VINEYARDS AT FOWLER
For profit - Corporation
49 Beds
AJC HEALTHCARE
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
38/100
#945 of 1155 in CA
Last Inspection: September 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
The Vineyards at Fowler has received a Trust Grade of F, indicating significant concerns about the facility's quality of care. Ranking #945 out of 1155 in California places it in the bottom half of all facilities in the state, and #27 out of 30 in Fresno County suggests only two local options are better. While the facility is improving, having reduced issues from 16 in 2024 to 3 in 2025, staffing remains a concern with a turnover rate of 52%, significantly higher than the state average. Although there have been no fines reported, the facility has less RN coverage than 97% of California facilities, which raises concerns about the level of medical oversight. Specific incidents noted by inspectors include failures in diabetic management for several residents and inadequate infection control practices, which could potentially place residents at risk.
- Trust Score
- F
- In California
- #945/1155
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 52% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most California facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 13 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 39 deficiencies on record. Higher than average. Multiple issues found across inspections.
38/100
Bottom 19%
Review needed
16 → 3 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 16 issues
2025: 3 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Below California average (3.1)
Below average - review inspection findings carefully
Staff Turnover: 52%
Near California avg (46%)
Higher turnover may affect care consistency
Chain: AJC HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 39 deficiencies on record
1 life-threatening
Aug 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
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 residents responsible party (RP- an individual who has t...
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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 residents responsible party (RP- an individual who has the authority to act on behalf of the patient)/family/emergency contact of a change in condition for two of three sampled residents (Resident 1, 6) when Resident 1 experienced seizures (abnormal electrical activity in the brain) and Resident 6 reported chest pain and were transferred to acute care hospital. This failure had the potential to result in Resident 1 and Resident 6's RP/family/emergency contact being unaware of the acute health conditions, hospital transfers, and treatment decisions, which could negatively impact continuity of care and right to have their representatives involved in care decisions. During a concurrent interview and record review on 8/22/25 at 1:41 p.m. with the Director of Nursing (DON) in the DON office, Resident 1's Situation Background Assessment Recommendation Form (SBAR-a tool used to improve the clarity and efficiency of information exchange) form dated 8/17/25 was reviewed. The SBAR indicated Resident 1 had active seizures lasting 3 to 4 minutes. The physician was notified on 8/17/25 at 5:30 a.m. and ordered to send Resident 1 to the acute hospital for further evaluation. The SBAR indicated on 8/17/25 at 5:30 a.m. Resident 1 was notified he was being transferred to the acute care hospital. The DON stated the RP should have been notified when a resident had a change of condition and transferred to the acute hospital. The DON stated the facility did not notify Resident 1's RP when he had changed of condition and was transferred to acute care hospital. The DON stated the license nurse should have called Resident 1's RP unless Resident 1 does not want his RP to be notified. The DON stated the documentation did not indicate Resident 1 declined to have his family notified of the acute care hospital transfer. During a review of Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 8/22/25, the AR indicated Resident 1 was a [AGE] year old male, admitted to the facility on [DATE] with diagnoses: left middle cerebral artery infarction (a blood clot to a major blood vessel on the left side of the brain that control the ability to use ones senses, move and language), muscle weakness, dysphagia (difficulty swallowing), type 2 diabetes mellitus (DM2- a condition where your body does not use a hormone that helps move sugar from your blood into your cells for energy properly), hallucinogen (drugs used for their ability to alter human perception and mood) abuse, cerebral edema (swelling of the brain), essential hypertension (abnormally high blood pressure that's not the result of a medical condition), and atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart and increase the risk of stroke and heart failure). During a concurrent interview and record review on 8/22/25 at 1:58 p.m. with the DON in the DON office, Resident 6's SBAR Communication Form dated 8/5/25 and the AR dated 8/22/25 were reviewed. The SBAR indicated on 8/5/25 at 11:30 a.m. Resident 6 had chest pain. The physician was notified on 8/5/25 at 11:30 a.m. and ordered the nurse to administer medication and transfer Resident 6 to the acute care hospital if the medication was not effective. Resident 6 received two medication doses for chest pain without effect and Resident 6 was transferred to the acute care hospital. Resident 6 was his own RP, and his mother was the emergency contact. The DON stated the facility did not have to notify Resident 6's emergency contact of the transfer to the acute care hospital because Resident 6 was his own RP. During a review of Resident 6's AR, dated 8/22/25, the AR indicated Resident 6 was a[AGE] year old male, admitted to the facility on [DATE] with diagnoses: anemia in chronic kidney disease (a condition in which your blood has a lower-than-normal amount of red blood cells that carry oxygen from your lungs to the rest of your body), severe protein-calorie malnutrition a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), atherosclerotic ( hardening of your arteries) heart disease without angina pectoris (chest pain), ischemic cardiomyopathy ( the heart's decreased ability to pump blood properly), other pulmonary embolism (a blood clot that blocks and stops blood flow to an artery in the lung), asthma (a chronic lung disease caused by inflammation and muscle tightening around the airways making it hard to breathe), pleural effusion (the buildup of excess fluid between the layers of the pleura outside your lungs), and end stage renal disease (permanent kidney failure that requires a regular course of dialysis or a kidney transplant).During an interview on 8/22/25 at 1:20 p.m. with the Administrator (ADM) in the ADM office, the ADM stated the RP or Emergency Contact should have been notified when residents have a change of condition and transferred to the acute care hospital regardless of resident's mental status. During a phone interview n 8/27/25 at 8:52 a.m. with the Licensed Vocational Nurse (LVN), the LVN stated the RP/family/emergency contact should have been notified when a resident had a change of condition and transferred to the acute care hospital. The LN stated it was important to notify the RP/family/emergency contact so they would know of the resident's change of condition and allow the ability to visit or contact the residents at the hospital. The LN stated the risk of not notifying the RP/family/emergency contact could result in delayed care or worsened medical condition if the hospital required consent for procedures and the RP/family/emergency contact were unaware resident had a change of condition and in the hospital. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 2/2021, the P&P indicated, .4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: .b. there is a significant change in the resident's physical, mental, or psychosocial status; e. it is necessary to transfer the resident to a hospital/treatment center.5. Except in medical emergencies, 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, Transfer and Discharge (including AMA), dated 12/17/24, the P&P indicated, .12. Emergency Transfers/Discharges-initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified) .g. Provide a notice of transfer.to the resident and representative as indicated.
Feb 2025
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
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 received adequate supervision to prevent elopemen...
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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 received adequate supervision to prevent elopement for one of six sampled residents (Resident 1) when Resident 1 left the faciity on 2/17/25 without facility staff's knowledge and did not return.
This failure resulted for Resident 1 at a higher risk of harm such as dangerous weather exposure, getting hit by a car or being assaulted.
Finding:
During a review of Resident 1's admission Record (AR- a document containing resident medical and personal information), undated, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that include . Non displaced intertrochanteric( area between the two trochanters (thigh bone) of the femur) fracture (complete of partial break in a bone) of left femur(bone of the thigh) Alcoholic cirrhosis (a chronic liver disease characterized by the formation of scar tissue) .Bipolar Disease (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) .Pseudocyst (cysts) of pancreas ( a large gland behind the stomach which secrets digestive enzymes) .
During a review of Residents 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1's cognition was intact.
During an interview on 2/19/25 at 8:45 a.m. with Administrator, (ADM) The ADM stated, the facility could not find Resident 1. The ADM stated, she knew Resident 1 was non-compliant and did not notify staff when leaving the facility. ADM stated, Resident 1did not sign out on the Leave of Absence (LOA) Binder on 2/17/25.
During an interview on 2/19/25 at 8:45 a.m. with Social Services Director (SSD), SSD stated, Resident 1 was scheduled to go to a Drug and Alcohol Rehabilitation Facility on 2/18/25 at 8:30 a.m. SSD, stated, Resident 1 left the faciity on 2/17/25 and did not return. SSD stated, Resident 1 was noncompliant when leaving the facility.
During an interview on 2/19/25 at 10:00 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 1 liked being outside and would go to the store. LVN 1 stated, he always returned within 1-2 hours. LVN 1 stated she asked to Resident 1 to notify her when leaving the facility and to sign the LOA binder, but Resident 1 did not comply.
During an interview on 2/19/25 at 10:15 a.m. with LVN 2, LVN 2 stated, Resident 1 was alert and oriented. LVN 2 stated he asked Resident on several occasions to sign the LOA binder when leaving the facility, but Resident 1 did not comply.
During an interview on 2/20/25 at 8:00 a.m., with LVN 1, LVN 1 stated, she worked on 2/17/25 until 7:30 p.m. LVN 1 stated she was not aware Resident 1 was not in the facility when she left. LVN 1 stated Resident 1 did not sign out in the LOA binder on 2/17/25. LVN 1 stated when staff noticed a resident was missing, they were supposed to call the Administrator and authorities. LVN 1 stated when she returned to work on 2/28/25 at 6:22 a.m., LVN 4 told her Resident 1 had not returned. LVN 1 stated staff failed to respond when Resident 1 was missing. LVN 1 stated Resident 1 was missing all night and was at risk of being injured, exposed to the weather, or hit by a car. LVN 1 stated, facility staff were unaware of Resident 1's location and his medical status.
During an interview on 2/20/25 at 8:15 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated, she worked the night shift on 2/17/25. CNA 1 stated, when she started her shift on 2/17/25 at 10:30 p.m., she did not see Resident 1. CNA 1 stated, when a resident was missing, staff go outside to look for the resident. CNA 1 stated staff were supposed to call the ADM and the authorities. CNA 1 stated, staff did not know where Resident 1's was. CNA 1 stated the facility staff did not look for Resident 1 and did not notify the ADM and authorities. CNA 1 stated, Resident 1 was at risk of being exposed to cold weather and could have been injured.
During a telephone interview on 2/20/25 at 9:15 a.m. with LVN 3, LVN 3 stated, he worked the afternoon shift on 2/17/25. LVN 3 stated, when he arrived for work at 2:30 p.m., he saw Resident 1 in the facility. LVN 3 stated, he saw Resident 1 sitting by the front door in his wheelchair around 6 p.m. LVN 1 stated he did not see Resident 1 leave the facility and Resident 1 did not notify him he was leaving. LVN 3 stated he finished his shift at 10 p.m. and gave a report to the incoming LVN (LVN 4). LVN 3 stated he told LVN 4 Resident 1 had not returned. LVN 3 stated he should have called the ADM, Director of Nursing, and the authorities to report missing resident before leaving on 2/17/25 after his shift ends.
During a telephone interview on 2/20/25 at 9:35 a.m., with LVN 4, LVN 4 stated, LVN 3 informed him Resident 1 had not returned to the facility. LVN 4 stated, he became concerned around 12 a.m. and sent a text message to ADM and DON regarding Resident 1 missing but he did not get a response from them. LVN 4 stated, he should have called the ADM and Authorities at the beginning of my shift at 10:30 p.m. LVN 4 stated he contacted the ADM and DON on 2/18/25. LVN 4 stated, the facility staff did not know where Resident 1 was throughout the night.
During an interview on 2/20/25 at 10 a.m. with the DON, the DON stated, Resident 1 left the facility without signing out in the logbook or notifying the staff. The DON stated, she did not see the text message from LVN 4 until the next morning. The DON stated LVN 3 & 4 failed to notify the facility administration and authorities. The DON stated, this put Resident 1 at risk for serious injuries, exposure to cold weather, and being hit by a motor vehicle. The DON stated, we did not follow our Policy and Procedure (P & P) to keep our residents safe.
During an interview on 2/20/25 at 10:15 a.m. with ADM, the ADM stated, when LVN 3 notified LVN 4 Resident 1 had not returned on 2/17/25, LVN 4 should of called us immediately. The ADM stated Resident 1 was non-compliant and did not notify staff before to leaving. The ADM stated, Resident 1 did not sign out on LOA binder. The ADM stated Resident 1 was at risk to exposed to the elements, getting hit by a car, or being assaulted.
During a review of the facility's P&P titled Elopements and Wandering Residents dated 2024, the P & P indicated, This facility ensures that residents who exhibit wandering behavior and /or at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk . 'Elopement occurs when a resident leaves the premises or a safe area without authorization .Procedure for locating Missing Resident . Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol .The designated facility staff will look for the resident .If a resident is not located in the building or on the grounds, Administrator or designee will notify the police department .
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 F0726
(Tag F0726)
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 Licensed Nurses have the competencies necessary...
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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 Licensed Nurses have the competencies necessary to meet the needs and safety of the residents for one of six sampled residents (Resident 1) when Licensed Vocational Nurses (LVN) 3 and LVN 4 failed to notify the facility Administrator (ADM), Director of Nursing (DON) and the authorities when Resident 1 left the facility and did not return.
This failure resulted in delayed in emergency response and placed Resident 1 at increased risk for harm such as dangerous weather exposure, getting hit by a car or being assaulted.
Findings:
During a review of Resident 1's admission Record (AR- a document containing resident medical and personal information), undated, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that include . Non displaced intertrochanteric( area between the two trochanters (thigh bone) of the femur) ( fracture (complete of partial break in a bone) of left femur(bone of the thigh) Alcoholic cirrhosis (a chronic liver disease characterized by the formation of scar tissue) .Bipolar Disease (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) .Pseudocyst (cysts) of pancreas ( a large gland behind the stomach which secrets digestive enzymes) .
During a review of Residents 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1's cognition was intact.
During an interview on 2/20/25 at 8:00 a.m., with LVN 1, LVN 1 stated, she worked on 2/17/25 until 7:30 p.m. LVN 1 stated she was not aware Resident 1 was not in the facility when she left. LVN 1 stated Resident 1 did not sign out in the LOA binder on 2/17/25. LVN 1 stated when staff noticed a resident was missing, they were supposed to call the Administrator and authorities. LVN 1 stated when she returned to work on 2/28/25 at 6:22 a.m., LVN 4 told her Resident 1 had not returned. LVN 1 stated staff failed to respond when Resident 1 was missing. LVN 1 stated Resident 1 was missing all night and was at risk of being injured, exposed to the weather, or hit by a car. LVN 1 stated, facility staff were unaware of Resident 1's location and his medical status.
During an interview on 2/20/25 at 8:15 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated, she worked the night shift on 2/17/25. CNA 1 stated, when she started her shift on 2/17/25 at 10:30 p.m., she did not see Resident 1. CNA 1 stated, when a resident was missing, staff go outside to look for the resident. CNA 1 stated staff were supposed to call the ADM and the authorities. CNA 1 stated, staff did not know where Resident 1's was. CNA 1 stated the facility staff did not look for Resident 1 and did not notify the ADM and authorities. CNA 1 stated, Resident 1 was at risk of being exposed to cold weather and could have been injured.
During a telephone interview on 2/20/25 at 9:15 a.m. with LVN 3, LVN 3 stated, he worked the afternoon shift on 2/17/25. LVN 3 stated, when he arrived for work at 2:30 p.m., he saw Resident 1 in the facility. LVN 3 stated, he saw Resident 1 sitting by the front door in his wheelchair around 6 p.m. LVN 1 stated he did not see Resident 1 leave the facility and Resident 1 did not notify him he was leaving. LVN 3 stated he finished his shift at 10 p.m. and gave a report to the incoming LVN (LVN 4). LVN 3 stated he told LVN 4 Resident 1 had not returned. LVN 3 stated he should have called the ADM, Director of Nursing, and the authorities to report missing resident before leaving on 2/17/25 after his shift ends.
During a telephone interview on 2/20/25 at 9:35 a.m., with LVN 4, LVN 4 stated, LVN 3 informed him Resident 1 had not returned to the facility. LVN 4 stated, he became concerned around 12 a.m. and sent a text message to ADM and DON regarding Resident 1 missing but he did not get a response from them. LVN 4 stated, he should have called the ADM and Authorities at the beginning of my shift at 10:30 p.m. LVN 4 stated he contacted the ADM and DON on 2/18/25. LVN 4 stated, the facility staff did not know where Resident 1 was throughout the night.
During an interview on 2/20/25 at 10 a.m. with the DON, the DON stated, Resident 1 left the facility without signing out in the logbook or notifying the staff. The DON stated, she did not see the text message from LVN 4 until the next morning. The DON stated LVN 3 & 4 failed to notify the facility administration and authorities. The DON stated, this put Resident 1 at risk for serious injuries, exposure to cold weather, and being hit by a motor vehicle. The DON stated, we did not follow our Policy and Procedure (P & P) to keep our residents safe.
During a review of the facility's P&P titled Elopements and Wandering Residents dated 2024, the P & P indicated, This facility ensures that residents who exhibit wandering behavior and /or at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk . 'Elopement occurs when a resident leaves the premises or a safe area without authorization .Procedure for locating Missing Resident . Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol .The designated facility staff will look for the resident .If a resident is not located in the building or on the grounds, Administrator or designee will notify the police department .
During a review of the facility's P&P titled Job Description dated 2020, the P & P indicated, .Provide direct nursing care to the residents .Provides nursing leadership to nursing personnel .Report any incidents or unusual occurrences to the supervisor, unit manager, assistant director of nursing or director of nursing and participates in the investigation processes needed .
Sept 2024
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, and facility policy review, the facility failed to support a resident's choice to be out of bed by not providing the necessary specialized wheelchair ne...
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Based on observation, interview, record review, and facility policy review, the facility failed to support a resident's choice to be out of bed by not providing the necessary specialized wheelchair needed for the resident to be out of bed for 1 (Resident #26) of 16 sampled residents.
Findings included:
A facility policy titled, Resident Rights, with a copyright date of 2024, revealed, 5. Self-determination. The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to: a. The resident has the right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part. b. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident.
An admission Record revealed the facility admitted Resident #26 on 12/05/2023. According to the admission Record, the resident had a medical history that included diagnoses of abnormalities of gait and mobility, lack of coordination, and weakness.
A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/13/2024, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff for chair/bed-to-chair transfers. The MDS indicated the resident had not used a mobility device in the last seven days prior to the ARD.
Resident #26's care plan included a focus area, revised 06/13/2024, that indicated the resident had little activity involvement related to physical limitation. Interventions directed staff to assist/escort Resident #26 with activity functions (revised 12/06/2023).
A physical therapist's Physical Therapy Treatment Encounter Note, dated 01/05/2024, indicated Resident #26 was able to tolerate sitting in a geri chair (a specialized reclining chair) for approximately 20 minutes during therapy.
Resident #26's IDT [Interdisciplinary Team] - Care Conference Summary, dated 09/13/2024, indicated the resident expressed a desire to get up more frequently to participate in activities of interest.
On 09/17/2024 at 1:47 PM, Resident #26's Responsible Party, stated the resident required a special wheelchair with a high back as the resident slumped over when they became too tired. Resident #26's Responsible Party stated the resident did not have a wheelchair, and therefore, could not get out of bed. Resident #26's Responsible Party stated they understood the aides borrowed a wheelchair from another resident for Resident #26 to use. During a concurrent interview, Resident #26 stated if they had a wheelchair, they would get out of bed more. Resident #26 stated they would like to get out of bed more.
On 09/19/2024 at 8:23 AM, Certified Nurse Aide (CNA) #2 stated Resident #26 did not have a wheelchair and the staff borrowed one from another resident for Resident #26. CNA #2 stated Resident #26 required a tilting wheelchair, the facility had not provided the resident one, and she was unsure of the reason the resident had not been provided a wheelchair. CNA #2 stated Resident #26 got up about three times weekly, but the resident would not be able to get up if the wheelchair was in use.
On 09/19/2024 at 8:57 AM, the Director of Rehabilitation (DOR) stated Resident #26 needed a reclining wheelchair. The DOR stated the chairs were expensive and one had not been ordered for the resident. The DOR stated the facility had a tilt-in-space (a wheelchair designed to allow the entire chair to tilt) wheelchair that was shared between Resident #26 and another resident.
On 09/19/2024 at 10:32 AM, Licensed Vocational Nurse (LVN) #3 stated if a resident required a special chair the resident must be measured and given the exact chair needed. LVN #3 stated Resident #26 did not have a wheelchair. LVN #3 stated Resident #26 did get up occasionally, and the resident should have their own wheelchair.
On 09/20/2024 at 12:22 PM, the Director of Nursing (DON) stated residents had every right to get out of bed, and they should be gotten up. The DON stated residents should not be required to borrow equipment from other residents. The DON stated the equipment should be ordered, and it only took two or three days to get an order for equipment. The DON stated, if a resident was residing in the facility long-term, the facility should supply the resident with a wheelchair.
On 09/20/2024 at 12:40 PM, the Administrator stated staff should work in conjunction with therapy and make him aware of the needed equipment. The Administrator stated he was not aware the need existed, and he was not aware Resident #26 did not have a wheelchair. The Administrator stated, if the chair was needed, he wanted the residents to have what they needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, and facility policy review, the facility failed to ensure activities of daily living (ADLs) were provided for 1 (Resident #4) of 16 sampled residents. S...
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Based on observation, interview, record review, and facility policy review, the facility failed to ensure activities of daily living (ADLs) were provided for 1 (Resident #4) of 16 sampled residents. Specifically, Resident #4's fingernails were not properly trimmed.
Findings included:
A facility policy titled, Nail Care implemented 10/2022, revealed, 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule.
An admission Record revealed the facility originally admitted Resident #4 on 10/04/2002. According to the admission Record, the resident had a medical history that included diagnoses of quadriplegia, contracture of muscle at multiple sites, generalized muscle weakness, pain in an unspecified limb, and wrist drop.
A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/25/2024, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #4 had upper and lower extremity impairments on both sides. The MDS indicated Resident #4 required partial/moderate assistance with personal hygiene.
Resident #4's care plan included a focus area, initiated 12/01/2022, that indicated the resident had an ADL self-care performance deficit related to quadriplegia. Interventions directed staff to assist Resident #4 with personal hygiene as the resident was totally dependent on staff for physical assistance (initiated 12/01/2022).
Resident #4's Personal Hygiene task record, for the timeframe from 08/22/2024 through 09/20/2024, did not indicate any refusals for personal hygiene care.
During a concurrent observation and interview on 09/17/2024 at 10:40 AM, Resident #4 was observed with long fingernails on both hands. Resident #4 stated that sometimes staff would offer to trim their fingernails, but the resident would ask the staff to come back later, and they did not come back.
During an interview on 09/19/2024 at 1:39 PM, Resident #4 stated it had been a while since staff had offered to trim their fingernails.
During an interview on 09/19/2024 at 1:42 PM, Certified Nurse Aide (CNA) #8, stated part of giving a resident a bath or shower included trimming the resident's fingernails, unless the resident was diabetic. CNA #8 stated she had never offered to trim Resident #4's fingernails.
During an interview on 09/19/2024 at 1:50 PM, CNA #9 stated part of giving a resident a shower/bath included trimming their nails. CNA #9 stated he had never given Resident #4 a bed bath or trimmed their fingernails, but the resident had never refused any type of care.
During an interview on 09/19/2024 at 2:05 PM, Licensed Vocational Nurse (LVN) #3 stated CNAs were supposed to trim the residents' fingernails during shower/baths or when needed. LVN #3 stated Resident #4 did not refuse care. LVN #3 stated Resident #4 was not diabetic, and the CNAs should be trimming Resident #4's fingernails.
During a concurrent observation and interview on 09/19/2024 at 2:09 PM, CNA #8 confirmed that Resident #4's fingernails were long and needed to be trimmed. CNA #8 stated she would trim Resident #4's nails right away.
During a concurrent observation and interview on 09/19/2024 at 2:10 PM, LVN #3 revealed that she would let the staff know that Resident #4 needed their nails trimmed.
