on 11/18/2024 at 1:26 p.m., with Registered Nurse (RN 1), Resident 1 ' s, situation, background, assessment, recommendation ([SBAR]-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 11/2/2024 was reviewed. RN 1 stated the SBAR, indicated Resident 1 was pacing in the hallway and was aggressive towards other residents. RN 1 stated Resident 1 ' s behavior pacing in the hallway should have a care plan.
During a concurrent interview and record review on 11/18/2024 at 1:40 p.m., with RN 1, Resident 1 ' s active care plans were reviewed. RN 1 stated Resident 1 did not have a care plan addressing her (Resident 1) behavior pacing in the hallway. RN 1 stated care plan should be completed upon admission, readmission, and when there was change on condition. RN 1 stated the licensed nurses were responsible for creating a care plan. RN 1 stated care plan would ensure staff providing care to Resident 1 were aware of the Resident 1 ' s behavior, and the necessary interventions to know the resident ' s needs, what specific could staff assist Resident 1 and to provide quality care.
During a concurrent interview and record review on 11/18/2024 at 1:50 p.m., with RN 1, Resident 1 ' s active physician order as of 11/1/2024 was reviewed, the RN 1 stated the order indicated buspirone HCL 10 milligram ([mg]- a unit of measurement) oral tablet, give one (1) tablet two times a day for anxiety manifested by (m/b) continuous pacing in the hallway. RN 1 stated the order indicated monitor Resident 1 for anxiety m/b continuous pacing in the hallway every shift. RN 1 stated buspirone was a new medication for Resident 1 and should have a care plan. RN 1 stated it could be a potential delay to necessary interventions without a care plan addressing the usage of buspirone.
b) During a review of Resident 3 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), anxiety disorder (feeling of fear, dread, and uneasiness), and abnormalities of gait (a manner of walking) and mobility.
During a review of Resident 3 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 9/2/2024, the MDS indicated Resident 3 ' s cognitive skills (the ability to think and process information) for daily decisions making was intact. The MDS indicated Resident 3 required supervision or touch assistance from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).
During a review of Resident 3 ' s order summary report, dated 10/22/2024, the order summary report indicated RNA would ambulate (walk) Resident 3 five times per week.
During a concurrent interview and record review on 11/19/2024 at 4:40 p.m., with Physical Therapist 1(PT -licensed professional who work with patient to restore, maintain, and improve ability to move), Resident 3 ' s Physical Therapy Discharge Summary (PTDS), dated 10/22/2024 was reviewed. PT 1 stated Resident 3 was discharged from PT services on 10/22/2024 with a physician order for RNA services for ambulation five times per week. PT 1 stated Resident 3 RNA services should have a care plan.
During a concurrent interview and record review on 11/19/2024 at 4:55 p.m., with Director of Nursing (DON), Resident 3 ' s active care plans were reviewed. The DON was not able to provide documentation that Resident 3 ' s RNA services care plan was initiated. The DON stated services and treatments provided for residents at the facility should have a care plan. The DON stated without care plan addressing Resident 3 ' s RNA services placed Resident 3 at risk not receiving necessary care, treatment, and service.
During a review of the facility ' s Policy and Procedure (P&P) titled Care Plan- Comprehensive, revised 9/2010, the P&P indicated individualized comprehensive care plan would be developed for each resident and should include measurable objectives and timetables to meet the resident ' s medical, nursing, mental and psychological needs.
During a review of the facility ' s policy and procedure (P&P) tilted Resident Mobility and Range of Motion, revised 7/2017 the P&P indicated a care plan would be developed and would include specific interventions, exercises, and therapy to maintain, and/or improve mobility.
During a review of the facility ' s P&P titled Restorative Nursing Assistant (RNA) Job Description, undated, the P&P the RNA would perform services in compliance with written care plan.
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 F0657
(Tag F0657)
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 revise a behavior care plan one of four sampled residents (Resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise a behavior care plan one of four sampled residents (Resident 1) to reflect resident ' s behavior (-how person ' s mental health affects their actions) pacing (walking back and forth) in the hallway, verbal, and physical aggressing toward other residents in the facility.
This deficient practice resulted to Resident 1 not having an individualized care plan that addresses specific interventions to establish effective behavior management and had the potential to affect the provision of necessary care and services for Resident 1.
Findings:
During a review of Resident 1 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), anxiety disorder (feeling of fear, dread, and uneasiness) , and diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 1 ' s Minimum Data Set ([MDS] - a resident assessment tool), dated 9/24/2024, the MDS indicated Resident 1 ' s cognitive skills (the ability to think and process information) for daily decisions making was intact.
During a concurrent interview and record review on 11/18/2024 at 11:37 a.m., with Licensed Vocational Nurse (LVN 1), Resident 1 ' s progress notes dated 10/1/2024-11/10/2024 were reviewed. LVN 1 stated the progress note, dated 10/1/2024 indicated Resident 1 was monitored for aggressive behavior towards staff. LVN 1 stated the progress note dated 11/9/2024, indicated Resident 1 observed pacing down the hallway multiple times. LVN 1 stated progress note, dated 11/10/2024 indicated Resident 1 was agitated toward staff, roommate, and visitor. LVN 1 stated Resident 1 ' s behavior was a change in Resident 1 ' s care plan should be reviewed, and revised when Resident 1 had a change in condition.
During a concurrent interview and record review on 11/18/2024 at 11:49 a.m., with LVN 1, Resident 1 ' s active care plans were reviewed. LVN 1 stated the care plan should have been reviewed and revised when there was change in condition. LVN 1 stated the licensed nurses were responsible for reviewing and revising a care plan. LVN 1 stated Resident 1 ' s care plan for pacing, verbal and physical aggression should have been revised to reflect the Resident 1 ' s behavior and would ensure staff providing care to Resident 1 were aware of the Resident 1 ' s behavior, and the necessary interventions address the Resident 1 ' s needs, and to provide quality care.
During a review of the facility ' s Policy and Procedure (P&P) titled Care Plan- Comprehensive, revised 9/2010, the P&P indicated residents care plans would be revised when there has been a change in resident ' s condition.
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 F0688
(Tag F0688)
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 a resident with or without limited range of motion (ROM-move...
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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 with or without limited range of motion (ROM-movement of the joints) receive appropriate treatment and services to increase, prevent, or maintain the ROM mobility (ability to move) for one of four sampled residents (Resident 3), by failing to:
a. Implement the facility ' s policy on Resident Mobility and Range of Motion by not providing Restorative Nursing Assistant (RNA) to maintain and /or improve the resident ' s mobility and ROM.
b. Ensure RNA services were provided as ordered by the physician for Resident 3.
These deficient practices had the potential to place Resident 3 at a decline in physical function and at risk for decline in mobility.
Findings:
During a review of Resident 3 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and abnormalities of gait (a manner of walking) and mobility.
During a review of Resident 3 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 9/2/2024, the MDS indicated Resident 3 ' s cognitive skills (the ability to think and process information) for daily decisions making was intact. The MDS indicated Resident 3 required supervision or touch assistance from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 3 required supervision or touch assistance from staff for sit and stand (the ability to come to a standing position from seating) and walk 10 feet (a unit of measurement for length) once standing in a room, corridor (hallway), or similar space.
During a review of Resident 3 ' s order summary report, dated 10/22/2024, the order summary report indicated RNA would ambulate (walk) Resident 3 five times per week.
During a concurrent interview and record review on 11/19/2024 at 4:40 p.m., with Physical Therapist 1(PT -licensed professional who work with patient to restore, maintain, and improve ability to move), Resident 3 ' s Physical Therapy Discharge Summary (PTDS), dated 10/22/2024 was reviewed. PT 1 stated Resident 3 was discharged from PT services on 10/22/2024 with a physician order for RNA services ambulation five times per week. PT 1 stated was important for Resident 3 to receive RNA services as ordered by the physician to maintain and/or improve his mobility and ROM. PT 1 stated not receiving RNA services as ordered by the physician placed Resident 3 at risk for decline in physical function, and potential for fall and injury.
During a concurrent interview and record review on 11/20/2024 at 8:05 a.m., with RNA 1, Resident 3 ' s Restorative Care Flow Record ([RCFR]- a document used to keep track of a resident health) for 10/24/2024 to 11/20/2024 was reviewed. RNA 1 stated the RCFR indicated from 10/24/2024 to 11/ 20/2024 Resident 3 was to receive 18 RNA services with ambulation. RNA 1 stated RCFR indicated Resident 3 received only 10 RNA services. RNA 1 there was no documentation that Resident 3 refused and/or was unavailable to receive RNA services. RNA 1 stated Resident 3 not receiving RNA services as ordered placed Resident 3 at risk for decline in mobility, muscle weakness (a lack of muscle strength), and loss of the ability to perform everyday activities like walking, standing, and potentially impacting quality of life.
During a review of the facility ' s policy and procedure (P&P) titled Resident Mobility and Range of Motion, revised 7/2017, the P&P indicated residents with limited mobility would receive appropriate services to maintain or improve mobility.
During a review of the facility ' s P&P titled Activity of Daily Living (ADL), revised 3/2018, the P&P indicated residents would be provided with services to ensure their ADLs do not decline. The P&P indicated facility would provide services to prevent functional decline.
During a review of the facility ' s P&P titled Restorative Nursing Assistant (RNA) Job Description, undated, the P&P indicated RNA would provide ROM, exercises, ambulating to the residents as ordered by the physician.
Oct 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 F0697
(Tag F0697)
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 pain management was effective for one of three sampled resid...
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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 pain management was effective for one of three sampled residents (Resident 1) by failing to re-assess Resident 1 ' s pain after the resident complained of 6-8 pain (pain rating reference: 1-3 mild pain; 4-6 moderate pain; 7-10 severe pain) and licensed nurses ' administration of Oxycodone (a drug used to treat moderate to severe pain).
This deficient practice had the potential to result in unresolved pain for Resident 1 and could negatively affect the resident ' s psychosocial well-being.
Findings:
During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), other chronic pain (pain that lasts longer than three months), dorsalgia unspecified (pain in the back that can affect the muscles, ligaments, bones, joints, and nerves of the spine.)
During a review of Resident 1 ' s History and Physical (H&P) dated 8/15/2024, the H&P indicated Resident 1 had the capacity to understand and make medical decisions.
During a review of Resident 1 ' s Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 8/20/2024, the MDS indicated Resident 1 had the ability to make self-understood and understand others. The MDS indicated Resident 1 required supervision or touching assistance with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene. The MDS indicated Resident 1 required partial to moderate assistance with transfers (moving between surfaces to and from bed, chair, and wheelchair.)
During an interview on 10/29/2024 at 9:30 a.m., with Resident 1, Resident stated he suffered with chronic pain, in his knees, back, legs, head, hands and arms. Resident 1 stated he took Oxycodone every 6 hours.
During a review of Resident 1 ' s physician orders (PO) dated 10/23/2024, the PO indicated to administer Oxycodone HCL 20mg 1 tablet by mouth every 6 hours for severe pain.
During a review of Resident 1 ' s Medication Administration Record (MAR) dated 10/2024, the MAR indicated Resident 1 was administered Oxycodone 20 mg on 10/24/2024 through 10/28/2024 at around 12:00 a.m., 6:00 a.m., 12:00 p.m. and was assessed with 6-8 pain prior to administration.
During a review of Resident 1 ' s medical records, there was documentation to support Resident 1 ' s pain was re-assessed after the resident received Oxycodone.
During a concurrent interview and record review on 10/29/2024 at 2:30 p.m., with the Licensed Vocational Nurse (LVN)1, Resident 1 ' s MAR dated 10/2024 was reviewed. LVN 1 stated Resident 1 was receiving Oxycodone as a routine medication for pain every 6 hours. LVN 1 stated there was no documentation to indicate Resident 1 ' s pain was reassessed to determine the effectiveness of the pain medication. LVN 1 stated if medications were not proper re-assessed, Resident 1 could be at risk of worsening pain and could lead to the resident feeling anxious (worry that causes tension and physical signs such as a rapid heart rate)
During an interview on 10/29/2024 at 3:55 p.m., with the Director of Nursing (DON) the DON stated, nurses should re-assess resident ' s pain after 30 min to one hour of administering pain medication to determine the pain medications effectiveness. The DON stated it was important for nurses to re-assess pain medications to help determine if the dosage needed to be adjusted by the physician. The DON stated by not re-assessing Resident 1 ' s pain, it placed Resident 1 at risk of suffering in pain.
During a review of the facility ' s Policy and Procedure (P&P) titled, Pain Assessment and Management dated 10/2022, the P&P indicated pain management is multidisciplinary care process that includes monitoring for the effectiveness of interventions and modifying approaches as necessary. The P&P indicated to assess pain using a consistent approach and a standardized pain assessment instrument appropriate to residents ' cognitive level.
Oct 2024
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
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 obtain informed consent (voluntary agreement to accept treatment an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to the initiation and administration of lorazepam (an antianxiety medication which is used to treat anxiety [a feeling of fear, dread, and uneasiness]) to one of three sampled residents (Resident 1).
This failure resulted in the removal of Resident 1 ' s right to make decisions about the care and treatments she were to receive in the facility.
Findings:
During a review of Resident 1 ' s admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that include but not limited to major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), type two (2) diabetes mellitus (a condition that results in too much sugar circulating in the blood), and insomnia (a sleep disorder that makes it difficult to fall asleep, stay asleep, or get quality sleep).
During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized screening and assessment tool), dated 7/19/2024, the MDS indicated Resident 1 ' s cognition (process of thinking) was moderately impaired. The MDS indicated Resident 1 required supervision with eating and moderate assistance (helper does less than half the effort) with oral hygiene, toileting, bathing, dressing, and personal hygiene. The MDS indicated Resident 1 took antianxiety and antidepressant medication (medication which is used to treat depression [a mood disorder that causes a persistent feeling of sadness]) in the facility.
During a review of Resident 1 ' s History and Physical Examination (H&P), dated 7/18/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1 ' s Order Recap Report, dated 7/15/2024 through 10/31/2024, the Order Recap Report indicated the following physician ' s orders:
1. Inject lorazepam 1 milligram (mg, unit of measurement), intramuscularly ([IM], into the muscle), one time only for anxiety as manifested by disruptive uncontrolled behavior. Order date was 8/23/2024.
2. Give lorazepam, 1 mg, by mouth, every six hours as needed for anxiety. Order date was 8/27/2024.
3. Inject lorazepam,1 mg IM, one time only for anxiety. Order date was 8/30/2024.
4. Inject lorazepam, 1 mg IM, as needed once a day for anxiety, for 14 days. Order date was 9/24/2024.
5. Inject lorazepam, 2 mg IM, one time a day for anxiety, as manifested by disruptive behavior. Order date was 9/30/2024.
During a review of Resident 1 ' s Medication Administration Record (MAR), dated 8/1/2024 through 8/31/2024, the MAR indicated Resident 1 was administered lorazepam 1 mg IM on 8/24/2024 at 10:45 a.m. and on 8/30/2024 at 9:10 p.m.
During a review of Resident 1 ' s MAR, dated 9/1/2024 through 9/30/2024, the MAR indicated Resident 1 was administered lorazepam 1 mg IM on 9/25/2024 at 6:07 p.m.
During a review of Resident 1 ' s MAR, dated 10/1/2024 through 10/31/2024, the MAR indicated Resident 1 was administered lorazepam 2 mg IM on 10/1/2024 at 8 a.m.
During an interview on 10/1/2024 at 10:15 a.m., with Resident 1, Resident 1 stated she could not recall her physician speaking to her about being given lorazepam.
During an interview on 10/1/2024 at 1:10 p.m., with the Medical Records Director (MRD), the MRD stated she could not find any documentation that informed consent for lorazepam was provided to Resident 1.
During an interview on 10/2/2024 at 8:30 a.m., with the Quality Assurance (QA) Nurse, the QA Nurse stated prior to a physician ' s order of psychotropic medication (medications that affect the mind, emotions, and behaviors) being implemented, the nurse was responsible for verifying the resident was informed of the medication and consented to the treatment. The QA Nurse stated informed consent was to be verified prior to the order being placed and once verified, the medication could be administered to the resident. The QA Nurse stated the physician was responsible for informing the resident regarding the medication being ordered, the indication, side effects, and any interactions it may have with other medications. The QA Nurse stated informed consent was not verified for any of the 1 mg doses of lorazepam nor the 2 mg dose. The QA nurse stated when Resident 1 ' s lorazepam dose was increased, another informed consent needed to be verified. The QA Nurse stated because the informed consents for lorazepam 1 mg and 2 mg doses were not obtained, Resident 1 would not have received the necessary information to make a fully aware decision about her care.
During an interview on 10/2/2024 at 9:33 a.m., with the Director of Nursing (DON), the DON stated the purpose of obtaining informed consent for psychotropic medication was to ensure the resident was fully aware of the medication to be administered to treat their diagnosis and behaviors. The DON stated Resident 1 needed to be informed about the use of lorazepam prior to the administration to ensure Resident 1 was aware of any side effects and would allow Resident 1 to refuse or accept the treatment.
During a review of the facility ' s policy and procedure (P&P) titled, Informed Consent, dated 6/2019, the P&P indicated the physician would obtain informed consent from the resident and/or their representative party when a new order was initiated or there was an increase in the psychotropic medication dose. The P&P indicated the licensed nurse would verify with the resident and/or their representative party that informed consent was obtained.
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
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 interview and record review, the facility failed to develop a person-centered care plan (document that helps nurses and...
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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 person-centered care plan (document that helps nurses and other team care members organize aspects of resident care) with interventions (actions a nurse takes to implement a care plan, intend to improve the resident ' s comfort and health) for one of three sampled residents ' (Resident 1) use of lorazepam (an antianxiety medication which is used to treat anxiety[a feeling of fear, dread, and uneasiness]), clonazepam (a medication used to treat anxiety), Paxil (an antidepressant medication which is used to treat depression [a mood disorder that causes a persistent feeling of sadness]), and venlafaxine (a medication used to treat depression).
This failure had the potential to result in the mismanagement of Resident 1 ' s care with the use of psychotropic medications (medications that affect brain activities associated with mental processes and behavior) which may increase Resident 1 ' s risk of adverse effects (unwanted, uncomfortable or dangerous effects that a drug may have). This failure had the potential to result in the impairment or decline in Resident 1 ' s mental condition or psychosocial status.
Findings:
During a review of Resident 1 ' s admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that include but not limited to major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), type two (2) diabetes mellitus (a condition that results in too much sugar circulating in the blood), and insomnia (a sleep disorder that makes it difficult to fall asleep, stay asleep, or get quality sleep).
During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized screening and assessment tool), dated 7/19/2024, the MDS indicated Resident 1 ' s cognition (process of thinking) was moderately impaired. The MDS indicated Resident 1 required supervision with eating and moderate assistance (helper does less than half the effort) with oral hygiene, toileting, bathing, dressing, and personal hygiene. The MDS indicated Resident 1 took antianxiety and antidepressant medication in the facility.
During a review of Resident 1 ' s History and Physical Examination (H&P), dated 7/18/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1 ' s Order Recap Report, dated 7/15/2024 through 10/31/2024, the Order Recap Report indicated the following physician ' s orders:
1. Give lorazepam, one milligram (mg, a unit of measurement) by mouth, every six hours, as needed for anxiety. Order date was 8/27/2024.
2. Inject lorazepam 2 mg per milliliters (ml, unit of measurement), intramuscularly ([IM], into the muscle), once a day, for anxiety as manifested by disruptive behavior. Order date was 9/30/2024.
3. Give clonazepam, 0.5 mg by mouth, every six hours, as needed for anxiety as manifested by verbalization of feelings of nervousness. Order date was 7/25/2024.
4. Give Paxil, 40 mg by mouth, one time a day, for depression as manifested by flat facial affect. Order date was 7/25/2024.
5. Give venlafaxine 37.5 mg by mouth, every 12 hours for depression as manifested by verbalization of hopelessness. Order date was 7/25/2024.
6. Monitor for anxiety manifested by disruptive behaviors every shift. Order date was 9/30/2024.
7. Monitor for anxiety manifested by verbalization of feelings of nervousness every shift. Order date was 7/16/2024.
8. Monitor for depression manifested by flat facial affect and verbalization of hopelessness. Order date was 7/16/2024.
During a concurrent interview and record review on 10/2/2024 at 9:07 a.m., with the Quality Assurance (QA) Nurse, Resident 1 ' s Care Plans were reviewed. There were no care plans addressing the use of lorazepam, clonazepam, Paxil, and venlafaxine. The QA Nurse stated Resident 1 should have had care plans developed that addressed Resident 1 ' s psychotropic medication use. The QA Nurse stated care plans were developed to navigate the care for the residents and included interventions on how to monitor the resident and how to intervene, if needed. The QA Nurse stated because Resident 1 did not have care plans with measurable goals and interventions specific to her psychotropic medication use, Resident 1 was at risk for unsafe administration of those medications.
During an interview on 10/2/2024 at 9:42 a.m., with the Director of Nursing (DON), the DON stated when a resident received psychotropic medications in the facility, a care plan should be developed to determine certain outcomes from the medications and the interventions to monitor for the effects of the medication and what to do incase the resident experienced an adverse reaction. The DON stated the care plan was a communication tool between the physician, staff, and other caregivers. The DON stated Resident 1 should have had a care plan created for her use of lorazepam, clonazepam, Paxil, and venlafaxine. The DON stated because Resident 1 did not have those care plans developed, Resident 1 ' s medications and care had the potential to be inappropriately managed.
During a review of the facility ' s policy and procedure (P&P) titled, Behavior/Psychotropic Drug Management, dated 6/2019, the P&P indicated, The Care Plan shall reflect the non-drug interventions prior to drug treatment, use of psychoactive medication(s), adverse reactions to psychoactive medication(s), and any reduction program in place, experienced by the resident and interventions taken.
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 F0657
(Tag F0657)
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 revise the person-centered care plan (document that helps nurses an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise the person-centered care plan (document that helps nurses and other team care members organize aspect of resident care) for one of three sampled residents (Resident 1) who was unable to be redirected (a technique used to guide people towards more appropriate behaviors or actions) while having uncontrollable behaviors and was administered lorazepam (an antianxiety medication which is used to treat anxiety[a feeling of fear, dread, and uneasiness]) on 8/24/2024 and 8/30/2024.
This failure had the potential to result in the mismanagement of Resident 1 ' s care by not having a guideline to follow after Resident 1 had a change in her behavior.
Findings:
During a review of Resident 1 ' s admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that include but not limited to major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), type two (2) diabetes mellitus (a condition that results in too much sugar circulating in the blood), and insomnia (a sleep disorder that makes it difficult to fall asleep, stay asleep, or get quality sleep).
During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized screening and assessment tool), dated 7/19/2024, the MDS indicated Resident 1 ' s cognition (process of thinking) was moderately impaired. The MDS indicated Resident 1 required supervision with eating and moderate assistance (helper does less than half the effort) with oral hygiene, toileting, bathing, dressing, and personal hygiene. The MDS indicated Resident 1 took antianxiety and antidepressant medication in the facility.
During a review of Resident 1 ' s History and Physical Examination (H&P), dated 7/18/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1 ' s Order Recap Report, dated 7/15/2024 through 10/31/2024, the Order Recap Report indicated the following physician ' s orders:
1. Inject lorazepam 1 milligram (mg, unit of measurement), intramuscularly ([IM], into the muscle), one time only for anxiety as manifested by disruptive uncontrolled behavior. Order date was 8/23/2024.
2. Inject lorazepam,1 mg IM, one time only for anxiety. Order date was 8/30/2024.
During a review of Resident 1 ' s Medication Administration Record (MAR), dated 8/1/2024 through 8/31/2024, the MAR indicated Resident 1 was administered lorazepam 1 mg IM on 8/24/2024 at 10:45 a.m. and on 8/30/2024 at 9:10 p.m.
During a review of Resident 1 ' s Progress Notes, dated 8/23/2024 at 11:54 p.m., the Progress Note indicated the nurse received a one-time order for lorazepam 1 mg IM and to administer to Resident 1 for disruptive, uncontrolled behavior.
During a review of Resident 1 ' s Progress Notes, there was no indication for the lorazepam 1 mg IM that was administered on 8/30/2024.
During a concurrent interview and record review on 10/2/2024 at 8:58 a.m., with the Quality Assurance (QA) Nurse, Resident 1 ' s Care Plans were reviewed. The Care Plans indicated Resident 1 had a mood problem and had impaired coping. The QA Nurse stated Resident 1 ' s Care Plans were initiated on 7/19/2024 and 7/20/2024 and there were not any revisions made when Resident 1 had two behavioral episodes in August 2024 that resulted in the administration of lorazepam 1 mg IM. The QA Nurse stated whenever a resident exhibits a change in condition or additional behavioral manifestations, their care plan had to be revised to communicate the interventions implemented. The QA Nurse stated the Resident 1 had Care Plans that indicated a problem and the nurses were responsible for updating the Care Plans as needed, especially when medications were administered so they knew how to monitor Resident 1 properly.
During an interview on 10/2/2024 at 9:48 a.m., with the Director of Nursing (DON), the DON stated Resident 1 ' s Care Plans should have been updated because her behaviors had changed and additional interventions had been implemented, which would change the Care Plan ' s goals. The DON stated Resident 1 had received lorazepam 1 mg IM and Resident 1 ' s Care Plans should have been revised to provide a guideline for the nurses to follow. The DON stated because Resident 1 ' s Care Plans were not revised, there was the potential that Resident 1 ' s care would be mismanaged.
During a review of the facility ' s policy and procedure (P&P) titled, Care Plans- Comprehensive, revised 9/2010, the P&P indicated, Assessments of residents are ongoing and care plans are revised as information about the resident and the resident ' s condition change.
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
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 ensure that one of three sampled residents (Resident 1) ' s drug re...
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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 that one of three sampled residents (Resident 1) ' s drug regiment was free of unnecessary medications by failing to:
1. Document the indication of Resident 1 ' s lorazepam (an antianxiety medication which is used to treat anxiety [a feeling of fear, dread, and uneasiness]) administration on 8/30/2024.
2. Discontinue and reevaluate the need for Resident 1 ' s pro re nata ([PRN], as needed) orders of lorazepam 1 milligram (mg, a unit of measurement) and clonazepam (a medication used to treat anxiety) 0.5 mg after 14 days.
This failure had the potential to result in the administration of anti-anxiety medication unnecessarily to Resident 1, which could lead to side effects and adverse consequences.
Findings:
a. During a review of Resident 1 ' s admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that include but not limited to major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), type two (2) diabetes mellitus (a condition that results in too much sugar circulating in the blood), and insomnia (a sleep disorder that makes it difficult to fall asleep, stay asleep, or get quality sleep).
During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized screening and assessment tool), dated 7/19/2024, the MDS indicated Resident 1 ' s cognition (process of thinking) was moderately impaired. The MDS indicated Resident 1 required supervision with eating and moderate assistance (helper does less than half the effort) with oral hygiene, toileting, bathing, dressing, and personal hygiene. The MDS indicated Resident 1 took antianxiety and antidepressant medication (medication which is used to treat depression [a mood disorder that causes a persistent feeling of sadness]) in the facility.
During a review of Resident 1 ' s History and Physical Examination (H&P), dated 7/18/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1 ' s Order Recap Report, dated 7/15/2024 through 10/31/2024, the Order Recap Report indicated to inject lorazepam,1 mg IM, one time only for anxiety. Order date was 8/30/2024.
During a review of Resident 1 ' s MAR, dated 8/1/2024 through 8/31/2024, the MAR indicated Resident 1 was administered lorazepam 1mg IM on 8/30/2024 at 9:10 p.m.
During an interview on 10/2/2024 at 8:42 a.m., with the Quality Assurance (QA) Nurse, the QA Nurse stated when a resident had a change of condition with new behavioral manifestations, the nurse was responsible for documenting the incident, the physician ' s order, and the medication administered. The QA Nurse stated this documentation would provide insight on what the resident was doing and what prompted the nurse to administer the one-time medication after informing the physician.
During a concurrent interview and record review on 10/2/2024 at 8:45 a.m., with the QA Nurse, Resident 1 ' s electronic health record (EHR) was reviewed. The EHR did not indicate any communication to Resident 1 ' s physician or Resident 1 ' s exhibited behaviors. The QA Nurse stated the nurse who administered the lorazepam 1 mg IM on 8/30/2024 was responsible for documenting either in the Progress Notes or create a Change of Condition document that indicated the incident, the physician ' s order, and the interventions implemented. The QA Nurse stated documenting Resident 1 ' s change of condition and communication with Resident 1 ' s physician would provide justification for the lorazepam administered. The QA Nurse stated without the proper documentation, Resident 1 was at risk for the unnecessary administration of lorazepam on 8/30/2024.
During an interview on 10/2/2024 at 9:29 a.m., with the Director of Nursing (DON), the DON stated the nurse was responsible for documenting any of Resident 1 ' s out of the ordinary behavior and any additional interventions done to address those behaviors. The DON stated documentation was important to help determine if they were treating Resident 1 ' s behaviors appropriately and if the medication administered was effective. The DON stated without the documentation of Resident 1 ' s behaviors, it looks like they randomly gave the medication. The DON stated without an indication for the lorazepam administration, Resident 1 could have possibly been given the medication unnecessarily.
During a review of the facility ' s policy and procedure (P&P) titled, Behavior/Psychotropic Drug Management, dated 6/2019, the P&P indicated, Licensed Nurse will conduct an assessment of resident ' s mood and behavior status using Change-of-Condition proves, if a resident manifests a change in his/her mood or behavior symptoms.
During a review of the facility ' s P&P titled, Change in a Resident ' s Condition or Status, revised 11/2015, the P&P indicated, The Nurse Supervisor/Charge Nurse will record in the resident ' s medical record information relative to changes in the resident ' s medical/mental condition or status.
b. During a review of Resident 1 ' s Medication Administration Record (MAR), dated 7/1/2024 through 7/31/2024, the MAR indicated Resident 1 was administered clonazepam 0.5 mg on 7/30/2024 at 9:34 p.m.
During a review of Resident 1 ' s MAR, dated 8/1/2024 through 8/31/2024, the MAR indicated Resident 1 was administered clonazepam 0.5 mg on 8/11/2024 at 12:23 p.m.
During an interview on 10/2/2024 at 8:52 a.m., with the QA Nurse, the QA Nurse stated when an antianxiety medication was ordered as PRN, the order would only be appropriate for 14 days and the medication would need to be reordered if necessary. The QA Nurse stated the order would only be appropriate for 14 days because the resident ' s physician would need to reevaluate the resident and the need for the medication.
During a concurrent interview and review on 10/2/2024 at 8:55 a.m., with the QA Nurse, Resident 1 ' s Order Recap Report, dated 7/15/2024 through 10/31/2024 was reviewed. The Order Recap Report indicated the following physician ' s orders:
1. Give lorazepam, 1 mg, by mouth, every six hours as needed for anxiety. Order date was 8/27/2024.
2. Give clonazepam, 0.5 mg by mouth, every six hours, as needed for anxiety as manifested by verbalization of feelings of nervousness. Order date was 7/25/2024.
The QA Nurse stated Resident 1 ' s order of lorazepam and clonazepam have been active longer than 14 days. The QA Nurse stated Resident 1 ' s PRN lorazepam and clonazepam should have been discontinued after 14 days and reordered if Resident 1 ' s physician deemed it necessary. The QA Nurse stated Resident 1 was at risk for the unsafe administration of lorazepam and clonazepam by potentially not treating Resident 1 ' s behaviors and conditions to the best of their ability.
During an interview on 10/2/2024 at 9:35 a.m., with the DON, the DON stated PRN medication were used if a resident had behaviors that were out of the ordinary and the resident needed to be treated with medication outside of their normally scheduled regimen. The DON stated Resident 1 ' s PRN antianxiety medication order should have only been active for 14 days and Resident 1 should have been reevaluated because she was still exhibiting those behaviors. The DON stated because Resident 1 ' s PRN lorazepam and clonazepam orders had been active longer than 14 days, Resident 1 has not had the opportunity to be evaluated by her physician for the need of those medications and was at risk of being administered those medications unnecessarily.
During a review of the facility ' s P&P titled, Behavior/Psychotropic Drug Management, dated 6/2019, the P&P indicated, Any Psychoactive Medication [medications that affect the mind, emotions, and behaviors] prescribed on a PRN basis, must be ordered not to exceed 14 days. If the Physician feels the medication needs to be continued, the reason(s) for the continued usage must be documented in the clinical record.
Aug 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 interview and record review, the facility failed to notify the physician of a resident's refusal to take Clozapine ([an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician of a resident's refusal to take Clozapine ([antipsychotic] medication to treat mental health conditions) for one of five sampled residents (Resident 2).
This deficient practice had the potential to result in Resident 2 experiencing visual hallucinations, and the potential for Resident 2 to engage in physical abuse with Resident 1.
Findings:
a. During a review of Resident 2 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included chronic obstructive pulmonary disease ([COPD] a lung disease that makes hard to breathe), anxiety (feeling of fear, dread, and uneasiness), schizoaffective disorder (mental illness that affects how person thinks, feels, and behaves), and major depression (a mental health condition that causes loss of interest, and ability to think).
During a review of Resident 2 ' s Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 8/8/2024, the MDS indicated Resident 2 could make his needs known, understand others and able to be understood. The MDS indicated Resident 2 required supervision or touching assistance (helper provides verbal cues and /or touching/steadying assistance as resident completes activity) from staff for toileting hygiene, shower, and personal hygiene.
During a review of Resident 2 ' s History and Physical (H&P), dated 8/16/2024, the H&P indicated Resident 2 could make needs known but could not make medical decisions.
During a review of Resident 2 ' s Medication Administration Record (MAR), dated 8/2024, the MAR indicated to administer Clozapine oral tablet, give 150 milligrams ([mg] a unit of measurement) given by mouth, one time a day for schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves) mental behavior visual hallucinations (an experience involving the apparent perception of something not present).
During a review of Resident 2 ' s Physical Aggression report dated 8/11/2024, the report indicated on 8/11/2024, Resident 2 approached the nurses ' station and claimed Resident 1 was stealing his belongings. The report indicated Resident 2 hit Resident 1 ' s left shoulder.
During an interview on 8/22/2024 at 10:20 a.m., with Resident 2. Resident 2 stated on the morning of 8/11/2024, at the nurses ' station, he hit Resident 1 on the shoulder. Resident 2 stated he saw Resident 1 enter into his room and steal his belongings. Resident 2 stated he was angry with Resident 1 for stealing his (Resident 2) belongings.
During an interview on 8/22/2024 at 10:25 a.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated on 8/11/2024 around 9:30 a.m., she observed Resident 1 standing in front of the nurses ' station calm and quiet. CNA 2 stated she then observed Resident 2 walking towards the nursing station fast and angrily. CNA 2 stated Resident 2 was pointing his finger toward Resident 1 yelling, She took my stuff, she took my stuff . CNA 1 stated Resident 2 approached Resident 1 and hit her (Resident 1) left shoulder. CNA 1 stated Resident 2 had a history of seeing things that were not there. CNA 1 stated she should have redirected Resident 2 right way when Resident 2 was observed walking angrily and yelling. CNA 2 stated that could have prevented Resident 1 ' s physical abuse.
During a concurrent interview and record review on 8/23/2024 at 12:10 p.m., with the Director of Nursing (DON), Resident 2 ' s MAR, dated 8/2024, was reviewed. The DON stated the MAR indicated Resident 2 was to be administered Clozapine 150 mg one time a day for schizophrenia mental behavior visual hallucinations. The DON stated the MAR indicated there was five consecutive days from 8/7/2024 to 8/11/2024, Clozapine oral tablet 150 mg at 08:00 was marked 2 (2=drug refused). The DON stated Resident 2 refused Clozapine 150 mg at 08:00 for five consecutive days, placing Resident 2 at risk for visual hallucinations. The DON stated there was no documentation the licensed nurses notified Resident 2 ' s physician of the resident ' s refusal of Clozapine. The DON stated the licensed nurses should have notified the physician regarding Resident 2's non-compliance with the medication.
b. During a review of Resident 1 ' s Face Sheet, the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), anxiety, Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills), and schizophrenia.
During a review of Resident 1 ' s MDS, dated [DATE], the MDS indicated Resident 1 ' s cognitive skills for daily decision-making were severely impaired (never/rarely made decisions). The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) from staff for toileting hygiene, shower, and personal hygiene.
During a review of Resident 1 ' s H&P, dated 7/6/2024, the H&P indicated Resident 1 had fluctuating (changing) capacity to understand and make decisions.
During a review of Resident 1 ' s Situation, Background, Appearance, Review (SBAR) Communication Form, dated 8/11/2024, the SBAR indicated Resident 2 approached Resident 1 and punched Resident 1 ' s left shoulder. The SBAR indicated Resident 1 had left shoulder pain rated at six (6) out of 10 (6/10 [0 – no pain, 1-3 mild pain, 4-6 moderate pain, 7-10 severe pain]) on a pain scale.
During an interview on 8/22/2024 at 10:10 a.m., with Resident 1. Resident 1stated in the morning of 8/11/2024 (Resident 1 did not remember the exact time), she (Resident 1) was standing by the facility ' s nurses ' station when suddenly a male resident approached her punched (strike with the fist) her on the left shoulder, and left arm. Resident 1 stated she felt scared, sad, upset, and disrespected.
During a review of the facility ' s Policy and Procedure (P&P) titled Change in Resident ' s Condition or Status, revised 11/2015, the P&P indicated the following:
1. Facility shall promptly notify the resident ' s attending physician of changes in the resident ' s medical/mental condition and or/ status.
2. The nurse will notify the resident ' s attending physician or on call physician when there has been a significant change in the resident ' s physical, emotional and mental condition.
3. The nurse will notify the attending physician of refusal of treatment or medications two (2) or more consecutive times.
4. Notifications will be made within twenty-four (24) hours of a change occurring in the resident ' s medical/mental condition or status.
During a review of the facility ' s P&P titled, Refusal of Care and Treatment, revised 2017, the P&P indicated detailed information relating to the refusal of care or treatment will be documented in the resident ' s medical record.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 ensure the residents have the right to be free from physical, and v...
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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 residents have the right to be free from physical, and verbal abuse for three of five sampled residents (Resident 1, 3, and 5), by failing to:
1. Adequately redirect (change direction) Resident 2 to prevent Resident 2 from hitting Resident 1 after Certified Nursing Assistant 2 (CNA 2) observed Resident 2 demonstrate verbal and physical aggressive behaviors toward Resident 1.
2. Administer Clozapine ([antipsychotic] medication to treat mental health condition) as ordered by the physician for Resident 2 ' s visual hallucinations (person seeing images that are not actually there).
3. Protect Resident 5 from Resident 4's physical abuse.
4. Protect Resident 3 from CNA 1's verbal abuse.
These deficient practices resulted in Resident 1 and 5 being physically abused by Resident 2 and Resident 4, and Resident 3 being verbally abused by CNA 1. These deficient practices also placed other residents at the facility at risk for abuse.
Findings:
a. During an interview on 8/22/2024 at 10:10 a.m., with Resident 1, Resident 1stated in the morning of 8/11/2024 (Resident 1 did not remember the exact time), she (Resident 1) was standing by the nurses ' station when suddenly a male resident (Resident 2) approached her and punched her on the left shoulder and left arm. Resident 1 stated she felt scared, sad, upset, and disrespected.
During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hypertension ( high blood pressure ), anxiety ( feeling of fear, dread, and uneasiness), Alzheimer ' s disease ( a brain disorder that slowly destroys memory and thinking skills), and schizophrenia ( a serios mental illness that affects how a person thinks, feels, and behaves).
During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 7/11/2024, the MDS indicated Resident 1 ' s cognitive skills (ability to think and process information) for daily decision-making were severely impaired (never/rarely made decisions). The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) from staff for toileting hygiene, shower, and personal hygiene.
During a review of Resident 1 ' s History and Physical (H&P), dated 7/6/2024, the H&P indicated Resident 1 had fluctuating (changing) capacity to understand and make decisions.
During a review of Resident 1 ' s Situation, Background, Appearance, Review (SBAR) Communication Form, dated 8/11/2024, the SBAR indicated Resident 2 approached Resident 1 and punched (strike with the fist) Resident 1 ' s left shoulder. The SBAR indicated Resident 1 had left shoulder pain rated at six (6) out of 10 (6/10 [0 – no pain, 1-3 mild pain, 4-6 moderate pain, 7-10 severe pain]) on a pain scale.
b. During an interview on 8/22/2024 at 10:20 a.m., with Resident 2. Resident 2 stated on the morning of 8/11/2024 at the nurses ' station he hit Resident 1 on her shoulder. Resident 2 stated he saw Resident 1 enter to his room and steal his belongings. Resident 2 stated he was angry with Resident 1 for stealing his (Resident 2) belongings.
During a review of Resident 2 ' s Face Sheet, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease ([COPD] a lung disease that makes hard to breathe), anxiety, schizoaffective disorder (mental illness that affects how person thinks, feels, and behaves), and major depression (a mental health condition that causes loss of interest, and ability to think).
During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 could make his needs known, understand others and able to be understood. The MDS indicated Resident 2 required supervision or touching assistance (helper provides verbal cues and /or touching/steadying assistance as resident completes activity) from staff for toileting hygiene, shower, and personal hygiene.
During a review of Resident 2 ' s H&P, dated 8/16/2024, the H&P indicated Resident 2 could make needs known but could not make medical decisions.
During a review of Resident 2 ' s Physical Aggression Report dated 8/11/2024, the report indicated Resident 2 approached the nurses ' station and claimed Resident 1 was stealing his belongings. The report indicated Resident 2 hit Resident 1 ' s left shoulder.
During an interview on 8/22/2024 at 10:25 a.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated on 8/11/2024 around 9:30 a.m., she observed Resident 1 calm and quiet standing in front of the nurses ' station. CNA 2 stated she then observed Resident 2 walking fast and angrily toward the nurses ' station. CNA 2 stated Resident 2 was pointing his finger toward Resident 1 yelling, She took my stuff, she took my stuff . CNA 1 stated Resident 2 approached Resident 1 and hit her (Resident 1) left shoulder. CNA 1 stated she should have redirected Resident 2 right away when CNA 2 observed Resident 2 walking angrily and yelling. CNA 2 stated that could have prevented Resident 1 ' s physical abuse.
During a concurrent interview and record review on 8/23/2024 at 12:10 p.m., with the Director of Nursing (DON), Resident 2 ' s Medication Administration Record (MAR), dated 8/2024, was reviewed. The DON stated the MAR indicated to administer Clozapine oral tablet 150 milligrams ([mg] a unit of measurement) by mouth one time a day for schizophrenia mental behavior visual hallucinations. The DON stated the MAR indicated there was five consecutive days from 8/7/2024 to 8/11/2024, Clozapine oral tablet 150 mg at 08:00, was marked 2 (2=drug refused). The DON stated Resident 2 refused Clozapine 150 mg at 08:00 for five consecutive days, placing Resident 2 at risk for visual hallucinations, and resulting in physical abuse towards Resident 1.
c. During an interview on 8/22/2024 at 2 p.m., with Resident 5, Resident 5 stated on the morning of 8/21/2024 (resident did not remember the exact time), his roommate (Resident 4) was jumping on his bed and making noises. Resident 5 stated he asked Resident 4 to stop jumping and stop making noises. Resident 5 stated Resident 4 got upset, angry, and suddenly ran toward him (Resident 5), jumped on the top of him, and hit him on his head, face, and mouth repeatedly. Resident 5 stated he felt scared and terrified for his life.
During a review of Resident 5 ' s Face Sheet, the Face Sheet indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis that affects only one side of your body) and hemiparesis (one-sided muscle weakness), epilepsy (a brain condition that causes unprovoked seizure), major depression, anxiety, and schizophrenia.
During a review of Resident 5 ' s MDS, dated [DATE], the MDS indicated Resident 5 had moderately impaired (poor decisions, cues/supervision required) cognition. The MDS indicated Resident 5 required maximal assistance (helper does more than half the effort) from staff for toileting hygiene, shower, and personal hygiene.
During a review of Resident 5 ' s H&P, dated 7/19/2024, the H&P indicated Resident 5 had fluctuating capacity to understand and make decisions.
During a review of Resident 5 ' s SBAR, dated 8/21/2024, the SBAR indicated Resident 5 was struck (hit forcibly) in the mouth by his roommate (Resident 4).
d. During an interview on 8/22/2024 at 2:25 p.m., with Resident 4, Resident 4 stated he (Resident 4) hit his roommate (Resident 5) on the head. Resident 4 stated he was upset and angry because Resident 5 was looking at him and telling him to shut up and stop making noises.
During a review of Resident 4 ' s Face Sheet, the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, anxiety, COPD, and dysphagia (difficulty swallowing).
During a review of Resident 4 ' s MDS, dated [DATE], the MDS indicated Resident 4 could make his needs known, understand others and able to be understood. The MDS indicated Resident 4 required moderate assistance from staff for toileting hygiene, oral hygiene, and personal hygiene.
During a review of Resident 4 ' s H&P, dated 8/17/2024, the H&P indicated Resident 4 had fluctuating capacity to understand and make decisions.
During an interview on 8/22/2024 at 3:05 p.m., with Registered Nurse (RN 1), RN 1 stated on the morning of 8/21/2024 around 9:30 a.m., he heard Resident 5 yelling for help. RN 1 stated he immediately went into Resident 5 ' s room and observed Resident 4 standing over Resident 5. RN 1 stated Resident 4 was hitting Resident 5 ' s face and head.
e. During a review of Resident 3 ' s Face Sheet, the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including paraplegia (a chronic condition that causes the loss muscle function in the lower half of the body, including both legs), COPD, anxiety, and depression.
During a review of Resident 3 ' s MDS, dated [DATE], the MDS indicated Resident 3 could make his needs known, understand others and able to be understood. The MDS indicated Resident 3 required maximal assistance from staff for toileting hygiene, showering, and personal hygiene.
During a review of Resident 3 ' s H&P, dated 8/1/2024, the H&P indicated Resident 3 had the capacity to make medical decisions.
During a review of the facility ' s Interdisciplinary Team ([IDT] a group of healthcare professionals who work together to provide patients with the care they need) conference report, dated 8/19/2024, the IDT report indicated on 8/18/2024 at 9:40 a.m., Resident 3 was involved in a verbal altercation with CNA 1. The IDT report indicated CNA 1 verbally threatened (tell someone that you will hurt or harm the person) Resident 3. The IDT report indicated CNA1 stated, Catch me outside. Let ' s go outside right now. The IDT report indicated a verbal altercation between CNA 1 and Resident 3 began escalating tension (a situation is increasing in size, seriousness, or intensity). The IDT report indicated Resident 3 was getting his laundry and was passing by CNA 1 at the time of the incident. The IDT report indicated Resident 3 stated CNA 1 was yelling and verbally threatened him.
During a telephone interview on 8/23/2024 at 10:20 a.m., with CNA 1, CNA 1 stated in the morning of 8/18/2024 around 9:30 a.m., Resident 3 was following him throughout the facility and was asking for his (Resident 3) laundry. CNA 1 stated he was busy helping another resident with a room change at the time. CNA 1 stated Resident 3 was blocking his (CNA 1) walkway with a wheelchair. CNA 1 stated he told Resident 3 to get out of the way and go back into his room. CNA 1 stated Resident 3 got angry and kept following CNA 1 throughout the facility and the resident kept saying dirty words and using profanity towards CNA 1. CNA 1 stated he had enough and snapped (got angry). CNA 1 stated he told Resident 3, Let ' s go outside on the patio. Meet me outside. CNA 1 stated he should not have said what he said to Resident 3. CNA 1 stated a verbal altercation was considered verbal abuse. CNA 1 stated residents at the facility have the right to be free from verbal abuse.
During an interview on 8/23/2024 at 12:10 p.m., with the DON, the DON stated on the morning of 8/18/2024 at 9:40 a.m., she was made aware by LVN 3 that CNA 1 was involved in a verbal altercation with Resident 3. The DON stated CNAs responsibilities were to provide care for residents and assist with residents needs when needed. The DON stated CNA 1 should not have engaged in verbal altercation. The DON stated CNA 1's action toward Resident 3 was considered verbal abuse. The DON stated it was the facility ' s policy that the residents at the facility shall be free from verbal, or physical abuse.
During a review of the facility ' s policy and procedure (P&P) titled Resident Rights, revised 8/2009, the P&P indicated the facility's employees shall treat all residents with kindness, respect, and dignity.
During a review of the facility ' s P&P tilted Abuse Prevention/Prohibition, dated 12/2018, the P&P indicated the facility did not condone any form of resident abuse, and mistreatment. The P&P indicated the facility was to promote an environment free from abuse and mistreatment. The P&P indicated Verbal Abuse was any use of oral language that willfully disparaging (express negative), and derogatory terms directed to residents, regardless of their age, ability to comprehend, or disability. The P&P indicated Physical Abuse was hitting, slapping, pinching, and kicking.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the State Survey Agency (Bureau of Health Facility Licensin...
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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 State Survey Agency (Bureau of Health Facility Licensing, Certification and Resident Assessment, within the Department of Public Health), a written report of the findings for the investigation of an allegation of abuse within five (5) working days for an incident of physical abuse for one of five sampled residents (Resident 5).
This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from further abuse.
Findings:
a. During an interview on 8/22/2024 at 2 p.m., with Resident 5, Resident 5 stated on the morning of 8/21/2024 (resident did not remember the exact time), his roommate (Resident 4) was jumping on his bed and making noises (loud unpleasant sound). Resident 5 stated he asked Resident 4 to stop jumping and stop making noises. Resident 5 stated Resident 4 got upset, angry, and suddenly ran toward him (Resident 5), jumped on the top of him, and hit him on his head, face, and mouth repeatedly. Resident 5 stated he felt scared and terrified (fear) for his life.
During a review of Resident 5 ' s Face Sheet, the Face Sheet indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis that affects only one side of your body) and hemiparesis (one-sided muscle weakness), epilepsy (a brain condition that causes unprovoked seizure), major depression, anxiety, and schizophrenia.
During a review of Resident 5 ' s Minimum Data Set (MDS, standardized resident assessment and care-screening tool) dated 7/25/2024,, the MDS indicated Resident 5 had moderately impaired (poor decisions, cues/supervision required) cognition. The MDS indicated Resident 5 required maximal assistance (helper does more than half the effort) from staff for toileting hygiene, showering, and personal hygiene.
During a review of Resident 5 ' s History and Physical (H&P), dated 7/19/2024, the H&P indicated Resident 5 had fluctuating capacity to understand and make decisions.
During a review of Resident 5 ' s Situation, Background, Assessment, and Recommendation (SBAR) form, dated 8/21/2024, the SBAR indicated Resident 5 was struck (hit forcibly) in the mouth by Resident 4.
b. During an interview on 8/22/2024 at 2:25 p.m., with Resident 4, Resident 4 stated he (Resident 4) hit his roommate (Resident 5) on the head. Resident 4 stated he was upset and angry because Resident 5 was looking at him and told him to shut up and to stop making noises.
During a review of Resident 4 ' s Face Sheet, the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, anxiety, COPD, and dysphagia (difficulty swallowing).
During a review of Resident 4 ' s MDS, dated [DATE], the MDS indicated Resident 4 could make his needs known, understand others and able to be understood. The MDS indicated Resident 4 required moderate assistance from staff for toileting hygiene, oral hygiene, and personal hygiene.
During a review of Resident 4 ' s H&P, dated 8/17/2024, the H&P indicated Resident 4 had fluctuating capacity to understand and make decisions.
During a review of Resident 4 ' s Interdisciplinary Team ([IDT] a group of healthcare professionals who work together to provide patients with the care they need) Conference Report, dated 8/21/2024, the IDT report indicated Resident 4 was involved in a physical altercation with Resident 5. The IDT report indicated Resident 5 hit Resident 4 in the mouth.
During an interview on 8/22/2024 at 3:05 p.m., with Registered Nurse (RN 1), RN 1 stated on the morning of 8/21/2024 around 9:30 a.m., he heard Resident 5 yelling for help. RN 1 stated he immediately went into Resident 5 ' s room and observed Resident 4 standing over Resident 5. RN 1 stated Resident 4 was hitting Resident 5 ' s face and head.
During a review of an SOC 341 (this form, as adopted by the California Department of Social Services CDSS, is required under Welfare and Institutions Code WIC, to report suspected dependent adult/elder abuse), the SOC 341 indicated that the incident was reported to the Los Angeles County Department of Public Health, Health Inspection Division on 8/21/2024 via fax (an image of a document made by electronic scanning).
During a telephone interview on 9/4/2024 at 1:35 p.m., with the Administrator (ADM), the ADM stated she was not able to provide proof/confirmation that the 5-Day Investigation Report was faxed to CDPH. The ADM stated the 5-Day Investigation Report was completed on 8/22/2024 but was not faxed to CDPH within 5 days.
During a review of the facility ' s Policy and Procedure (P&P), titled Abuse Reporting and Investigation ' , dated 11/2018, the P&P indicated the facility shall promptly and thoroughly investigate reports of abuse. The P&P indicated Abuse Prevention Coordinator (APC) shall provide a written report of the results of all abuse investigations and appropriate action taken to the CDPH Licensing and Certification required by state and local laws, within five (5) working days of the reported allegations.
Jul 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
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 residents were free of accidents and hazards for four of six...
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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 residents were free of accidents and hazards for four of six sampled residents (Residents 1, 3, 5, and 6) by failing to:
1. Ensure a broomstick in the outside patio was inaccessible to Resident 1.
2. Provide one to one ([1:1], close supervision to a resident by staff) monitoring for Resident 5.
These deficient practices resulted in Resident 1 striking Resident 3 on the forearm with the broomstick, and Resident 5 striking a staff and Resident 6.
Findings:
1. a. A review of Resident 1's Face Sheet, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included but not limited to epilepsy (a disorder in which nerve cell activity in the brain is disturbed), chronic obstructive pulmonary disease ([COPD], a lung disease characterized by long-term poor airflow), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).
A review of Resident 1's Minimum Data Set ([MDS], a standardized screening and assessment tool), dated 6/25/2024, indicated Resident 1 had some difficulty with cognitive skills (way of thinking) for daily decision making. The MDS indicated Resident 1 had physical behavioral symptoms (such as hitting, biting, pushing, scratching, and grabbing) directed towards others and verbal behavioral symptoms (such as threatening others, screaming at others, and cursing at others) directed towards others. The MDS indicated Resident 1 required setup or clean-up assistance with eating, oral hygiene, toileting, bathing, dressing, and personal hygiene.
A review of Resident 1's History and Physical (H&P), dated 6/23/2024, indicated Resident 1 lacked decision-making capacity.
A review of Resident 1's Situation Background Assessment Recommendation ([SBAR], tool used by healthcare professionals to communicate essential information) form, dated 6/25/2024, indicated Resident 1 had a disagreement with Resident 3. The SBAR indicated Resident 3 poked Resident 1's arm to get her attention. The SBAR indicated Resident 1 became angry and grabbed a broomstick and hit Resident 3 on the arm.
A review of Resident 1's Departmental Notes, dated 6/25/2024 and timed at 2:14 p.m., indicated Resident 1 informed the Social Services Director (SSD) that she hit Resident 3 with the broomstick because he poked her arm.
b. A review of Resident 3's Face Sheet, indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to psychosis (severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality), hypertensive heart disease (heart conditions caused by complications of high blood pressure), and cardiomegaly (enlarged heart).
A review of Resident 3's MDS, dated [DATE], indicated Resident 3's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 3 required setup or clean-up assistance with oral hygiene, dressing, and personal hygiene.
A review of Resident 3's SBAR, dated 6/25/2024, indicated Resident 3 had a disagreement with Resident 1 that resulted in Resident 1 striking Resident 3 on the arm.
During an observation on 7/9/2024 at 10:18 a.m., in the outside patio, a broomstick was observed against the gate behind a trashcan. Another broomstick and dustpan were observed behind the basketball hoop.
During an interview on 7/9/2024 at 10:32 a.m., with Resident 3, Resident 3 stated he saw Resident 1 feeding the stray cats and wanted to get her attention. Resident 3 stated he tapped Resident 1 on the shoulder, which Resident 1 did not like. Resident 3 stated Resident 1 grabbed a broomstick and hit him on the forearm.
During an interview on 7/9/2024 at 12:34 p.m., with Registered Nurse (RN) 1, RN 1 stated he was informed by Resident 3 that Resident 1 had hit him with a broomstick. RN 1 stated cleaning tools were stored outside on the patio by the Activities staff to pick up trash on the floor. RN 1 stated the broomstick should not have been accessible to the residents outside on the patio. RN 1 stated due to the resident population and unpredictable behaviors related to their diagnoses, the residents were at risk of using the broomstick to harm themselves or others.
During an interview on 7/9/2024 at 12:47 p.m., with Activities Assistant (AA) 1, AA 1 stated staff stored the broomstick and dustpan behind the basketball hoop. AA 1 stated the Activities staff used the broom to clean up the floor after the residents had their snacks. AA 1 stated residents should not have access to any of the cleaning tools on the patio.
During an interview on 7/10/2024 at 9:20 a.m., with the Activities Director (AD), the AD stated the Activities staff kept a broom in the outside patio to clean up trash and any cigarettes that may have fallen on the floor to ensure the residents did not pick up the discarded cigarettes. The AD stated the broomstick was stored behind the basketball hoop to keep it away from the residents. The AD stated the residents should not have access to the broomstick and the only time residents should have access to the broomstick was when they were supervised by staff to assist in cleaning the area. The AD stated Resident 1 should not have been able to access the broomstick. The AD stated because Resident 1 had access to the broomstick, Resident 1 was able to hit Resident 3.
During an interview on 7/10/2024 at 1:55 p.m., with the Director of Nursing (DON), the DON stated cleaning tools should be stored in a safe place away from the residents. The DON stated if residents had unsupervised access to cleaning tools, the cleaning tools could be used to hit others, which could result in injury to others or themselves
A review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents , revised December 2007, indicated, the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.
2a. A review of Resident 5's Face Sheet, indicated Resident 5 was admitted to the facility on [DATE] with diagnoses that included but not limited to type two (2) diabetes mellitus (a condition that results in too much sugar circulating in the blood), paranoid schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), and anxiety disorder (a group of mental disorders characterized by significant feelings of fear). The Face Sheet indicated Resident 5 was discharged from the facility on 7/2/2024.
A review of Resident 5's MDS, dated [DATE], indicated Resident 5's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 5 had hallucinations (an experience involving the apparent perception of something not present). The MDS indicated Resident 5 required maximal assistance (helper does more than half of the effort) with oral hygiene, toileting, bathing, and dressing.
A review of Resident 5's Departmental Notes, dated 7/1/2024 and timed at 7:40 a.m., indicated Resident 5 was on 1:1 monitoring throughout the shift and had aggressive behavior towards the certified nursing assistants (CNAs).
A review of Resident 5's Departmental Note, dated 7/1/2024 and timed at 12:36 p.m., indicated Resident 5 was making unwanted sexual advances towards female staff and was unable to be redirected. The Departmental Note indicated Resident 5 was to be transferred to the general acute care hospital (GACH).
A review of Resident 5's Progress Note, dated 7/1/2024 and timed at 9:10 p.m., indicated Resident 5 was restless with agitation (feeling of worry, nervous excitement) and was awaiting a transfer the GACH.
A review of Resident 5's Progress Note, dated 7/1/2024 and timed at 11:38 p.m., indicated Resident 5 had increased agitation, was belligerent, yelling and banging on the walls. The Progress Note indicated Resident 5 was to be sent out to the GACH for further evaluation.
A review of Resident 5's SBAR, dated 7/2/2024, indicated Resident 5 hit a staff member and when he was on his way back to his room. The SBAR indicated Resident 5 aslo hit Resident 6 on the right chest area.
b. A review of Resident 6's Face Sheet, indicated Resident 6 was admitted to the facility on [DATE] with diagnoses that included but not limited to hypertensive heart disease, gastro-esophageal disease ([GERD], chronic digestive disease where the contents of the stomach refluxes and irritates the esophagus), and pneumonia (lung inflammation).
A review of Resident 6's MDS, dated [DATE], indicated Resident 6's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 6 required maximal assistance with oral hygiene, toileting, bathing, dressing, and personal hygiene.
A review of Resident 6's H&P, undated, indicated Resident 6 had the capacity to understand and make decisions.
A review of Resident 6's SBAR, dated 7/2/2024, indicated Resident 6 was sitting in his wheelchair when Resident 5 hit him on the right side of his chest for no reason.
During an interview on 7/9/2024 at 10:25 a.m., with Resident 6, Resident 6 stated on 7/2/2024, he was sitting in his wheelchair and out of nowhere Resident 5 punched him in the chest. Resident 6 stated Resident 5 had hit another nurse prior to their altercation.
During an interview on 7/9/2024 at 2:37 p.m., with CNA 1, CNA 1 stated on 7/2/2024 Resident 5 hit Resident 6 when he was sitting in the hallway. CNA 1 stated Resident 5 hit one of the licensed vocational nurses (LVNs) prior to the incident. CNA 1 stated she was assigned to Resident 5 for the past three nights and stated the resident was becoming more agitated and was not sleeping during the 11 p.m. to 7 a.m. shift. CNA 1 stated Resident 5 was on 1:1 monitoring on 6/30/2024 at the beginning of the 11 p.m. to 7 a.m. shift. CNA 1 stated when she came onto her shift on 7/1/2024 for the 11 p.m. to 7 a.m. shift, Resident 5 was not on 1:1 monitoring as the night before.
During an interview on 7/10/2024 at 11 a.m., with RN 2, RN 2 stated on 7/1/2024, Resident 5 became more aggressive with his words and was getting in people's faces . RN 2 stated she called Resident 5's physician to inform him of Resident 5's behavior and received the order to transfer Resident 5 to the GACH. RN 2 stated on 6/30/2024, Resident 5 was on 1:1 monitoring, but when she came onto her shift on 7/1/2024, Resident 5 was not on 1:1 monitoring. RN 2 stated a resident had continuous 1:1 monitoring until they were sent out to the GACH.
During a concurrent interview and record review on 7/10/2024 at 11:48 a.m., with RN 1, Resident 5's 24 Hours Resident Monitor Log was reviewed. The Monitor Log indicated Resident 5's 1:1 monitoring was initiated on 6/30/2024 and the resident was on 1:1 monitoring from 11:15 p.m. until 7 a.m. on 7/1/2024. RN 1 stated he worked on 7/1/2024 during the 7 a.m. to 3 p.m. shift and Resident 5 was not on 1:1 monitoring. RN 1 stated when a resident was placed on 1:1 monitoring, it may be due to their unpredictable or worsening behavior and the resident would be kept on 1:1 monitoring until they were transferred to the GACH. RN 1 stated residents were placed on 1:1 monitoring to promote safety for others and themselves. RN 1 stated Resident 5 should have stayed on 1:1 monitoring. RN 1 stated because Resident 5 was taken off 1:1 monitoring [NAME] placed others and the resident at risk for injury.
During an interview on 7/10/2024 at 1:57 p.m., with the DON, the DON stated the purpose of placing a resident on 1:1 monitoring was to closely monitor them, especially if they were showing aggressive behavior, and to prevent the resident from harming themselves or others. The DON stated Resident 5 was placed on 1:1 monitoring due to his aggressive behavior and was waiting to be transferred to the GACH. The DON stated when a resident was placed on 1:1 monitoring, there were no reasons for them to be taken off until the resident transferred out of the facility. The DON stated, the ball got dropped and Resident 5 was taken off 1:1 monitoring for unknown reasons. The DON stated because Resident 5 was taken off 1:1 monitoring and the resident had the capability of striking the LVN and Resident 6. The DON stated the altercations surrounding Resident 5 could have been prevented if Resident 5 was kept on 1:1 monitoring.
A review of the facility's P&P titled, Safety and Supervision of Residents , revised December 2007, indicated, resident supervision is a core component of the systems approach to safety. The P&P indicated the type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The P&P indicated the type and frequency of resident supervision may vary among residents and over time for the same resident. The P&P indicated resident supervision may need to be increased when there are temporary hazards in the environment or if there is a change in the resident's condition.
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
Grievances
(Tag F0585)
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 file a grievance for one out of five sampled residents (Resident 2)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to file a grievance for one out of five sampled residents (Resident 2).
This deficient practice violated the residents' right to have his grievance addressed and followed-up.
Findings:
A review of Resident 2's admission record indicated Resident 2 was admitted to the facility on [DATE] with admitting diagnoses of hypertensive heart disease (changes in the heart chambers and arteries because of chronic high blood pressure) and schizoaffective disorder (a chronic mental health condition characterized primarily by hallucinations or delusions, and mania and depression).
A review of Resident 2's Minimum Data Set ([MDS] a comprehensive assessment and care screening tool), dated 3/4/2024, indicated Resident 2's cognitive (relating to the process of acquiring knowledge and understanding) status and decision-making skills were moderately impaired.
During an interview on 5/23/2024, at 11:15 a.m., with Resident 2, Resident 2 stated he had a harassment complaint about Resident 3 and Resident 5 who had joked about cutting off his penis on 5/21/2024, outside on the patio during Bingo. Resident 2 stated he informed Licensed Vocational Nurse (LVN) 1 about it on 5/22/2024.
During an interview on 5/23/2024 at 1:40 p.m. with Resident 3, Resident 3 stated Resident 2 misunderstood her, and that she would not have said something derogatory towards anyone.
During an interview on 5/23/2024 at 1:50 p.m., with Resident 4, Resident 4 stated she was there on 5/22/2024 when Residents 3 and 5 were joking about [NAME], and felt guilty because she was the one who had brought the subject after it was mentioned on the radio. Resident 4 stated her, and the girls (Resident 3 and Resident 5) were joking around, but it was not directed towards Resident 2.
During an interview on 5/23/2024, at 2:02 p.m., with Resident 5, Resident 5 stated her, Resident 3 and Resident 4 were making some adult jokes on 5/22/2024 but it was never about Resident 2.
During an interview on 5/23/2024, at 2:25 p.m., with Activities Director (AD), AD stated on 5/22/2024 she was informed by LVN 1 about Resident 2's complaint and called a meeting which included Resident 2, Resident 3, Resident 4, and Resident 5 to try to resolve the issue. AD stated Resident 2 believed Resident 3 and Resident 5 were making jokes about wanting to cut off his penis, but that Resident 2, Resident 3, and Resident 5 denied any jokes being made about him. AD stated she had followed up with Resident 2 on 5/23/2024 and Resident 2 had told her he felt better but that he still believed residents were talking about him.
During an interview on 5/23/2024, at 2:43 p.m., with LVN 1, LVN 1 stated on 5/22/2024 Resident 2 had told her he had a concern about other residents discussing cutting off a man's penis and believed it was about him, so she encouraged Resident 2 to stay away from them and
informed AD since activities was outside with the residents. LVN 1 stated she also spoke to Resident 3, Resident 4, and Resident 5 who had denied ever making such comments towards Resident 2.
During an interview on 5/23/2024, at 3:19 p.m., with the Director of Nursing (DON), the DON stated she was not aware of any grievance/complaint from Resident 2 but stated if there was a complaint it should be in the grievance log so Resident 2's concerns could be addressed and resolved.
During an interview on 5/24/2024, at 10:30 a.m., with Activities Aide (AA), AA stated she was outside with Resident 2, Resident 3, Resident 4, and Resident 5 on 5/21/2024, at 10:30 a.m. when the incident allegedly occurred, and AA stated Resident 2 said good morning to her and seemed fine that day. AA stated she did not hear anyone discussing anything inappropriate or see anything unusual.
During an interview on 5/24/2024, at 1:08 p.m., with Social Services Assistant (SSA), SSA stated if there was a grievance it would go inside the grievance binder, and Social Services would speak to the resident to try to resolve their concerns. SSA stated she had not received any report of Resident 2's complaint and that there was nothing in the grievance log about it. SSA stated if there was a complaint it should have been reported to social services so they can put it into the log to keep track of complaints, and address Resident 2's concerns.
During an interview on 5/24/2024, at 1:20 p.m., with the Administrator (ADM), the ADM stated if a Resident 2 had a complaint social service must be notified so they can fill out a grievance form, and then social services would bring it to her attention so she can review the resolutions to make sure residents' concerns were resolved.
A review of the facility's policy and procedure (P&P) titled Grievances/Complaint Log, dated 4/2008, indicated all resident grievances and/or complaints will be recorded in the facility's Resident Grievance/Complaint log and include the following:
1. The date grievance was received.
2. The name and room number of the resident filing the grievance/complaint.
3. The name and relationship of the person filing the grievance/complaint on behalf of the resident.
4. The date the alleged incident took place.
5. The name of the person(s) investigating the incident.
6. The date the resident, or interested party, was informed of the findings.
7. The disposition of the grievance (i.e., resolved, dispute, etc.).
May 2024
1 deficiency
1 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
Deficiency F0602
(Tag F0602)
Someone could have died · 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 six of six sampled residents ' (Residents 1, 2,...
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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 six of six sampled residents ' (Residents 1, 2, 3, 4, 5, and 6) personal property (debit cards) were safeguarded and were protected from potential financial abuse (deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent), by failing to ensure:
1. Implementation of its undated policy and procedures (P&P) titled, Abuse Prevention, Screening and Training Program, which indicated the facility should not condone (allow) any form of resident financial abuse and misappropriation (unlawful use) of resident property and wrongful use of resident ' s money without the resident ' s consent (permission).
2. The Social Services Designee (SSD) did not have access to residents ' financial documents including debit cards (a bank card linked to a checking account to access money) and cash for Residents 1, 2, 3, 4, 5, and 6. On 5/17/2024, at 10 am, the SSD ' s office drawer was observed with 6 debit cards that belonged to Residents 1, 2, 3, 4, 5, and 6, and an unknown amount of cash, that should not be in the SSD ' s drawer.
3. All residents ' (Residents 1, 2, 3, 4, 5, and 6) debit cards and cash were included in the residents ' Clothing and Possessions list (document that contained the lists of all residents ' belongings).
4. The responsible parties and residents were provided with receipts indicating how much money was withdrawn from their debit cards at any given time.
5. Residents ' cash and debit cards (Residents 1, 2, 3, 4, 5, and 6) were securely kept in a facility ' s locked cabinet.
6. The SSD did not keep debit cards for Residents 5 and 6, who no longer reside in the facility.
7. The facility had a tracking system in place to identify which residents have debit cards and money.
As a result, the facility placed Residents 1, 2, 3, 4, 5, and 6 at risk for unauthorized use of residents ' money and placed all 93 residents at risk for financial abuse.
On 5/17/2024 at 3:38 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has cause, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of Director of Nursing (DON) and Administrator (ADM) due to the facility ' s failure to protect Residents 1, 2, 3, 4, 5, and 6 from financial abuse by Social Services Director (SSD) on 5/17/2024.
On 5/19/2024 at 3:50 p.m., the facility submitted an acceptable IJ removal plan ([IJRP] interventions to immediately correct the deficient practices). After verification of IJRP ' s implementation through observation, interview, and record review, the IJ was removed while onsite on 5/19/2024 at 3:54 p.m., in the presence of the DON, ADM, and Infection Prevention Nurse (IP).
The IJRP included the following immediate actions:
1. On May 18, 2024, the ADM completed 80 percent (%) of facility ' s staff re-education/re-training of the P&P titled, Investigation of Theft and/or Misappropriation of Resident Property, with strict adherence and emphasis on the facility not condoning any form of resident financial abuse, misappropriation of resident property, and wrongful use of residents ' money without the resident and/or responsible party's consent.
2. On May 18, 2024, the facility ADM gave a stern (serious) warning that any staff found to be in violation of the facility ' s resident abuse protocol may result in final disciplinary notice, with the potential termination, without progressive disciplinary actions.
3. On May 17, 2024, the SSD was placed on preventative suspension followed by termination, for violation of facility's Abuse Prevention and Prohibition policy, code of conduct and failure to follow instructions given by the ADM.
4. On May 17, 2024, to ensure that the SSD would no longer had access to residents' financial documents including debit cards and cash for Residents 1, 2,3, 4, 5, and 6, the debit cards and cash in the amount of twenty-seven dollars ($27) were removed from the SSD's office, itemized on a log and placed in a lockbox located at the Business Office for safekeeping.
5. On May 18, 2024, the facility ordered a safe (a secured container) in which the Business Office Manager/Designee will utilize to maintain all residents' (Residents 1, 2,3, 4, 5, and 6) debit cards and cash.
6. On May 18, 2024, the Quality Assurance Nurse (QA, an advocate for both the patient and health organization) completed the audit and updated the inventory list (Clothing and Possessions list), including, but not limited to, debit cards and cash, belongings for Residents 1, 2, 3, 4, 5 and 6.
7. On May 18, 2024, the QA Nurse initiated audits for all other current residents' inventory list and began updating all residents ' clothing and possessions in the residents ' inventory list to include debit cards and cash belonging to the residents to ensure accuracy. If any debit cards and cash found in residents' possession, they will be surrendered to the Business Office Manager/ Designee with the Resident and/or Responsible Party's consent. If Resident and/or Responsible Party refuses to surrender their debit cards and/or cash and have it recorded in the Inventory List, the Resident's and/or Responsible Party's consent will be obtained by facility staff, that any missing cash or debit cards, will no longer be the responsibility of the facility, using the Notice of Safekeeping Residents Personal Belongings/Cash form. Immediately upon admission/re-admission of a resident, the assigned Certified Nurse Assistant (CNA) and/or the Registered Nurse (RN) Supervisor/ Designee will initiate an inventory check of resident's debit cards and cash and these items will be immediately surrendered to the Business Office Manager/ Designee with the resident and/or Responsible Party's consent. If the admission/re-admission is after business hours, the RN Supervisor/Designee will maintain the debit cards and cash in an envelope labeled with the resident's name and locked in the narcotic drawer of Nursing Station 1. It will be immediately surrendered to the Business Office Manager/Designee the following business day for safekeeping. The debit cards and cash will be documented in the resident's inventory List, signed by a facility staff member and the resident/responsible party.
8. Medical Records Director/Designee will continue the audit of Resident's' Inventory List on resident's admission/re-admission, quarterly, and as needed for three (3) months and then annually, and as needed thereafter, until a replacement SSD is found.
9. On May 18, 2024, the facility updated the Resident Personal Belongings Inventory List to include valuables such as credit cards, debit cards, cellphones, IDs, social security card, rings, watches, and cash.
10. On May 18, 2024, The Administrator initiated a re-education/re-training for facility staff on the strict implementation of the Policy and Procedures titled: Investigation of Theft and/or Misappropriation of Resident Property which emphasizes on:
a. No staff members shall perform unauthorized transactions using residents' bank cards or cash.
b. appropriate handling of Residents' funds/belongings
c. chain of custody and inclusion on Inventory List of Residents' debit cards/cash.
d. Only the Business Office Director/Designee shall be allowed to handle residents' financial matters.
11. On May 18, 2024, the Business Office created a log which included, but not limited to, which debit cards and cash belonged to which residents, and a tracking of receipts provided to residents and/or Responsible Parties indicating how much money was withdrawn from residents ' debit cards at any given time. This log will be inspected by the Administrator twice a week and will be reviewed during the monthly Quality Assurance meeting for review and recommendation.
12. On May 18, 2024, the Business Office created a log to show residents/responsible parties were provided with receipts indicating how much money was withdrawn from resident's debit cards at any given time. A copy of these receipts will also be maintained with the log in the Business Office.
Findings:
a). A review of Resident 1 ' s admission record, indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and adult failure to thrive (poor appetite, weight loss, fatigue, and overall progressive decline in a person's ability to carry out everyday activities).
A review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 1/5/2024, indicated Resident 1 understood and was able to make self-understood. The MDS indicated Resident 1 required set up for eating and substantial assistance (helper does more than half the effort) with oral hygiene and personal hygiene. The MDS indicated resident was dependent with toileting and showers.
A review of Resident 1 ' s History and Physical (H&P), dated 10/25/2023 indicated Resident 1 did not have the capacity to understand and make decisions.
A review of Resident 1 ' s Clothing and Possessions List, dated 10/24/2023, Resident 1 ' s belongings such as clothes, and shoes but did not indicate Resident 2 had a debit card/or money.
During a concurrent observation and interview on 5/17/2024 at 10:40 a.m., with Resident 1, in the resident ' s room, Resident 1 was in bed, awake and alert but unable to respond to questions.
During an interview on 5/23/2024 at 11:50 a.m., with Family member (FM) 1, FM 1 stated she was not aware the SSD had Resident 1 ' s debit card. FM 1 stated she never received any bank statements, or receipts for any of Resident 1 ' s transactions.
b). A review of Resident 2 ' s admission record, indicated Resident 2 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Resident 2 ' s diagnoses included schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves) and bipolar disorder (serious mental illness that causes unusual shifts in mood).
A review of Resident 2 ' s MDS, dated [DATE], indicated Resident 2 had the ability to understand and be understood. The MDS indicated Resident 2 required assistance with setup or clean up with eating and oral hygiene. The MDS indicated Resident 2 required supervision with toileting, showering, and bathing. The MDS indicated Resident 2 required supervision with personal hygiene.
A review of Resident 2 ' s H&P, dated 1/19/2024 indicated Resident 2 had fluctuating (changing) capacity to understand and make decisions.
A review of Resident 2 ' s Clothing and Possessions List, dated 1/17/2024, indicated Resident 2 ' s belongings such as socks and one nightgown, but did not indicate Resident 2 had a debit card/or money.
During interview on 5/17/2024 at 10:42 a.m., with Resident 2, Resident 2 stated the SSD took him to the bank every three months and withdrew $50.00 from his account to buy snacks. Resident 2 stated the SSD never gave him any of his bank statements. Resident 2 stated the SSD kept all bank statements each time they went to the bank to withdraw money from his account.
c). 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 of adult failure to thrive and schizophrenia.
A review of Resident 3 ' s MDS, dated [DATE], indicated Resident 3 had the ability to understand and be understood. MDS indicated Resident 3 was independent with eating. The MDS indicated Resident 3 required supervision with oral hygiene, and required moderate assistance with toileting hygiene, shower, and bathing.
A review of Resident 3 ' s H&P, dated 2/15/2024 indicated Resident 3 had fluctuating capacity to understand and make decisions.
A review of Resident 3 ' s Clothing and Possessions List, dated 2/5/2024, indicated Resident 3 ' s belongings such as clothes and dentures, but did not indicate Resident 3 had a debit card/or money.
During an interview on 5/17/2024 at 10:45 a.m., with Resident 3, Resident 3 stated he did not know anything about money. Resident 3 stated he could not answer any further questions because the SSD managed his money.
d). A review of Resident 4 ' s admission record, indicated Resident 4 was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses of adult failure to thrive and dysphagia (difficulty swallowing).
A review of Resident 4 ' s MDS, dated [DATE], indicated Resident 4 had the ability to understand and be understood. The MDS indicated Resident 4 was dependent with eating, oral hygiene, toileting hygiene, shower, bathing, and personal hygiene.
A review of Resident 4 ' s Clothing and Possessions List, dated 2/5/2024, indicated Resident 4 ' s belongings such as one hospital gown, but did not indicate Resident 4 had a debit card/or money.
During a concurrent observation and interview on 5/17/2024 at 10:49 a.m., with Resident 4, Resident 4 was laying in bed, with eyes closed. Resident was unable to answer any questions.
During an interview on 5/23/2024 at 12:10 p.m., with a Public Guardian (PG), the PG stated she was not aware the SSD was in possession of Resident 4 ' s debit card. The PG stated she was never given any statements or receipts for any of Resident 4 ' s transactions.
e). A review of Resident 5 ' s admission record, indicated Resident 5 was admitted to the facility on [DATE], with diagnoses of bipolar disorder, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
A review of Resident 5 ' s MDS, dated [DATE], indicated Resident 5 had the ability to understand and be understood. The MDS indicated Resident 5 required a two person assist with bed mobility, transfer, locomotion (moving from place to place), dressing, eating, toilet use and personal hygiene.
A review of Resident 5 ' s ' s H&P, dated 7/10/2022 indicated Resident 5 had fluctuating capacity to understand and make decisions.
A review of Resident 5 ' s ' s Clothing and Possessions List, dated 4/26/2023, indicated Resident 5 ' s belongings such as clothes and two sweaters but, did not indicate Resident 5 had a debit card and/or money.
A review of facility ' s daily census dated 5/19/2024, did not indicate Resident 5 was a resident at the facility.
During an interview on 5/17/2024 at 10:00 a.m., with the SSD, the SSD stated Resident 5 no longer resided in the facility. The SSD stated she forgot to return Resident 5 ' s debit card to the resident or the responsible party at the time of discharge.
f). A review of Resident 6 ' s admission record, indicated Resident 6 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Resident 8 ' s diagnoses included schizoaffective disorder, bipolar type (a mental condition marked by alternating periods of elation and depression) and muscle wasting (weakening, shrinking, and loss of muscle caused by disease or lack of use).
A review of Resident 6 ' s MDS, dated [DATE], indicated Resident 6 had the ability to understand and be understood. The MDS indicated Resident 6 required set up assistance for bed mobility, transfer, locomotion, dressing, eating, toilet use and personal hygiene.
A review of Resident 6 ' s H&P, dated 3/9/2023 indicated Resident 6 had fluctuating capacity to understand and make decisions.
A review of Resident 6 ' s Clothing and possessions List, dated 3/17/2023, indicated Resident 6 ' s belongings such as socks and one hospital gown but did not indicate Resident 6 had a debit card.
A review of facility ' s daily census dated 5/19/2024, did not indicate Resident 6 was still a resident at the facility.
During an interview on 5/17/2024 at 10:00 a.m., with the SSD, the SSD stated Resident 6 was discharged from the facility months ago. The SSD stated she forgot to return Resident 6 ' s debit card to the resident or the responsible party at the time of discharge. The SSD stated she should not have kept debit cards for residents who no longer resided in the facility.
During an interview on 5/16/2024 at 2:18 p.m., with CNA 1, CNA 1 stated residents ' debit cards and money were kept by the SSD. CNA 1 stated CNAs did not list residents ' debit cards and money in the Clothing and Possession List because the SSD was the one who took care of residents ' debit cards and money.
During an interview on 5/16/2024 at 2:30 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated the SSD kept residents ' money and debit cards in her office.
During an interview on 5/16/2024 at 2:40 p.m., with the SSD, the SSD stated she did not have any debit cards or cash for any residents in the facility. The SSD stated if the debit cards were not noted on the residents clothing and possession list, it meant the facility did not receive the items.
During a concurrent observation and interview on 5/17/2024 at 10:00 a.m., with the SSD and the Social Services Assistant (SSDA), in the SSD ' s office, the SSD opened the unlocked right bottom drawer of her (SSD) desk. The drawer was observed to have an unlocked tin box with an unknown amount of cash. The drawer also contained the following items:
1. Four residents ' (Residents 1, 5, 13 and 14) social security cards
2. Three residents ' (Residents 15, 16 and 17) birth certificates
3. One debit card belonging to Resident 1
4. Two debit cards belonging to Resident 2
5. Three debit cards belonging to Resident 3
6. One debit card and a check book belonging to Resident 4
7. One debit card belonging to Resident 5
8. One debit card belonging to Resident 6
9. Two temporary debit cards with unidentified names
The SSD stated the box also contained old cards belonging to residents including Residents 5 and 6, who no longer resided (lived) in the facility. The SSD stated the drawer used to have a lock, but it broke, and was never repaired so the drawer had been unlocked for over a year. The SSD stated she was the only one with access to the contents of the drawer. The SSA stated she only had access to the drawer when instructed by SSD to get her (the SSD ' s) purse. The SSD stated she had no means of tracking the items in the drawer because she did not have a log or binder to indicate what each resident had. The SSD stated she had been working in the facility for 16 years, kept residents ' debit cards and money but never had any documentation or evidence of residents ' items in her possession. The SSA stated the SSD always took residents to the bank to withdraw their money. The SSD stated she did not have any receipts of residents ' funds withdrawn or amounts in her possession, because the residents kept their own receipts.
During an interview on 5/17/2024 at 10:58 a.m., with Business Manager (BM), the BM stated the SSD was the one who always took residents to their banks. The BM stated she was not aware if SSD provided residents with receipts after each bank transaction.
During a concurrent observation and interview on 5/17/2024 at 1:15 p.m., with the ADM, in the SSD ' s office, the office drawer was observed. The ADM opened the unlocked drawer and the tin box and stated the box contained residents ' cash, debit cards, social security cards and birth certificates. The ADM stated the items should have been locked and no one should have access to residents ' debit cards, cash, social security cards, identification cards, passport, and birth certificates. The ADM stated leaving residents ' private documents in an unlocked drawer placed the residents at risk for misappropriation of property, identity theft and unauthorized access to their funds. The ADM stated the SSD was not supposed to manage any of residents ' debit cards and cash. The ADM stated every day, she asked the SSD if she (the SSD) was in possession of any residents ' debit cards or cash and the SSD denied every time. The ADM stated she was asking SSD daily about resident ' s debit cards and cash because she wanted to ensure the facility was compliant with a previous deficiency in which the SSD had residents debit cards and cash. The ADM stated all residents ' possessions including debit cards, social security cards, cash, and identification cards should have been included in their clothing and possessions ' list. The ADM stated staff had not been listing debit cards, social security cards, cash and identification cards in the residents ' possession lists.
A review of the facility ' s undated P&P titled, Personal Property, indicated a resident ' s personal belonging and clothing shall be inventoried and documented upon admission.
A review of the facility ' s undated P&P titled, Management of Residents ' Personal Funds, indicated, if the resident elects to have the facility manage his or her personal funds, it must be authorized in writing by the resident or the resident's representative, and a copy of such authorization must be documented in the resident's medical record. The P&P indicated; a copy of all financial transactions will be filed in the resident's permanent records.
A review of the facility ' s undated P&P titled, Abuse Prevention/Prohibition, indicated that the facility should 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 to promote an environment free from abuse and mistreatment.
Apr 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
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:
1. Ensure one of three sampled residents (Resident 2) was free fro...
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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 one of three sampled residents (Resident 2) was free from fiduciary abuse .
This failure had the potential to impact the physical and mental well-being of the resident.
Findings:
During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 ' s diagnoses included dementia (loss of the ability to think, remember, and reason to levels that affect daily life and activities), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and schizophrenia (a mental disorder that affects a person ' s ability to think, feel and behave clearly).
During a review of Resident 2's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 12/19/2023, the MDS indicated Resident 2 had a BIMS - (brief interview for mental status) of 3 which suggests severe cognitive impairment. The MDS indicated Resident 2 required supervision from staff for activities of daily living (ADLs) such as eating, dressing and oral hygiene and needed moderate assistance from staff for showering and toileting.
During a review of Resident 2 ' s Statement dated 12/19/23 thru 1/19/24 disclosed $1,104.36 was taken from Resident 2 ' s bank account.
During a review of Resident 2 ' s Statement dated 1/20/24 thru 2/16/24 disclosed $ 1,224.22 was taken from Resident 2 ' s bank account
During an interview with the Administrator (Admin), on 4/2/24 at 3:35 p.m., she stated stealing money from a residents was abuse.
During a review of the facility's P&P, titled Abuse Prevention, Screening, and Training Program, dated 12/21/2023, indicated the facility did not condone any form of resident abuse, neglect, misappropriation of resident property and exploitation. The P&P indicated misappropriation of resident property and financial abuse were the deliberate misplacement, exploitation, or wrongful use of a resident ' s belongings or money without the resident ' s consent.
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:
1.Implement its abuse policy and procedure (P&P) titled Abuse, Neg...
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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.Implement its abuse policy and procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating to ensure an allegation of abuse was reported to the California Department of Public Health (CDPH) within two hours, for one of three sampled residents (Resident 2).
This deficient practice resulted to the delay in the abuse (monies) investigation by the CDPH and placed Resident 2 and others at risk for further abuse.
Findings:
During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 ' s diagnoses included dementia (loss of the ability to think, remember, and reason to levels that affect daily life and activities), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and schizophrenia (a mental disorder that affects a person ' s ability to think, feel and behave clearly).
During a review of Resident 2's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 12/19/2023, the MDS indicated Resident 2 had a BIMS - (brief interview for mental status) of 3 which suggests severe cognitive impairment. The MDS indicated Resident 2 required supervision from staff for activities of daily living (ADLs) such as eating, dressing and oral hygiene and needed moderate assistance from staff for showering and toileting.
During a review of Resident 2 ' s Statement dated 12/19/23 thru 1/19/24 disclosed $1,104.36 was taken from Resident 2 ' s bank account.
During a review of Resident 2 ' s Statement dated 1/20/24 thru 2/16/24 disclosed $ 1,224.22 was taken from Resident 2 ' s bank account.
During an interview with Resident 2 ' s case manager on 3/14/24 at 10 a.m., the case manager stated she received Resident 2 ' s bank statements and discovered thousands of dollars was stolen from the account. The case manager further stated she reported the facility to the police and went to obtain Resident 2 ' s bank card and wallet from the Social Service Designee (SSD) on 2/16/24. The case manager further stated money was missing from his wallet.
During a concurrent observation and interview on 3/14/2024 at 1:18 p.m. with SSD, the SSD stated that when the case worker handed me Resident 2 ' s wallet, card and money bag, I placed it my drawer. SSD stated it was in my drawer until the day Resident 2 ' s case manager came for it.
During an interview on 3/14/2024 at 4:40 p.m. with Director of Nursing (DON), the DON stated resident ' s money must be handles by the business office. DON stated the business office keeps an accounting record of the resident ' s money. DON stated if money is not given to the business office there is no way of tracking the money.
During an interview with SSD, on 4/2/24 at 3:15 p.m., SSD stated she does not have an abuse policy to follow in her binder or to report missing money to appropriate agencies. The SSD further stated she does not know who stole Resident 2 ' s money.
During an interview with the Administrator (Admin), on 4/2/24 at 3:35 p.m., she stated they focused on the residents clothing and did not report the missing money to CDPH.
During a review of the facility's P&P, titled Theft and Loss Policy dated 07/2017, indicated, residents ' personal property will be safeguarded and when a resident ' s property was missing, the facility will investigate and document the incident on a theft and loss log. The P&P indicated residents ' money and other valuables should be taken to the business office for safe keeping. The P&Pindicated staff will strongly urge resident/resident representative that some valuables be taken home by the resident representative in which case these items are not to be listed on the resident inventory and upon the request of the resident/resident representative, the Maintenance Department provides for a secured area for the safekeeping of the resident's property. This may include the placement of a lock on the resident's bedside drawer or closet. The provision of a secured area is at the expense of the resident.
During a review of the facility's P&P, titled Abuse Prevention, Screening, and Training Program, dated 12/21/2023, indicated the facility did not condone any form of resident abuse, neglect, misappropriation of resident property and exploitation. The P&P indicated misappropriation of resident property and financial abuse were the deliberate misplacement, exploitation, or wrongful use of a resident ' s belongings or money without the resident ' s consent.
Mar 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
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 ensure one of four residents (Resident 2) was free from physical ab...
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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 four residents (Resident 2) was free from physical abuse by Resident 1 by failing to:
1. Follow Resident 1 ' s Care plan to address the resident ' s episodes of mood swings, rapid fluctuations of emotion ranging from calmness to anger on 3/4/2024, 3/7/2024, 3/10/2024 and 3/11/2024.
2. Revise and individualize (tailoring to the resident) the Care Plan for Resident 1, who had a history of altercations and aggressive behavior.
These deficient practices had to potential to result in Resident 2 sustaining injuries and negatively affecting the resident ' s psychosocial well-being.
Findings:
During a review of Resident 1 ' s admission record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]and re-admitted on [DATE] with a diagnoses that included schizoaffective disorder (mental health condition characterized by symptoms such as hallucinations [hearing, seeing, smelling, tasting or feeling things that are not real], delusions [fixed false belief that conflicts with reality], mania [abnormally elevated, extreme changes in mood] and depression [persistent feeling of sadness and loss of interest]), anxiety disorder (mental health condition characterized by feelings of worry or fear) unspecified dementia (loss of memory, language, problem-solving and other thinking abilities).
During a review of Resident 1 ' s History and physical (H&P) dated, 3/6/2024 the H&P indicated Resident 1 did not have the mental capacity to understand and make medical decisions.
During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 2/21/2024, the MDS indicated Resident 1 required substantial/maximal assistance with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side).
During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included Major depressive disorder, anxiety disorder, and Schizophrenia.
During a review of Resident 2 ' s H&P dated 2/13/2024, the H&P indicated Resident 2 had fluctuating mental capacity to understand and make medical decisions.
During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated Resident 2 required set-up or clean-up assistance with ADLs such as dressing, toilet use, personal hygiene, transfer and bed mobility.
During a review of Resident 1 ' s Care Plan for behavior dated 2/12/2024, the Care Plan indicated Resident 1 had behavioral symptoms as manifested by hallucination (visual, auditory), mood swing as evidenced by (AEB) rapid fluctuation of emotion ranging from calmness to anger, crawling out of bed. The Care Plan indicated approaches and plan included to provide behavioral management or modification as needed such as finding out the reason for behavior and provide interventions as needed and providing redirection when exhibiting inappropriate behavior. The approaches and plan also included to monitor resident ' s interaction with another resident to prevent offensive behavior.
During a review of Resident 1 ' s physician orders dated 2/13/2024, the physician orders indicated Resident 1 had an order to monitor for bipolar disorder (condition associated with episodes of mood swings ranging from depressive lows to manic highs) manifested by mood swings AEB rapid fluctuations of emotion ranging from calmness to anger every shift.
During a review of Resident 1 ' s Medication Administration Record (MAR) dated 3/2024, the MAR indicated Resident 1 was being monitored for bipolar disorder manifested by mood swings AEB rapid fluctuations of emotion ranging from calmness to anger every shift. The MAR indicated Resident 1 had two episodes on 3/4/2024 during the day shift, one episode on 3/7/2024 during the evening shift, two episodes on 3/10/2024 during the night shift, and one episode on 3/11/2024 during the day shift.
During a review for Resident 1 ' s Department Notes, the Notes indicated there was no documentation to indicate Resident 1 ' s mood swings and behaviors were addressed according to Resident 1 ' s Care Plan.
During a review of Resident 1 ' s Situation, Background, Assessment and Recommendation (SBAR) dated 3/13/2024 at 4:05 p.m., the SBAR indicated Resident 1 was sitting in the doorway of Medical Records office when another resident (Resident 2) came from behind to forcefully move Resident 1 and Resident 1 hit Resident 2 on his hands and wrist with a closed hand. The SBAR indicated Resident 1 had a history of altercations.
During an interview on 3/15/2024 at 11:40 a.m. with Certified Nursing Assistance (CNA) 3, CNA 3 stated, Resident 1 was confused and had episodes of anger and calmness. CNA 3 stated, Resident 1 was unpredictable with her behavior.
During an interview on 3/15/2024 at 1:40 p.m. with Registered Nurse (RN), RN stated, Resident 1 would follow directions intermittently, was unpredictable and moods changed frequently.
During a concurrent Record Review and Interview on 4/10/2024 at 1:52 p.m. with the Director of Nursing, Resident 1 ' s Care Plans and physician ' s orders were reviewed. The DON stated Resident 1 was involved in resident-to-resident altercations on 2/7/2024, 3/2/2024 and 3/13/2024 and was the perpetrator of abuse. The DON stated Resident 1 ' s Care Plans should have been revised and individualized after the altercation on 3/2/2024 however was not done. The DON stated it was important to revise and individualize the resident ' s care plan to customize the care to the resident ' s need, prevent future occurrences of abuse and ensure the residents were provided a safe environment.
During a subsequent Record Review and interview on 4/10/2024 at 2:10 p.m. with the DON, Resident 1 ' s physician ' s order dated 2/13/2024 and MAR dated 3/2024 were reviewed. The DON stated the doctor ordered to monitor residents ' mood swings from calmness to anger every shift. The DON stated, the nurses should tally and document the number of times the resident exhibited the behavior. The DON stated, the nurse should have also documented the specific behavior and incident observed along with any interventions performed. The DON stated there was no supporting documentation to indicate the specific behavior and incident was documented or that any interventions or follow-up was done. The DON stated it was important to document behaviors and incidents to help address the issue and give a better picture to the doctor when evaluating the resident ' s plan. The DON stated it was also important to ensure immediate issues were addressed and communicated to the care team.
During a review of the facility ' s P&P titled, Care Plans-Comprehensive dated 9/2010 indicated, an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident ' s medical, nursing, mental and psychological needs was developed for each resident. The P&P indicated Assessments of residents were ongoing and care plans were revised as information about the resident and the resident ' s condition changed. The P&P also indicated the Care Planning/Interdisciplinary Team was responsible for the review and updating of care plans: when there was a significant change in the resident ' s condition and when the desired outcome was not met.
During a review of the facility ' s P&P titled, Abuse Prevention/Prohibition dated, 11/2028, the P&P indicated the facility did not condone any form of resident abuse, neglect, misappropriation of resident property and develops facility policies, procedures, training programs and systems in order to promote an environment free from abuse and mistreatment. The P&P indicated the facility conducted mandatory facility staff training programs on prohibiting and preventing all forms of abuse, understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. These symptoms include aggressive and/or catastrophic reactions of residents and outbursts or yelling out.
During a review of the facility ' s P&P titled, Behavioral Assessment, Intervention and Monitoring dated 3/2019, the P&P indicated the interdisciplinary team would evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. The P&P indicated safety strategies would be implemented immediately if necessary to protect the resident and other from harm
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 F0657
(Tag F0657)
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 revise and individualize (tailoring to the resident) the Care Plan ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise and individualize (tailoring to the resident) the Care Plan for Resident 1, who had a history of altercations and aggressive behavior.
This deficient practice resulted in Resident 2 being physically abused by Resident 1 and had the potential to result in Resident 2 sustaining injuries or psychosocial harm.
Findings:
During a review of Resident 1 ' s admission record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]and re-admitted on [DATE] with a diagnoses that included schizoaffective disorder (mental health condition characterized by symptoms such as hallucinations [hearing, seeing, smelling, tasting or feeling things that are not real], delusions [fixed false belief that conflicts with reality], mania [abnormally elevated, extreme changes in mood] and depression [persistent feeling of sadness and loss of interest]), anxiety disorder (mental health condition characterized by feelings of worry or fear) unspecified dementia (loss of memory, language, problem-solving and other thinking abilities).
During a review of Resident 1 ' s History and physical (H&P) dated, 3/6/2024 the H&P indicated Resident 1 did not have the mental capacity to understand and make medical decisions.
During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 2/21/2024, the MDS indicated Resident 1 required substantial/maximal assistance with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side).
During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included Major depressive disorder, anxiety disorder, and Schizophrenia.
During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated Resident 2 required set-up or clean-up assistance with ADLs such as dressing, toilet use, personal hygiene, transfer and bed mobility.
During a review of Resident 2 ' s H&P dated 2/13/2024, the H&P indicated Resident 2 had fluctuating mental capacity to understand and make medical decisions.
During a review of Resident 1 ' s Situation, Background, Assessment and Recommendation (SBAR) dated 3/13/2024 at 4:05 p.m., the SBAR indicated Resident 1 was sitting in the doorway of Medical Records office when another resident (Resident 2) came from behind to forcefully move Resident 1 and Resident 1 hit Resident 2 on his hands and wrist with a closed hand. The SBAR indicated Resident 1 had a history of altercations.
During a concurrent Record Review and Interview on 4/10/2024 at 1:52 p.m. with the Director of Nursing, Resident 1 ' s Care Plans and physician ' s orders were reviewed. The DON stated Resident 1 was involved in resident-to-resident altercations on 2/7/2024, 3/2/2024 and 3/13/2024 and was the perpetrator of abuse. The DON stated Resident 1 ' s Care Plans should have been revised and individualized after the altercation on 3/2/2024 however was not done. The DON stated it was important to revise and individualize the resident ' s care plan to customize the care to the resident ' s need, prevent future occurrences of abuse and ensure the residents were provided a safe environment.
During a review of the facility ' s P&P titled, Care Plans-Comprehensive dated 9/2010 indicated, an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident ' s medical, nursing, mental and psychological needs was developed for each resident. The P&P indicated Assessments of residents were ongoing and care plans were revised as information about the resident and the resident ' s condition changed. The P&P also indicated the Care Planning/Interdisciplinary Team was responsible for the review and updating of care plans: when there was a significant change in the resident ' s condition and when the desired outcome was not met.
Feb 2024
16 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a dignified existence when the facility failed...
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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 a dignified existence when the facility failed to provide a resident with a clean room that was free of belongings that belonged to the former occupant, space for the resident's belongings, and a bedside table to eat breakfast on for one out of six sampled residents (Resident 297):
This failure had the potential to make Resident 297 feel undervalued and exhibit feelings of anger or sadness after eating breakfast without a bed side table and not having adequate space in his room due to the size and amount of the former occupant's belongings that remained in the room.
Findings:
During a review of Resident 297's Face Sheet (admission Record), the Face Sheet indicated Resident 297 was admitted to the facility on [DATE] at 8:04 p.m. with diagnoses that included but not limited to asthma (a breathing disorder) and abnormalities of gait (ability to walk) and mobility.
During a review of Resident 16's Face Sheet (admission Record), the Face Sheet indicated Resident 16 was originally admitted to the facility on [DATE] and readmitted [DATE] (in Room A) with diagnoses that included but not limited to absence of left leg (below the knee), difficulty in walking, and muscle wasting.
During a review of Resident 297's Electronic Health Record Screen, dated 2/21/2024, the Electronic Health Record Screen indicated Resident 297's assigned room was Room A.
During a review of Resident 16's Departmental Notes, dated 2/20/2024 to 2/23/2024, the notes indicated Resident 16 was assigned Room A. The notes also indicated Resident 16 was sent to the General Acute Care Hospital (GACH) at 12:45 a.m. (on 2/21/2024) and Resident 16 returned from the GACH at 2/22/2024 at 10:35 p.m.
During a concurrent observation and interview, on 2/22/2024, at 7:40 a.m., with the Activities Director, Resident 297's room (Room A) was observed. Resident 297 was laying on Resident 16's assigned bed. Resident 297's half-eaten breakfast food tray was on the floor, Resident 297's yellow jacket was set on Resident 16's wheelchair, Resident 16's prosthetic (artificial) leg and shoes were on the nightstand, the nightstand drawer was filled with Resident 16's belongings and there was no bedside table. The AD stated if there was no bedside table and another resident's belongings remained the room, then the facility did not provide Resident 297 with dignified care. The AD stated the room should have been emptied prior to Resident 297's arrival.
During an interview, on 2/22/2024, at 7:40 a.m., with Resident 297, Resident 297 stated that he was admitted to the facility the night before, and all the items in the room (the wheelchair, the prosthetic leg, the items inside of the nightstand) did not belong to him. Resident 297 stated that he ate breakfast on his lap this morning and was never given a bed side table since his arrival.
During a concurrent observation and interview, on 2/22/2024, at 7:43 a.m., with the Infection Prevention Nurse (IPN), Resident 297's room was observed. Resident 297 was laying on Resident 16's assigned bed. Resident 297's half-eaten breakfast food tray was on the floor, Resident 297's yellow jacket was set on Resident 16's wheelchair, Resident 16's prosthetic leg and shoes were on the nightstand, the nightstand drawer was filled with Resident 16's belongings and there was no bedside table. The IPN stated that the normal process that was observed when admitting a resident was that the nurses and staff ensure that the bed, nightstand, and closet was clean and ready for the next resident. The IPN stated, Having food on the floor is an infection control issue and having Resident 16's belongings still in the room indicates that the room was not cleaned. There is a possibility for cross contamination (exposure to bacteria or illness) if the room is not cleaned. The IPN stated that the facility did not honor Resident 297's dignity and right to a clean room when he was placed in an uncleaned room with Resident 16's belongings, and no bedside table.
During an interview, on 2/22/2024, at 7:54 a.m., with Certified Nursing Assistant (CNA) 7, CNA 7 stated that all nursing staff were responsible for ensuring Resident 297's room was ready for his admission yesterday evening. CNA 7 stated that Resident 16's belongings should have been removed from the room, the room should have been cleaned and the Resident 297 should have been provided a bedside table. CNA 7 stated that she was too busy to pack Resident 16's belongings this morning, and stated the staff did not provide dignified care to Resident 297 if he was not provided a clean room and a bedside table.
During an interview, on 2/22/2024, at 7:58 a.m., with the Social Services Director (SSD), the SSD stated that every time a resident is discharged or sent to the hospital, she expected the nursing staff to at least, gather all the former resident's belongings so that she could store them. The SSD stated that there was a possibility of Resident 16's belongings to be stolen or lost if another is admitted to Resident 16's same room.
During an interview, on 2/22/2024, at 7:58 a.m., with the 8:15am interview with the Admissions Coordinator (AC), AC stated, I usually tell the nurses which room new residents are assigned to. Resident 297 was assigned Room A and I called the hospital to ensure Resident 16 (the former occupant of Room A) was not coming back to the facility. The nurses are expected to clean out the room, gather all prior patients' stuff when they first discharge to hospital and pack it up so that it does not go missing. AC stated that Resident 297 was assigned Room A for the meantime because another Resident was scheduled for a discharge that same day (2/22/2024). AC stated, Temporarily housing Resident 297 in Resident 16's room is not the best practice and is not honoring his (Resident 297's) dignity.
During an interview on 2/22/2024, at 3:38 p.m., with Registered Nurse (RN) 1, RN 1 stated that Resident 297's room should have been cleaned prior to his arrival and since the 3 p.m. to 11 p.m. shift (on 2/21/2024) were made aware of his admission, the nurses should have made sure the room was ready and a bed side table was provided. RN 1 stated that there was a possibility that Resident 16's belongings could have been lost or stolen, the unclean room could have led to cross contamination, and the facility did not honor Resident 297's dignity when the room was left unclean, Resident 16's belongings still occupied the room, and he was not provided a bedside table.
During an interview, on 2/23/2024, at 12:36 p.m., with the Director of Nursing (DON), the DON stated, Once a resident is accepted to the facility, the room is assigned, and housekeeping or AC goes to the room to check if the room and the bed is clean and ready to receive a resident. The DON stated that the facility did not treat Resident 297 with dignity and respect when the staff did not provide Resident 297 with a bedside table and ensure the room was cleaned. The DON stated that there was a possibility that Resident 16's belongings could have been misplaced, or misused and there was a possibility of cross contamination.
During a review of the facility's Policy and Procedure, titled, Quality of Life - Dignity, dated 8/2009, the policy indicated the facility was to ensure that each resident shall be care for in a manner that promotes and enhances quality of life and dignity.
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:
1. Ensure the call light device was within reach for...
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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 the call light device was within reach for one of 22 sampled residents (Resident 42).
This failure had the potential to result in a delay or in the inability for Resident 42 to obtain necessary care and services from the facility staff.
Findings:
During a review of Resident 42's Face Sheet, the Face Sheet indicated Resident 42 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that include but not limited to schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration), and major depressive disorder (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 42's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 2/9/2024, the MDS indicated Resident 42 was able to understand and be understood by others. The MDS indicated Resident 42's cognition (process of thinking) was severely impaired. The MDS indicated Resident 42 required setup or clean-up assistance with eating, oral hygiene, and upper and lower body dressing. The MDS indicated Resident 42 required supervision with toileting hygiene, bathing, and personal hygiene.
During a review of Resident 42's History and Physical Examination (H&P), dated 1/19/2024, the H&P indicated Resident 42 had fluctuating capacity to understand and make decisions.
During an observation on 2/20/2024 at 9:58 a.m., in Resident 42's room, Resident 42 was laying in bed with his eyes closed and the call light was plugged into the wall, however, the call light was not on Resident 42's bed or person.
During a concurrent observation and interview on 2/20/2024 at 10:05 a.m., with Licensed Vocational Nurse (LVN) 1, in Resident 42's room, Resident 42's call light was caught under Resident 42's roommates bed. LVN 1 had to move the other bed to grab the call light. LVN 1 stated Resident 42 was very independent and if he needed anything, he would walk to the nurses' station and alert any of the nurses. LVN 1 stated even though Resident 42 was able to make his needs known at the nurses' station, his call light should still be accessible. LVN 1 stated if Resident 42 needed to use the call light, he would not be able to access the call light because she had to maneuver the other bed to obtain it.
During an interview on 2/22/2024 at 12:35 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated every time she enters a resident's room, she would ensure the call light was within reach in case the resident needed assistance. CNA 1 stated the call light had to be always within the resident's reach. CNA 1 stated some residents will move the call light elsewhere, however, she was responsible for educating the resident the purpose of the call light and to ensure the resident had access to it. CNA 1 stated the call light had to be within reach for the resident to alert the staff they needed assistance. CNA 1 stated residents who were independent still required the call light to be within reach in case of any emergency. CNA 1 stated any staff member who entered the residents' room were responsible for ensuring the call lights were within reach and accessible to the resident. CNA 1 stated the call lights were in place for the residents' safety, so they could ask for assistance.
During an interview on 2/22/2024 at 12:44 p.m., with Registered Nurse (RN) 1, RN 1 stated call lights were the communication system between the residents and staff. RN 1 stated everyone was responsible to ensure the call lights were within reach so the residents could call for assistance. RN 1 stated when a resident was in bed, the call light was supposed to be within reach. RN 1 stated emergencies could happen and that was the best way to alert staff. RN 1 stated emergencies such as a fall, a heart attack, or choking episode could occur and if the call light was not within reach, the resident would not be able to alert staff.
During an interview on 2/22/2024 at 3:40 p.m., with the Director of Nursing (DON), the DON stated the residents used the call lights to notify staff members that they needed assistance. The DON stated everyone was responsible for ensuring the residents were educated on how to use it, the call lights were within reach and functional. The DON stated when the resident was in bed, they must ensure the call light was within reach, even if the resident knocked it on the floor and placed it elsewhere. The DON stated if the call light was not accessible, there would be no way for the resident to call for assistance, especially if he was experiencing an emergency.
During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, revised October 2010, the P&P indicated, When a resident is in bed or confined to a chair be sure the call light is within easy reach of the 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
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 interview and record review, the facility failed to notify the physician and Responsible Party (RP) of a change in cond...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician and Responsible Party (RP) of a change in condition for two of eight sampled residents (Residents 78 and 247) by failing to:
1. Inform Resident 247's physician and RP when Resident 247 initially eloped (leaving the facility without notice or permission) from the facility.
2. Accurately inform Resident 247's RP of the details regarding Resident 247's elopement.
3. Inform Resident 78's RP when Resident 78 was found to have a stage three pressure injury (full thickness tissue loss where fatty tissue may be visible, but bone or muscle was not exposed) on his sacrum (area of the lower back and lower part of the spine) and when it progressed to a stage four (full thickness tissue loss with exposed bone, tendon, or muscle).
These failures resulted in Resident 78 and 247's RP being unaware of their status and condition. These failures had the potential to result in a delay in obtaining appropriate instruction from Resident 247's physician.
Findings:
a. During a review of Resident 247's Face Sheet, the Face Sheet indicated Resident 247 was admitted to the facility on [DATE] with diagnoses included but not limited to hyperlipidemia (an abnormally high concentration of fat particles in the blood), anxiety disorder (a group of mental disorders characterized by significant feelings of fear), and nicotine (addictive drug found in tobacco products such as cigarettes) dependence. The Face Sheet indicated Resident 247 was discharged from the facility on 2/21/2024 at 1:30 p.m.
During a review of Resident 247's Minimum Data Set (MDS, a standardized screening and assessment tool), dated 2/16/2024, the MDS indicated Resident 247 was able to understand and be understood by others. The MDS indicated Resident 247's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 247 did not exhibit behavior of wandering (going to one location to another aimlessly, usually without a plan or definitive purpose).
During a review of Resident 247's History and Physical Examination (H&P), dated 2/13/2024, the H&P indicated Resident 247 could make needs known but could not make medical decisions.
During a review of Resident 247's Renew Situation-Background-Assessment-Recommendation (SBAR), dated 2/19/2024, the SBAR indicated Resident 247 returned to the facility at approximately 12:35 a.m. on 2/19/2024. The SBAR indicated a staff member saw Resident 247 walking along the street and reported it to the facility. The SBAR indicated Resident 247 went out through his window and eloped from the facility. The SBAR indicated Physician 1 was made aware with no response and Physician 2 was notified and obtained medication orders. The SBAR indicated Physician 2 was notified on 2/19/2024 at 12:47 a.m. and RP 1 was notified on 2/19/2024 at 3:46 a.m.
During an interview on 2/22/2024 at 11:24 a.m., with RP 1, RP 1 stated she received an early morning call on 2/19/2024 and she was informed that [Resident 247] attempted to elope out of his window. RP 1 stated, I was not aware that he [Resident 247] actually left the facility and was out in the community. RP 1 stated she expected the staff members at the facility to inform her of any changes and the status of Resident 247 because she had been appointed to be responsible for his care and well-being.
During an interview on 2/22/2024 at 2:30 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated when a resident could not be found within the facility and a search was initiated, the facility was responsible for informing the resident's RP and their physician that the resident had eloped from the facility. LVN 2 stated the resident's RP and physician should be updated throughout the search and once the resident was found. LVN 2 stated keeping the resident's RP and physician updated throughout the process informed them that the facility was doing their part to look for the resident and ensure their safety. LVN 2 stated RP 1 should have been informed of all the details regarding Resident 247's elopement because they had trusted the facility to care for Resident 247 and expect to be informed all their status and condition throughout their stay.
During an interview on 2/22/2024 at 3:05 p.m., with Registered Nurse (RN) 1, RN 1 stated when the facility deemed a resident eloped from the facility, they had to notify the resident's RP and physician. RN 1 stated the facility was responsible for the residents' care and their RP should be notified immediately of any changes. RN 1 stated the resident's RP and physician would be informed when the resident was returned to the facility. RN 1 stated the resident's RP should be informed of all details so they aware are of all the events that transpired until the resident returned to the facility. RN 1 stated the resident's physician was notified from beginning to end of the situation so they could prepare for all possibilities such as whether the resident returned harmed or did not return at all.
During an interview on 2/22/2024 at 3:57 p.m., with the Director of Nursing (DON), the DON stated the nurses were responsible for notifying the resident's physician and RP when the resident eloped from the facility. The DON stated they were notified when it was decided that the resident was no longer in the facility and notified once the resident was found. The DON stated the resident's physician was informed so they were aware that the resident was no longer in the facility and if the resident were to come back injured, the physician would be prepared with the appropriate interventions. The DON stated the resident's RP was informed because the resident was gone and they needed to be aware, in that moment, the facility was unable to monitor the resident's safety. The DON stated when informing the resident's RP of an elopement, the details needed to be clear so the resident's RP could understand the situation and there would not be any confusion. The DON stated the physician and RP should be informed of the situation as it was happening so they could be aware of the facility's efforts in locating the resident and the outcome once the resident was returned to the facility.
During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopement, undated, the P&P indicated, In the event that the resident cannot be located, charge nurse will notify the Administrator/Designee, DON/Designee, Attending Physician, [and] Responsible Party . When a resident returns to the facility, the Licensed nurse must examine the body for any possible injury (ies) and document result in the clinical record as well as vital signs and notify the MD [physician] and responsible party of the return of the Resident and result of the body check.
b. During a review of Resident 78's Face Sheet, the Face Sheet indicated Resident 78 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and hyperlipidemia.
During a review of Resident 78's MDS, dated [DATE], the MDS indicated Resident 78 was able to usually understand and sometimes be understood by others. The MDS indicated Resident 78's cognition was severely impaired. The MDS indicated Resident 78 was dependent with toileting and bathing. The MDS indicated Resident 78 required moderate assistance with rolling left and right in bed, moving from sitting to lying, and moving from lying to sitting on the side of the bed.
During a review of Resident 78's History and Physical (H&P), dated 11/27/2023, the H&P indicated Resident 78 was able to make decisions for activities of daily living.
During a review of Resident 78's Wound Assessment Report, dated 1/11/2024, the Wound Assessment Report indicated Resident 78 had a new stage three pressure injury on the sacrum. The Wound Assessment Report indicated Resident 78's physician was notified on 1/11/2024. The Wound Assessment Report did not indicate that Resident 78's RP was notified.
During a review of Resident 78's Wound Assessment Report, dated 2/1/2024, the Wound Assessment Report indicated Resident 78's wound had deteriorated (worsened) and was not a stage four pressure injury on the sacrum. The Wound Assessment Report did not indicate that Resident 78's RP was notified.
During an interview on 2/20/2024 at 3:50 p.m., with RP 2, RP 2 stated she was not aware that Resident 78 had any skin integrity issues or any wounds. RP 2 stated if she was informed of Resident 78's pressure injury, she would have written this information in her report and would have called the facility to follow up with the Treatment Nurse (TN) and the physician, while also requesting weekly reports.
During an interview on 2/22/2024 at 10 a.m., with the TN, the TN stated he was unable to procure an SBAR report that indicated when Resident 78's RP was notified regarding his pressure injury. The TN stated Resident 78's wound was identified on 1/11/2024 and the wound specialist treated him that day and every week afterwards. The TN stated the wound specialist treated the resident on 2/1/2024 and debrided (removal of dead or unhealthy tissue from a wound) the wound and the wound specialist assessed the pressure injury as a stage four. The TN stated Resident 78's RP should have been informed of his pressure injury when he first assessed the wound and again when the wound progressed from a stage three to a stage four. The TN stated Resident 78's RP had the right to be informed of Resident 78's status and current treatment and allow them to follow-up with Resident 78's care as necessary.
During an interview on 2/22/2024 at 2:17 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated when a resident has any change in condition, their RP must be notified. LVN 1 stated if the resident's RP was not informed of any changes in their condition, the RP would be unaware and be unable to make decisions regarding the resident's care.
During an interview on 2/22/2024 at 3:14 p.m., with Registered Nurse (RN) 1, RN 1 stated any change in a resident's condition, their physician and RP would be notified. RN 1 stated if an SBAR report was not done, there was no indication that Resident 78's RP was notified of his wound.
During an interview on 2/22/2024 at 4:11 p.m., with the Director of Nursing (DON), the DON stated Resident 78's RP should have been notified of his wound and when the wound progressed from a stage three to a stage four. The DON stated Resident 78's RP should have been informed so she could have followed up with the facility on the progression of Resident 78's wound and intervene as necessary.
During a review of the facility's policy and procedure (P&P) titled, Change in Resident's Condition or Status, revised November 2015, the P&P indicated, Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative (sponsor) when . there is a significant change in the resident's physical, mental, or psychosocial status.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
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 residents' valuables were not stored insid...
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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 residents' valuables were not stored inside the medication cart for one of one sampled resident (Resident 98) and other unidentified residents.
This failure had the potential to result in the theft, loss, or bartering (exchanging of goods) of items left in a medication cart.