During a concurrent observation and interview on 09/19/2024 at 2:15 PM, the Director of Nursing (DON) stated Resident #4 needed to have their fingernails trimmed. The DON stated she expected the staff to offer to trim the fingernails of the residents on their shower days and as needed. The DON stated she would get someone to trim Resident #4's fingernails as soon as possible.
An observation on 09/20/2024 at 10:42 AM revealed Resident #4's fingernails had not been trimmed at that time.
During an interview on 09/20/2024 at 2:21 PM, the Administrator stated he expected the staff to trim the residents' fingernails to promote good hygiene.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, and facility policy review, the facility failed to have a physician's order for the use of supplemental oxygen for 1 (Resident #98) of 1 sampled residen...
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Based on observation, interview, record review, and facility policy review, the facility failed to have a physician's order for the use of supplemental oxygen for 1 (Resident #98) of 1 sampled resident reviewed for respiratory care.
Findings included:
A facility policy titled, Oxygen Administration, implemented 10/2022, revealed, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. The policy further indicated, Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency.
An admission Record revealed the facility originally admitted Resident #98 on 04/14/2023 and readmitted the resident on 09/16/2024. According to the admission Record, the resident had a medical history that included diagnoses of acute respiratory failure with hypoxia, acute pulmonary edema, and chronic obstructive pulmonary disease (COPD).
A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/26/2024, revealed Resident #98 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident received oxygen therapy during the assessment period.
Resident #98's care plan, included a focus area revised 04/01/2024, that indicated the resident had altered respiratory status and difficulty breathing related to anxiety, (COPD, and acute and chronic respiratory failure with hypoxia. Interventions directed staff to administer supplemental oxygen as ordered (initiated 01/19/2024).
Resident #98's care plan, included a focus area revised 04/01/2024, that indicated the resident had oxygen therapy related to the diagnosis of COPD. Interventions included supplemental oxygen settings at 2-4 liters by nasal canula (revised 04/19/2024).
Resident #98's Order Summary Report, dated 09/18/2024, with active orders, revealed it did not include an order for supplemental oxygen.
During an observation on 09/17/2024 at 10:24 AM, Resident #98 was observed receiving supplemental oxygen at 2½ liters per minute (lpm) by nasal cannula. During a concurrent interview Resident #98 stated they were readmitted the previous evening (09/16/2024) and were receiving oxygen because of their COPD. Resident #98 stated when they were in the hospital, they received oxygen at 4 lpm but were supposed to be on 3 lpm now.
An observation on 09/20/2024 at 9:00 AM revealed Resident #98 was receiving supplemental oxygen at 3 lpm.
During a concurrent observation and interview on 09/20/2024 at 9:05 AM, Licensed Vocational Nurse (LVN) #3 observed Resident #98's supplemental oxygen and stated it was set at 3 lpm.
After reviewing Resident #98's orders in the electronic health record, LVN #3 stated there was no order for the supplemental oxygen. LVN #3 stated she would let the doctor know so they could get an order.
On 09/20/2024 at 9:07 AM, the Director of Nursing (DON) stated she expected residents receiving supplemental oxygen to have a physician's order for it. The DON reviewed Resident #98's orders in the electronic health record and confirmed the resident did not have an order for supplemental oxygen.
On 09/20/2024 at 12:19 PM, the Administrator stated that anyone receiving supplemental oxygen should have a physician's order for it.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected 1 resident
Based on interview, facility document review, and facility policy review, the facility failed to ensure a registered nurse (RN) was on duty daily for eight consecutive hours. This deficient practice h...
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Based on interview, facility document review, and facility policy review, the facility failed to ensure a registered nurse (RN) was on duty daily for eight consecutive hours. This deficient practice had the potential to affect all residents who resided in the facility.
Findings included:
A facility policy titled, Nursing Services-Registered Nurse (RN), implemented 10/2022, revealed, 1. The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days per week.
A facility nursing schedule for September 2024, indicated there were no RNs scheduled to work on 09/05/2024. However, RN #5's Employee Time Cards, dated 09/05/2024, revealed she worked 1.40 hours that day.
A facility nursing schedule for September 2024, indicated there were no RNs scheduled to work on 09/08/2024. However, a Nursing Staffing Assignment and Sign-in Sheet, dated 09/08/20024, revealed RN #7 worked nonconsecutively for 7 hours that day.
During an interview on 09/20/2024 at 1:07 PM, the Director of Nursing (DON) stated she was out sick from 09/01/2024 through 09/05/2024, but she thought she had scheduled adequate RN coverage during that time. The DON stated she was aware that the RN on 09/05/2024 was only able to work a few hours, but she did not have any other options.
During an interview on 09/20/2024 at 1:10 PM, RN #7 stated she did not know she had to work eight hours in a row to meet the regulation.
During a follow-up interview on 09/20/2024 at 1:41 PM, the DON stated that she was not aware that the RNs had to work eight hours consecutively, but after reviewing the regulation she would in-service the RNs on the importance of meeting the requirement.
During an interview on 09/20/2024 at 2:21 PM, the Administrator stated he expected the facility to have a RN on duty at least 8 hours consecutively, daily.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on interview, record review, and facility policy review, the facility failed to ensure a PRN (pro re nata, as-needed) psychotropic medication had a 14-day stop date for 1 (Resident #12) of 5 res...
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Based on interview, record review, and facility policy review, the facility failed to ensure a PRN (pro re nata, as-needed) psychotropic medication had a 14-day stop date for 1 (Resident #12) of 5 residents reviewed for unnecessary medications.
Findings included:
A facility policy titled, Use of Psychotropic Medication, implemented 10/2022, indicated, 9. PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. [id est, that is] 14 days). a. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order.
An admission Record revealed the facility initially admitted Resident #12 on 07/06/2023 and readmitted the resident on 08/08/2024. According to the admission Record, the resident had a medical history that included a diagnoses of schizoaffective disorder.
An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/12/2024, revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident had a diagnosis of schizophrenia.
Resident #12's care plan, included a focus area revised 05/25/2024, that indicated the resident took aripiprazole (an atypical antipsychotic injection used for the treatment of agitation) related to schizoaffective disorder with agitation. Interventions directed staff to administer psychotropic medications as ordered by the physician (initiated 07/09/2023).
Resident #12's Order Summary Report, with active orders as of 09/17/2024, included an order dated 08/08/2024, for aripiprazole oral tablet 2 mg with instructions to give one tablet by mouth every 24 hours nightly as needed for agitation. Further review revealed there was no end date for the order.
On 09/19/2024 at 11:43 AM, the Director of Nursing (DON) stated PRN psychotropic medications should have a 14-day end date.
On 09/20/2024 at 12:36 PM, the Administrator stated the order should have a stop date of 14 days. The Administrator stated PRN orders must be updated and reviewed every 14 days and evaluated for routine use based on the resident's needs.
On 09/20/2024 at 8:08 AM, the Pharmacist stated PRN psychotropic medications should have a 14 day stop date unless addressed by the physician and the medication ordered for more than 14 days.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview, record review, and facility policy review, the facility failed to accurately transcribe hospital discharge medication orders for 1 (Resident #12) of 5 residents reviewed for unnece...
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Based on interview, record review, and facility policy review, the facility failed to accurately transcribe hospital discharge medication orders for 1 (Resident #12) of 5 residents reviewed for unnecessary medications.
Findings included:
A facility policy titled, Transcribing Physician Orders and Consulting Physician/Practitioner Orders, implemented 10/2022, revealed, 2. For consulting physician/practitioner orders received in writing or via fax [facsimile], the nurse in a timely manner will: c. Follow facility procedures for verbal or telephone orders including: noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record.
An admission Record revealed the facility initially admitted Resident #12 on 07/06/2023 and readmitted the resident on 08/08/2024. According to the admission Record, the resident had a medical history that included a diagnosis of schizoaffective disorder.
An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/12/2024, revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident had a diagnosis of schizophrenia.
Resident #12's care plan, included a focus area revised 05/25/2024, that indicated the resident took aripiprazole (an atypical antipsychotic injection used for the treatment of agitation) related to schizoaffective disorder with agitation. Interventions directed staff to administer psychotropic medications as ordered by the physician (initiated 07/09/2023).
A hospital record titled, Case Management Discharge Summary/Orders Report, dated 08/08/2024, indicated Resident #12's discharge medications included aripiprazole (Abilify) with instructions to take one tablet 2 milligrams (mg) total by mouth daily.
Resident #12's Order Summary Report, with active orders as of 09/17/2024, included an order dated 08/08/2024, for aripiprazole oral tablet 2 mg with instructions to give one tablet by mouth every 24 hours nightly as needed for agitation.
On 09/19/2024 at 1:15 PM, Licensed Vocational Nurse (LVN) #1 stated the order was transcribed incorrectly, and it should not have been entered as an as-needed order.
On 09/19/2024 at 11:43 AM, the Director of Nursing (DON) stated the aripiprazole should not have been an as-needed order. The DON stated the aripiprazole should not have been given as a PRN (pro re nata, as-needed) order unless it had been prescribed like that from the hospital. The DON stated it looked like Resident #12 went out of the facility, and, when the resident returned, the order was not transcribed correctly.
On 09/20/2024 at 12:36 PM, the Administrator stated the order would be reviewed and the transcription would reflect the orders from the physician at the hospital. The Administrator stated the errors would be revised based on the order and sent to the physician for approval.
On 09/20/2024 at 8:08 AM, the Pharmacist stated the admission nurse should check the orders and make sure they were accurate. The Pharmacist stated the order was transcribed incorrectly, and it would be written up as a medication error.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected most or all residents
Based on interview, facility document review, and facility policy review, the facility failed to ensure the facility-wide assessment was updated and reviewed annually. This deficient practice had the ...
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Based on interview, facility document review, and facility policy review, the facility failed to ensure the facility-wide assessment was updated and reviewed annually. This deficient practice had the potential to affect all residents who resided in the facility.
Findings included:
A facility policy titled, Facility Assessment, implemented 06/2024, revealed, 10. The facility assessment will be reviewed and updated as necessary and at least annually.
A Facility Assessment Tool, revealed the sections for Date(s) of assessment or update and Date(s) assessment reviewed with QAA [Quality Assurance Assessment]/QAPI [Quality Assurance and Performance Improvement] committee, were dated 08/31/2023.
During an interview on 09/17/2024, the Administrator stated the facility assessment had not been reviewed prior to 08/31/2023. The Administrator stated they planned to review the facility assessment the last week of 09/2024.
During an interview on 09/20/2024 at 2:21 PM, the Administrator stated the facility assessment was done on 09/10/2024, but it had not been reviewed or revised. The Administrator stated the assessment was his responsibility.
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
Based on interview and facility policy review, the facility failed to maintain an effective infection control program. Specifically, the facility failed to establish and implement a surveillance plan ...
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Based on interview and facility policy review, the facility failed to maintain an effective infection control program. Specifically, the facility failed to establish and implement a surveillance plan to identify, track, and monitor infections. This had the potential to affect all residents who resided in the facility.
Findings included:
A facility policy titled, Infection Prevention and Control Program, implemented 10/2022, revealed, Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. The section titled Policy Explanation and Compliance Guidelines, included, 3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. b. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee.
On 09/18/2024 at 11:17 AM, the Infection Preventionist (IP) was unable to provide evidence of tracking and trending each month of all infections. The IP stated she had been in the position for two months and no one had shown her how or what to do with the infection information. The IP stated she was waiting for guidance from the corporate infection control consultant. The IP stated she had access to the previous IP, who still worked at the facility, but the previous IP had not shown her how to track, monitor, or trend infections for surveillance purposes.
During an interview on 09/19/2024 at 11:27 AM, the Director of Nursing (DON) stated the IP should keep up with all infections for every resident at least monthly. The DON stated the IP should also look for infection trends such as clusters of urinary tract infections (UTIs). The DON stated the IP was relatively new to their position but had other staff members that were coaching her and had a consultant the IP called for guidance. The DON stated she was unaware the IP had not been tracking infections daily or looking for monthly trends and possible resolutions to prevent the spread of infections. The DON stated she expected the IP to track all infections daily and to identify, track, and trend infections and clusters of infections monthly.
During an interview on 09/20/2024 at 1:38 PM, the Administrator stated he expected the IP to implement a system of surveillance for the purposes of preventing and controlling infections for all residents. The Administrator stated he expected the system of surveillance to include the identification of all infections by room and unit and the reporting and investigation of infections. The Administrator stated, at the end of each month, he expected the IP to map out the infections on the facility map, so, at a glance, the different infections could be seen by resident name and location. The Administrator stated the surveillance information was needed to provide in-services such as proper hand hygiene, perineal care, or other interventions to decrease the spread of infection.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0911
(Tag F0911)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility policy review, the facility failed to ensure 2 (room [RO...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility policy review, the facility failed to ensure 2 (room [ROOM NUMBER] and room [ROOM NUMBER]) of 16 residents' rooms accommodated no more than four residents per room.
Findings included:
A facility policy titled, Resident Rooms, implemented 10/2022, revealed, Resident bedrooms will not accommodate more than four residents.
A Client Accommodations Analysis, dated 09/19/2024, revealed that room [ROOM NUMBER] had a floor area of 963.9 square (sq) feet (ft) with an approved capacity of eight residents. Further review revealed room [ROOM NUMBER] had a floor area of 733.22 sq ft with an approved capacity of eight resident.
An observation on 09/20/2024 at 10:21 AM, revealed there were seven residents residing in room [ROOM NUMBER]. The observation revealed the room size was comfortable, with bedside tables and adequate closet space. The observation revealed there were no concerns with square footage per resident.
An observation on 09/20/2024 at 10:23 AM, revealed there were eight residents residing in room [ROOM NUMBER]. The observation revealed the room size was comfortable, with bedside tables and adequate closet space. The observation revealed there were no concerns with square footage per resident.
On 09/20/2024 at 12:47 PM, the Administrator stated a maximum of four residents should resident in a room. The Administrator stated the facility had two rooms that had eight beds.
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, facility document review, and facility policy review, the facility failed to provide the requir...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility policy review, the facility failed to provide the required 80 square (sq) feet (ft) of living space per resident in 6 (Rooms 1, 6, 8, 10, 11, and 16) of 16 multiple occupancy resident rooms. This failure had the potential for residents to not have reasonable accommodations for privacy or adequate space for care to be rendered.
Findings included:
A facility policy titled, Resident Rooms, implemented 10/2022, revealed, 2. Resident bedrooms will measure at least 80 square feet per resident in multiple resident bedrooms.
A Client Accommodation Analysis, dated 09/19/2024, revealed the following living space per resident:
- In room [ROOM NUMBER], there was 72.5 sq ft for each resident.
- In room [ROOM NUMBER], there was 77.4 sq ft for each resident.
- In room [ROOM NUMBER], there was 78.9 sq ft for each resident.
- In room [ROOM NUMBER], there was 73.1 sq ft for each resident.
- In room [ROOM NUMBER], there was 73.1 sq ft for each resident.
- In room [ROOM NUMBER], there was 64.9 sq ft for each resident.
On 09/20/2024 at 10:30 AM, during a concurrent observation and interview, the Department Head of Maintenance (DHM) measured Rooms 1, 6, 8, 10, 11, and 16. The DHM stated Rooms 1, 6, 8, 10, 11, and 16 did not meet the requirement of 80 sq ft per resident. The observation revealed residents had privacy, closet and storage space for their belongings, and bedside tables for personal items. The observation revealed resident bathrooms were unobstructed. The observation revealed there was sufficient room for staff to provide care, and residents did not voice any concerns about the space.
During an interview on 09/20/2024 at 12:30 PM, the Director of Nursing (DON) stated each resident must have 80 sq ft per resident.
During an interview on 09/20/2024 at 12:47 PM, the Administrator stated each resident was supposed to have 80 sq ft per resident.
During a follow-up interview on 09/20/2024 at 1:41 PM, the DON stated she was aware of the issue with the rooms' square footage per resident, and they had requested a waiver for those rooms.
During an interview on 09/20/2024 at 2:21 PM, the Administrator stated he was aware they would be cited for the rooms' square footage per resident, and he had submitted a waiver request.
May 2024
6 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 one of two residents (Resident 1) had a correctly completed ...
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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 two residents (Resident 1) had a correctly completed Minimum Data Set Assessment (MDS, a comprehensive, standardized assessment tool) when a review indicated six (6) incorrect entries. These six (6) errors indicated a pattern of incorrect assessment results, resulting in Resident 1's MDS that was not reflective of her status at the time of the assessment, and had the potential for Resident 1 to have unmet care needs that did not address her status, needs, strengths, and areas of decline.
Findings:
During a review of Resident 1's Minimum Data Set (MDS), dated [DATE], the MDS indicated at Question A2300 as having an Assessment Reference Date of [DATE], which indicated a look back period of 7 days (unless another time period is indicated). For Resident 1's MDS assessment, the 7-day time period was [DATE] through [DATE].
The MDS contained six (6) errors at the following questions:
Question C1310C
Question E900
Question I2300
Question J1800
Question K0310
Question P200E
(Question C1310C)
During a review of Resident 1's MDS, dated [DATE], the MDS indicated at Question C1310C, Disorganized Thinking - Was the resident's thinking disorganized or incoherent. unclear or illogical ideas. The answer indicated Behavior not present.
During a review of Resident 1's admission Record (AR), dated [DATE], the AR indicated Resident 1 was admitted to the facility with diagnoses that included psychosis (refers to a collection of symptoms that affect the mind, where there has been some loss of contact with reality, a person's thoughts and perceptions are disrupted and they may have difficulty recognizing what is real and what is not); and Strange and Inexplicable behavior.
During a review of Resident 1's Progress Notes (PN), dated [DATE], at 2:14 PM, the PN indicated Resident 1 was outside in the parking area with a Certified Nursing Assistant (CNA), when gate began to open, and resident stood up and ran out of the gate. CNA stopped resident while calling for help. Multiple staff members came out. Resident stated I want to be free. Resident refused to come back into facility. Staff member is sitting outside with her.
During a concurrent interview and record review on [DATE], at 1:30 PM, with the Director of Social Services (SSD), Resident 1's PN dated [DATE], and MDS dated [DATE] were reviewed. The SSD stated she was the staff member that had answered Question C1310C on Resident 1's MDS. The SSD stated, That was episode of disorganized thinking. It was answered incorrectly. When I completed that MDS, I wasn't thinking of that situation [on [DATE]]. I don't always look at the nurses' notes [PN from the 7-day assessment reference period].
During a concurrent interview and record review on [DATE], at 4 PM, with the Director of Nursing (DON), Resident 1's PN dated [DATE], and MDS dated [DATE] were reviewed. The DON stated Resident 1 certainly had cognitive impairment [confusion or memory losses].
(Question E900)
During a review of Resident 1's MDS, dated [DATE], the MDS indicated at Question E900 - Wandering - Presence & Frequency - Does the resident wander? The answer indicated, Behavior not exhibited.
During a review of the Centers for Medicaid and Medicare Services' Long Term Care Facility Assessment Instrument 3.0 User's Manual, Version 1.18.11 (RAI Manual, provides guidance and instruction on how to accurately complete a MDS), dated [DATE], the RAI Manual indicated Wandering is the act of moving (walking or locomotion in a wheelchair) from place to place with or without a specified course or known direction. Wandering may or may not be aimless. The wandering resident may be oblivious to their physical or safety needs. The resident may have a purpose such as searching to find something, but they persist without knowing the exact direction or location of the object, person or place. The behavior may or may not be driven by confused thoughts or delusional ideas (e.g., when a resident believes they must find their parent, who staff know is deceased ).
During a concurrent interview and record review on [DATE], at 1:39 PM, with the MDS Coordinator (MDS-C), Resident 1's PN dated [DATE], the MDS dated [DATE], and the RAI Manual guidance on Question E900 were reviewed. The MDS-C stated she was not employed at the facility during [DATE], and she did not complete Resident 1's MDS from that date. The MDS-C stated Question E900 should have been marked 'yes', indicating wandering behavior was present for Resident 1.
(Question I2300)
During a review of Resident 1's MDS, dated [DATE], the MDS indicated at Question I2300 Urinary Tract Infection (UTI) in the last 30 days[?]. The answer indicated Resident 1 had not had a UTI in the last 30 days.
The RAI Manual indicated regarding MDS Question I2300 Urinary tract infection (UTI): The UTI has a look-back period of 30 days for active disease instead of 7 days. Code only if both of the following are met in the last 30 days: It was determined that the resident had a UTI using evidence-based criteria such as McGeer. in the last 30 days, AND A physician documented UTI diagnosis. in the last 30 days.
During a review of McGeer's Criteria, Table 5, at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538836/ , dated 10/12, the McGeer's Criteria indicated, a UTI is defined as a having symptoms such as painful urination (dysuria) and having greater than 100,000 bacteria in the urine.
During a review of Resident 1's PN dated [DATE], at 6:37 AM, and 6:15 PM, the PN indicated she was being monitored for complaints of painful urination. The PN dated [DATE], at 8:42 PM, indicated Resident 1's physician ordered her to start antibiotics for a UTI. The PN dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], indicated nursing staff was monitoring performing additional assessments for Resident 1's UTI.
During a concurrent interview and record review on [DATE], at 4 PM, with the Director of Nursing (DON), Resident 1's Culture and Sensitivity Report (C&S), dated [DATE], were reviewed. The DON stated Resident 1's C&S indicated she had greater than 100,000 bacteria in her urine. The PN dated [DATE] was reviewed with the DON and she confirmed Resident 1 had complained of painful urination, and her physician had prescribed her medication for a UTI.
During a concurrent interview and record review on [DATE], at 1:39 PM, with the MDS-C, Resident 1's PN dated [DATE] through [DATE], the MDS dated [DATE], and the RAI Manual guidance on Question I2300 were reviewed. The MDS-C stated Question I2300 confirmed Question I2300 was answered as 'no UTI in last 30 days.'
(Question J1800)
During a review of Resident 1's MDS, dated [DATE], the MDS indicated at Question J1800 Has the resident had any falls since admission/entry or reentry or the prior assessment. whichever is more recent? The answer indicated No.
The RAI Manual indicated regarding J1800, An intercepted fall is considered a fall.
During a concurrent interview and record review on [DATE], at 1:39 PM, with the MDS-C, Resident 1's PN dated [DATE], at 2:14 PM, the MDS dated [DATE], and the RAI Manual guidance on Question J1800 were reviewed. The PN indicated, . resident started to lose balance and was guided to the ground. The MDS-C stated Question J1800 should have been answered as yes.
During an interview with the DON on [DATE], at 4 PM, the DON stated that a fall is defined any change in plane.
(Question K0310)
During a review of Resident 1's MDS, dated [DATE], the MDS indicated at Question K0310 Weight Gain - [Has the resident experienced a] Gain of 5% or more in the last month or gain of 10% or more in the last 6 months. The question was answered as No.
During a concurrent interview and record review on [DATE], at 1:39 PM, with the MDS-C, Resident 1's PN dated [DATE], at 12:22 PM, the MDS dated [DATE], and the RAI Manual guidance on Question K0310 were reviewed. The PN indicated, Change in Condition and that Resident 1 had gained 12.2 pounds, which resulted in an overall gain of 8.7% of her body weight. Resident 1's weights were reviewed with the MDS-C. The MDS-C stated Resident 1 weighed 153.2 pounds on [DATE]; 148 pounds on [DATE]; and 142 pounds on [DATE]. The MDS-C stated K0310 should have been answered as 'yes'.
(Question P200E)
During a review of Resident 1's MDS, dated [DATE], the MDS indicated at Question P200E, Alarms - An alarm is any physical or electronic device that monitors resident movement and alerts the staff when movement is detected - E - Wander/elopement alarm. The answer indicated such an alarm was not used for Resident 1.
During a review of Resident 1's Care Plan (CP), dated [DATE], the CP indicated, resident has wander guard [an electronic monitoring bracelet that the resident wears that activates an alarm when in the vicinity of a sensor, usually placed at facility exits] in place on her right ankle - Date Initiated: [DATE].
During a concurrent interview and record review on [DATE], at 1:39 PM, with the MDS-C, Resident 1's PN dated [DATE] through [DATE], the MDS dated [DATE] were reviewed.
The PN dated [DATE], at 1:25 PM, indicated, alarm is on and working properly.
The PN dated [DATE], at 10:01 AM, indicated, alarm is on and working properly.
The PN dated [DATE], at 2:16 PM, indicated, alarm is on and working properly.
The PN dated [DATE], at 1:18 PM, indicated, alarm is on and working properly.
The MDS-C stated Resident 1's MDS Question P200E should have been answered yes for the wander guard that she wears.
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 a comprehensive person-centered care plan 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 and implement a comprehensive person-centered care plan for one of three sampled residents (Resident 1) when Resident 1 had a new onset of confusion, hallucinations (seeing and/or hearing things that are not real) and was yelling.
This failure resulted for Resident 1's new onset of altered level of consciousness needs such as monitoring and safety to go unmet.
Findings:
During a review of Resident 1's admission Record, dated 4/17/24, at 4:08 PM, the admission Record indicated Resident 1 was a [AGE] year-old female admitted to the facility on [DATE].
During a review of Resident 1's Minimum Data Set (MDS, a standardized, comprehensive assessment tool), dated 3/26/24, the MDS indicated at Section C500, Brief Interview for Mental Status, a score of eight out of 15, which indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired.
During a review of Resident 1's clinical record, Progress Notes, dated 3/19/24, at 10:52 PM, the Progress Notes indicated Resident 1 was yelling and talking about a fire and had slight confusion.
During a review of Resident 1's Progress Notes, dated 3/21/24, at 1:50 PM, the Progress Notes indicated a care conference meeting was held with Resident 1's Family Member (FM 1). The Progress Notes indicated Discussed recent behaviors such as audio and visual hallucinations.
During a review of Resident 1's Progress Notes, dated 3/22/24, at 00:08 AM, the Progress Notes indicated Resident noted to have yelling behaviors throughout night.
During an interview with the Social Services Director (SSD), on 4/17/24, at 11:40 AM, the SSD stated Resident 1 had episodes of confusion.
During an interview with Certified Nursing Assistant (CNA) 1, on 4/17/24, at 1:08 PM, CNA 1 stated Resident 1 was sometimes confused.
During an interview with Resident 1's Family Member (FM) 1, who is also her Responsible Party, on 4/17/24, at 1:54 PM, FM 1 stated, We noticed some confusion most every day. My father and sister visit almost every day, for 2-3 hours at a time. The confusion was new. She was not confused before admission there. After admission to facility, she was disoriented, delusional, confused. That confusion was not there earlier, before admission. The confusion started after she was placed there.
During a concurrent interview and record review on 4/17/24, at 3:30 PM, with Licensed Vocational Nurse (LVN) 1, Resident 1's Progress Notes, various dates, was reviewed. LVN 1 stated Resident 1's Progress Notes indicated periods of confusion.
During a concurrent interview and record review on 4/17/24, at 3:40 PM, with the Clinical Resource Registered Nurse (CRRN) 3:40 PM, Resident 1's Care Plan (CP), was reviewed. The CRRN stated that there was no CP addressing Resident 1's altered level of consciousness and a CP should have been done to ensure resident safety.
During a review of the facility's policy and procedure titled admission of a Resident, dated 2/22, the document indicated, in part, Policy: The admission process is intended to obtain all the information possible about the resident, for the development of comprehensive plans of care, and to assist the resident in becoming comfortable in the facility. Upon admission, the designated facility staff will obtain information and perform assessments as per their respective departments and as per facility protocol. Information gathered will be placed into the resident's medical record via the facility's means of recordkeeping (i.e., paper, electronic).
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 services provided met professional standards of quality 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 ensure services provided met professional standards of quality for one of three sampled residents (Resident 1) when Resident 1 was assessed with a new onset of confusion and hallucination (seeing and/or hearing things that are not real) and a physician's order for urine culture and sensitivity test (lab test to check for bacteria and germs in the urine) was not done to determine if an infection was present and the cause of the confusion.
This failure resulted for Resident 1's urinary tract infection (UTI-a condition in which bacteria invades and grow in the urinary tract) to go untreated which led to Resident 1's new onset of confusion and hallucination.
Findings:
During a review of Resident 1's admission Record (AR), dated 4/17/24, at 4:08 PM, the AR indicated Resident 1 was a [AGE] year-old female admitted to the facility on [DATE].
During a review of Resident 1's Progress Notes (PN), dated 3/19/24, at 10:52 PM, the PN indicated Resident 1 was yelling, talking about a fire, and had slight confusion. The nursing staff notified physician and ordered a UA and a culture and sensitivity test if indicated.
During a review of Resident 1's Order Summary Report (OSR), dated 4/17/24, the OSR indicated on 3/19/24 the physician ordered for a urinalysis and culture and sensitivity test if indicated and may collect the urine sample from the urinary catheter bag (a drainage bag that collects urine that is connected by a tube inserted into the urinary bladder).
During a review of Resident 1's Laboratory Report (LR), dated 3/20/24, at 9:01 PM, the LR indicated a urinalysis test was performed for Resident 1. Resident 1's urinalysis indicated several abnormal results, including:
1. Positive [NAME] Blood Cells (An increased number of white blood cells in the urine may indicate an infection or inflammation in the urinary tract. [NAME] blood cells are the body's natural infection fighters)
2. High levels (4+) of Leukocyte Esterase (High levels of leukocytes in the urine typically indicate an infection in the urinary system. Leukocytes are a type of white blood cells)
3. Positive Nitrates (Nitrites in urine are a common sign of a UTI. UTIs are caused by different types of bacteria)
4. Positive Protein (A large amount of protein in urine may indicate a problem with the kidneys (organs that filter extra water and wastes out of blood to make urine)
5. Positive Red Blood Cells (Indicated there is blood in the urine and may indicate a UTI)
6. Many Bacteria (Often associated with a UTI, especially if the resident is having symptoms of a UTI, including confusion)
The Laboratory Report indicated TEXT WAIT CS [culture and sensitivity] and was signed by Physician 1 on 3/21/24, at 1:03 PM.
During a review of Resident 1's PN, dated 3/21/24, at 6:51 AM, the PN indicated MD [Medical Doctor] digitally signed Labs Report with no new orders at this time. waiting CS report.
During a review of Resident 1's PN, dated 3/21/24, at 1:50 PM, the PN indicated a care conference meeting was held with Resident 1's Family Member (FM 1). The PN indicated Discussed recent behaviors such as audio and visual hallucinations. Informed [FM 1] that UA was obtained, results received, C&S pending with [no new orders] now from MD.
During a review of Resident 1's PN, dated 3/22/24, at 00:08 AM, the PN indicated UA ordered and reviewed by MD. C/S [culture sensitivity] result pending. Resident noted to have yelling behaviors throughout night.
During a review of Resident 1's PN, dated 3/22/24, at 11:03 AM, the PN indicated UA collected and reviewed by MD awaiting C+S [culture and sensitivity] results. Resident was yelling out briefly.
During a review of Resident 1's PN, dated 3/23/24, at 9:29 PM, the PN indicated UA ordered and reviewed by MD. C&S result pending.
During a review of Resident 1's PN, dated 3/25/24, at 8:20 AM, the PN indicated Results for UA are pending. There were no further entries in Resident 1's Progress Notes regarding her UA or C/S results.
During a review of Resident 1's Minimum Data Set (MDS - a standardized, comprehensive assessment tool), dated 3/26/24, the MDS indicated at Section C500, Brief Interview for Mental Status, a score of eight out of 15, which indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired.
During an interview with the Infection Preventionist Nurse (IPN) on 4/17/24, at 11:20 AM, the IPN stated Resident 1 had hallucination and did not make sense when she speaks. The IPN stated Resident 1 would say a man was in her room, when there was no one.
During an interview with the Social Services Director (SSD), on 4/17/24, at 11:40 AM, the SSD stated Resident 1 had episodes of confusion.
During an interview with Certified Nursing Assistant (CNA) 1, on 4/17/24, at 1:08 PM, CNA 1 stated Resident 1 had episodes of confusion.
During an interview with Resident 1's Family Member (FM) 1 and Responsible Party, on 4/17/24, at 1:54 PM, FM 1 stated, We noticed some confusion most every day. My father and sister visit almost every day, for 2-3 hours at a time. The confusion was new. She was not confused before admission there. After admission to facility, she was disoriented, delusional, confused. That confusion was not there earlier, before admission. The confusion started after she was placed there [Skilled Nursing Facility].
During a concurrent interview and record review on 4/17/24, at 3:30 PM, with Licensed Vocational Nurse (LVN), Resident 1's LR, dated 3/20/24 and clinical record was reviewed. LVN 1 stated Resident 1 was having confusion and confusion was of the common sign for elderly with urinary tract infection. LVN 1 stated Resident 1's UA result was abnormal, and a CS was indicated to determine if Resident 1 had a urinary tract infection and the treatment needed. LVN 1 was unable to find the CS result. LVN 1 stated a CS was not done and should have been done to determine the cause of the confusion.
During a concurrent interview and record review on 4/17/24, at 3:40 PM, with the Clinical Resource Registered Nurse (CRRN) 3:40 PM, Resident 1's clinical record was reviewed. The CCRN was unable to find Resident 1 CS result. The CCRN stated altered level of consciousness, such as confusion, was a common sign of UTI in elderly. The CCRN stated, There should have been follow-up on the UA, determine what happened with the culture and sensitivity report. Someone should have asked where it [CS] is?
During an interview with the IPN, on 4/17/24, at 4:15 PM, the IPN stated Resident 1 had a urinary catheter and she just learned from the facility contracted laboratory for residents with a urinary catheter there should be a separate physician order for the CS. The IPN stated the CS was never done because there was no separate physician's order. The IPN stated she and the facility license nurses was not aware of the facility contracted lab services policy and procedures for UA and CS. The IPN stated Resident 1 had a new onset of confusion and the physician ordered a UA, the UA result had abnormal values indicative of a UTI and a CS should have been done.
During a review of the professional reference from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9827929/#:~:text=Symptoms%20of%20UTI%20are%20atypical,the%20absence%20of%20a%20fever titled, Urinary Tract Infection Induced Delirium [ ] in Elderly Patients: A Systematic Review dated 12/2022. The Professional indicated, Urinary tract infection (UTI) is common in older adults, mainly due to several age-related risk factors. Symptoms of UTI are atypical in the elderly population, like hypotension, tachycardia, urinary incontinence, poor appetite, drowsiness, frequent falls, and delirium. UTI manifests more commonly and specifically for this age group as delirium or confusion in the absence of a fever . Urinary tract infection (UTI) is a common infection in the elderly, mainly due to age-related risk factors like malnutrition, inadequately controlled diabetes mellitus [a condition that results in too much sugar in blood], poor bladder control leading to urinary retention or incontinence, constipation, long-term hospitalizations . and altered mental state. UTIs are responsible for around 25% of all geriatric hospitalizations attributing to almost 6.2% of deaths due to infectious diseases and repeated emergency department . UTI manifests more atypically for this age group as delirium, confusion, dizziness, drowsiness, falls, urinary incontinence, or poor appetite in the absence of fever making the diagnosis of UTI a difficult task as patients are unable to report their urinary symptoms clearly .
During a review of the professional reference from https://www.healthline.com/health/uti-in-elderly titled, Urinary Tract Infections (UTIs) in Older Adults Older adults may not always show the classic signs of a UTI. They may experience other symptoms, including confusion and lethargy. The classic symptoms of a urinary tract infection (UTI) are burning pain and frequent urination . When bacteria enter the urethra (opening that carries urine to the bladder [an organ that stores urine]) and your immune system doesn't fight them off, they may spread to the bladder and kidneys. The result is a UTI . What causes a urinary tract infection? The main cause of UTIs, at any age, is usually bacteria. Escherichia coli [a type of bacteria] is the primary cause, but other organisms can also cause a UTI. In older adults who catheters or live in a nursing home or other full-time care facility . Diagnosing a urinary tract infection in older adults . uncommon symptoms such as confusion make UTIs challenging to diagnose in many older adults. If your doctor suspects a UTI, a urinalysis will likely be ordered along with other tests to determine the true cause of the symptoms. Your doctor may perform a urine culture to determine the type of bacteria causing the infection and the best antibiotic to treat it . Treating a urinary tract infection in older adults . More severe infections may require a broad-spectrum antibiotic [medication used to kill harmful or disease-causing bacteria] .You should start antibiotics as soon as possible and take them for the entire duration of treatment as prescribed by your doctor. Stopping treatment early, even if symptoms resolve, increases the risks of recurrence and antibiotic resistance .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had a history of psychological problems and previous attempts to leave the facility o...
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Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had a history of psychological problems and previous attempts to leave the facility on 4/11/24, received the necessary supervision from staff during another attempt to leave the facility on 5/12/24. This failure resulted in Resident 1 being unattended while in the parking area of the facility, who then quickly left the facility without supervision and was found 20 minutes later wandering on a nearby street. This failure had the potential for injury to Resident 1.
Findings:
During a review of Resident 1's admission Record (AR), dated 5/29/24, the AR indicated Resident 1 was admitted to the facility with diagnoses that included psychosis (refers to a collection of symptoms that affect the mind, where there has been some loss of contact with reality, a person's thoughts and perceptions are disrupted and they may have difficulty recognizing what is real and what is not), and Strange and Inexplicable Behavior.
During a review of Resident 1's Care Plan (CP), dated 3/18/24, the CP indicated Resident 1 had attempted elopement. The CP dated 3/25/24 indicated Resident 1 is an elopement risk/wanderer as evidenced by History of attempts to leave facility unattended and impaired safety awareness. The CP dated 4/11/24 indicated Resident 1 had eloped [from] from the facility. The CP dated 5/12/24 indicated elopement. The CP dated 5/12/24 indicated Staff educated to keep resident in line of sight while attempting to get help. Use call phone to call the facility/staff to assist rather than 'going to get help.'
During a review of Resident 1's Progress Notes (PN), dated 5/12/24, at 9:10 AM, the PN indicated, Approximately around 0830, [Certified Nursing Assistant, or CNA] came to let writer know that the resident is not in the facility, wheelchair was outside near main gate, Writer look inside and then drove car to look outside, writer found her approximately around 0850am in church, writer tried to convince resident to come back to facility, Resident refused, writer called [Director of Nursing] and administrator, made them aware, called Police and explain them, writer and other 2 staff member were following resident in street while talking to police and giving direction to them. resident was walking down the street, and it was unsafe for resident crossing the road, writer was stopping the cars. after discussion with Police, Resident convinced and ready to come back to facility and ask for ride, one of the staff members gave ride and resident came back to facility around 9am. The PN was written by Registered Nurse (RN) 1.
During a review of Resident 1's PN, dated 5/12/24, at 11:18 AM, the PN indicated, Around 0825 Writer was doing med pass and heard the door alarm. writer ran to door to check, Resident was outside, writer went outside to convinced her to come back, she refused, rude, aggressive to writer, writer came back to facility to get assistance, then another CNA came to let writer know that the resident was nowhere to be found. CNA went outside and seen her [wheel]chair outside next to the gate. This is not the first-time resident has attempted to leave the facility. Resident has been educated and redirected of why leaving the facility can be not safe. Writer notified RN supervisor, DON, and [Medical Doctor] via telephone. RN supervisor went looking for the resident and found her approximately around 0850am. RN supervisor informed writer that the resident was walking down the street and how unsafe it was for her crossing the road. Resident came back to the facility around 9am. The PN was written by Licensed Vocational Nurse (LVN) 1.
During an interview on 5/29/24, at 12:44 PM, with Activities Director (AD), the AD stated she noted an empty wheelchair in the facility's parking area while she was driving into work on 5/12/24, at about 9 AM. The AD stated there are two gates, one for cars, one for pedestrians. The AD stated that as the car gate slid open, she noticed empty wheelchair by pedestrian gate. The AD stated no other staff were present in the area at this time. The AD stated she then called a facility nurse from her cell phone while still in her car. The AD stated she looked at the empty wheelchair and recognized it as belonging to Resident 1. The AD stated she then saw some Certified Nursing Assistants (CNAs) coming out of the facility to look for her. The AD stated I drove around the neighborhood in my car looking for her, and others were out looking too. The AD stated we found Resident 1 about 100-150 yards away from the facility, walking into the road area, the sidewalk-road area, in a zig-zag way. The AD stated the police arrived and brought Resident 1 back to the facility. The AD stated Resident 1 had said she was walking to Fresno (about 11 miles away), and wanted to visit her husband, but her chart says she has no family.
During a concurrent interview and observation on 5/29/24, at 12:50 PM, with Resident 1, in the facility dining room, Resident 1 stated, Yes, I went for a walk a while ago. I feel safe out there because I had a nurse with me. Resident 1 was noted to be seated in a wheelchair and wearing a wander guard, an electronic monitoring bracelet, on her right ankle.
During an interview on 5/29/24, at 1 PM, with LVN 1, LVN 1 stated she recalled that on the morning of 5/12/24, at about 8:30 AM, Resident 1] coming to my medication cart asking for her medications. LVN 1 stated I gave them to her, then Resident 1 wheeled herself down the hall towards the front door. LVN 1 stated I heard the wander guard alarm go off and could tell it was the front door alarm. LVN 1 stated, that after about 1-2 minutes, I went outside to check on Resident 1. LVN 1 stated Resident 1 can be aggressive and stated, I didn't want to get hit, I avoid getting hit. I don't want to get her mad. LVN 1 stated Resident 1 didn't want to come back in. LVN 1 stated, I came back in. That was my mistake. My plan was to come inside and get more staff to convince her to come inside. LVN 1 stated that once back inside, LVN 1 told a CNA and RN charge nurse what happened. LVN 1 stated, We looked for her through the windows, I saw the empty wheelchair. This was about 10 minutes later. Then [the AD] called me. This was maybe 5-10 minutes after she first left the building. [The AD] called me about 9-ish. I was in panic mode. We could not find her through the window. LVN 1 stated she had updated RN 1 on these events.
During an interview on 5/29/24, at 1:47 PM, with the AD, the AD stated, [Resident 1] is wobbly, but she can get out of wheelchair and run. The AD stated, I was told to not leave her alone, she has to be watched at all times when outside because of her elopement risk, ever since her elopement in April. She has threatened to hit me before, yelling, being profane. She's never actually hit anyone as far as I know. She's not physically violent.
During an interview on 5/29/24, at 2 PM, with the Director of Nursing (DON), the DON stated, [Resident 1] is quick. She had 2 previous elopements [prior to the one on 5/12/24]. She can get out of her wheelchair. The nurse was with her, then stepped inside to get help - but we can't take our eyes off of her. She's a quick one. She's whizzed past me before.
During an interview on 5/30/24 at 9:45 AM with RN 1, RN 1 stated she recalled that on the morning of 5/12/24, Certified Nursing Assistant (CNA) 1, informed her that there was an empty wheelchair outside the facility. RN 1 stated, I went outside, I didn't find resident. RN 1 stated that LVN 1 had heard the wander guard alarm, LVN 1 went outside, then she came inside and told us Resident 1 was out there. RN 1 stated, I used my car look for her, I was the one who found her. I tried to convince her to come back, but she was not listening. I called cops for help. Two CNAs were with me, we were following her all the way. The cops finally able to convince her to return. RN 1 stated the nurse that came back inside the facility to get help was LVN 1. RN 1 stated CNA 1 assisted her with finding Resident 1.
During an interview on 5/30/24, at 10:20 AM, with CNA 1, CNA 1 stated, I went with the other nurses to go and find [Resident 1. RN 1] found her first. I saw [Resident 1]. She had behavior problems, she was trying to swing and fight back. She didn't want to come with us at all. She was just walking everywhere, walking in middle of street. She has behaviors, thinking problems. We had to stop cars to make sure she wasn't in the way of cars, they moved around her. Like 3 or 4 cars passed by while she was in the street.
During a review of the facility Policy and Procedure (P&P) titled, Elopements and Wandering Residents, dated 4/16/21, the P&P indicated, in part, Policy: The facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Elopement occurs when a resident leaves the premises or a safe area without authorization. and/or any necessary supervision to do so. Alarms are not a replacement for necessary supervision. Adequate supervision will be provided to help prevent accidents or elopements.
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 F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 48 sampled residents (Resident 1) received Trauma Inf...
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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 48 sampled residents (Resident 1) received Trauma Informed Care Evaluation (a process that acknowledge the need to understand patients ' life experiences to deliver effective care and treatment) performed when the Social Services Director (SSD) did not complete a Trauma Informed Care Evaluation for Resident 1.
This failure had the potential for the facility ' s inability to identify triggers which could result in Resident 1 ' s re-traumatization (the reactivation of trauma symptoms by way of thoughts, memories, or feelings related to past experienced).
Findings:
During a review of Resident 1 ' s admission Record, dated 4/17/24, at 4:08 PM, the admission Record indicated Resident 1 was a [AGE] year-old female admitted to the facility on [DATE].
During a review of Resident 1 ' s Progress Notes, dated 3/21/24, at 1:50 PM, the Progress Notes indicated a care conference meeting was held with Resident 1 ' s Family Member (FM 1).
During an interview on 4/17/24, at 1:54 PM, with Resident 1 ' s Family Member (FM) 1, FM 1 stated she attended a care plan meeting regarding Resident 1 ' s care. FM 1 stated, I was not asked if she had a history of trauma or mental illness.
During a concurrent interview and record review on 4/17/24, at 11:40 AM with the SSD, Resident 1 ' s clinical record was reviewed. The SSD stated Resident 1 did not have a Trauma Informed Care Evaluation. The SSD stated she was responsible to complete the Trauma Informed Care Evaluation for each resident within 48 hours after admission in the facility. The SSD stated she should have completed the Trauma Informed Care Evaluation for Resident 1 to ensure appropriate intervention was implemented if needed. The SSD stated she started working at the facility on 3/7/24 and had been playing catch-up since I ' ve got here. I ' m not caught up now.
During a review of the facility document titled Social Services Director - Job Description dated 3/7/24, the document indicated All facilities must provide medically related social services to residents. The Social Services Director is responsible for overseeing the development, implementation, supervision, and ongoing evaluation of the Social Services Department designed to meet and assist residents in attaining or maintain their highest practicable well-being. This included identifying the need for medically related social services and ensuring that these services are provided in accordance with State and Federal regulations. The Social Services Director – Job Description was signed by SSD on 3/7/24.
During a review of the facility ' s policy and procedure titled admission of a Resident, dated 2/22, the document indicated, in part, Policy: The admission process is intended to obtain all the information possible about the resident, for the development of comprehensive plans of care, and to assist the resident in becoming comfortable in the facility. Upon admission, the designated facility staff will obtain information and perform assessments as per their respective departments and as per facility protocol. Information gathered will be placed into the resident ' s medical record via the facility ' s means of recordkeeping (i.e., paper, electronic). The social service designee should determine any needs for the use of outside resources, such as psychosocial services .
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 F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 48 sampled residents (Resident 1) had a Social Servic...
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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 48 sampled residents (Resident 1) had a Social Services Evaluation completed.