Findings:
During a review of Resident 98's Face Sheet, the Face Sheet indicated Resident 98 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations [visual, verbal or physical illusion that a person sees, hears or feels and mistakes for reality] and/or delusions [false or unrealistic beliefs]) bipolar type (shifts in mood, energy, and concentration), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and hyperlipidemia (an abnormally high concentration of fat particles in the blood). The Face Sheet indicated Resident 98 was discharged from the facility on [DATE].
During a concurrent observation and interview on [DATE] at 10:59 a.m., with Licensed Vocational Nurse (LVN) 1, at Medication Cart B, two unlabeled cellular devices and a plastic bag labeled with Resident 98's name were found in a locked drawer in the medication cart. Within the plastic bag labeled with Resident 98's name were envelopes with paper inside and a brown wallet that contained four dollars. LVN 1 stated any unidentified and identified possessions of discharged residents were supposed to be given to the Social Services department. LVN 1 stated Resident 98's belongings should not have been kept in the medication cart because anyone with the keys could have taken the money inside the wallet.
During an interview on [DATE] at 12:52 p.m., with Registered Nurse (RN) 1, RN 1 stated any unlabeled items that were found were to be given to the Social Services department in case someone reported the item missing. RN 1 stated Resident 98 was deceased , and it had been a few months. RN 1 stated Resident 98's belongings should not have been in the medication cart because any items of a deceased resident should be given to the Social Services department so they can inform the family. RN 1 stated if a resident asked the nurses to keep any of their possessions for safe keeping and accessibility, the item would be labeled and kept secured. RN 1 stated the unlabeled cellular devices and Resident 98's processions should not have been kept in the medication cart. RN 1 stated money should never be kept in the medication cart because someone could divert the money into their own pocket.
During an interview on [DATE] at 1:55 p.m., with the Social Services Director (SSD), the SSD stated if any staff member found an item, they did not know who it belonged to, they were supposed to give it to her. The SSD stated if an item was found on the weekend, the item would be placed in the medication storage room or the locked drawer under the desk in the nurses' station, which would then be given to her the following Monday. The SSD stated she was the bridge between the facility and the residents and their family. The SSD stated any deceased resident's belongings were to be given to her so she could reach out to any family. The SSD stated Resident 98 passed away no more than three months ago and he did not have any family that they knew of. The SSD stated any personal belongings such as pictures and wallets were kept in her office in the event a family member was to come to the facility to obtain those items. The SSD stated there was no reason that Resident 98's belongings and the unlabeled cellular devices should have been in the medication cart.
During an interview on [DATE] at 4:21 p.m., with the Director of Nursing (DON), the DON stated any unlabeled items and deceased residents' belongings were to be given to the Social Services department. The DON stated the SSD would contact the residents' family and inform them of the possessions that were left at the facility. The DON stated the cellular devices and Resident 98's belongings should not have been left in the medication cart. The DON stated there was a potential for Resident 98's money could have been taken and spent.
During a review of the facility's policy and procedure (P&P) titled, Lost and Found, revised [DATE], the P&P indicated, Our facility shall assist all personnel and residents in safe guarding their personal property . All items found on the premises must be turned over to the business office within 24 hours after the items are found. Items left by discharged residents must be reported to the Director of Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
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. Inform the Responsible Party (RP) of the facility's bed hold po...
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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. Inform the Responsible Party (RP) of the facility's bed hold policy and complete a Bed Hold Notification Form for one of three sampled residents (Resident 247) when Resident 247 was transferred to a general acute care hospital (GACH).
This failure resulted in Resident 247's Responsible Party (RP) 1 to be unaware of Resident 147's right to return to the facility.
Findings:
During a review of Resident 247's Face Sheet, the Face Sheet indicated Resident 247 was admitted to the facility on [DATE] with diagnoses included but not limited to hyperlipidemia (an abnormally high concentration of fat particles in the blood), anxiety disorder (a group of mental disorders characterized by significant feelings of fear), and nicotine (addictive drug found in tobacco products such as cigarettes) dependence. The Face Sheet indicated Resident 247 was discharged from the facility on 2/21/2024 at 1:30 p.m.
During a review of Resident 247's Minimum Data Set (MDS, a standardized screening and assessment tool), dated 2/16/2024, the MDS indicated Resident 247 was able to understand and be understood by others. The MDS indicated Resident 247's cognition (process of thinking) was moderately impaired.
During a review of Resident 247's History and Physical Examination (H&P), dated 2/13/2024, the H&P indicated Resident 247 could make needs known but could not make medical decisions.
During a review of Resident 247's Departmental Notes, dated 2/21/2024 and timed at 12:43 p.m., the Departmental Notes indicated report was given to a registered nurse at the receiving GACH and the estimated time of arrival for pickup was 1:30 p.m.
During an interview on 2/22/2024 at 11:24 a.m., with RP 1, RP 1 stated she was notified when Resident 247 was transferred to the GACH for behavioral evaluation. RP 1 stated she was not informed over the telephone that Resident 247's bed would be held for seven days.
During an interview on 2/22/2024 at 1:25 p.m., with Nurse Practitioner (NP) 1, NP 1 stated Resident 247 was transferred to the GACH for further evaluation for his agitation and aggressive behavior when he punched the window in his room.
During a concurrent interview and record review on 2/22/2024 at 1:27 p.m., with Registered Nurse (RN) 1, Resident 247's Bed Hold Notification Form, undated, was reviewed. RN 1 stated the Bed Hold Notification Form was not filled out on the to be completed upon transfer portion. RN 1 stated Resident 247's psychiatrist ordered for Resident 247's transfer to the GACH after he punched the window in his room on 2/20/2024. RN 1 stated when a resident was transferred to the GACH, he was responsible for notifying the resident's RP regarding the transfer and that his bed would be held for seven days. RN 1 stated after informing the resident and their RP about the bed hold, the Bed Hold Notification Form would be filled out with the appropriate information. RN 1 stated he did not notify RP 1 about the seven-day bed hold. RN 1 stated RP 1 had the right to be informed about the facility's bed hold policy.
During an interview on 2/22/2024 at 4:08 p.m., with the Director of Nursing (DON), the DON stated the Bed Hold Notification Form was to be completed on admission and upon transfer. The DON stated when a resident was transferred out of the facility, the nurse was responsible for calling the resident's RP and inform them of the bed hold. The DON stated if a resident's RP was not informed of the facility's bed hold policy after a resident was transferred out of the facility, they would not be aware that the resident had a bed to return to if and when they returned to the facility.
During a review of the facility's policy and procedure (P&P) titled, Hold Bed Space, revised December 2006, the P&P indicated, Our facility shall inform residents upon admission and prior to a transfer for hospitalization or therapeutic leave of our bed-hold policy.
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 develop and/or implement an individualized person-cen...
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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 develop and/or implement an individualized person-centered care plan (document helps nurses and other team care members organize aspect of resident care) with measurable objectives, timeframes, and interventions to meet the residents' needs for one resident out of 22 sampled residents (Resident 83) by failing to:
1. Develop an individualized comprehensive care plan for Resident 83's oxygen administration.
This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 83.
Findings:
During a review of Resident 83's admission Record, the admission record indicated Resident 83 was admitted to the facility on [DATE] with a diagnosis of respiratory failure (a serious condition that makes it difficult to breathe on your own, lungs can't get enough oxygen into the blood) and pleural effusion (a buildup of fluid between the layers of tissue that line the lungs and chest cavity).
During a review of Resident 83's History and Physical (H&P) dated 2/13/2024, the H&P indicated Resident 83 had the capacity to understand and make decisions. The H&P indicated Resident 83 had a diagnosis of pulmonary hypertension (a condition that affects the blood vessels in the lungs. It develops when the blood pressure in your lungs is higher than normal).
During a review of Resident 83's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/7/2024, the MDS indicated that Resident 83's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 83 needed staff supervision for oral hygiene, upper body dressing and personal hygiene. The MDS indicated Resident 83 had a diagnosis of asthma (a condition in which a person's airways become inflamed, narrow, and swell, and produce extra mucus, which makes it difficult to breathe). The MDS indicated Resident 83 received oxygen treatment on admission and currently as a resident at the facility. The MDS indicated Resident 83 received oxygen therapy intermittently and continuous.
During a review of Resident 83's Physician Orders, dated 1/26/2024, the physician's order indicated to provide oxygen at 2 liters per minute (LPM) via nasal cannula to Resident 83 due to hypoxia (a state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis), asthma, and congestive heart failure ([CHF] a chronic condition in which the heart doesn't pump blood as well as it should, this happens when heart cannot pump (systolic) or fill (diastolic) adequately).
During a review of Resident 83's Care Plan for oxygen administration, unable to locate.
During a concurrent interview and record review on 2/21/2024 at 10:25 a.m. with Licensed Vocational Nurse (LVN) 4, Resident 83's Care Plan was reviewed. The LVN 4 stated he did not find the care plan for oxygen administration. The LVN 4 stated oxygen administration should be care planned because it serves as a plan of care. The LVN 4 stated the care plan would indicate to put a no smoking sign out on display, would indicate how many liters of oxygen should be delivered to the resident, and it would indicate if oxygen order was continuous or as needed.
During an interview on 2/23/2024 at 1:16 p.m. with Director of Nursing (DON), the DON stated oxygen administration should be part of Resident 83's care plan because it was a medication. The DON stated a care plan serves as a plan of care for staff. The DON stated when oxygen administration is not care planned it would potentially cause Resident 83 to receive too much oxygen or not receive enough oxygen and it would affect residents' condition.
During a review of facility's Policy and Procedure (P&P) titled Care Plans-Comprehensive, dated 9/2010, the P&P indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The P&P indicated each resident's comprehensive care plan is designed to aid in preventing or reducing declines in the resident's functional status and/or functional levels. The P&P indicated a resident's comprehensive care plan is developed within seven days of the completion of the resident's comprehensive assessment (MDS).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
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. Follow up the provision of a functional and workin...
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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. Follow up the provision of a functional and working hearing aids to meet the hearing needs of a resident for one out of three sampled residents (Resident 88).
This failure had the potential to make Resident 88 exhibit feelings of anger, frustration, and hopelessness when attempting to engage in meaningful conversations and dialogue with other residents and staff.
Findings:
During a review of Resident 88's Face Sheet (admission Record), the Face Sheet indicated Resident 88 was admitted to the facility on [DATE] with diagnoses that included but not limited to respiratory (breathing) disorders, depressive (mood) disorder, and abnormalities of gait (ability to walk) and mobility.
During a review of Resident 88's Minimum Data Set ([MDS]- a standardized assessment and care planning tool), dated 1/15/2024, the MDS indicated that Resident 88's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 88 used a hearing aid and needed supervision for showering and getting dressed.
During a review of Resident 88's Care Plan, titled Auditory or Hearing, the Care Plan indicated Resident 88 was at risk for auditory decline and that the facility was to follow up on audiology and/ or an ears, neck, and throat (ENT) consults for Resident 88.
During a review of Resident 88's Audiologic Report and Hearing Aid Evaluation Sheet, dated 12/6/2023, the sheet indicated Resident 88 had bilateral moderate to profound hearing loss.
During a review of the Social Services Progress Notes, dated 12/2023 to 2/20/2024, there had been no documentation to indicate any actions were taken to provide Resident 88 with hearing aids or ensure Resident 88 had working hearing aids.
During an observation and interview on 2/20/2024, at 10:23 a.m., with Resident 88, in Resident 88's room, Resident 88's hearing aids were observed. The hearing aids were inside of the case with no indication that the hearing aids worked (no power light flashed or sounds). Resident 88 had furrowed brows and raised his voice and stated, See these hearing aids? They do not work. They only hold a charge for 30 minutes after I have been charging them for the entire day. I told the Social Worker a month ago and she said she was going to do something about it, but she has not gotten back to me.
During an interview, on 2/21/2024, at 11:29 a.m., with Physician 3, Physician 3 stated that he had evaluated Resident 88's hearing on 12/6/2023 and had made the facility aware that Resident 88's right hearing aid was damaged, or not working well.
During an interview, on 2/21/2024, at 11:35 a.m., with the Social Services Director (SSD), the SSD stated she was aware Resident 88 had difficulty hearing, and that she usually had to make sure she was raising her voice into Resident 88's good ear so that he could hear her. The SSD stated that she was made aware that there was an issue with Resident 88's hearing aids, and that they were not working. The SSD stated she had placed a consult with Physician 3 to evaluate Resident 88's hearing and hearing aids because she was made aware that the hearing aids were not working. The SSD stated that she should have followed up after the audiologic exam (on 12/6/2023) to confirm whether Resident 88 needed new hearing aids, and that it must have slipped her mind. SSD stated that she should have followed up because not having the ability to hear could have affected Resident 88's quality of day-to-day life and that it did not honor Resident 88's dignity.
During an interview, on 2/21/2024, at 12 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated she normally communicated with Resident 88 by speaking loudly into his working ear. LVN 3 stated that she was not aware Resident 88's hearing aids were not working and did not know why he had not been wearing his hearing aids. LVN 3 stated she would have made the SSD aware if she had been made aware that Resident 88's hearing aids were not working. LVN 3 stated that if there had not been an effort to follow up on the provision of working hearing aids for Resident 88, then the facility did not maintain Resident 88's best mental and psychosocial well-being because he would not be able to hear the nurses or engage in other conversations.
During an interview, on 2/22/2024, at 3:18 p.m., with Registered Nurse (RN) 1, RN 1 stated that he was aware Resident 88 had difficulty hearing. RN 1 stated that he had to raise his voice whenever he spoke to Resident 88. RN 1 stated that if he had known Resident 88's hearing aids were not working, then he would have notified the SSD. RN 1 stated he would have expected the SSD to follow up on the provision of working hearing aids. RN 1 stated that if the SSD did not follow up or try to get Resident 88 new hearing aids after she had been made aware, then the facility did not enhance or promote Resident 88's dignity or quality of life.
During a concurrent review and interview, on 2/23/2024, at 12:45p.m., with the Director of Nursing (DON), Resident 88's Audiologic Report and Hearing Aid Evaluation Sheet, dated 12/6/2023, was reviewed. The sheet indicated Resident 88 had Bilateral moderate to profound hearing loss. The DON stated that she would have expected the SSD to follow up and ensure Resident 88 had functional hearing aids. The DON stated that she was aware Resident 88 was hard of hearing and Resident 88 had expressed a need for new hearing aids. The DON stated that she had made the SSD aware about Resident 88's need for new hearing aids about two to three weeks ago. The DON stated that she would have expected the SSD to follow up on Resident 88's need for new hearing aids after the audiologic exam was performed on 12/6/2023 and after she had made the SSD aware. The DON stated that she would usually have to use a pen and paper to communicate to Resident 88 about his needs. The DON stated, Resident 88 was very pleasant when he wore his (working) hearing aids and it was a dignity issue if the facility did not make an effort to provide Resident 88 with working hearing aids. The DON stated that the facility did not maintain or enhance Resident 88's level of psychosocial well-being by not providing Resident 88 with working hearing aids.
During a review of the facility's Policy and Procedure (P&P), titled, Quality of Life - Accommodation of Needs, dated 8/2009, the policy indicated the facility was to ensure the staff shall keep hearing aids in working order and behaviors were directed towards assisting the resident to maintain and or achieve independent functioning, dignity, and well-being.
During a review of the facility's Job Description, titled, Social Services Designee, dated 5/2008, the job description indicated the Social Services Designee was to respond timely to requests and concerns, follows up with timely resolution, coordinate support services for audiology, assure resident specific needs are met, and promotes resident rights.
During a review of the facility's Policy and Procedure, titled, Quality of Life - Dignity, dated 8/2009, the policy indicated the facility was to ensure that each resident shall be care for in a manner that promotes and enhances quality of life and dignity.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate oxygen administration practices for o...
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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 adequate oxygen administration practices for one out of 22 sampled residents (Resident 83) by failing to:
1. Ensure the humidifier bottle (medical device that increases the humidity in the nostrils while using supplemental oxygen) hooked up to an oxygen concentrator (a device that concentrates the oxygen from a gas supply by selectively removing nitrogen to supply an oxygen-enriched product gas stream) had enough water to prevent nostril dryness.
2. Ensure Resident 83 received oxygen per doctors order of 2 Liters per Minute (LPM).
3. Date Resident 83 nasal cannula (a plastic medical device to provide supplemental oxygen therapy to people who have lower oxygen levels, device goes directly into the nostrils) for oxygen delivery.
These deficient practice had the potential to cause a negative respiratory outcome and increased the risk for Resident 83 to acquire a respiratory infection.
Findings:
During a review of Resident 83's admission Record, the admission record indicated Resident 83 was admitted to the facility on [DATE] with a diagnosis of respiratory failure (a serious condition that makes it difficult to breathe on your own, lungs can't get enough oxygen into the blood) and pleural effusion (a buildup of fluid between the layers of tissue that line the lungs and chest cavity).
During a review of Resident 83's History and Physical (H&P) dated 2/13/2024, the H&P indicated Resident 83 had the capacity to understand and make decisions. The H&P indicated Resident 83 had a diagnosis of pulmonary hypertension (a condition that affects the blood vessels in the lungs. It develops when the blood pressure in your lungs is higher than normal).
During a review of Resident 83's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/7/2024, the MDS indicated that Resident 83's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 83 needed staff supervision for oral hygiene, upper body dressing and personal hygiene. The MDS indicated Resident 83 had a diagnosis of asthma (a condition in which a person's airways become inflamed, narrow, and swell, and produce extra mucus, which makes it difficult to breathe). The MDS indicated Resident 83 received oxygen treatment on admission and currently as a resident at the facility. The MDS indicated Resident 83 received oxygen therapy intermittently and continuous.
During a review of Resident 83's Physician Orders, dated 1/26/2024, the physician's order indicated to provide oxygen at 2 liters per minute (LPM) via nasal cannula to Resident 83 due to hypoxia (a state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis), asthma, and congestive heart failure ([CHF] a chronic condition in which the heart doesn't pump blood as well as it should, this happens when heart cannot pump (systolic) or fill (diastolic) adequately).
During an observation on 2/20/2024 at 10:05 a.m. in Resident 83's room, Resident 83 received oxygen at three and a half LPM. The humidifier bottle was attached to the oxygen concentrator and the bottle was empty. The nasal cannula was not labeled with an opened date.
During an observation on 2/21/2024 at 8:03 a.m. in Resident 83's room, Resident 83 received oxygen at three LPM. The nasal cannula was not labeled with an opened date.
During an observation on 2/22/2024 at 9:13 a.m. in Resident 83's room, Resident 83 received oxygen at three LPM. The nasal cannula was not labeled with an opened date.
During an interview on 2/22/2024 at 10:25 a.m. with Licensed Vocational Nurse (LVN) 4, the LVN 4 stated he was responsible to check on Resident 83's oxygen equipment. The LVN 4 stated a nurse must check doctor's orders before starting oxygen administration. The LVN 4 stated the order indicated how many liters of oxygen get delivered to Resident 83 and if the oxygen was continuous or as needed only. The LVN 4 stated the humidifier bottle and nasal cannula get changed every Sunday and they must be labeled with the open date and initialed by the person that opened equipment. The LVN 4 stated he went to Resident 83's room this morning (2/22/2024) but did not check Resident 83's oxygen equipment. The LVN 4 stated he did not know how many liters of oxygen Resident 83 was receiving, he did not know if Resident 83's humidifier bottle and nasal cannula were labeled with an open date and he did not know if the humidifier bottle had water because he did not check. The LVN 4 stated it was important for Resident 83 to receive the correct liters of oxygen because she had a diagnosis of asthma and respiratory failure and will improve Resident 83's quality of life.
During an interview on 2/23/2024 at 1:16 p.m. with Director of Nursing (DON), the DON stated nurses must check doctors order first before administering oxygen to a resident in order to deliver the correct amount of oxygen. The DON stated doctor orders indicate how many liters of oxygen are to be delivered to the resident. The DON stated oxygen equipment got labeled with open date and with the initials of the person that opened the equipment for infection control practice. The DON stated oxygen cannulas did not get labeled because that was not the facility's practice. The DON stated if oxygen equipment is not labeled, it could possibly be old equipment and it would be used on a resident. The DON stated it was important to check doctors' orders before oxygen administration to prevent mistakes of over oxygenation or under oxygenation for a resident with respiratory health problems.
During a review of facility's Policy and Procedure (P&P) titled Oxygen Administration, dated 10/2010, the P&P indicated to review physicians orders and resident care plan before administering oxygen to a resident. The P&P indicated to check humidifier bottle, check to see if the water level is high enough that the water bubbles as oxygen flows through. The P&P indicated to periodically check on humidifier bottle for water level.
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** During an observation, interview, and record review the facility failed to follow their policy and procedure (P&P) for medicatio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an observation, interview, and record review the facility failed to follow their policy and procedure (P&P) for medication administration for one of one sampled resident (Resident 22) the facility to:
1. Administer 9:00 a.m., 1:00 p.m., and 5:00 p.m. medications to Resident 22.
2. Document Resident 22's medications that was not administered.
3. Reorder medication on a timely manner and caused Resident 22 to not receive medications.
This deficient practice caused Resident 22 to have an interruption with medication therapy and exposed Resident 22 to have a potential adverse effect to medications.
Findings:
During a review of Resident 22's admission Record, the admission record indicated Resident 22 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and bipolar disorder (a mental illness that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks).
During a review of Resident 22's History and Physical (H&P) dated 1/07/2024, the H&P indicated Resident 22 had the capacity to understand and make decisions. The H&P indicated Resident 22 had a diagnosis of Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) and congestive heart failure ([CHF] a chronic condition in which the heart doesn't pump blood as well as it should. Heart failure can occur if the heart cannot pump (systolic) or fill (diastolic) adequately).
During a review of Resident 22's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/10/2024, the MDS indicated that Resident 22's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 22 needed substantial/maximal assistance (helper does more than half the effort) from staff for all activities of daily living. The MDS indicated Resident 22 had a diagnosis of diabetes mellitus ([DM] a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine).
During a review of Resident 22's Physician Orders dated 2/2024, the orders indicated Resident 22 was ordered to receive:
1. Furosemide 40 milligrams ([mg] one thousand of a gram) tablet, 1 tablet per mouth for CHF at 9:00 a.m.
2. Metformin HCL 500 mg tablet, 1 tablet per mouth two times a day for DM.
3. Olanzapine 5 mg tablet, 1 tablet per mouth two times a day for schizophrenia.
4. Depakote DR 250 mg tablet, 1 tablet per mouth two times a day for bipolar.
5. Benztropine MES 1 mg tablet, 1 tablet per mouth three times a day for extrapyramidal symptoms ([eps] increased motor tone, changes in the amount and velocity of movement, and involuntary motor activity).
6. Austedo 12 mg tablet, 1 tablet per mouth two times a day for tardive dyskinesia (an uncontrollable condition where the face, body or both make sudden, irregular movements. Movements are repetitive and involuntary).
During a review of Resident 22's Medication Administration Record (MAR) dated 2/1/2024 - 2/21/2024, the MAR indicated Resident 22 received:
1. Furosemide 40 milligrams ([mg] one thousand of a gram) tablet, 1 tablet per mouth for CHF at 9:00 a.m.
2. Metformin HCL 500 mg tablet, 1 tablet per mouth two times a day for DM, with meals at 7:30 a.m. and at 5:30 p.m.
3. Olanzapine 5 mg tablet, 1 tablet per mouth two times a day for schizophrenia at 9:00 a.m. and 5:00 p.m.
4. Depakote DR 250 mg tablet, 1 tablet per mouth two times a day for bipolar at 9:00 a.m. and 5:00 p.m.
5. Benztropine MES 1 mg tablet, 1 tablet per mouth three times a day for extrapyramidal symptoms ([eps] increased motor tone, changes in the amount and velocity of movement, and involuntary motor activity) at 9:00 a.m., 1:00 p.m., and 5:00 p.m.
6. Austedo 12 mg tablet, 1 tablet per mouth two times a day for tardive dyskinesia (an uncontrollable condition where the face, body or both make sudden, irregular movements. Movements are repetitive and involuntary) at 9:00 a.m. and 5:00 p.m.
During a review of Resident 22's Care Plan for behavior, dated 1/6/2024, the Care Plan indicated Resident 22's goal was not to have more than one episode of sudden mood swings. The Care Plan indicated Resident 22's approach/plan was to receive medication as ordered and to receive Depakote DR 250 mg 1 tablet per mouth, two times a day.
During a review of Resident 22's Care Plan for risk of injury related to eps, dated 1/6/2024, the Care Plan indicated Resident 22's goal was to be free from injury for 90 days. The Care Plan indicated Resident 22's approach/plan was to receive benztropine 1 mg 1 tablet per mouth 3 times a day.
During a review of Resident 22's Care Plan for CHF, dated 1/6/2024, the Care Plan indicated Resident 22's goal was to demonstrate a normal cardiac output for 90 days and Resident 22 will be free from shortness of breath during daily activities. The Care Plan indicated Resident 22's approach/plan was to receive furosemide 40 mg 1 tablet per mouth every day.
During a review of Resident 22's Care Plan for risk of hyperglycemia related to DM, dated 1/6/2024, the Care Plan indicated Resident 22's goal was to have a blood sugar level of 70 - 110. The Care Plan indicated Resident 22's approach/plan was to administer medication for diabetes mellitus as ordered.
During a review of Resident 22's Care Plan for risk of injury from tremors and involuntary movement due to Parkinson's Disease, dated 1/6/2024, the Care Plan indicated Resident 22's goal was to be free from injury for 90 days. The Care Plan indicated Resident 22's approach/plan was to receive benztropine 1 mg 1 tablet per mouth 3 times a day and Austedo 12 mg 1 tablet per mouth 2 times a day.
During a record review of Consolidated Delivery Sheets (order slips) dated 1/18/2024, the order slip indicated furosemide 40 mg, metformin HCL 500 mg, olanzapine 5 mg, Depakote DR 250 mg, and benztropine MES 1 mg were delivered to the facility on 1/19/2024. The order slip dated 2/20/2024 indicated furosemide 40 mg, metformin HCL 500 mg, olanzapine 5 mg, Depakote DR 250 mg, and benztropine MES 1 mg were delivered to the facility on 2/21/2024. The order slips indicated all medications were filled for 31 days.
During a record review of Consolidated Delivery Sheets (order slips) dated 1/09/2024, the order slip indicated austedo 12 mg tablets were delivered to the facility on 1/10/2024. The order slip dated 1/22/2024 indicated austedo 12 mg tablets were delivered to the facility on 1/23/2024. The order slips indicated medications were filled for 14 days.
During a review of Resident 22's Nursing Progress Notes, unable to locate nursing documentation indicating furosemide 40 mg, metformin HCL 500 mg, olanzapine 5 mg, Depakote DR 250 mg, benztropine MES 1 mg and Austedo 12 mg was not administered to Resident 22.
During an interview on 2/20/2024 at 12:25 p.m. with Resident 22, in Resident 22's room, the Resident 22 stated she was concerned that she had not received her medications today. Resident 22 stated she did not know why she was not given her medications and she was worried that she would not receive them. The Resident 22 stated she needed her medications because it helped her deal with everyday things.
During an observation on 2/21/2024 at 12:10 p.m. at the nurses' station, Resident 22 told Licensed Vocational Nurse (LVN) 2 she was still waiting for her medications and LVN 2 stated he was waiting for her medications to be delivered to the facility.
During an interview on 2/22/2024 at 10:39 a.m. with LVN 2, the LVN 2 stated he worked yesterday (2/21/2024) and he realized Resident 22 did not have a couple of medications (furosemide 40 mg, metformin HCL 500 mg, olanzapine 5 mg, Depakote DR 250 mg, and benztropine MES 1 mg, austedo 12 mg) in the medication cart. The LVN 2 stated Resident 22 did not receive her medications on 2/21/2024 because the medications were not ordered on a timely manner. The LVN 2 stated he called pharmacy to reorder the medications and he notified the Director of Nursing (DON) and Resident 22's doctor about not administering medication to resident 22. The LVN 2 stated Resident 22 did not receive furosemide 40 mg, metformin HCL 500 mg, olanzapine 5 mg, Depakote DR 250 mg, benztropine MES 1 mg and Austedo 12 mg for morning and evening doses. The LVN 2 stated it was important for Resident 22 to receive her medications on time for a better quality of life, to minimize diagnosis and to prevent further health problems. The LVN 2 stated the medication administration process was to administer medication to a resident and then to sign for the medication. The LVN stated he signed that he administered the medications to Resident 22 when he did not administer the medications to Resident 22 by mistake. The LVN 2 stated when a nurse signed that they administered a medication to a resident and they did not do it, that was falsifying documentation. The LVN 2 stated he was not able to say when the last time was Resident 22 received her medications because all staff are documenting that they gave the medications when there was no medication on hand.
During an interview on 2/22/2024 at 1:40 p.m. with pharmacist, the pharmacist stated the facility did not reorder the medications on time and that was why they did not receive the medications on time. The pharmacist stated medications are usually delivered the same day the facility orders them. The pharmacist stated Resident 22 missed medication doses based on the days the facility reordered the medications. The pharmacist stated the austedo medication was last ordered on 1/22/2024 and that medication order was good for 14 days. The pharmacist stated the facility needed to request a refill on 2/6/2024 but they did not. The LVN 4 stated it was important for Resident 22 to get her medications because it helped Resident 22 stay stable and continue activities of daily life.
During an interview on 2/22/2024 at 3:58 p.m. with LVN 4, the LVN 4 stated that she signed that she administered the medication but she did not administer the medications to Resident 22. The LVN 4 stated she knew that Resident 22 did not have austedo medication on hand but was not aware of the other medications (furosemide 40 mg, metformin HCL 500 mg, olanzapine 5 mg, Depakote DR 250 mg, and benztropine MES 1 mg, and austedo 12mg). LVN 4 stated she was not supposed to sign that she administered medication when she did not do it.
During a concurrent interview and record review on 2/22/2024 at with LVN 4, Resident 22's MAR, dated February 2024 was reviewed. The MAR indicated on 2/21/2024 LVN 3 signed that she administered medications (metformin HCL 500 mg, olanzapine 5 mg, Depakote DR 250 mg, and benztropine MES 1 mg, and austedo 12mg) to Resident 22. The LVN 4 stated she signed for those medications but she did not know why because those medications were not available.
During an interview on 2/23/2024 at 1:47 p.m. with DON, in the conference room, the DON stated she expected her nursing staff to administer medication to resident first and then sign that they administered medications. The DON stated LVN 2 notified her on 2/22/2024 that medications (furosemide 40 mg, metformin HCL 500 mg, olanzapine 5 mg, Depakote DR 250 mg, and benztropine MES 1 mg, and austedo 12mg) were not available for Resident 22. The DON stated LVN 2 did not notify her when he realized medication was not in the medication cart (2/21/2024). The DON stated LVN 2 notified her that he signed for medications, indicating that he administered medications to Resident 22, but he did not administer the medications to Resident 22. The DON stated it was not an acceptable practice to sign for a medication that was not administered to a resident. The DON stated she was the one that called the pharmacy to reorder medication and she called Resident 22's doctor to notify him of the missing medication doses and not the LVN 2. The DON stated that during the last week of availability for a medication, the nursing staff must reorder the medication to have it available when the current medication is finished. The DON stated it was important for Resident 22 to receive her medications on a timely matter to prevent health complications and stated it would cause adverse reactions if she did not receive her medications.
During a review of facility's Policy and Procedure (P&P) titled Administering Medications, dated 12/2012, the P&P indicated medications would be administered in a safe and timely manner and as prescribed. The P&P indicated the individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones.
During a review of facility's Policy and Procedure (P&P) titled Documentation of Medication Administration, dated 4/2007, the P&P indicated a nurse would document all medications administered to each resident on the resident's MAR. The P&P indicated documentation included the reason why a medication was withheld, not administered, or refused.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:
1. Implement effective infection prevention measures...
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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. Implement effective infection prevention measures for one of eight residents (Resident 1) when Resident 1 had a cough and was not immediately tested for Coronavirus Disease 2019 (COVID-19, infectious disease that affects a person's organs and tissues that aid in breathing).
This failure had the potential to result in the facility being unaware of Resident 1's COVID-19 status and had the potential to spreading COVID-19 to other resident, family members and staff.
Findings:
During a review of Resident 1's Face Sheet, the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), acute kidney failure (the sudden and rapid loss of kidney's ability to filter waste and balance fluid in blood), and metabolic encephalopathy (problem in the brain caused by chemical imbalances in the blood).
During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 11/24/2023, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1's cognition (process of thinking) was severely impaired.
During a review of Resident 1's History and Physical Examination (H&P), dated 12/3/2023, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.
During a review of Resident 1's Departmental Notes, dated 2/22/2024, the Departmental Notes indicated Resident 1 had a nonproductive cough (a cough that does not produce mucus). Resident 1's physician was notified and a new order for Geri-tussin (cough medication) 100 milligrams (mg, unit of measurement) per five milliliters (mL, unit of measurement) solution, to take 15 mL by mouth, every six hours as needed for cough for seven days.
During an observation on 2/22/2024 at 9:22 a.m., in Resident 1's room, Resident 1 was laying bed and Resident 1 coughed without producing any mucus.
During an interview on 2/22/2024 at 10:34 a.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated she was not aware that Resident 1 had a cough. LVN 1 stated she would assess Resident 1 and inform the physician of her findings.
During a review of Resident 1's Medication Administration Record (MAR), dated February 2024, the MAR indicated Resident 1 was administered Geri-tussin 15 mL on 2/22/2024 at 10:59 a.m.
During an interview on 2/22/2024 at 2:10, with LVN 1, LVN 1 stated she assessed the resident and informed Resident 1's physician, who had given the order for cough medication. LVN 1 stated she administered the cough medication to Resident 1, and it was effective.
During an interview on 2/22/2024 at 4:30 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated a resident was tested immediately for COVID-19 if they had any respiratory symptoms such as shortness of breath, coughing, sneezing, and severe headache. The IPN stated he relied on the nurses and certified nursing assistants to inform him of any residents who presented with COVID-19 symptoms. The IPN stated he had not been informed that Resident 1 had a cough. The IPN stated they had to test residents for COVID-19 immediately so they could act quickly if the resident were to test positive. The IPN stated the current strain of COVID-19 was quick spreading and if Resident 1 was positive, they would have to isolate him and be vigilant residents and staff who were in close-contact to him. The IPN stated the purpose to immediate testing was to prevent the spread of COVID-19 and other respiratory diseases to others.
During an interview on 2/22/2024 at 4:40 p.m., with the Director of Nursing (DON), the DON stated residents who presented with a cough, fever, body aches, or nausea should be tested immediately for COVID-19. The DON stated any nurse could test the residents for COVID-19 and they should always inform the IPN of any symptoms. The DON stated testing the residents for COVID-19 allowed the staff to input the proper interventions to care for the resident. The DON stated if a resident tested positive for COVID-19, they would follow their COVID-19 protocol and isolate the resident. The DON stated not testing a resident with respiratory symptoms had the potential of spreading COVID-19 or other diseases to other residents and staff.
During a review of the facility's policy and procedure (P&P) titled, Coronavirus Disease (COVID-19)- Infection Prevention and Control Measures, revised April 2020, the P&P indicated, This facility follows recommended standard and transmission-based precautions, environmental cleaning, and social distancing practices to prevent the transmission of COVID-19 within the facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
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 accurate low air mattress settings were set for...
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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 accurate low air mattress settings were set for two out of 33 residents (Resident 31 and Resident 84) by failing to:
1. Ensure air mattress setting was correct for a Resident that weighed 103 pounds (Resident 31) by setting mattress for a person that weighed 210 pounds.
2. Ensure air mattress setting was correct for a Resident that weighed 126 pounds (Resident 84) by setting mattress for a person that weighed 210 pounds.
This deficient practice placed Resident 31 and Resident 84 on an air mattress that did not help with ulcer prevention.
Findings:
1. During a review of Resident 31's admission Record, the admission record indicated Resident 31 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of heart failure (progressive heart disease that affects pumping action of the heart muscles. This causes fatigue, shortness of breath) and chronic kidney disease (gradual loss of kidney function. Kidneys are unable to filter wastes and excess fluids from blood).
During a review of Resident 31's History and Physical (H&P) dated 7/10/2023, the H&P indicated Resident 31 had the fluctuating capacity to understand and make decisions. The H&P indicated Resident 31 had a diagnosis of calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function).
During a review of Resident 31's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/31/2024, the MDS indicated that Resident 31's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was moderately impaired. The MDS indicated Resident 31 needed substantial/maximal assistance (helper does more than half the effort) from staff for all activities of daily living. The MDS indicated Resident 31 was always urinary and bowel incontinent. The MDS indicated Resident 31 had a diagnosis of dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). The MDS indicated Resident 31 was at risk of pressure ulcers/injuries (an open sore caused by poor blood flow). The MDS indicated Resident 31's skin and ulcer/injury treatment was a pressure reducing device for bed.
During a review of Resident 31's Physician Orders, dated 11/1/2023, the physician's order indicated to monitor the low air loss mattress (LALM) settings every day.
During a review of Resident 31's Treatment Administration Record (TAR), dated February 2024, the TAR indicated Treatment Nurse (TN) checked Resident 31's LALM settings on 2/1/2024 - 2/21/2024.
During a review of Resident 31's Braden Scale Risk Assessment (assessment to predict pressure sore risk),dated 1/31/2024, the assessment indicated Resident 31's score was 13 (Score 9 or less: very high risk, score 10-12: high risk, score 13-14: moderate risk, score 15-18: mild risk) due to Resident 31's limited mobility.
2. During a review of Resident 84's admission Record, the admission record indicated Resident 84 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of muscle wasting (a weakening, shrinking, and loss of muscle caused by disease or lack of use) and failure to thrive (a decline seen in older adults - typically those with multiple chronic medical conditions - resulting in a downward spiral of poor nutrition, weight loss, inactivity, depression and decreasing functional ability).
During a review of Resident 84's History and Physical (H&P) dated 10/17/2023, the H&P indicated Resident 84 had the capacity to understand and make decisions. The H&P indicated Resident 84 had a diagnosis of chronic obstructive pulmonary disease (group of chronic lung diseases that block airflow and make it harder to breathe air out of the lungs).
During a review of Resident 84's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/4/2024, the MDS indicated that Resident 84's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 84 needed partial/moderate assistance (helper does less than half the effort) from staff for oral hygiene, dressing, and personal hygiene. The MDS indicated Resident 84 was always urinary and bowel incontinent. The MDS indicated Resident 84 had a diagnosis of dementia. The MDS indicated Resident 84 was at risk of pressure ulcers/injuries. The MDS indicated Resident 84's skin and ulcer/injury treatment was a pressure reducing device for bed.
During a review of Resident 84's Physician Orders, dated 1/23/2024, the physician's order indicated facility to provide a LALM to Resident 84 for skin maintenance.
During a review of Resident 84's Braden Scale Risk Assessment, dated 10/17/2023, the assessment indicated Resident 84's score was 15 (at risk for the development of pressure ulcers) due to Resident 84's very limited mobility.
During an observation on 2/20/2024 at 12:05 p.m. in Resident 84's room, Resident 84's LALM was set for a resident that weighed 210 pounds.
During an observation on 2/20/2024 at 12:28 p.m. in Resident 31's room, Resident 31's LALM was set for a resident that weighed 210 pounds.
During an interview on 2/21/2024 at 10:33 a.m. with Licensed Vocational Nurse (LVN) 4, the LVN 4 stated he had checked LALM settings for Resident 84 and Resident 31 today. The LVN 4 stated it was the nurse assigned to those residents that was responsible to monitor settings. The LVN 4 stated that he monitored the LALM settings to be set according to resident's weight. The LVN 4 stated the LALM settings were accurate. The LVN 4 stated it was important to have the correct LALM settings to prevent skin breakdown/injuries.
During an observation on 2/21/2024 at 11:16 a.m. in Resident 84's room, Resident 84's LALM was set for a resident that weighed 140 pounds.
During an observation on 2/21/2024 at 11:50 a.m. in Resident 31's room, Resident 31's LALM was set for a resident that weighed 140 pounds.
During an interview on 2/22/2024 at 2:14 p.m. with Treatment Nurse (TN), the TN stated he checked the LALM settings and they were accurate. The TN stated the LALM settings should be set according to resident's weight. The TN stated Residents with low mobility and bed bound residents get a LALM to prevent skin ulcers. The TN stated one week ago Resident 84 developed a skin ulcer on her right foot and Resident 84 did need a LALM to prevent further skin issues. The TN stated two months ago Resident 31 developed skin ulcer on her gluteus. The TN stated Resident 31 would benefit from a LALM and that it was important to have accurate settings to prevent further skin issues.
During an interview on 2/23/2024 at 1:33 p.m. with the Director of Nursing (DON), the DON stated residents use a LALM to prevent further skin breakdown and to help existing wounds. The DON stated that it was important to accurately set settings of LALM to alleviate pressure for immobile residents, to promote a timely healing and for residents' comfort. The DON stated that settings are set up per manufacturers specifications. The DON stated if the LALM is not set to residents weight it will be ineffective and it can worsen the skin's condition if the mattress is underinflated or overinflated. The DON stated the TN was responsible to check LALM settings daily and that it was part of the TAR to monitor LALM settings.
During a review of facility's Policy and Procedure (P&P) titled Prevention of Pressure Ulcers, dated 9/2013, the P&P indicated intervention and prevention measures is determine if a resident needs a special mattress for bed selection.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:
1. Ensure a tuberculin vial (medication use to dete...
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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 a tuberculin vial (medication use to detect a certain, active infection in a resident) was discarded in a timely manner.
2. Label and date an open vial of the influenza vaccine.
3. Discard a vial of Resident 99's Lorazepam (an anxiety [feeling of fear, dread, and uneasiness] medication) in a timely manner.
4. prevent employees from putting drinks Gatorades in the medication room refrigerator.
5. Store one unopened bottle of Humulin R (type of insulin that was used to treat high blood sugar) in the refrigerator for Resident 97.
6. Label a bottle of Lantus (type of insulin) was labeled with the open date for Resident 12.
These failures had the potential for cross contamination (exposure of bacteria) to occur during medication administration, drug diversion (drug loss) to occur, and/or administration of medication with reduced efficacy.
Findings:
a. During a concurrent observation and interview, on 2/21/2024 at 10:30 a.m., with Registered Nurse (RN) 1, in Medication Room A, the facility's medication refrigerator was observed. There was a capless tuberculin vial that was labeled with the open date of 8/24/2023 and RN 1 stated that the medication should have been disposed of within 30 days after it was opened (9/23/2023). RN 1 stated, If the vial was not disposed, it could be administered and can cause possible interaction. The vial can possibly cause an infection (for the resident receiving the dose from the vial) due to the top of the vial being exposed for too long.
During an interview, on 2/23/2024, at 12:11 p.m., with the Infection Prevention Nurse (IPN), the IPN stated that he usually checks the medication refrigerators, and he might have missed the tuberculin vial. The IPN stated that if the tuberculin vial was opened on 8/24/2023, it should have been disposed of within 30 days to prevent other nurses from using the medication and so that it can reduce the accidental exposure of bacterial growth on the top of the vial to the other residents.
During an interview, on 12/23/2024, at 12:52 a.m., with the Director of Nursing (DON), the DON stated, The vial (dated 8/24/2023) should have been disposed. The DON stated, Over time, there is a chemical break down that occurs and the medication becomes less effective. The DON stated if it were not discarded, then there was penitential that is could be administered.
During a review of the facility's Policy and Procedure (P&P), titled, Storage of Medications, dated 4/2007, the policy indicated the facility was to ensure all discontinued, outdated, or deteriorated drugs were to be destroyed and not to be used.
b. During a concurrent observation and interview, on 2/21/2024, at 10:30 a.m., with RN 1, in Medication Room A, the facility's medication refrigerator was observed. There was a capless vial of the influenza vaccine that did not have an open date labeled on the box or exterior of the vial. RN 1 stated that the medication should have had an open date to indicate when it was opened so that the nurses can ensure that the dose being administered has maximal efficacy. RN 1 stated that if it was not labeled, there was a potential for the vaccine (with decreased potency [effectiveness]) to be administered to the residents.
During an interview, on 12/23/2024, at 12:52 a.m., with the DON, the DON stated, There should have been a date on the influenza vial because it can cause inflection control issues.
During a review of the facility's Policy and Procedure (P&P), titled, Storage of Medications, dated 4/2007, the policy indicated the facility was to ensure all discontinued, outdated, or deteriorated drugs were to be destroyed and not to be used.
c. During a concurrent observation and interview, on 2/21/2024, at 10:30 a.m., with Registered Nurse (RN) 1, in Medication Room A, the facility's medication refrigerator was observed. There was an opened vial of Lorazepam located inside of a medication zip-lock bag that was labeled with Resident 99's name. RN 1 stated that the resident had been discharged since 11/1/2023 and the medication should have been discarded. RN 1 stated that the Lorazepam medication was a controlled substance (a medication that is highly regulated) and that it was important for the medication to be brought to the DON's office right away so that she can keep record of all of the remaining doses, the facility could avoid medication discrepancies and to avoid drug diversion.
During a review of Resident 99's Face Sheet (admission Record), the Face Sheet indicated Resident 99 was originally admitted to the facility on [DATE], readmitted on [DATE], and discharged from the facility on 11/1/2023 with diagnoses that included but not limited to respiratory (breathing) conditions, protein-calorie malnutrition, and schizophrenia (mood disorder).
During a review of the label affixed to the medication zip-lock bag of the Lorazepam vial, dated 10/3/2023, the label indicated Resident 99 was to receive Lorazepam 2 milligrams (MG- unit of measurement) / milliliter (ML- unit of measurement) daily as needed for aggression. The label indicated the medication had been ordered on 10/2/2023 and delivered to the facility on [DATE].
During an interview, on 12/23/2024, at 12:52 a.m., with the Director of Nursing (DON), the DON stated, The discontinued medication should have been brought to me so that I can dispose of it, avoid drug diversion, and to account for all narcotics in the facility.
During a review of the facility's Policy and Procedure, titled, Discarding and Destroying Medications dated 10/2024, the policy indicated the facility was to ensure the disposal of controlled substances must take place immediately (no longer than three days) after discontinuation of use by the resident.
d. During a concurrent observation and interview, on 2/21/2024 at 10:30 a.m., with Registered Nurse (RN) 1, in Medication Room A, the facility's medication refrigerator was observed. There was a blue beverage, labeled Gatorade. RN 1 stated that there should never be food or beverage in the medication room, because it was an infection control issue and that there was a possibility for cross contamination of the medications and the beverage.
During an interview, on 2/23/2024, at 12:11 p.m., with the Infection Prevention Nurse (IPN), the IPN stated that there should not be food in the medication room because there was a potential for the food or beverage to contaminate the medications in the medication room and be administered to the residents.
During an interview, on 12/23/2024, at 12:52 a.m., with the Director of Nursing (DON), the DON stated, There should not be food in the medication room because there is a risk for cross contamination. It is an infection control issue.
During a review of the facility's Policy and Procedure (P&P), titled, Storage of Medications, dated 4/2007, the policy indicated food was to be stored separately from medications.
e. During a review of Resident 97's Face Sheet, the Face Sheet indicated Resident 97 was admitted to the facility on [DATE] with diagnoses that included but not limited to type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), major depressive disorder (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 97's Physician Orders, dated February 2024, the Physician Orders indicated to inject Humulin R 100 units (unit of measurement) per milliliter (ml, unit of measurement) before meals and at bedtime, subcutaneously (injection into the fatty tissue), per the sliding scale based on the blood glucose level (amount of sugar in the blood stream, the normal value between 70 milligrams [mg, unit of measurement] per (/) deciliter [dL, unit of measurement] and 100 mg/dL) for diabetes mellitus:
0-150 mg/dL = 0 units
151-200 mg/dL = 1 unit
201-250 mg/dL = 2 units
251-300 mg/dL = 3 units
301-350 mg/dL = 4 units
351-400 mg/dL = 5 units
greater than 400 mg/dL = 6 units and call the physician
During a concurrent observation and interview on 2/21/2024 at 10:50 a.m., with Licensed Vocational Nurse (LVN) 1, at Medication Cart B, an unopened vial of Humulin R was inside the medication cart. LVN 1 stated the insulin vial was unopened and insulin was supposed to be stored in the refrigerator until it is ready to use. LVN 1 stated she was unsure who received the medication and whoever received the medication should have placed it in the refrigerator for storage.
During an interview on 2/22/2024 at 12:48 p.m., with Registered Nurse (RN) 1, RN 1 stated unopened insulin should be stored inside the refrigerator per the manufacturer guidelines. RN 1 stated storing insulin in the refrigerator prolongs its shelf life so once it was removed from the refrigerator, it would be effective when administered to the resident. RN 1 stated storing unopened insulin at room temperature had the potential for it to break down and become not as potent.
During an interview on 2/22/2024 at 4:17 p.m., with the Director of Nursing (DON), the DON stated unopened insulin had to be stored in the refrigerator until it was ready to use and opened. The DON stated storing unopened insulin in the refrigerator helped maintain the quality and efficacy. The DON stated storing unopened insulin at room temperature could cause it to breakdown and might not be as effective when it was time to administer to the resident.
During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, revised April 2007, the P&P indicated, Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location.
f. During a review of Resident 12's Face Sheet, the Face Sheet indicated Resident 12 was admitted to the facility on [DATE] with diagnoses that included but not limited to Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), and major depressive disorder.
During a review of Resident 12's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 2/7/2024, the MDS indicated Resident 12 was able to understand and be understood by others. The MDS indicated Resident 12's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 12 received insulin. The MDS indicated Resident 12 had a diagnosis of diabetes mellitus.
During a review of Resident 12's History and Physical Examination (H&P), undated, the H&P indicated Resident 12 had the capacity to understand and make decisions.
During a review of Resident 12's Physician Orders, dated February 2024, the Physician Orders indicated to inject Insulin Glargine 25 units, subcutaneously at bedtime, for type 2 diabetes mellitus, hold if blood glucose level less than 100.
During a review of Resident 12's Medication Administration Record (MAR), dated February 2024, the MAR indicated Resident 12 was administered Insulin Glargine throughout the month of February.
During a concurrent observation and interview on 2/21/2024 at 11:02 a.m., with Licensed Vocational Nurse (LVN) 2, at the Medication Cart Middle, an opened Insulin Glargine pen without an open date written on the label was inside the medication cart. LVN 2 stated the Insulin Glargine pen was opened and the open date was not written on the label. LVN 2 stated when an insulin pen was opened, the insulin pen was viable for 28 days. LVN 2 stated labeling the insulin pen with the open date would communicate to any licensed nurse, who was to administer the insulin to the resident, when the 28 days was so they could request a refill and obtain a new insulin pen from the pharmacy. LVN 2 stated the insulin pen had to be used within the 28 days to ensure the accuracy of the potency because if the insulin pen was used past the 28 days, the medication would not be as strong. LVN 2 stated if the insulin pen was used past the 28 days after it was opened, it may not have the efficacy to treat the resident's blood glucose level.
During an interview on 2/22/2024 at 12:50 p.m., with RN 1, RN 1 stated when an insulin pen was initially opened, the nurse was to write on the label the date it was opened. RN 1 stated labeling the insulin pen with the open date ensured the insulin would not be used past the 28 days to protect its potency. RN 1 stated using an insulin pen past the 28 days could put the resident at risk for elevated blood glucose level due to the decrease in potency of the insulin.
During an interview on 2/22/2024 at 4:20 p.m., with the DON, the DON stated prior to administering insulin to a resident from the pen, the nurse was responsible for assessing if the insulin pen was opened and was full. The DON stated the nurse who opened the insulin pen was responsible for labeling the insulin pen with the date it was opened to maintain its efficacy. The DON stated if an insulin pen was not labeled with the open date, the nurse would be unsure how long the insulin pen was opened and could potentially administer expired medication to the resident.
During a review of the facility's P&P titled, Administering Medications, revised December 2012, the P&P indicated, the expiration/beyond use date on the medication must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected most or all residents
Based on observations, interviews, and record review the facility failed to:
1. Ensure two (2) of two cooks were unable to verbalize the corresponding cutting board color for food items.
2. Ensure t...
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Based on observations, interviews, and record review the facility failed to:
1. Ensure two (2) of two cooks were unable to verbalize the corresponding cutting board color for food items.
2. Ensure two of (2) staff was unable to demonstrate and verbalize proper dishmachine temperature checks.
3. Ensure two (2) of 2 staff were not following the manufacturer's guidelines when checking the concentration of the QUAT sanitizing (a chemical used for disinfection) solution.
4. Ensure one Nursing Supervisor was not able to verbalize the facility Resident's food from home policy.
This failure had a potential to result to potential cross-contamination (a transfer of bacteria from one object to another), ineffective dishmachine, and unsanitized dishes that could lead to food borne illness (an illness caused by contaminated food and beverages) in 98 of 98 medically compromised residents who received food and ice from the kitchen.
Findings:
1. During an interview with the [NAME] 2 on 2/20/2024 at 9:56 AM, [NAME] 2 stated they hardly use yellow cutting board and they do not use the blue cutting board. [NAME] 2 stated that the brown cutting board was used for fish.
During an interview with Dietary Supervisor (DS) on 2/20/2024 at 9:58 AM stated the yellow cutting board was used for cooked meats, red cutting board was for raw meats, brown cutting board was for vegetables, blue chopping board was for raw fish. DS stated she has not conducted an in-service about cutting boards to the staff and she did not have a cutting board poster for staff to look at. DS stated it was important to use the correct color of cutting board to a particular food item to prevent cross contamination.
During an observation of food preparation by [NAME] 1 on 2/20/2024 at 11:16 AM, [NAME] 1 used blue cutting board for cooked foods.
During an interview with [NAME] 1 on 2/20/2024 at 1:12 PM. [NAME] 1 stated blue cutting board was for cooked foods, yellow cutting board was for poultry, brown cutting board was for fish, red cutting board was for red meats and white cutting board was for bread and cheese. [NAME] 1 stated it was important to use the right cutting boards to prevent cross-contamination.
A review of [NAME] 2's job description titled Cook dated and signed by [NAME] 2 on 8/30/2016, indicated Duties and Responsibilities: Ensure that all dietary procedures are followed in accordance with established policies. Safety and Sanitation: Prepare food in accordance with sanitary regulations as well as our established policies and procedures. Ensure that safety regulations and precautions are followed at all times by all dietary personnel.
A review of [NAME] 2's competency checklist titled Cook Competency Evaluation and Performance Satisfactory Completion dated and signed by [NAME] 2 and DS on 1/11/2024, indicated [NAME] 2 was competent on the skill to prepare and cook in safe and efficient manner.
A review of [NAME] 1's job description titled Head Cook dated and signed by [NAME] 1 on 1/1/2016, indicated Duties and Responsibilities: Ensure that all dietary procedures are followed in accordance with established policies. Safety and Sanitation: Prepare food in accordance with sanitary regulations as well as our established policies and procedures. Ensure that safety regulations and precautions are followed at all times by all dietary personnel.
A review of [NAME] 1's competency checklist titled Cook Competency Evaluation and Performance Satisfactory Completion dated and signed by [NAME] 1 and DS on 1/11/2024, indicated [NAME] 1 was competent on the skill to prepare and cook in safe and efficient manner.
A review of the facility's policy and procedure (P&P) titled Cutting Board Policy dated 1/16/2024, indicated The appropriate cutting boards shall be used for the appropriate foods to avoid cross-contamination.
Red: raw meat
Blue: raw fish
Yellow: cooked meats
Green: salad and fruit
Brown: vegetables
Purple: allergies
White: dairy
2. During a demonstration of dishmachine temperature checks for wash and rinse and interview with Dietary Aide 1 (DA 1) on 2/21/2024 at 9:41 AM, DA 1 got a test strip and dipped the test strip in the dishwasher water after the wash cycle. DA 1 compared the test strips with the color chart and stated the test strips read between 100-200 degree Fahrenheit (°F, a scale of temperature) hence the dishmachine temperature was at 120°F. DA 1 stated she used the test strips to read the temperature of the dishmachine. DA 1 stated she did the same process of checking the rinse temperature by dipping the chlorine test strips to the dishmachine after the rinse cycle. DA 1 sticked a test strip on a tray and stated the color was at 130°F. DA 1 stated she recorded the dishmachine temperatures in the dishmachine log before each meal.
During an interview with DS on 2/21/2024 at 10:03 AM, DS stated they checked the dishmachine temperature by checking the temperature gauge on the dishmachine. DS 1 stated the wash and rinse temperature was at 100°F and this was not an acceptable temperature, however, it was okay because the other temperature gauge reached 140°F. DS stated she needed to call the dishmachine vendor to verify the use of the second temperature gauge. DS stated the dishmachine needed to be at 120°F and above to kill bacteria.
During an interview with the dishmachine vendor (DMV) on 2/21/2024 at 1:48 PM, DMV stated he adjusted to dishmachine temperature to 130°F as it did not meet the temperature earlier today because the facility worked on pipes. DMW stated there were two temperature gauge on the dishmachine, one was for the dishmachine temperature, and the other temperature gauge was for the water temperature of the entire facility.
A review of the facility's job description titled Dietary Aide dated and signed by DA 1 on 6/6/2022, indicated Specific Job Functions: Performs dishwashing procedures appropriately with care for sanitizing, water temperatures, and drying practices.
A review of the facility's competency checklist titled Dietary Aide Competency Evaluation and Performance Satisfactory Completion dated and signed by DA 1 on 1/12/2024 indicated DA 1 was competent on operating kitchen equipment.
A review of the facility's job description titled Director of Food Services dated and signed by DS on7/8/2020 indicated Purpose of Your Job Position. The primary purpose of your job position is to assist the Dietitian in planning, organizing, developing overall operation of the Dietary Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean, safe and sanitary manner. Assist in the development of and participate in the planning, conducting, and scheduling of timely in-service training classes that provide instructions on how to do the job, and that ensure a well-educated dietary services department. Monitor dietary service personnel to assure that they are following established safety regulations in the use of equipment and supplies.
A review of the facility's policy and procedure (P&P) titled Dishwashing dated 1/16/2024, indicated Please check your manufacturer's recommendations which should be posted on your machine, and insert the temperature on the above posted line. This will allow the information to be handy if needed. Low-temperature machine: If you do not have the manufacturer's recommendations, use the machine range of 120°F to 140°F.
A review of Food Code 2017 indicated 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitation- Temperature, pH, Concentration, and Hardness. Verifying the adequacy of chlorine-based solutions can be accomplished on an on-going basis by confirming that the concentration, temperature, and pH of the sanitizing solutions comply with paragraphs 4-501.114 (A) using acceptable test methods and equipment. The manufacturer should provide methods (e.g. test strips, kits, etc.) to verify that the equipment consistently generates solution on-site at the necessary concentration to achieve sanitation.
3. During a concurrent demonstration of the Quat sanitizer testing process and interview with DA 1 on 2/21/2024 at 9:41 AM, DA 1 filled the red bucked with a premix Quat sanitizer then pulled out a test strips and dipped the test strips in the solution for ten (10) seconds. DA 1 compared the test strips to the color chart and stated the test strip read 200 parts per million (ppm, a unit of measuring concentration) DA 1 did not check the water temperature for Quat sanitizer testing. DA 1 stated it was important to check the concentration of Quat sanitizer to make sure it killed germs.
During a concurrent demonstration of the Quat sanitizer testing process and interview with DS on 2/21/2024 at 10:03 AM, DS got a test strip, dipped the test strips in the Quat sanitizer and compared the test strip to the color chart. DS stated it read 200ppm and it was in the acceptable concentration range. DS stated the Quat sanitizer was premixed and ready to test. DS tested the sanitizer concentration without taking the temperature.