This failure had the potential for unmet care needs for Resident 1, who was recently admitted to the facility, including care for mood and behaviors, adjustment to the new environment, mental health history, support systems, and behavioral interventions.
Findings:
During a review of Resident 1 ' s admission Record, dated 4/17/24, at 4:08 PM, the admission Record indicated Resident 1 was a [AGE] year-old female admitted to the facility on [DATE].
During a concurrent interview and record review on 4/24/24, at 10 AM with the Social Services Director (SSD), Resident 1 ' s clinical record was reviewed. The SSD stated Resident 1 did not have a Social Services Evaluation. The SSD stated Resident 1 was admitted on [DATE] and the Social Services Evaluation should have been done. The SSD stated she was responsible to complete Resident 1 ' s Social Services Evaluation. The SSD stated she started working at the facility on 3/7/24 and did not know which assessments to do. The SSD stated she did not get any training until about three weeks in the job.
During a review of the facility document titled Social Services Evaluation, undated, the Social Services Evaluation indicated questions for residents and/or family members which included Work History, Interests/Hobbies, Ability to see and hear, Communication status, Cognition status, Mood & Behaviors, Social/Mental Health History, Adjustment to Environment, Other mood & behavior concerns, Behavioral Interventions, Support Systems, and Resident Strengths.
During a review of the facility document titled Social Services Director - Job Description dated 3/7/24, the document indicated All facilities must provide medically related social services to residents. The Social Services Director is responsible for overseeing the development, implementation, supervision, and ongoing evaluation of the Social Services Department designed to meet and assist residents in attaining or maintain their highest practicable well-being. This included identifying the need for medically related social services and ensuring that these services are provided in accordance with State and Federal regulations. The Social Services Director – Job Description was signed by SSD on 3/7/24.
During a review of the facility ' s policy and procedure titled admission of a Resident, dated 2/22, the document indicated, in part, Policy: The admission process is intended to obtain all the information possible about the resident, for the development of comprehensive plans of care, and to assist the resident in becoming comfortable in the facility. Upon admission, the designated facility staff will obtain information and perform assessments as per their respective departments and as per facility protocol. Information gathered will be placed into the resident ' s medical record via the facility ' s means of recordkeeping (i.e., paper, electronic). The social service designee should determine any needs for the use of outside resources, such as psychosocial services, equipment, clothing, money, etc., and make attempts to arrange for the goods or services as soon as possible.
May 2021
16 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Quality of Care
(Tag F0684)
Someone could have died · 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 seven of 13 sampled residents (Residents 10, 1...
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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 seven of 13 sampled residents (Residents 10, 11, 13, 25, 32, 33, and 36) received diabetic (disease in which the body's ability to produce or respond to the hormone insulin is impaired) management care in accordance with professional standards of practice when:
1. Resident 10 did not have a baseline (starting point) hemoglobin A1C (HBA1c- test tells you your average level of blood sugar over the past two to three months; the target A1c level for people with diabetes is usually less than 7% [percent]. The higher the hemoglobin A1c, the higher the risk of having complications related to diabetes) obtained upon admission to the skilled nursing facility (SNF), licensed nurses (LNs) did not notify the physician when Resident 10 exhibited consistent elevated blood sugars, and the interdisciplinary team (IDT-approach involves team members from different disciplines working collaboratively, with a common purpose, to set goals, and make decisions and share sources and responsibilities) failed to assess Resident 10's consistent elevated blood sugars;
2. Resident 11 did not have a baseline HBA1c obtained upon admission to the SNF, Resident 11 was on a regular diet, LNs did not notify the physician when Resident 11 exhibited consistent elevated blood sugars, and the IDT failed to assess Resident 11's consistent elevated blood sugars;
3. Resident 13 did not have a baseline HBA1c obtained upon admission to the SNF, LNs did not notify the physician when Resident 13 exhibited consistent elevated blood sugars, and the IDT failed to assess Resident 13' consistent elevated blood sugars;
4. Resident 25 did not have a baseline HBA1c obtained upon admission to the SNF, Resident 25 was on a regular diet, LNs did not notify the physician when Resident 25 exhibited consistent elevated blood sugars, and the IDT failed to assess Resident 25's consistent elevated blood sugars;
5. Resident 32 was on a regular diet, LNs did not notify the physician when Resident 32 exhibited consistent elevated blood sugars, and the IDT failed to assess Resident 32's consistent elevated blood sugars;
6. Resident 33 did not have a baseline HBA1c obtained upon admission to the SNF, Resident 33 was on a regular diet, LNs did not notify the physician when Resident 33 exhibited consistent elevated blood sugars, and the IDT failed to assess Resident 33's consistent elevated blood sugars; and
7. Resident 36 did not have a baseline HBA1c obtained upon admission to the SNF, LNs did not notify the physician when Resident 36 exhibited consistent elevated blood sugars, and the IDT failed to assess Resident 36's consistent elevated blood sugars.
Because of the serious potential harm to Residents 10, 11, 13, 25, 32, 33, and 36 due to not following professional standards of practice with care of residents with diabetes (a disease in which your blood glucose, or blood sugar, levels are too high) in obtaining a baseline HBA1c upon admission, four of the seven residents were on a regular diet and not a consistent carbohydrate diet (the focus of the diet is eating the same amount of carbohydrates every day; this helps keep your blood sugar, or glucose, levels stable), licensed nurses did not notify the physician when residents presented with consistent elevated blood sugars and the IDT did not assess the consistent elevated blood sugars, an Immediate Jeopardy (IJ-a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) situation was called on 5/14/21 at 3:44 p.m. under Code of Federal Regulations (CFR) 483.25 Quality of Care (F684) with the Director of Operations, Administrator (ADM), Director of Nursing (DON), Director of Social Services (DSS), and the Minimum Data Set Consultant (MDSC). The IJ template was provided to the ADM. The facility submitted an acceptable IJ Plan of Removal (Version 3) on 5/17/21, at 8:55 a.m. The IJ Plan of Removal included but was not limited to the following: 1) Immediate training to LNs, Certified Nursing Assistants (CNAs), and IDT on diabetes management. 2) Immediate training to dietary staff on consistent carbohydrate diet. 3) Obtaining baseline HBA1c levels on all 17 diabetic residents. 4) IDT review all 17 residents with diagnosis of diabetes and evaluated the therapeutic diet (meal plan that controls the intake of certain foods or nutrients). 5) IDT including physician evaluate residents with diagnosis with diabetes with persistent hyperglycemia (too much sugar in the blood) and evaluate treatment plan. 5) Create a system for the IDT to review and manage diabetic residents' blood sugar levels and HBA1c and follow up as required. The components of the IJ Plan of Removal was validated through observations, interviews, and record review. The IJ was removed on 5/18/21 at 3:54 p.m. with the Director of Operations, ADM, DON, and the Nurse Consultant.
These failures resulted in Resident 11 to experience headache and dizziness and had the potential for Residents 10, 11, 13, 25, 32, 33, and 36 to continue to have elevated blood sugars not assessed and had the potential for life-threatening complications/conditions.
Findings:
1. During a review of Resident 10's admission Record (AR-document that gives a resident's information at a quick glance) undated, the AR indicated, .admission Date 10/28/2020 .Diagnosis Information .Type 2 Diabetes Mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal breakdown of carbohydrates and elevated levels of sugar in the blood and urine) with Diabetic Chronic Kidney Disease (serious kidney related complication of diabetes) .
During a review of Resident 10's Laboratory Report dated 3/3/21, the Laboratory Report indicated .GLYCOHGB (A1c) .Abnormal Summary .7.3 H [high] .
During a review of Resident 10's Medication Administration Record (MAR) dated March 2021, the MAR indicted the blood sugar results from 6:30 a.m. ranged from 107 mg/dl (milligrams per deciliter - units of measurement) to 191 mg/dl (the ideal goal for adults with diabetes is to achieve glucose levels between 70 and 130 mg/dl). The blood sugar results from 11:30 a.m. ranged from 118 mg/dl to 195 mg/dl. The blood sugar results 4:30 p.m. ranged from 110 mg/dl to 255 mg/dl.
During a review of Resident 10's MAR dated April 2021, the MAR indicted the blood sugar results from 6:30 a.m. ranged from 108 mg/dl to 188 mg/dl. The blood sugar results from 11:30 a.m. ranged from 116 mg/dl to 207 mg/dl. The blood sugar results from 4:30 p.m. ranged from 111 mg/dl to 245 mg/dl.
During a review of Resident 10's MAR dated May 2021, the MAR indicted the blood sugar results from 6:30 a.m. ranged from 79 mg/dl to 184 mg/dl. The blood sugar results from 11:30 a.m. ranged from 130 mg/dl to 188 mg/dl. The blood sugar results 4:30 p.m. ranged from 147 mg/dl to 279 mg/dl.
During a review of Resident 10's Order Summary Report dated 2/11/21, the Order Summary indicted, .Carbohydrate Controlled diet .
During an interview on 5/10/21, at 8:04 a.m., with Resident 10, Resident 10 stated he was on a diabetic diet and he was not getting the correct foods. Resident 10 stated no one from the facility had discussed his diet with him.
During a concurrent interview and record review with the Dietary Service Manager (DSM) on 5/11/21 at 12:20 p.m. the facility's document titled, Spring Cycle Menus dated 5/10/21 was reviewed. The facility Menu indicated, .Regular .Oatmeal 4 oz (ounces- units of measurement) .Pancakes 1 (quantity) .Oven Roasted Potatoes 1/4 cup .Pasta bean soup 4 oz .Egg salad sandwich 1 .CCHO (controlled carbohydrate diet) .Oatmeal 4 oz .Pancakes 1 .Oven Roasted Potatoes 1/4 cup .Pasta Bean Soup 4 oz .Egg salad sandwich 1. The DSM stated the cooks followed the menu's portion sizes. The DSM validated the portion sizes of the regular and controlled carbohydrate diet were the same.
During an interview on 5/13/21 at 3:12 p.m., with the DSM, the DSM stated his expectation was for the nursing staff to inform him when residents had consistent elevated blood sugars so he could work with residents on their diet. The DSM stated he had no training on diabetes or blood sugar control. The DSM stated Registered Dietitian (RD) 1, should have been onsite at the facility when she evaluated residents. The DSM stated he would have expected RD 1 to assist him in planning meals for diabetic residents with consistent elevated blood sugars.
During an interview on 5/13/21 at 3:52 p.m., with the DON, the DON stated her expectation was for the LNs to notify her [DON] when residents had consistent elevated blood sugars. The DON stated the expectation was for the LNs to call the physician when the blood sugar was over 400 mg/dl. The DON stated the physician would give an order for a HBA1c when the blood sugars were elevated. The DON stated the DSM should have been involved when the residents' blood sugars were elevated. The DON stated she aware the residents' blood sugars were an issue. The DON stated she should have followed up with the residents' diets. The DON stated the RD was not called or was informed of the elevated blood sugars. The DON was unable to verbalize and explain the role of the RD and the oversight the RD provided to the facility.
During a telephone interview on 5/14/21, at 3:21 p.m., with the Medical Director (MD), the MD validated he was the primary physician for Residents 10, 11, 13, 25, 32, 33, and 36. The MD stated he conducted facility visits once a month and he expected the LNs to notify him when the blood sugars were high, if the LNs had questions, and to discuss the care of diabetes management. The MD stated his expectation was for the LNs to provide him a list of the residents along with their elevated blood sugars to determine what the next steps were. Resident 10, 11, 13, 25, 32, 33, and 36's blood sugars readings for March, April and May 2021 were shared with the MD. The information of the residents' blood sugars readings was consistently over 150 mg/dl. The MD stated when an individual reviewed the residents' blood sugars, it looked like they are high and they were definitely high. The MD stated he was not aware diabetic residents had asked for a change from regular diet to controlled carbohydrate diet, the MD stated nursing staff did not bring this to his attention. The MD stated the facility should have made an effort to help get the residents' diet changed. The MD stated physicians are not physically present in the facility during the residents' admission, so he depended on what the nurses informed him. The MD stated he wrote the residents' diet orders based on the information he received from the nursing staff. The MD stated residents can experience acute (new) and chronic (long term) changes in their blood sugars. The facility should have considered a referral to an endocrinologist (a medical practitioner qualified to diagnosis and treat disorders like diabetes) for the chronic elevated blood sugars. The MD stated if residents were in the facility for long term care, a baseline HBA1c should have been ordered upon admission. The MD stated the registered dietitian should have been engaged in residents' diabetic management.
During an interview on 5/16/21, at 12:20 pm, with Resident 10, Resident 10 stated .I get carbs and too much salt .
During an interview on 5/17/21, at 4:20 p.m., with Registered Dietitian (RD) 2, RD 2 stated it was her first day in this facility. RD 2 stated the facility had called her on Friday (5/14/21) and she was made aware of the IJ situation at the facility because diabetic residents had uncontrolled blood sugars, and the RD, physician, and IDT had not assessed the elevated glucose (sugar) levels. RD 2 stated the facility asked her why diabetic residents were not on a controlled carbohydrate diet. RD 2 stated residents needed nursing intervention and communication to the DON and physician. RD 2 stated her expectation was for the facility to notify her if the residents' blood sugars were consistently high. RD 2 stated her expectation of the facility staff was to be informed if they the HBA1c and blood sugars were elevated. RD 2 stated, I definitely need to be in the loop. RD 2 stated the facility should have reviewed the residents' charts to see if anything changed with their meal percentages (intake of food), infection, changes, and review the HBA1c to review trends. RD 2 stated she talked to the ADM and informed him there was no communication system between the facility and the RD [RD 2]. RD 2 stated communication system needed to be improved. RD 2 stated she followed the American Diabetes Association (ADA) standards.
During an interview on 5/19/21, at 9:47 a.m., with the Social Worker (SW), the SW stated she distributed the snacks from the snack cart to the residents. The SW stated that the residents could choose from common items on the snack cart, such as chips, cookies, and bananas. The SW stated nursing staff had not brought up the topic of diabetic residents and what snacks diabetic resident could or could not have.
During a concurrent interview and record review on 5/19/21 at 10:21 a.m., with the DON, Residents 10, 11, 13, 25, 32, 33, and 36's blood sugars dated March, April and May 2021 were reviewed. The DON stated the facility system that was in place (communication of blood sugars) was not working. The DON reviewed Residents 10, 11, 13, 25, 32, 33, and 36's blood sugars and validated the blood sugars were consistently elevated and should have been communicated to the physician. The DON stated LNs had not communicated to her [DON], the CNAs, DSM, RD or the physician regarding the consistent elevated blood sugars. The DON stated the physician was not notified by the LNs of the consistent elevated blood sugars and the physician should have been notified. The DON reviewed Residents 10, 11, 13, 25, 32, 33, and 36's medical records and validated there were no IDT notes to address the residents' blood sugars. The DON stated the RD should have educated diabetic residents on the consistent carbohydrate diet and explained the differences between a regular diet and a consistent carbohydrate diet.
During a review of the facility's policy and procedure (P&P) titled, Diabetes Management Guideline revised December 2015, the P&P indicated, Guidelines statement: All residents will have appropriate treatment and services to manage their Diabetes .admission Assessments .Residents with diabetes are at very high risk for skin breakdown. Risks include vascular wounds (When there's reduced blood flow, skin and tissues in the affected areas are deprived of oxygen and nutrients, these areas will become irritated and form an open wound), pressure ulcers, infection and delayed healing .Recent lab values- A1C .Daily Observation by all staff should include: nutritional intake, glucose control .The American Diabetes Association states that the ideal goal for adults with diabetes is to achieve glucose levels between 70 and 130 mg/dl before meals, and less than 180 two hours after starting a meal, with a glycated hemoglobin (A1C) level less than 7 percent . Hyperglycemia: is common cause of illness and is the cause of secondary complications of the disease. Common signs and symptoms: .More frequent urination, incontinence, increased fatigue, unexplained weight loss, new vision problems, decreased mental function, confusion .Advanced Signs and Complications: .Poorly healing wounds, incisions, tingling, burning, numbness, persistent infections, dehydration, vomiting, renal dysfunction, cardiac symptoms .Nutrition .Maintaining health and promoting quality of life are two goals of nutritional care of the resident with Diabetes. The registered dietitian will complete a nutritional assessment upon admission and make changes as needed to food plans. The food plan and nutritional goals focus on the daily intake of carbohydrates, fats, protein and soluble fiber for those with diabetes. The Consistent Carbohydrate diet (Con CHO) is designed for individuals with a stable diabetes condition. A liberalized diet can enhance both the quality of life and nutritional status (relaxing the original diet prescriptions meant to control disease states like diabetes) .In caring for an individual with diabetes .b. Regularly review the meal plans and medication list of your residents .Monitoring/Compliance: The following elements are in place for the center to demonstrate satisfactory compliance with the guide: MD notification parameters in place .Hyperglycemia . Review patterns of blood glucose levels and communicate to physician .Communicate with physician if: Blood Glucose > (greater) 300 [mg/dl] .
During a professional reference review of the American Diabetes Association retrieved from https://care.diabetesjournals.org/content/39/2/308
on 5/26/21, titled, Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association dated February 2016, the professional reference indicated, Diabetes is more common in older adults, has a high prevalence in long-term care (LTC) facilities, and is associated with significant disease burden and higher cost . Several organizations have developed diabetes guidelines for patients living in LTC settings. Almost all of these guidelines emphasize the need to individualize care goals and treatments related to diabetes, the need to avoid sliding scale insulin (SSI) as a primary means of regulating blood glucose, and the importance of providing adequate training and protocols to LTC staff who may be operating without the presence of a practitioner for prolonged periods .Hyperglycemia . persistent hyperglycemia increases the risk of dehydration, electrolyte abnormalities (imbalance of minerals in the body), urinary incontinence, dizziness, falls, and hyperglycemic hyperosmolar syndrome (occurs when a person's blood sugar levels are too high for a long period, leading to severe dehydration and confusion) .Improving Nutrition Health . a consistent carbohydrate meal plan that allows for a wide variety of food choices (e.g., general diet) may be more beneficial for both nutritional needs and glycemic control in patients with type 1 diabetes (is a chronic condition in which the pancreas produces little or no insulin) or type 2 diabetes on mealtime insulin .Diabetes Management During Transitions of Care . At the time of admission to a facility, transitional care documentation should include the current meal plan, activity levels, prior treatment regimen, prior self-care education, laboratory tests (including A1C, lipids [family of organic compounds, composed of fats and oils], and renal function), hydration status, and previous episodes of hypoglycemia (low blood sugar) (including symptoms and patient's ability to recognize and self-treat) .Integration of Diabetes Management Into LTC Facilities .Recommendation . Patients admitted to LTC facilities are not seen daily by a practitioner. Because of this reality, successful diabetes care needs to include a dedicated interprofessional team. This team may be composed of practitioners (physicians, nurse practitioners, and physician assistants), registered nurses, licensed practical/vocational nurses, certified nursing assistants, diabetes educators, dietitians, food service managers, consultant pharmacists, physical therapists, and/or social workers . In order to assess and improve facility-wide management of diabetes directed by multiple practitioners, the facility leadership (e.g., the director of nursing, nurse managers, medical director, and consultant pharmacist) should collect data and trends and plan strategies to improve selected process or outcome indicators relevant to diabetes management. These could include sharing data with managerial staff, providing staff education, and planning a performance improvement project. In general, the facility medical leadership and nursing administration have the opportunity to develop and implement patient care policies that can facilitate optimal management of the older patient with diabetes and to coordinate efforts with the multidisciplinary team. Nursing leadership training programs for nurses working in LTC facilities that include skills in diabetes management can also help to improve quality of care offered to patients in these facilities .Figures & Tables .Table 6 - specific situations needing attention in patients with diabetes in LTC setting .glucose meter readings >300 mg/dl during all or part of 2 consecutive day .Confirm high glucose value by laboratory test .Evaluate nutritional intake .
2. During a review of Resident 11's AR undated, the AR indicated, .admission Date 2/9/21 .Diagnosis Information .Type 2 Diabetes Mellitus with Diabetic Neuropathy ( type of nerve damage that can occur if you have diabetes) .Hyperglycemia .Long Term (Current) Use of Insulin . Resident 11 was admitted on [DATE] from a general acute care hospital.
During a review of Resident 11's Laboratory Report from the acute care hospital dated 8/28/2020 (prior to admission to the skilled nursing facility), the Laboratory Report indicated .HGBA1c .6.3 . [goal is less than 7 for diabetics] .
During a review of Resident 11's Laboratory Report dated 5/5/21, the Laboratory Report indicated .GLYCOHGB (A1c) .Abnormal Summary .10.5 H [high] .
During a review of Resident's 11's MAR dated May 2021, the MAR indicated Resident 11's blood sugar obtained on 5/10/21 at 11 a.m. was 370 mg/dl.
During a concurrent observation and interview, on 5/10/21, at 11:45 a.m., in Resident 11's room, Resident 11 was observed in bed with his eyes closed and his left hand pressed against the left side of his head. Resident 11 stated he was diabetic, and he got too much pasta. Resident 11 stated his blood sugar was high, sometimes it was over 400 mg/dl. Resident 11 stated he experienced a headache and was dizzy. Resident 11 stated he requested a diabetic diet from nursing staff but continued to receive a regular diet.
During a concurrent observation and interview, on 5/10/21, at 12:35 p.m., in Resident 11's room, Resident 11 sat on the side of bed eating lunch. Resident 11's lunch tray included: rice, pasta, green beans and pinto beans. Resident 11 stated he ate the green beans and pinto beans but did not want the rice and pasta. Resident 11 stated his blood sugar was 371 before lunch.
During a concurrent observation and interview, on 5/10/21, at 4:09 p.m., in Resident 11's room, Resident 11 stated when he was in the hospital (prior to admission to the SNF), .They [hospital] gave me a diabetic diet and my blood sugars were not high.
During an interview on 5/12/21 at 8:55 a.m., with the DSM, the DSM stated Resident 11 was on a regular diet.
During a review of Resident 11's Order Summary Report dated 2/11/21, the Order Summary indicted, .Regular Diet .
During an interview on 5/11/21, at 11:30 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated she had just assisted Resident 11 in ambulating with a walker from his room to the dining room for lunch. CNA 1 stated Resident 11 did Really good, but he was dizzy. CNA 1 stated Resident 11 complained of being dizzy when he walked to the dining room.
During a review of Resident 11's MAR dated 5/11/21, the MAR indicated Resident 11's blood sugar was 361 mg/dl at 11:57 a.m.
During an interview on 5/11/21, at 1:10 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the physician was notified when blood sugars were over 400 mg/dl. LVN 3 stated she did not notify the physician when the blood sugars were over 300 mg/dl, two or more consecutive days. LVN 3 stated RD 1 did not receive notification of Resident 11's blood sugars that were over 300 mg/dl two or more consecutive days.
During a concurrent observation and interview on 5/12/21 at 12:30 p.m. with LVN 4 during the noon medication pass, Resident 11 was observed. LVN 4 obtained Resident 11's blood sugar, the result was 325 mg/dl. Resident 11 stated he needed help from the surveyors to assist with his blood sugars and diet. Resident 11 stated he told the facility to stop feeding him carbs like pasta, corn and bread. Resident 11 stated his blood sugar reading in the morning was 400 mg/dl. LVN 4 did not respond to Resident 11's comments. When LVN 4 was asked if she was going to intervene with Resident 11's blood sugar, LVN 4 stated because it was under 400 mg/dl, she did not need to call the physician. LVN 4 stated, .His blood sugar is hard to control, he is always eating the wrong food .
During a telephone interview on 5/12/21, at 2:55 p.m., with RD 1, RD 1 stated Resident 11 was on a regular diet and she had not received any notification Resident 11 had requested a controlled carbohydrate diet. RD 1 stated she was unaware Resident 11's blood sugars were consistently over 300 mg/dl. RD 1 stated, Thanks for letting me know.
During an interview on 5/13/21 at 1:10 p.m., with the DSM, the DSM stated, No one ever mentioned his [Resident 11] blood sugars .
During an interview on 5/13/21 at 3:12 p.m., with the DSM, the DSM stated his expectation was for the nursing staff to inform him when residents had consistent elevated blood sugars so he could work with residents on their diet. The DSM stated he had no training on diabetes or blood sugar control. The DSM stated RD 1, should have been onsite at the facility when she evaluated residents. The DSM stated he would have expected RD 1 to assist him in planning meals for diabetic residents with consistent elevated blood sugars.
During an interview on 5/13/21 at 3:52 p.m., with the DON, the DON stated her expectation was for the LNs to notify her [DON] when residents had consistent elevated blood sugars. The DON stated the expectation was for the LNs to call the physician when the blood sugar was over 400 mg/dl. The DON stated the MD would give an order for a HBA1c when the blood sugars were elevated. The DON stated she was unaware of 11's request for a diet change from a regular diet to a consistent carbohydrate diet. The DON stated the DSM should have been involved when the residents' blood sugars were elevated. The DON stated she aware the residents' blood sugars were an issue. The DON stated she should have followed up with the residents' diets. The DON stated the RD was not called or was informed of the elevated blood sugars. The DON was unable to verbalize and explain the role of the RD and the oversight the RD provided to the facility.
During a telephone interview on 5/14/21, at 3:21 p.m., with the MD, the MD validated he was the primary physician for Residents 10, 11, 13, 25, 32, 33, and 36. The MD stated he conducted facility visits once a month and he expected the LNs to notify him when the blood sugars were high, if the LNs had questions, and to discuss the care of diabetes management. The MD stated his expectation was for the LNs to provide him a list of the residents along with their elevated blood sugars to determine what the next steps were. Resident 10, 11, 13, 25, 32, 33, and 36's blood sugars readings for March, April and May 2021 were shared with the MD. The information of the residents' blood sugars readings was consistently over 150 mg/dl. The MD stated when an individual reviewed the residents' blood sugars, it looked like they are high and they were definitely high. The MD stated he was not aware diabetic residents had asked for a change from regular diet to controlled carbohydrate diet, the MD stated nursing staff did not bring this to his attention. The MD stated the facility should have made an effort to help get the residents' diet changed. The MD stated physicians are not physically present in the facility during the residents' admission, so he depended on what the nurses informed him. The MD stated he wrote the residents' diet orders based on the information he received from the nursing staff. The MD stated residents can experience acute and chronic changes in their blood sugars. The facility should have considered a referral to an endocrinologist for the chronic elevated blood sugars. The MD stated if residents were in the facility for long term care, a baseline HBA1c should have been ordered upon admission. The MD stated the registered dietitian should have been engaged in residents' diabetic management.
During an interview on 5/17/21, at 4:20 p.m., with RD 2, RD 2 stated it was her first day in this facility. RD 2 stated the facility had called her on Friday (5/14/21) and she was made aware of the IJ situation at the facility because diabetic residents had uncontrolled blood sugars, and the RD, physician, and IDT had not assessed the elevated glucose levels. RD 2 stated the facility asked her why diabetic residents were not on a controlled carbohydrate diet. RD 2 stated residents needed nursing intervention and communication to the DON and physician. RD 2 stated her expectation was for the facility to notify her if the residents' blood sugars were consistently high. RD 2 stated her expectation of the facility staff was to be informed if they the HBA1c and blood sugars were elevated. RD 2 stated, I definitely need to be in the loop. RD 2 stated the facility should have reviewed the residents' charts to see if anything changed with their meal percentages (intake of food), infection, changes, and review the HBA1c to review trends. RD 2 stated she talked to the ADM and informed him there was no communication system between the facility and the RD [RD 2]. RD 2 stated communication system needed to be improved. RD 2 stated she followed the American Diabetes Association (ADA) standards.
During an interview on 5/19/21, at 9:47 a.m., with the SW, the SW stated she distributed the snacks from the snack cart to the residents. The SW stated that the residents could choose from common items on the snack cart, such as chips, cookies, and bananas. The SW stated nursing staff had not brought up the topic of diabetic residents and what snacks diabetic resident could or could not have.
During a concurrent interview and record review on 5/19/21 at 10:21 a.m., with the DON, Residents 10, 11, 13, 25, 32, 33, and 36's blood sugars dated March, April and May 2021 were reviewed. The DON stated the facility system that was in place (communication of blood sugars) was not working. The DON reviewed Residents 10, 11, 13, 25, 32, 33, and 36's blood sugars and validated the blood sugars were consistently elevated and should have been communicated to the physician. The DON stated LNs had not communicated to her [DON], the CNAs, DSM, RD or the physician regarding the consistent elevated blood sugars. The DON stated the physician was not notified by the LNs of the consistent elevated blood sugars and the physician should have been notified. The DON reviewed Residents 10, 11, 13, 25, 32, 33, and 36's medical records and validated there were no IDT notes to address the residents' blood sugars. The DON stated the RD should have educated diabetic residents on the consistent carbohydrate diet and explained the differences between a regular diet and a consistent carbohydrate diet.
During a review of Resident 11's Order Summary Report dated 2/9/21, the Order Summary Report indicated, Insulin [brand name] Solution 100 UNIT/ML, inject as per sliding scale, (sliding scale refers to the progressive increase of the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges). Give subcutaneously (into the skin) before meals and at bedtime:
150 - [TRUNCATED]
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 provide a safe, clean, and homelike environment when:
1. ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed provide a safe, clean, and homelike environment when:
1. One of one bathroom (Bathroom [ROOM NUMBER]) had baseboards there were peeled, the walls had even paint, and tiles were missing and broken near the shower tub;
2. One of one bathroom (Bathroom [ROOM NUMBER]) had a soap dispenser that was not functional; and
3. One of 35 Residents (Resident 34) had a gap between the window and the window seal.
These failures created an environment that was not homelike and had the potential to result in a decreased quality of life for residents in the facility.
Findings:
1. During an observation on 5/11/21, at 10 a.m., in Bathroom [ROOM NUMBER], the baseboard by the wall in the shower area was peeled off. The walls had uneven paint. There were missing tiles pieces and broken tile pieces by the shower tub.
During a concurrent observation and interview on 5/11/21, at 4:49 p.m., in Bathroom [ROOM NUMBER], with Certified Nursing Assistant (CNA) 3, CNA 3 stated Residents 25 and Resident 5 used Bathroom [ROOM NUMBER].
During a concurrent observation and interview on 5/11/21, at 4:56 p.m., with the Maintenance (MAINT), in Bathroom [ROOM NUMBER], the MAINT stated he had worked in the facility 22 years. The MAINT stated he did not have assistance for maintenance repairs in the facility. The MAINT stated part of his job description was to ensure residents in the facility were safe, fix the air conditioner, clean, paint, clean the carpet and fix the baseboards. The MAINT stated he would not conduct observations in the facility because the Administrator (ADM), Director of Nurses (DON), Dietary Service Manger (DSM) would do rounds of the building and notified him if something needed to be fixed. The MAINT acknowledged the broken tile, peeling baseboards and uneven paint on the walls. The MAINT stated he had worked on the broken tile and the baseboard for two weeks. The MAINT stated Bathroom [ROOM NUMBER] was under construction. The MAINT validated the broken tile and baseboards were still not fixed on 5/11/21. The MAINT stated residents in the facility would use Bathroom [ROOM NUMBER]. The MAINT stated the tile near the shower tub in Bathroom [ROOM NUMBER] was broken and the shower tub was still being used by residents. The MAINT stated he was not able to fix everything in the facility. The MAINT stated those items were not his priority.
During a concurrent observation and interview on 5/11/21, at 5:17 p.m. with the ADM, in Bathroom [ROOM NUMBER], the ADM stated he was aware of the broken tile and the uneven paint. The ADM stated his expectation for MAINT was for him to ensure safety in the facility. The ADM stated Bathroom [ROOM NUMBER] was a work in progress. The ADM stated the broken tile, loose baseboard and uneven paint did not look good.
A request was made for the facility's policy and procedure and the facility did not provide one prior to the exit of the survey.
During review of the facility document titled Job Description . Maintenance Supervisor dated October 10, 1995, the Job Description indicated, . To ensure the building(s), equipment and utilities are maintained in good working order and facility grounds are properly maintained . Duties . Ensure equipment and work areas are clean, safe and orderly . and promptly address any hazardous conditions and equipment . Perform minor repairs and supervise the day-today repair, improvement and preventative maintenance of the building, equipment . may perform and supervise floor care .
2. During an observation on 5/10/21, at 3:54 p.m., in Bathroom [ROOM NUMBER], the soap dispenser was not functional. The handle on the soap dispenser was loose and there was no soap in the dispenser.
During an observation on 5/11/21, at 10:16 a.m , in Bathroom [ROOM NUMBER], the soap dispenser was not functional. The handle on the soap dispenser was loose and there was no soap in the dispenser.
During a concurrent observation and interview on 5/11/21, at 4:45 p.m., with CNA 3, in Bathroom [ROOM NUMBER], CNA 3 stated the soap dispenser did not work. CNA 3 stated there was no soap in the soap dispenser. CNA 3 stated the soap dispenser should have worked because she needed to wash her hands after providing residents with care. CNA 3 stated she needed soap to wash her hands to ensure she did not get an infection and protect herself and the residents in the facility.
During a concurrent observation and interview on 5/13/21, at 9:13 a.m., with CNA 7, in Bathroom [ROOM NUMBER], CNA 7 stated the soap dispenser did not work. CNA 7 stated the MAINT was notified the soap dispenser did not work. CNA 7 stated she verbally notified MAINT the soap dispenser did not work.
During a concurrent observation and interview on 5/13/21, at 9:29 a.m. with the MAINT, in Bathroom [ROOM NUMBER], the MAINT stated one of the facility supervisors should have notified him the soap dispenser did not work. The MAINT stated once he was notified, he would notify the housekeeping supervisor to order a new soap dispenser, and he would replace the broken soap dispenser. The MAINT stated he had not been notified the bathroom soap dispenser was broken. The MAINT stated he did not have a system in place for staff to let him know when items needed to be fixed in the facility.
During an interview on 5/13/21, at 10:38 a.m. with the MAINT, the MAINT stated he did not have a system in place for staff to notify him when items needed to be fixed in the facility. The MAINT stated he used to have an electronic record system for documenting preventative maintenance, but the system had not been working for the past three weeks.
A request was made for the facility's policy and procedure and the facility did not provide one prior to the exit of the survey.
During review of the facility document titled Job Description . Maintenance Supervisor dated October 10, 1995, the Job Description indicated, . To ensure the building(s), equipment and utilities are maintained in good working order and facility grounds are properly maintained . Duties . Ensure equipment and work areas are clean, safe and orderly . and promptly address any hazardous conditions and equipment . Perform minor repairs and supervise the day-today repair, improvement and preventative maintenance of the building, equipment . may perform and supervise floor care .
3. During a concurrent observation and interview on 5/11/21, at 10:04 a.m., with Resident 34, in Resident 34's room, a gap between the window and the window frame seal was observed. Resident 34 stated, It does not look good, I have to tell [MAINT], I told him long time ago. Resident 34 stated, . It's sealed on the outside, so no heat or air come in, but it does not look good.
During a concurrent observation and interview on 5/11/21, at 5:10 p.m., with the MAINT, in Resident 34's room, the MAINT stated the bedrail from Resident 34's bed had lifted the window frame. The MAINT stated he was not made aware of the gap between the window and the window frame. The MAINT stated the window seal should not have a gap because Resident 34 could get hurt by the wood and obtain a splinter and it was not safe. The MAINT provided measurements of the window gap, the measurements were measured 71 inches in length, five inches in width and the gap measure half inch.
During a concurrent observation and interview on 5/11/21, at 5:15 p.m. with the ADM, in Resident 34's room, the ADM stated the window gap should be fixed and the facility had not identified the gap because the environment was not a priority. The ADM stated his expectation was for MAINT to fix things in the facility. The ADM stated Resident 34's window should not have a gap because it was not a feature to have and needed to be fixed and it was not okay that it looked because it if was okay then MAINT would not have to fix the window gap.
A request was made for the facility's policy and procedure and the facility did not provide one prior to the exit of the survey.
During review of the facility document titled Job Description . Maintenance Supervisor dated October 10, 1995, the Job Description indicated, . To ensure the building(s), equipment and utilities are maintained in good working order and facility grounds are properly maintained . Duties . Ensure equipment and work areas are clean, safe and orderly . and promptly address any hazardous conditions and equipment . Perform minor repairs and supervise the day-today repair, improvement and preventative maintenance of the building, equipment . may perform and supervise floor care .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a baseline (starting point) care plan for one of six sample...
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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 baseline (starting point) care plan for one of six sampled residents (Resident 188), when Resident 188 did not have a care plan for hospice (care focuses on terminally ill patient's pain and symptoms and emotional and spiritual needs at the end of life) care within 48 hours of admission.
This failure had the potential to result in Resident 188's hospice needs to go unmet.
Findings:
During a review of Resident 188's admission Record (AR-document that gives a resident's information at a quick glance) dated 5/6/21, the AR indicated, .admission Date 05/01/2021 .Diagnosis Information .OTHER SEQUELAE (condition which is the consequence of a previous disease or injury) OF CEREBRAL INFARCTION (blockage in the brain) .
During a review of Resident 188's Order Summary Report undated, the Order Summary Report indicated, .Admit to [name of company] Hospice for Dx (diagnosis): End stage Sequelae of cerebral vascular . order date: 5/2/202 .
During a concurrent interview and record review on 5/12/21, at 2:51 p.m., with the Minimum Data Set (MDS- standardized clinical assessment of each resident's functional capabilities and health needs) nurse, the MDS nurse reviewed Resident 188's care plan dated 5/10/21. The MDS nurse stated the care plan was initiated on 5/10/21, the MDS nurse stated the care plan should have been initiated within 48 hours Resident 188 was admitted in the facility. The MDS nurse stated Resident 188 was admitted in the facility under hospice care on 5/1/21. The MDS nurse stated the care plan directed and guided the staff on the care necessary to take care of residents' needs.
During an interview on 5/13/21, at 1:10 p.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated baseline care plans were completed within 24 hours of admission. LVN 4 stated Resident 188's care plan for hospice should have been initiated within 24 hours of admission because Resident 188 was already under hospice care when admitted to the facility. LVN 4 stated the care plan was a very important tool because it directed staff on the interventions necessary to take care of Resident 188's needs.
During an interview on 5/18/21, at 10:11 a.m., with the Director of Nursing (DON), the DON stated baseline care plans were completed within 48 hours of admission. The DON stated Resident 188's care plan for hospice should have been initiated and completed within 48 hours of admission. The DON stated Resident 188 was admitted to the facility on [DATE] and was already on hospice. The DON stated Resident 188's hospice care plan should have been initiated within 48 hours of admission but was not.
During a review of the facility's policy and procedure titled, Care Planning Process dated 12/11/17, the policy and procedure indicated, .1. Upon admission to the center, a baseline care plan will be developed within 48 hours. 2. A written summary of the baseline care plan will be presented to the patient/resident and if applicable, the resident representative, before the comprehensive care plan is completed .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan for one of three sampled residents (Resident 187), when Resident 187's did n...
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Based on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan for one of three sampled residents (Resident 187), when Resident 187's did not have a care plan to address his hard of hearing and Resident 187's care plan for activities of daily living (ADL- routine activities people do every day without assistance. There are six basic ADLs: eating, bathing, getting dressed, toileting, mobility, and continence) was incomplete.
This failure had the potential to result in Resident 187's hard of hearing and ADL care needs to go unmet.
Findings:
During a concurrent observation and interview on 5/10/21, at 8:35 a.m., with Resident 187, Resident 187 was observed leaned forward to try to hear what was said. Res 187 stated he did not hear well from both ears. Resident 187 stated he had a hearing aid prior to admission to the facility on 4/29/21. Resident 187 stated he did not use his hearing aid because it make loud noises and it made him unable to hear what people said.
During a concurrent interview and record review on 5/12/21, at 9:15 a.m., with the Director of Social Services (DSS), the DSS stated Res 187 complained of hard of hearing to both ears since he was admitted to the facility. The DSS stated she did not check Res 187's hearing aid batteries to see if it worked. The DSS reviewed Resident 187's care plan and stated there was no care plan for hard of hearing. The DSS stated hard of hearing should have care planned, and it should have been individualized to the resident. The DSS stated, It was my responsibility to put together a care plan to address [Resident 187's] the hard of hearing. The DSS stated care plans were important because it guided staff on how to provide care to residents.
During a concurrent interview and record review on 05/12/21, at 2:57 p.m., with the Minimum Data Set (MDS) nurse, the MDS nurse reviewed Resident 187's clinical record titled, Care plans. The MDS nurse stated she did not find a care plan for hearing to address Resident 187's hard of hearing. The MDS nurse stated there should have been a care plan for hard of hearing. The MDS nurse reviewed Resident 187's care plan and stated Resident 187's care plan for ADL care was incomplete. The MDS nurse stated the ADL care plan should had been completed and individualized. The MDS nurse stated care plans were important because it directed and guided staff on taking care of residents' needs.
During an interview on 5/18/21 at 10:20 a.m., with the Director of Nursing (DON), the DON stated all care plans should be person-centered and individualized to residents' needs. The DON stated the nurse and/or the Interdisciplinary Team (IDT- approach involves team members from different disciplines working collaboratively, with a common purpose, to set goals, and make decisions and share sources and responsibilities) were responsible in creating a care plan, reviewing and revising the care plan as needed to fit residents' needs.
During a review of facility's policy and procedure titled, Care Planning Process dated 12/11/17, the policy and procedure indicated, .3. The comprehensive care plan will be developed by the interdisciplinary team that includes the attending physician, a member of nutritional services, an RN (registered nurse) and a can (certified nursing assistant) with responsibility for the patient/resident. The patient/resident and if applicable, the resident representative will be encouraged to participate in development of the care plan. 4. The care plan will be person-centered and incorporate the patient/resident's goals of care and treatment .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure professional standards of practice were impleme...
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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 professional standards of practice were implemented for two of two sampled residents (Resident 7 and Resident 20) when:
1. Resident 7 was provided a house supplement (beverage containing protein and other performance substances as ingredients mixed with milk or water for the purposes of improved nutrition) for weight loss and did not have a physician's order for a house supplement; and
2. Resident 20 suffered a fall on 2/12/21 and the licensed nurse on duty did not complete an assessment of Resident 20. Resident 20 had an x-ray (type of radiation called electromagnetic waves, creates pictures of the inside of your body, the images show the parts of the body in different shades of black and white to checking for broken bones) completed on 2/17/21 which indicated a fracture of the long middle finger.
These failures resulted in Resident 7 and Resident 20 not receiving professional care and presented with delayed treatment and care.
Findings:
1. During an observation on 5/10/21, at 12:16 p.m., in the dining room, Resident 7 was observed eating lunch. Resident 7 had gelatin, a sandwich that was cut into four pieces, potatoes and green beans on her plate. Resident 7 had a cup of coffee and a cup of water. Resident 7 notified the Infection Preventionist (IP) she was done eating and was not hungry.
During an observation on 5/10/21, at 12:24 p.m., in the dining room, the IP asked Resident 7 if she was done eating and Resident 7 stated Yes. The IP picked up Resident 7's plate and cups from the table.
During a review of Resident 7's Tray Card (TC) dated 5/10/21, the TC indicated, [Resident 7] .Diet Order: Finger Foods, Regular . Standing Orders: 1 . House Supplement .
During a concurrent interview and record review on 5/10/21, at 12:31 p.m., with the IP, Resident 7's TC dated 5/10/21 was reviewed. The IP stated she would assist in passing out meal trays in the dining room a couple of times a week. The IP stated she had worked in the facility for two years. The IP stated Resident 7 would come into the dining room every day to have lunch so staff could encourage her to eat due to weight loss. The IP stated on 5/10/21, she checked the lunch trays to ensure all items were provided to the residents in the dining before the trays were passed out to each resident. The IP stated she would check the lunch trays for consistency, correct food, and fluids. The IP stated Resident 7 did not receive the house supplement for lunch as indicated on the tray card. The IP stated she forgot to provide Resident 7 with the house supplement. The IP stated it was important for Resident 7 to have the house supplement because Resident 7 had recent weight loss. The IP stated the house supplement should have been provided to Resident 7 during lunch and Resident 7 did not eat her lunch on 5/10/21.
During a concurrent interview and record review on 5/12/21, at 2:51 p.m., with the IP, Resident 7's admission Record (AR) undated and Resident 7's Order Summary Report (OSR) dated 5/12/21 were reviewed. The IP stated Resident 7 was admitted on [DATE]. The IP reviewed the OSR and stated Resident 7 did not have a physician's order for the house supplement in the medical record. The IP stated the Dietary Service Manger (DSM) would generate the TC on a daily basis. The IP stated Resident 7 should have had a physician order for the house supplement.
During a concurrent interview and record review on 5/12/21, at 3:24 p.m., with the DSM, Resident 7's clinical record was reviewed. The DSM stated he had worked in the facility since March 2020. The DSM stated he generated and printed the tray cards daily. The DSM stated when there was a change in the residents' diet, the nurses would send him a communication slip with any changes in diet or when nutritional supplements were added or discontinued. The DSM stated a standing order was an order he would receive through the communication slip form the nurses. The DSM stated a diet change or house supplement required a physician order. The DSM stated the house supplement required a physician's order and had to be entered in the tray card as a standing order to ensure residents received the correct diet. The DSM reviewed Resident 7's tray card dated 5/12/21 and stated Resident 7 had a standing order for a house supplement. The DSM stated he was responsible to input the information onto the tray card and Resident 7 should have received a house supplement with her lunch on 5/10/21. The DSM stated Resident 7 had recent weight loss and the facility had ordered the house supplement. The DSM stated the house supplement was not provided to Resident 7 on 5/10/21 and should have been provided to Resident 7.
During an interview on 5/13/21, at 9:05 a.m. with the DSM, the DSM stated he was not able to locate Resident 7's communication slip for the house supplement.
During an interview and concurrent record review on 5/15/21, at 9:25 a.m. with the Director of Nursing (DON), Resident 7's clinical record was reviewed. The DON reviewed Resident 7's Progress Notes (PN) dated 4/22/21. Resident 7's PN indicated, Resident had weight loss 1.0 [pound times one week]. On regular texture diet, able to feed self with set up assistance . [Medical Director (MD)] gave order . house supplement between meals. This writer offered house supplement, resident states, I don't like any shakes and I will throw up. [MD] informed ok to [discontinue house supplement]. Resident, nurse on duty and dietary informed. The DON stated Resident 7 had weight loss of one pound. The DON stated on 4/22/21, Resident 7 was offered the house supplement, but she refused and the house supplement was discontinued on 4/22/21. The DON reviewed Resident 7's TC and stated a standing order on the tray card required a physician's orders and the house supplement should have been discontinued from the TC. The DON stated because the TC had a standing order for house supplement, it was required to have a physician order. The DON stated Resident 7 did not have an order for the house supplement, but the tray card indicated she had a standing order for the house supplement. The DON stated she put in the order for Resident 7's house supplement on 5/12/21. The DON reviewed the facility's policy and procedure (P&P) titled, Physician Orders undated. The DON stated per the facility's P&P, a house supplement required a physician's order if it was administered to Resident 7.