During a concurrent interview with DS and review of the manufacturer's guidelines of Quat Sanitizer test strips titled Qua-10 Test Paper Lot no. 231422 with expiry date of 11/1/2024 on 2/21/2024 at 10:20 AM, indicated:
Immense for 10 seconds, compare when wet.
Dip paper in Quat solution, not foam surface for 10 seconds. Do not shake.
Compare colors at once.
Testing solution should be between 65-75°F.
Testing solution should have a neutral pH.
Follow manufacturer's dilution instructions carefully.
DS stated, she did not test the water temperature because she used cold water, however, she did not know that the Quat solution testing should be at 65-75°F. DS stated the potential outcome for not following manufacturer's guidelines for testing would be the Quat sanitizer concentration would not kill bacteria in the food preparation surfaces in the kitchen.
During an interview with DS on 2/21/2023 at 10:29 AM, DS stated that last time she gave an in-service to staff regarding Quat sanitizer and dishmachine was in 12/2023 but she forgot to document the exact date. DS stated she showed DA 1 how to check the dishmachine temperatures and Quat sanitizer testing but she did not have DA 1 do a return demonstration.
A review of Food Code 2017 indicated 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration. Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device.
4. During an interview with Registered Nurse Supervisor 1 (RN Supervisor 1) on 2/21/2024 at 11:17 AM, RN Supervisor 1 stated the facility discouraged residents to bring food from the outside that would last multiple day and it should be something that residents could consume within a single eating or a single day. RN Supervisor 1 stated, the facility could not do it if residents brought food for more than a single consumption because they have not received the food safety training that they needed to have. RN Supervisor 1 stated he did not know about the food from home policy.
A review of the facility's policy and procedure (P&P) titled Bringing in Food for A resident dated 1/16/2024, indicated If you plan to bring food into facility for a resident, please be sure to follow these food safety suggestions:
a. Food and beverages should be labeled and dated to monitor for food safety.
b. Food or beverages in the original containers marked with manufacturer expiration dates and unopened, need to be marked with resident's name.
c. Food or beverage items without a manufacturer's expiration date will be dated upon the arrival in the facility and thrown away two days after the date marked, or if frozen 30 days.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to:
a. Ensure two (2) freezers and 2 refrigerators had dirt debris on the bottom shelves.
b. Ensure pots and pans storage by pr...
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Based on observation, interview, and record review, the facility failed to:
a. Ensure two (2) freezers and 2 refrigerators had dirt debris on the bottom shelves.
b. Ensure pots and pans storage by preparation and trayline (an area where resident's foods are assembled) area had chipped paint.
c. Ensure knife storage area did not have dust debris and dirt build up.
d. Ensure the bottom shelves used for sheet pans storage were cleaned.
e. Remove a dented (hallow or dip in a surface caused by pressure or blow) can in the dry storage area.
f. Ensure internal parts of the mixer did not have dust buildup and oil residue.
g. Chopping boards were not chipped or cracked.
h. Clean the kitchen hood and exhaust.
i. Ensure Resident's trays were not chipped, cracked, and stained.
j. Ensure staff monitored the time and temperature for thawing of meat.
k. Ensure the low temperature on the dishmachine did not meet acceptable temperature ranges when washing kitchen wares from breakfast and lunch service.
l. Ensure expired chlorine test paper for dishmachine sanitizer's use.
m. Ensure the ice machine baffle (slanted component used to keep ice from falling out of the bin when the door is opened) had black dirt residue.
n. Ensure Resident's refrigerator was cleaned and debris free.
o. Ensure emergency water boxes were stored on the floor and paper supplies were not at least six (6) inches stored above the floor.
These failures had the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne illness (an illness caused by contaminated food and beverages) in 98 of 98 medically compromised residents who received food from the kitchen.
Findings:
a. During an initial kitchen tour observation of the freezer by the trayline area on 2/20/2024 at 8:41 AM, the bottom shelves of the freezer had dirty debris and dried brown fluid.
During an initial kitchen tour observation of the refrigerator by the preparation area on 2/20/2024 at 8:45 AM, the bottom shelves of the refrigerator had dirt debris.
During an initial kitchen tour observation of the refrigerator near the kitchen exit door on 2/20/2024 at 8:47 AM, the bottom shelves of the refrigerator had dirt debris.
During an initial kitchen tour observation of the freezer next to the stove on 2/20/2024 at 8:56 AM, the bottom selves of the freezer had dirty debris.
During a concurrent observation of all freezers and refrigerators in the kitchen and interview with the Dietary Supervisor (DS) on 2/20/2024 at 9:08 AM, DS stated all the freezer and refrigerator in the kitchen had dirt debris in the bottom shelves. DS stated the dirt and dust debris was from the boxes of food and it should be cleaned. DS stated they clean the freezer and refrigerator weekly and as needed and the last time it was detailed clean was on 2/15/2024. DS stated it was important to maintain the cleanliness of the freezer and refrigerator because there was food in there and food storage areas needed to be free from any particles, dirt, and spill to prevent cross-contamination of dirty to food. DS stated the food would not be safe to eat.
A review of the facility's Policy and Procedure (P&P) titled Refrigerator and Freezer, dated 1/6/2024, indicated, Maintaining a clean refrigerator and freezer can improve the safety and quality of your foods. For the best cleaning results, always refer to your owner's manual. (1) Refrigerator and freezer should be on a weekly cleaning schedule. (2) Wipe up spills immediately.
A review of Food Code 2017 indicated 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) where is not exposed to splash, dust, or other contamination; and (3) At least 15 centimeters (cms )(6 inches) above the floor.
b. During an initial kitchen tour observation of the pots and pans storage by the preparation area on 2/20/2024 at 8:58 AM, pots and pans storage surfaces was not smooth, paint was coming off and chipped.
During a concurrent observation of the pots and pans storage and interview with DS on 2/20/2024 at 9:20 AM, DS stated the pots and pans storage area was a clean area, but it had cracked paint and it has been cracked since she started working for the facility. DS stated the storage surface was not acceptable because pant and particles could go to the pans and food of the residents causing cross-contamination. DS stated the area was cleaned last Tuesday and it needed to be cleaned.
A review of the facility's P&P titled Sanitation dated 1/6/2024 indicated All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners will be kept in good repair.
A review of Food Code 2017 indicated 3-304.11 Food Contact with Equipment and Utensils. Food shall only contact surfaces of (A) Equipment and utensils that are cleaned as specified under Part 4-6 of this code and sanitized as specified under Part 4-7 of this code; (B) Single-service and single-use articles; or (C) Linens such as cloth napkins, as specified under 3-304.13 that are laundered as specified under Part 4-8 of this code.
c. During an initial kitchen tour observation on 2/20/2024 at 8:59 AM, knife storage area ha dust and dirt buildup.
During a concurrent observation of the knife storage area and interview with DS on 2/20/2024 at 9:20 AM, DS stated the last time the staff cleaned the storage area was last Tuesday however it needed to be cleaned because the knife had dirt particles and dust buildup. DS stated it was important to clean food surfaces to prevent cross contamination of dust into the food.
A review of the facility's P&P attachments titled Sanitation, dated 1/6/2024, indicated, (3) All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soil by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions.
A review of Food Code 2017 indicated 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be clean to sight and touch. (B) NonFood-Contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris.
d. During an initial kitchen tour observation on 2/20/2024 at 9:01 AM, the sheet pans storage on the bottom shelves in the trayline area had white dirt residue.
During a concurrent observation of the sheet pan storage and interview with the DS on 2/20/2024 at 9:25 AM, DS stated there were white particles on the bottom shelves of trayline where the sheet pans were located. DS stated the area also needed to be cleaned to prevent cross-contamination of dirt to food.
A review of the facility's P&P titled Shelves, Counters, and Other Surfaces including Sinks (Handwashing, Food Preparation, etc.), dated 1/6/2024, indicated Cleaning Procedure: (1) Remove any large debris and wash surface with warm detergent solution following manufacturer's instructions. (2) Rinse with clear water using a clean sponge or cloth. Wipe dry with clean cloth. (3) Spray with a sanitizer.
e. During an initial kitchen tour observation at the dry storage area on 2/20/2024 at 9:04 AM, one dented can was stored along with undented cans and food supplies.
During a concurrent observation of the dented can in the storage area and interview with DS on 2/20/2024 at 9:49 AM, DS stated dented cans were in a separate area because staff could not use dented cans due to particles could go in the food. DS stated she did not put away one dented can in the designated area. DS stated the possible outcome for storing the dented cans along with the non-dented cans was staff could grab and use the dented can for the residents.
A review of the facility's P&P titled Food Storage-Dented Cans dated 1/6/2024, indicated Policy: Food is unlabeled, rusty, leaking, broken containers or cans with side seam dents, rim dents or swells shall not be retained or used by the facility. Procedure: All dented (defined as side seam or rim dents) and rusty cans are to be separated from remaining stock and placed in a specific labeled area for return to purveyor for refund. All leaking cans are to be disposed immediately.
A review of Food Code 2017 indicated 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of §3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard.
f. During a kitchen observation of the mixer on 2/20/2024 at 9:35 AM, the planetary action part (an agitator that moves around the bowl like a planet) had oil, dried up food debris and dust build up. The upper portion of the mixer was not covered with plastic while not in use.
During a concurrent observation of the mixer and interview with DS and [NAME] 1 on 2/20/2024 at 9:53 AM, [NAME] 1 stated he did not use the mixer today. DS stated they use the mixer for mixing something like whip cream and clean the mixer after each use. DS stated the mixer had dried up dirty and food residue. Ds stated it was important to clean and cover the mixer while not in use to protect the mixer from dust and dirt preventing cross-contamination to food.
A review of the facility's P&P titled Electrical Food Machines, dated 1/6/2024, indicated, Keep and maintain all food machines in good operating, sanitary condition. This includes mixers, grinders, slicers, and toasters. Mixing Machines (3) Clean the beater shaft and body of the machine with warm water and detergent following manufacturer's instructions. Hard scrubbing and harsh soap might remove the paint.
A review of Food Code 2017 indicated 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be clean to sight and touch. (B) NonFood-Contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris.
g. During an observation of the cutting boards on 2/20/2024 at 9:36 AM, yellow, blue, brown, and red cutting boards were chipped and cracked.
During a concurrent observation of the cutting boards and interview with the DS on 2/20/2024 at 9:58 AM, DS stated the chopping boards were chipped. DS stated it was not okay to use chipped cutting boards because of bacterial growth on the chipped surface and the potential outcome to the resident would be cross-contamination. DS stated residents could get sick.
A review of facility's P&P titled Sanitation dated 1/6/2024, indicated (12). Plastic wares, china and glassware that cannot be sanitized or are hazardous because of chips, cracks or loss of glaze shall be discarded. Damaged or broken equipment that cannot be repaired shall be discarded.
A review of Food Code 2017 indicated 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections.
h. During an observation of the hood and exhaust in the kitchen on 2/20/2024 at 9:41 AM, the hood and exhaust system had dust and dirt buildup.
During a concurrent observation of the hood and exhaust in the kitchen and interview with DS on 2/20/2024 at 10:00 AM, DS stated they cleaned hood and exhaust every two (2) weeks and the last time it was done was last Thursday. DS stated the good and exhaust had dust and dirt buildup and it could fall in the food since the staff cooked under it.
A review of the facility's P&P titled Hoods, Filters and Vents, dated 1/6/2024 indicated HOODS. Hoods must be cleaned every two weeks and must be free from dust and grease. HOOD SHAFTS. Hood exhaust shafts are to be cleaned by a contract maintenance service company to maintain safety and meet local fire code requirements. VENTS. Vents must be free of dust and dirt.
i. During an observation of the resident's tray and carts for lunch service on 2/20/2024 at 11:07 AM, 86 of 95 resident's tray were chipped and cracked.
During an concurrent observation of the resident's tray and interview with DS on 2/20/2024 at 1:09 PM, DS stated trays used for lunch service had cracks and chip. DS stated cracked and chip trays were not acceptable because residents could get scratched, presentation of the food was affected, and bacteria can grow on those cracked surfaces for cross-contamination.
A review of facility's P&P titled Resident Trays dated 1/6/2024 indicated Resident trays will remain free from chips, cracks, and stains. Porous materials that are cracked or chipped or stained can carry harmful bacteria.
j. During an observation of meat thawing in the kitchen sink on 2/20/2024 at 11:15 AM, four (4) packs of ground meats were thawed in the preparation sink.
During a concurrent observation of thawing of 4 ground meats in the preparation sink and interview with [NAME] 2 on 2/20/2024 at 11:26 AM, [NAME] 2 stated he started thawing the ground meat around 11AM for tomorrow's use. [NAME] 2 stated the process of thawing meat were as follows:
Placed the ground meats in a pan.
Let water run through the ground meats for two (2) hours.
Thaw the meat all the way and put the meat back in the refrigerator for tomorrow's use
Cook 2 stated thawing of meat in the sink was his usual way of thawing meats.
Cook 2 stated they monitor the temperature for thawing however he did not monitor the temperature of the water and the time he started to thaw the ground beef. [NAME] 2 stated he records the temperature in the cooling log posted on the refrigerator.
During an interview with DS on 2/20/2024 at 11:32 AM, DS stated the methods that they used for thawing meats were refrigerator method and the sink method. DS stated the refrigerator method was the process of pulling the meat from the freezer to the refrigerator to thaw for three days. DS stated the sink method was thawing under a cold running water and putting the meat back to the refrigerator after for tomorrow's use. DS stated they monitored meat temperature, and it should be at 40° F and less but could not remember the exact temperature. DS stated they also check, and monitor water temperature and it should not be more than 70°F. DS stated she could not remember the policy for defrosting meats and needed to look into it. DS stated it was important to prevent the growth of bacteria in food during the thawing process that was why the meat needed to go back to the refrigerator.
During an interview with the Registered Dietitian (RD) on 2/20/2024 at 11:40 AM, RD stated it was a safe practice to thaw meat in the sink and place it back in the refrigerator to ensure it was not on the danger zone (define) where bacteria started to grow in food and residents could get sick.
During a concurrent observation of the thawing process and interview with [NAME] 2, the ground beef was transferred from preparation sink to the refrigerator without checking the temperature. [NAME] 2 stated he did not take the ground beef's temperature. [NAME] 2 stated he was off from work the other day that was why they were not able to pull the ground beef out of the freezer.
During an interview with DS on 2/20/2024 at 11:52 AM, DS stated there was no monitoring for time and temperature for thawing meats, but she could make a log.
During an interview with RD on 2/20/2024 at 12:46PM, RD stated they threw the thawed ground beef because they were unsure if it was on the danger zone.
A review of facility's P&P titled Thawing of Meats dated 1/6/2024 indicated PROCEDURE: (3) Submerge under running potable water at a temperature of 70°F or lower, with a pressure sufficient to flush away loose particles. (a) The food product cannot remain in the temperature danger zone (41°F to 140°F) for more than four hours, which includes the time the food is thawed. Use immediately.
A review of the Food Code 2017 indicated 3-501.13 Thawing. Except as specified (D) of this section, Time/Temperature control for safety food shall be thawed: (B) Completely submerged under running water: (1) At a water temperature of 21°C (70°F) or below. (2) With sufficient water velocity to agitate and float off loose particles in an overflow; and (3) For a period of time that does not allow thawed portions of ready-to-eat food to rise above 5°C (41°F) or (4) For a period of time that does not allow thawed portion of raw animal food requiring cooking as specified under 3-401.11 (A) or (B) to above 5°C (41), for more than 4 hours including: (a) the time the food is exposed to the running water and the time needed for preparation and cooking or (b) The time it takes under refrigeration to lower the food temperature to 5°C (41°F).`
k. During a concurrent observation of the low temperature dishmachine and interview of DS on 2/21/2024 at 10:03 AM, wash and rinse temperature gauge read 100°F. DS stated dishmachine temperature needed to be at the acceptable temperature of 120°F and above to kill bacteria. DS stated the dismachine was only at 100°F meaning they were not washing dishes properly.
During an interview with DS on 2/21/2024 at 2:00 PM, DS stated the dishmachine temperature was unacceptable and this means the dishmachine did not clean the dishes properly for breakfast and lunch dishwashing. DS stated this could also be cross contamination of bacteria to the wares.
A review of facility's P&P titled Dishwashing dated 1/6/2024 titled POLICY: All dishes will be properly sanitized through the dishwasher. The dishwasher will be kept clean and in good working order. Low-temperature machine: If you do not have the manufacturer's recommendation, use the machine at range of 120°F to 140°F.
A review of the facility's P&P titled Sanitation dated 1/6/2024 indicated Dishwashing machines must be operated using the following specifications:
Low-Temperature Dishwasher (chemical sanitation) (a) Wash temperature (120°F).
l. During a concurrent interview with DS and review of the chlorine test paper manufacturer's guidelines with lot number 040621 on 2/21/2024 at 10:03 AM, chlorine test paper had expiration date of 10/2023. DS stated the test strips were expired and it would not work and test the sanitizing solution accurately. DS stated it was important to accurately test the sanitizer to make sure the dishes were sanitized.
A review of facility's procedure titled How to Use Your Precision Chlorine Test Strips dated 1/6/2024, indicated The strip's colour indicates the concentration, or strength, of the chlorine bleach in the water. It is measured in parts per million (ppm).
m. During a concurrent observation of the ice machine in the utility room and interview with DS on 2/21/2024 at 10:40 AM, the ice machine baffle had black dirt particles after wiping it with a paper towel. DS stated the facility used the ice machine for resident's water and it was last cleaned by maintenance on 2/1/2024. DS stated she would not give the ice from the ice machine to the residents because it was not clean as it looks like, and residents could get sick.
A review of the facility's P&P titled Sanitation dated 1/6/2024 indicated
(12). Ice machines and ice storage containers will be drained, cleaned, and sanitized per manufacturer's instructions and facility policy.
n. During a concurrent observation of the resident's refrigerator in Station A and interview with DS on 2/21/2024 at 11:15 AM, resident's refrigerator shelves had dust debris and ice buildup. DS stated the refrigerator was used to store resident's food from the outside and the one responsible cleaning it was the housekeeping department.
During an interview with the Housekeeping Supervisor (HKS) on 2 /21/2024 at 1:57 PM, HKS stated the resident's refrigerator was scheduled to be cleaned and disinfected yesterday and the reason why it was not cleaned this morning because the staff was in a hurry and did not clean the refrigerator thoroughly yesterday. HKS stated it was important to maintain the cleanliness of the refrigerator due to infection control and refrigerator must be clean to touch, free from dirt and dust.
A review of facility's P&P titled Refrigerator and Freezers dated 1/6/2024 indicated (10) Refrigerators and freezers will be kept clean, free from debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary.
o. During a concurrent observation of the paper supplies in the emergency food supply storage and interview with DS on 2/21/2024 at 1:52 PM, DS measured the paper supply storage using a ruler and it was five (5) inches.
During a concurrent observation of the emergency water in the garage in front of the maintenance office and interview with DS and Maintenance Supervisor (MS) on 2/21/2024 at 2PM, boxes of water were on the floor. Four boxes of water were wet. DS stated the water supply came in last Friday (2/9/2024). MS stated the plan was to move everything out so they can arrange the water supply in the garage. DS stated it was important to store the water boxes in the proper storage and not on the floor to prevent cross-contamination.
A review of facility's P&P titled Food Receiving and Storage dated (5) Food and designated dry storage areas shall be kept off the floor (at least 18 inches) and clear sprinkler heads, sewage/waste disposal pipes and vents.
A review of Food Code 2017 indicated 3-305.11 Food Storage. Except as specified in (B) and (C) of this section, Food shall be protected from contamination by storing the food: (3) at least 15 cm (6 inches) above the floor.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to:
1. Dispose garbage and refuse properly by not covering the three (3) of 3 overflowing dumpster (a large trash container desi...
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Based on observation, interview, and record review, the facility failed to:
1. Dispose garbage and refuse properly by not covering the three (3) of 3 overflowing dumpster (a large trash container designed to be emptied into a truck) for two (2) hours.
This deficient practice attracted flies to the dumpster area then flies were observed in the kitchen placing 98 of 98 facility residents getting food from the kitchen cross-contamination (a transfer of harmful bacteria from one place to another).
Findings:
During an observation of the garbage area located outside the kitchen on 2/20/2024 at 11:24 AM, there were three (3) overflowing trash bins not covered. There were 3 trash bags and two (2) wet boxes on the floor.
During a concurrent observation of the garbage area and interview with the Dietary Supervisor on 2/20/2024 at 11:54 AM, DS stated 3 trash bins were too full of trash and were not covered. DS stated the trash bins needed to be covered to prevent contamination and the Maintenance Supervisor was the one responsible calling the trash company.
During a concurrent observation and interview with the Maintenance Supervisor (MS) on 2/20/2024 at 1:23 PM, MS stated 3 trash bins were overflowing with trash and was not covered. MS stated he was responsible of maintain the trash area clean and he called the trash company. MS stated the trash company would pick up the trash around 12-3PM. MS stated the usual trash pickup would be first thing in the morning or late in the afternoon. MS stated it was important to always cover the trash to prevent the spread of bacteria, infection and it could be a source of pest (an insect or small animal that transfer bacteria from one place to another).
During an interview with the MS on 2/20/2024 at 2:32 PM, MS stated the garbage company did not pick up the trash yesterday due to issue in the area.
A record review of the facility's Policy and Procedure (P&P) titled Pest Control dated 1/1/2012, indicated Purpose: To ensure the facility is free from insect, rodents, and other pests that could compromise the health, safety, and comfort of residents, facility staff, and visitors. Policy: The facility maintains an ongoing pest control program to ensure the building and grounds are kept free from insects, rodents, and other pests. General Practices: (B) Garbage and trash are not permitted to accumulate in any part of the facility.
A review of the facility's P&P titled Miscellaneous Areas dated 1/6/2024, indicated Garbage and Trach. Procedure: (1) All food waste must be placed in sealed leak proof, non-absorbent, tightly closed containers (i.e., plastic bags) and shall be disposed of as necessary to prevent a nuisance or unsightliness. Trash Collection Area. (1) The trash collection area is a potential feeding ground for vermin and rodents and must be kept clean.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0912
(Tag F0912)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an observation, interview, and record review the facility failed to:
1. Provide 80 square feet of room space per resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an observation, interview, and record review the facility failed to:
1. Provide 80 square feet of room space per resident for 22 rooms out of 40 rooms.
This deficient practice could potentially not provide residents privacy and could potentially affect residents health and safety.
Findings:
During a review of facility's Client accommodations Analysis form, undated, the form indicated 22 rooms in the facility did not meet the room size requirement.
During a review of facility's waiver/variation for room size requirements, dated 6/5/2019, the waiver indicated the facility was granted their request for room size waiver/variation. The waiver was for rooms 11, 12, 14, 15, 17, 18, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, and 36.
During a concurrent observation and interview on 2/23/2024 at 8:22 a.m. with Maintenance Director (MD), in residents' rooms (room [ROOM NUMBER], 15, 23, 28, and 36) MD measured rooms and stated that measurements did not meet the room size requirements. The MD stated resident rooms should be at least 80 square feet per resident for safety reasons and privacy.
During an interview on 2/23/2024 at 2:03 p.m. with the Director of Nursing (DON), the DON stated not meeting the room size requirement could potentially cause problems and may be a hazard to residents in the room. The DON stated it was important to have enough space for each resident because they needed privacy, for their dignity and for safety reasons.
During a review of facility's Policy and Procedure (P&P) titled Bedrooms, dated 5/2017, the P&P indicated all residents would be provided with a clean, comfortable, and safe bedroom that met federal and state requirements.
Nov 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 implement adequate supervision and monitoring interve...
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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 adequate supervision and monitoring interventions for one of five sampled residents (Resident 2) who was identified with wandering and elopement (to leave unnoticed) risk behaviors.
This deficient practice resulted in Resident 2 wandering into Resident 1's and Resident 4's room causing a physical altercation.
Findings:
During a review of Resident 2's admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE] with the following diagnoses which included dementia (inability to remember, think, or make decisions and interferes with doing everyday activities), hydrocephalus (a buildup of fluid in the brain), and vitamin B12 deficiency (a lack of vitamin B12 in the blood).
During a review of Resident 2's Minimum Data Set (MDS; a standardized assessment and care screening tool) dated 11/6/2023, the MDS indicated Resident 2 was moderately impaired with cognitive skills for daily decision making (ability to understand, remember, reason, and make decisions).
During a review of Resident 2's Departmental Nursing Notes, dated 11/16/2023, the nursing notes indicated Resident 2 attempted to leave the facility premises multiple times through the emergency doors throughout the day.
During a review of Resident 2's Departmental Nursing Notes, dated 11/15/2023, the nursing notes indicated that Resident 2 was being monitored for an altercation with another resident and at times going in other resident's room and taking their belongings.
During a review of Resident 2's Situation-Background-Assessment-Recommendation (SBAR - a technique used to provide a framework for communication between members of the health care team), dated 11/15/2023, the SBAR indicated Resident 2 was involved in a resident-to-resident altercation where Resident 2 attempted to go into Resident 1's room and when Resident 1 attempted to redirect, Resident 2 threw water into Resident 1's face and shoved him to the floor.
During a review of Resident 2's Mental and Behavioral Health Treatment Progress Note, dated 11/15/2023, the progress note indicated that Resident 2 pushed another resident down for no apparent reason and has a diagnosis of conduct aggression (aggression toward others and a callous disregard for their rights and needs) and dementia.
During a review of Resident 2's Multi-Interdisciplinary Team (IDT - a group of healthcare professionals from different disciplines who work together to treat a patient's injury or condition) Conference note, dated 11/16/2023, the Multi-IDT Conference note indicated Resident 2 attempted to go into another resident's (Resident 1) room and when redirected by the resident (Resident 1), Resident 2 threw water into Resident 1's face and shoved the resident to the floor on 11/15/2023. Resident 2 will see a psychologist, continue to monitor, redirect as needed and notify medical doctor (MD) as needed.
During a review of Resident 2's Behavior care plan, dated 11/3/2023, the care plan indicated Resident 2 had concerns of behavioral symptoms as manifested by agitation/delirium (a mental state in which you are confused, disoriented, and not able to think or remember clearly) and dementia. The approach and plan indicated to provide behavioral modifications as needed which included providing redirection when exhibiting inappropriate behavior and monitoring interaction with another resident to prevent offensive behavior.
During a review of Resident 2's care plan titled, Altercation, dated 11/15/2023, the care plan indicated Resident 2 was the aggressor in a physical altercation with another resident (Resident 1).
During a review of Resident 2's care plan titled, Physical Device, dated 11/16/2023, the care plan indicated a Wanderguard (a device placed on a resident that triggers an alarm when the resident approaches a door) was placed to the right ankle to alert staff of the resident trying to leave the facility.
During a review of Resident 2's care plan titled, Wandering, implemented on 11/17/2023 at 5:14 p.m., the care plan indicated Resident 2 had a history of wandering around the facility in other resident's rooms and going outside of the facility. A plan was added for one-to-one monitoring as needed as wandering behaviors escalate.
During an interview on 11/17/2023 at 9:21 a.m., with Resident 1, Resident 1 stated he was hanging his socks out on the patio when Resident 2 came to the doorway of his room and attempted to enter the room from the patio. Resident 1 stated he tried to tell Resident 2 she was entering the wrong room and not to enter his room. Resident 1 stated Resident 2 then splashed water in the resident's face and pushed Resident 1 down.
During an attempted interview with Resident 2, on 11/17/23 at 9:41 a.m., Resident 2 stated she would not be able to speak because she must go pay her bills. When asked how she was planning to get there, Resident 2 stated, I have to catch the bus because I don't have a car.
During an interview on 11/17/2023 at 11:21 a.m., with Resident 3 (Resident 1's roommate), Resident 3 stated he witnessed the incident between Resident 1 and Resident 2 on 11/15/2023. Resident 3 stated that a few days prior, Resident 1 was standing outside on the resident's patio door which led to Resident 3's room. Resident 3 stated Resident 2 came up and pushed Resident 1 to the ground. Resident 3 stated, It shouldn't have happened. I didn't like seeing that.
During an interview on 11/17/2023 at 11:33 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 2 was an extreme wanderer and went into different resident rooms. CNA 1 stated Resident 2 could also be verbally aggressive and went into resident's rooms and took the resident's personal belongings. CNA 1 stated Resident 2 made Resident 4 angry because she was always attempting to go in her room (points in direction of Resident 4 who was sitting in a wheelchair outside of her door). CNA 1 stated that was why she (Residenr 4) sat in her doorway. CNA 1 stated she was unaware of any monitoring interventions in place for Resident 2 but stated she (CNA 1) attempted to check on Resident 2 every 1 to 2 hours to make sure the resident was not in another resident's room.
During an interview on 11/17/2023 at 2:19 p.m., with the Activities Assistant (AA), the AA stated on 11/15/2023, he witnessed Resident 2 splash water in Resident 1's face and push him down. The AA stated Resident 2 was in the dining room watching television and then abruptly got up and went out of the door that led to a small patio. The AA stated when Resident 2 attempted to re-enter from Resident 1's room, Resident 1 told her to go around. The AA stated that this was when Resident 2 splashed water in Resident 1's face and pushed him to the ground. The AA stated Resident 2 had Wanderguards in place for residents that were at risk of elopement or wandering, but the Wanderguards only worked if a resident was attempting to leave out of the front door.
During an interview on 11/17/23 at 3:08 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 2 always wandered but could be redirected when she first arrived. LVN 1 stated the facility did an SBAR to get a Wanderguard for Resident 2 on 11/16/2023 because Resident 2 attempted to open the doors and leave the facility several times. LVN 1 stated Resident 2 also went into other resident's rooms thinking it was her room because she had been moved around from different rooms which caused the resident to be confused about where her room was located. LVN 1 stated Resident 2 had dementia and moving the resident around made it difficult for the resident to remember where her room was located.
During an interview on 11/17/2023 at 3:13 p.m., with LVN 2, LVN 2 stated Resident 2 had dementia and has been in everybody's room. LVN 2 stated Resident 2 needed constant redirection because she wandered into other resident's room and took their personal belongings thinking it belonged to her.
During an observation on 11/17/2023 at 4:00 p.m., Resident 4 was observed sitting in front of the doorway to her room. Resident 4 called out and asked, Can you get someone fired? Resident 4 then pointed inside of her room, where Resident 2 was observed in the room of Resident 4 rummaging through the drawers and personal belongings of the other residents. Resident 4 yelled to have Resident 2 taken out of her room immediately. Resident 4 screamed out repeatedly, Get out! She doesn't belong in here! CNA 2 approached the room and watched as Resident 2 continued to ruggage through the resident's belongings that were on the bed and in the drawers. CNA 2 was asked if it was Resident 2's room, but CNA 2 did not answer and continued to allow Resident 2 to sit on the bed and go through the drawers of Resident 4.
During an interview with CNA 2, on 11/17/2023 at 4:10 p.m., CNA 2 was asked if Resident 2 resided in the same room with Resident 4. CNA 2 stated Resident 2 did not belong in the room with Resident 4, but she was not sure which room Resident 2 resided in when she initially saw her in Resident 4's room.
During an interview with Registered Nurse (RN) Supervisor, (RN 1), on 11/17/2023 at 4:33 p.m., RN 1 stated the CNAs knew Resident 2 must be monitored and redirected because the resident got confused. RN 1 stated CNA 2 should know what to do in the situation with Resident 2 and Resident 2 has been assigned to CNA 2 before. RN 1 stated when a CNA was assigned to Resident 2, that CNA must sit outside in the hallways to monitor the resident. RN 1 stated Resident 2 must be monitored.
During an interview with the Housekeeper on 11/22/2023 at 10:30 a.m., the Housekeeper stated some time before 7 a.m. on 11/18/2023, Resident 2 attempted to go into Resident 4's room through the adjoining restroom. The Housekeeper stated there was no CNA in the room at the time. The Housekeeper stated she was mopping the floor in Resident 4's room while Resident 4 was asleep. The Housekeeper stated she attempted to redirect Resident 2 back into her own room but Resident 2 would not listen to her. The Housekeeper stated Resident 2 told her to get out of the way and threatened to hit her. The Housekeeper stated she moved back to keep from getting hit by Resident 2 but continued to verbalize for Resident 2 to leave Resident 4's room. The Housekeeper stated Resident 2 proceeded to Resident 4's bed and started going through the items on Resident 4's nightstand. The Housekeeper stated this woke Resident 4 up from her sleep. The Housekeeper stated when Resident 4 woke up she asked Resident 2 what she was doing and why she was taking her shoes. The Housekeeper stated Resident 4 tried to take her shoe away from Resident 2 and that was when Resident 4 hit Resident 2 in the head. The Housekeeper stated she began to yell out for help because no one was there to assist with the altercation. The Housekeeper stated eventually a CNA came into Resident 4's room and pulled Resident 2 off of Resident 4 who was still lying in bed.
During an interview with CNA 5 on 11/22/2023 at 11:20 a.m., CNA 5 stated she heard someone yelling out, Help! She is hitting her! . CNA 5 stated she went to the room to assist and found Resident 2 on top of Resident 4 while Resident 4 was lying in bed. CNA 5 stated that Resident 2 and Resident 4 were fighting over a shoe. CNA 5 stated she tried to hold Resident 2 under the arms and pull her off of Resident 4 because Resident 2 was trying to hit Resident 4 again. CNA 5 stated she also had to yell out for assistance because no other staff was around to help. CNA 5 stated if a CNA was assigned to a one-to-one resident, they should not be assigned to other residents.
During an interview with the the Director of Social Services (DSD) on 11/22/2023 at 11:55 a.m., the DSD stated if a CNA was assigned to a one-to-one resident, that CNA must monitor that resident. The DSD also stated that if the CNA that was assigned to the one-to-one resident must step away for any reason, that CNA was to communicate to the charge nurse so that the resident could be monitored by another staff member. The DSD stated something bad could happen if the CNA did not communicate to have someone watch the resident while they did something else. The DSD stated the CNA assigned to Resident 2 did not inform someone to watch the resident while she was away from the resident.
During an interview with the the Director of Nursing (DON) on 11/22/2023 at 12:30 p.m., the DON stated she was informed the CNA assigned to monitor Resident 2 was down the hall helping another resident. The DON stated the CNA should not have been down the hall helping another resident. The DON also stated the CNA assigned to Resident 2 should have stayed on her post and the charge nurse should have made sure the CNA assigned to monitor Resident 2 stayed on her post.
During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopement, dated 2018, the P&P indicated that the IDT would assess residents for risk of wandering and elopement upon admission to identify residents who are at risk and develop a plan of care with interventions to prevent elopement and/or divert wandering behavior. The purpose of these interventions is to enhance the safety of the residents of the facility and to minimize possible injury.
During a review of the facility's P&P titled, Policy on 1:1 Resident Monitoring, dated 2017, the P&P indicated the facility shall assess the resident for a need of one-to-one monitoring for resident's safety for himself and from others. The P&P also indicated that a staff member will be assigned to the resident every shift and that it is the responsibility of the staff assigned to watch the resident and log the resident's actions and condition on the monitoring sheet. It is also the responsibility for the staff assigned to be at least arm reach in distance from the resident being monitored.
Oct 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
Deficiency F0697
(Tag F0697)
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 1) was pain free be...
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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 1) was pain free before providing care and ensure Certified Nurse Assistant (CNA 2) reported Resident 1's complaints of pain to the licensed nurse.
This deficient practice caused Resident 1 to experience pain during routine peri-care (the cleaning of private parts) and when repositioning in bed.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to facility on 7/28/2023. Resident 1's diagnoses included malignant neoplasm of endometrium (a disease in which malignant [cancer] cells form in the tissues of the endometrium [lining of the uterus, a hollow, muscular organ in a woman's pelvis]) and spondylosis of the spine (condition that involves inflammation of the spine, causing pain, stiffness, or tenderness in the back, hip pain, and limited mobility).
During a review of Resident 1's History and Physical (H&P) dated, 7/30/2023, the H&P indicated Resident 1 had the capacity to understand and make decisions. The H&P indicated Resident 1 had a history of bone cancer (unusual cells grow out of control in the bone and they destroy normal bone tissue) and lower back pain.
During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/11/2023, the MDS indicated Resident 1's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 1 required extensive assistance for bed mobility, dressing, and personal hygiene. The MDS indicated Resident 1 was totally dependent on staff for transfer and for toilet use. The MDS indicated Resident 1 had a diagnosis of malignant neoplasm of the spinal cord (an abnormal mass of tissue within or surrounding the spinal cord and/or spinal column) and systemic lupus erythematosus (autoimmune disease in which the immune system attacks its own tissues).
During a review of Resident 1's care plan titled, Resident at risk of pain/discomfort and impaired physical mobility due to degenerative joint disease (DJD, the wearing down of the protective tissue at the ends of bones [cartilage] occurs gradually and worsens over time), neuropathy (damage to the nerves of the spinal cord), spinal stenosis (pressure on the spinal cord and the nerves within the spine), cancer process and decreased mobility, initiated on 7/28/2023, the care plan's goal was to minimize Resident 1's pain and discomfort after inventions daily and Resident 1's pain would be resolved after 1 hour of intervention. The staff's interventions indicated to encourage Resident 1 to verbalize pain, handle Resident 1 gently, carefully, and unhurriedly during transfer, mobility, and repositioning, and to give medication for pain as ordered.
During a review of Resident 1's Medication Administration Record (MAR), dated 10/1/2023 to 10/12/2023, the MAR indicated Resident 1 was prescribed oxycodone hydrochloride ([HCL] medication used to help relieve moderate to severe pain) 10 milligrams (mg, a unit of measurement of mass in the metric system equal to a thousandth of a gram), 1 tablet every 4 hours for severe pain (7 to 10); Tylenol 500 mg tablet (pain reliever), 1 tablet four times a day for pain management; and tramadol HCL 50 mg tablet (used for the short-term relief of moderate to severe pain), 1 tablet every 6 hours for moderate pain (4-6).
During an interview with Licensed Vocational Nurse (LVN) 1 on 10/11/2023 at 1:20 p.m., LVN 1 Resident 1 did not mention to her one of the Certified Nurse Assistants (CNAs) hurt her. LVN 1 stated she did not notice any marks on Resident 1's skin. LVN 1 stated Resident 1 usually complained of pain and she was prescribed a couple of pain medications. LVN 1 stated it was a good idea to premedicate Resident 1 before treatments or providing care.
During an interview with CNA 1 on 10/11/2023 at 1:35 p.m., CNA 1 stated Resident 1 complained of pain almost every day. CNA 1 stated Resident 1 usually complained of pain while providing care to the resident. CNA 1 stated when Resident 1 stated she had pain, CNA 1 gave Resident 1 a break and left the room to notify the charge nurse Resident 1 was in pain. CNA 1 stated she would come back to room to check on Resident 1 to see if the resident was still in pain.
During an interview with CNA 2 on 10/11/2023 at 1:55 p.m., CNA 2 stated on 10/7/2023, he assisted Resident 1 with repositioning in bed and changed the resident's diaper. CNA 2 stated Resident 1 had told him she was in pain when he was moving her. CNA 2 stated he could tell Resident 1 was in pain because of the way the resident was acting. CNA 2 stated he did not stop moving Resident 1 after the resident told CNA 2 she was in pain. CNA 2 stated he wanted to change Resident 1's diaper and reposition the resident fast to prevent further pain. CNA 2 stated he did not inform Resident 1's nurse Resident 1 was complaining of pain because he did not know that he had to. CNA 2 stated on that day (10/11/2023), he went to Resident 1's room and the resident asked CNA 2 to leave the resident's room and CNA 2 did not know why.
During an observation with CNA 2 and Resident 1 on 10/11/2023 at 1:55 p.m., in Resident 1's room, Resident 1 identified CNA 2 as the CNA that roughly handled her during care. Resident 1 stated CNA 2 was the person that caused her pain. CNA 2 stated he did not know Resident 1 accused CNA 1 of hurting the resident.
During an interview with the DON on 10/12/2023 at 3:51 p.m., the DON stated staff failed to listen to Resident 1. The DON stated when Resident 1 told the CNAs she was in pain the CNAs should have stopped providing care and informed the charge nurse Resident 1 was in pain. The DON stated the CNAs should have gone back to Resident 1 to ask if the resident had any pain. If Resident 1 did not have pain, the CNAs could have provided care for Resident 1. The DON stated Resident 1 must be premedicated before providing care if Resident 1 was complaining of pain. The DON stated not listening to a resident when the resident said they were in pain could cause more pain, apprehension from receiving care and could affect the residents' psychosocial wellbeing.
During a review of the facility's Policy and Procedure (P&P) titled, Pain – Clinical Protocol, dated 6/2013, the P&P indicated nursing staff must identify any situation or intervention where an increase in the resident's pain may be anticipated, for example, wound care, ambulation, or repositioning. The P&P indicated the staff will observe the resident (during rest and movement) for evidence of pain; for example grimacing while being repositioned.
Oct 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
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, interviews, and record review, the facility failed to develop a comprehensive person-centered plan of care...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to develop a comprehensive person-centered plan of care for one of five sample residents (Resident 1) to address Resident 1 ' s refusal to participate in Restorative Nursing Assistant ([RNA] provides care for residents to maintain or regain daily level of independence and functional ability) exercises as ordered by the physician.
This deficient practice had the potential to result a delay or lack of provision of necessary care and services and for Resident 1.
Findings:
During a review of Resident 1 ' s Face Sheet, the Face sheet indicated Resident 1 was admitted on [DATE] with diagnoses including muscle spasm (cramps, when muscle involuntarily move and forcibly contracts), polyneuropathy (a condition in which a person's peripheral nerves are damaged), and primary generalize osteoarthritis (characterized by joint pain, stiffness, limited range of motion, and weakness).
During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 8/18/2023, the MDS indicated Resident 1 ' s was capable of understanding and be understood by others. The MDS indicated Resident 1 required supervision with bed mobility (how resident moved to and from lying position and turns side to side) and extensive assistance (resident involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with dressing, toilet use and personal hygiene.
During a review of Resident 1 ' s physician orders dated 10/2023, the physician orders indicated RNA to perform RNA exercises daily (QD), 5 times a week for Passive Range of Motion ([PROM] movement of a joint achieved by outside force such as a therapist) of bilateral (both) lower extremities (BLE) as tolerated and PROM of bilateral wrist and hands QD 5 times a week or as tolerated for Resident 1.
During a review of Resident 1 ' s Stop and Watch Early Warning Tool dated 9/25/2023 at 2:38 p.m., the Tool indicated, Resident 1 was not in bed at agreed time for treatment.
During a review of Resident 1 Stop and Watch Early Warning Tool dated 10/16/2023 at 2:00 p.m., the Tool indicated, Resident 1 was not in bed at agreed time of treatment.
During a review of Resident 1 ' s progress notes dated 10/18/2023 timed 8:30 a.m., the progress notes indicated Resident 1 refused RNA services as ordered.
During an interview on 10/18/2023 at 10:30 a.m., with Resident 1, Resident 1 stated, she did not want to have RNA services before 2:00 pm and stated she wanted to have it whenever she was ready, otherwise she would refuse RNA services.
During an interview on 10/18/2023 at 2:05 p.m., with RNA 2, RNA 2 stated, Resident 1 requested to have her therapy at 2:00 p.m., every day however the resident would sometimes not be in her room at 2:00 p.m. and would miss RNA services. RNA 2 stated, Resident 1 would refuse RNA services despite waiting for the resident.
During a concurrent record review and interview on 10/18/2023 at 2:20 p.m. with Licensed Vocational Nurses (LVN) 1, Resident 1 ' s medical records were reviewed. LVN 1 stated there was no care plan to address Resident 1 ' s refusal of RNA services. LVN 1 stated, it was important to develop a care plan to address the resident ' s refusal of RNA services so nurses would know which interventions to implement for the resident.
During an interview on 10/19/2023 at 9:12 a.m. with the Director of Nursing (DON), DON stated, it was essential to have a care plan for refusal of care or treatment, so the nurses could find solutions for the problem. DON stated assessment of residents were ongoing and care plans were revised as information about the resident and the residents condition changed.
During a review of the facility ' s policies and procedures (P&P) titled, Care Plans- Comprehensive, dated 9/2010 the P&P indicated it was the facility's policy that an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs, were developed for each resident. The P&P also indicated each resident's comprehensive careplan was designed to enhance the optimal functioning of the resident by focusing on a rehabilitative program; and reflect currently recognized standard of practice for problems areas and conditions.
Oct 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
Deficiency F0602
(Tag F0602)
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 three of three sampled resident ' s (Resident 1, Resident 2...
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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 three of three sampled resident ' s (Resident 1, Resident 2, and Resident 3) right to be free from misappropriation of property when Activity Assistant 1 (AA 1) used Resident 1's and Resident 3's electronic benefit transfer card (EBT, an electronic system that allows state welfare departments to issue benefits via a magnetically encoded payment card) to shop and purchase food for Resident 1, Resident 2, Resident 3 and herself.
This deficient practiced caused Resident 1 to be upset because of lost funds from the resident's EBT card account and caused Resident 1 to lose trust in staff who were to be watching out for the resident's best interest.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) and generalized abdominal pain (refers to pain felt in more than half of your abdominal area).
During a review of Resident 1's History and Physical (H&P) dated, 8/28/2023, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/31/2023, the MDS indicated Resident 1's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 1 required supervision for locomotion on and off the floor, for eating and for toilet use. The MDS indicated Resident 1 required limited assistance for dressing and for personal hygiene.
During a review of Resident 1's care plan titled, Risk for abuse/neglect related to (r/t) Resident 1 giving her EBT card to unauthorized staff to make purchases, initiated on 10/3/2023. The care plan's goal indicated Resident 1 was to be able to express comfort and feeling safe in current environment and the resident would not experience further financial loss. The care plan indicated Resident 1 would be educated about having unauthorized staff to make purchases and encourage Resident 1 to verbalize her feelings fear and /or frustrations.
During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] with diagnoses including suicidal ideations (suicidal thoughts or ideas, is a broad term used to describe a range of contemplations, wishes, and preoccupations with death and suicide) and dysphagia (difficulty or discomfort in swallowing ).
During a review of Resident 2's H&P dated, 8/8/2023, the H&P indicated Resident 2 did not have the capacity to understand and make decisions.
During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was intact. The MDS indicated Resident 2 required supervision for activities of daily living (ADLs, self-care activities performed daily such as grooming, personal hygiene, and dressing) and required limited assistance with personal hygiene.
During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] with diagnoses including bipolar disorder (a mental illness that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks) and an immunocompromised disease (virus that attacks the body's immune system )
During a review of Resident 3's H&P dated, 4/18/2023, the H&P indicated Resident 3 had the capacity to understand and make decisions.
During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making was not intact. The MDS indicated Resident 3 required extensive assistance for all ADLs.
During an interview with Resident 1 on 10/11/2023 at 9:11 a.m., in Resident 1's room, Resident 1 stated AA 1 and Resident 2 stole money from her EBT card. Resident 1 stated she was short $300 dollars. Resident 1 stated she asked AA 1 to buy her food with her EBT card and AA 1 also bought food for herself (AA 1) with Resident 1's EBT card. Resident 1 stated AA 1 went shopping for the resident and bought the wrong items and asked AA 1 to exchange the items for what the resident wanted. Resident 1 stated AA 1 never exchanged and returned the items to Resident 1. Resident 1 stated AA 1 asked her to borrow money and AA 1 never paid the resident back. Resident 1 stated AA 1 allowed Resident 2 to buy a lot of items using Resident 1's EBT card. Resident 1 stated she was sad because she had no more money to buy groceries for her family member as the resident was the family members provider.
During an interview with Resident 2 on 10/11/2023 at 10:44 a.m., in Resident 2's room, Resident 2 stated he did not have problems with AA 1 because she was a good person and AA 1 shopped for Resident 2 with no problems. Resident 2 stated Resident 1 lied about AA 1 taking Resident 1's money and lied about Resident 2 taking Resident 1's EBT card. Resident 2 stated Resident 1 gave him (Resident 2) the EBT card because Resident 1 stated she had $500 dollars in the account but lied because Resident 1 had no money in the account.
During an interview with the Activity Director (AD) on 10/11/2023 at 12:04 p.m., in the conference room, the AD stated Resident 1 came to her (AD) and complained AA 1 had stolen funds from Resident 1's EBT card. The AD stated Resident 1 had mentioned Resident 2 was also involved in the missing of funds. The AD stated she tried to talk to Resident 2 but the resident did not want to be interviewed. The AD stated she had previously learned AA 1 was shopping for another resident and had spoken AA 1 about not shopping for residents because that was not part of AA 1's job. The AD stated AA 1 told the AD she used Resident 1's EBT card to go shopping for Resident 1 .
During an interview with Resident 3 on 10/11/2023 at 12:51 p.m., in Resident 3's room, Resident 3 stated she (Resident 3) gave money to AA 1 and asked AA 1 to go to the store to buy the resident some items. Resident 3 stated she asked AA 1 to buy her fast food with Resident 3's EBT card and AA 1 also bought food for herself.
During an interview with the Social Services Director (SSD) on 10/11/2023 at 2:31 p.m., in the conference room, the SSD stated AA 1 should not get money or cards from residents for shopping because that was not part of her job. The SSD stated only herself, the AD, and the business office staff dealt with residents' money.
During an interview with the Director of Nursing (DON) on 10/12/2023 at 10:53 a.m., in the conference room, the DON stated Resident 1 told her she gave the resident's EBT card to AA 1 buy the resident some items. The DON stated Resident 1 told her (DON) AA 1 spent more money than she should have. The DON stated Resident 1 told her AA 1 spent $300 dollars from her EBT card account. The DON stated the only staff that could go shopping for residents was the SSD, the AD, and the business office staff. The DON stated it was important to have Resident 1 feel safe and comfortable in the resident's own home because it would make Resident 1 thrive more.
During an interview with AA 1 on 10/12/2023 at 11:33 a.m., in the conference room, AA 1 stated she used Resident 1's EBT card to go shopping for Resident 1 and Resident 2. AA 1 stated Resident 2 gave her a list of things that he and Resident 1 wanted from the store. AA 1 stated Resident 2 gave her Resident 1's EBT card to go shopping and AA 1 stated the transaction totaled $167 dollars. AA 1 stated Resident 1 bought her lunch a couple of times from two different fast food chains. AA 1 stated Resident 1 gave AA 1 money for gas when AA 1 went shopping for her. AA 1 stated she was supposed to exchange some items for Resident 1 but did not. AA 1 stated those items have been in AA 1's car for over two weeks. AA 1 stated she had previously gone shopping for Resident 3 but got caught and had to stop. AA 1 stated Resident 3 gave AA 1 money and Resident 3's card to go shopping for Resident 3. AA 1 stated Resident 3 gave her money to buy some fast food for Resident 3 and for herself. AA 1 stated it was not within her job description to go shopping for residents with the resident's money. AA 1 stated it was important not to take residents' cards or money because AA 1 could get blamed for missing funds.
During an interview with the DON on 10/12/2023 at 3:51 p.m., in the conference room, the DON stated she was not aware AA 1 used Resident 1's EBT card to go shopping. The DON stated AA 1 should have known that shopping for residents was not part of her job description.
During a review of the facility's policy and procedure (P&P) titled, Gifts, Gratuities, and Payments , dated 2/2008, the P&P indicated the facility prohibited employees from receiving or giving any gift, gratuity, or payment for services rendered; the making of any promise(s) on behalf of the facility; or engaging in any activity, or act which conflicts with the interest of the facility or its residents. The P&P indicated the giving or accepting of anything of value by their employees to or from any of their suppliers, residents' family members, visitors is prohibited. Such conduct may be criminal under certain laws.
Sept 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 interview and record review, the facility failed to ensure staff provided adequate supervision for one of three sampled...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff provided adequate supervision for one of three sampled residents (Resident 1) while escorting the resident to pick up his personal belongings from his apartment.
This deficient practice resulted in Resident 1 eloping (leaving without authorization and supervision) and had the potential to result in an accident and injuries for the resident.
Findings:
During a review of Resident 1 ' s Face Sheet, the Face Sheet indicated Resident 1 was admitted on [DATE] with diagnoses including Parkinson ' s Disease (a disorder of the central nervous system that affects movement), bipolar (a disorder associated with episodes of mood swings), and anxiety disorder (a mental health disorder characterized by feeling of worry and fear).
During a review of Resident 1 Elopement Risk Assessment dated 8/29/2023, the Risk Assessment indicated Resident 1 was not at risk for elopement.
During a review of Resident 1 ' s History and Physical (H&P) dated 8/31/2023, indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 9/1/2023, the MDS indicated Resident 1 had the ability to understand and to be understood by others. The MDS also indicated Resident 1 required limited (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance to extensive (resident involved in activity, staff provide weight bearing support) assistance for Activities of Daily Living (ADL ' s) including mobility, transfer, dressing, and personal hygiene.
During a review of Resident 1 Departmental Notes dated 9/11/2023 at 6:12 p.m., the Notes indicated that Resident 1 made two attempts to leave the facility.
During a review of Resident 1 ' s Department Notes dated 9/13/2023 at 2:54 p.m., the Notes indicated Resident 1 was taken to his apartment by facility staff to obtain his personal belongings then without notice, resident left abruptly and was unable to be located.
During an interview on 9/14/2023 at 11:00 a.m., with facility driver (Driver), Driver stated she was instructed by the Social Services Director (SSD) to take Resident 1 to his apartment to pick up some of his belongings. Driver stated that she was accompanied by a male staff ([Monitor Tech] MT) to supervise Resident 1. Driver stated that she helped Resident 1 put a picture frame into the transportation van and Resident 1 then went back into the apartment to obtain more personal items, however, did not come back outside. Driver stated that they looked for Resident 1 in the apartment and around the neighborhood and was not able to find the resident. Driver also stated she then called the facility and reported to the SSD that Resident 1 was missing.
During an interview on 9/22/2023 at 10:38 a.m., with MT, MT stated he went to accompany Resident 1 and the driver to Resident 1 ' s house to get some of his belongings. MT stated he stayed in the transportation van and did not go into the house with Resident 1. MT stated they looked for Resident 1 and could not locate the resident.
During an interview on 9/22/2023 at 11:25 a.m., with SSD, SSD stated that she sent MT along with Resident and Driver so that MT could keep an eye on Resident 1 to prevent him from eloping.
During an interview on 9/22/2023 at 1:06 p.m., with the Director of Nursing (DON), The DON stated Resident 1 ' s made two prior attempts to elope from the facility. DON also stated Resident 1 should have closely monitored ([1:1 monitoring] nursing or observation care to an individual resident) pending psychiatric evaluation.
During a review of the facility ' s Policy and Procedure (P&P) titled, Safety and Supervision of Residents dated 12/2007, the P&P indicated, resident safety, supervision, and assistance to prevent accidents were facility wide priorities. The P&P indicated resident supervision was a core component of the systems approach to safety and the type and frequency of resident supervision was determined by the individual resident ' s assessed needs and identified hazards in the environment.
Sept 2023
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 interview and record review, the facility failed to notify the physician for one of three sampled residents (Resident 1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician for one of three sampled residents (Resident 1) when Resident 1 had an unwitnessed fall on the floor on [DATE].
This failure had the potential for Resident 1 to have suffered from undetected injuries to the head (such as a brain bleed) and possible undetected fractures (broken bones) to the upper and lower extremities, followed by a decline in health and even death.
Findings:
During a review of Resident 1's Face Sheet (admission Record), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of spinal stenosis (narrowing of the spine), Parkinson's disease (disorder of the nerves in the body affecting movement of the body), and hypertensive disease (condition in which the force of blood against the vessels in the body are too high).
During a review of Resident 1's Minimum Dat Set (MDS, comprehensive assessment), dated [DATE], the MDS indicated Resident 1 had severe cognitive (ability to reason and think) impairment and required extensive assistance with bed mobility, transfers (from bed to chair), toileting and personal hygiene.
During an interview on [DATE], at 11:00 a.m., with the Hallway Monitor (HM 1), HM 1 stated he arrived in the facility at 11 p.m. for his shift on [DATE]. HM 1 stated after 15 minutes, Registry Charge Nurse (RCN 1) started yelling for help because Resident 1 had fallen to the floor. HM 1 stated Resident 1 fell at 11:20 p.m. HM 1 stated RCN 1 got upset and asked why RCN 2 did not do anything about the fall. HM stated RCN 1 alerted RCN 3 and LVN 2 about the fall and had left the facility.
During a review of Resident 1's nursing progress notes (NPN), dated [DATE], the NPN indicated there was no documentation regarding Resident 1's fall.
During a review of Resident's 1 NPN, dated [DATE], authored at 8:53 a.m., the NPN indicated LVN 1 notified the physician at 8:53 a.m. and initiated 72-hour neurological monitoring (assessment tool to identify any changes in a way a person thinks, speaks, and moves).
During an interview, on [DATE], at 9:30 a.m., with LVN 1, LVN 1 stated, when she notified the physician, she had not received a reply. LVN 1 stated the normal practice was no new orders if a physician had not replied.
During a review of Resident 1's NPN, dated [DATE] and [DATE], the NPN indicated there was no documentation regarding a follow up, or clarification of orders with the physician.
During an interview, on [DATE], at 9:38 a.m., with LVN 3, LVN 3 stated the normal process when notifying the physician was to call or text the physician, and if there was no reply throughout the shift, then a follow up call or text would be needed. LVN 3 stated it was not in her practice to assume that a lack of response from the physician automatically meant no new orders . LVN 3 stated it could have also meant the physician did not receive the original message. LVN 3 stated she would have called the physician immediately, started 72-hour neurological monitoring right away, and sent the resident to the nearest hospital for an evaluation if the resident had an unwitnessed fall and had possibly hit his head. LVN 3 stated it was important to notify the doctor and start neurological monitoring right away because the resident may have had a brain bleed, or the resident could have died in his or her sleep.
During an interview, on [DATE], at 11:33 p.m., with LVN 4, LVN 4 stated the normal practice was to call the medical director if there was no response from physician and stated it was not in his practice to assume the physician had no new orders if the physician did not respond to a call or a text.
During an interview, on [DATE], at 12:08 p.m., with Physician 1, Physician 1 stated he covered for Resident 1's primary physician and was not made aware Resident 1 fell. Physician 1 stated he expected the nurses to notify him immediately when a resident fell so he could send the resident to the hospital for scans to evaluate him for any injury or damage. Physician 1 stated he would have ordered for Resident 1 to be sent out to the emergency room for an evaluation. Physician 1 stated if the resident was not sent out, then there was a possibility to have missed treatment for an injury.
During an interview on [DATE], at 2:40 p.m. with the Director of Staff Development (DSD), the DSD stated the nurses should have followed up with the physician if they did not receive a response about Resident 1 falling. The DSD stated RCN 3 would have had the responsibility to notify the Physician about Resident 1's fall. The DSD stated it was not RCN 3's first time working at the facility, and she should have known to assume care of Resident 1 during the 11 p.m. to 7 a.m. shift on [DATE].
During an interview on [DATE], at 3:25p.m., with the Director of Nursing (DON), the DON stated she would have waited an hour before calling the physician again if she had not received a response the first time. The DON stated the practice of failing to seek clarification from the Physician could have caused a delay in treatment and possible harm for Resident 1. The DON stated Physician notification meant relaying information about an incident regarding the resident and receiving a reply or acknowledgement, and if the Physician cannot be contacted, then the Medical Director should have been contacted. The DON stated the expectation was that the nurses that were on shift 11p.m. to 7a.m. shift on [DATE], should have notified the physician and initiated the 72-hour monitoring.
During a review of the facility's Job Description Charge Nurse RN/LVN , dated 11/2015, the Job Description indicated the facility was to report changes of condition to the physician and to follow up on orders and document . The job description also indicated the charge nurse was to give a thorough report to the oncoming charge nurse, which included details regarding changes in conditions, incidents, and new orders.
During a review of the facility's policy and procedure (P&P) titled, Changes in the Resident's Condition or Status , dated 11/2015, the P&P indicated the facility was to notify the resident's attending Physician or on-call Physician when there was an accident or incident that involved the resident.
During a review of the facility's P&P titled, Falls – Clinical Protocol , dated 3/2018, the P&P indicated, The staff, with the physician's guidance, would follow up on any fall . until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. The P&P indicated, Staff will evaluate, and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc.
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
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 interview and record review, the facility failed to develop a comprehensive care plan that addressed an actual fall for...
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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 care plan that addressed an actual fall for two of three sampled residents (Resident 1 and Resident 2).
This failure had the potential to result in Resident 1 and Resident 2 sustaining another fall.
Findings:
a. During a review of Resident 1's Face Sheet (admission Record), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including but not limited to Parkinson's disease (brain disorder that causes unintended and uncontrollable movements), dementia (condition affecting brain function such as memory and judgement), and atrial fibrillation (fast and irregular heartbeat).
During a review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated 8/31/2023, the MDS indicated Resident 1's cognition (process of thinking) was severely impaired. Resident 1 required one person to assist when transferred from bed, chair, wheelchair, or standing position.
During a review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR, way of notifying healthcare team of an incident), dated 9/3/2023, the SBAR indicated on 9/2/2023, Resident 1 fell off the bed.
b. During a review of Resident 2's Face Sheet (admission Record), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including but not limited to type 2 diabetes (high blood sugar), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and chronic kidney disease (a condition where the kidneys are damaged and cannot filter blood as well as they should).
During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 1's cognition (process of thinking) was severely impaired. Resident 1 required one person to assist when transferred from bed, chair, wheelchair, or standing position.
During a review of Resident 2's Nurses Notes, dated 8/2/2023, the Nurses Notes indicated Resident 2 fell on 8/2/2023 when she reached for the bedside table. Resident 2 had a laceration over her right eye.
During an interview on 9/6/2023 at 9:30 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, on 9/3/2023, Resident 1 told her Resident 1 had fallen out of bed the night before. LVN 1 stated, she documented Resident 1's statement on the SBAR and notified Resident 1's physician.
During an interview on 9/6/2023, at 11:00 a.m., with the Hallway Monitor (HM) 1, the HM 1 stated he arrived in the facility at 11 p.m. for his shift on 9/2/2023. HM 1 stated after 15 minutes, Registry Charge Nurse (RCN 1) started yelling for help because Resident 1 had fallen to the floor. HM 1 stated Resident 1 fell at 11:20p.m.
During a concurrent interview and record review on 9/6/2023 at 1:05 p.m., with LVN 1, Resident 1's Care Plans were reviewed. LVN 1 stated, Resident 1 did not have a care plan that addressed his fall on 9/2/2023. LVN 1 stated, a Fall Care Plan could have been created by any nurse that oversaw Resident 1's care.
During an interview on 9/6/2023 at 3:25 p.m., with the Director of Nursing (DON), the DON stated, when a resident sustained a fall, a care plan was supposed to be created. The DON stated, a care plan for falls contained interventions the staff could implement to help prevent another fall or decrease the chance of injury if another fall were to occur.
During a concurrent interview and record review on 9/6/2023 at 4:45 p.m. with the DON, Resident 2's Care Plans were reviewed. The DON stated, Resident 2 did not have a care plan that addressed her fall on 8/2/2023. The DON stated, any nurse could have created a fall care plan for Resident 2.
During a review of the facility's policy and procedure (P&P) titled, Care Plans- Comprehensive , dated 9/2010, the P&P indicated Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change . The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans when the resident has been readmitted to the facility from a hospital stay.
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 timely initiate and complete a 72-hour neurological check (assessme...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely initiate and complete a 72-hour neurological check (assessment tool to identify any changes in a way a person thinks, speaks, and moves) for one of three sample residents (Resident 1) when Resident 1 had an unwitnessed fall.
This failure had the potential to result in undetected changes in Resident 1's neurological status.
Findings:
During a review of Resident 1's Face Sheet (admission Record), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including but not limited to Parkinson's disease (brain disorder that causes unintended and uncontrollable movements), dementia (condition affecting brain function such as memory and judgement), and atrial fibrillation (fast and irregular heartbeat).
During a review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated 8/31/2023, the MDS indicated Resident 1's cognition (process of thinking) was severely impaired. Resident 1 required one person to assist when transferred from bed, chair, wheelchair, or standing position.
During a review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR, way of notifying healthcare team of an incident), dated 9/3/2023, the SBAR indicated on 9/2/2023, Resident 1 fell off the bed.
During an interview on 9/6/2023 at 7:30 a.m., with Registry Charge Nurse (RCN) 1, RCN 1 stated on 9/2/2023, she found Resident 1 on the ground. RCN 1 stated she took Resident 1's vital signs (measurement of a person's pulse rate, temperature, respiration rate, and blood pressure to indicate a person's essential body functions) and handed them to RCN 3. RCN 1 stated, she was unsure what happened to Resident 1 after she left at the beginning of her shift.
During an interview on 9/6/2023 at 9:30 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, on 9/3/2023, Resident 1 told her that he had fallen out of bed the night before. LVN 1 stated, she documented Resident 1's statement on the SBAR and notified Resident 1's physician. LVN 1 stated, Resident 1's fall was not endorsed to her by any nurse from the previous shift. LVN 1 stated, when she was made aware of Resident 1's fall, she initiated the 72-hour neurological checks. LVN 1 stated the 72-hour neurological checks were to be initiated immediately after knowledge of a fall.
During a concurrent interview and record review on 9/6/2023 at 9:38 a.m., with LVN 3, Resident 1's 72 Hours Neuro- Checklist was reviewed. LVN 3 stated, Resident 1 had 72-hour neurological checks for an unwitnessed fall, and it was supposed to be completed for the full 72 hours. LVN 3 stated, the 72 Hours Neuro- Checklist was not completed. LVN 3 stated the first documentation was on 9/3/2023 at 8 a.m. and the last documentation was 9/3/2023 at 9:30 p.m. LVN 3 stated, Resident 1 was supposed to have neurological checks until 9/5/2023 at 1 a.m. LVN 3 stated, the nurses performed the neurological checks to assess the resident's baseline (how a person behaves normally) and to be aware of any changes that would necessitate a call to the physician. LVN 3 stated, Resident 1's neurological checks were not completed, and if there were changes in his baseline, those changes could have been missed.
During an interview on 9/6/2023, at 11:00 a.m., with the Hallway Monitor (HM) 1, the HM 1 stated he arrived in the facility at 11 p.m. for his shift on 9/2/2023. HM 1 stated after 15 minutes, RCN 1 started yelling for help because Resident 1 had fallen to the floor. HM 1 stated Resident 1 fell at 11:20 p.m.
During an interview on 9/6/2023 at 1:56 p.m., with RCN 3, RCN 3 stated RCN 1 told her Resident 1 fell and he was okay . RCN 3 stated, after RCN 1 left, she took over Resident 1's care but did not go into the room to see him.
During an interview on 9/6/2023 at 3:25 p.m., with the Director of Nursing (DON), the DON stated, when a resident fell, the 72-hour neurological checks were initiated immediately after the fall was acknowledged and if there were any changes to the resident's baseline, the nurses would notify the physician. The DON stated, if the neurological checks were not completed or initiated immediately, there could be undetected neurological changes that could lead to a decline in the resident's status.
During a review of the facility's policy and procedure (P&P) titled, Neurological Assessment , dated 9/2010, the P&P indicated Neurological assessments are indicated following an unwitnessed fall.
During a review of the facility's P&P titled, Falls- Clinical Protocol , dated 3/2018, the P&P indicated, The staff will evaluate, and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to maintain accountability for all narcotics (class of medications used to treat pain often having a high potential for abuse) inside the Midd...
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Based on interview and record review, the facility failed to maintain accountability for all narcotics (class of medications used to treat pain often having a high potential for abuse) inside the Middle Cart (medication cart used by the charge nurses to dispense medication for the residents) when Registry Charge Nurse (RCN) 2 did not count the narcotics with a second charge nurse.
This failure had the potential affect all 93 residents within the facility by potentially exposing the residents to unprescribed narcotics, and staff that may be providing care under the influence of narcotics that may not have been accounted for.
Findings:
During an interview, on 9/6/2023 at, 10:57 a.m., with Registry Charge Nurse (RCN) 2, RCN 2 stated she has worked at this facility for about a year as a registry nurse. RCN 2 stated she worked a double shift (7 a.m. to 11 p.m.) on 9/2/2023. RCN 2 stated she had left her shift at 10:50 p.m. because there were two nurses present for the 11 p.m. to 7 a.m. shift and RCN 1 had arrived late. RCN 2 stated she told Licensed Vocational Nurse (LVN) 1 there were no issues during her shift and left the keys at the nursing station.
During an interview on 9/6/2023, at 2:26 p.m., with RCN 2, RCN 2 stated she should have endorsed care the proper way and counted the narcotics with an available nurse, and verbally endorsed care to the next scheduled charge nurse. RCN 2 stated the purpose of counting the narcotics was to prevent missing narcotics and drug diversion.
During an interview, on 9/6/2023, at 2:40 p.m. with the Director of Staffing Development (DSD), the DSD, stated, The normal process for shift change endorsement is to count the narcotics, and round with the next nurse and endorse any changes of the residents. When there is no other nurse to count with, the nurses can count with any other charge nurse that is present or they can count with me. If the nurses do not count with another nurse, that increases the risk of drug diversion.
During a concurrent interview and record review, on 9/6/2023, at 3:05 p.m., with the DSD, the Narcotic Medication Surveillance form, dated 9/2023, was reviewed. The Narcotic Medication Surveillance form indicated there was no signature present in the column allotted for the 11 p.m. on-coming nurse on 9/2/2023. The form indicated there was one signature present for the out going nurse on 9/2/2023 at 11 p.m. The DSD stated this meant that RCN 2 had not counted with a second nurse before she left her shift. The DSD stated RCN 2 had not followed policy and procedure and should have counted the narcotics because this could have increased the risk of drug diversion and have possibly caused resident harm.
During an interview, on 9/6/2023, at 3:25 p.m. with the Director of Nursing (DON), the DON stated, The nurses were supposed to count the narcotics with another nurse. If the narcotics are not counted, then there could have been drug diversion and that can negatively affect the all the other staff and all the residents.
During a review of the facility's policy and procedure (P&P) titled, Controlled Substances , dated 12/2012, the P&P indicated, Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count [of narcotics] together.
Aug 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
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 revise the care plan titled, Altercation, for one of six sampled re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise the care plan titled, Altercation, for one of six sampled residents (Resident 2) when Resident 1 notified staff that Resident 2 hit him on the left chest at the nurses' station.
This failure had the potential to result in Resident 1 and Resident 2 having another physical altercation that could result in serious bodily injury.
Findings:
During a review of Resident 1's Face Sheet, the Face Sheet indicated Resident 1 was originally admitted to the facility 5/24/2016 and last readmitted [DATE] with diagnoses that included monoplegia (inability to move one limb or region of the body) and peripheral neuropathy (weakness, numbness, and pain from nerve damage).
During a review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment), dated 6/22/2023, the MDS indicated Resident 1 had no cognitive (ability to think and reason) impairments, and required extensive assistance when walking, limited assistance when using the toilet and performing personal hygiene. The MDS also indicated Resident 1 had an impairment of his lower extremities and used a wheelchair for mobility.
During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoss that included but not limited to schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly).
During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severe cognitive impairment and required supervision with bed mobility, transfers, toilet use and performing personal hygiene.
During a review of Resident 2's nursing progress note, dated 6/4/2023, the progress note indicated on 6/4/2023, there was an observation of Resident 2 grabbing Resident 1 and appearing to attempt to pull Resident 1 out of his wheelchair in station A hallway.
During a review of Resident 2's care plan (CP), dated 6/4/2023, the CP indicated Resident 2 grabbed a hold of his roommate in an aggressive manner while he was sitting in the hallway in his wheelchair . The CP indicated the interventions were to separate the residents as soon as possible, change the resident's room, redirect resident to another area away for the group of residents and visual observation .
During an interview with Resident 1, on 8/14/2023, at 10:12a.m., Resident 1 stated that Resident 2 hit him on his left chest at the nurse's station that night and felt unsure if Resident 2 would hit him again when Resident 2 passed him in the hallways.
During a concurrent interview and record review on 8/15/2023, at 3:15p.m., with the Director of Nursing (DON), the Resident 2's CP, dated 8/7/2023, was reviewed. The CP indicated Resident 2 allegedly hit another resident (Resident 1) with an open hand on his left shoulder . The CP indicated the interventions were to separate the residents as soon as possible, change the resident's room, redirect resident to another area away for the group of resident and transfer to the hospital as ordered. The DON stated the implementation did not effectively prevent Resident 1 and Resident 2 from having another altercation.
During a concurrent interview and record review on 8/15/2023, at 3:45p.m., with the DON, Resident 2's altercation care plans, dated 6/4/2023 and 8/7/2023, were reviewed. The DON stated the two care plans were similar and if it were revised it may have prevented further altercations.
During a review of the facility's policy and procedure (P&P), titled Care Planning , dated 9/2013, indicated the care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident.
During a review of the facility's P&P titled, Resident to Resident Altercations , dated 12/2007, indicated the facility is to make any necessary changes in the care plan approaches to any or all the involved individuals.
During a review of the facility's P&P titled, Safety and Supervision of Residents , dated 12/2007, indicated the facility is to implement interventions to reduce accident risks and hazards by modifying or replacing interventions as needed; and evaluating the effectiveness of new or revised interventions.
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 adequate supervision for two of six sampled r...
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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 adequate supervision for two of six sampled residents (Resident 1 and Resident 2), who had a history of previous physical altercations.
This failure resulted in Resident 1 having to notify staff that Resident 2 hit Resident 1's left chest at the nurses' station, and Resident 1 verbalizing feeling unsure of his safety when passing Resident 2 in the hallways.
Findings:
During a review of Resident 1's Face Sheet, the Face Sheet indicated Resident 1 was originally admitted to the facility 5/24/2016 and last readmitted [DATE] with diagnoses that included monoplegia (inability to move one limb or region of the body) and peripheral neuropathy (weakness, numbness, and pain from nerve damage).
During a review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment), dated 6/22/2023, the MDS indicated Resident 1 had no cognitive (ability to think and reason) impairments, and required extensive assistance when walking, limited assistance when using the toilet and performing personal hygiene. The MDS also indicated Resident 1 had an impairment of his lower extremities and used a wheelchair for mobility.
During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis that included but not limited to schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly).
During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severe cognitive impairment and required supervision with bed mobility, transfers, toilet use and performing personal hygiene.
During an interview on, 8/14/2023, at 10:12 a.m., with Resident 1, Resident 1 stated Resident 2 hit him on his left chest at the nurse's station on the night of 8/6/2023. Resident 1 stated he felt unsure if Resident 2 would hit him again when Resident 2 passed him in the hallways.
During a concurrent observation and interview, on 8/14/2023 at 11:05 a.m., with Licensed Vocational Nurse 4 (LVN 4), Resident 2 was observed walking down the same hallway of Resident 1's room without close supervision. LVN 4 confirmed Resident 2 was in the same hallway as Resident 1's room. LVN 4 stated that she did not know about the residents' previous physical altercations and she if had known, she would keep Resident 2 out of that particular hallway to prevent further altercations.
During an interview, on 8/14/2023, at 11:28 a.m., with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated Resident 2 was usually very sweet 90% of the time, but the other 10% he's not towards a particular resident . he's not good with (Resident 1). CNA 3 stated Resident 1 told her that Resident 2 always messes with him and they have had prior altercations in the hallways. CNA 3 stated Resident 2 either grabbed on Resident 1 or tried to hit him. CNA 3 stated their altercations usually happened in the hallway. CNA 3 stated Resident 2 freely walked around the facility, and it was in her practice to try to walk alongside Resident 2 when he was near Resident 1 and did not know if the other CNAs do the same. CNA 3 stated it was more of a responsibility of the hallway monitors.
During an observation, on 8/14/2023, at 11:45a.m., the hallway monitor (HM 1) was observed sitting at the front desk near the entrance of the facility.
During an interview, on 8/14/2023, at 11:50a.m., with HM 1, HM 1 stated hallway monitors walk around the hallways, making sure residents were not entering each other's rooms and alert charge nurses if there were any issues. HM 1 stated that he was not aware of Resident 1 and Resident 2 having any previous physical altercations and stated it was something he should know so that future altercations could be prevented.
During an interview, on 8/14/2023, at 12:50p.m., with the Director of Nursing (DON), the DON stated the staff did close visual observations, not one to one monitoring . The DON stated all hallway monitors, LVNs and registry LVNs should know which residents to look out for to prevent another event like this from happening. The DON stated the LVNs chart their visual observations and stated there was no documented time log for visual checks and observations.
During a concurrent interview and record review, on 8/15/2023, at 3:54 p.m., with the DON, Resident 2's nursing progress notes for the months of 7/2023 and 8/2023 were reviewed. The DON confirmed that there were no documentation of close visual observation or behavior monitoring throughout all shifts on 8/7/2023 and 8/8/2023 (dates after the alleged altercation). The DON stated that it was important to monitor Resident 2 so the facility can redirect as needed and there should have been documentation so the next shift can read and be aware of Resident 2's behaviors.
During an interview, on 8/15/2023, at 3:15 p.m., with the DON, the DON stated Resident 2's care plan and listed interventions were not effective, and the hallway monitors should have had a focus list of residents so that each hallway monitor knew which residents have a history of aggression and the monitors knew exactly what to monitor to prevent future resident to resident physical altercations.
During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents , dated 12/2007, the P&P indicated the facility is to implement interventions to reduce accident risks and hazards by communicating specific interventions to all relevant staff and monitoring the effectiveness of interventions by ensuring that interventions are implemented correctly and consistently; evaluating the effectiveness of interventions; modifying or replacing interventions as needed; and evaluating the effectiveness of new or revised interventions. The P&P also indicated the type and frequency of resident supervision is determined by the individual resident's assessed needs .
During a review of the facility's P&P titled, Resident to Resident Altercations , dated 12/2007, the P&P indicated the facility is to document in the resident's clinical record all interventions and their effectiveness. The P&P also indicated the facility will institute measures to address the needs of residents/patients and minimize the possibility of abuse .
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
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 procedures (P&P) titled Abuse Reporting 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 procedures (P&P) titled Abuse Reporting and Investigation, by failing to report an alleged staff to resident abuse to the California Department of Public Health (CDPH) within 2 hours for one of four sampled residents (Resident 1).
This deficient practice delayed the investigation by the State agency (CDPH) and placed Resident 1 and other residents at risk for continuous staff abuse.
Findings:
During a review of Resident 1 ' s face sheet (admission record), dated 7/27/2023, the face sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia (a disorder that affects a person ' s ability to think, feel, and behave clearly), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and rheumatoid arthritis (a chronic progressive disease causing swelling in the joints and resulting in painful deformities and immobility).
During a review of Resident 1 ' s History and Physical (H&P), dated 9/9/2022, the H&P indicated Resident 1 had capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 5/4/2023, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 required supervision for all activities of daily living.
During a review of Resident 1 ' s Situation Background Assessment and Recommendation (SBAR) report, dated 7/25/2023, the SBAR indicated on 7/25/2023 at 9:29 p.m., Resident 1 was observed to have discoloration and swelling under his right eye extending to his nose.
During a review of the fax conformation report, dated 7/26/2023, the report indicated the report was sent to the CDPH on 7/26/2023 at 4:33 p.m.
During a concurrent observation and interview with Resident 1 on 7/27/2023 at 2:42 p.m., Resident 1 was observed to have a discoloration under his right eye. Resident 1 stated someone hit him at night.
During a phone interview with Licensed Vocational Nurse (LVN) 3, on 7/31/2023 at 2:07 p.m., LVN 3 stated on 7/24/2023 Resident 1 informed LVN 3 that he was bleeding on the nose. LVN 3 stated Resident 1 denied falling and stated he did not know what caused the bleeding. LVN 3 stated he did not suspect abuse because Resident 1 did not have any discoloration under his eye on 7/24/2023. LVN 3 stated the discoloration became visible on 7/25/2023 and that was when Resident 3 stated he was punched the night before.
During an interview with the Director of Nursing (DON) on 7/31/2023 at 2:15 p.m., the DON stated on 7/25/2023 during the 3 p.m. to 11 p.m., shift, the charge nurse observed Resident 1 had discoloration underneath his right eye. The DON stated Resident 1 stated an unidentified male staff hit him during the 11 p.m. to 7 a.m., shift on 7/24/2023. The DON stated the abuse investigation was initiated on 7/25/2023 but the report was not sent to the CDPH until 7/26/2023. The DON stated the report of the incident should have been sent to appropriate agencies on 7/25/2023, per the facility ' s P&P. The DON stated if the report was sent out late, the residents could be exposed to further abuse.
During an interview with the Registered Nurse Supervisor (RN) 1, on 7/31/2023 at 3:31 p.m., RN 1 stated on 7/25/2023 at approximately 9 p.m., the charge nurse informed RN 1 about the discoloration under Resident 1 ' s eye. RN 1 stated, the charge nurse told RN 1 that Resident 1 alleged to have been hit by a staff member. RN 1 stated per the facility ' s P&P the alleged abuse incident should have reported to the appropriate agencies within two hours. RN 1 stated she filled out the report on 7/25/2023 but did not send it because wanted to clarify some important information with the DON the next day prior to reporting the abuse allegation to the CDPH.
During a review of the facility ' s P&P titled Abuse Reporting and Investigation, dated 11/2018, the P&P indicated the facility would report all allegations of abuse to the appropriate agencies within two (2) hours.
Jul 2023
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a functioning call light for one of four sampled residents (R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a functioning call light for one of four sampled residents (Resident 3).
This deficient practice had the potential to result in a delay in meeting Resident 3's needs for hydration, toileting, activities of daily living and could potentially led to a fall or an accident.
Findings:
During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was originally admitted to the facility on [DATE] with a diagnoses of suicidal ideations (actions and thoughts a person has about taking his or her own life) and absence epileptic syndrome (seizure that causes a person to blank out or stare into space for a few seconds).
During a review of Resident 3's History and Physical (H&P), dated 6/23/2023, the H&P indicated that Resident 3 had fluctuating capacity to understand and make decisions. The H&P indicated Resident 3 had dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations).
During a review of Resident 3's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 7/3/2023, the MDS indicated Resident 3's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was not intact. The MDS indicated Resident 3 needed extensive assistance for all activities of daily living. The MDS indicated that Resident 3's balance during transitions and walking were not steady, resident only able to stabilize with staff assistance. The MDS indicated that Resident 3 had a history of depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act) and chronic kidney disease (gradual loss of kidney function).
During an observation on 7/14/2023 at 2:00 p.m. in Resident 3's room, Resident 3's call light was missing button to push, had an empty hole where the red button should have been at and was not working.
During an interview on 7/14/2023 at 2:04 p.m. with Resident 3, Resident 3 stated she did not know that the call light was missing a button and that maybe that was why no one showed up when she pushed it.
During an interview on 7/14/2023 at 2:07 p.m. with Resident 3's daughter, Resident 3's daughter stated that she could not believe that her mother did not have a call light to use for an emergency. Resident 3's daughter stated that she was afraid for her mom, that if she needed help, she would not be able to call for help.
During an interview on 7/14/2023 at 2:15 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated that she had placed Resident 3's call light within reach. CNA 1 looked at the call light and stated the call light was missing the red button and she did not check it prior to giving it to Resident 3. CNA 1 stated it was important for a resident to have a functioning call light for resident's safety. CNA 1 stated that it was the responsibility of all staff that enter a resident's room to check if a call light was within a residents reach and if it was functioning.
During an observation on 7/17/2023 at 9:20 a.m., inside Resident 3's room, the call light was observed still missing a button, not functioning and had not been repaired.
During an interview on 7/17/2023 at 12:13 p.m. with the Director of Staff Development (DSD), DSD stated that she had instructed her staff to place call lights within residents reach and to make sure that call lights were working. The DSD stated that it was important to have a call light that works because it helped resident feel safe that they could call for help.
During a concurrent interview and record review on 7/17/2023 at 12:48 p.m., with Maintenance Supervisor (MS), the facility's maintenance repair request form dated 7/14/2023 was reviewed. The maintenance record indicated that call light was fixed on 7/14/2023 by the MS. The MS stated that he had replaced the call light on 7/14/2023. The MS stated that he had replaced the call light with a new call light that worked. The MS looked at the call light and stated Resident 3's call light was missing the a button used to call for assistance. The MS stated that he was confused and did not replace Resident 3's call light, even though he had documented he had fixed Resident 3's call light.
During an interview on 7/17/2023 at 1:45 p.m. with the Director of Nursing (DON), the DON stated that all staff were responsible to check residents call lights. The DON stated that staff must check if call lights were assessable to residents and if they were functioning. The DON stated that it was important to have a functioning call light in order to help residents if they need anything and for residents to be able to make their needs known. The DON stated that she was not aware that Resident 3's call light was not in working condition.
During a review of facility's policy and procedure (P&P) titled, Answering Call Lights , dated October 2010, the P&P indicated, all defective call lights must be reported to charge nurse promptly.
During a review of facility's P&P titled, Maintenance, General Policies and Procedural Guidelines , dated January 20, 2008, the P&P indicated that all necessary repairs must be carried out as soon as possible. P&P indicated that equipment must meet state and federal safety requirements.
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
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide respect and dignity to two of four sampled residents (Residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide respect and dignity to two of four sampled residents (Resident 1 and Resident 2) by:
1. Staff not knocking the door before entering a room of blind residents (Resident 1 and 2).
2. Staff not introducing themselves to Resident 1 and 2.
These deficient practices caused residents (Resident 1 and Resident 2) to feel disrespected, insecure about their care and caused a negative impact on their psychosocial well-being.
Findings:
a. During a review of Resident 1 ' s admission Record (Face Sheet), the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with a diagnoses of chronic obstructive pulmonary disease (group of chronic lung diseases that make it harder to breathe air out of the lungs) and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations).
During a review of Resident 1 ' s History and Physical (H&P), dated 1/5/2023, the H&P indicated that Resident 1 had the capacity to understand and make decisions. The H&P indicated Resident 1 was legally blind (a term that the government used to describe a person with vision below certain measurement).
During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/17/2023, indicated Resident 1 ' s cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 1 needed extensive assistance for activities of daily living. The MDS indicated Resident 1 ' s balance during transitions and walking were not steady, and only able to stabilize with staff assistance. The MDS indicated that Resident 1 had a history of anxiety and blindness on right and left eyes.
During a review of Resident 1 ' s care plan for Risk of Emotional Psychological Disturbance, date initiated 1/25/2023, the care plan indicated the approach/plan was to establish a trusting relationship as possible with resident.
During a review of Resident 1 ' s care plan for Vision, date initiated 1/4/2023, the care plan indicated Resident 1 ' s vision was severely impaired. The care plan for behavior indicated that staff must approach Resident 1 calmly and speak calmy to Resident 1.
b. During a review of Resident 2 ' s Face Sheet, the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease ([COPD] group of chronic lung diseases that make it harder to breathe air out of the lungs) and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations).
During a review of Resident 2 ' s H&P, dated 3/7/2023, the H&P indicated Resident 2 did not have the capacity to understand and make decisions.
During a review Resident 2 ' s MDS, dated [DATE], indicated Resident 2 ' s cognitive skills for daily decision making was not intact. The MDS indicated Resident 2 has an unclear speech but can make her needs known. The MDS indicated Resident 2 needed extensive assistance for activities of daily living. The MDS indicated Resident 2 needed extensive assistance with activities of daily living and was total dependent on staff for transfers. The MDS indicated Resident 2 had blindness to both eyes.
During an interview on 7/14/2023 at 1:25 p.m. with Resident 1, Resident 1 stated that every day staff opened her room door and did not knock on the door before they entered her room, and that staff did not introduce themselves when they entered her room. Resident 1 stated that when she heard the door opened it frightened her, especially because she did not know who entered the room. Resident 1 stated that this practice has made her feel insecure. Resident 1 stated staff ' s behavior was disrespectful, that this was a sign that they do not care about her feelings and that staff were inconsiderate to her visual impairment.
During an observation on 7/14/2023 at 1:30 p.m., in Resident 1 and Resident 2 ' s room, Licensed Vocational Nurse (LVN) 1 opened room door without knocking. LVN 1 entered room without greeting residents and introducing herself. LVN 1 spoke to Resident 1 without identifying herself.
During an observation on 7/14/2023 at 1:39 p.m., in Resident 1 and Resident 2 ' s room, Resident 2 asked out loud who was there. Resident 2 questioned out loud if the person that entered the room was LVN 1. LVN 1 did not answer to Resident 2. Resident 2 continued to ask if LVN 1 was in the room.
During an interview on 7/14/2023 at 1:41 p.m. with Resident 2, Resident 2 stated she wanted to know who was in the room. Resident 2 stated she wanted to talk to LVN 1.
During an interview on 7/14/2023 at 3:29 p.m. with LVN 1, LVN 1 stated that it was important to knock before she entered residents ' rooms because this was residents ' home, and it was a way to respect residents ' privacy. LVN 1 stated that she did not knock or introduce herself when she entered resident room because she was worried the door was closed, and she just opened it to see what was going on. LVN 1 stated that she was on a rush to enter room and forgot to knock on door and to introduce herself before she gave medication to the Resident 1.
During an interview on 7/17/2023 at 1:35 p.m. with the Director of Nursing (DON), the DON stated she expected her staff to knock on room door before they entered residents ' room for residents ' dignity. DON stated that staff should introduce themselves to residents because it was important for residents to know who they had an encounter with. The DON stated that an introduction sets the tone for the interaction, and it helps residents feel safe.
A review of the facility ' s policy and procedure (P&P) titled, Quality of Life - Dignity, dated August 2009, the P&P indicated, all residents shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. P&P indicated that staff must knock and request permission before entering residents ' rooms.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
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 provide a licensed vocational nurse (LVN) to provide c...
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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 a licensed vocational nurse (LVN) to provide care for 37 of 90 residents.
This deficient practice resulted in Resident 5, Resident 6, and Resident 7 not receiving their medications as scheduled and had the potential for 37 of 37 residents in Nursing Station B not receiving nursing services and care.
Findings:
a. During a review of Resident 4's admission Record (Face Sheet), the Face Sheet indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses of hypertension (high blood pressure) and schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions).
During a review of Resident's 4's History and Physical (H&P), dated 1/4/2022, the H&P indicated that Resident 4 had fluctuating capacity to understand and make decisions. The H&P indicated Resident 4 had a history of alcohol abuse (a pattern of drinking too much alcohol too often, it interferes with daily life).
During a review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/3/2023, the MDS indicated Resident 4's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was not intact. The MDS indicated Resident 4 needed supervision for all activities of daily living. The MDS indicated Resident 4's balance during transitions and walking was not steady but was able to stabilize without staff assistance. The MDS indicated Resident 4 had a history of Dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and generalized idiopathic epilepsy (convulsions, stiffening, tremors, staring spells, unresponsiveness, biting the tip of the tongue, side to side head movements, crying and/or screaming, neck and spine bending backwards, eyes closed/flickering, and thrusting of the hips).
During an observation on 7/17/2023 at 10:12 a.m., in the hallway, Resident 4 was observed asking staff where her nurse was. Resident 4 asked Health Facility Evaluator Nurse (HFEN) if she knew where her nurse was. Resident 4 stated that she needed to talk to her nurse regarding not receiving her medications. Certified Nurse Attendant (CNA) 2 was observed comforting Resident 4 and wheeled her to her room.
b. During a review of Resident 5's Face Sheet, the Face Sheet indicated Resident 5 was originally admitted to the facility on [DATE] with a diagnosis of human immunodeficiency virus (HIV - a virus that attacks the body's immune system. There's no cure for HIV) and chronic viral hepatitis C (An infection caused by a virus that attacks the liver and leads to inflammation, this virus is spread by contact with contaminated blood).
During a review of Resident 5's History and Physical (H&P), dated 4/18/2023, the H&P indicated Resident 5 had the capacity to understand and make decisions. The H&P indicated Resident 5 had a history of chronic obstructive pulmonary disease (group of chronic lung diseases that block airflow and make it harder to breathe air out of the lungs).
During a review of Resident 5's MDS, dated [DATE], indicated Resident 5's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 5 needed extensive assistance for all activities of daily living. The MDS indicated Resident 5's balance during transitions and walking were not steady, and only able to stabilize with staff assistance. The MDS indicated Resident 5 had a history of bipolar disorder (a mental illness that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks) and asthma (a condition in which a person's airways become inflamed, narrow, and swell, and produce extra mucus, which makes it difficult to breathe).
During an observation on 7/17/2023 at 12:24 p.m., in the hallway, observed Resident 5 ask DSD for the nurse. Resident 5 stated that she did not remember seeing a nurse come to visit her today and it was already late in the day.
c. During a review of Resident 6's Face Sheet, the Face Sheet indicated Resident 6 was originally admitted to the facility on [DATE] with a diagnoses of malignant neoplasm of prostate (cancerous tumor in the prostate that is likely to spread beyond its point of origin) and atherosclerotic heart disease (damage or disease in the heart's major blood vessels, caused by the buildup of plaque that causes coronary arteries to narrow, limiting blood flow to the heart.)
During a review of Resident 6's H&P dated 3/11/2023, the H&P indicated Resident 6 had a history of pulmonary hypertension (type of high blood pressure that affects arteries in the lungs and in the heart, it affects arteries in the lungs and the right side of the heart. Symptoms are shortness of breath, dizziness, and chest pressure).
During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognitive skills for daily decision making was intact, Resident 6 did not demonstrate disorganized thinking, altered level of consciousness, and inattention. The MDS indicated Resident 6 needed limited assistance for bed mobility, locomotion on and off unit and needed extensive assistance for transfers, dressing, toilet use and personal hygiene. The MDS indicated Resident 6 had a diagnosis of polyneuropathy (when multiple peripheral nerves become damaged), hypertension (high blood pressure) and right bundle-branch block (a delay or blockage along the pathway that electrical impulses travel to make the heartbeat on the right side of the heart).
During an interview with Resident 6 on 7/17/2023 at 12:44 p.m., Resident 6 stated that he had a concern about not seeing his medication nurse today. Resident 6 stated that he had not received his medications. Resident 6 stated that maybe his medication nurse was running late but that he wanted his medications soon.
During a review of Resident 6's MAR dated July 17,2023, the MAR indicated that at 9:00 a.m. Resident 6 was scheduled to receive Lovenox 40 mg (anticoagulant), Multivitamin with Iron (supplement), Amlodipine Besylate 10 mg (medication for high blood pressure), Lisinopril 10 mg (medication for high blood pressure), Vitamin C (for healthy cell formation), and Gabapentin 300 mg (medication for neuropathy) and have not received it yet.
d. During a review of Resident 7's Face Sheet, the Face Sheet indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted to facility on 5/23/2023 with a diagnosis of schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and hypertension (high blood pressure).
During a review of Resident 7's H&P dated 5/25/23, the H&P indicated Resident 7 had fluctuating capacity to understand and make decisions. H&P indicated that Resident 7 had a history of chronic obstructive pulmonary disease (group of chronic lung diseases that block airflow and make it harder to breathe air out of the lungs) and Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves).
During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7 cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 7 was independent with his activities of daily living. The MDS indicated Resident 7 had a history of seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain.) and asthma (condition in which a person's airways become inflamed, narrow, swell, and produce extra mucus, which makes it difficult to breathe).
During an interview with Resident 7 on 7/17/2023 at 1:03 p.m., Resident 7 stated that he did not remember getting his morning medication. Resident 7 stated that he wanted to get his medication soon because he was afraid to get sick. Resident 7 stated that the medication nurse had been late in giving him his medication in the past but not this late.
During a review of Resident 7's MAR dated July 17, 2023, the MAR indicated at 9:00 a.m. Resident 7 was scheduled to receive Coreg 6.25 mg (for high blood pressure), Escitalopram 10mg (for depression), Famotidine 20 mg (for GERD), Fish oil 1,000 mg (supplement), Benztropine 1 mg (for Parkinson's disease), Haloperidol 5 mg (for schizophrenia), Levetiracetam 100mg (seizures), and Olanzapine 15 mg (schizophrenia), Depakote 500 mg (mood swings) and record indicated Resident 7 had not received medication yet.
During an interview on 7/17/2023 at 10:16 a.m., with CNA 2, CNA 2 stated the nurse for station B had called off. CNA 2 stated that residents in station B had not received their medications.
During an interview on 7/17/2023 at 10:35 a.m., with the Director of Nursing (DON), the DON stated that station B had no nurse right now. The DON stated that she had a late call off and was trying to find a replacement. The DON stated that from 7:30 a.m. to 10:30 a.m., residents did not have a nurse to care for their nursing needs. The DON stated that she would call Director of Staff Development (DSD) to work in station B today.
During an interview on 7/17/2023 at 10:45 a.m., with CNA 2, CNA 2 stated station B did not have an LVN because the assigned LVN called off today. CNA 2 stated that she informed charge nurse that Resident 4 was asking for her medication. CNA 2 stated that not having an LVN on duty has happened before and that usually they call registry or ask other LVN's from other shifts to come in to work.
During an interview on 7/17/2023 at 11:15 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated that she had not been asked to take extra residents or to help in station B. LVN 2 stated that she had informed DSD that station B did not have an LVN, and that DSD stated she was taking care of it.
During an interview on 7/17/2023 at 12:19 p.m., with the DSD, the DSD stated that she arrived at station B to work at 12:00 p.m. and was about to start passing medications because they had not received their medications. The DSD stated that Resident 4 did receive her medications. The DSD stated that LVN 2 had given Resident 4 her medications.
During an interview on 7/17/2023 at 1:44 p.m., with the DON, the DON sated that that she did not have sufficient staffing today due to a sick call. The DON stated that not having an assigned nurse in station B was not ideal and she had to pull other licensed nurses to help in that station. The DON stated that she had LVN 2 help by passing medications to residents in station B. The DON stated that it was important to have a licensed nurse for all residents to provide care and help residents with their nursing needs.
During a review of facility's policy and procedure (P&P) titled, Staffing , dated April 2007, the P&P indicated that the facility would provide adequate staffing to meet needed care for resident population. P&P indicated that the facility maintained adequate staffing on each shift to ensure that resident's needs and services are met. P&P indicated that licensed registered nurses and licensed nursing staff would be available to provide and monitor the delivery of resident care services.
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
Pharmacy Services
(Tag F0755)
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 follow physician's orders for three of four sampled re...
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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 follow physician's orders for three of four sampled residents (Resident 5, 6, and 7) by not administering medications at the time indicated on Medication Administration Record (MAR).
This deficient practice caused residents to feel stressed out and had the potential to negatively impact residents' health.
Findings:
a. During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was originally admitted to the facility on [DATE] with a diagnosis of human immunodeficiency virus (HIV - a virus that attacks the body's immune system. There's no cure for HIV) and chronic viral hepatitis C (An infection caused by a virus that attacks the liver and leads to inflammation, this virus is spread by contact with contaminated blood).
During a review of Resident 5's History and Physical (H&P), dated 4/18/2023, the H&P indicated that Resident 5 had the capacity to understand and make decisions. The H&P indicated that Resident 5 had a history of chronic obstructive pulmonary disease ([COPD]group of chronic lung diseases that block airflow and make it harder to breathe air out of the lungs).
During a review of Resident 5's Minimum Data Set ([MDS] a standardized assessment and care planning tool), dated 4/21/2023, indicated Resident 5's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 5 needed extensive assistance for all activities of daily living. The MDS indicated Resident 5's balance during transitions and walking were not steady, and only able to stabilize with staff assistance. The MDS indicated Resident 5 had a history of bipolar disorder (a mental illness that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks) and asthma (a condition in which a person's airways become inflamed, narrow, and swell, and produce extra mucus, which makes it difficult to breathe).
During a review of Resident 5's MAR dated July 17, 2023, the MAR indicated that at 9:00 a.m. Resident 5 was to receive pyridoxine (supplement) 25 milligrams (mg), Thiamine 100 mg (supplement), Folic Acid 1 mg (medication for anemia), Multivitamin tablet (supplement), Loratadine 10 mg (medication for allergy), Biktarvy 25 mg (medication for HIV), and Spiriva inhaler 18 micrograms ([mcg] unit of measurement) (for COPD).
b. During a review of Resident 6's Face Sheet, the Face Sheet indicated Resident 6 was originally admitted to the facility on [DATE] with a diagnoses of malignant neoplasm of prostate (cancerous tumor in the prostate that is likely to spread beyond its point of origin) and atherosclerotic heart disease (damage or disease in the heart's major blood vessels, caused by the buildup of plaque that causes coronary arteries to narrow, limiting blood flow to the heart.)
During a review of Resident 6's H&P dated 3/11/2023, the H&P indicated Resident 6 had a history of pulmonary hypertension (type of high blood pressure that affects arteries in the lungs and in the heart, it affects arteries in the lungs and the right side of the heart. Symptoms are shortness of breath, dizziness, and chest pressure).
During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognitive skills for daily decision making was intact, Resident 6 did not demonstrate disorganized thinking, altered level of consciousness, and inattention. The MDS indicated Resident 6 needed limited assistance for bed mobility, locomotion on and off unit and needed extensive assistance for transfers, dressing, toilet use and personal hygiene. The MDS indicated Resident 6 had a diagnosis of polyneuropathy (when multiple peripheral nerves become damaged), hypertension (high blood pressure) and right bundle-branch block (a delay or blockage along the pathway that electrical impulses travel to make the heartbeat on the right side of the heart).
During a review of Resident 6's MAR dated July 17,2023, the MAR indicated that at 9:00 a.m. Resident 6 was to receive Lovenox 40 mg (anticoagulant), Multivitamin with Iron (supplement), Amlodipine Besylate 10 mg (medication for high blood pressure), Lisinopril 10 mg (medication for high blood pressure), Vitamin C (for healthy cell formation), and Gabapentin 300 mg (medication for neuropathy).
c. During a review of Resident 7's Face Sheet, the Face Sheet indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted to facility on 5/23/2023 with a diagnosis of schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and hypertension (high blood pressure).
During a review of Resident 7's H&P dated 5/25/23, the H&P indicated Resident 7 had fluctuating capacity to understand and make decisions. H&P indicated that Resident 7 had a history of chronic obstructive pulmonary disease (group of chronic lung diseases that block airflow and make it harder to breathe air out of the lungs) and Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves).
During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7 cognitive skills for daily decision making was intact. The MDS indicated Resident 7 was independent with his activities of daily living. The MDS indicated Resident 7 had a history of seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain.) and asthma (condition in which a person's airways become inflamed, narrow, swell, and produce extra mucus, which makes it difficult to breathe).
During a review of Resident 7's MAR dated July 17, 2023, the MAR indicated at 9:00 a.m. Resident 7 was to receive Coreg 6.25 mg (for high blood pressure), Escitalopram 10mg (for depression), Famotidine 20 mg (for GERD), Fish oil 1,000 mg (supplement), Benztropine 1 mg (for Parkinson's disease), Haloperidol 5 mg (for schizophrenia), Levetiracetam 100mg (seizures), and Olanzapine 15 mg (schizophrenia), Depakote 500 mg (mood swings).
During an observation on 7/17/2023 at 10:12 a.m., in the hallway, observed Resident 4 ask staff where her medication nurse was. Resident 4 stated that she had not received her morning medication. Resident 4 told Certified Nurse Assistant (CNA) 2 that she had not received her medications. CNA 2 stated to Resident 4 that her nurse was not here, and she would get her medication soon.
During an interview with CNA 2 on 7/17/2023 at 10:16 a.m., CNA 2 stated Resident 4 had not received her morning medication because there was no nurse assigned to station B.
During an interview with Director of Nursing (DON) on 7/17/2023 at 10:35 a.m., the DON stated that she was aware that residents in station B had not received their medications. The DON stated residents had not received their medication because the nurse assigned to station B called in sick and she was in the process of assigning a nurse to pass out medication in station B.
During an interview with CNA 2 on 7/17/2023 at 10:45 a.m., CNA 2 stated that station B did not have an LVN because the assigned LVN called off today. CNA 2 stated she informed charge nurse that Resident 4 was asking for her medication. CNA 2 stated Resident 4 had not received her medications and that was why she was in the hallway asking staff for medication.
During an interview with Director of Staff Development (DSD) nurse on 7/17/2023 at 12:15 p.m., the DSD nurse stated that the DON asked her to work in station B today. The DSD nurse stated that residents in station B had not received their 9:00 a.m. medications. DSD nurse stated that it was important for residents to receive their medications in a timely manner to prevent a health decline and to maintain a good health.
During an observation on 7/17/2023 at 12:22 p.m., in the hallway, Resident 5 was observed asking the DSD nurse where the medication nurse was because she had not seen her, and she thought she had not received her medications today. The DSD nurse informed Resident 5 she had not received her morning medications and that she would give her the medications soon.
During an interview with Resident 5 on 7/17/2023 at 12:39 p.m., Resident 5 stated she did not remember if she had taken her medications today that was why she went to ask a nurse that she saw in the hallway. She stated that the nurse in the hallway told her she had not received her medications today but that she would give them to her soon. Resident 5 stated that she was glad that she received her medication. Resident 5 stated that she felt worried because she was not sure if she had received her medication.
During an interview with Resident 6 on 7/17/2023 at 12:44 p.m., Resident 6 stated that he had a concern about not seeing his medication nurse today. Resident 6 stated that he had not received his medications. Resident 6 stated that maybe his medication nurse was running late but that he wanted his medications soon.
During an interview with Resident 7 on 7/17/2023 at 1:03 p.m., Resident 7 stated that he did not remember getting his morning medication. Resident 7 stated that he wanted to get his medication soon because he was afraid to get sick. Resident 7 stated that the medication nurse had been late in giving him his medication in the past but not this late.
During an interview with the DON on 7/17/2023 at 1:35 p.m., the DON stated that residents in station B did not receive their medications on time today. The DON stated that not receiving their medications on time can be considered a missed medication and can widen medication errors. The DON stated that a missed medication can potentially cause negative outcomes to resident's health. The DON stated that for example, a resident that did not receive his blood pressure medication can cause their blood pressure to go high up.
During an interview with the DSD on 7/21/2023 at 10:47 a.m., the DSD stated that she administered the 9:00 a.m. medications to Resident 5 at 12:30 p.m., to Resident 6 at 1:00 p.m., and to Resident 7 between 1:30 p.m.to 2:00p.m. The DSD stated LVN 2 had given Resident 4 her medications but could not tell at what time they were given.
During a review of facility's policy and procedure (P&P) titled, Administering Medications , dated December 2012, the P&P indicated that medications shall be administered in a safe and timely manner, and as prescribed. P&P indicated that medications must be administered in accordance with the orders, including any required time frame. P&P indicated that medications must be administered within one hour of their prescribed time.
Jun 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
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 maintain a safe, clean, sanitary, and accident-free e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe, clean, sanitary, and accident-free environment for one of five sampled residents (Resident 2).
This deficient practice has the potential for Resident 2 to be exposed to a fall hazard and affect Resident 2's health and psychosocial well-being.
Findings:
During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including malignant neoplasm of rectosigmoid junction (a disease in which cancer cells develop in the rectum), malignant neoplasm of prostate (a disease in which malignant [cancer] cells form in the tissues of the prostate [a small gland in men that helps make semen]) and malignant neoplasm of vertebral column (a malignant bone tumor that can develop inside the spinal column anywhere along its length).
During a review of Resident 2's History and Physical (H&P) dated 1/26/2023, the H&P indicated Resident 2 had the capacity to understand and make decisions.
During a review of Resident 2's Minimum Data Sheet (MDS, a standardized assessment and care planning tool) dated 4/28/2023, the MDS indicated Resident 2's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact and the resident required supervision with bed mobility, transfer, walking in the room/corridor, locomotion on/off the unit, dressing, eating, toilet use and personal hygiene.
During a concurrent observation and interview with Resident 2 on 6/28/2023 at 10:20 a.m., in Resident 2's room, multiple items were observed cluttered on the bedside dresser and on the floor next to Resident 2's bed. On the left side of the bed on the floor were 3 gallons of plastic containers, juice, fruit punch and a yellow-colored plastic gallon container, which Resident 2 stated was a vitamin C drink. The 3-gallons of containers were not labeled with Resident 2's name or dated. Resident 2 stated he bought the items yesterday (6/27/23) when he went to a dentist appointment outside of the facility. A plastic bag and a pair of sandals were adjacent to the 3-gallon containers. Observed on the bedside dresser were on CD player, a 48 fluid ounce bottle of Prune Juice, a container of salt, a water pitcher, a restaurant menu, and a small plastic container of a dark-colored sauce.
During an interview with Certified Nurse Assistant (CNA) 3 on 6/28/2023 at 1:20 p.m., CNA 3 stated, Resident 2 likes to order food from the outside and only sometimes eats the facility food. CNA 3 stated, Resident 2 likes to drink soda and other drinks. CNA 3 stated, Resident 2 likes to keep a lot of stuff at his bedside. The times I have worked he has all that stuff at his bedside. CNA 3 stated, Resident 2 has kept all that stuff at his bedside for a while now.
During an interview with CNA 2 on 6/28/2023 at 1:45 p.m., CNA 2 stated, Resident 2 has a lot of items around his bed and on his dresser drawer most of the time. CNA 2 stated she has cleaned the area around his bed on 6/27/2023 when Resident 2 went to his dentist appointment. CNA 2 stated she did not see the room when Resident 2 came back from his appointment on 6/27/2023 because her shift was over. CNA 2 stated the room today (6/28/2023) with all that stuff around his bedside was not there yesterday because she cleaned the area.
During a concurrent record review and interview with Dietary Supervisor (DS) 1 on 6/28/2023 at 3:35 p.m., DS 1 reviewed the photo of the 3 gallons of drinks located on the floor next to Resident 2's bedside. DS 1 stated she was unaware that there were 3 containers at Resident 1's bedside. DS 1 stated the kitchen did not have any place to keep any resident's food or drinks to be refrigerated. DS 1 stated it was recommended to family and visitors to bring only enough food or drink a resident can consume in one sitting.
During a review of the facility's Policy and Procedure (P&P) titled, Food for Residents from Outside Sources, dated 2018, the P&P indicated food brought from outside the facility kitchen for resident's consumption will be monitored. This is done to measure the effectiveness of this intervention in residents with low food intake, to be sure the food is within the guidelines of the diet order, and to better assess nutrient intake. The P&P further indicated prepared foods, beverages, or perishable food that requires refrigeration, can be stored for the resident in the facility kitchen, nursing station's refrigerator or in the residents' personal refrigerator. In the food service department, the policy on food storage will apply.
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
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 implement the care plan interventions for one of five...
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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 the care plan interventions for one of five sampled residents (Resident 2) which included:
1. Fall risk interventions for placing the call light within reach.
2. Impaired vision interventions for keeping the resident's surroundings free of hazards.
3. Spontaneous pathological fracture (a complete or partial break of a bone) interventions by providing a safe and hazard-free environment.
4. Altered nutrition/hydration interventions by honoring resident's fluid preferences.
These deficient practices had the potential for Resident 2 to be placed at an increased risk for falls and insufficient provision of care and services.
Findings:
a. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including malignant neoplasm of rectosigmoid junction (a disease in which cancer cells develop in the rectum), malignant neoplasm of prostate (a disease in which malignant [cancer] cells form in the tissues of the prostate [a small gland in men that helps make semen]) and malignant neoplasm of vertebral column (a malignant bone tumor that can develop inside the spinal column anywhere along its length).
During a review of Resident 2's History and Physical (H&P) dated 1/26/2023, the H&P indicated Resident 2 had the capacity to understand and make decisions.
During a review of Resident 2's Minimum Data Sheet (MDS, a standardized assessment and care planning tool) dated 4/28/2023, the MDS indicated Resident 2's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact and the resident needed supervision with bed mobility, transfer, walking in the room/corridor, locomotion on/off the unit, dressing, eating, toilet use and personal hygiene.
During a record review of Resident 2's care plan titled, Fall Risk, updated on April 2023 with a re-evaluation date of July 2023, the care plan intervention indicated, Place call light within reach.
During a record review of Resident 2's care plan titled, Vision, updated on April 2023 with a re-evaluation date of July 2023, the care plan intervention indicated, Keep resident surroundings free of hazard.
During a record review of Resident 2's care plan titled, Resident at risk for spontaneous pathological fracture related to osteoporosis, updated on April 2023 with a re-evaluation date of July 2023, the care plan intervention indicated, Provide a safe and hazard free environment.
During a concurrent observation and interview with Resident 2 on 6/28/2023 at 10:20 a.m., in Resident 2's room, Resident 2 stated he was unable to call for help when he needed it because he could never find his call light. Resident 2's bed was observed raised at a 30-degree angle and the call light cord was around and through the bedframe behind the head of the bed. The call light was not in Resident 2's line of vision nor was it accessible to Resident 2.
During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 2 on 6/28/2023 at 11:45 a.m., LVN 2 was informed about Resident 2's call light not within reach. LVN 2 went to Resident 2's room and observed the call light was behind the head of the bed and the cord went through the bedframe and was out of Resident 2's sight. LVN 2 put on gloves and informed Resident 2 she was going to find his call light. Resident 2 stated to LVN 2, I can never find the call light when I need it. LVN 2 was observed reaching behind the bed to get the call light cord and pulled it from the bedframe. Next, LVN 2 was observed clipping the call light to the linen at the head of the bed within easy reach of Resident 2.
LVN 2 was observed testing the call light to verify that it was working. The wall button light was observed turning on and the light above the room door frame was on and visible to anyone outside the room. LVN 2 stated it is important that the call light is working and within reach of Resident 2 because if he needs help or if there is an emergency then staff can respond right away.
During a review of the facility's Policy and Procedure (P&P) titled, Answering the Call Light, revised 10/2010, the P&P indicated when a resident is in bed, make sure the call light is within easy reach of the resident. The P&P indicated call lights must be answered as soon as possible.
b. During a concurrent record review and interview with Dietary Supervisor (DS) 1 on 6/28/2023 at 3:35 p.m., DS 1 reviewed the photo of the breakfast tray from this morning (6/28/2023).
DS 1 stated the breakfast slip indicated Resident 2's dislike was Milk and Fried Eggs.
DS 1 stated the photo indicated there was a cup of 8 ounce (oz) milk on Resident 2's food tray, although the breakfast slip indicated he disliked milk.
DS 1 stated Resident 2 liked to order different drinks and sometimes the resident did not want milk and other times he was told he could order it.
DS 1 stated she did the food preferences screening. DS 1 stated the slip should be updated.
During a record review of Resident 2's care plan titled, At risk for altered nutrition/hydration related to gastrointestinal (GI) issues/dyspepsia (pain or an uncomfortable feeling in the upper middle part of your stomach area), cancer, behavioral issues, updated on April 2023 with a re-evaluation date of July 2023, the care plan intervention indicated, Snacks per resident preference, honor food/fluid preferences.
During a record review of Resident 2's Nutritional Screening Assessment, dated 5/2/2023, the assessment indicated, Food Preferences Dislikes: Milk, Fry eggs. The assessment further indicated under, Other Pertinent Information, Resident continue on regular texture diet NAS with good tolerance, variable meal intake, resident refuses to eat at times however he will order food at times, will continue to monitor intake, weight, offer food preferences, assist with meals as needed.
During a review of the facility's P&P titled ,Nutritional Assessment, revised 2011, the P&P indicated, Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident's risks for nutritional complications. Such interventions will be developed within the context of the resident's prognosis and personal preferences.
The P&P further indicated, Individualized care plans shall address, to the extent possible: b. The resident's personal preferences; d. Time frames and parameters for monitoring and reassessment.
During a review of the facility's P&P titled, Safety and Supervison of Residents, revised 12/2007, the P&P indicated, Implementing interventions to reduce accident risks and hazards shall include the following: a) communicating specific interventions to all relevant staff, b) assigning responsibility for carrying out interventions, d) ensuring that interventions are implemented and documented. The P&P further indicated, Monitoring the effectiveness of interventions shall include the following: a) ensuring that interventions are implemented correctly and consistently, b) evaluating the effectiveness of interventions, c) modifying or replacing interventions as needed, and d) evaluating the effectiveness of new or revised interventions.
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 F0675
(Tag F0675)
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 one of five sampled residents (Resident 2) was...
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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 one of five sampled residents (Resident 2) was given a call light (within the resident's reach) to use for assistance.
This deficient practice has the potential to cause a negative impact on Resident 2's health and psychosocial well-being.
Findings:
During a review of Resident 2's admission Record, the admission Record indicated that Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including malignant neoplasm of rectosigmoid junction (a disease in which cancer cells develop in the rectum), malignant neoplasm of prostate (a disease in which malignant [cancer] cells form in the tissues of the prostate [a small gland in men that helps make semen]) and malignant neoplasm of vertebral column (a malignant bone tumor that can develop inside the spinal column anywhere along its length).
During a review of Resident 2's History and Physical (H&P) dated 1/26/2023, the H&P indicated Resident 2 had the capacity to understand and make decisions.
During a review of Resident 2's Minimum Data Sheet (MDS, a standardized assessment and care planning tool) dated 4/28/2023, MDS indicated Resident 2's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact and the resident required supervision with bed mobility, transfer, walking in the room/corridor, locomotion on/off the unit, dressing, eating, toilet use and personal hygiene.
During a concurrent observation and interview with Resident 2 on 6/28/2023 at 10:20 a.m., in Resident 2's room, Resident 2 stated he was unable to call for help when he needed it because he could never find his call light. Resident 2's bed was observed raised at a 30-degree angle and the call light cord was around and through the bedframe behind the head of the bed. The call light was not in Resident 2's line of vision nor was it accessible to Resident 2.
During a concurrent observation and interview with Licensed Vocational Nurse 2 (LVN 2) on 6/28/2023 at 11:45 a.m., LVN 2 was informed about Resident 2's call light not within reach. LVN 2 went to Resident 2's room and observed the call light was behind the head of the bed and the cord went through the bedframe and was out of Resident 2's sight. LVN 2 put on gloves and informed Resident 2 she was going to find his call light. Resident 2 stated to LVN 2, I can never find the call light when I need it. LVN 2 was observed reaching behind the bed to get the call light cord and pulled it from the bedframe. Next, LVN 2 was observed clipping the call light to the linen at the head of the bed within easy reach of Resident 2.
LVN 2 was observed testing the call light to verify that it was working. The wall button light was observed turning on and the light above the room door frame was on and visible to anyone outside the room. LVN 2 stated it is important that the call light is working and within reach of Resident 2 because if he needs help or if there is an emergency then staff can respond right away.
During a review of the facility's Policy and Procedure (P&P) titled, Answering the Call Light, revised 10/2010, the P&P indicated that when a resident is in bed, make sure the call light is within easy reach of the resident. The P&P indicated that call lights must be answered as soon as possible.
Apr 2023
4 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
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 provide the appropriate accommodations for one of fou...