During a review of the facility's P&P titled, Physician Orders undated, the P&P indicated, To ensure the physician orders are obtained on admission, reviewed and transcribed, signed and filed appropriately . Physician's Orders: Obtain Physician's admission orders for the Resident's immediate care and treatment .orders . should include . diet, including nutritional supplements .
During a professional reference review titled, Lippincott Manual of Nursing Practice 10th Edition, dated 2014, pages 16-17 indicated, . Standards of Practice . General Principles . These standards describe what nursing is, what nurses do, and the responsibilities for which nurses are accountable . A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to a less than accurate recollection of the specific events . Common Departures from the Standards of Nursing Care . Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record, administer medications as ordered, and follow physician's orders that should have been questioned or not followed . Common Legal Claims for Departure from Standards of Care . Failure to implement a physician's . order properly . Failure to adhere to facility policy or procedural guidelines .
2. During an interview on 5/11/21, at 4:19 p.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated she worked in the facility for six months. CNA 3 stated she had worked with Resident 20 for about three months. CNA 3 stated she worked the evening shifts in the facility. CNA 3 stated Resident 20 was alert to self and able notify staff he needed to be changed or when he needed a shower. CNA 3 stated Resident 20 had suffered a fall in the shower room while she assisted Resident 20. CNA 3 was unable to recall the date Resident 20 fell in the shower room. CNA 3 stated the fall happened around 3:30 p.m. to 4 p.m. CNA 3 stated on the day of the fall, during the evening shift, Resident 20 sat on the shower chair, Resident 20 stood up, held on to the bar in the shower room and he slipped down towards wall and sat down on the floor. CNA 3 stated Resident 20 did not hit his head in the shower room. CNA 3 stated when Resident 20 fell down to the floor, she yelled for CNA 2's help. CNA 3 stated Resident 20 wanted to get up from the floor. CNA 3 stated CNA 2 assisted her (CNA 3) in helping Resident 20 to get up from the floor. CNA 2 stated Resident 20 stated he was not in pain and said, I need to get up. CNA 3 stated CNA 2 went to notify the licensed nurse on shift and the licensed nurse did not come to the shower room. CNA 3 stated she did not notify the licensed nurse Resident 20 had fallen. CNA 3 stated at the time of the fall Resident 20 did not have an injury because he did not complain of pain. CNA 3 stated three or four days later, Resident 20 had bruising to the right middle finger. CNA 3 stated when a resident suffered a fall, the CNAs had to call for help and the licensed nurse needed to assess the residents before the resident could be moved.
During an interview on 5/12/21, at 5:07 p.m., with CNA 2, CNA 2 stated she worked the day Resident 20 fell in the shower room. CNA 2 stated she was working across the shower where Resident 20 fell when she heard CNA 3 calling for help. CNA 2 stated when she entered the shower room, Resident 20 was on the floor. CNA 2 stated CNA 3 and she (CNA 2) attempted to get Resident 20 up from the floor. CNA 2 stated she looked out into the hallway and the licensed nurse was by room [ROOM NUMBER] giving medications. CNA 2 stated Resident 20 was attempting to stand up on his own and was transferred from the floor to the commode by CNA 3. CNA 2 stated she went to the licensed nurse and notified her Resident 20 had fallen in the shower room and the licensed nurse replied, OK, I will be there. CNA 2 stated the licensed nurse did not come in to assess Resident 20. CNA 2 stated the licensed nurse did not work in the facility anymore. CNA 2 stated she went back to the shower room to make sure Resident 20 and CNA 3 were okay and then she continued on with her duties. CNA 2 stated she wrote a statement of what occurred on the day of the fall and signed it. CNA 2 stated when a resident suffered a fall in the facility, one CNA had to stay with the resident and one CNA had to call the licensed nurse. CNA 2 stated when a resident suffered a fall, the licensed nurses in the facility would observe the resident and ask questions about pain, check for bruising and ask if the resident was hurt. CNA 2 stated CNA 3 and she (CNA 2) should have waited for the licensed nurse to assess Resident 20.
During an interview on 5/13/21, at 2:50 p.m., with the Nurse Consultant (NC), the NC stated she reviewed Resident 20's medical record and verified there was no nursing or progress notes from 2/10/21 to 2/12/21.
During a concurrent interview and record review on 5/15/21, at 8:51 a.m. with the DON, Resident 20's clinical record was reviewed. The DON reviewed the admission Record (AR) undated, the AR indicated Resident 20 was admitted on [DATE]. The DON reviewed Resident 20's Clinical Health Status (CHS) dated 12/28/2020, the CHS indicated, . low risk for falls . The DON stated Resident 20 suffered a fall in the shower room on 2/12/2021 but Resident 20's clinical record did not have a fall documented on 2/12/2021. The DON stated on 2/15/21 around 7 a.m. one of the licensed nurses notified her (DON) that Resident 20 had a bruise on his right hand. The DON stated she assessed Resident 20 and asked Resident 20 what happened. The DON stated Resident 20 notified her he had fallen on Friday (2/12/2021). The DON stated she started her investigation and interviewed staff. The DON stated CNA 3 was giving Resident 20 a shower when Resident 20 was holding on to the shower bar and lost his balance. The DON stated CNA 3 called for help, CNA 2 went to the shower room and CNA 2 and CNA 3 assisted Resident 20 to the chair. The DON stated Resident 20 had bruising to the right middle finger. The DON stated the physician was notified on 2/15/2021 and ordered application of ice, immobilization of the right hand and an x-ray of Resident 20's right hand. The DON stated the x-rays were completed on 2/15/21 and the x-rays were questionable, and the x-rays were repeated on 2/17/21.
During an interview on 5/15/21, at 9 a.m., with the Administrator (ADM), the ADM stated CNA 3 stayed with Resident 20 during the time of the fall on 2/12/21. The ADM stated CNA 2 went to call the nurse and returned to the shower room. The ADM stated after CNA 2 and CNA 3 assisted Resident 20 back to the chair, CNA 3 took Resident 20 back to his room. The ADM stated CNA 2 informed the licensed nurse who was working the evening shift. The ADM stated when he spoke to the licensed nurse, the licensed nurse stated she did not hear CNA 2 and CNA 3 call her. The ADM stated the licensed nurse received disciplinary actions for failure to assess after a fall.
During an interview on 5/15/21, at 9:05 a.m., with the DON, the DON stated she spoke to the licensed nurse and the licensed nurse stated she did not hear CNA 2 and CNA 3 calling her.
During a review of the facility's documented titled, 3 Step Employee Memorandum dated 2/18/2021, the 3 Step Employee Memorandum indicated, . As per staff discoloration to Residents [right] hand reported to charge nurse on 2/14/2021 after dinner. Fall on 2/12/2021 Fail to assess Resident .
During a review of Resident 20's Patient Report dated 2/17/21, the Patient Report indicated, . Right Hand . there is cortical (outer layer) irregularity about the base of the proximal phalanx (digital bones of the hand) of the long finger. Suspect nondisplaced fracture .
During a review of Resident 20's Progress Notes (PN) dated, 2/15/21 at 11:42 p.m., the PN indicated, CNA notify this writer 2/15/2021 about fall, per CNA .On Friday 2/12/2021 resident lost balance while in shower, ask the resident he have any pain but the residents denies any pain and discomfort at that time, but I forgot to report the nurse on that day [Physician] notified via fax and [responsible party] notified via phone .
During a concurrent interview and record review on 5/15/21, at 9:12 a.m., with the DON and the ADM, the ADM stated the interdisciplinary team (IDT- team consists of practitioners from different health professions, who have a shared patient. population and common patient care goals) met on 2/18/21. The DON reviewed Resident 20's PN dated 2/18/2021 at 4:32 p.m. The PN indicated, IDT review in attendance [DON . Infection Preventionist . ADM due to status post fall on 2/12/2021. Resident had finished with his shower in attendance of CNA, and while in shower room, CNA moved shower chair to dry area for dressing and to transfer to his [wheelchair]. CNA remained preset and assisted resident to stand using hand rail, resident lost balance and slid to the floor. CNA ensured resident safety then called or another staff member to assist. The other CNA went to shower room to help. CNA tried to get nurses attention at the same time. Resident denied pain and began to assist himself from sitting position on the floor, CNA assisted resident to stand and then sit on commode, directly next to him, CNA then transferred Resident to his [wheelchair] safely. Staff asked resident if has in any pain. Resident said, No, I'm okay. CNA observed No skin integrity issues including no immediate swelling or bruising, resident denies pain. On 2/15/2021 [morning] staff informed Resident has a dark purple discoloration to right hand middle fingers. [Licensed Nurse] completed a head to toe observation assessment, then notified [physician], a new order for x ray right hand. [Responsible party] son was informed . The DON stated the licensed nurse should have assessed Resident 20, notified the physician, and notified the family and place Resident 20 on alert charting for delayed trauma and monitoring for 72 hours. The DON stated Resident 20 should have been assessed by the licensed nurse. The DON stated the licensed nurse did not follow the facility's policies and procedures for fall prevention.
During a review of the facility's P&P titled, Fall Prevention and Fall Related Injury Management dated 4/11/17, the P&P indicated, . The care center will evaluate, treat, investigate and document fall incident investigations . Care and Documentation: 1. when a patient/resident fall occurs, the employee making the discovery immediately notifies the licensed nurse to conduct an appropriate evaluation, provide interventions and/or emergency care as needed. 2. Patient/resident fall incidents are reported to the attending physician and responsible party. Date, time and details are documented in the medical record. The licensed nurse will complete an SBAR/Change in Condition .
During a professional reference review titled, Lippincott Manual of Nursing Practice 10th Edition dated 2014, pages 16-17 indicated, . Standards of Practice . General Principles . These standards describe what nursing is, what nurses do, and the responsibilities for which nurses are accountable . A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to a less than accurate recollection of the specific events . Common Departures from the Standards of Nursing Care . Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record, administer medications as ordered, and follow physician's orders that should have been questioned or not followed . Common Legal Claims for Departure from Standards of Care . Failure to implement a physician's . order properly . Failure to adhere to facility policy or procedural guidelines .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
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 care and services to ensure a reside...
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 necessary care and services to ensure a resident's abilities of daily living did not diminish for two of twelve sampled residents (Resident 5 and Resident 29) when:
1. Resident 5 requested a grooming services for a haircut from staff and there was not staff available to provide him with a haircut; and
2. Resident 29's Restorative Nurse Assistant (RNA-helps residents gain/improve strength and mobility) exercises and ambulation were not provided per the physician's order.
These failures resulted in Resident 5 expressing and verbalizing not liking his long hair on multiple occasions and had the potential for Resident 29 to decline in her ability to carry out activities of daily living (ADL-skills required to manage one's basic physical needs including personal hygiene or grooming, dressing, toileting , transferring or ambulating, and eating), strength, and mobility.
Findings:
During a concurrent observation and interview on 5/10/21, at 8:10 a.m., in Resident 5's room, Resident 5's hair was uncombed. Resident 5 stated his hair was long and he needed a haircut.
During an interview on 5/11/21, at 3:11 p.m., with Family Member (FM) 1, FM 1 stated they would like for Resident 5 to get a haircut.
1. During an interview on 5/12/21, at 12:18 p.m., with Certified Nursing Assistant (CNA) 7, CNA 7 stated she had worked in the facility for four and a half years. CNA 7 stated Resident 5 was admitted to the facility on [DATE]. CNA 7 stated before the COVID-19 (infection symptoms can be serious, leading to pneumonia and in some cases death) pandemic, the facility had a beautician (a person whose job is to do hair styling, manicures, and other beauty treatments). CNA 7 stated a month ago, the beautician returned to the facility and the beautician refused to do a rapid test (detects protein fragments specific to the Coronavirus) before coming into the building and was not allowed to come into the facility. CNA 7 stated Resident 5 had been asking for a haircut for about a month. CNA 7 stated Resident 5 had complained his hair was long and wanted to go to the parlor. CNA 7 stated Resident 5 constantly talked about getting a haircut because his hair was long. CNA 7 stated she notified the Director of Social Services (DSS) that Resident 5 wanted a haircut.
During a concurrent interview on 5/12/21, at 4:19 p.m., with the Administrator (ADM) and Nurse Consultant (NC), the NC stated the facility did not have a policy and procedure for grooming (things that people do to keep themselves clean and make their face, hair, and skin look nice) of residents in the facility.
During an interview on 5/12/21, at 4:43 p.m., with the Director of Nursing Services (DON), the DON stated the facility did not have a beautician due to the COVID-19 pandemic. The DON stated the beautician came to the facility about a month ago and she refused to get tested for COVID-19. The DON stated she would like for someone to come to the facility to provide grooming services. The DON stated families could bring their own beauticians, but the requirements was for the beautician to be vaccinated for COVID-19. The DON stated if the DSS was aware of Resident 5 requesting a haircut, his [Resident 5's] needs should have been accommodated. The DON stated Resident 5's needs for grooming had not been communicated to her.
During a concurrent observation and interview on 5/13/21, at 9:15 a.m., with Resident 5, in Resident 5's room, Resident 5 stated I never let my hair grow this long. I like it short.
During an interview and record review on 5/13/21, at 11:10 a.m., with the DSS, the facility's policy and procedure (P&P) titled, Preservation of Resident Rights undated was reviewed. The DSS stated Resident 5 should not be worried about getting a haircut. The DSS stated she was not aware Resident 5 had requested a haircut. The DSS stated she would observe residents' grooming and personal care, but did not look at Resident 5's hair. The DSS stated she was aware Resident 5's hair was long, but she never removed his hat or asked him about his care. The DSS reviewed the P&P Preservation of Resident Rights and stated part of her role was to look at the residents in the facility and be involved in the personal care, address the residents' concerns, and find a solution.
During an interview on 5/19/21, at 8:51 a.m., with the ADM, the ADM stated the facility had a beautician come to the facility about a month ago but the beautician was not vaccinated for COVID-19 and refused to get a COVID-19 rapid test. The ADM stated because the beautician was required to be closer than six feet to the residents, she was not allowed to come in to the facility. The ADM stated, Yes, I knew he [Resident 5] wanted a haircut . The ADM stated Resident 5's family had to take him to get a haircut. The ADM stated the facility reached out to a sister facility and had set up for the beautician to come into the facility.
During a review of the facility's P&P titled, Preservation of Resident Rights undated, the P&P indicated, . The Social Services staff will promote and advocate the preservation of all resident rights The social services staff will take an active role in training employees and monitoring practice on issues regarding residents . personal care .
2. During a review of Resident 29's admission Record, dated 5/12/21, the admission Record indicated Resident 29 was admitted to the facility on [DATE] with diagnoses that included, . Fusion of Spine, Cervicothoracic Region (surgical procedure performed through the back of the neck, involves joining two or more damaged cervical vertebrae[neck bones]), hypertension (high blood pressure) and muscle weakness .
During a review of Resident 29's clinical record titled, Functional Maintenance Program Training, dated 12/23/20, the Functional Maintenance Program Training indicated, .RNA Program 3Xweek (three times per week) for 90 days .3. Bilateral (both sides) Lower Extremities (BLE) therapy exercises active range of motion (AROM) 3X10 . 4. Gait training front wheel walker (FWW) when patient can put shoes on .
During a concurrent observation and interview on 5/10/21, at 12:02 p.m., with Resident 29 in his room, resident sat at the edge of his bed. Resident 29 stated he used to be able to walk using a walker, but not anymore. Resident 29 stated during the COVID-19 pandemic, no one walked him. Resident 29 stated he wanted to get therapy to walk again.
During a concurrent observation and interview on 5/13/21, at 9:17 a.m., with Resident 29 in his room, Resident 29's legs were swollen. Resident 29 stated, My legs are swollen because they are not walking me. Resident 29 stated prior to the COVID-19 pandemic, he was able to walk to the front door without stopping and only used a walker. Resident 29 stated before the COVID-19 pandemic, the RNA used to walk him three times a week. Resident 29 stated, Certified Nurse Assistant (CNA) 10/Restorative Nurse Assistant (RNA)2 tried to find time to walk Resident 29 but she was busy all the time. Resident 29 stated he sits on his wheelchair all day.
During a concurrent interview and record review on 5/13/21, at 1:52 p.m., with CNA 10/RNA 2, CNA 10/RNA 2 stated she worked as RNA between 11 a.m., to 11:30 a.m. and 1:30 p.m., to 5 p.m. CNA 10/RNA 2 stated she worked with Resident 29 when he was first admitted in the facility. CNA 10/RNA 2 stated Resident 29 walked using a four-wheel walker with assistance. CNA 10/RNA 2 stated she did not work with Resident 29 during the COVID-19 pandemic. CNA 10/RNA 2 stated she remembered physical therapist (PT) worked with Resident 29 after Resident 29 was cleared from COVID-19 infection, but did not know how long PT worked with him. CNA 10/RNA 2 stated she remembered working with Resident 29 after PT worked with him. CNA 10/RNA 2 reviewed the RNA notes to show the minutes RNA worked with Resident 29, but unable to find documentation. CNA 10/RNA 2 stated she should have documented when she worked with Resident 29, but she did not. CNA 10/RNA 2 stated she did not remember discussing Resident 29's decline in function and mobility with the charge nurse, PT or occupational therapist (OT). CNA 10/RNA 2 stated she should have reported it to charge nurse and/or therapist.
During a concurrent interview and record review on 5/14/21, at 11:47 a.m., with the Director of Rehabilitation (DOR), the DOR stated she had only been in her position for three weeks. The DOR reviewed therapy orders for Resident 29 and stated Resident 29 worked with PT for one week in 7/2020 and improved. The DOR stated Resident 29 was diagnosed with COVID-19 back in 12/2020 and was weak and declined with all his mobility and function. The DOR stated therapy should have worked with Resident 29 after he (Resident 29) was cleared from COVID-19 infection to help with the decline in function and mobility.
During a concurrent interview and record review on 5/19/21, at 8:22 a.m., with the Minimum Data Set Coordinator (MDSC), the MDSC reviewed Resident 29's clinical record titled MDS section G (Functional Status) dated 10/10/20, and MDS section G dated 4/13/21. The MDSC stated there was a decline in the function and mobility of Resident 29. MDSC stated Resident 29 was COVID-19 positive on 12/27/20 and was cleared from isolation on 1/18/21. The MDSC stated he was not sure whether Resident 29 was referred for therapy after Resident 29 cleared of COVID-19 infection.
During an interview on 5/19/2, at 10:21 a.m., with the DON, the DON stated, .During COVID-19 pandemic everything stopped, including RNA. The DON stated she did not know if Resident 29's decline was communicated to nursing and therapy.
During an interview on 5/19/21, at 10:52 a.m., with the ADM, the ADM stated Resident 29 wanted therapy and was given therapy but did not have documentation to show Resident 29 worked with therapist.
During a review of the facility's document titled, Nurse Assistant Restorative undated, the document indicated, .We provide both short-term rehabilitation and long-term care at the highest professional standards, along with comprehensive skilled nursing and progressive treatment plans promoting quality care that inspires our patients positively. An interdisciplinary care team made up of nursing staff .develop and customized plan of care that addresses the specific care needs and therapy goals necessary for the resident to reach their personal goals .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0678
(Tag F0678)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to implement and maintain a safe environment with an effective infection prevention and control program for the prevention of Co...
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Based on observation, interview, and record review, the facility failed to implement and maintain a safe environment with an effective infection prevention and control program for the prevention of Corona Virus (COVID-19- a contagious serious respiratory infection transmitted from person to person) transmission when one of one sampled Licensed Vocational Nurses (LVN 4) did not follow the use of a fit tested (a fit test determines if a tight-fitting respirator can be worn without having any leaks) N95 respirator (protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) when caring residents identified as PUI (person under investigation- someone on observation for symptoms of COVID-19 [a serious respiratory illness caused by a virus which is the cause of a current worldwide pandemic [prevalent over a whole country or the world]) COVID-19.
This practice potentially placed the residents and staff at risk for the spread and transmission of COVID-19, complications from COVID -19 and death.
Findings:
During a concurrent observation and interview, on 5/15/21, at 7:08 a.m., with Licensed Vocational Nurse (LVN) 4, during a medication pass observation in the PUI zone, LVN 4 was observed wearing a surgical mask under an N95 respirator. LVN 4 stated she had been fit tested for an N95 respirator. LVN 4 stated she wore a surgical mask underneath the N95 respirator because she would remove the N95 respirator in the resident's room and she would have a surgical mask on. LVN 4 stated she would continue to wear same surgical mask when she stepped outside the room.
During an interview on 5/15/21, at 10:02 a.m., with the Infection Preventionist (IP), the IP stated she did not conduct fit testing in the facility. The IP stated the previous IP conducted the fit testing of N95 respirators.
During a concurrent interview and record review on 5/15/21, at 10:08 a.m., with the IP, the [Skilled Nursing Facility] ALL STAFF In-Service dated 4/28/21 was reviewed. The IP stated she conducted an in-service on the topic, Yellow zone observation, donning (putting on) doffing (taking off) Personal Protective Equipment (PPE-equipment worn to minimize exposure to hazards that cause serious workplace injuries), Hand washing, [no return demonstration]. The IP stated she educated the staff how to don and doff PPE. The IP stated staff should don PPE by performing hand washing, putting on a gown, putting on an N95 respirator, goggles and gloves outside the room. The IP stated staff should doff PPE by removing the gloves, then the gown, then goggles, the N95 respirator, perform hand hygiene and put on a surgical mask. The IP stated she provided the staff education on removing the surgical mask prior to donning an N95 respirator. The IP stated staff should not be going into the room with two masks and it was not okay to have a surgical mask under an N-95 respirator. The IP stated she did not have staff do a return demonstration to validate for competency.
During a review of the facility's document titled, Using Personal Protective Equipment (PPE) dated 4/23/21, indicated, Who Needs PPE .Healthcare personnel should adhere to Standard and Transmission-based Precautions when caring for patients with SARS-cov-2 infection . 1. Identify and gather the proper PPE to don. Ensure choice of gown size is correct (based on training) 2. Perform hand hygiene using hand sanitizer. 3. Put on isolation gown. Tie all of the ties on the gown. Assistance may be needed by other healthcare personnel. 4. Put on NIOSH-approved N95 filtering facepiece respirator or higher (use a facemask if a respirator is not available). If the respirator has a nosepiece, it should be fitted to the nose with both hands, not bent or tented. Do not pinch the nosepiece with one hand. Respirator/facemask should be extended under chin. Both your mouth and nose should be protected. Do not wear respirator/facemask under your chin or store in scrubs pocket between patients. Respirator: Respirator straps should be placed on crown of head (top strap) and base of neck (bottom strap). Perform a user seal check each time you put on the respirator. Facemask: Mask ties should be secured on crown of head (top tie) and base of neck (bottom tie). If mask has loops, hook them appropriately around your ears. 5. Put on face shield or goggles. When wearing an N95 respirator or half facepiece elastomeric respirator, select the proper eye protection to ensure that the respirator does not interfere with the correct positioning of the eye protection, and the eye protection does not affect the fit or seal of the respirator. Face shields provide full face coverage. Goggles also provide excellent protection for eyes, but fogging is common. 6. Put on gloves. Gloves should cover the cuff (wrist) of gown. 7. Healthcare personnel may now enter patient room
During a professional reference review retrieved from https://www.cdc.gov/niosh/docs/2010-133/pdfs/2010-133.pdf titled How to Properly Put on and Take off a Disposable Respirator undated, indicated, WASH YOUR HANDS THOROUGHLY BEFORE PUTTING ON AND TAKING OFF THE RESPIRATOR. If you have used a respirator before that fit you, use the same make, model and size. Inspect the respirator for damage. If your respirator appears damaged, DO NOT USE IT. Replace it with a new one. Do not allow facial hair, hair, jewelry, glasses, clothing, or anything else to prevent proper placement or come between your face and the respirator. Follow the instructions that come with your respirator . Employers must comply with the OSHA Respiratory Protection Standard, 29 CFR 1910.134 if respirators are used by employees performing work-related duties
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to make information available for three of seven sampled residents (Residents 23, 25 and 29) when residents were unaware of how t...