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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 the appropriate accommodations for one of four sampled residents (Resident 1), who was Russian-speaking only and legally blind, when the facility did not:
1. Provide a means to improve communication.
2. Provide the appropriate bed to reduce risk of injuries.
3. Provide a call light within reach and/or other means to call for assistance.
4. Provide access to water.
5. Provide access to the bathroom.
These deficient practices resulted in staff guessing the needs of Resident 1, increased the risk of the resident injuring her bilateral (pertaining to both sides) lower legs when she hit the metal framing of the bed, not having a means to call staff for help as needed, the resident potentially not being hydrated, and the resident using adult briefs instead of being taken to the bathroom for staff convenience. These deficient practices also increased the risk of not meeting the physical and psychosocial needs of Resident 1.
Findings:
During a review of Resident 1's admission Record (face sheet), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including dementia (condition characterized by impairment of brain functions, such as memory loss and judgement), legal blindness, history of falling, schizophrenia (a mental disorder characterized by thoughts that seem out of touch with reality and affects a person's ability to think, feel, and behave clearly), and anxiety disorder (a mental disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities).
During a review of Resident 1's Minimum Data Set ([MDS], a standardized resident assessment and care screening tool), dated 2/18/2023, the MDS indicated Resident 1's cognitive (ability to understand) skills for daily decision making was severely impaired. The MDS indicated Resident 1 required supervision for bed mobility, transfers out of bed, walking in the room and required extensive assistance for dressing, eating, toilet use, and personal hygiene.
During an observation on 4/5/2023, at 10:40 a.m., in Resident 1's room, observed the resident's room was bare and a non-homelike environment. Observed call light and water pitcher were placed out of Resident 1's reach and were located on top of the overhead light fixture. Observed Resident 1 was asleep and lying on a low, metal-framed bed. Observed an old, discolored bedside table with a wooden table and metal legs, and a wooden dresser on the opposite wall of the room. Observed the walls of the room were bare except for three Russian translation handouts taped to the wall labeled Medical, Descriptions, and Family. Observed Resident 1 had a light purple bruise on the left side of the forehead, a purple and yellow bruise above the upper lip area which radiated to the left side of the resident's face. Observed Resident 1 had a small skin tear on her right elbow and on her right hand which appeared dry and had a scab.
During an interview on 4/5/2023, at 10:48 a.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 1 spoke only Russian, and he could not communicate with the resident. CNA 1 stated it was difficult to change Resident 1 because the resident was also blind and did not know what was being done to her, so she would become aggressive toward the staff. CNA 1 stated no one in the facility spoke Russian and the facility did not have a translation system. CNA 1 stated it was difficult to check on Resident 1 because he had 12 residents assigned and six of the 12 residents were dependent and required more assistance for their ADLs. CNA 1 confirmed Resident 1's bed was blocking the entrance to the bathroom, and he did not know why the bed was placed there. CNA 1 stated Resident 1 used to go to the bathroom was got used to wearing a brief and no longer goes to the bathroom. CNA 1 stated it was good that Resident 1 wore a brief because he could not take her to the bathroom sometimes when he was busy, so he would change her brief and put another brief on her instead of taking her to the bathroom. CNA 1 confirmed the call light, and the water pitcher were on top of the overhead light fixture and out of Resident 1's reach. CNA 1 stated Resident 1 should have access to the call light to call for help, but she would pull the call light out of the wall and the call light would stay on and the resident would wrap the call light cord around her waist. CNA 1 stated the water pitcher was placed out of Resident 1's reach because she would spill water on the floor and could slip and fall. CNA 1 stated he was not sure how Resident 1 got the skin tears on her shins but stated he had seen the resident hit her legs on the metal-framing of her bed, bump the wall, and the dresser.
During an interview on 4/5/2023, at 11:25 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 knew some basic words in English, such as food, eat, yes, and no, but the resident spoke Russian. LVN 1 stated the only Russian words she knew were yes and no. LVN 1 stated the facility had no means of communication for Resident 1. LVN 1 stated the Resident 1 became combative because she did not understand what care was being provided due to the lack of communication. LVN 1 stated she had no means of communicating to Resident 1 what medications she administered. LVN 1 stated she crushed Resident 1's medications and mixed it with apple sauce and the resident would just think it was food and take the medications. LVN 1 stated she had seen Resident 1 walk into her dresser and has moved the entire mattress off her bed. LVN 1 stated Resident 1's call light was kept out of reach because she was blind, and she may get tangled with the cord and fall. LVN 1 stated there was no other type of call light given to Resident 1 as an alternative to call for help. LVN 1 stated the water pitcher was kept out of Resident 1's reach because she has spilled water and she may fall if there was water on the floor. LVN 1 stated she thought Resident 1 should be one-on-one because she was blind, did not speak English, and she was confused which made her more prone to accidents.
During a concurrent observation and interview on 4/5/2023, at 12:52 p.m., in Resident 1's room, CNA 1 and Restorative Nursing Assistant (RNA) 1 assisted Resident 1 to the bathroom. Observed Resident 1 was barefoot. No shoes or socks observed in the room. CNA 1 confirmed Resident 1 was barefoot and should be wearing non-skid socks to prevent resident from slipping. Observed Resident 1 stand up and walked with staff guiding her to the restroom. Observed Resident 1 stand up on her own from the toilet and RNA 1 cleaned Resident 1's buttocks and perineum with a towel. CNA 1 and RNA 1 applied a clean adult brief.
During a concurrent observation and interview on 4/5/2023, at 1 p.m., in Resident 1's room, the Treatment Nurse (TX) changed Resident 1's dressings to her shins. Observed Resident 1 had skin abrasions on both shins, a dry scab and bruise on her left palm, and a wound on the right hand. The TX stated he had seen Resident 1 pull the mattress off the bed and knock over the bedside table and stated Resident 1 could have potentially hurt herself.
During an interview on 4/5/2023, at 1:56 p.m., with LVN 1, LVN 1 stated Resident 1 was blind, and she was at risk for falls so the bathroom was kept locked for her safety. LVN 1 stated she did not know Resident 1 had the ability to use the bathroom because she thought she was incontinent. LVN 1 stated she wondered if Resident 1 had a one-to-one staff if she could use the restroom. LVN 1 stated Resident 1 had no quality of life because she was kept in her room all the time, she could not communicate with anyone in her native language. LVN 1 stated it would be nice if the facility had translator services.
During an interview on 4/6/2023, at 10:34 a.m., with LVN 2, LVN 2 stated there was a communication board in Resident 1's room with Russian words but she could not pronounce the words. LVN 2 stated she tried to guess the needs of Resident 1 because it was difficult to understand the resident. LVN 2 stated the lack of communication could potentially affect the resident emotionally and cause frustration. LVN 2 stated Resident 1 would benefit from translator services. LVN 2 stated she thought Resident 1 may have scratched her shins from bumping into the metal bed frame. LVN 2 stated Resident 1 would benefit from having a different type of bed and a different type of dresser to help prevent Resident 1 from injuring herself. LVN 2 stated Resident 1 could use the bathroom with assistance, but she preferred for the resident to wear a brief because she would then sleep all night.
During an interview on 4/6/2023, at 1:13 p.m., with the Director of Staff Development (DSD), the DSD stated all residents should have a call light to call for assistance, to prevent falls, to request water, a brief change, and request anything they may need. The DSD stated Resident 1 had the ability to press the call light and she should have her call light placed within her reach. The DSD stated Resident 1 could use the restroom with assistance. The DSD stated it was more convenient for Resident 1 to wear a brief, but stated the resident had the right to use the bathroom. The DSD stated the bathroom door should be kept open so Resident 1 could feel her way to the bathroom and stated the path to the bathroom should be clear and the bed should not be blocking the bathroom entrance.
During an interview on 4/6/2023, at 3:36 p.m., with LVN 3, LVN 3 stated Resident 1 was known to move the furniture around in her room and bumped into the walls, so staff blocked the bathroom door so resident would not hurt herself. LVN 3 stated a few months ago, Resident 1 was sent to the hospital because she had scratched scabs on her legs and made herself bleed. LVN 3 stated if Resident 1 had more supervision she would not get hurt. LVN 3 stated Resident 1 should be one-on-one.
During an interview on 4/6/2023, at 4:20 p.m., with the Director of Nursing (DON), the DON stated the facility did not have interpreter services and stated it would be good to have these services. The DON stated it was important to have interpreter services so residents could communicate their needs. The DON stated Resident 1 should have access to her call light so she could call the nurses for assistance. The DON stated Resident 1 had not had repetitive instruction for use of the call light and she should have. The DON stated the communication barrier was the bigger issue and the facility had not met the communication needs of Resident 1 which could have affected her psychosocial well-being. The DON stated Resident 1 should have access to water and the staff should offer water to the resident often. The DON stated the facility had not provided Resident 1 another means for water access besides a water pitcher. The DON stated the risk to Resident 1 not having access to water was dehydration.
During an interview on 4/14/2023, at 10:08 a.m., with the Physical Therapist (PT), the PT stated Resident 1 was able to use the restroom with assistance, stated she required guidance to the restroom.
During an interview on 4/19/2023, at 10:56 a.m., with the DON, the DON stated the facility's only means of communication available for Resident 1 were the handouts posted in the resident's room with Russian words, the one to two words the staff and the resident could understand. The DON stated it would be helpful to understand the resident better with more understanding of her language. The DON stated other resources to improve communication with Resident 1 had not been used and she could not explain why. The DON stated Resident 1 should have access to the bathroom and she did not understand why the bathroom door was blocked by the bed and why the bathroom door was locked. The DON stated there should be consistency with the nursing staff taking Resident 1 to the bathroom and there was not. The DON stated Resident 1 was not receiving consistent care from the staff. The DON stated, Honestly with the current interventions that have been implemented with her, it appears on some shifts she gets more assistance than others and the result is no consistency. The DON stated the inconsistency in Resident 1's care was due to the lack of personalized care plans and may lead to a decline in the resident's function level and independence. Resident 1's annual IDT care conference, dated 11/2/2022, was reviewed with the DON. The DON indicated an IDT was done to review the care of the resident and make changes as needed for any identified declines. The DON stated the facility had not explored any interventions to improve Resident 1's plan of care for her vision impairment and communication barrier because no issues were identified. The DON stated Resident 1's physical and psychosocial well-being may have declined due to the lack of consistency in the care and the lack of a individualized care plans. The DON stated the facility was not maintaining Resident 1's highest level of independence and her highest practical physical and psychosocial well-being with the current plan of care.
During a review of the facility's policy and procedure (P&P) titled, Quality of Life- Accommodation of Needs , dated 8/2009, the P&P indicated, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity, and well-being. The policy indicated, The resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis. In order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom and bathroom, the common areas in the facility .In order to accommodate individual needs and preferences, staff attitudes and behaviors must be directed towards assisting the residents in maintaining independence, dignity, and well-being to the extent possible and in accordance with the resident's wishes .
During a review of the facility's P&P titled Quality of Life- Dignity , dated 8/2009, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. The P&P indicated, Staff shall keep the resident informed and oriented to their environment. Procedures shall be explained before they are performed, and residents will be told in advance if they are going to be taken out of their usual or familiar surroundings. The P&P indicated, Staff shall treat cognitively impaired residents with dignity and sensitivity .
During a review of the facility's P&P titled Translation and/or Interpretation of Facility Services , dated 5/2017, the P&P indicated, This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. The P&P indicated, Competent oral translation of vital information that is not available in written translation, and non-vital information shall be provided in a timely manner and at no cost to the resident through the following means (as available to the facility):
a. A staff member who is trained and competent in the skill of interpreting;
b. A staff interpreter who is trained and competent in the skill of interpreting;
c. Contracted interpreter service;
d. Voluntary community interpreters who are trained and competent in the skill of interpreting; and
e. Telephone interpretation service.
The P&P indicated, Family members and friends shall not be relied upon to provide interpretation services for the resident, unless explicitly requested by the resident. If family or friends are used to interpret, the resident must provide written consent for disclosure of protected health information. It is understood that providing meaningful access to services provided by this facility requires also that the LEP resident's needs and questions are accurately communicated to the staff. Oral interpretation services therefore include interpretation from the LEP resident's primary language back to English. It is understood that in order to provide meaningful access to services provided by this facility, translation and/or interpretation must be provided in a way that is culturally relevant and appropriate to the LEP individual.
During a review of the facility's P&P titled Answering the Call Light , dated 10/2010, the P&P indicated, The purpose of this procedure is to respond to the resident's requests and needs. The P&P indicated, Explain the call light to the new resident. Demonstrate the use of the call light. Ask the resident to return the demonstration so that the resident can operate the system .Be sure that the call light is plugged in at all times. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.
During a review of the facility's P&P titled Safety and Supervision of Residents , dated 12/2007, the P&P indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P&P indicated under Facility-Oriented Approach to Safety, Our resident-oriented approach to safety addresses safety and accident hazards for individual residents. The P&P indicated under Resident-Oriented Approach to Safety, The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents. The P&P indicated under Systems Approach to Safety, Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.
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
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 observation, interview, and record review, the facility failed to develop and implement an individualized resident-cent...
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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 develop and implement an individualized resident-centered plans of care with interventions to meet the needs of one of four sampled residents (Resident 1), who was Russian-speaking only and legally blind.
This deficient practice negatively affected the delivery of necessary care and services for Resident 1 and potentially affected the resident's quality of life and reaching her highest level of independence and highest practical physical and psychosocial well-being.
Findings:
During a review of Resident 1's admission Record (face sheet), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the diagnoses including dementia (condition characterized by impairment of brain functions, such as memory loss and judgement), legal blindness, history of falling, schizophrenia (a mental disorder characterized by thoughts that seem out of touch with reality and affects a person's ability to think, feel, and behave clearly), and anxiety disorder (a mental disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities).
During a review of Resident 1's Minimum Data Set ([MDS], a standardized resident assessment and care screening tool), dated 2/18/2023, the MDS indicated Resident 1's cognitive (ability to understand) skills for daily decision making was severely impaired. The MDS indicated Resident 1 required supervision for bed mobility, transfers out of bed, walking in room and required extensive assistance for dressing, eating, toilet use, and personal hygiene.
During a review of Resident 1's Vision care plan, dated 2/27/2023, the care plan indicated the resident was at risk of sensory perception deficit related to confusion, dementia, high blood pressure, aging process, and legal blindness. The care plan indicated Resident 1's vision was severely impaired, and interventions included to keep resident surroundings free of hazard, keep frequently used personal belongings within reach as shoes, etc.
During a review of Resident 1's Fall Risk care plan, dated 2/27/2023, the care plan indicated the resident was at risk of fall and injury due to the following:
1. Impaired cognition
2. Impaired decision-making
3. Impaired communication
4. Impaired vision
5. Poor safety awareness
6. Poor judgement
7. History of fall
The care plan indicated the staff's interventions included to assist Resident 1 with Activities of Daily Living (ADLs, activities such as toilet use, grooming, hygiene, eating, etc.), transfer, mobility, positioning, and locomotion as needed, provide safety education such as importance of calling for assistance (use call light or verbal calling), and place call light within reach
During a review of Resident 1's care plan for Alzheimer's/Dementia, dated 2/27/2023, the care plan indicated the resident had episodes of confusion/forgetfulness, with risk for further decline in cognition related to dementia. The care plan indicated the staff's interventions included to explain all procedures prior to assisting care, give simple directions, one at a time using short words and simple sentences, reassurance as needed with frequent verbal reminders and re-orientation to reality as necessary, and monitor and anticipate needs and meet them.
During a review of Resident 1's care plan for Cognition, dated 2/27/2023, the care plan indicated Resident 1 was at risk for increased confusion related to dementia. The care plan indicated the staff's interventions included to encourage Resident 1 to verbalize needs, feelings, concerns for interventions, talk/communicate with the resident in simple phrases, ask questions that can be answered Yes or No if necessary, provide adequate time for resident to respond, and encourage activity participation for sensory stimulation and socialization.
During a review of Resident 1's care plan for Communication, dated 2/27/2023, the care plan indicated Resident 1's communication was impaired related to psychiatric diagnosis, dementia, and due to the language barrier of speaking Russian. The care plan indicated the staff's interventions included to provide resident adequate time to respond when talking with resident, and encourage activity participation for sensory stimulation and socialization.
During a review of resident 1's care plan for ADL and Functional Mobility, dated 2/27/2023, the care plan indicated Resident 1 had self-care deficit due to impaired cognition, impaired decision, impaired communication, dementia/Alzheimer, and psychiatric diagnosis. The care plan indicated the staff's interventions included to assist with ADLs as needed and praise with attempts to do self-care or if with participation, assist with functional mobility as needed (i.e. transfer, bed mobility, etc.), encourage to do as much for self as possible to increase independence, allow to participate with decision making process, maintain privacy during care, and Rehab referral as needed.
During a review of Resident 1's care plan for Activities, dated 2/18/2023, the care plan indicated the goal was to provide Resident 1 with music and one-to-one socializing. The care plan indicated the staff's interventions included hand-held assistance to successful participation and to continue to monitor, encourage, and offer meaningful activities and interest.
During a review of Resident 1's care plan for Nutrition, dated 2/27/2023, the care plan indicated Resident 1 was at risk for altered nutrition/hydration related to the following including dementia/inability to stay on task at meals, malnutrition, dysphagia (difficulty swallowing), poor dentition, inadequate intake, and behavioral issues of yelling and screaming. The care plan indicated the staff's interventions included to monitor weight weekly and monthly, no weights for comfort and dignity, risk/benefit counseling, and social/restorative nurse assistant (RNA, provides rehabilitation care to help people regain or improve their physical, mental and emotional health) dining.
During a review of Resident 1's Care Area Triggers (CAT, indicates a condition that should be care planned) Worksheet for Problem Area: 02. Cognitive Loss/Dementia, dated 11/2/2022, the worksheet indicated the following care plan considerations, Proceed to care plan focusing on enhancing quality of life, sustaining functional capabilities, resolve the health and safety issues to improve the quality of life and minimizing decline and preserving freedom, independence, and dignity to lay the foundation for reasonable staff and family expectations concerning resident's capacity and needs. And approach to gain understanding and trust. Provide reality reorientation daily.
During a review of Resident 1's CAT for Problem Area: 03. Visual Function, dated 11/2/2022, the worksheet indicated the resident was at risk for falls or injuries related to resident was legally blind. The worksheet indicated the following care plan considerations, Proceed to care plan to ensure resident safety focusing on preventing eye infection, use of corrective devices (if appropriate), prevention of falls and/or weight loss.
During a review of Resident 1's CAT for Problem Area: 04. Communication, dated 11/2/2022, the worksheet indicated the following care plan considerations, Proceed to care plan to incorporate resident strengths/weaknesses, provide reassurance when patient wants to communicate, provide communication devices as needed, anticipate needs and met daily and provide enough time to respond/express self, to minimize decline and promote quality of life with dignity and self-respect. Establish and maintain a consistent routine, environment, monitor hydration and appetite. Provide calm and quiet environment/approach.
During a review of Resident 1's CAT for Problem Area: 06. Incontinence and Indwelling Catheter, dated 11/2/2022, the worksheet indicated the following care plan considerations, Proceed to care plan focusing on assisting to the toilet as needed with ambulation and transfers, and keep resident dry, clean, and odor free and monitor for skin breakdown and respecting resident rights by preserving dignity.
During a review of Resident 1's CAT for Problem Area: 11. Falls, dated 11/2/2022, the worksheet indicated resident was at risk for falls or injuries related to cognitive impairment, impaired functioning, muscle weakness, gait problems, legal blindness, history of fall, and other risk factors that can contribute to risk of fall. The worksheet indicated the following care plan considerations, Proceed to care plan focusing on resident safety, preserving resident dignity and to assure risk of falls is minimized by combination of medical treatment, rehabilitation, and environmental changes, while meeting resident's ADL needs on time, toileting them on time, and encourage them to use call light for help and other needs, keep room well lighted and clutter free at all times. Free from falls is one very important way to allow resident to attain and maintain the highest physical, and psychosocial well-being.
During an observation on 4/5/2023, at 10:40 a.m., in Resident 1's room, observed the resident's room was bare and a non-homelike environment. Observed the call light was out of reach and was placed on top of the overhead light along with the Resident 1's water pitcher. Observed Resident 1 was asleep and lying on a low, metal-framed bed. Observed an old, discolored bedside table with a wooden table and metal legs, and a wooden dresser on the opposite wall of the room. Observed the walls of the room were bare except for three Russian translation handouts taped to the wall labeled Medical, Descriptions, and Family. Observed Resident 1 had a light purple bruise on the left side of the forehead, a purple and yellow bruise above the upper lip area which radiated to the left side of the resident's face. Observed Resident 1 had a small skin tear on her right elbow and on her right hand which appeared dry and had a scab.
During an interview on 4/5/2023, at 10:48 a.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 1 spoke only Russian, and he could not communicate with the resident. CNA 1 stated it was difficult to change Resident 1 because the resident was also blind and did not know what was being done to her, so she would become aggressive toward the staff. CNA 1 stated no one in the facility spoke Russian and the facility did not have a translation system. CNA 1 stated Resident 1 was incontinent, but she was able to walk and but needed guidance to the bathroom because she was blind. CNA 1 stated Resident 1 used to go to the bathroom on her own, but he thinks the resident got used to wearing a brief. CNA 1 confirmed the bed was blocking the entrance to the bathroom and stated he did not know why the bed was placed in front of the bathroom door. CNA 1 confirmed Resident 1's call light and water pitcher were out of reach and were on top of the overhead light. CNA 1 stated Resident 1 should have access to the call light to call for help but stated the resident would wrap the call light cord around her waist and the call light would stay on when she pulled it out of the wall outlet. CNA 1 stated the water pitcher was out of reach because Resident 1 would spill water on the floor, and she may slip and fall. CNA 1 stated to keep Resident 1 safe she was kept in bed. CNA 1 stated the only time he has taken Resident 1 out of her room was to give her a shower. CNA 1 stated it was difficult to come see Resident 1 due to having so many residents. CNA 1 stated six of 12 of his residents were dependent (residents who require more assistance for ADLs), so it was good that Resident 1 was wearing an adult brief because he could not come take her to the restroom sometimes. CNA 1 stated when he was busy, he would change Resident 1 and put another brief on her instead of taking her to the bathroom. CNA 1 stated Resident 1 did not go to activities. CNA 1 stated he had seen Resident 1 hit her legs on the metal frame of the bed and stated she had skin tears on her shins. CNA 1 stated he had seen Resident 1 bump into the wall and the dresser and that it would be better for the resident to be one-on-one for her safety.
During an interview on 4/5/2023, at 11:25 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 knew some basic words in English, such as food, eat, yes, and no, but the resident spoke Russian. LVN 1 stated the only Russian words she knew were yes and no. LVN 1 stated the facility had no means of communication for Resident 1. LVN 1 stated the Resident 1 became combative because she did not understand what care was being provided due to the lack of communication. LVN 1 stated she had no means of communicating to Resident 1 what medications she administered. LVN 1 stated she crushed Resident 1's medications and mixed it with apple sauce and the resident would just think it was food and take the medications. LVN 1 stated Resident 1 wore an adult brief because she was blind and incontinent. LVN 1 stated Resident 1 was able to feed herself, but the food gets all over the place, so the CNAs and Restorative Nursing Assistant (RNA) feed her. LVN 1 stated Resident 1 stayed in her room and kept to herself. LVN 1 stated Resident 1 was able to walk but she had not seen the resident walked outside or in the hallway in a while. LVN 1 stated she had not seen any activities for Resident 1 and stated the staff should be more accommodating to the resident's needs and have appropriate activities. LVN 1 stated the call light and water pitcher were kept out of reach of Resident 1 to prevent an accident. LVN 1 stated she did not know how Resident 1 sustained her injuries to her face and shins but had seen the resident walk into and move the dresser around her room and had pulled the mattress off the bed before. LVN 1 stated Resident 1 should be one-on-one because she was blind, did not speak the language, and she was confused so she should have someone giving her more attention. LVN 1 stated not being one-to-one made Resident 1 prone to accidents.
During an interview on 4/5/2023, on 1:56 p.m., with LVN 1, LVN 1 stated Resident 1 had no quality of life because she was kept in her room all the time and she could not communicate with anyone in her native language, and she did not have any activities catered to her. LVN 1 stated it would be nice if the facility had translator services. LVN 1 stated she could count on one hand how many times she had seen Resident 1 taken to walk outside of her room in the two years she had worked at the facility.
During an interview on 4/6/2023, at 10:34 a.m., with LVN 2, LVN 2 stated it was difficult to understand the needs of Resident 1 because the resident spoke Russian. LVN 2 stated she tried her best to help Resident 1, but she had to guess what the resident needed due to the lack of ability to communicate with the resident. LVN 2 stated when she guessed what Resident 1 needed, she had offered food, changed her brief, and gave her pain medication. LVN 2 stated the pain medication would relax the resident and she would go to sleep. LVN 2 stated she was not sure Resident 1 understood the concept of using the call light. LVN 2 stated Resident 1 yelled when she needed something. LVN 2 stated she did not remember if she had been trained to care for a blind resident. LVN 2 stated the lack of communication may affect Resident 1 emotionally and may cause frustration. LVN 2 stated Resident 1 was a very strong and active woman who moved the furniture in her room and climbed into the closet. LVN 2 stated she thought Resident 1 may have scratched her shins from bumping into the metal bed frame. LVN 2 stated it was not safe to leave Resident 1 alone and it would help to prevent injuries if the resident had more supervision, a different type of bed and dresser.
During an interview on 4/6/2023, at 1:30 p.m., with the Activities Director (AD), the AD stated the activities she had for Resident 1 included playing Russian music from a cassette she found online and stated the resident liked the sound of the chip dropping in the game Connect 4. The AD stated Resident 1 had not been to activities in a month or so.
During a concurrent record review and interview on 4/6/2023, at 2:28 p.m., with LVN 1, Resident 1's care plans titled Cognition, Communication, ADL & Functional Mobility, Alzheimer's/Dementia, Vision, and Fall Risk, dated 2/27/2023, were reviewed. LVN 1 stated the care plans were not personalized for Resident 1. LVN 1 stated it was important for care plans to be individualized to meet the specific needs of the Resident 1. LVN 1 stated Resident 1 did not have a care plan for wandering and she should have one. LVN a stated it was important to have a care plan for wandering to implement measures to keep Resident 1 safe.
During an interview on 4/13/2023, at 1:54 p.m., with the Social Services Director (SSD), the SSD stated there was always an interdisciplinary team (IDT) meeting when there was a change in condition (COC) so everyone on the team, the family and the staff would be aware of the incident/COC and for the team to make decisions, plan interventions to keep a resident safe, get the resident to a stable condition, and back to their baseline if at all possible. The SSD stated she was not aware the call light and water pitcher were removed out of Resident 1's reach for her safety. The SSD stated the interventions were not determined by nursing alone and should be done with the IDT and the responsible party (RP) to determine the appropriate plan and interventions to keep Resident 1 safe, but it was not done. The SSD stated it did not sound right to her that the call light and water pitcher were out of reach and on top of the overhead light in Resident 1's room. The SSD stated she was not aware Resident 1's bed was blocking the bathroom door and that the door was locked. The SSD an IDT should have been done before implementing such interventions, but it was not done.
During a concurrent record review and interview on 4/19/2023, at 10:56 a.m., with the Director of Nursing (DON), Resident 1's care plans titled Cognition, Communication, ADL & Functional Mobility, Alzheimer's/Dementia, Vision, and Fall Risk, and Nutrition dated 2/27/2023, were reviewed. Reviewed Resident 1's care plan for Activities, dated 2/18/2023 with the DON. The DON stated the care plans for Resident 1 were limited, not individualized, and interventions were not appropriate to meet the needs of the resident because the interventions were not specific enough. The DON stated it was important to have individualized care plans to guide the care and have consistency in the care provided to the resident. The DON stated Resident 1 was not receiving consistent care from the staff. The DON stated, Honestly with the current interventions that have been implemented with her, it appears on some shifts she gets more assistance than others and the result is no consistency. The DON stated the inconsistency in Resident 1's care was due to the lack of personalized care plans and may lead to a decline in the resident's function level and independence. The DON stated Resident 1 did not have customized activities for tactile stimulation. The DON stated too many things fell off the wayside due to the pandemic. The DON stated Resident 1's care plan was not individualized to meet the resident's need for appropriate activities for her diagnosis of legal blindness and dementia. Resident 1's annual IDT care conference, dated 11/2/2022, was reviewed with the DON. The DON indicated an IDT was done to review the care of the resident and make changes as needed for any identified declines. The DON stated the facility had not explored any interventions to improve Resident 1's plan of care for her vision impairment and communication barrier because no issues were identified. The DON stated Resident 1's physical and psychosocial well-being may have declined due to the lack of consistency in the care and the lack of a individualized care plans. The DON stated the facility was not maintaining Resident 1's highest level of independence and her highest practical physical and psychosocial well-being with the current plan of care.
During a review of the facility's policy and procedure (P&P) titled Care Planning- Interdisciplinary Team , dated 9/2013, the P&P indicated, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The P&P indicated, The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not necessarily limited to the following personnel:
a. The resident's Attending Physician
b. The Registered Nurse who has responsibility for the resident
c. The Dietary Manager/Dietician
d. The Social Services Worker responsible for the resident
e. The Activity Director/Coordinator
f. Therapists (speech, occupational, recreational, etc.), as applicable
g. Consultants (as appropriate)
h. The Director of Nursing (as applicable)
i. The Charge Nurse responsible for resident care
j. Nursing Assistants responsible for the resident's care
k. Others as appropriate or necessary to meet the needs of the resident.
During a review of the facility's P&P titled Care Plans- Comprehensive , dated 9/2010, the P&P indicated, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. The P&P indicated, Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The comprehensive carte plan is based on a thorough assessment that includes, bit is not limited to, the MDS. The P&P indicated, Each resident's comprehensive care plan is designed to:
a. Incorporate identified problem areas
b. Incorporate risk factors associated with identified problems
c. Build on the resident's strengths
d. Reflect the resident's expressed wishes regarding care and treatment goals
e. Reflect treatment goals, timetables, and objectives in measurable outcomes
f. Identify the professional services that are responsible for each element of care
g. Aid in preventing or reducing declines in the functional status and/or functional levels
h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program
i. Reflect currently recognized standards of practice for problem areas and conditions.
The P&P indicated, Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. No single discipline can manage the task in isolation .
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
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 provide a means for staff to communicate effectively ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a means for staff to communicate effectively with one of one sampled resident (Resident 1) who speaks Russian-language and is legally blind.
This deficient practice resulted in staff being unable to communicate and guessing the needs of Resident 1. This deficient practice had the potential to negatively impact Resident 1's psychosocial well-being and increased the risk of potentially not meeting the needs of the resident.
Findings:
During a review of Resident 1's admission Record (face sheet), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the diagnoses including dementia (condition characterized by impairment of brain functions, such as memory loss and judgement), legal blindness, history of falling, schizophrenia (a mental disorder characterized by thoughts that seem out of touch with reality and affects a person's ability to think, feel, and behave clearly), and anxiety disorder (a mental disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities).
During a review of Resident 1's Minimum Data Set ([MDS], a standardized resident assessment and care screening tool), dated 2/18/2023, the MDS indicated Resident 1's cognitive (ability to understand) skills for daily decision making was severely impaired. The MDS indicated Resident 1 required supervision for bed mobility, transfers out of bed, walking in room and required extensive assistance for dressing, eating, toilet use, and personal hygiene.
During a review of Resident 1's Communication care plan, dated 2/27/2023, the care plan indicated Resident 1 had impaired communication related to speaking Russian, psychiatric diagnosis, and dementia. The care plan indicated the staff's interventions included to provide resident adequate time to respond when talking with the resident and to encourage activity participation for sensory stimulation and socialization.
During an observation on 4/5/2023, at 10:40 a.m., in Resident 1's room, observed the resident's room was bare and a non-homelike environment. Observed Resident 1 was asleep and lying on a low, metal-framed bed. Observed an old, discolored bedside table with a wooden table and metal legs, and a wooden dresser on the opposite wall of the room. Observed the walls of the room were bare except for three Russian translation handouts taped to the wall labeled Medical, Descriptions, and Family. Observed Resident 1 had a light purple bruise on the left side of the forehead, a purple and yellow bruise above the upper lip area which radiated to the left side of the resident's face. Observed Resident 1 had a small skin tear on her right elbow and on her right hand which appeared dry and had a scab.
During an interview on 4/5/2023, at 10:48 a.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 1 spoke only Russian, and he could not communicate with the resident. CNA 1 stated it was difficult to change Resident 1 because the resident was also blind and did not know what was being done to her, so she would become aggressive toward the staff. CNA 1 stated no one in the facility spoke Russian and the facility did not have a translation system.
During an interview on 4/5/2023, at 11:25 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 knew some basic words in English, such as food, eat, yes, and no, but the resident spoke Russian. LVN 1 stated the only Russian words she knew were yes and no. LVN 1 stated the facility had no means of communication for Resident 1. LVN 1 stated the Resident 1 became combative because she did not understand what care was being provided due to the lack of communication. LVN 1 stated she had no means of communicating to Resident 1 what medications she administered. LVN 1 stated she crushed Resident 1's medications and mixed it with apple sauce and the resident would just think it was food and take the medications.
During an observation on 4/5/2023, at 12:47 p.m., in Resident 1's room, LVN 1 explained to Resident 1 that she was going to check her oxygen level. Resident 1 was pulling and hitting LVN 1's arm and hand when LVN 1 tried to check her oxygen level.
During an interview on 4/5/2023, on 1:56 p.m., with LVN 1, LVN 1 stated Resident 1 had no quality of life because she was kept in her room all the time and she could not communicate with anyone in her native language, and she did not have any activities catered to her. LVN 1 stated it would be nice if the facility had translator services. LVN 1 stated she could count on one hand how many times she had seen Resident 1 taken to walk outside of her room in the two years she had worked at the facility.
During an interview on 4/5/2023, at 4:26 p.m., with CNA 2, CNA 2 stated Resident 1 was blind and was never cooperative when she was changed. Stated Resident 1 only spoke Russian and the facility had no means of communication available to the resident.
During an interview on 4/6/2023, at 10:34 a.m., with LVN 2, LVN 2 stated it was difficult to understand the needs of Resident 1 because the resident spoke Russian. LVN 2 stated she tried her best to help Resident 1, but she had to guess what the resident needed due to the lack of ability to communicate with the resident. LVN 2 stated when she guessed what Resident 1 needed, she had offered food, changed her brief, and gave her pain medication. LVN 2 stated the pain medication would relax the resident and she would go to sleep. LVN 2 stated Resident 1 had not used the call light. LVN 2 stated she was not sure Resident 1 understood the concept of using the call light. LVN 2 stated Resident 1 yelled when she needed something. LVN 2 stated she did not remember if she had been trained to care for a blind resident. LVN 2 stated it was everyone's responsibility to orient a blind resident to their room. LVN 2 stated the lack of communication may affect Resident 1 emotionally and may cause frustration. LVN 2 stated Resident 1 would benefit from having translation services.
During an interview on 4/6/2023, at 2:49 p.m., with the Social Services Director (SSD), the SSD stated Resident 1's son-in-law was called to interpret sometimes. The SSD stated Resident 1 spoke only a couple words in English. The SSD stated the facility did not offer interpreter services but should.
During an interview on 4/6/2023, at 4:00 p.m., with LVN 3, LVN 3 stated Resident 1 spoke Russian and she did not understand what the resident said.
During an interview on 4/6/2023, at 4:20 p.m., with the Director of Nursing (DON), the DON stated the facility did not have interpreter services and stated it would be good to have these services. The DON stated the staff and Resident 1 was not able to communicate because the resident spoke Russian. The DON stated it was important to have interpreter services so residents could communicate their needs. The DON stated Resident 1 had not had repetitive instruction for use of the call light and she should have. The DON stated the communication barrier was the bigger issue and the facility had not met the communication needs of Resident 1 which could have affected her psychosocial well-being. The DON stated the facility needed to increase the hands-on staff availability for Resident 1. The DON stated Resident 1 required more care than the facility was providing.
During a review of the facility's policy and procedure (P&P) titled Translation and/or Interpretation of Facility Services , dated 5/2017, the P&P indicated, This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. The P&P indicated, Competent oral translation of vital information that is not available in written translation, and non-vital information shall be provided in a timely manner and at no cost to the resident through the following means (as available to the facility):
a. A staff member who is trained and competent in the skill of interpreting;
b. A staff interpreter who is trained and competent in the skill of interpreting;
c. Contracted interpreter service;
d. Voluntary community interpreters who are trained and competent in the skill of interpreting; and
e. Telephone interpretation service.
The P&P indicated, Family members and friends shall not be relied upon to provide interpretation services for the resident, unless explicitly requested by the resident. If family or friends are used to interpret, the resident must provide written consent for disclosure of protected health information. It is understood that providing meaningful access to services provided by this facility requires also that the LEP resident's needs and questions are accurately communicated to the staff. Oral interpretation services therefore include interpretation from the LEP resident's primary language back to English. It is understood that in order to provide meaningful access to services provided by this facility, translation and/or interpretation must be provided in a way that is culturally relevant and appropriate to the LEP individual.
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
Accident Prevention
(Tag F0689)
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 provide adequate supervision and a safe environment f...
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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 adequate supervision and a safe environment for one of four sample residents (Resident 1).
This deficient practice resulted in Resident 1 sustaining injuries to her face, hands, and bilateral lower legs potentially caused by resident bumping into the metal framed bed and the wooden dresser in her room.
Findings:
During a review of Resident 1's admission Record (face sheet), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the diagnoses including dementia (condition characterized by impairment of brain functions, such as memory loss and judgement), legal blindness, history of falling, schizophrenia (a mental disorder characterized by thoughts that seem out of touch with reality and affects a person's ability to think, feel, and behave clearly), and anxiety disorder (a mental disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities).
During a review of Resident 1's Minimum Data Set ([MDS], a standardized resident assessment and care screening tool), dated 2/18/2023, the MDS indicated Resident 1's cognitive (ability to understand) skills for daily decision making was severely impaired. The MDS indicated Resident 1 required supervision for bed mobility, transfers out of bed, walking in room and required extensive assistance for dressing, eating, toilet use, and personal hygiene.
During a review of Resident 1's Physician's Orders, dated 2/27/2023, the orders indicated Resident 1 had orders including Eliquis (Medication used to prevent the formation of blood clots. Side effects include bleeding from cuts that take longer to stop, dizziness, and bruising easily) 2.5 milligrams (mg), Metoprolol Succinate ER (Medication used to treat high blood pressure) 25 mg, Olanzapine (medication used to treat schizophrenia) 10 mg, and Norco 5-325 mg, one tablet every six hours as needed for severe pain.
During a review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR) 4.0 Communication Form, dated 11/1/2022, the SBAR indicated Resident 1 was seen scratching her left shin (front of the lower leg) and reopened a laceration she previously had.
During a review of Resident1's SBAR, dated 1/6/2023, the SBAR indicated old, open ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising) wound, dark and scaly.
During a review of Resident 1's SBAR, dated 2/15/2023, the SBAR indicated Resident 1 was noted with bleeding on her left shin. Resident 1 was found scratching her left shin and detached the scab.
During a review of Resident 1's SBAR, dated 3/23/2023, the SBAR indicated Resident 1 was observed picking at her right dorsal (back side) hand. Open ecchymosis with skin flap attached and minor bleeding noted.
During a review of Resident 1's SBAR, dated 3/31/2023, the SBAR indicated Resident 1 was bleeding from her right leg where she had sustained a skin tear. The SBAR indicated the condition that made this condition or symptom worse were that resident was blind.
During a review of Resident 1's SBAR, dated 4/3/2023, the SBAR indicated resident 1 had open ecchymosis on the left outer palm and discoloration and swelling on the upper lip.
During a review of Resident 1's Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal of a resident) conference meeting, dated 2/28/2023, the IDT indicated Resident 1 required frequent redirection due to her mental status and blindness. The IDT indicated Resident 1 had difficulty expressing herself due to language barrier and her admitting diagnosis.
During a review of Resident 1's Vision care plan, dated 2/27/2023, the care plan indicated the resident was at risk of sensory perception deficit related to confusion, dementia, high blood pressure, aging process, and legal blindness. The care plan indicated Resident 1's vision was severely impaired, and staff's interventions included to keep the resident surroundings free of hazard, keep frequently used personal belongings within reach as shoes, etc.
During a review of Resident 1's Fall Risk care plan, dated 2/27/2023, the care plan indicated the resident was at risk of fall and injury due to the following:
1. Impaired cognition;
2. Impaired decision-making;
3. Impaired communication;
4. Impaired vision;
5. Poor safety awareness;
6. Poor judgement; and
7. History of fall
The care plan indicated the staff's interventions included to assist resident with Activities of Daily Living (ADLs, activities such as toilet use, grooming, hygiene, eating, etc.), transfer, mobility, positioning, and locomotion as needed, provide safety education as importance of calling for assistance (use call light or verbal calling), and place the call light within reach.
During a review of Resident 1's care plan for Alzheimer's/Dementia, dated 2/27/2023, the care plan indicated resident had episodes of confusion/forgetfulness, with risk for further decline in cognition related to dementia. The care plan indicated the staff's interventions included to explain all procedures prior to assisting care, give simple directions, one at a time using short words and simple sentences, reassurance as needed with frequent verbal reminders and re-orientation to reality as necessary, and monitor and anticipate needs and meet them.
During an observation on 4/5/2023, at 10:40 a.m., in Resident 1's room, observed the resident's room was bare and a non-homelike environment. Observed call light and water pitcher were placed out of Resident 1's reach and were located on top of the overhead light fixture. Observed Resident 1 was asleep and lying on a low, metal-framed bed. Observed an old, discolored bedside table with a wooden table and metal legs, and a wooden dresser on the opposite wall of the room. Observed the walls of the room were bare except for three Russian translation handouts taped to the wall labeled Medical, Descriptions, and Family. Observed Resident 1 had a light purple bruise on the left side of the forehead, a purple and yellow bruise above the upper lip area which radiated to the left side of the resident's face. Observed Resident 1 had a small skin tear on her right elbow and on her right hand which appeared dry and had a scab.
During an interview on 4/5/2023, at 10:48 a.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 1 was blind and spoke only Russian. CNA 1 stated it was difficult to check on Resident 1 because he had 12 residents assigned and six of the 12 residents were dependent and required more assistance for their ADLs. CNA 1 stated he was not sure how Resident 1 got the skin tears on her shins but stated he had seen the resident hit her legs on the metal-framing of her bed, bump the wall, and the dresser. CNA 1 stated Resident 1 pulled the sheets off the mattress and moved the dresser around her room. CNA 1 stated he did not know how Resident 1 got the bruising on her face. CNA 1 stated it would be better for Resident 1 to be one-to-one because she would probably be safer.
During an interview on 4/5/2023, at 11:25 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had bruises on her face and on her left palm and had wounds on both of her shins. LVN 1 stated she did not know what caused Resident 1's injuries. LVN 1 stated she had seen Resident 1 walk into her dresser and has moved the entire mattress off her bed. LVN 1 stated she thought Resident 1 should be one-on-one because she was blind, did not speak English, and she was confused which made her more prone to accidents.
During a concurrent observation and interview on 4/5/2023, at 12:52 p.m., in Resident 1's room, CNA 1 and Restorative Nursing Assistant (RNA) 1 assisted Resident 1 to the bathroom. Observed Resident 1 was barefoot. No shoes or socks observed in the room. CNA 1 confirmed Resident 1 was barefoot and should be wearing non-skid socks to prevent resident from slipping. Observed Resident 1 stand up and walked with staff guiding her to the restroom. Observed Resident 1 stand up on her own from the toilet and RNA 1 cleaned Resident 1's buttocks and perineum with a towel. CNA 1 and RNA 1 applied a clean adult brief.
During a concurrent observation and interview on 4/5/2023, at 1:00 p.m., in Resident 1's room, the Treatment Nurse (TX) changed Resident 1's dressings to her shins. Observed Resident 1 had skin abrasions on both shins, a dry scab and bruise on her left palm, and a wound on the right hand. The TX stated he did not know how Resident 1 sustained her injuries. The TX stated Resident 1 had a history of scratching and picking at scabs on her skin. The TX stated he had seen Resident 1 destroy her room before. The TX stated Resident 1 used to have wooden blinds and she had ripped them off and broke them. The TX stated he had seen Resident 1 pull the mattress off the bed and knock over the bedside table and stated Resident 1 could have potentially hurt herself.
During an interview on 4/5/2023, at 4:26 p.m., with CNA 2, CNA 2 stated she did not know how Resident 1 got her injuries. CNA 2 stated Resident 1 pulled the sheets off the bed and moved the furniture around the room. CNA 2 stated Resident 1 was redirected when she wandered out of her room.
During an interview on 4/6/2023, at 10:34 a.m., with LVN 2, LVN 2 stated Resident 1 was a very strong and active woman who moved the furniture in her room and climbed into the closet. LVN 2 stated she thought Resident 1 may have scratched her shins from bumping into the metal bed frame. LVN 2 stated it was not safe to leave Resident 1 alone and it would help to prevent injuries if the resident had more supervision. LVN 2 stated Resident 1 would benefit from having a different type of bed and a different type of dresser to help prevent Resident 1 from injuring herself.
During an interview on 4/6/2023, at 1:13 p.m., with the Director of Staff Development (DSD), the DSD stated staff would sometimes put socks on Resident 1 to prevent her from slipping. The DSD stated Resident 1 should be wearing non-skid socks and should have access to her shoes to prevent a fall.
During an interview on 4/6/2023, at 1:30 p.m., with the Activities Director (AD), the AD stated Resident 1 required redirection and had to be one-on-one with activities because she would walk away if she was left alone. The AD stated Resident 1 felt her way around her room by touching the walls. The AD stated she had witnessed Resident 1 push the dresser around her room and spilled water on the floor. The AD stated Resident 1 removed the linens off the mattress and pocketed the call light. The AD stated Resident 1 pocketed everything. The AD stated it was not safe to leave Resident 1 alone during activities because she could hurt herself if she bumped into things and/or someone, could walk away, and fall. The AD stated Resident 1 was a busy-body , always moving things.
During an interview on 4/6/2023, at 3:36 p.m., with LVN 3, LVN 3 stated Resident 1 was known to move the furniture around in her room and bumped into the walls, so staff blocked the bathroom door so resident would not hurt herself. LVN 3 stated a few months ago, Resident 1 was sent to the hospital because she had scratched scabs on her legs and made herself bleed. LVN 3 stated if Resident 1 had more supervision she would not get hurt. LVN 3 stated Resident 1 should be one-on-one.
During an interview on 4/6/2023, at 4:20 p.m., with the Director of Nursing (DON), the DON stated Resident 1 had been at the facility for nine years. The DON stated Resident 1 required frequent monitoring because she was blind and had dementia. The DON stated Resident 1 wandered in her room and the in the hallway across from her room. The DON stated Resident 1 had a history of a fall. The DON stated Resident 1 had pulled the privacy curtain and pulled the blinds off the window, and she used to flood the room. The DON stated Resident 1 required more hands-on availability of staff. The DON stated she was not sure frequent monitoring was enough and stated Resident 1 needed more than the facility was providing.
During a review of the facility's policy and procedure (P&P) titled Safety and Supervision of Residents , dated 12/2007, the P&P indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P&P indicated under Facility-Oriented Approach to Safety, Our resident-oriented approach to safety addresses safety and accident hazards for individual residents. The P&P indicated under Resident-Oriented Approach to Safety, The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents. The P&P indicated under Systems Approach to Safety, Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.
During a review of the facility's P&P titled Policy on 1:1 Resident Monitoring , dated 2017, the P&P indicated, It is the policy of the facility to ensure the resident is safe and if is needed to be monitored closely in certain period of time. The P&P indicated, Based on the facility's assessment on the resident's need for 1:1 monitoring, a staff member will be assigned to the resident every shift.
Apr 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 their written abuse prevention policy and procedure (P&P)...
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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 their written abuse prevention policy and procedure (P&P) by not reporting an allegation of physical abuse, within twenty four hours, between two of six sampled residents (Resident 1 and 2 ) to the State Survey Agency (SSA) and the Ombudsman (an agency who investigates, reports on, and helps settle complaints against the facility) in accordance with State law and Federal Regulations, after Resident 1 and 2 were involved in a verbal altercation that led to Resident 2 pushing Resident 1 when she stood up on 3/11/2023.
This deficient practice resulted in a delay of investigation of the allegation of physical abuse, potentially placing Resident 1 at risk for further abuse and violation of resident rights.
Findings:
During a record review of Resident 1's Face Sheet (admission Record) dated 3/9/2023, the Face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (mental health problem where perception of reality is abnormal and the resident will either be very sad or have high periods of energy]) and anxiety disorder (mental health problem characterized with extreme worry).
During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/4/2023, the MDS indicated Resident 1's cognitive skills for daily decisions making was severely impaired (ability to think and reason). The MDS indicated Resident 1 required supervision with eating, bed mobility, transfer, needed limited assistance with dressing, personal hygiene, and toilet use.
During a review of Resident 2's face sheet, the face sheet indicated Resident 2 was readmitted to the facility on [DATE] with diagnoses that included schizophrenia (mental health problem characterized by an altered perception of reality), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily life), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and anxiety disorder.
During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 1's cognitive skills for daily decisions making was severely impaired. The MDS indicated Resident 1 required supervision with eating, bed mobility, transfer, dressing, needed limited assistance with personal hygiene, and toilet use.
During a review Resident 2's Situation, Background, Assessment, and Recommendation form ([SBAR] a communication tool used by licensed staff when a resident has a change in condition) dated 3/15/2023 at 6:30 p.m., the SBAR indicated on 3/11/23 Resident 1 was allegedly involved in a physical altercation with another resident. Residents 1 and 2 were observed having an intense conversation when suddenly Resident 1 stood and began to scream obscenities at Resident 2. Resident 2 pushed Resident 1 back down in her wheelchair.
During a review of Resident 2's Departmental Progress Notes dated 3/15/2023 at 7:29 p.m., the notes indicated the physical altercation between Resident 1 and 2 occurred on 3/11/2023. The notes indicated the administrator, director of nursing (DON), California Department of Public Health (CDPH), ombudsman, and the local police department were all notified.
During a review of the facility's Transmission verification report, the report indicated the altercation between Resident 1 and 2 was reported to all the authorities on 3/15/2023 at 5:40 p.m.
During a telephone interview with Registered Nurse (RN) 1 on 4/24/2023 at 3: 23 p.m., RN 1 stated Resident 1 and 2's altercation occurred on 3/11/2023 and should have been reported to the abuse coordinator sooner and reported to the authorities sooner for the safety of the residents. RN 1 stated the incident was reported on 3/15/2023.
During a telephone interview with the Director of Nursing (DON) on 4/26/2023 at 12:01 p.m., the DON stated the altercation between Resident 1 and 2 should have been reported sooner and not 4 days after the incident.
During a record review of the facility's Policy and Procedure (P&P) titled, Abuse Reporting and Investigation (updated 11/2018), the P&P indicated the facility will report all allegations of abuse by law and regulations to the appropriate agencies within two hours . The Abuse Prevention Coordinator (APC) or designee will notify law enforcement, ombudsman, and CDPH Licensing and Certification by telephone immediately or as soon as practicable, and in writing ([SOC 341]Report of Suspected Dependent Adult/Elder Abuse) within twenty-four (24) hours including weekends of all other types of allegations of abuse.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
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 written abuse prevention policy and procedure by not ...
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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 written abuse prevention policy and procedure by not submitting a final investigative report of an allegation of physical abuse (intentional body injury) between two of seven sampled residents (Resident 1 and Resident 2) to the State Agency within 5 working days of the incident.
This deficient practice resulted in a delay of investigation of the allegation of physical abuse, potentially placing Resident 1 at risk for further abuse and violation of resident rights.
Findings:
During a record review of Resident 1's Face Sheet (admission Record) dated 3/9/2023, the Face sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses including schizoaffective disorder (mental health problem where perception of reality is abnormal and the resident will either be very sad or have high periods of energy]) and anxiety disorder (mental health problem characterized with extreme worry).
During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/4/2023, the MDS indicated Resident 1's cognitive skills for daily decisions making was severely impaired (ability to think and reason). The MDS indicated Resident 1 required supervision with eating, bed mobility, transfer, needed limited assistance with dressing, personal hygiene, and toilet use.
During a review of Resident 2's face sheet, the face sheet indicated Resident 2 was readmitted to the facility on [DATE] with a diagnoses that included schizophrenia (mental health problem characterized by an altered perception of reality), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily life), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and anxiety disorder.
During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 1's cognitive skills for daily decisions making was severely impaired. The MDS also indicated that Resident 1 required supervision with eating, bed mobility, transfer, dressing, needed limited assistance with personal hygiene, and toilet use.
During a review Resident 2's Situation, Background, Assessment, and Recommendation form ([SBAR] a communication tool used by licensed staff when a resident has a change in condition) dated 3/15/2023 at 6:30 p.m., the SBAR indicated on 3/11/23 Resident 1 was allegedly involved in a physical altercation with another resident. Residents 1 and 2 were observed having an intense conversation when suddenly Resident 1 stood and began to scream obscenities at Resident 2. Resident 2 pushed Resident 1 back down in her wheelchair.
During a review of Resident 2's Departmental Progress notes dated 3/15/2023 at 7:29 p.m., the notes indicated the physical altercation between Resident 1 and 2 occurred on 3/11/2023. The notes indicated the administrator, director of nursing (DON), California Department of Public Health (CDPH), ombudsman, and the local police department were all notified.
During a review of the facility's Transmission verification report, the report indicated Resident 1 and 2's altercation summary report was faxed to CDPH on 3/17/2023.
During a phone interview with the Director of Nursing (DON) on 4/26/2023 at 12:01 p.m., the DON stated a written report of the abuse investigations should have been submitted to the state agency within 5 days of the incident.
During a record review of the facility's Policy and Procedure (P&P) titled, Abuse Reporting and Investigation (updated 11/2018), the P&P indicated the Abuse Prevention Coordinator (APC) will provide a written report of the results of the abuse investigations and appropriate action taken within five working days of the reported allegation.
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
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 interview and record review, the facility failed to develop and implement an individualized resident-centered plans of ...
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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 and implement an individualized resident-centered plans of care with interventions to meet the needs of one of four sampled residents (Resident 1).
This deficient practice negatively affected the delivery of necessary care and services for Resident 1 and potentially affected the resident's quality of life and reaching her highest level of independence and highest practical physical and psychosocial well-being.
Findings:
During a record review of Resident 1's Face Sheet (admission Record) dated 3/9/2023, the Face sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses including type 2 diabetes (disease that affect the way the body process glucose [sugar]) with diabetic chronic kidney disease (the body cant filter waste from the blood), hypertensive heart disease (changes in the heart that causes high blood pressure [pressure it takes for heart to pump the blood to the body]), gout (common form of inflammatory arthritis [group of conditions whereby the body's defense system attacks the tissues of the joints instead of germs and other foreign substances]) of one joint a time, usually painful) schizoaffective disorder (mental health problem where perception of reality is abnormal and the resident will either be very sad or have high periods of energy]) and anxiety disorder (mental health problem characterized with extreme worry).
During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/4/2023, the MDS indicated Resident 1's cognitive skills for daily decisions making was severely impaired. The MDS also indicated that Resident 1 required supervision with eating, bed mobility, transfer, needed limited assistance with dressing, personal hygiene, and toilet use.
During a record review of Resident 1's Physician Orders for the month of March 2023, the orders indicated the following medication orders:
a. Started on 10/25/2022:
1. Aspirin (medication to stop swelling and pain) 81 milligrams (mg) one tablet orally daily;
2. Hydrochlorothiazide (medication for high blood pressure) 25 mg take one tablet orally daily;
3. Potassium chloride extended release (supplement) 8 milliequivalents one tablet orally daily;
4. Amlodipine besylate (medication for high blood pressure) 5 mg one tablet twice a day orally;
5. Lisinopril (medication for high blood pressure) 20 mg one tablet twice a day orally;
6. Allopurinol (medication for high blood pressure) one tablet orally twice a day;
7. Metoprolol (medication for high blood pressure) 50 mg take one tablet orally twice a day;
8. Novolog (medication to lower high blood sugar)100 unit/ milliliter flex pen, inject subcutaneous per sliding scale (depending on the blood sugar level a specific dose is to be administered);
b. Started on 11/9/2022, Pro-stat (protein supplement) sugar free liquid give 30 cubic centimeter orally twice a day;
c. Started on 2/16/2023 Risperdal (medication to treat schizophrenia) 0.5mg/milliliter solution give 0.5 ml equal (=) 0.5 mg orally twice a day.
During a record review or Resident 1's Medication Administration Records (MAR) from November 2022 to February 2023, the MARs indicated Resident 1 was noncompliant with taking her medications.
During a review of Resident 1's Situation Background and Assessment and Recommendation (SBAR) communications form dated 11/8/2022 and reevaluated on 2/2023, the SBAR indicated Resident 1 was verbally aggressive seen arguing with herself or yelling at the walls. The SBAR also indicated Resident 1 was noncompliant with medications and unable to be redirected.
During a review of Resident 1's care plan, dated 11/8/2022 and , titled, Noncompliance with medication, the goal indicated Resident 1 would be informed of risk and consequences of noncompliance with treatment. The plan included to transfer to the hospital and to administer Haldol (medication to manage symptoms of schizophrenia) 5 milligrams and Ativan (medication to treat anxiety) 1 mg by injection times one dose. There were no other measures indicated to address the residents noncompliance with medications.
During a review of Resident 1's Medication Administration Record (MAR) for the month of March 2023, the MAR indicated, from 3/1/2023 to 3/18/2023 the following medications were not administered:
1. Aspirin Enteric coated not administered thirteen times.
2. Hydrochlorothiazide was not administered fourteen times
3. Potassium chloride was not administered ten times
4. Allopurinol was not administered thirteen times
5. Amlodipine besylate was not administered 29 times out of 36 opportunities
6. Lisinopril was not administered 29 times out of 36 opportunities.
7. Metoprolol was not administered 29 times out of 36 opportunities
8. Pro-stat was not administered 26 times out of 36 opportunities
9. Risperdal was not administered 28 times out of 36 opportunities.
During a review or Resident 1's Departmental Progress Notes from November 2022 to March 2023, the notes indicated there was no documented evidence of any plans or interventions addressing the resident's noncompliance with medication mentioned.
During a review of an undated Interdisciplinacy Team (IDT, group of different disciplines working together towards a common goal of a resident) document, the IDT document indicated there was no documented evidence of the discussion of Resident 1's noncompliance.
During a review of Resident 1's Multi Interdisciplinary Team (IDT) Conference record dated 3/13/2023, the record indicated there was no documented evidence of Resident 1's noncompliance with medications.
During a review of Resident 1's Encounter- Home Visit (psychiatric notes) dated 1/11/2023, 2/16/2023, 3/8/2023, the notes indicated nothing about the resident's noncompliance with medications. The notes indicated there were no interventions or plans to address the resident's noncompliance.
During a telephone interview with Registered Nurse (RN) 1 on 4/24/2023 at 3: 23 p.m., RN 1 stated Resident 1 has been refusing most of her medications. RN 1 stated an SBAR was completed on 11/8/2022 because of the resident's noncompliance with medications. RN 1 stated the resident received a one-time dose of Haldol and Ativan as ordered. RN 1 stated a comprehensive and person centered care plan should have been developed to address resident's noncompliance with medications.
During a telephone interview with the Director of Nursing (DON) on 4/26/2023 at 12:01 p.m., the DON stated a comprehensive person centered care plan should have been created for the resident to guide the care rendered and to guide the staff on how to handle noncompliance.
During a review of the facility's policy and procedure (P&P) titled, Care Planning- Interdisciplinary Team , dated 9/2013, the P&P indicated, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The P&P indicated, The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team.
During a review of the facility's P&P titled Care Plans- Comprehensive , dated 9/2010, the P&P indicated, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. The P&P indicated, Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The comprehensive carte plan is based on a thorough assessment that includes, bit is not limited to, the MDS. The P&P indicated, Each resident's comprehensive care plan is designed to:
a. Incorporate identified problem areas
b. Incorporate risk factors associated with identified problems
c. Build on the resident's strengths
d. Reflect the resident's expressed wishes regarding care and treatment goals
e. Reflect treatment goals, timetables, and objectives in measurable outcomes
f. Identify the professional services that are responsible for each element of care
g. Aid in preventing or reducing declines in the functional status and/or functional levels
h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program
i. Reflect currently recognized standards of practice for problem areas and conditions.
The P&P indicated, Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. No single discipline can manage the task in isolation .
Apr 2023
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
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 deliver sufficient nursing staff to provide care for two of four sa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to deliver sufficient nursing staff to provide care for two of four sampled residents (Resident 1 and 5) by failing to ensure the resident's call lights (device used by residents to signal his or her need for assistance from healthcare staff) were answered in a timely manner.
This deficient practice resulted in Resident 1 and 5's unmet needs that can lead to a diminished wellbeing.
Findings:
During a record review of the Resident council minutes dated 1/13/2023, the minutes indicated Resident 1 and 5 complained to the council that nurses were not coming back as promised when answering call lights.
a. During a record review of Resident 1's Face Sheet (admission Record) dated 11/17/2022, the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including paraplegia (is a specific pattern of paralysis [which is when you can't deliberately control or move your muscles] that affects your legs), primary generalized osteoarthritis (joints deteriorate and the it is characterized by joint pain, stiffness, limited range of motion, and weakness), anxiety disorder (mental health problem characterized by persistent worry), and polyneuropathy (the simultaneous malfunction of many nerves throughout the body which causes problems with sensation, coordination, and or other body functions).
During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/16/2023, the MDS indicated Resident 1's cognitive skills for daily decisions making was intact (ability to think and reason). The MDS also indicated that Resident 1 required supervision with eating, needed limited assistance with bed mobility and transfer, and required extensive assistance from one staff with personal hygiene, dressing, and toilet use.
During an interview with Resident 1 on 4/5/2023 at 11:33 a.m., Resident 1 stated the call light goes unanswered sometimes all night which meant that she had to sit on extended periods in a wet soaking adult briefs that leaks to her pants. Resident 1 stated it was an ongoing problem. Resident 1 stated being unattended leaves her feeling cold and sad.
During an interview with Licensed Vocational Nurse (LVN) 1 on 4/5/2023 at 12:34 p.m., LVN 1 stated that the call light needed to be answered in a timely manner to ensure residents' needs were met. LVN 1 stated if residents' soiled briefs needed to be change it should be timely to prevent skin problems. LVN 1 stated she read the Resident Council minutes and it did state that nurses were not answering the call lights in a timely manner by not returning to the residents as promised.
b. During a record review of Resident 5's Face Sheet dated 4/72023, the Face Sheet indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including polyneuropathy, epilepsy (abnormal brain activity causing sudden alteration in behavior), and respiratory failure (serious condition making it difficult to breath).
During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5's cognitive skills for daily decisions making was intact. The MDS also indicated Resident 5 required supervision with eating, and required extensive assistance from one staff with bed mobility, transfers, personal hygiene, dressing, and toilet use.
During an interview with Resident 5 on 4/5/2023 at 2:13 p.m., Resident 5 stated call lights do not get answered for a long time on the 11 p.m. to 7 a.m. (night) shift, and on the 3 p.m. to 11 p.m. (evening) shift. Resident 5 stated she did not know how long but she waited for a long time.
During an interview with the Director of Staff Development (DSD) on 4/6/2023 at 1:14 p.m., the DSD stated all residents' call lights should be answered in a timely manner.
During an interview with the Director of Nursing (DON) on 4/6/2023 at 4:20 p.m., the DON stated the call light should always be answered in a timely manner.
During a record review of the facility Policy and Procedure (P&P) titled, Answering the Call Light (revised 10/2010), the P&P indicated the purpose of the procedure was to respond to resident's requests and needs. The P&P indicated staff needed to answer the call lights as soon as possible. The P&P indicted if you promised the resident you will return, do so promptly.
During a review of the facility's Facility Assessment Tool (revised 3/15/2023), the tool indicated CNA staffing assignments were adjusted based on the resident's need, census, and acuity.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
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 two of four sampled residents' (Resident 1 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 ensure two of four sampled residents' (Resident 1 and 4) call light (device used by residents to signal his or her need for assistance from healthcare staff) was within reach.
This deficient practice had the potential to result in Resident 1 and 4's inability to call for help when needed which can negatively impact the resident's wellbeing.
Findings
a. During a record review of Resident 4's Face Sheet (admission Record) dated 2/8/2023, the Face Sheet indicated Resident 4 , who was legally blind, was readmitted to the facility on [DATE] with diagnoses including encephalopathy (brain problem), generalized osteoarthritis (joints deteriorate and the it is characterized by joint pain, stiffness, limited range of motion, and weakness), dementia (general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), schizophrenia (serious mental disorder in which people interpret reality abnormally), and anxiety disorder (mental health problem characterized by persistent worry).
During a review of Resident 4's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/1/2023, the MDS indicated Resident 4's cognitive skills for daily decisions making was severely impaired (ability to think and reason). The MDS indicated Resident 4 required supervision with bed mobility, transfers and walking in the room, needed limited assistance with walking in the corridor, bed mobility and transfer, and required extensive assistance from one staff with eating, personal hygiene, dressing, and toilet use.
During an observation in Resident 4's room on 4/5/2023 at 10:40 a.m., the call light was observed on top of the overhead light where the resident could not reach it.
During a concurrent observation of the placement of Resident 4's call light and an interview with Certified Nurse Assistant (CNA) 4 on 4/5/2023 at 10:48 a.m., CNA 4 stated Resident 4 could not reach her call light. CNA 4 stated Resident 4 should have a call light within her reach.
b. During a record review of Resident 1's Face Sheet (admission Record) dated 11/17/2022, the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses including paraplegia (is a specific pattern of paralysis [which is when you can't deliberately control or move your muscles] that affects your legs), primary generalized osteoarthritis, and anxiety disorder.
During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1's cognitive skills for daily decisions making was intact. The MDS also indicated Resident 1 required supervision with eating, needed limited assistance with bed mobility and transfer, and required extensive assistance from one staff with personal hygiene, dressing, and toilet use.
During a concurrent observation and interview with Resident 1 on 4/5/2023 at 11:33 a.m., Resident 1's call light was observed to be tied on the right side rail of the bed and the resident was sitting by the opposite side (left side) of the bed. The call light was not in reach. Resident 1 stated she should not reach the call light all the time.
During an observation on 4/5/2023 at 11:48 a.m., CNA 1 entered the room to help Resident 1 and when CNA 1 left the room, CNA 1 did not move the resident's call light closer to Resident 1.
During a concurrent observation and interview with CNA 2 on 4/5/2023 at 12:02 p.m., the call light was still noted tied to the bed where Resident 1 could not reach the call light. CNA 2 stated Resident 1's call light was in the opposite side of the bed and was out of reach of the resident. CNA 2 stated call light should be within reach so she can call for help.
During an interview with Licensed Vocational Nurse (LVN) 1 on 4/5/2023 at 12:25 p.m., LVN 1 stated the call light needed to be in reach so residents can call. LVN 1 stated the residents' call light should have been in reach and she need to be changed when she was wet to prevent skin problems.
During an interview with the Director of Staff Development (DSD) on 4/6/2023 at 1:14 p.m., the DSD stated all residents should have a call light so they can call for help when they need it; and the call light needs to be within reach.
During an interview with the Director of Nursing (DON) on 4/6/2023 at 4:20 p.m., the DON stated all residents should have a call light within reach so they can call the nurse for assistance.
During a record review of the facility's Policy and Procedure (P&P) titled, Answering the Call Light (revised 10/2010), the P&P indicated the purpose of the procedure was to respond to resident's requests and needs with a call light. The P&P indicated when resident was confined to a chair be sure the call light was within reach of the resident.
Mar 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
Deficiency F0688
(Tag F0688)
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 one of three sampled residents (Resident 1), w...
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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 one of three sampled residents (Resident 1), with limited range of motion (ROM - the extent of movement of a joint) on both upper and lower extremities, received restorative nursing care (RNA program [a program available in nursing homes that helps residents maintain any progress they've made during therapy treatments, enabling them to function at a high capacity]) five times a week as indicated in the physician's order by failing to:
1. Ensure Resident 1 received 84 RNA program services from January to February 2023 as ordered.
2. Develop and implement individualized resident-centered care plan for Resident 1's limited ROM on both upper and lower extremities.
This deficient practice had the potential to place Resident 1 at risk for further ROM decline and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).
Findings:
During a review Resident 1's admission Record (Face Sheet), the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included paraplegia (is the loss of muscle function in the lower half of the body, including both legs), osteoarthritis (the wearing down of the protective tissue at the ends of bones, occurs gradually and worsens over time), 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), polyneuropathy (is the simultaneous malfunction of many peripheral nerves throughout the body), muscle spasm and lower back pain.
During a review of Resident 1's Minimum Data Set (MDS, a comprehensive standardized assessment and care-screening tool), dated 2/16/2023, the MDS indicated Resident 1 had severe impaired cognition (ability to think and reason). The MDS for functional limitation in range of motion indicated Resident 1 had impairment on both upper and lower extremities.
During a concurrent observation and interview with Resident 1 on 3/1/2023 at 9 a.m., in Resident 1's room. Resident 1 was observed sitting on a wheelchair, both hands were contracted and both legs were paralyzed (inability to move). Resident 1 stated she was not getting proper treatment for RNA program services. Resident 1 stated she tried to perform ROM exercises on her own, however both hands were contracted and painful. Resident 1 was observed with teary eyes when verbalizing she was not being helped by the nurses.
During an interview with Certified Nurse Assistant (CNA) 1 on 3/1/2023 at 10:20 a.m., CNA 1 stated Resident 1 has been refusing care because she did not like Spanish speaking staff. CNA 1 stated she notified Licensed Vocational Nurse (LVN) 1 regarding Resident 1's refusal of care. CNA 1 stated she was not reassigned to other residents even though Resident 1 did not like her.
During an interview with LVN 1 on 3/1/2023 at 10:30 a.m., LVN 1 stated Resident 1 complainted about every single thing. LVN 1 stated Resident 1 had been verbally aggressive to staff and refused care. LVN 1 stated Resident 1's physician should be notified regarding Resident 1's behavior of refusing care, because continuous refusal would cause further decline in ROM and contractures.
During a telephone interview with Restorative Nurse Assistant (RNA) 2 on 3/10/2023 at 2:30 p.m., RNA 2 stated Resident 1 had been refusing the RNA program on different occasions. RNA 2 stated she documented Resident 1's refusal episodes on the restorative record (RR) on a daily basis, and document on the restorative nursing weekly summary (RNWS) on a weekly basis. RNA 2 stated she notified Resident 1's change nurse for the resident's refusal of RNA program services.
During a telephone interview with Registered Nurse (RN) 1 on 3/10/2023 at 2:43 p.m., RN 1 stated Resident 1's refusal of RNA program services should be reported to the physician immediately. RN 1 stated Resident 1's behavior of refusal of RNA program services would further decline Resident 1's limited ROM and contractures. RN 1 stated it was very important to document and report Resident 1's refusal to reevaluate the effectiveness of treatment.
During a telephone interview with RNA 1 on 3/17/2023 at 10:38 a.m. RNA 1 stated Resident 1 did not like RNA1 because she was Hispanic. RNA 1 stated she only approached Resident 1 with RNA 3 (non-Hispanic), however Resident 1 still refused the RNA program.
During a telephone interview with the Rehabilitation Director (RD) on 3/17/2023 at 11:29 a.m., the RD stated she was aware Resident 1 was refusing RNA services on some occasions because of personal reasons towards RNA 1. The RD stated the rehabilitation department explained to Resident 1 the benefits of the RNA program and the consequence of not receiving it. The RD stated the rehabilitation department provided in-service trainings to RNA staff twice a month.
During a review of Resident 1's Physician's Orders, for the month of March 2023, the orders indicated as follows:
1. RNA for bilateral (both) wrist and hand passive range of motion (PROM - achieved when an outside force [such as a therapist] exclusively causes movement of a joint and is usually the maximum range of motion that a joint can move} daily, 5 times per week or as tolerated.
2. RNA to apply bilateral hand splints (device designed to protect and support painful, swollen or weak joints and their surrounding structures by making sure your hand and wrist are positioned correctly) used for 4 to 6 hours daily, 5 times per week or as tolerated. Perform skin inspection before and after application.
3. RNA daily, 5 times per week for gentle PROM on bilateral lower extremities (BLE) as tolerated. RNA to Monitor pain level before , during and after. Notify Charge Nurse if pain noted.
4. RNA daily, 5 times per week for application of bilateral ankle foot orthosis (AFO) for 2 to 4 hours or as tolerated.
5. RNA daily, 5 times per week for application of bilateral knee extension splints for 2 to 4 hours or as tolerated. RNA to monitor any complaints of pain and skin discoloration prior and after splint application and report to charge nurse.
During a review of Resident 1's Restorative Record (RR) from January 1, 2023 to February 28, 2023, the RR indicated Resident 1 did not receive a total of 84 RNA program services. There was no change of condition reported to Resident 1's physician.
During a review of Resident 1's Restorative Nursing Weekly Summary (RNWS) for the months of January and February 2023, the weekly summmaries indicated Resident 1's refusal of services were not recorded.
During a review of Resident 1's Medication Administration Record (MAR) for the month of February 2023, for pain assessment every shift, the MAR indicated Resident 1 had complaints of severe pain on the following dates: February 1, 2, 3, 7, 13, 17, 20, 21, 22, 25, 26, 27, 2023. The MAR indicated pain medication was given, however no change of condition initiated, nor 72-hour monitoring.
During a review of Resident 1's care plan titled, Risk for decrease in range of motion (ROM) on bilateral upper extremities (BUE), initiated on 8/22/2022, the care plan indicated the goal was to maintain current ROM on the resident's BUE (hand and wrist). The staff's interventions indicated to provide gentle PROM on bilateral wrists and hands.
During a review of Resident 1's care plan titled, Risk for decrease in ROM on bilateral lower extremities (BLE), initiated on 5/10/2022 and revised on 11/17/2022, the care plan indicated the goals were to maintain current ROM on BLE. The staff's interventions indicated to provide RNA program daily, 5 times per week, gentle PROM on BLE, application of bilateral ankle foot orthosis (AFO - splint for the ankle to help stabalize the ankle and foot) and knee extension splints for 2 to 4 hours as tolerated, with skin check every 2 hours, and monitor complaint of pain during activity and notify Charge Nurse if any.
During a review of the facility's policy and procedures (P&P) titled, Rehabilitative Nursing Care, revised 7/2013, the P&P indicated the rehabilitative nursing care is provided for each resident admitted . The P&P indicated the following:
1. General rehabilitative nursing care is that which does not require the use of a qualified Professional Therapist to render such care.
2. Nursing personnel are trained in rehabilitative nursing care. Our facility has an active program of rehabilitative nursing which is developed and coordinated through the resident's care plan.
3. The facility's rehabilitative nursing care program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence.
4. Rehabilitative nursing care is performed daily for those residents who require such service. Such program includes, but is not limited to:
a. Maintaining good body alignment and proper positioning;
b. Encouraging and assisting bedfast residents to change positions at least every two (2) hours ( day and night) to stimulate circulation and to prevent decubitus ulcers, contractures, and deformities;
c. Making every effort to keep residents active and out of bed for reasonable periods of time, except when contraindicated by physicians' orders, and encouraging residents to achieve independence in activities of daily living by teaching self care and ambulation activities;
d. Assisting residents to adjust to their disabilities, to use their prosthetic devices, and to redirect their interests, if necessary;
e. Assisting residents to carry out prescribed therapy exercises between visits of the therapists;
f. Assisting residents with their routine range of motion exercises;
g. Bowel and bladder training; and
h. Others as prescribed by the resident's Attending Physician.
5. Through the resident care plan, the goals of rehabilitative nursing care are reinforced in the Activities Program, Therapy Services, etc.
6. Rehabilitative nursing techniques are included in the orientation program and the ongoing Staff Development Program.
Feb 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
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 abuse prevention policy for one of two sampled reside...
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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 abuse prevention policy for one of two sampled residents (Resident 1), who alleged being raped (type of sexual assault usually involving sexual intercourse or other forms of sexual penetration carried out against a person without their consent or against their will) by another resident (Resident 2), by failing to:
1. Identify an alleged allegation of rape as a violation involving sexual abuse between Residents 1 and 2.
2. Report an alleged abuse incident to the Administrator and to the Department of Public Health (DPH).
This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect Resident 1 and other residents from abuse.
Findings:
a. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and major depressive disorder (serious medical illness that negatively affects how you feel, the way you think and how you act. Depression causes feelings of sadness and/or a loss of interest in activities you once enjoyed).
During a review of Resident 1's History and Physical (H&P), dated 5/22/2022, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.
During a review of Resident 1's Minimum Data Sheet (MDS, a standardized assessment and care planning tool), dated 8/9/2022, the MDS indicated Resident 1's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was not intact. The MDS indicated Resident 1 had no temporal orientation. The MDS indicated Resident 1 was independent and required supervision with activities of daily living (ADLs, self-care activities performed daily such as grooming, personal hygiene, and toileting). The MDS indicated Resident 1 had a diagnosis of anxiety disorder (disorder- intense, excessive, persistent worry and fear about everyday situations.), depression (feelings of sadness), bipolar disorder (a mental illness that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks) and schizophrenia.
b. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] with diagnoses that included angina pectoris (a type of chest pain caused by reduced blood flow to the heart) and bradycardia (slow heart rate. Heart rate less than 60 beats a minute).
During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was intact. The MDS indicated Resident 2 required supervision with ADLs.
During an interview with the Administrator (ADM) on 10/14/2022 at 1:25 p.m., the ADM stated while investigating an altercation between Resident 1 and Resident 2 on 10/13/2022, ADM discovered Certified Nursing Assistant (CNA 1) has documented on CNA 1 attestation notes dated 10/11/2022 that there was a prior incident on 10/3/2022 where Resident 1 screamed rape. The ADM stated he started his investigation upon discovering Resident 1's allegation he was raped by Resident 2. During his interview with CNA 1, CNA 1 informed him that Resident 1 screamed rape on 10/3/2022 and CNA 1 went to Resident 1's room but did not see any signs of abuse. CNA 1 found both residents (Resident 1 and 2) were fully clothed and in their beds then informed Licensed Vocational Nurse (LVN) 1 and LVN 1 went to the resident's room.
Further interview with the ADM, the ADM stated during his investigation on 10/13/2022, LVN 1 told him that he assessed the situation between Resident 1 and Resident 2 and LVN 1 felt there was no rape that happened. The ADM stated LVN 1 interviewed Resident 1's roommate (Resident 3) and Resident 3 said he did not witness anything happened. The ADM stated LVN 1 assigned staff to monitor Resident 1 and 2, and both residents were on continuous watch because they (Resident 1 and Resident 2) were the only residents in the red zone area (designated area of the facility for residents with COVID-19 [highly infectious respiratory disease]). The ADM stated LVN 1 told him that he did not inform any one about the alleged rape because he did not see any sign of assault. The ADM stated LVN 1 should have reported the allegation of sexual abuse to the ADM as soon as it was reported to LVN 1 on 10/3/2022, so it could have been investigated timely.
During an interview with CNA 1 on 2/7/023 at 3:12 p.m., CNA 1 stated when she became aware of the alleged abuse, CNA 1 went to investigate the situation between Resident 1 and Resident 2. CNA 1 stated she informed LVN 1 about the alleged abuse. CNA 1 stated she documented the alleged abuse between Resident 1 and Resident 2.
During a review of the facility's policy and procedure (P/P) titled, Abuse Investigations, dated April 2014, the P/P indicated all reports of resident abuse shall be thoroughly and promptly investigated by facility management.
Feb 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
Deficiency F0776
(Tag F0776)
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 obtain radiology services in a timely manner to meet th...
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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 obtain radiology services in a timely manner to meet the needs of one of 3 sampled residents (Resident 1) by failing to follow-up on the physician's order for an x-ray (test that produces images of the structures inside body, particularly bones) of the right hip for the resident after a fall.
This deficient practice has the potential to result in a delay in treatment and complications for Resident 1.
Findings:
During a review of Resident 1 ' s Face Sheet, the Face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including difficulty in walking (abnormal gait), muscle wasting and atrophy (wasting or thinning of muscle mass.), malignant neoplasm of the prostate (cancer that begins in the gland cells of the prostate.)
During a review of Resident 1 ' s History and Physical (H&P) dated 8/10/2022, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool) dated 11/3/2022, the MDS indicated the resident required limited assistance (resident highly involved in activity; staff provided guided maneuvering of limbs or other non-weight-bearing assistance) for activities of daily living (ADL ' s) including bed mobility, transfer, eating, personal hygiene and toileting.
During a review of Resident 1 ' s Situation, Background, Assessment and Recommendation ([SBAR], an internal communication form) dated 12/14/2022, the form indicated the resident had an unwitnessed fall at the facility in the morning while attempting to transfer from bed to wheelchair and complained of new pain to the right leg. The form also indicated resident exhibited guarding/bracing and body stiffening due to pain.
During a review of Resident 1 ' s Physician ' s Telephone Order dated 12/14/2022 at 2:18 p.m., the order indicated x-ray of the right humerus (upper arm bone), right knee and bilateral (both) hips should be completed for the resident.
During a review of Resident 1 ' s Department Notes dated 12/16/2022 at 1:10 p.m., the notes indicated Resident ' s 1 x-ray should have been done on 12/15/2022 however was not done. The notes also indicated Licensed Vocational Nurse (LVN) 2 contacted the x-ray company on 12/16/2022 at 8:15 a.m. to follow-up on the order.
During a concurrent interview and record review on 12/27/2022 at 1:40 p.m. and 2:48 p.m. with Registered Nurse (RN) 2, RN 2 stated the physician was notified on 12/16/2022 at 2:50 p.m. about Resident 1 ' s x-ray not being completed, and the physician gave an order for the resident to be transferred to a general acute care hospital (GACH). The resident's x-ray was completed on 12/16/2022 at 5:22 p.m. and indicated he had a right femoral (thigh bone) neck fracture. RN 2 also stated the facility should have followed-up with x-ray on 12/15/2022 however was not done.
During an interview on 12/27/2022 at 2:50 p.m. with Director of Nursing (DON), DON stated licensed nurses were responsible to follow-up with physician ' s orders for x-rays and should be done within 24 hours. DON stated it was unacceptable to wait 48 hours for an x-ray to be done and this was important to ensure the physician was notified of the result if there was injury, implement a plan of care and transfer the resident to the hospital sooner.
During a review of the facility ' s policy and procedure (P&P) titled, Lab and Diagnostic Test Results. Clinical Protocol dated 11/2018, the P&P indicated the staff would process test requisitions and arrange for tests. A nurse would try to determine whether the test was done; As a routine screen or follow-up.
Aug 2021
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Residents 53 and 82) were free from verbal abuse from Resident 65.
This deficient prac...
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Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Residents 53 and 82) were free from verbal abuse from Resident 65.
This deficient practice had the potential for Residents 53 and 82 to feel powerless and unprotected.
Findings:
During an observation on 7/26/21 at 10 a.m., Resident 65 was observed calling her roommate (Resident 82) ni-ger, b-tch, and stupid. Resident 65 was then observed yelling at other residents and staff demanding get me some coffee now.
During a concurrent observation and interview with Resident 82 on 7/26/21 at 11:16 a.m., Resident 82 stated Resident 65 was verbally abusive to her. Resident 82 stated Resident 65 called her tramp and b-tch, and yelled at her all night causing her an inability to sleep well. Resident 82 stated staff have to come in and calm Resident 65 down every day, especially at night. Resident 65 was observed yelling at Resident 82 stating, You b-tch, I hate you b-tch. Resident 65 was also observed telling Resident 82, You talk too much and you're a liar. Resident 65 was observed stating to Resident 82, Get off of your lazy ass and get me some coffee while Resident 82 laid in bed and tried to take a nap after her activities. Resident 82 stated Resident 65 called her racist names such as ni-ger all night long. Resident 53 was observed shaking her head and staring out of the window.
During a subsequent interview with Resident 53, Resident 53 stated Resident 65 was loud but the resident did not bother her too much. Resident 53 stated Resident 65 bothered Resident 82 during the night.
During an interview on 7/27/21 at 10:00 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 65 had displayed aggressive behavior. CNA 1 stated Resident 65 yelled if she was touched by staff or if she did not want to be disturbed. CNA 1 stated she has observed Resident 65 disturbing other residents verbally and has been observed physically hitting staff while changing her wet brief. CNA 1 stated she informed some of the charge nurses of Resident 65's verbally aggressive behavior, but the behavior continued. CNA 1 stated the charge nurse's response was that's just her behavior.
During an interview on 7/27/21 at 10:05 a.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she had not encountered Resident 65 displaying aggressive behavior towards her roommates but the resident was aggressive towards staff. LVN 1 stated she witnessed Resident 65 yelling at staff for coffee and demanding medication.
During an interview on 7/27/21 10:34 a.m. with the Social Services Director (SSD), the SSD stated she was in the process of placing Resident 65 in a different room that was compatible with the resident's personality. SSD stated Resident 65 has been mentally declining over the past month. SSD was not aware if Resident 65's physician was notified of the escalation in the resident's aggressive behavior. SSD stated Resident 65 used to go outside and drink coffee and now she refuses to get out of bed.
During an interview on 7/28/21 at 10:28 a.m. with the Director of Nursing (DON), the DON stated, I don't know much about the resident (Resident 65). The DON stated Resident 65 stayed in her bed and was receiving antipsychotics (medications used to treat psychotic disorders). DON stated she was not notified of Resident 65's display of verbal and physical abuse towards other residents and staff. DON stated she only received report on residents that have had a change of condition. DON stated the process of dealing with a verbally and physically abusive resident was by making a compatible room change.
During an interview on 7/27/21 at 10:50 a.m. with the Activity Director (AD), AD stated Resident 65 preferred to be left alone and did not like any talking around her. AD stated Resident 65 refused television, art and crafts, music or going outside. AD stated Resident 65 received snacks, and room visits in which she refused and coffee. AD stated, I have offered everything that I can possibly offer as far as activities and nothing helps. AD stated she had to redirect Resident 65 when the resident became verbally abusive.
During an interview on 7/27/21 at 1:40 p.m. with the SSD, the SSD stated Resident 65's room was changed to a room close to her office with better compatibility in roommates. The SSD stated she would monitor Resident 65.
During an interview on 7/27/21 at 3:16 p.m. with CNA 2, CNA 2 stated, When she (Resident 65) wants something, she is loud until she gets it. CNA 2 stated if she did not get what she wanted she verbally and physically assaulted you. CNA 2 stated Resident 65 did it for her coffee. CNA 2 stated Resident 65 refused to get out bed all the time.
During a concurrent interview and review of Resident 65's Medication Administration Record (MAR) on 7/27/21 at 1:17 p.m., the MAR indicated Resident 65 was receiving Risperdal ([risperidone] medication used to treat psychosis) 2 milligrams ([mg] unit of mass) by mouth two times a day. LVN 1 stated, This dosage is not therapeutic. LVN 1 stated she did not notify Resident 65's physician, the Interdisciplinary Team ([IDT] group of different disciplines working together towards a common goal of a resident), Registered Nurse (RN) supervisor or DON to follow up on the resident's condition. LVN 1 stated the facility should call the physician, notify the IDT and RN supervisor of a resident's escalating aggressive behavior to intervene.
During a concurrent observation and interview on 7/29/21 at 9:53 a.m with LVN 5, LVN 5 was observed at Resident 65's door passing medication. LVN 5 stated Resident 65's behavior had improved since the room change and the modified antipsychotic medication dosage was administered on 7/28/21 during the 3 p.m. to 11 p.m. (evening) shift.
During a review of Resident 65's behavioral care plan, updated on 7/28/21 at 11:14 a.m., the behavioral care plan indicated Resident 65 refused to get out of bed and was able to turn herself. The behavioral care plan indicated Resident 65 was verbally abusive when the resident did not want to get out of bed.
During a review of Resident 65's physician orders, dated 7/28/21 at 10:13 a.m., the physician orders indicated to increase Risperdal (risperidone) 2 mg tablets to 4 mg tablets twice a day for schizophrenia (long-term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality) and angry outburst.
During a review of the facility's policy and procedure (P/P), titled, Abuse prevention/prohibition policy, dated 11/20/18, the P/P indicated the facility defines verbal abuse as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms directed to residents or within hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. The P/P stated the facility does not condone any form of resident abuse and they have established systems in place to promote an environment free from abuse and mistreatment.
During a review of facility's job duties, dated 5/08, the job duties indicated the LVN's responsibilities are to communicate residents' condition and nursing care to appropriate people i.e., supervisor, administered, physician, family, etc In addition, the LVN duties are to report change of condition to physician and families and make rounds on each shift on every assigned resident to identify care needs, change of condition, and to evaluate nursing care and mistreatment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
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 the Minimum Data Set ([MDS] a resident assessment and care-s...
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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 Minimum Data Set ([MDS] a resident assessment and care-screening tool) assessment was accurate for one of one sampled residents (Resident 56).
This deficient practice had the potential to result in adverse consequences in nursing care and treatment and inadequate interventions as well as the resident's quality of life.
Findings:
During a review of Resident 56's admission Record (Face Sheet), the admission Record indicated Resident 56 was admitted to the facility 1/12/2016, and last readmitted [DATE]. Resident 56's diagnoses included right heart failure (inability of the heart to function), diabetes mellitus (high blood sugar), drug induced subacute dyskinesia (movement of the body) and anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).
During a review of Resident 56's physician's order summary dated 7/2021, the physician's order summery indicated an order dated 5/12/2021 indicated for restorative nursing assistant (RNA) program every day three times per week for ambulation (walk) with parallel bar or front wheel walker (FWW) as tolerated.
During a review of Resident 56's RNA care plan dated 5/11/2021, the RNA care plan indicated the resident was at risk for a decrease in ambulation skills. The nursing interventions indicated the RNA program was to be provided for eight weeks, three times a week with a FWW every morning shift.
During a review of Resident 56' RNA Administration Record, the RNA Administration Record indicated RNA program every day three times a week for ambulation with parallel bars or FWW as tolerated Monday, Wednesday, and Friday.
During a review of Resident 56's MDS dated [DATE], the MDS indicated Resident 56 had impairment of the upper and lower extremities under the section for functional limitation.
Section O of the MDS indicated Resident 56 was not in the RNA program.
During an interview and record review on 7/28/21 at 5:17 p.m. with the MDS Assistant, the MDS Assistant stated the MDS was conducted because it was mandated by the government to use the Resident Assessment Instrument (RAI) so that the government could picture the resident's conditions or wellbeing. MDS Assistant stated if the MDS was not accurately coded, the resident care plan would not reflect the resident's condition, since care plans were developed from information derived from the MDS.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the nursing staff failed to revise a care plan after one of 21 sampled residents (Residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the nursing staff failed to revise a care plan after one of 21 sampled residents (Resident 19) sustained a fall from her wheelchair.
This deficient practice had the potential to place Resident 19 at risk for recurrent falls and injury.
Findings:
During a review of Resident 19's admission Record (Face Sheet), the admission Record indicated Resident 19 was admitted to the facility on [DATE].
During a review of Resident's 19 History and Physical (H/P), dated 7/19/2021, the H/P indicated Resident's 19's diagnosis included cerebrovascular accident (the sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain) with left sided weakness.
During a review of Resident 19's Minimum Data Set (MDS), a resident assessment and care screening planning tool, dated 5/12/2021, the MDS indicated Resident 19 had no memory problems or decision making, and was able to make needs known and understand others. The MDS indicated Resident 19 required extensive assist of one-person physical assist for transfers and bed mobility.
During a review of Resident 19's care plan, dated 6/29/2021, the care plan indicated the goals were to minimize further fall and injury after intervention daily for 30 days. The care plan indicated Resident 19 would not get out of bed or wheelchair without assistant daily for 30 days and the resident would call for assistance using the call light or verbal calling if needed to get out of bed or wheelchair daily for 30 days. The staff's interventions included to encourage Resident 19 to call for assistance using the call light or by verbal calling and provide safety education, monitor vital signs or neuro-check and notify the physician for abnormalities.
During a review of Resident 19's care plan, dated 7/26//2021, the care plan indicated the resident's goals were to minimize further fall and injury after intervention daily for 30 days. The care plan indicated Resident 19 would not get out of bed or wheelchair without assistant daily for 30 days, and the resident would call for assistant using call light or verbal calling if needed to get out of bed or wheelchair daily for 30 days. The staff's interventions included to encourage Resident 19 to call for assistance using the call light or by verbal calling and provide safety education, monitor vital signs or neuro-check and notify the physician for abnormalities.
During an interview on 7/29/2021 at 11:46 a.m. with Registered Nurse 1 (RN 1), RN 1 verified there was no updated care plan after Resident 19's fall. RN 1 stated it was important to keep a record of Resident 19's interventions, which also facilitates the implementation of safety. RN 1 stated it was very important to update care plans to measure their effectiveness and to guide staff if it needed to be changed or updated.
During an interview on 7/30/2021 at 2:35 p.m. with Licensed Vocational Nurse 3 (LVN 3), LVN 3 confirmed she did not update Resident 19's care plan in accordance to the facility's policy and procedures.
During a review of the facility's policy and procedure (P/P) titled, Care Planning- Interdisciplinary Team, revised 2013, the P/P indicated the Interdisciplinary Team must review and update the care plan, when there has been a significant change in the resident's condition, when the desire outcome is not met. The P/P indicated when the resident has been readmitted to the facility from a hospital stay.
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 obtain a physician order for monitoring Phenobarbital ([anti-seizur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain a physician order for monitoring Phenobarbital ([anti-seizure medication] medication used to decrease seizure [sudden, uncontrolled electrical disturbance in the brain] activity ) therapeutic levels, and also failed to ensure a Prothrombin Time and International Normalized Ratio ([PT/INR] test to help diagnose bleeding or clotting disorders which measures how much time it takes for your blood to clot) laboratory orders was also obtained for one of one sampled residents (Resident 15).
These deficient practices of not monitoring for the therapeutic levels of Phenobarbital and PT/INR had the potential of Resident 15 to have low therapeutic levels thereby having frequent seizure disorders and increased the resident's risk of bleeding.
Findings:
During a review of Resident 15's admission Record (face sheet), the admission Record indicated the resident was admitted to the facility on [DATE], and readmitted [DATE]. Resident 15's diagnosis included generalized idiopathic epilepsy (disorder causing seizures), intractable with stat epilepsy.
During a review of Resident 15's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 5/6/2021, the MDS indicated Resident 15's cognitive (thought process) skills for daily decision-making was intact. The MDS indicated Resident 15 required supervision from staff with activities of daily living ([ADLs] self-care activities performed daily such as bathing, eating, dressing and personal hygiene)
During a review of Resident 15's History and Physical (H/P) dated 7/15/2021, the H/P indicated Resident 15 did not have the capacity to understand and make decisions.
During a review of Resident 15's Situation Background Assessment Recommendation ([SBAR] internal communication to address a resident's change in condition) form dated 6/16/2021, the SBAR indicated Resident 15 had a seizure that lasted for one minute and was transferred to general acute care hospital (GACH) via emergency response (911). The SBAR indicated Resident 15 had decreased oxygen saturation (amount of oxygen bound to hemoglobin in the blood) of 89 percent ([%] Normal Reference Range 92-100).
During a review of Resident 15's physician's order dated 7/2021, ordered 7/13/21, the physician's order indicated Phenobarbital 32.4 milligrams ([mg] unit of mass) tablet, give 1 tablet by mouth three times a day for seizure disorder. Coumadin 2 mg tablet. Give 1 tablet by mouth every 5 p.m. start 4/21/2021 for diagnosis of deep vein thrombosis ([DVT] occurs when a blood clot forms in one or more of the deep veins in your body, usually in the legs).
During a review of Resident 15's care plan titled, Seizure Disorder, dated 7/13/2021, the care plan indicated Resident 15 was at risk for injury as evidenced to seizure activity. The nursing interventions indicated to administer medication as ordered, and monitor labs as ordered.
During an interview on 7/29/21 at 1:46 p.m. with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated Resident 15 had active seizures during the 3 p.m. to 11 p.m. (evening) shift approximately one month prior. LVN 4 stated Resident 15 was transferred to a GACH via 911. LVN 4 stated Resident 15 had been given Coumadin and the resident's PT/INR had to be monitored to prevent the resident's blood from becoming too thin which could result in excessive bleeding. LVN 4 stated Phenobarbital levels had to be monitored to determine the medication therapeutic levels to prevent seizure activities.
During an interview on 7/29/21 at 3:11 p.m. with Registered Nurse 1 (RN 1), RN 1 stated Resident 15 was on seizure medication and had to be monitored for seizure activities every shift. RN 1 stated there should have been a floor mat, padded side rails, and lab work to determine the therapeutic level or toxicity in Resident 15's blood stream. RN 1 stated if there was no order for blood work, nurses had to inform the physician and obtain an order to monitor the lab work. RN 1 confirmed there was no order for monitoring Resident 15's Phenobarbital levels and PT/INR in the clinical record. RN 1 stated not monitoring Resident 15's labs could lead to further seizure activities.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record, the facility failed to ensure one of one sampled residents (Resident 57) maintained acceptable pa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record, the facility failed to ensure one of one sampled residents (Resident 57) maintained acceptable parameters of nutritional status, by not ensuring:
1. Resident 57 had a significant weight loss of 10 pounds in one week, 7.5 percent (%) in one month and 11 pounds in three months.
2. Ensure the Registered Dietician ([RD] a health professional with special training in the use of diet and nutrition to keep the body healthy) recommendations were carried out.
3. Ensure Resident 57's weekly weight was accurately monitored and documented.
4. Ensure a physician's order for Intravenous ([IV] in the vein) fluid was carried out and implemented.
These deficient practices had the potential to result in further weight loss, and more serious complications that could lead death.
Findings:
During a review of Resident 57's admission Record (face sheet), the admission Record indicated the resident was initially admitted to the facility on [DATE], and last readmitted on [DATE]. Resident 57's diagnoses included Type 2 diabetes mellitus (high blood sugar), chronic kidney disease (progressive loss of normal kidney function), and unspecified dementia (progressive memory loss) without behavioral disturbance.
During a review of Resident 57's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/22/21, the MDS indicated the resident's cognitive (thought process) skills of daily decision-making were impaired. The MDS indicated Resident 57 required extensive assistance with some activities of daily livings ([ADLs] self-care activities performed daily, such as dressing, eating, grooming, and personal hygiene) and supervision with eating.
During a review of Resident 57's History and Physical (H/P) dated 6/30/21, the H/P indicated Resident 57 did not have the capacity to understand and make decisions.
During a review of Resident 57's care plan titled, At risk of nutritionally altered diet, dated 11/19/2021, the care plan indicated the resident was on mechanically altered diet (consists of foods that can be safely and successfully swallowed) and required assistance with meals. The nursing interventions indicated to offer Resident 57 a substitute if meal intake was below 75%, monitor weight weekly, offer Megace ([Megestrol] medication used to treat the symptoms of loss of appetite) 400 milligrams ([mg] unit of mass), Registered Dietician (RD) consult as indicated and encourage fluid as tolerated.
During a review of Resident 57's RD monthly weight review dated 12/3/2020, the monthly weight review indicated Resident 57 had a weight loss of 7.5% and 10 pound in three months (8.3 %). The monthly weight review indicated Resident 57 consumed less than 40% of her meal. RD recommended weekly weight times four weeks, and extra water during medication pass. There was no documentation indicating the RD recommendations were carried out.
During a review of Resident 57's Interdisciplinary Team ([IDT] group of different disciplines working together towards a common goal for a resident) Note dated 12/11/2020, the IDT note indicated Resident 57 had a weight loss of 10 pounds in three months.
During a review of Resident 57's IDT Note dated 12/17/2020, the IDT note indicated Resident 57 had a weight loss of 11 pounds in three months. The IDT recommendations indicated to continue weekly weights, continue on nutrition regimen as ordered (mechanical soft ,no added salt), and assist Resident 57 with meals.
During a review of Resident 57's Change of Condition (COC) form dated 2/26/2021, the COC form indicated Resident 57 lost 10 pounds in one week.
During a review of Resident 57's COC form dated 3/26/2021, the COC form indicated Resident 57 had a loss of five pounds in one month.
During a review of Resident 57's Certified Nursing Assistant (CNA) Flow sheets dated 2/17/2021, 2/27/2021, 3/17/2021, 3/18/2021, 4/17/21, 4/18/2021, 4/22/2021 and 7/24/21, the flow sheets indicated Resident 57 refused meals. There was no documented evidence substitute meals were offered.
During a review of Resident 57's care plan dated 6/21/2021, the care plan indicated Resident 57 was receiving a mechanical soft fortified (food with added nutrients) diet with nectar thick liquid. There was no documented evidence indicating Resident 57's daily intake and output were monitored.
During a review of the facility's undated Weight Log, the Weight Log indicated Resident 57 had a weight loss of 13% in six months.
During an interview on 7/28/2021 at 4:12 p.m. with the Director of Nursing (DON) regarding Resident 57's weight loss, the DON stated Resident 57 would be referred to the RD, resident's family would be informed, and IDT had to develop interventions to address the weight loss. DON stated she was not sure if the resident was placed on weekly weights, calories count or feeding program. The DON verified there was no documentation indicating Resident 57's physician was informed of the resident's weight loss.
During an interview on 7/29/21 at 11:18 a.m. with Licensed Vocational Nurse 8 (LVN 8), LVN 8 stated Resident 57 sometimes refused to eat her food. LVN 8 stated Resident 57's weight loss had to be reported to the physician, a weight care plan had to be developed, the resident needed to be monitored during mealtimes, weekly weights and provide substitute meals. LVN 8 stated Megace was ordered on 7/12/2021 and dispensed 7/16/21.
During an interview on 7/29/21 at 11:53 a.m. with the Dietary Supervisor, the DS stated she was aware of Resident 57's weight loss of 7.5% in 12/2020. When asked if dietary supplements were offered, DS had no response.
During an interview on 7/29/21 at 12:37 p.m. with the Regional RD Consultant (RRDC), RRDC stated she had not been working for facility but did assist the facility if needs arise. RRDC stated she had not visited the facility since March 2021. RRDC stated she had been in the facility twice as the RRDC. RRDC stated if the resident had 5% or 7.5 % weight loss in a month, it was considered significant weight loss and had to be treated aggressively to resolve the significant weight loss. According to RRDC, the IDT had to look at the resident medication, diagnoses, weight history, resident goal, skin issues like pressure sore or diabetes, psychosocial status, mental issue, and food preferences, RRDC stated the IDT should assess the resident's Advanced Directive, swallow or chewing difficulties, self-feeding ability and develop a plan based on the resident as a whole. When asked if she was aware of Resident 57's significant weight loss, RRDC stated she did not read the resident's chart and did not know the resident due to her absence from the facility.
During an interview on 7/29/21 at 1:50 p.m. with CNA 8, CNA 8 stated Resident 57 would eat all of her food, if assisted. CNA 8 stated Resident 57 ate all her of meal (100%) that same day (7/29/21).
During a telephone interview on 7/30/21 at 12:15 p.m. with Resident 57's Physician (Physician 1), Physician 1 stated she was informed once regarding Resident 57's weight loss of 10 pounds on 11/20/2020. Physician 1 stated she ordered Megestrol and IV fluids on 11/24/2020 and on 2/28/2021 after receiving a telephone call from the facility informing Physician 1 Resident 57 refused to eat. Physician 1 stated an order was given to continue Megestrol and later changed to Mirtazapine ([Remeron] used to treat depression) and Resident 57 was transferred to a general acute care hospital (GACH) on 3/2021, due to hyponatremia (lower than normal level of sodium in the bloodstream). Physician 1 stated on 6/16/2021, she received a telephone call from Resident 57's family member (FM 1) and stated the resident would no longer be under Physician 1's care because the resident had been placed on hospice (end of life care that focuses on quality of life and comfort).
During a review of the facility's policy and procedure (P/P) titled, Medication and Treatment Orders, revised 6/2016, the P/P indicated medication shall be administered upon the written order of a person duly licensed and by the state.
During a review of the facility's nutrition P/P titled, Unplanned Weight Loss, revised 9/2017, the P/P indicated the physician and the staff will monitor the nutritional status, collaborate in adjusting interventions, causes of the weight loss and provide hydration related to severe or prolonged weight loss.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
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 pain management was provided for one of six sa...
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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 pain management was provided for one of six sampled residents (Resident 24).
This deficient practice resulted in Resident 24 suffering unnecessary pain.
Findings:
During a review of Resident 24's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE]. Resident 24's diagnoses included hypokalemia (low potassium in the blood), unspecified severe protein-calorie malnutrition (protein- calorie undernutrition), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic high), anemia (low red blood cells), alcohol dependence (individual is physically and/or psychologically dependent upon alcohol), and bacteremia (presence of bacteria in the body).
During a review of Resident 24's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/18/2021, the MDS indicated Resident 24's cognition (thought process) was intact. The MDS did not indicate Resident 24 had mouth or facial pain, discomfort or difficulty with chewing.
During a review of Resident 24's physician order dated 2/5/2021 the physician order indicated a dental consult and treatment PRN (as needed) for dental problem.
During a review of Resident 24's Dental Consult Note dated 3/5/2021, the Dental Consult note indicated Resident 24 had pain on tooth #30. Broken. No visual infection. Recommendation is for Full Mouth X-ray ([FMX] - series of 18-20 X-rays that allows a comprehensive look at every tooth) for further evaluation As Soon As Possible (ASAP).
During a review of Resident 24's Dental notes dated 5/21/2021, the Dental note indicated Patient has pain on L.R. (right lower [mandibular] quadrant). Need for x-ray for further evaluation. Recommendation is for FMX.
During a review of Resident 24's Dental notes dated 6/21/2021, the Dental note indicated Resident 24 has pain on area of 30, 31. Need to P/A (periapical - type of x-ray taken to show whole length of tooth, its roots and surrounding bone). FMX taken. Recommendation note indicated need to complete FMX (computer malfunction).
During a review of Resident 24's physician order dated 6/21/2021, the physician order indicated may have tooth extraction.
During a review of Resident 24's Dental note dated 6/29/2021, the Dental note indicated Resident 24 has pain of L.R. #30 - root tip, #31 broken. Patient wants to remove both. No visual swelling or infection. Recommendation notes indicate refer to doctor for XB (extraction) #30, #31 ASAP.
During a concurrent observation and interview on 7/26/2021 at 12:06 p.m., Resident 24 was observed sitting in his wheelchair near the nursing station, loudly complaining and upset about his excruciating toothache. Resident 24 stated he waited too long for the facility to get the dentist to pull his teeth out. Resident 24 stated he has had ten out of ten ([10/10] pain scale, 0- no pain, 10- being the worst pain) tooth pain for months now and that the pain medications did not work. Resident 24 stated he was supposed to have a dental appointment for extraction on 7/23/2021, but no one came, AGAIN! Resident 24 stated no one in the facility was doing anything to help him, no one cared and that they were not taking care of him because they were well aware of his dental needs.
During a concurrent interview and record review on 7/26/2021 at 12:16 p.m. with Registered Nurse 1 (RN 1), RN 1 stated he was not aware of resident's toothache until just a few days prior. RN 1 stated according to Resident 24's dental consult, the resident was having pain on 3/5/2021. RN 1 stated he was not aware of Resident 24's extraction appointment on 7/23/2021. RN 1 stated Resident 24 had been upset and screaming since 7/25/2021, but did not know the reason. RN 1 stated Resident 24 had been loud, disruptive and difficult to communicate with, and it was out of his usual behavior because he was for the most part respectful and calm. RN 1 stated Resident 24 could be behaving that way because he was in pain. RN 1 stated there was a dental consult on 3/5/2021 which recommended full mouth x-ray for tooth pain, but RN 1 could not verify if the x-ray was ordered or done. RN 1 stated there was no notes regarding Resident 24's dental issues or consults from the nursing staff or Director of Social Service (SSD). RN 1 stated on 6/21/2021, another consult was done indicating Resident 24 had tooth pain with FMX taken, but was not completed due to computer malfunction. RN 1 stated there were no notes found from nursing or SSD. RN 1 stated there was a physician order for tooth extraction ordered on 6/21/2021, but no extraction had taken place. RN 1 stated on 6/29/2021, an evaluation was done again with a physician referral for extraction as soon as possible. RN 1 stated he did not know if Resident 24 was scheduled for an appointment for extraction. RN 1 stated he did not know for sure who follows up after a recommendation was made, usually the SSD, but there were no notes found from the SSD regarding Resident 24's dental issues at all.
During a review of Resident 24's physician's telephone order dated 7/27/21, the telephone order indicated Norco (pain medication) 5/325 tablet 1 tab twice a day (BID) PRN for moderate to severe pain was changed to Norco 5/325 tablet 1 tab PO every (q) six hours (h) PRN for moderate to severe pain (7-10).
During a review of Resident 24's nursing note dated 7/27/21, the nursing note indicated Resident 24's pain management medication order was changed from PRN BID to q6h to better manage pain.
During a concurrent interview and record review of Resident 24's Medication Administration Record (MAR) and physician's order on 8/2/2021 at 12:41 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated on 6/21/2021 she was aware that Resident 24's needed tooth extractions, but the morning of 7/26/2021 was the first time she heard the resident complain about tooth pain. LVN 2 stated Resident 24's mouth was drooling, maybe because of pain, because he did not drool on a normal basis. LVN 2 stated according to Resident 24's MAR, Resident 24 did not receive pain medication until 7:22 p.m. on 7/26/2021. LVN 2 verified Resident 24's physician order indicated an order on 6/21/2021 the resident may have tooth extraction. LVN 2 stated there was a tooth extraction order obtained on 6/21/2021, and on 6/29/2021 there was a surgical tooth extraction recommendation, but that was nowhere to be found in the care plans. LVN 2 stated there was no care plan for Resident 24's tooth pain or needed dental procedures. LVN 2 stated it might have been missed. LVN 2 stated care plans are staff's guide to resident care, needs and goals and failure to initiate a care plan could mean lack of or delay in resident care.
During an interview on 8/2/2021 at 3:44 p.m. with the Administrator (ADMIN), ADMIN stated the facility's system for consults was defective. ADMIN stated the SSD kept everything in a binder, but that information should be accessible in the resident chart along with the SSD notes for staff accessibility. ADMIN stated the SSD should have documented notes and nursing staff should a have a process that flagged recommendations, orders and follow ups. ADMIN stated the SSD and nursing staff did not have an affective process regarding consults, which may cause delay in residents care and needed medical procedures.
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:
1. Ensure that one (1) bottle of an over-the-counter...
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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 that one (1) bottle of an over-the-counter medication was not expired, located in one (1) medication storage room, out of three (3) total medication storage rooms at the facility.
This deficient practice had the potential for harm to residents due to the potential loss of strength of the medication, and the potential for the residents to receive ineffective medication dosages due to expired medication.
Findings:
During an observation on [DATE] at 10:23 a.m., at the Station A Medication Room, one bottle of Vitamin E (vitamin supplement) 90 milligrams ([mg] strength in units), equal to 200 International Units ([IU] strength in International Units) Softgels (a specialized oral capsule with a gelatin based shell surrounding a liquid fill), quantity of 100, had an expiration date 6-21 ([DATE]).
During an interview on [DATE] at 10:30 a.m. with Registered Nurse supervisor (RN 1), regarding the expired bottle of Vitamin E 90 mg Softgels, RN 1 acknowledged the expired bottle and stated, Expired [DATE]st (2021), I will put it in the expired ('medication for destruction') box.
During a review of the facility's pharmacy policy and procedures (P/P), titled, Storage of Medications, revised [DATE], the P/P indicated, Policy Interpretation and Implementation .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be .destroyed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
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 necessary dental services for one of six samp...
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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 necessary dental services for one of six sampled residents (Resident 24).
This deficient practice had the potential to result in inability to effectively chew food, weight loss, and unnecessary pain for Resident 24.
Findings:
During a review of Resident 24's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE]. Resident 24's diagnoses included hypokalemia (low potassium), unspecified severe protein-calorie malnutrition (protein- calorie undernutrition), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic high), anemia (low red blood cells), alcohol dependence (individual is physically and/or psychologically dependent upon alcohol), and bacteremia (presence of bacteria in the body).
During a review of Resident 24's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/18/2021, the MDS indicated the resident's cognition (thought process) was intact. The MDS did not indicate Resident 24 had mouth or facial pain, discomfort or difficulty with chewing.
During a review of Resident 24's physician order dated 2/5/2021 the physician order indicated a dental consult and treatment PRN (as needed) for dental problem.
During a review of Resident 24's Dental Consult Note dated 3/5/2021, the Dental Consult note indicated Resident 24 had pain on tooth #30. Broken. No visual infection. Recommendation is for Full Mouth X-ray ([FMX] - series of 18-20 X-rays that allows a comprehensive look at every tooth) for further evaluation As Soon As Possible (ASAP).
During a review of Resident 24's Dental notes dated 5/21/2021, the Dental note indicated Patient has pain on L.R. (right lower [mandibular] quadrant). Need for x-ray for further evaluation. Recommendation is for FMX.
During a review of Resident 24's Dental notes dated 6/21/2021, the Dental note indicated Resident 24 has pain on area of 30, 31. Need to P/A (periapical - type of x-ray taken to show whole length of tooth, its roots and surrounding bone). FMX taken. Recommendation note indicated need to complete FMX (computer malfunction).
During a review of Resident 24's physician order dated 6/21/2021, the physician order indicated may have tooth extraction.
During a review of Resident 24's Dental note dated 6/29/2021, the Dental note indicated Resident 24 has pain of L.R. #30 - root tip, #31 broken. Patient wants to remove both. No visual swelling or infection. Recommendation notes indicate refer to doctor for XB (extraction) #30, #31 ASAP.
During a concurrent observation and interview on 7/26/2021 at 12:06 p.m., Resident 24 was observed sitting in his wheelchair near the nursing station, loudly complaining and upset about his excruciating toothache and that he has waited too long for the facility to get the dentist to pull them out. Resident 24 stated he gave the facility an F because they were not doing anything for him. Resident 24 stated he has had ten out of ten ([10/10] pain scale, 0-no pain, 10- being the worst pain) tooth pain for months and the pain medication did not work. Resident 24 stated he was supposed to have a dental appointment for tooth extraction on 7/23/2021, but no one came, AGAIN! Resident 24 stated no one in the facility was doing anything to help him, no one cared and that they were not taking care of him because they were well aware of his dental needs.
During a concurrent interview and record review on 7/26/2021 at 12:16 p.m. with Registered Nurse Supervisor (RN 1), RN 1 stated he was not aware of Resident 24's toothache until just a few days prior. Resident 24 stated he was not aware of an extraction appointment on 7/23/2021. RN 1 stated Resident 24 had been upset and screaming since 7/25/2021, but he did not know the reason. RN 1 stated Resident 24 had been loud, disruptive and difficult to communicate with, and that it was out of the resident's usual behavior because the resident was for the most part respectful and calm. RN 1 stated Resident 24 could be behaving that way because he was in pain. RN 1 stated had a dental consult on 3/05/2021 which recommended full mouth x-ray for tooth pain, but RN 1 was unable to verify if the X-rays were ordered or done. RN 1 stated there were no notes found regarding Resident 24's dental issues or consults from nursing staff or the Director of Social Service (SSD). RN 1 stated another FMX was recommended on 5/21/2021, for tooth pain, but could not verify if X-rays were ordered or done. RN 1 stated there were no notes found from nursing staff or the SSD. RN 1 stated on 6/21/2021, another consult was done indicating Resident 24 had tooth pain with FMX taken, but not completed due to computer malfunction. RN 1 stated there were no notes found from nursing or the SSD. RN 1 stated there was a physician order for tooth extraction ordered on 6/21/2021, but no extraction had taken place. RN 1 stated on 6/29/2021, an evaluation was done again with a physician referral for tooth extraction as soon as possible. RN 1 stated he did not know if Resident 24 had been scheduled for an appointment for extraction. RN 1 stated he did not know for sure who followed up after a recommendation was made, usually the SSD, but there were no notes found from the SSD regarding Resident 24's dental issues.
During a concurrent interview and record review on 7/26/2021 at 12:54 p.m. with the SSD, the SSD stated she called Resident 24's dentist in the morning and made an appointment for tooth extraction on 7/28/2021. The SSD stated she just found out of Resident 24's tooth pain that day. The SSD stated that on the days consults were done, she was given a list of residents that were seen. The SSD stated she then charts it in her book. Consults and recommendations for X-ray were found in the SSD's binder without notes. The SSD stated Resident 24's first dental consult was done 3/05/2021 for tooth pain with FMX recommendation, the SSD stated she did not know what FMX was. The SSD stated she did not know if or when X-rays were done. Reviewed dental notes dated 5/21/2021, the SSD stated another X-ray was most likely recommended because they needed more information. The stated she was pretty sure Resident 24 X-rays were done, but the SSD was not positive. The SSD stated the X-ray would be in resident's chart. The SSD checked Resident 24's chart and stated there were no X-ray found in the resident's chart.
During a concurrent interview and record review on 7/27/2021 at 2:50 p.m. with the SSD, the SSD provided an X-ray that was taken 6/21/2021 and stated those were the only dental X-rays done for Resident 24. The SSD stated she did not know why it took from 3/5/20201 through 6/21/2021 to obtain an x-ray. The SSD stated she did not know why Resident 24's tooth extraction was not done yet. The SSD stated she followed up by calling the resident's dental office, but did not document. The SSD stated it was her fault and moving forward she would document notes, follow up on all consults and leave her notes in resident charts for all other staff to have access to. The SSD stated she knew Resident 24 was in pain and upset, updating him would have given him peace of mind that the facility was following up on his care.
During an interview on 8/2/2021 at 3:44 p.m. with the Administrator (ADMIN), the ADMIN stated the system the facility had in place for consults was defective. ADMIN stated the SSD kept everything in a binder, but that information should be accessible in the resident chart along with the SSD notes for staff accessibility. ADMIN stated the SSD should have documented notes and nursing staff should a have a process that flagged recommendations, orders and follow ups. ADMIN stated the SSD and nursing staff did not have an effective process regarding consults, which may cause delay in residents care and needed medication procedures.
During a review of the facility's policy and procedure (p/p) titled, Dental Availability of Services, revised 8/2007, the P/P indicated dental services are available to all residents requiring routine and emergency dental care .Social Services will be responsible for making necessary dental appointments. All requests for routine and emergency dental services should be referred to Social Services to assure appointments can be made in a timely manner. Inquiries concerning the availability of dental services should be referred to Social Services or to the Director of Nursing.
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 ensure safe and sanitary food storage in the kitchen by storing one personal Starbuck's cup of coffee and one personal bottle...