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Based on observation, interview and record review, the facility failed to make information available for three of seven sampled residents (Residents 23, 25 and 29) when residents were unaware of how to file a grievance or complaint.
This failure had the potential to result in Resident 23, 25 and 29 to have their concerns or grievances unaddressed.
Findings:
During an interview on 5/12/21, at 10:20 a.m., with Resident 23, Resident 23 stated the Director of Social Services (DSS) was the grievance official. Resident 23 stated, I do not know how to file a grievance .
During a review of Resident 23's Minimum Data Set (MDS) assessment (an evaluation used to identify resident care needs), dated 3/29/21, the MDS assessment indicated, Resident 23 was cognitively intact with a Brief Interview for Mental Status (BIMS) (an evaluation of attention, orientation and memory recall) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment).
During an interview on 5/12/21, at 10:30 a.m., with Resident 29, Resident 29 stated, I don't know how to file a grievance on a form . Resident 29 stated he would notify staff if he had a complaint but had not filed a formal grievance.
During a review of Resident 29's MDS assessment, dated 4/13/21, the MDS assessment indicated, Resident 29 was cognitively intact with a BIMS score of 15.
During an interview on 5/12/21, at 10:36 a.m. with Resident 25, Resident 25 stated, I have not filed a grievance. I don't know to file a grievance. Resident 25 stated the facility should have forms to fill out but he did not know where the forms were located.
During a review of Resident 25's MDS assessment, dated 4/9/21, the MDS assessment indicated, Resident 25 was moderately impaired with a BIMS score of 10.
During a concurrent interview and record review on 5/13/21, at 11:18 a.m., with the DSS, the grievance folder was reviewed. The DSS stated residents in the facility could file a complaint or grievance regarding concerns with care or lost items. The DSS stated a complaint or grievance could be brought to her attention by the nurses and she would follow up with the residents. The DSS stated complaints could be made verbally to her by staff and the residents. The DSS stated when verbal complaints were brought up to her, she did not file the complaint on the grievance form. The DSS stated she should document the complaints on the grievance form. The DSS stated she would keep the grievance forms in a binder, and she would keep the binder in her office. The DSS reviewed the grievance folder and stated for the months of April 2021 and May 2021, there were no grievances filed. The DSS stated the previous DSS trained her on how to file a grievance, what a grievance was, the process to file a grievance and making sure the grievance or complaint was resolved. The DSS stated she placed the grievance forms outside of her office near the back of the building. The DSS stated she did not notify the residents where the forms were located and she should have notified the residents so residents were aware of how to locate the grievance forms and their right to file a grievance. The DSS stated she had not documented grievances or complaints and would address the concerns with the residents but did not have documentation. The DSS stated the grievance forms should be located in the nurse's station but was unsure if the grievance forms were located in the nurse's stations.
During a concurrent observation and interview on 5/14/21, at 4:53 p.m., with the Director of Nursing (DON), the DON stated the grievance forms were located outside of the DSS' office towards the back of the facility.
During a concurrent observation and interview on 5/14/21, at 4:55 p.m., with Licensed Vocational Nurse (LVN) 1 and Medical Records (MR), in the nurse's station, LVN 1 and the MR were unable to locate a grievance form.
During an interview on 5/14/21, at 5:29 p.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated she did not know what a grievance form was and did not know where to locate a grievance form if a resident asked for a grievance form. CNA 3 stated she would not be able to help a resident file a grievance forms if requested.
During a concurrent interview on 5/15/21, at 9:51 a.m., with the DON and the Administrator (ADM), the DON was unable to name the grievance official. The ADM stated the DSS was the grievance official and she was responsible to follow up with the grievance forms.
During a review of the facility's document titled, Resident Grievance/Complaint Procedures, undated, the facility document indicated, .A resident . may file a verbal or written grievance or complaint concerning, treatment, abuse, neglect, harassment, medical care, behavior of other residents or staff members . You are requested to follow the procedures outlined below when filing a written grievance or complaint: 1. Obtain a Resident Grievance/Complaint Form from the nurses' station or from outside the Social Services office. It is the policy of the facility to assist you in filing a grievance or complaint as needed . 4. Give the completed form to the Grievance Official. If the Grievance Official is not available you may leave the form with the supervisor on duty . 8. Grievance Official contact information: Name: [Administrator] .
During a review of the facility's policy and procedure (P&P) titled, [Skilled Nursing Facility] Grievance Policy, dated 5/14/17, the P&P indicated, . A resident will be notified individually or through postings in prominent locations throughout the care center of: The right to file a grievance orally (meaning spoken) or in writing . A Grievance Official will: Oversee the grievance process . Receive and track grievances through their conclusion .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
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 Minimum Data Set (MDS-a resident assessment...
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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 used to identify resident care needs) assessment accurately reflected the resident's current status for three of three sampled residents (Residents 5, 13, and 39) when:
1. Resident 5's MDS assessment of hearing and cognition were not coded accurately;
2. Resident 13's dialysis (use of machine to remove wastes from the body and keep body in balance) status was not coded (a system of signals used to represent letters or numbers in transmitting messages) accurately in Section O (Special Treatments, Procedures, and Programs) of the MDS assessment; and
3. Resident 39's MDS assessment for identification information was not coded accurately to indicate the accurate discharge status.
These failures had the potential of the facility to not provide the necessary care and services to meet the residents' individualized needs.
Findings:
1. During a concurrent observation and interview on 5/10/21, at 8:15 a.m., with Resident 5, in Resident 5's room, Resident 5 was hard of hearing and did not have hearing aids in his ears.
During an interview on 5/11/21, at 9:40 a.m., with Resident 5, Resident stated he did not have hearing aids because the hearing aids were at home.
During an interview on 5/12/21, at 12:24 p.m., with Certified Nursing Assistant (CNA) 7, CNA 7 stated Resident 5 was heard of hearing because when she talked to him while standing at the foot of his bed, Resident 5 could not hear her. CNA 7 stated Resident 5 did not have hearing aids.
During a review of Resident 5's MDS assessment .Section B Hearing, Speech and Vision dated 2/19/21, the MDS assessment, Section B indicated, Ability to hear (with hearing aid or hearing appliances if normally used): Adequate-no difficulty in normal conversation, social interaction, listening to TV .
During a review of Resident 5's MDS assessment Section C Cognitive Patterns dated 2/19/21, the MDS assessment, Section C Cognitive Patterns was blank.
During a review of Resident 5's Care Plan (CP), dated 2/15/21, the CP indicated, Focus: Impaired Communication due to . [diagnosis] of hearing loss bilateral (both sides) .
During a review of Resident 5's admission Record (AR- document that gives a resident's information at a quick glance), undated, the AR indicated, . admission Date: 2/12/2021 . Diagnosis Information . Unspecified Hearing Loss, Bilateral . Onset Date: 2/12/2021 .
During a concurrent interview and record review on 5/13/21, at 1:43 p.m. with the Director of Staff Development (DSD) and the Minimum Data Set Consultant (MDSC), Resident 5's MDS assessment Section B and Section C dated 2/19/21 were reviewed. The MDS assessment Section B indicated, Ability to hear (with hearing aid or hearing appliances if normally used): Adequate-no difficulty in normal conversation, social interaction, listening to TV . The MDS assessment Section C was blank. The DSD stated she had been working in the facility for one year. The MDSC stated he had been helping the facility to complete the MDS assessments since March 2021 and was training the DSD on MDS assessment completion. The DSD stated she started in April 2021 as the MDS assessment nurse. The MDSC stated he reviewed Resident 5's medical record and the nurse's documentation to determine Resident 5 hearing status. The MDSC stated Resident 5 was admitted with hearing loss. The MDSC stated hard of hearing indicated, . loss where they may be enough residual hearing . The MDSC stated Resident 5 had a communication deficit and bilateral hearing loss. The MDSC stated he co-signed the hearing assessment on 3/13/21 as adequate. The MDSC stated he did not assess Resident 5's hearing status and coded the assessment for hearing as adequate. The DSD stated Resident 5's BIMS was not assessed on 2/19/21 and the assessment was blank. The MDSC stated the Resident 5's BIMS assessment was blank because staff had not completed the assessment. The MDSC stated the BIMS assessment should be completed upon admission, quarterly and annually. The MDSC stated Resident 5's BIMS (Brief Interview for Mental Status-an evaluation of attention, orientation and memory recall) assessment was missed.
During a review of the facility's policy and procedure (P&P) titled, [Resident Assessment Instrument (RAI) Process .Clinical Assessment and Reimbursement dated 8/20/15, the P&P indicated, .All Living Centers will utilize the CMS (Centers for Medicare and Medicare Services- federal agency that administers the nation's major healthcare programs) regulations which are considered the definitive source in completion of the [Resident Assessment Instrument] process. This include coding the MDS, completion of Care Area Assessments (CAA's) and the development of the comprehensive plan of care . All Living Centers will utilize the CMS RAI Manual for completion and compliance of the RAI Process .
During a review of the Centers for Medicare & Medicaid Services, Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1 October 2019. The RAI process indicated, . 1. the assessment accurately reflects the resident's status .In addition, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident ' s medical record, physician, and family, guardian, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident ' s actual status was during that observation period) by the IDT completing the assessment .
2. During a concurrent observation and interview on 5/10/21, at 8:30 a.m., with Resident 13, Resident 13 sat in his wheelchair inside his room. Resident 13 had an elastic bandage on his right arm. Resident 13 stated he had a fistula (a connection that's made between an artery and a vein for dialysis access) on his right arm for dialysis. Resident 13 stated, I have been going to dialysis for years and I go to Fresno every Tuesdays, Thursdays and Saturdays.
During a review of Resident 13's AR, the AR dated 4/27/21, indicated, . admission Date 2/22/21 . Diagnosis Information . End Stage Renal Disease (Kidney function declined that kidney function can no longer function on their own) . Dependence on Renal Dialysis .
During a concurrent interview and record review on 5/12/21, at 9:40 a.m., with the MDS nurse, the MDS nurse reviewed the MDS Section O of Resident 13's five day MDS assessment dated [DATE]. The MDS nurse stated Resident 13's dialysis was not coded in Section O. The MDS nurse stated MDS Section O, Dialysis was coded as No, the MDS nurse stated the MDS assessment should have been coded as Yes because Resident 13 received dialysis prior to admission in the facility and while Resident 13 was a resident in the facility. The MDS nurse stated Resident 13's dialysis status was not accurately assessed and should have been.
During an interview on 5/18/21, at 10:11 a.m., with the Director of Nursing (DON), the DON stated she expected the MDS assessments to be accurate. The DON stated Resident 13 was already receiving dialysis prior to his admission in the facility and continued to receive dialysis while a resident in the facility. The DON stated Resident 13's MDS assessment should have been accurately assessed and coded in the MDS assessment section O.
During a review of the facility's P&P titled, RAI Process .Clinical Assessment and Reimbursement dated 8/20/15, the P&P indicated, .All Living Centers will utilize the CMS (Centers for Medicare and Medicare Services- federal agency that administers the nation's major healthcare programs) regulations which are considered the definitive source in completion of the [Resident Assessment Instrument] process. This include coding the MDS, completion of Care Area Assessments (CAA's) and the development of the comprehensive plan of care . All Living Centers will utilize the CMS RAI Manual for completion and compliance of the RAI Process .
During a review of the Centers for Medicare & Medicaid Services, Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1 October 2019. The RAI process indicated, . 1. the assessment accurately reflects the resident's status .In addition, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident ' s medical record, physician, and family, guardian, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident ' s actual status was during that observation period) by the IDT completing the assessment .
3. During a review of Resident 39's AR undated, the AR indicated, . admission Date 2/14/2021 .
During a review of Resident 39's Progress Notes (PN), dated 3/12/21, the PN indicated, . Resident discharged today home [at] 11:15 a.m. with home health [physical therapy occupational therapy and nursing .]
During a review of Resident 39's MDS assessment .Section A dated 3/12/21, the MDS assessment, Section A indicated, . Discharge Status .Acute Care Hospital .
During a concurrent interview and record review on 5/13/21, at 2:16 p.m., with the DSD and the MDSC, Resident 39's AR undated and MDS assessment, Section A dated 3/12/21 were reviewed. The MDSC stated Resident 39 was admitted to the facility on [DATE] and discharged home on 3/12/21. The MDSC stated the MDS assessment, Section A indicated Resident 39 was discharged to the acute care hospital. The MDSC stated the discharge status was inaccurate and the assessment should have indicated Resident 39 was discharged to the community. The MDSC and DSD stated Resident 39's MDS assessment was inaccurate. The DSD stated she completed Resident 39's discharge assessment and the assessment was inaccurate. The MDSC stated it was important to have accurate assessment information for the residents in the facility because the Centers for Medicare and Medicaid (CMS- federal agency that administers the nation's major healthcare programs) would review the information and would track the information.
During an interview on 5/19/21, at 9:01 a.m., with the Administrator (ADM), the ADM stated the facility had a Minimum Data Set Coordinator in August 2020. The ADM stated the facility had received assistance from other facilities to conduct the MDS assessments since August 2020. The ADM stated the MDSC was training the DSD to complete MDS assessments. The ADM stated the MDSC would come to the facility to assist in MDS assessment completion two to three days a week. The ADM stated his expectation was for the MDSC to come into the building and complete the assessments onsite.
During an interview on 5/19/21, at 9:04 a.m., with the DON, the DON stated the MDSC and the DSD should complete accurate assessments for the residents in the facility because the information was transferred to CMS. The DON stated the expectation for the MDSC and DSD was to complete accurate assessments.
During a review of the facility's P&P titled, RAI Process . Clinical Assessment and Reimbursement . dated 8/20/15, the P&P indicated, Living Centers adhere to all CMS regulations which are considered the definitive source in completion of the [Resident Assessment Instrument] process. This include coding the MDS, completion of Care Area Assessments (CAA's) and the development of the comprehensive plan of care . All Living Centers will utilize the CMS RAI Manual for completion and compliance of the RAI Process .
During a review of CMS's RAI Version 3.0 Manual Version 1.17.1 dated October 2019, indicated, Chapter 3 Section A OBRA Discharge Status . Steps for Assessment 1. Review the medical record including the discharge plan and discharge orders for documentation of discharge location . Code . 1, community (private home . if discharge location is a private home . Section B: Hearing .Problems with hearing can contribute to sensory deprivation, social isolation, and mood and behavior disorders. Unaddressed communication problem related to hearing impairment can be mistaken for confusion or cognitive impairment . Steps for assessment 1. Ensure that the resident is using his or her normal hearing appliance if they have one . 2. Interview the resident and ask about hearing function in different situations (e.g. hearing staff members, talking to visitors, using telephone, watching TV, attending activities). 3. Observe the resident during your verbal interactions and when he or she interacts with others throughout the day. 4. Think through how you can best communicate with the resident. For example, you may need to speak more clearly, use a louder tone, speak more slowly or use gestures. The resident may need to see your face to understand what you are saying, or you may need to take the resident to a quieter area for them to hear you. All of these are cues that there is a hearing problem. 5. Review the medical record. 6. Consult the resident's family, direct care staff, activities personnel, and speech or hearing specialists. Code 0, adequate: No difficulty in normal conversation, social interaction, or listening to TV. The resident hears all normal conversational speech and telephone conversation and announcements in group activities. Code 1, minimal difficulty: Difficulty in some environments (e.g., when a person speaks softly or the setting is noisy). The resident hears speech at conversational levels but has difficulty hearing when not in quiet listening conditions or when not in one-on-one situations. The resident's hearing is adequate after environmental adjustments are made, such as reducing background noise by moving to a quiet room or by lowering the volume on television or radio. Code 2, moderate difficulty: Speaker has to increase volume and speak distinctly. Although hearing-deficient, the resident compensates when the speaker adjusts tonal quality and speaks distinctly; or the resident can hear only when the speaker's face is clearly visible. Code 3, highly impaired: Absence of useful hearing. The resident hears only some sounds and frequently fails to respond even when the speaker adjusts tonal quality, speaks distinctly, or is positioned face-to-face. There is no comprehension of conversational speech, even when the speaker makes maximum adjustments . Section C: Cognitive Patterns . Steps for Assessment: Basic Interview Instructions for BIMS 1.Refer to Appendix D for a review of basic approaches to effective interviewing techniques. 2. Interview any resident not screened out by Should Brief Interview for Mental Status Be Conducted? (Item C0100). 3. Conduct the interview in a private setting. 4. Be sure the resident can hear you. Residents with hearing impairment should be tested using their usual communication devices/techniques, as applicable . Planning for Care o
The BIMS is a brief screener that aids in detecting cognitive impairment. It does not assess all possible aspects of cognitive impairment. A diagnosis of dementia should only be made after a careful assessment for other reasons for impaired cognitive performance. The final determination of the level of impairment should be made by the resident's physician or mental health care specialist; however, these practitioners can be provided specific BIMS results and the following guidance: The BIMS total score is highly correlated with Mini-Mental State . scores. Scores from a carefully conducted BIMS assessment where residents can hear all questions and the resident is not delirious suggest the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
During an observation, interview, and record review the facility failed to provide an ongoing activities program for three of seven sampled residents (Residents 1, 11, and 23) when the facility did no...
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During an observation, interview, and record review the facility failed to provide an ongoing activities program for three of seven sampled residents (Residents 1, 11, and 23) when the facility did not support residents in their choice of activities.
This failure had the potential to result in Resident 1, 11, and 23 being bored and verbalizing the facility did not have activities to do daily.
Findings:
During an interview on 5/11/21, at 2:58 p.m., with Certified Nursing Assistant (CNA) 4, CNA 4 stated the Activities Director (AD) was on leave. CNA 4 stated she was the Activities Assistant (AA). CNA 4 stated the AD was to come back after her leave but had not returned. CNA 4 stated she had been working in the facility since June 2019. CNA 4 stated she started doing activities in June 2020.
During a concurrent observation and interview on 5/11/21, at 3:21 p.m., with CNA 4, in the hallway, a calendar dated May 2021 was reviewed. CNA 4 stated she would follow the calendar as scheduled. CNA 4 stated on 5/11/21 at 1 p.m. Aroma Therapy was scheduled. CNA 4 stated she did not do the Aroma Therapy activity because she was completing her documentation. CNA 4 stated Aroma Therapy included using different lotions on hands so the residents could have an activity to do. CNA 4 stated she worked in the facility part time and would document in the Activity Attendance Record the days she completed activities.
During an interview on 5/12/21, at 10:20 a.m., with Resident 23, Resident 23 stated the facility had an activities calendar outside of the dining room in the hallway. Resident 23 stated the facility did not have ongoing activities as scheduled on the calendar. Resident 23 stated the facility used to provide popcorn and movies. Resident 23 stated he enjoyed looking at the board, but the activities would not occur. Resident 23 stated for the month of April 2021 and May 2021 the same activities were scheduled. Resident 23 stated the facility did not have an Activities Director (AD) because she was on leave. Resident 23 stated CNA 4 would come into the facility once or twice per week to do activities and no one else in the facility would do activities.
During a review of Resident 23's Minimum Data Set (MDS) assessment (an evaluation used to identify resident care needs), dated 3/29/21, the MDS assessment indicated, Resident 23 was cognitively intact with a Brief Interview for Mental Status (BIMS) (an evaluation of attention, orientation and memory recall) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment).
During an interview on 5/12/21, at 10:48 a.m., with Resident 11, Resident 11 stated the facility had a calendar in the hallway with activities but the activities he would see on the calendar would not occur. Resident 11 stated he had been at the facility for four months and there had been no activities, no bingo and no popcorn.
During an interview on 5/12/21, at 10:54 a.m., with Resident 1, Resident 1 stated there had not been many activities in the facility and she would like more activities during the day.
During a review of Resident 1's Minimum Data Set (MDS) assessment (an evaluation used to identify resident care needs), dated 5/3/21, the MDS assessment indicated, Resident 1 was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) (an evaluation of attention, orientation and memory recall) score of 11 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment).
During an interview on 5/14/21, at 11:40 a.m., with the Director of Social Services (DSS), the DSS stated the AD was on leave. The DSS stated the AD was scheduled to come back in February 2021. The DSS stated activities should have been completed per the calendar in the hallway. The DSS stated when the AA completed activities she would document in the Activity Attendance Record. The DSS stated since the facility did not have an AD, the facility was not able to schedule activities based on the monthly calendar. The DSS stated Residents 1, 11 and 23 should not have to worry about the activities in the facility. the DSS stated residents in the facility enjoyed activities and if there were no activities they could be sad. The DSS stated she was not able to validate if Resident 1, 11, and 23 attended activities.
During a concurrent interview and record review, on 5/14/21, at 11:48 a.m., with the DSS, Resident 23's Activity Attendance Record (AAR) dated May 2021 was reviewed. The AAR indicated on 5/5/21 and 5/11/21, 5/12/21 and 5/13/21 were the days documented that Resident 23 participated in activities.
During a concurrent interview and record review, on 5/14/21, at 11:50 a.m., with the DSS, Resident 11's AAR dated May 2021 was reviewed. The AAR indicated on 5/5/21 and 5/11/21, 5/12/21 and 5/13/21 were the days documented that Resident 11 participated in activities.
During a concurrent interview and record review, on 5/14/21, at 11:53 a.m., with the DSS, Resident 1's AAR dated May 2021 was reviewed. The AAR indicated on 5/5/21 and 5/11/21, 5/12/21 and 5/13/21 were the days documented that Resident 1 participated in activities.
During a concurrent interview on 5/19/21, at 9:25 a.m., with the Director of Nursing (DON) and the Administrator (ADM), the ADM stated the AD was on leave. The ADM stated the facility did not have an AD since December 2020 and CNA 4 had continued to do activities. The ADM stated the facility would do activities with residents but did not document the activities completed. The ADM stated Resident 1 would stay in her bed. The ADM stated Resident 11 had not mentioned to him he wanted to do activities. The ADM stated activities were important to residents in the facility.
During a review of the facility's policy and procedure (P&P) titled, Recreation dated 6/29/2016, the P&P indicated, A program calendar will be developed that reflects planned programming based on the current assessed needs and interests of the LivingCenter population . The purpose of the calendar is to inform residents, family, staff and volunteers for the current's months recreation program . The Activities Director or designee will plan the calendar of events for the activity department each month . the activity calendar for the following moth will be reviewed and approved the facility administrator and residents group . the recreation program calendars indicate the following information, month, year, dates and days of the week, the starting and name of each program, location of each program, each activity should start at he scheduled time, a large activity calendar will be posted in a central location, in an accessible area, viewed by all, by the (date) of the proceeding months. Residents will be informed of any changes to the calendar (by verbal communication, intercom announcement, etc.) . any changes in the schedule will be maintain in a master calendar an updated in the survey readiness book .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0800
(Tag F0800)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure food served met the daily nutritional needs for 21 of 37 residents (Residents 1, 3, 7, 10, 12, 13, 15, 16, 19, 20, 21,...
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Based on observation, interview, and record review, the facility failed to ensure food served met the daily nutritional needs for 21 of 37 residents (Residents 1, 3, 7, 10, 12, 13, 15, 16, 19, 20, 21, 22, 23, 28, 29, 31, 33, 34, 187, 189 and 190) when residents on regular and large portion diets were served more than the required portion size of the main dish [meatballs].
This failure had the potential to result in Resident 1, 3, 7, 10, 12, 13, 15, 16, 19, 20, 21, 22, 23, 28, 29, 31, 33, 34, 187, 189 and 190 to receive more than the recommended daily calorie intake based on residents nutritional dietary needs.
Findings:
During a review of facility document titled, Order Listing Report, dated 5/11/21, the order listing report indicated, .Status: Current, Order Category: Diet, Order Status: Current. Resident Name: Resident 31, Order Summary: Controlled Carbohydrate diet Regular texture .Resident 13, Renal Diet, Regular Texture .Resident 29, Regular Large Portion diet Regular texture .Resident 3, Regular diet Regular texture .Resident 16, Regular diet Regular texture .Resident 20, Regular diet Regular texture .Resident 189, Regular diet Regular texture .Resident 22, Regular diet Regular texture .Resident 23, Regular diet Regular texture .Resident 190, Regular diet Regular texture .Resident 33, Regular diet Regular texture .Resident 15, Regular diet Regular texture .Resident 10, Controlled Carbohydrate diet Regular texture .Resident 34, Regular diet Regular texture .Resident 19, Regular diet Regular texture .Resident 187, Regular diet Regular texture .Resident 28, Regular diet Regular texture .Resident 21, Regular diet Regular texture .Resident 7, Regular diet Finger foods texture .Resident 12, Regular diet Regular texture .Resident 1, Regular diet Regular texture .
During a concurrent observation, interview, and record review on 5/11/21, at 11:45 a.m., during tray line, the dietary cook (DC) served three pieces of the main dish [meatballs] to residents with regular diets .The DC served four pieces of the main dish [meatballs] to residents with large portion diet. The DC weighed three pieces of the main dish [meatballs] and the weight was four ounces. The DC weighed four pieces of main dish [meatballs] and the weight was five ounces. The DC reviewed the facility document titled, RECIPE: MEATBALLS AND GRAVY undated, the recipe indicated, .Portion size: 2 meatballs (3 ounces protein). The DC reviewed facility document titled, Spring Cycle Menus, dated 5/11/21, the spring cycle menus indicated, .under Regular Column: Meatballs with Gravy .under Regular column: 2 (1-2 oz) Large Column: 2 (1-2 oz) .under CCHO (Controlled Carbohydrate) diet: Meatballs with Gravy .under Regular column: 2 . The DC stated the residents who were on regular diet should have been served 2 pieces of the main dish [meatballs] instead of three pieces. The DC stated the residents on a large portion diet should have been served two pieces of the main dish [meatballs] instead of four pieces. The DC stated the menu portion size should have been followed.
During a concurrent interview, and record review on 5/11/21, at 12:20 p.m., with the Dietary Service Manager (DSM), the DSM reviewed the facility documents titled, RECIPE: MEATBALLS AND GRAVY, undated and Spring Cycle Menus, dated 5/11/21. The DSM stated the DC did not follow the menu portion size. The DSM stated, She (DC) gave more than the recommended amount/portion of food. The DSM stated DC should have given two pieces of the main dish to residents on regular and large portion diets.
During a phone interview on 5/19/21, at 9:52 a.m., with the Registered Dietitian (RD) 2, RD 2 stated the DC should have followed the menu. RD 2 stated DC should have checked the menu portions prior to serving food. RD 2 stated the residents with regular and large portion diets were served more than what was indicated on the menu. RD 2 stated the residents received more than the recommended calorie intake, which could lead to weight gain.
During a review of the facility's policy and procedure (P&P) titled, Food Service Distribution, dated 2011, the P&P indicated, .The director of dining services or designee is responsible for seeing that all meal service .Meets the therapeutic and consistency requirements of prescribed diets and personal preferences .Diets should be offered as ordered by a Physician .Serve proper portions according to the menus. Use portion-control utensils and scales as noted on menu and meal tickets .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
Based on interview, and record review the facility failed to provide suitable, nourishing snacks for four of seven sampled residents (Residents 1, 11, 23, and 29) when facility staff did not provide a...
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Based on interview, and record review the facility failed to provide suitable, nourishing snacks for four of seven sampled residents (Residents 1, 11, 23, and 29) when facility staff did not provide a variety of snacks for residents in the facility.
This failure resulted in Resident 1, 11, 23, and 29 verbalizing and requesting different types of snacks from staff and staff did not notify the Dietary Service Manager (DSM).
Findings:
During an interview on 5/12/21, at 10:20 a.m., with Resident 23, Resident 23 stated the facility staff did not pass out evening snacks.
During a review of Resident 23's Minimum Data Set (MDS) assessment (an evaluation used to identify resident care needs), dated 3/29/21, the MDS assessment indicated, Resident 23 was cognitively intact with a Brief Interview for Mental Status (BIMS) (an evaluation of attention, orientation and memory recall) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment).
During an interview on 5/12/21, at 10:30 a.m., with Resident 29, Resident 29 stated the facility staff did not pass out evening snacks. Resident 29 stated on 5/11/21 snacks were not passed out. Resident 29 stated the facility used to have peanut butter crackers and they did not provide them anymore during the evening shift snacks.
During a review of Resident 29's MDS assessment, dated 4/13/21, the MDS assessment indicated, Resident 29 was cognitively intact with a BIMS score of 15.
During an interview on 5/12/21, at 10:48 a.m., with Resident 11, Resident 11 stated the facility staff did not pass out evening snacks. Resident 11 stated he would like a peanut butter and jelly sandwich as an evening snack.
During an interview on 5/12/21, at 10:54 a.m. with Resident 1, Resident 1 stated the facility staff did not pass out evening snacks. Resident 1 stated staff would notify the residents, the kitchen was closed and there were no snacks available. Resident 1 stated she would like peanut butter crackers.
During an interview on 5/12/21, at 3:42 p.m., with the Dietary Service Manager (DSM), the DSM stated residents in the facility would be provided snacks at 10 a.m. 2 p.m. and 7 p.m. The DSM stated the dietary aids would make the snack carts and the activity department would pass out the 10 a.m. and 2 p.m. snacks. The DSM stated CNA's would pass out the evening snacks. The DSM stated the evening shift cook would prepare the snack cart that would go out to the residents in the facility. The DSM stated the snack cart included cereal with milk, cookies, pureed and thickened liquids, danishes, coffee and fruit. The DSM stated he was not aware there were not enough snacks in the evening time. The DSM stated the kitchen would close at 7:30 p.m. and if a resident requested a snack at 8 p.m. the CNA would have to check the snack to cart to see if there were any snacks left in the cart because the kitchen was closed.
During an interview on 5/12/21, at 4:57 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated she had been working in the facility since July 2020. CNA 2 stated residents would complain about wanting different types of snacks. CNA 2 stated Resident 11 was diabetic and the snack cart did not have an evening snack for him because he was diabetic. CNA 2 stated Resident 11 had notified the nurses he wanted an evening snack. CNA 2 stated on the evening of 5/11/2021, the snack tray had peanut butter and jelly sandwich, cookies, yogurt, mixed fruits, bananas and strawberries. CNA 2 stated there were no options for residents on a diabetic diet, but they were still offered a snack. CNA 2 stated two trays of snacks would be provided by the kitchen staff. CNA 2 stated there were times when no snacks were provided to some residents because there was not enough, and the dietary staff had left home. CNA 2 stated snacks were documented if they were offered. CNA 2 stated Resident 23 would give up his snacks to other residents if there were no snacks available. CNA 2 stated about three or four weeks ago there were no snacks available.
During an interview on 5/17/21, at 4:20 p.m., with Registered Dietitian (RD) 2, RD 2 stated 5/17/21 was her first day in this facility. RD 2 stated the facility should pass out snacks in between meals. RD 2 stated she did not know what type of snacks the facility provided to residents in the facility. RD 2 stated snacks were provided to residents based on their diet order. RD 2 stated snacks had to be available for residents with diabetes (disease in which your blood glucose, or blood sugar, levels are too high). RD 2 stated residents with diabetes should be provided fresh fruit, fifteen milligram (mg-(unit of measurement) peanut butter crackers and a variety of snacks which all residents in the facility could eat. RD 2 stated if the facility had 40 residents then 40 snacks would have to be available to the residents. RD 2 stated she was not able to verbalize the system the facility had in place to pass out snacks and would have to talk to the DSM. RD 2 stated the facility should provide a variety of snacks to the residents in the facility.
During an interview on 5/19/21, at 9:47 a.m., with the Social Worker (SW), the SW stated she distributed the snacks from the snack cart to the residents. The SW stated that the residents could choose from common items on the snack cart, such as chips, cookies, and bananas. The SW stated nursing staff had not brought up the topic of diabetic residents and what snacks diabetic resident could or could not have.
During a review of the facility's document titled, Continental Breakfast Cart undated, indicated, . 6 PM Snack Cart Fresh Fruit- 4 of each . Assorted Cookies and Crackers-20 packages . yogurt/pudding- 6 swirl cups . ice cream- 6 individual cups . juice or punch- 1 pitcher . ½ sandwiches- 6 as needed . HS nourishments .
During a review of the facility's policy and procedure (P&P) titled Dining Services dated 7/20/16, the P&P indicated, Snacks will be available through the day in accordance with residents preferences and plan of care . snacks are food or beverages in addition to the menu not sued for nutritional intervention When providing snacks, determine quantities to be distributed to each nursing station, based on the diet census and usage history . a variety of snacks will be offered based on residents' preferences . when residents request a specific snack, it will be individually prepared and distributed .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to prepare and serve food in accordance with professional standards for food safety when the Dietary [NAME] (DC) did not documen...
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Based on observation, interview, and record review, the facility failed to prepare and serve food in accordance with professional standards for food safety when the Dietary [NAME] (DC) did not document the temperatures of the food served on 5/10/21 and 5/11/21.
This failure had the potential to cause foodborne illness (caused by consuming contaminated foods or beverages) in 37 of 39 residents who consumed food prepared the kitchen.
Findings:
During a review of the facility document titled, Spring Cycle Menus, dated 5/10/21, the spring cycle menus indicated, . Temp [blank] Grape juice .Temp [blank] breakfast meat . Temp [blank] Broccoli salad .Temp [blank] egg salad sandwich .
During a review of the fancily document titled, Spring Cycle Menus, dated 5/11/21, the spring cycle menus indicated, .Temp [blank] Apple Juice .Temp [blank] Toasted Oats .Temp [blank] Ham and Egg Scrambles .Temp [blank] Bran Muffin .Temp [blank] Milk .
During a review of the facility's document titled, Order Listing Report, dated 5/11/21, the order listing indicated, .Status: Current, Order Category: Diet, Order Status: Active . The Order Listing Report, indicated 37 residents are served food prepared in the kitchen.
During a concurrent observation interview and record review on 5/11/21, at 9:25 a.m., with Dietary [NAME] (DC), in the kitchen, the DC reviewed facility document titled, Spring Cycle Menus, dated 5/10/21, the DC stated there are missing food temperatures in the temperature section of spring cycle menus dated 5/10/21 and 5/11/21. The DC stated she took the temperatures but did not document. The DC stated she should have documented the temperatures as soon as she took the temperatures. The DC stated the practice was to take temperatures of all the foods served to residents and document. The DC stated, It is important to take the temperature and document to make sure residents are served foods that are the right temperature, serving foods that are not the right temperature to residents may make residents sick.
During a concurrent interview and record review on 5/11/21, at 9:45 with Dietary Service Supervisor (DSS), the DSS reviewed the facility document titled, Spring Cycle Menus, dated 5/10/21 and 5/11/21. The DSS stated the Spring Cycle Menus dated 5/10/21 and 5/11/21 had missing temperatures. The DSS stated food temperatures needed to be checked and recorded for all meals. The DSS stated, Temperatures are taken and recorded to make sure residents are served safe foods.
During a phone interview on 5/19/21, at 9:52 a.m., with Registered Dietitian (RD), the RD stated the practice is to record food temperatures for each meal to make sure foods are at the right temperatures for food safety and palatability. The RD stated the cook should have recorded the temperatures as soon as she took the food temperatures.
During a review of the facility's policy and procedure titled, Food Temperatures dated 2011, the policy and procedure indicated, .Meal services may consist of a combination of foods that require different temperatures - the director of dining or designee is responsible for ensuring that all food is at the proper serving temperature(s) before meal service starts .Heat food to the proper temperature by direct heat (using a stove, oven, steamer, etc) .
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0911
(Tag F0911)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview during the survey period from 5/10/21 through 5/19/21, the facility failed to ensure each be...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview during the survey period from 5/10/21 through 5/19/21, the facility failed to ensure each bedroom accommodated no more than four residents (rooms [ROOM NUMBERS]).
This failure had the potential to adversely effect care provided to residents in room [ROOM NUMBER] and 14.
Findings:
During an observation on 4/10/21 through 4/19/21, in room [ROOM NUMBER] and 14, the two resident bedrooms had more than four residents. Each room met the required needs of the residents, as well as the square footage. Closet and storage space were adequate. Bedside stands were available. There were sufficient room for nursing care to be provided to the residents. Wheelchair and toilet facilities were accessible. The health and safety of residents would not be adversely affected by the continuance of this waiver.
Room Number
Number of Beds Square footage
4 8 677.16
14
8 681.49
Recommend waiver continue in effect.
________________________________________________________________
Health Facilities Evaluator Supervisor Signature Date
Request waiver continue in effect.
________________________________________________________________
Facility Administrator Signature
Date
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 during the survey period of 5/10/2021 to 5/19/2021, the facility failed to pro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during the survey period of 5/10/2021 to 5/19/2021, the facility failed to provide the minimum of at least 80 square feet per resident in multiple rooms (Rooms 1, 2, 6, 8, 10, 11 and 16).
This failure had the potential for residents to not have reasonable accommodations for privacy or adequate space for care to be rendered.
Findings:
During a concurrent observation and interview on 5/13/21, at 8:40 a.m., with the Maintenance Supervisor (MS), an environmental tour was conducted. The MS measured six rooms and stated the rooms did not meet the minimum square footage of 80 square feet per resident. These rooms were as follows:
Room Number: Square Feet: Number of Residents
room [ROOM NUMBER] 150.29 2 beds
room [ROOM NUMBER] 239.56 3 beds
room [ROOM NUMBER] 301.32 4 beds
room [ROOM NUMBER] 160.8 2 beds
room [ROOM NUMBER] 149.34 2 beds
room [ROOM NUMBER] 148.03 2 beds
room [ROOM NUMBER] 302.4 4 beds
During the observations made on 5/10/2021 to 5/19/2021, the residents had reasonable amount of privacy. Closets and storage space were adequate, bedside stands were available. There was sufficient room for nursing to provide care and for residents to ambulate. Toilet facilities and wheelchairs were accessible. The waiver will not adversely affect the health and safety of residents.
Recommend waiver continue in effect.
________________________________________________________
Health Facilities Evaluator Supervisor Signature Date
Request waiver continue in effect.
_________________________________________________________
Administrator Signature Date
Apr 2019
4 deficiencies
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to address physical environment conditions necessary to keep the residents safe when the facility assessment did not include a water managemen...
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Based on interview and record review, the facility failed to address physical environment conditions necessary to keep the residents safe when the facility assessment did not include a water management program for the detection of Legionella (a waterborne bacteria which can cause life threatening pneumonia) or other waterborne bacteria in the facility.
This practice failed to establish an individualized facility assessment to meet the requirement for a water management program and to ensure the health and safety of the residents.
Findings:
During an interview with the Administrator (ADM), on 4/23/19, at 11:30 a.m., she stated she was aware of the facility's requirement to establish a water management plan issued by the Centers of Medicare and Medical Services (CMS) in September 17, 2018. The ADM stated the requirement indicated all healthcare facilities were required to develop a plan for water management in an effort to reduce the risk of growth and spread of waterborne bacteria. The ADM stated she was working to develop a plan to test the facility water system specific for Legionella.
During a concurrent interview and record review with ADM, on 4/23/19, at 11:30 a.m., the facility document titled, Facility Assessment Tool dated 3/19, did not have any information regarding the facility's need for a water management program. The ADM stated the plan for water testing was not addressed in the facility assessment.
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
Based on observation, interview and record review, the facility failed to have an effective infection control program when:
1. A facility water management plan was not created or implemented to reduce...
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Based on observation, interview and record review, the facility failed to have an effective infection control program when:
1. A facility water management plan was not created or implemented to reduce the risk of Legionella (a waterborne bacteria) or other waterborne bacterias.
This failure resulted in the facility not having a water management program which placed residents at risk of exposure to Legionella causing respiratory infections.
2. One of 1 (Resident 32) oxygen concentrator (a device that concentrates the oxygen from the ambient air) was found to have a filter containing lint and dust.
This failure had the potential to contribute to the increased risk of respiratory type infections.
3. During medication observation, the Licensed Vocational Nurse (LVN) did not disinfect the wrist blood pressure (bp) cuff (a device used to measure the force of blood against the artery wall) before and after checking Resident 19 and 31's blood pressure.
This failure had the potential to result in cross contamination and spread of infection.
Findings:
1.During an interview with the Administrator (ADM), on 4/23/19, at 11:30 a.m., the ADM stated she was aware of the facility's requirement to establish a water management plan issued by the Centers of Medicare and Medical Services (CMS) in September 17, 2018. The ADM stated the requirement indicated all healthcare facilities were required to develop a plan for water management in an effort to reduce the risk of growth and spread of waterborne bacteria. The ADM stated she was working to develop a plan to test the facility water system specific for Legionella.
During a concurrent interview and record review with ADM, on 4/23/19, at 11:30 a.m., the facility document titled, Facility Assessment Tool dated 3/19, did not have any information regarding the facility's need for a water management program. The ADM stated the plan for water testing was not addressed in the facility assessment.
2. During a concurrent observation and interview with the Director of Staff Development (DSD), on 4/22/19, at 9:36 a.m., in Resident 32's room, Resident 32 was in bed receiving supplemental oxygen by way of a nasal cannula (a tube that delivers oxygen through the nose), connected to an oxygen concentrator. The DSD looked at the oxygen concentrator filter and stated the filter was not clean, filled with dust and lint. The DSD stated the night shift (NOC) nurse was responsible for checking and cleaning the filters once a week on Saturday.
During an interview with LVN 2, on 4/23/19, at 9:30 a.m., she stated the NOC nurse was responsible for checking and cleaning the oxygen concentrators filters every Saturday.
During an interview with the ADM, on 4/23/19, at 10:30 a.m., in her office, she stated the NOC shift nurse was responsible for cleaning the oxygen concentrator's filter weekly. The ADM stated they have no specific policy and procedure on cleaning the oxygen concentrators' filters.
The facility policy and procedure titled Oxygen Administration undated, indicated .Procedure Details: .10. At regular intervals . check and clean oxygen equipment .
3. During a medication observation on 4/23/19, at 8:21 a.m., in Residents 19 and 31's room , Licensed Vocational Nurse (LVN) 2 took the bp of Resident 19 using a wrist bp wrist cuff, then took the bp of Resident 31 using the same wrist bp device wihout disinfecting the bp wrist cuff.
During an interview with LVN 2, on 4/23/19, at 8:30 a.m., she stated she took the bp of Resident 19 and 31 without disinfecting the bp wrist cuff. LVN 2 stated she should have disinfected the bp wrist cuff between residents.
During an interview with Director of Staff Development (DSD), on 4/23/19, at 2:44 p.m., she stated LVN 2 should have disinfected the bp wrist cuff with the disposable germicidal surface wipes with every use for infection control.
The facility policy and procedure titled Cleaning and Disinfecting Non Critical Resident- Care Item dated11/15/15, indicated .Procedure .3 .c. Non-critical items .1. Non critical resident- care items .blood pressure cuff .d. Reusable items are cleaned and disinfected or sterilized between residents .
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0911
(Tag F0911)
Minor procedural issue · This affected multiple residents
Based on observation and interview, during the survey period from 4/22/19 through 4/25/19, the facility failed to ensure each bedroom accommodated no more than four residents. (Rm 4 and 14)
This failu...
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Based on observation and interview, during the survey period from 4/22/19 through 4/25/19, the facility failed to ensure each bedroom accommodated no more than four residents. (Rm 4 and 14)
This failure had the potential to result in overcrowding that could affect the residents delivery of care and wellbeing.
Findings:
During an observation on 4/22/19 through 4/25/19, two resident bedrooms had more than four residents in each bedroom. Each room met the required needs of the residents, as well as the square footage. The residents had a reasonable amount of privacy, closet and storage space was adequate. Bedside stands were available. There was sufficient room for resident equipment and for nursing care to be provided to the residents. The health and safety of the residents would not adversely affected by this waiver.
Rm. No No. of Beds: Sq. Footage:
4
8
677.16
14
8
681.49
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
Based on observation during the survey period of 4/22/19 through 4/25/19, the facility failed to provide the minimum square footage in seven of 16 resident rooms( Rooms 1,2,6,8,10, 11 and 16).
This f...
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Based on observation during the survey period of 4/22/19 through 4/25/19, the facility failed to provide the minimum square footage in seven of 16 resident rooms( Rooms 1,2,6,8,10, 11 and 16).
This failure placed the residents at potential risk of unmet needs including privacy, storage and care.
Findings:
During an observation throughout the survey from 4/22/19 through 4/25/19, the residents had a reasonable amount of privacy and there was enough shared closet and storage space for each resident. There was sufficient room for the provision of nursing care to the residents. The health and safety of the residents would not be adversely affected by the continuance of the waiver.
Rm. Dimensions Sq. Footage No. of Beds
1 11'2 x 12'10 143.31 sq. ft. 2
2 11'2 x 21'2 236.80 sq. ft. 3
6 12'2 x 26'1 317.34 sq. ft. 4
8 13'3 x 11'11.5 158.45 sq.ft. 2
10 13' x 11'1 144.09 sq. ft. 2
11 11'2 x 13' 145.16 sq. ft. 2
16 25'2 x 11'10 297.81 sq. ft. 4
Recommend waiver.
______________________________________
Health Facilities Evaluator Supervisor Date
Request waiver.
______________________________________
Facility Administrator
Date
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?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most California facilities.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s). Review inspection reports carefully.
- • 39 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • Grade F (38/100). Below average facility with significant concerns.
Bottom line: Trust Score of 38/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Vineyards At Fowler's CMS Rating?
CMS assigns VINEYARDS AT FOWLER 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 Vineyards At Fowler Staffed?
CMS rates VINEYARDS AT FOWLER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 52%, compared to the California average of 46%.
What Have Inspectors Found at Vineyards At Fowler?
State health inspectors documented 39 deficiencies at VINEYARDS AT FOWLER during 2019 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 32 with potential for harm, and 6 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 Vineyards At Fowler?
VINEYARDS AT FOWLER 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 AJC HEALTHCARE, a chain that manages multiple nursing homes. With 49 certified beds and approximately 42 residents (about 86% occupancy), it is a smaller facility located in FOWLER, California.
How Does Vineyards At Fowler Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, VINEYARDS AT FOWLER's overall rating (2 stars) is below the state average of 3.1, staff turnover (52%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Vineyards At Fowler?
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?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Vineyards At Fowler Safe?
Based on CMS inspection data, VINEYARDS AT FOWLER has documented safety concerns. 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 Vineyards At Fowler Stick Around?
VINEYARDS AT FOWLER has a staff turnover rate of 52%, which is 6 percentage points above the California average of 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 Vineyards At Fowler Ever Fined?
VINEYARDS AT FOWLER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Vineyards At Fowler on Any Federal Watch List?
VINEYARDS AT FOWLER 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.