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Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage in the kitchen by storing one personal Starbuck's cup of coffee and one personal bottle of Gatorade in the facility's kitchen freezer.
This deficient practice had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 93 out of 93 residents who received food from the kitchen.
Findings:
During an observation on 7/26/2021 at 8:50 a.m. one cup of Starbuck's coffee was observed in Freezer 1 and one bottle of Gatorade was observed in Freezer 2 of the facility's kitchen.
During an interview on 7/29/2021 at 8:27 a.m. with the Dietary Supervisor (DS), the DS acknowledged staff placed a personal cup of coffee in Freezer 1 of the kitchen. The DS stated, There are no personal items to be stored in freezer. I didn't know the cup of coffee was in the freezer until you took a picture of it. I interviewed the staff and they said someone forgot to take the cup of coffee out of the freezer. I didn't see the Gatorade bottle in the freezer. Maybe someone removed it before I went to the freezer to check. I spoke to the kitchen staff and told them they are not supposed store personal items in the freezer.
During an interview on 7/30/2021 at 10:34 a.m. with the Dietary Aide (DA), the DA stated, We are not allowed to store personal items in the freezer but I saw someone had put a Starbucks cup in the freezer and they weren't supposed to. We do not have a personal cooler for ourselves and it gets really hot in the kitchen so sometimes people place their drinks in the kitchen freezers. We were in serviced and instructed to not store personal items in the kitchen freezers.
During a review of the facility's policy and procedure (P/P), dated 2020 and titled, Employee Meals, the P/P indicated food brought by employees from outside the facility shall not be kept in the facility's refrigerator in the kitchen nor prepared or reheated in the facility's kitchen.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee failed to identify and implemen...
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Based on observation, interview, and record review, the facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee failed to identify and implement a plan of action to ensure the facility had a systematic approach or plan of action and evaluation to ensure the facility had an effective follow up process with dental consults recommendations, services, and treatments. (Cross referenced F791)
This deficient practice resulted and could continue to result in residents not receiving the treatments necessary to meet their highest potential and well-being.
Findings:
The QAA /QAPI committee failed to monitor the provisions of care of the facility staff's to ensure residents were provided the necessary dental services as indicated on dental consults for one of six sampled residents. (Resident 24).
During a concurrent interview and record review on 7/26/2021 at 12:54 p.m. with the Social Services Designee (SSD), the SSD stated she called Resident 24's dentist in the morning and made an appointment for tooth extraction for 7/28/2021. The SSD stated she just found out of Resident 24's tooth pain that day (7/26/21). The SSD stated that on the days consults were done, she was given a list of residents that were seen. The SSD stated she then charts it in her book. Consults and recommendations for X-ray found in SSD's binder were without notes. The SSD stated Resident 24's first dental consult was done 3/5/2021 for tooth pain with FMX recommendation. The SSD stated she did not know what FMX meant. The SSD stated she did not know if or when X-rays were done. Reviewed dental notes dated 5/21/2021, the SSD stated another X-ray was most likely recommended because they need more information. The SSD stated she was pretty sure Resident 24 X-rays were done, but the SSD stated she was not positive. The SSD stated the X-ray results should be in resident's chart. The SSD verified there was no X-ray results in Resident 24's medical record.
During a concurrent interview and record review on 7/27/2021 at 2:50 p.m. with the SSD, the SSD verified a X-ray that was taken on 6/21/2021 and stated those were the only dental X-ray done for Resident 24. The SSD stated she did not know why it took from 3/5/20201 through 6/21/2021 to obtain an X-ray. The SSD stated she did not know why Resident 24's tooth extraction had not been done yet. The SSD stated she followed up by calling the resident's dental office, but did not document. The SSD stated it was her fault and moving forward she would document notes, follow up on all consults and leave her notes in resident medical records for all other staff to have access to. The SSD stated she knew Resident 24 was in pain and upset, updating him would have given him peace of mind that the facility was following up on his care.
During an interview on 8/2/2021 at 3:44 p.m. with the Administrator (ADMIN), the ADMIN stated the system the facility had in place for consults was defective. The ADMIN stated the SSD kept everything in a binder, but that information should be accessible in the resident's medical record along with the SSD notes for staff accessibility. The ADMIN stated the SSD should have documented notes and nursing staff should a have a process that flagged recommendations, orders and follow ups. The ADMIN stated the SSD and nursing staff did not have an effective process regarding consults, which may cause delay in the residents care and needed medical procedures.
During a review of the facility's policy and procedure (P/P) titled, Facility Assessment Tool, revised on 3/1/2021, the P/P indicated the intent of the facility assessment is for the facility to evaluate its resident population and identify the resources need to provide the necessary person-centered care and services the residents require.
During a review of the facility's untitled and undated P/P, the P/P indicated that Quality Assurance and Performance Improvement (QAPI) goals and purpose is to provide excellent quality resident/patient care and services. Quality is defined as meeting or exceeding the needs, expectations and requirements of the patients cost-effectively while maintaining good resident/patient outcomes and perceptions of patient care. Our nursing home has a Performance Improvement Program which systemically monitors, analyzes and improves its performance to improve resident/patient outcome. It recognizes that value in healthcare is the appropriate balance between good measures and excellent care and services and cost.
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 the toilet in the shared restroom of rooms [RO...
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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 toilet in the shared restroom of rooms [ROOM NUMBERS] were both free of water leaks.
This deficient practice had the potential to result in infection, accidents or injuries to the residents, staff and visitors.
Findings:
During a review of Resident 69's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE]. Resident 69's diagnoses included pulmonary embolism (one or more arteries in the lungs become blocked by a blood clot), hypertension (high blood pressure), and abnormal gait and mobility (deviation from normal walking).
During a review of Resident 69's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 6/30/2021, the MDS indicated Resident 69's cognition (thought process) was moderately impaired. The MDS indicated Resident 69 required extensive assistance with a one-person physical assist for toilet use.
During a review of Resident 69's History and Physical (H/P) dated 6/24/2021, the H/P indicated Resident 69 had the capacity to understand and make decisions. The H/P indicated Resident 69 was on fall precautions.
During an interview on 7/26/2021 at 4:40 p.m. with Resident 69, Resident 69 stated for the prior two weeks, the bathroom floor in his room was always wet. Resident 69 stated he was not sure if there was a leak from the toilet. Resident 69 stated, It's a nuisance.
During a review of Resident 39's admission Record, the admission Record indicated the resident's original admission date to the facility was 5/27/2021, and was re-admitted on [DATE]. Resident 39's diagnoses included seizure (sudden, uncontrolled electrical disturbance in the brain), hypertension, diabetes mellitus (abnormal blood sugar level), and generalized muscle weakness.
During a review of Resident 39's MDS, dated [DATE], the MDS indicated Resident 39's cognition was intact. The MDS indicated Resident 39 required limited assistance with a one-person physical assist for toilet use.
During an interview on 7/26/2021 at 4:37 p.m. with Resident 39, Resident 39 stated in the past week and a half, the bathroom was wet. Resident 39 stated there was a leak somewhere around the base of the toilet. Resident 39 stated he was constantly cleaning and wiping the floor dry. Resident 39 stated he reported the issue to the staff, but nothing was done.
During an observation on 7/26/2021 at 4:44 p.m. of rooms [ROOM NUMBERS]'s shared restroom, a small puddle of clear liquid was observed on the floor around the base of the toilet bowl.
During a concurrent observation and interview with Resident 39 on 7/28/2021 at 1:03 p.m., there was clear liquid observed around the base of the toilet and all over the floor in the shared restroom of rooms [ROOM NUMBERS]. Three pieces of paper towels were placed on the floor which became quickly soaked. Resident 39 stated the floor was constantly wet and all the paper towels in the half filled trash bin were all the paper towels he used to wipe the floor dry. Resident 39 stated the toilet seemed to leak more when flushed. The toilet was flushed and a leak was observed coming from the back plumbing of the toilet bowl dripping to the floor.
During a concurrent observation, interview, and record review on 7/28/021 at 1:18 p.m. with Certified Nurse Assistant 9 (CNA 9), CNA 9 confirmed the restroom floor was wet. CNA 9 was observed flushing the toilet and stated the water was coming from the pipe leaking from the back of the toilet bowl. CNA 9 stated the leaking toilet was a big fall risk issue and needed to be reported right away. CNA 9 stated the process was to redirect the residents to use another restroom, and document the issue on the maintenance log that maintenance checked daily. CNA 9 placed a wet floor sign in the restroom. CNA 9 verified the issue was not documented on the maintenance log, and CNA 9 proceeded to fill out the maintenance log.
During an interview on 7/28/2021 at 3:42 p.m. with the Maintenance Supervisor (MS), MS stated when there was something that needed to be repaired, the Maintenance Log was filled out and the log was checked every morning on a daily basis or when staff directly informed them of an issue. The MS stated when the issues are taken care of, it was signed off in the maintenance log with a written resolution. MS stated two staff were assigned to make daily rounds in the resident rooms to check the call lights, bathroom, electrical out let, and trash. MS stated there was no log of the rounds made, but each of the supervisors have their assigned resident rooms they were responsible for checking on a daily basis which they call 'Room Runs.' MS stated they each have to fill out a form daily of what they found. MS stated he was mainly responsible for the outside of the building.
During a concurrent interview and record review at 7/28/2021 at 3:56 p.m. with the Infection Control Preventionist Nurse (IP), the IP stated 'Room Runs' were internal documents and could not be provided. IP stated each department head was assigned to check resident rooms at least three times per week. IP stated if there was something broken, it was logged in the maintenance log. Review of the maintenance log with the IP indicated the only report regarding the restroom in rooms [ROOM NUMBERS] was made by CNA 9.
During a concurrent observation and interview on 7/28/2021 at 4:06 p.m. with the IP and Administrator (ADMIN), the IP and ADMIN stated 'Room Run' checks were done daily and included the resident restrooms. IP and ADMIN observed the restroom floor of rooms [ROOM NUMBERS] was wet. ADMIN was observed flushing the toilet and confirmed that it was leaking. IP stated the wet floor put residents at risk for fall, and the ADMIN agreed.
During a review of the facility's undated policy and procedure (P/P) titled, Maintenance, General Policies and Procedural Guidelines, the P/P indicated facility grounds, fixtures, equipment and building are maintained in a clean, sanitary, safe and operational condition. The P/P indicated plumbing and drainage facilities are maintained in compliance with state and local codes.
During a review of the facility's P/P titled, Accommodation of Needs, revised 1/2020, the P/P indicated the facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being.
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 observation, interview, and record review, the facility failed to develop an individualized person-centered plan of car...
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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 develop an individualized person-centered plan of care with measurable objectives, timeframes, and interventions to meet the residents' needs for one of six sampled residents (Residents 24) by failing to:
1. Develop an individualized/person-centered care plan with goals and interventions to address Resident 24's dental service needs.
2. Develop an individualized/person-centered care plan to address Resident 24's tooth pain.
These deficient practices had the potential to result in a delay of nursing care, medical interventions, and services for Resident 24. (Cross referenced to F697)
Findings:
During a review of Resident 24's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE]. Resident 24's diagnoses included hypokalemia (low potassium), unspecified severe protein-calorie malnutrition (protein- calorie undernutrition), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic high), anemia (low red blood cells), alcohol dependence (physically and/or psychologically dependent upon alcohol), and bacteremia (presence of bacteria in the body).
During a review of Resident 24's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 5/18/2021, the MDS indicated Resident 24's cognition (thought process) was intact. The MDS did not indicate Resident 24 had mouth or facial pain, discomfort or difficulty with chewing.
During a concurrent observation and interview on 7/26/2021 at 12:06 p.m., Resident 24 was observed sitting in his wheelchair near the nursing station, loudly complaining and upset about an excruciating toothache. Resident 24 stated he had been waiting too long for the facility to get the dentist to pull his teeth out. Resident 24 stated he has had ten out of ten ([10/10] pain scale, 0 - no pain; 10 - the worst possible pain) tooth pain for months and the pain medications did not work. Resident 24 stated he was supposed to have a dental appointment for extraction on 7/23/2021, but no one came, AGAIN! Resident 24 stated no one in the facility was doing anything to help him, no one cared and that they were not taking care of him because they were well aware of his dental needs.
During a concurrent interview and record review on 7/26/2021 at 12:16 p.m. with Registered Nurse 1 (RN 1), RN 1 stated if there was not a care plan in the chart, then it was not done. RN 1 stated he could not find a care plan addressing Resident 24's tooth pain. RN 1 stated there was not a care plan regarding any of Resident 24's dental services needs and medical intervention as recommended during evaluation, such as full mouth x-rays and two tooth extractions as soon as possible. RN 1 stated care plans were important to keep everyone informed of how to provide care and what services were needed for the resident. RN 1 stated a delay in care or even failing to implement care could happen without a care plan initiated.
During a concurrent interview and record review on 8/2/2021 at 12:41 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated there was no care plan for Resident 24's tooth pain or dental procedures. LVN 2 stated there was a tooth extraction order obtained on 6/22/2021, and on 6/29/2021 there was a surgical tooth extraction recommendation, but that was nowhere to be found in the care plans. LVN 2 stated care plans were staff's guide to resident care, needs and goals. LVN 2 stated failure to initiate a care plan can mean lack of or delay in resident care.
During an interview on 8/2/2021 at 3:44 p.m. with the Administrator (ADMIN), the ADMIN stated the facility's system for consults was defective. ADMIN stated the social services director (SSD) kept everything in a binder, but that information should be accessible in the resident chart along with the SSD progress notes for staff accessibility. ADMIN stated the SSD should have documented notes and nursing staff should a have a process that flagged recommendations, orders and follow ups. ADMIN stated the SSD and nursing staff did not have an effective process regarding consults, which may cause delay in residents care and needed medical procedures.
During a review of the facility's policy and procedure (P/P) titled, Comprehensive Person-Centered Care Plans, revised 12/2016, the P/P indicated areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. The P/P indicated identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). The P/P indicated assessments of residents are ongoing and care plans are revised as information about the residents and residents' conditions change.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five (5) ...
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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 medication error rate of less than five (5) percent, due to four (4) medication administration errors involving two out of two total residents observed during medication administration (med pass).
The deficient practice of a medication administration error rate of fourteen and twenty-nine one hundredths percent (14.29 %) exceeded the five (5) percent threshold. The four (4) medication errors did not meet professional standards of quality.
Findings:
a. During an observation, on 7/26/21, at approximately 9:45 a.m., at the Station A Medication Cart A, of the medication administration (med pass) of Resident 17, Licensed Vocational Nurse 2 (LVN 2) unwrapped a Lidocaine (topical anesthetic used for pain relief) Patch 5% (strength in percentage), then lifted Resident 17's shirt to apply the new patch to his back and found an old patch from a prior medication administration (med pass).
During an interview on 7/26/21 at 9:46 a.m. with LVN 2, LVN 2 stated that she would not apply today's patch now and would check with Resident 17's physician as old patch was still on the resident's back.
During a review of Resident 17's physician orders, dated 4/17/21 at 9 p.m., the physician orders indicated Lidocaine 5% Patch, remove patch from left shoulder at 9 p.m., 12 hours on/12 hours off.
During a review of Resident 17's admission Record (face sheet), the admission Record indicated an admission date of 5/1/19. Resident 17's diagnoses included osteoarthritis (degeneration of joint cartilage and the underlying bone, most common from middle age onward, it causes pain and stiffness) of the knee and other abnormalities of gait and mobility.
During a review of the facility's pharmacy policy and procedures (P/P) titled, Administering Medications, revised April 2019, the P/P indicated, Policy interpretation and Implementation Medications are administered in accordance with prescriber orders .
b. During an observation on 7/26/21 at 10:11 a.m., at the Station B Medication Cart B, of the medication administration (med pass) of Resident 86, LVN 1 was observed administering Ibuprofen (a non-steroidal anti-inflammatory medication used to treat pain or inflammation) 800 mg (strength in milligram units). LVN 1 did not administer the Ibuprofen with food, or during or after breakfast.
During a review of Resident 86's physician orders dated 9/15/19 at 9:00 a.m., the physician orders indicated, Ibuprofen 800 mg tablet [by mouth], give with food/after food, [diagnosis] pain [management]/[Osteoarthritis].
During a review of the facility's chart, Meal Serving Time, undated, the Meal Serving Time indicated, Station B, 7:25 a.m.
During an interview on 7/26/21 at 2:03 p.m. with LVN 1, regarding the physician order for Ibuprofen 800 mg tablet with food or after food, LVN 1 stated, I didn't give it with food. Breakfast was around 7:30 a.m. or 8:00 a.m.
During a review of Resident 86's admission Record (face sheet), the admission Record indicated Resident 86 was admitted to the facility on [DATE]. Resident 86's diagnoses included rheumatoid arthritis (a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers wrists, feet, and ankles), unspecified, and primary generalized (osteo)arthritis (degeneration of joint cartilage and the underlying bone, most common from middle age onward, it causes pain and stiffness).
During a review of the facility's pharmacy P/P titled, Administering Medications, revised April 2019, the P/P indicated, Policy interpretation and Implementation Medications are administered in accordance with prescriber orders The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route of administration) before giving the medication .
c. During an observation on 7/26/21, at 10:11 a.m., at the Station B Medication Cart B, of the medication administration (med pass) of Resident 86, LVN 1 was observed administering Diclofenac Sodium (a non-steroidal anti-inflammatory medication used to treat rheumatoid arthritis and osteoarthritis) Topical (applied to skin) Gel 1% (strength as percentage) by squeezing an unmeasured amount on her gloved hand and applying it to Resident 86's shoulder and lower back.
During a review of Resident 86's physician orders, the physician orders indicated Order Date 11/4/20, Diclofenac Sodium 1% Gel, apply 2 [grams topically to right wrist [two times a day], [diagnosis] [right] wrist pain; Order Date 11/4/20, Diclofenac Sodium 1% Gel, apply 2 [grams] topically to right shoulder [two times a day], [diagnosis] right shoulder pain; Order Date 11/23/20, Diclofenac Sodium 1% Gel, apply 2 [grams] topically to low back [two times a day], [diagnosis] arthritis; Order Date 11/23/20, Diclofenac Sodium 1% Gel, apply 2 [grams] topically to right knee [two times a day], [diagnosis] arthritis.
During a review of Resident 86's electronic medication administration record (eMAR), the eMAR indicated a dose of 2 grams for all four orders.
During an observation on 7/26/21 at 2:05 p.m., the labeling on the carton and tube for Diclofenac Sodium Topical Gel 1% indicated, Use with dosing card inside carton. The carton did not contain a dosing card. The package insert contained a printed illustration, Dosing card for Diclofenac Sodium Topical Gel 1%, which indicated an oblong rectangular box with the measurement of 2.25 inches for the 2 gram dose, and an adjacent oblong rectangular box with the cumulative measurement of 4.5 inches for the 4 gram dose.
During an interview on 7/26/21 at 2:27 p.m. with LVN 1, regarding Diclofenac 2 gram administration, LVN 1 stated, I put some in my hand, I didn't know I had to measure it. LVN 1 was unaware of a dosing card with the dosing measurements and the package insert with the illustrated dosing card measurement.
During a review of the facility's pharmacy P/P titled, Administering Medications, revised April 2019, the P/P indicated, Policy interpretation and Implementation Medications are administered in accordance with prescriber orders The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route of administration) before giving the medication .
d. During an observation on 7/26/21 at 10:24 a.m., at the Station B Medication Cart B, of the medication administration (med pass) of Resident 86, LVN 1 and the surveyor counted and verified 11 tablets and one ointment before med pass administration.
During a review of Resident 86's physician orders, after the med pass, the physician orders indicated an additional medication, Order Date 9/15/19, Multivitamin, 1 tablet [by mouth daily, supplement], that was not administered with the morning medications.
During an interview on 7/26/21 at 2:24 p.m. with LVN 1, regarding the multivitamin tablet that was not administered to Resident 86, LVN 1 stated, Oh really? I don't remember.
During a review of the facility's pharmacy P/P titled, Administering Medications, revised April 2019, the P/P indicated, Policy interpretation and Implementation Medications are administered in accordance with prescriber orders The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route of administration) before giving the medication .
The medication error rate was calculated as four (4) medication errors divided by twenty-eight (28) opportunities, multiplied by one-hundred (100), which resulted in the medication error rate of fourteen and twenty-nine one hundredths percent (14.29 %) exceeded the five (5) percent threshold.
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:
1. Ensure that nursing staff timely removed a topical medication patch the night before the morning application, per physici...
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Based on observation, interview, and record review, the facility failed to:
1. Ensure that nursing staff timely removed a topical medication patch the night before the morning application, per physician's order.
This deficient practice had the potential for harm to the residents due to a potential drug overdose.
2. Ensure that nursing staff administered a medication with food or after food, per physician's order.
This deficient practice had the potential for harm to the resident due to potential adverse effects of the medication without food.
3. Ensure that nursing staff applied a topical medication using a dosing card to measure the strength prescribed by the physician.
This deficient practice had the potential for harm to the resident due to potential for underdosing or overdosing of the medication.
4. Ensure that nursing staff administered one (1) over-the-counter medication to a resident, per physician's order.
This deficient practice had the potential for harm to the resident by not receiving a medication.
5. Ensure that the change of shift narcotics reconciliation records, for two (2) out of three (3) medication carts at the facility, were not missing a total of one hundred thirty-five (135) licensed nurse signatures in the designated nurse signature boxes over a seven (7) month period.
This deficient practice had the potential for loss of accountability, which affected the controls against drug loss, diversion, or theft.
6. Accurately document Risperidone (medication used to treat mental disorders) was administered on the electronic Medication Administration Record (eMAR).
This deficient practice had the potential for duplicate therapy and adverse side effects.
Findings:
a. During an observation on 7/26/21 at 9:45 a.m., at the Station A Medication Cart A, of the medication administration (med pass) of Resident 17, Licensed Vocational Nurse 2 (LVN 2) unwrapped a Lidocaine (topical anesthetic used for pain relief) Patch 5% (strength in percentage), then lifted Resident 17's shirt to apply the new patch to his back and found an old patch from a prior medication administration (med pass).
During an interview on 7/26/21 at 9:46 a.m., LVN 2 stated that she would not apply today's patch now and would check with Resident 17's physician as the old patch was still on the resident's back.
During a review of Resident 17's physician order dated 4/17/21 at 9 p.m., the physician's order indicated Lidocaine 5% Patch, remove patch from left shoulder at 9 p.m., 12 hours on/12 hours off.
During a review of Resident 17's admission Record, the admission Record indicated an admission date of 5/1/19. Resident 17's diagnoses included osteoarthritis (degeneration of joint cartilage and the underlying bone, most common from middle age onward, it causes pain and stiffness) of the knee and other abnormalities of gait (walking) and mobility.
During a review of the facility's pharmacy policy and procedures (P/P) titled, Administering Medications, revised April 2019, the P/P indicated, Policy interpretation and Implementation Medications are administered in accordance with prescriber orders .
b. During an observation on 7/26/21 at 10:11 a.m., at the Station B Medication Cart B, of the medication administration (med pass) of Resident 86, LVN 1 administered Ibuprofen (a non-steroidal anti-inflammatory medication used to treat pain or inflammation) 800 milligrams ([mg]strength in milligram units). LVN 1 did not administer the Ibuprofen with food, or during or after breakfast.
During a review of Resident 17's physician's order dated 9/15/19 at 9:00 a.m., the physician's order indicated, Ibuprofen 800 mg tablet [by mouth], give with food/after food, [diagnosis] pain [management]/[Osteoarthritis].
During a review of the facility's chart, Meal Serving Time, not dated, the Meal Serving Time indicated, Station B, 7:25 a.m.
During an interview on 7/26/21 at 2:03 p.m. with LVN 1, regarding the physician order for Ibuprofen 800 mg tablet with food or after food, LVN 1 stated, I didn't give it with food. Breakfast was around 7:30 a.m. or 8:00 a.m.
During a review of Resident 86's admission Record, the admission Record indicated an admission date of 10/18/17. Resident 86's diagnoses included rheumatoid arthritis (a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers wrists, feet, and ankles), unspecified, and primary generalized (osteo)arthritis (degeneration of joint cartilage and the underlying bone, most common from middle age onward, it causes pain and stiffness).
During a review of the facility's pharmacy P/P titled, Administering Medications, revised April 2019, the P/P indicated, Policy interpretation and Implementation Medications are administered in accordance with prescriber orders The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route of administration) before giving the medication .
c. During an observation on 7/26/21 at 10:11 a.m., at the Station B Medication Cart B, of the medication administration (med pass) of Resident 86, LVN 1 administered Diclofenac Sodium (a non-steroidal anti-inflammatory medication used to treat rheumatoid arthritis and osteoarthritis) Topical (applied to skin) Gel 1% (strength as percentage) by squeezing an unmeasured amount on her gloved hand and applying it to Resident 86's shoulder and lower back.
During a review of Resident 86's physician orders, the physician orders indicated, Order Date 11/4/20, Diclofenac Sodium 1% Gel, apply 2 [grams topically to right wrist [two times a day], [diagnosis] [right] wrist pain; Order Date 11/4/20, Diclofenac Sodium 1% Gel, apply 2 [grams] topically to right shoulder [two times a day], [diagnosis] right shoulder pain; Order Date 11/23/20, Diclofenac Sodium 1% Gel, apply 2 [grams] topically to low back [two times a day], [diagnosis] arthritis; Order Date 11/23/20, Diclofenac Sodium 1% Gel, apply 2 [grams] topically to right knee [two times a day], [diagnosis] arthritis.
During a review of Resident 86's Electronic Medication Administration Record (eMAR) indicated a dose of two grams for all four orders.
During an observation on 7/26/21 at 2:05 p.m., the labeling on the carton and tube for Diclofenac Sodium Topical Gel 1% indicated, Use with dosing card inside carton. The carton did not contain a dosing card. The package insert contained a printed illustration, Dosing card for Diclofenac Sodium Topical Gel 1%, which indicated an oblong rectangular box with the measurement of 2.25 inches for the 2 gram dose, and an adjacent oblong rectangular box with the cumulative measurement of 4.5 inches for the 4 gram dose.
During an interview on 7/26/21 at 2:27 p.m. with LVN 1, regarding Diclofenac 2 gram administration, LVN 1 stated, I put some in my hand, I didn't know I had to measure it. LVN 1 was unaware of a dosing card with the dosing measurements and the package insert with the illustrated dosing card measurement.
During a review of the facility's pharmacy P/P titled, Administering Medications, revised April 2019, the P/P indicated, Policy interpretation and Implementation Medications are administered in accordance with prescriber orders The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route of administration) before giving the medication .
d. During an observation on 7/26/21 at 10:24 a.m., at the Station B Medication Cart B, of the medication administration (med pass) of Resident 86, LVN 1 and the surveyor counted and verified 11 tablets and 1 ointment before med pass administration.
During a review of Resident 86's physician orders, after the med pass, the physician orders indicated an additional medication, Order Date 9/15/19, Multivitamin, 1 tablet [by mouth daily, supplement], that was not administered with the morning medications.
During an interview on 7/26/21 at 2:24 p.m. with LVN 1, regarding the multivitamin tablet that was not administered to Resident 86, LVN 1 stated, Oh really? I don't remember.
During a review of the facility's pharmacy P/P titled, Administering Medications, revised April 2019, the P/P indicated, Policy interpretation and Implementation Medications are administered in accordance with prescriber orders The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route of administration) before giving the medication .
e. During an observation on 7/27/21 at 1:29 p.m., of the Station A/B Medication Cart Middle, LVN 3 provided the shift change narcotics count log book.
During a review of the shift change narcotics count log sheets, titled, Narcotic Medication Surveillance, dated February 2021 to July 2021 (up to 7/27/21, 7 a.m.), the Narcotic Medication Surveillance sheets indicated eighty-four (84) missing nurse signatures, out of a total of one thousand fifty-eight (1,058) nurse signature boxes.
During a review of the Narcotic Medication Surveillance sheets, from 2/1/21 to 7/27/21, 7 a.m. shift change, the Narcotic Medication Surveillance sheets indicated missing nurse signatures in the signature boxes shown by date, shift, on-coming or leaving: 2/1/21, 7 am, on-coming; 2/1/21, 3 p.m., on-coming; 2/1/21, 3 p.m., leaving; 2/1/21, 11 p.m., leaving; 2/2/21, 3 p.m., on-coming; 2/2/21, 11 p.m., leaving; 2/3/21, 3 p.m., on-coming; 2/3/21, 11 p.m., leaving; 2/4/21, 3 p.m., on-coming; 2/4/21, 3 p.m., leaving; 2/5/21, 7 am, on-coming; 2/11/21, 3 p.m., leaving; 2/24/21, 11 p.m., leaving; 3/2/21, 3 p.m., leaving; 3/14/21, 7 am, on-coming; 3/24/21, 11 p.m., leaving; 3/25/21, 3 p.m., leaving; 3/26/21, 3 p.m., leaving; 3/27/21, 11 p.m., on-coming; 3/28/21, 7 am, leaving; 3/31/21, 7 am, on-coming; 3/31/21, 7 am, leaving; 3/31/21, 3 p.m., on-coming; 4/1/21, 7 am, on-coming; 4/1/21, 3 p.m., leaving; 4/2/21, 11 p.m., leaving; 4/5/21, 3 p.m., on-coming; 4/5/21, 3 p.m., leaving; 4/7/21, 3 p.m., on-coming; 4/7/21, 11 p.m., leaving; 4/8/21, 11 p.m., leaving; 4/10/21, 11 p.m., on-coming; 4/11/21, 7 am, leaving; 4/12/21, 7 am, on-coming; 4/12/21, 3 p.m., leaving; 4/16/21, 3 p.m., on-coming; 4/16/21, 11 p.m., leaving; 4/17/21, 3 p.m., on-coming; 4/17/21, 11 p.m., leaving; 4/26/21, 7 am, leaving; 4/30/21, 3 p.m., on-coming; 4/30/21, 11 p.m., leaving; 5/16/21, 11 p.m., leaving; 5/17/21, 11 p.m., leaving; 5/22/21, 11 p.m., leaving; 5/24/21, 3 p.m., on-coming; 5/24/21, 11 p.m., leaving; 5/25,21, 3 p.m., on-coming; 5/25/21, 11 p.m., leaving; 5/26/21, 3 p.m., on-coming; 5/26/21, 11 p.m., leaving; 6/2/21, 3 p.m., leaving; 6/3/21, 3 p.m., leaving; 6/7/21, 3 p.m., leaving; 6/10/21, 3 p.m., leaving; 6/18/21, 3 p.m., on-coming; 6/18/21, 11 p.m., leaving; 6/19/21, 11 p.m., on-coming; 6/20/21, 7 am, leaving; 6/24/21, 11 p.m., on-coming; 6/25/21, 7 am, on-coming; 6/25/21, 7 am, leaving; 6/25/21, 3 p.m., leaving; 6/25/21, 11 p.m., on-coming; 6/26/21, 7 am, leaving; 6/26/21, 3 p.m., leaving; 6/26/21, 11 p.m., on-coming; 6/27/21, 7 am, leaving; 6/29/21, 3 p.m., leaving; 6/30/21, 3 p.m., leaving; 7/2/21, 3 p.m., on-coming; 7/2/21, 11 p.m., leaving; 7/6/21, 11 p.m., leaving; 7/11/21, 3 p.m., leaving; 7/12/21, 11 p.m., leaving; 7/13/21, 7 am, on-coming; 7/13/21, 3 p.m., leaving; 7/14/21, 7 am, leaving; 7/17/21, 7 am, on-coming; 7/21/21, 7 am, on-coming; 7/21/21, 3 p.m., leaving; 7/22/21, 3 p.m., leaving; 7/23/21, 7 am, on-coming; and, 7/23/21, 3 p.m., leaving.
During an interview on 7/27/21 at 1:55 p.m. with LVN 3, LVN 3 acknowledged the missing nurse signatures. Regarding if the nurses are supposed to sign at the same time, LVN 3 stated, Yes, they are. Regarding the blank spaces since February 2021, LVN 3 stated, I have been here a month. You're supposed to sign as an incoming and outgoing (nurse).
f. During an observation on 7/28/21 at 1:16 p.m., of the Station B Medication Cart B, LVN 1 provided the shift change narcotics count log book.
During a review of the shift change narcotics count log sheets, titled, Narcotic Medication Surveillance, dated January 2021 to July 2021 (up to 7/28/21, 7 a.m.), the Narcotic Medication Surveillance sheets indicated fifty-one (51) missing nurse signatures, out of a total of one thousand forty-four (1,244) nurse signature boxes.
During a review of the Narcotic Medication Surveillance sheets, from 1/1/21 to 7/28/21 7 a.m. shift change, the Narcotic Medication Surveillance sheets indicated missing nurse signatures in the signature boxes shown by date, shift, on-coming or leaving: 1/1/21, 7 am, on-coming; 1/1/21, 7 am, leaving; 1/1/21, 3 p.m., on-coming; 1/1/21, 3 p.m., leaving; 1/1/21, 11 p.m., on-coming; 1/1/21, 11 p.m., leaving; 1/2/21, 7 am, on-coming; 1/2/21, 7 am, leaving; 1/2/21, 3 p.m., on-coming; 1/2/21, 3 p.m., leaving; 1/2/21, 11 p.m., on-coming; 1/2/21, 11 p.m., leaving; 1/3/21, 7 am, on-coming; 1/3/21, 7 am, leaving; 1/3/21, 3 p.m., on-coming; 1/3/21, 3 p.m., leaving; 1/3/21, 11 p.m., on-coming; 1/3/21, 11 p.m., leaving; 1/4/21, 7 am, on-coming; 1/4/21, 7 am, leaving; 1/4/21, 3 p.m., on-coming; 1/4/21, 3 p.m., leaving; 1/4/21, 11 p.m., on-coming; 1/4/21, 11 p.m., leaving; 1/5/21, 7 am, on-coming; 1/5/21, 7 am, leaving; 1/5/21, 3 p.m., leaving; 1/9/21, 7 am, leaving; 1/19/21, 7 am, on-coming; 1/19/21, 3 p.m., leaving; 1/20/21, 11 p.m., leaving; 1/26/21, 3 p.m., on-coming; 1/26/21, 11 p.m., leaving; 3/13/21, 7 am, leaving; 3/20/21, 7 am, on-coming, 3/20/21, 3 p.m., leaving; 5/16/21, 3 p.m., on-coming; 5/16/21, 11 p.m., leaving; 5/17/21, 3 p.m., on-coming; 6/6/21, 3 p.m., on-coming; 6/7/21, 3 p.m., leaving; 6/8/21, 3 p.m., leaving; 6/13/21, 11 p.m., on-coming; 6/14/21, 7 am, leaving; 7/4/21, 3 p.m., on-coming; 7/4/21, 11 p.m., leaving; 7/8/21, 7 am, on-coming; 7/8/21, 3 p.m., leaving; 7/11/21, 7 am, on-coming; 7/11/21, 3 p.m., leaving; and, 7/13/21, 3 p.m., leaving.
During an interview on 7/28/21 at 1:42 p.m. with LVN 1, LVN 1 acknowledged the missing nurse signatures. Regarding what the nurses are supposed to do during narcotics counts, LVN 1 stated , We count, and we sign. We both sign. That's a lot (of missing signatures).
During a review of the facility's pharmacy P/P titled, Controlled Substances, revised December 2012, the P/P indicated, Policy Interpretation and Implementation .Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services.
g. During a concurrent observation, interview, and record review of Resident 65's eMAR on 7/29/21 at 9:53 a.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 was observed passing medications at Resident 65's door. LVN 2 stated Resident 65 was not administered her evening dose of Risperidone the previous night. LVN 2 revealed a full bubble pack of Resident 65's medication labeled Risperidone 4 mg by mouth to be administered twice a day. LVN 2 stated she would have to ask her supervisor why the new scheduled dose was not administered at 5 p.m. on 7/28/21, the previous evening shift. Resident 65's eMAR indicated to discontinue the bubble pack on 7/28/21 and start new dosage of Risperidone immediately. In addition, there was two pills missing on the 7/28/21 bubble back labeled Risperidone 2 mg by mouth twice a day administration. When asked the process when new dosages are prescribed to residents, LVN 2 took out a new bubble pack with unused medications that was on 7/28/21 at unknown time to Resident 65's pocket of medications. LVN 2 stated the evening shift LVN assigned to Resident 65 gave two tablets of Risperidone 2 mg tablets from the old package on the evening shift because the new medication with the new dosage prescribed had not arrived from the pharmacy. LVN 2 stated, sometimes the new adjusted dose does not arrive until the next day so we can administer medication from the old pack. Resident 65's eMAR indicated on 7/28/21 at 5 p.m. there was no documentation of Risperidone on the evening shift bubble pack, two tablets of Risperidone were missing and the new bubble pack with the adjusted dosage was full with no pills missing.
During an interview on 7/29/21 at 11:01 a.m. with the Director of Nursing (DON), the DON stated the facility encountered some unexpected staffing issues on 7/28/21 during the evening shift. The DON stated LVN 4 went home sick around 7 p.m. and LVN 3 was asked to pick up her assignment at that time. The DON stated the facility's Quality Assurance and Performance Improvement (QAPI) committee was conducting a root cause analysis weekly to audit the electronic medication charts to ensure that there was less missed documentation of medications. The DON stated she along with designated LVNs also help with audits on a weekly basis. The DON stated it was very important to document missed medications to avoid double dosing on the next shift. The DON stated the process of documenting medication was to always use the five patient rights of medication administration (right patient, right medication, right time, right dose, right route, right documentation, right reason, and right response) to avoid medication errors.
During an interview on 7/29/21 at 11:18 a.m. with Registered Nurse Supervisor (RN 1), RN 1 stated the RN supervisor or LVN charge nurse looked for missing medication for their own residents but it was not something the RN supervisor would be specifically given the task to audit. RN 1 stated, If I am on the cart and I see a missed medication that is how I will catch it. RN 1 stated when we get all the new medication's for residents that was when the RN supervisor or anyone administering medications would notice. RN 1 stated, The only way I can see if a medication isn't signed for is if I'm passing meds. RN 1 stated the resident MARs were audited by the QAPI committee and medical records monthly. RN 1 stated the DON also performed audits and had been implementing changes in the system to decrease missed medication documentation. RN 1 stated if medications are not documented it leaves room for medication errors and liabilities to the facility.
During an interview on 7/29/21 at 3:02 p.m. with LVN 3, LVN 3 stated, on 7/28/21 at 3 p.m. she was assigned a heavy assignment due to LVN 4 going home early due to illness. LVN 3 stated she was assigned to Resident 65's care on the 3 p.m. to 11 p.m. (evening) shift on 7/28/21. LVN 3 stated Resident 65's order for Risperidone (medication used to treat mental illness) 2 mg by mouth twice a day prescription was increased to 4 mg by mouth twice a day. LVN 3 stated she noticed the order changed, but the new medication cassette had not arrived so two 2 mg tablets of Risperidone pill form was administered. LVN 3 stated she duplicated the medications and gave two pills from Resident 65's cassette until the new cassette arrived. LVN 3 stated she administered Risperidone two 2 mg tablets around 6:30 p.m. on 7/28/21 and was sure to chart the medication. LVN 3 stated, I am new so I may have forgotten to click the x for that day. LVN 3 denied going over Resident 65's administered medications with the night shift during shift change. LVN 3 stated normally during shift change the process would be to go over the medication changes and what was administered but we did not that particular day. LVN 3 stated medications administered but not charted put resident's at risk for double dosages of an antipsychotic which could inadvertently harm the resident. LVN 3 stated all medications should be charted in the eMAR when administered.
During an interview on 7/29/21 at 4:30 p.m. with the Director of Staff Development (DSD), the DSD stated it was the LVNs responsibility to document medications when administered. The DSD stated if the medications were not documented, then medication errors occur. The DSD stated LVN's were required to follow the facility's job description for their role along with policies and procedures the facility had in place for documenting medications pertaining to pharmacy services.
During a review of the facility's P/P titled, Administering mediations - Mess Pass, dated 4/2019, the P/P indicated the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.
During a review of the facility's LVN job description dated 5/08, the job description the LVN's general duties were to ensure documentation was always complete and legible.
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 a medication error rate of less than five (5) percent, due to four (4) medication administration errors involving two ...
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Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five (5) percent, due to four (4) medication administration errors involving two (2) residents out of two (2) total residents observed during medication administration (med pass).
The deficient practice of a medication administration error rate of fourteen and twenty-nine one hundredths percent (14.29 %) exceeded the five (5) percent threshold.
Findings:
a. During an observation on 7/26/21 at 9:45 a.m., at the Station A Medication Cart A, of the medication administration (med pass) of Resident 17, Licensed Vocational Nurse 2 (LVN 2), LVN 2 unwrapped a Lidocaine (topical anesthetic used for pain relief) Patch 5% (strength in percentage), then lifted Resident 17's shirt to apply the new patch to his back and found an old patch from a prior medication administration (med pass).
During an interview on 7/26/21 at 9:46 a.m. with LVN 2, LVN 2 stated she will not apply today's patch now and will check with physician as old patch was still on the resident's back.
During a review of Resident 17's physician orders, dated 4/17/21 at 9 p.m., the physician orders indicated Lidocaine 5% Patch, remove patch from left shoulder at 9 p.m., 12 hours on/12 hours off.
During a review of Resident 17's admission Record the admission Record indicated an admission date of 5/1/19. Resident 17's diagnoses included osteoarthritis (degeneration of joint cartilage and the underlying bone, most common from middle age onward, it causes pain and stiffness) of the knee and other abnormalities of gait (walking) and mobility.
During a review of the facility's pharmacy policy and procedures (P/P) titled, Administering Medications, revised April 2019, the P/P indicated, Policy interpretation and Implementation Medications are administered in accordance with prescriber orders .
b. During an observation on 7/26/21 at 10:11 a.m., at the Station B Medication Cart B, of the medication administration (med pass) of Resident 86, LVN 1 administered Ibuprofen (a non-steroidal anti-inflammatory medication used to treat pain or inflammation) 800 mg (strength in milligram units). LVN 1 did not administer the Ibuprofen with food, or during or after breakfast.
During a review of the Resident 86's physician orders, dated 9/15/19 at 9:00 a.m., the physician orders indicated, Ibuprofen 800 mg tablet [by mouth], give with food/after food, [diagnosis] pain [management]/[Osteoarthritis].
During a review of the facility's chart, Meal Serving Time, not dated, the Meal Serving Time indicated, Station B, 7:25 a.m.
During an interview on 7/26/21 at 2:03 p.m. with LVN 1, regarding the physician order for Ibuprofen 800 mg tablet with food or after food, LVN 1 stated, I didn't give it with food. Breakfast was around 7:30 a.m. or 8:00 a.m.
During a review of Resident 86's admission Record, the admission Record indicated an admission date of 10/18/17. Resident 86's diagnoses included rheumatoid arthritis (a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers wrists, feet, and ankles), unspecified, and primary generalized (osteo)arthritis (degeneration of joint cartilage and the underlying bone, most common from middle age onward, it causes pain and stiffness).
During a review of the facility's pharmacy P/P titled, Administering Medications, revised April 2019, indicated, the P/P indicated Policy interpretation and Implementation Medications are administered in accordance with prescriber orders The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route of administration) before giving the medication .
c. During an observation on 7/26/21 at 10:11 a.m., at the Station B Medication Cart B, of the medication administration (med pass) of Resident 86, LVN 1 administered Diclofenac Sodium (a non-steroidal anti-inflammatory medication used to treat rheumatoid arthritis and osteoarthritis) Topical (applied to skin) Gel 1% (strength as percentage) by squeezing an unmeasured amount on her gloved hand and applying it to Resident 86's shoulder and lower back.
During a review of Resident 86's physician orders indicated, the physician orders indicated Order Date 11/4/20, Diclofenac Sodium 1% Gel, apply 2 [grams topically to right wrist [two times a day], [diagnosis] [right] wrist pain; Order Date 11/4/20, Diclofenac Sodium 1% Gel, apply 2 [grams] topically to right shoulder [two times a day], [diagnosis] right shoulder pain; Order Date 11/23/20, Diclofenac Sodium 1% Gel, apply 2 [grams] topically to low back [two times a day], [diagnosis] arthritis; Order Date 11/23/20, Diclofenac Sodium 1% Gel, apply 2 [grams] topically to right knee [two times a day], [diagnosis] arthritis.
During a review of Resident 86's electronic Medication Administration Record (eMAR) indicated a dose two grams for all four orders.
During an observation on 7/26/21 at 2:05 p.m., the labeling on the carton and tube for Diclofenac Sodium Topical Gel 1% indicated, Use with dosing card inside carton. The carton did not contain a dosing card. The package insert contained a printed illustration, Dosing card for Diclofenac Sodium Topical Gel 1%, which indicated an oblong rectangular box with the measurement of 2.25 inches for the 2 gram dose, and an adjacent oblong rectangular box with the cumulative measurement of 4.5 inches for the 4 gram dose.
During an interview on 7/26/21 at 2:27 p.m. with LVN 1, regarding Diclofenac 2 gram administration, LVN 1 stated, I put some in my hand, I didn't know I had to measure it. LVN 1 was unaware of a dosing card with the dosing measurements and the package insert with the illustrated dosing card measurement.
During a review of the facility's pharmacy P/P titled, Administering Medications, revised April 2019, indicated, the P/P indicated Policy interpretation and Implementation Medications are administered in accordance with prescriber orders The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route of administration) before giving the medication .
d. During an observation on 7/26/21 at 10:24 a.m., at the Station B Medication Cart B, of the medication administration (med pass) of Resident 86, LVN 1 and the surveyor counted and verified 11 tablets and one ointment before med pass administration.
During a review of Resident 86's physician orders, after the med pass, the physician orders indicated an additional medication, Order Date 9/15/19, Multivitamin, 1 tablet [by mouth daily, supplement], that was not administered with the morning medications.
During an interview on 7/26/21 at 2:24 p.m. with LVN 1, regarding the multivitamin tablet that was not administered to Resident 86, LVN 1 stated, Oh really? I don't remember.
During a review of the facility's pharmacy P/P titled, Administering Medications, revised April 2019, the P/P indicated, Policy interpretation and Implementation Medications are administered in accordance with prescriber orders The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route of administration) before giving the medication .
The medication error rate was calculated as four (4) medication errors divided by twenty-eight (28) opportunities, multiplied by one-hundred (100), which resulted in the medication error rate of fourteen and twenty-nine one hundredths percent (14.29 %) exceeded the five (5) percent threshold.
CONCERN
(E)
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:
1. Maintain contact isolation (an isolation in which a...
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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. Maintain contact isolation (an isolation in which anyone entering the patient's room and having direct contact with the patient wears gloves and a gown) for three of three residents (Residents 494, 57, 5)
2. Refer three of three residents (Residents 494, 57, and 5) who had body rashes to a dermatologist (specialist for treating skin diseases).
3. Report one of three residents (Resident 5) who had presumptive scabies (a contagious, intensly itchy skin condition caused by a tiny, burrowing mite [tiny animal] that burrows into the upper layer of the skin where it lives and lays its eggs) and were treated with Elimite (a topical scabicidal agent for the treatment of infestation with scabies).
4. Ensure newly hired employees completed a pre-employment physical examination and immunization records were obtained for two of five newly hired employees.
These deficient practices had the potential of spreading infection to other residents, staff and visitors.
Findings:
a. During observations of a contact isolation room for scabies, on 07/26/21 at 01:46 p. m., Resident 494 was aggressively rubbing her back against the bed. An instructional note with pictures of personal protective equipment (PPE's) was observed placed beside the resident's door, indicated please do not enter, consult with nurse's prior entry the room. In a concurrent interview with the treatment nurse, she stated both residents had generalized rashes and had been treated with permethrin for contact dermatitis (when the body encounters an object, that is, (diapers, linens, bed surface, and skin).
During a review of Resident 494 admission Record indicated the resident was readmitted to the facility on [DATE] with diagnoses that included but were not limited to congestive heart failure (inability of the had to function), contact dermatitis, .
During a review of the nursing progress notes dated 5/19/2021, 5/23/2021, 5/24/21, 5/25/21, 6/2/21, 6/4/21, 6/5/21, 6/7/2021, 6/14/2021, indicated the resident was monitored for contact dermatitis, rash on the right trunk area and itching on bilateral inner thigh and dry nose.
During a review of Resident 494's physician order sheet, dated 7/13/2021, indicated the resident had contact dermatitis on the right trunk and both inner thighs and had been treated with Fluocinonide 1 percent, apply to affected areas daily and Oxiconazole 1 percent cream -apply to affected area daily.
During a review of physician telephone order sheet dated 7/23/2021, indicated May apply permethrin topical cream 5 % (topical medication given to treat scabies) to generalized body when available to rule out unspecified dermatitis then again on 7/30/2021.
During a review of Resident 494's general acute care hospital records (physical examination) dated 7/21/2021, indicated the resident had rash and had been treated for presumptive scabies, positive for skin rash which is treated for presumptive scabies. The record also indicated the resident had diffuse reddish erythematous rash with dry skin also noticed.
During a review of Resident 494's treatment nurse's progress note dated 7/23/2021, indicated the resident was readmitted from acute care hospital with generalized body rash or dermatitis, of the right lower abdomen area with yellowish and purple discoloration on the right upper extremities with scattered ecchymosis and dry nose scab,
During a review of Resident 494's care plan skin rash generalized body dated 7/23/2021, TX. as ordered, daily body check to monitor for skin breakdown, monitor for scratching of sign of infection, permethrin cream to generalized body and then follow up again on 7/30/2021
On 07/27/21, at 02:07 p. m., during an interview with director of nursing (DON) stated Resident 494 was admitted with body rash since 1/26/2021. The [NAME] further stated she was not sure if the resident was seen by a dermatogist (skin doctor).
On 07/28/21, at 01:05 p. m., during an interview with Administrator stated the department of public (PHD) had to be notified if residents had a presumptive scabies because it is a communicable disease and to have guidance on how to treat the infection. According to the administrator, Permethrin had been given prophylaxis treatment or as presumptive treatment for scabies. Administrator stated residents were placed in contact Isolation to prevent other residents from been infected (precautionary measures. According to the administrator, the facility's policy indicated if scabies is suspected or confirmed, it should be reported to the state department, resident's belongings and curtains disinfected; Bag all the linens should be bagged in a black bag and wash separately at a high temperature and the room should be disinfected, the room, placed resident in contact isolated or cohort if the other residents have scabies.
On 07/28/21, at 01:41 p. m., in a follow up interview with the DON, stated three residents had been treated with Permethrin for scabies prophylaxis and would be repeated on 7/30/2021. According to DON were dried off., the resident's rashes were scatted on affected areas, reddish and some dried off. DON stated Resident 494 was treated presumptively for scabies in the general acute care hospital and was placed in isolation upon her return with her roommates. DON stated both residents had not been examined by a dermatologist but were seen by a wound care doctor. DON stated skin checks /assessments were conducted for all residents on 7/17/2021. When questioned, DON stated it's the facility's protocol. According to DON skin scraping was performed on 7/27/2021 a week after permethrin was applied. seen by wound care doc, but resident had no open skin or wounds at this time.
On 07/29/21, at 11:31 a. m., during an interview with CNA 9 stated resident had rash on both inner tights, scattered rash on the chest and both arms, upper back and truck areas. According to CNA 8 the resident had been itching and scratching herself before the permethrin was applied.
b. During a review of Resident 57's admission Record (Face sheet) indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnosis that included but were not limited to type 2 diabetes mellitus with diabetes (high blood sugar), chronic kidney disease ((inability of the kidney to function) and unspecified dementia without behavioral disturbance.
During a review of Resident 57's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/22/21, indicated the resident's cognitive skills of daily decision making were impaired. The MDS assessment also indicated the resident required extensive assistance with some activities of daily livings and supervisor with eating
During a review of Resident 57's History and Physical dated 6/30/21, indicated the resident does not have the capacity to understand and make decisions.
During a review of Resident 57's physician's order dated 7/23/2021, indicated apply permethrin topical cream 5 % to generalized body to role out unspecified dermatitis and again on 7/30/2021.
During a review of the care plan skin dated 7/23/23/2021, indicated skin rash generalized body. The nursing intervention were, treat as ordered, daily body checks, notify physician and apply permethrin cream.
On 7/30/2021. At 10 a. m. during an interview with LVN 9 stated the second treatment with permethrin was applied as ordered by the physician on 7/30/2021.
c. During a of Resident 5's admission Record (Face sheet) indicated the resident was initially admitted to the facility on [DATE], with diagnosis that included but were not limited to type 2 diabetes mellitus with diabetes (high blood sugar), chronic kidney disease ((inability of the kidney to function) and unspecified dementia without behavioral disturbance.
During a review of Resident 5's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 7/26/21, indicated the resident's cognitive skills of daily decision making were impaired. The MDS assessment also indicated the resident required extensive assistance with some activities of daily livings and supervisor with eating
During a review of Resident 5's History and Physical dated 4/22/21, indicated the resident does not have the capacity to understand and make decisions.
During a review of Resident 5's physician's order dated 7/23/2021, indicated apply permethrin topical cream 5 % to generalized body to roll out unspecified dermatitis and again on 7/30/2021.
During a review of Resident 5's care plan skin dated 7/23/23/2021, indicated skin rash generalized body. The nursing intervention were, treat as ordered, daily body checks, notify physician and apply permethrin cream.
On 7/30/2021. At 10 a. m. during an interview with LVN 9 stated the second treatment with permethrin was applied as ordered by the physician on 7/30/2021.
Accord to the facility's policy and procedure title Reporting Communicable Disease revised 6/14, indicated the facility shall report any suspected and confirmed communicable disease to the appropriate government agency or authority, local, district or state health department, The policy further indicated reportable diseases are put in a mandatory written form, mandatory reporting by phone.
d. On 07/30/21, at 11:35 a. m., a review of the employee's files in the present of the director of staff development (DSD) two employee's files did not have physical examination forms conducted by a physician. Both employees' files did not have immunization records.
A review of the Employee 1's file indicated she was hired was on 7/8/2020, the file had no documentation indicated a physical examination was conducted. No immunization records in file at the time of review.
A review of Employee 2's file indicated she was hired on 6/9 /2021; file did not have immunization records but had a physical examination form dated on 7/30/2020. File had blank forms of Hepatitis B virus, Mumps/Measles/Rubella and varicella vaccine consent/disclination. In a concurrent interview with the DSD, stated after been hired, she went over all new employees' files and found out that employee 2 physical did not have a date. According to her, the physician had to sign it with the date indicated on the form. According to the DSD, employee 2 said she declined to be vaccinated. However, the was no documented evidence indicating the employee refused to be vaccinated.
A review of Employee 3's file had no immunization records. In a concurrent interview with DSD stated she was newly hired and would make sure all employee files are updated with missing records. According to DSD, not providing pre-employment physical examination and testing, immunization for recommended and required vaccines and providing employee screening for communicable diseases and infection put the residents and other staffs at risk of been infected.
According to the facility's policy and procedures Employee Health Program revised 1/2012, indicated the facility's employee health program shall promote the health, safety and well-being of all staffs and residents and prevent the spread of communicable disease among staff and residents by providing pre-employment physical examination and testing, immunization for recommended and required vaccines and providing employee screening.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · 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 that 22 of 39 resident bedrooms measured at lea...
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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 that 22 of 39 resident bedrooms measured at least 80 square feet (sq. ft.) per resident in multiple resident rooms.
Rooms 11, 12, 14, 15, 17, 18, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, and 36 measured less than 80 sq. ft. per resident.
This failure had the potential to result in inadequate space for the residents and can impact the residents' quality of life or quality of care.
Findings:
During an interview and record review on 08/2/2021 at 2:32 p.m., the Administrator (ADM) provided a copy of room waiver approval for resident rooms with less than 80 sq. ft., dated 06/5/2021. He stated 22 rooms does not meet the minimum requirement of 80 sq. ft. per resident.
Rooms measuring less than 80 sq. ft. per resident for which the variance was requested were for the following:
room [ROOM NUMBER] measure 224.7 sq. ft. with 3 residents in each room. Requirement is 240 sq. ft.
room [ROOM NUMBER] measure 224.4 sq. ft. with 3 residents in each room. Requirement is 240 sq. ft.
room [ROOM NUMBER] and 22 measure 216.3 sq. ft. with 3 residents in each room. Requirement is 240 sq. ft.
room [ROOM NUMBER] measure 215.3 sq. ft. with 3 residents in each room. Requirement is 240 sq. ft.
room [ROOM NUMBER] measure 215.1 sq. ft. with 3 residents in each room. Requirement is 240 sq. ft.
room [ROOM NUMBER] measure 227.3 sq. ft. with 3 residents in each room. Requirement is 240 sq. ft.
room [ROOM NUMBER] measure 235.4 sq. ft. with 3 residents in each room. Requirement is 240 sq. ft.
room [ROOM NUMBER], 24, 28, 29, 30, 31, 32, 33, 35 and 36 measure 214.3 sq. ft. with 3 residents in each room. Requirement is 240 sq. ft.
room [ROOM NUMBER], 26, 27, and 34 measure 214.1 sq. ft. with 3 residents in each room. Requirement is 240 sq. ft.
During an observation from 07/26/21 to 08/2/2021, regarding provision of residents care by the facility staff indicated there were no adverse effects on the residents' health and safety related to less than 80 sq. ft. per resident room.
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
- • 39% turnover. Below California's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 1 life-threatening violation(s), 3 harm violation(s), $112,022 in fines, Payment denial on record. Review inspection reports carefully.
- • 122 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $112,022 in fines. Extremely high, among the most fined facilities in California. Major compliance failures.
- • 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 Santa Fe Heights Healthcare Center, Llc's CMS Rating?
CMS assigns SANTA FE HEIGHTS HEALTHCARE CENTER, LLC an overall rating of 2 out of 5 stars, which is considered 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 Santa Fe Heights Healthcare Center, Llc Staffed?
CMS rates SANTA FE HEIGHTS HEALTHCARE CENTER, LLC's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 39%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Santa Fe Heights Healthcare Center, Llc?
State health inspectors documented 122 deficiencies at SANTA FE HEIGHTS HEALTHCARE CENTER, LLC during 2021 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 3 that caused actual resident harm, 116 with potential for harm, and 2 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Santa Fe Heights Healthcare Center, Llc?
SANTA FE HEIGHTS HEALTHCARE CENTER, LLC 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 CRYSTAL SOLORZANO, a chain that manages multiple nursing homes. With 99 certified beds and approximately 94 residents (about 95% occupancy), it is a smaller facility located in COMPTON, California.
How Does Santa Fe Heights Healthcare Center, Llc Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, SANTA FE HEIGHTS HEALTHCARE CENTER, LLC's overall rating (2 stars) is below the state average of 3.1, staff turnover (39%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Santa Fe Heights Healthcare Center, Llc?
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 Santa Fe Heights Healthcare Center, Llc Safe?
Based on CMS inspection data, SANTA FE HEIGHTS HEALTHCARE CENTER, LLC 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 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-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 Santa Fe Heights Healthcare Center, Llc Stick Around?
SANTA FE HEIGHTS HEALTHCARE CENTER, LLC has a staff turnover rate of 39%, which is about average for California nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Santa Fe Heights Healthcare Center, Llc Ever Fined?
SANTA FE HEIGHTS HEALTHCARE CENTER, LLC has been fined $112,022 across 3 penalty actions. This is 3.3x the California average of $34,199. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Santa Fe Heights Healthcare Center, Llc on Any Federal Watch List?
SANTA FE HEIGHTS HEALTHCARE CENTER, LLC 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.