CHESTNUT RIDGE POST ACUTE LLC
For profit - Limited Liability company
106 Beds
Independent
Data: November 2025
3 Immediate Jeopardy citations
Trust Grade
17/100
#767 of 1155 in CA
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Chestnut Ridge Post Acute LLC has received a Trust Grade of F, indicating significant concerns about the facility's care quality. Ranking #767 out of 1155 in California places it in the bottom half of state facilities, and #171 out of 369 in Los Angeles County means only a small number of local options are worse. While the staffing rating of 4 out of 5 stars and a low turnover rate of 23% are strengths, the facility has critical deficiencies, including failure to ensure proper accountability for controlled medications and violations of residents' rights, particularly for justice-involved residents. Although the trend shows improvement in the number of issues from 28 in 2024 to 4 in 2025, the facility still faces $13,385 in fines, which is average for the area, and the overall star rating is only 2 out of 5, indicating below-average performance.
- Trust Score
- F
- In California
- #767/1155
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ✓ Good
- 23% annual turnover. Excellent stability, 25 points below California's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- $13,385 in fines. Lower than most California facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 22 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 70 deficiencies on record. Higher than average. Multiple issues found across inspections.
17/100
Bottom 34%
Review needed
28 → 4 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 28 issues
2025: 4 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Low Staff Turnover (23%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (23%)
25 points below California average of 48%
Facility shows strength in staffing levels, quality measures, staff retention, fire safety.
The Bad
2-Star Overall Rating
Below California average (3.1)
Below average - review inspection findings carefully
Federal Fines: $13,385
Below median ($33,413)
Minor penalties assessed
The Ugly 70 deficiencies on record
3 life-threatening
Jul 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who displayed behaviors of refusing medications r...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who displayed behaviors of refusing medications received treatment and services to correct the assessed problem, was provided behavioral health services for one of three sampled residents ( Resident 1) whose primary diagnosis was schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and bipolar disorder (a brain disorder that causes changes in a person's mood, energy, and ability to function) by failing to: 1.Notify the physician when Resident 1 refused Haloperidol (a medicine used to treat and manage various mental health and behavioral condition, including schizophrenia and bipolar disorder) 10 milligram (MG, a unit of measurement) one tablet by mouth two times a day for a total of 35 doses. 2. Notify the physician when Resident 1 refused Valproic Acid (a medicine used to treat bipolar disorder) 250 MG three capsules by mouth as two times a day for a total of 14 doses and partial administration of Valproic Acid for 4 doses. 3. Notify the physician when Resident 1 refused one dose of Venlafaxine (a medicine used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest] and anxiety [a common emotion characterized by feelings of unease, worry, or fear, which can range from mild to severe])5 MG one tablet by mouth two times a day. 4. Conduct an interdisciplinary team (IDT) meeting when Resident 1 continued to refuse psychotropic medications. 5. Assess and document the reason for Resident 1's constant refusal of psychotropic medications. These deficient practices resulted in Resident 1 pushing Resident 2 during a resident-to resident altercation on 6/20/2025. Subsequently, Resident 1 was transferred to a General Acute Care Hospital (GACH) and placed on a 5150 (the California Welfare and Institutions Code, which allows a qualified professional to place someone in an involuntary 72-hour psychiatric hold if they are a danger to themselves or others or are gravely disabled). During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 5/26/2025 with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and bipolar disorder (a brain disorder that causes changes in a person's mood, energy, and ability to function). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 5/30/2025, the MDS indicated Resident 1 had moderately impaired cognition (ability to understand and make decisions) and memory. The MDS indicated Resident 1 exhibited little interest or pleasure in doing things and trouble failing or staying asleep, or sleeping too much nearly every day, feeling down, depressed, or hopeless, feeling tired or having little energy, poor appetite or overeating several days over the last two weeks. The MDS also indicated Resident 1 required supervision or touching assistance with eating, and partial/moderate assistance with oral hygiene, toileting hygiene, shower/bathe self, personal hygiene, and chair/bed-to-chair transfer. During a review of Resident 1's Order Summary Report, dated 6/20/2025, the Report indicated the physician ordered to administer the following medications: 1.Haloperidol (a medicine used to treat and manage various mental health and behavioral condition, including schizophrenia and bipolar disorder) 10 milligram (MG, a unit of measurement) one tablet by mouth two times a day for bipolar manifested by striking out at staff, starting on 5/27/2025. 2.Valproic Acid (a medicine used to treat bipolar disorder) 250 MG three capsules by mouth as two times a day for bipolar disorder manifested by inconsolable screaming, starting on 5/27/2025. 3.Venlafaxine (a medicine used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest] and anxiety [a common emotion characterized by feelings of unease, worry, or fear, which can range from mild to severe])5 MG one tablet by mouth two times a day for restlessness, starting on 5/27/2025. During a review of Resident 1's Medication Administration Record (MAR), dated 5/2025, the MAR indicated Resident 1 refused to take Haloperidol 10 MG one tablet on 5/27/2025 at 6 PM, 5/28/2025 at 9 AM at 6 PM, 5/29/2025 at 9 AM and 6 PM, 5/30/2025 at 9 AM. The MAR also indicated Resident 1 refused to take Valproic Acid 250 MG three capsules on 5/28/2025 9 AM and 5/29/2025 9 AM. During a review Resident 1's MAR, dated 6/2025, the MAR indicated Resident 1 refused to take Haloperidol 10 MG one tablet on: a. 6/1/2025 at 9 AM and 6 PM b. 6/2/2025 at 9 AM and 6 PM c. 6/3/2025 at 9 AM and 6 PM d. 6/4/2025 at 9 AM e. 6/5/2025 at 9 AM and 6 PM f. 6/6/2025 at 9 AM and 6 PM g. 6/7/2025 at 9 AM h. 6/8/2025 at 9 AM and 6 PM i. 6/10/2025 at 9 AM and 6 PM j. 6/11/2025 at 9 AM and 6 PM k. 6/12/2025 at 6 PM l. 6/13/2025 at 9 AM and 6 PM m. 6/14/2025 at 9 AM n. 6/15/2025 at 9 AM and 6 PM o. 6/16/2025 at 9 AM p. 6/17/2025 at 6 PM q. 6/19/2025 at 6 PM r. 6/20/2025 at 9 AM and 6 PM During a review of Resident 1's MAR, dated 6/2025, the MAR indicated Resident 1 refused to take Valproic Acid 250 MG three capsules on: a. 6/3/2025 at 9 AM b. 6/6/2025 at 6 PM c. 6/12/2025 at 6 PM d. 6/13/2025 at 9 AM and 6 PM e. 6/14/2025 at 9 AM f. 6/15/2025 at 9 AM and 6 PM g. 6/17/2025 at 6 PM h. 6/19/2025 at 6 PM i. 6/20/2025 at 9 AM and 6 PM The MAR indicated Resident 1 received only a partial administration of Valproic Acid 250 MG three capsules on 6/8/2025 at 6 PM, 6/9/2025 at 6 PM, 6/10/2025 at 6 PM and 6/11/2025 at 6 PM. The MAR indicated Resident 1 did not receive the entire dose of Valproic Acid 250 MG three capsules on 6/5/2025 at 6 PM and was only administered one tablet. During a review of Resident 1's MAR, dated 6/2025, the MAR indicated Resident 1 refused to take Venlafaxine 75 MG one tablet on 6/6/2025 at 6 PM. During a review of Resident 1's Progress Notes (PN), dated 6/8/2025 at 5:34 PM, the PN indicated Resident only took one capsule of Valproic Acid 250 MG. During a review of Resident 1's Change in Condition Evaluation (COC), dated 6/12/2025 at 10:22 AM, the COC indicated Registered Nurse (RN) 1 reported to the physician that Resident 1 was non complaint with medication administration since Resident 1 kept refusing to take the medication, valproic acid. During a review of Resident 1's PN, dated 6/12/2025 at 10:22 AM, the PN indicated RN 1 reported to the physician that Resident 1 kept on refusing medications but there was no documentation for recommendations, new testing orders and new intervention ordered by the physician. During a review of Resident 1's PN, dated 6/20/2025 at 3:14 PM, the PN indicated that at 12:25 PM, Resident 1 allegedly approached Resident 2 in the smoking patio and asked Resident 2 for a cigarette, but Resident 2 stated he did not have a cigarette, so Resident 1 pushed Resident 2 and continued a verbal altercation. During a review of Resident 1's PN, dated 6/20/2025 at 8:04 PM, the PN indicated that the facility called 911 and transferred Resident 1 to the General Acute Care Hospital (GACH) at 7:10 PM for 5150. During an interview on 7/9/2025 at 11:25 AM with Restorative Nursing Assistant (RNA) 1, RNA 1, RNA 1 stated on 6/20/2025 after lunch, he was doing something in the hallway and he heard Resident 1 and Resident 2 arguing in the smoking patio, then, he tried to separate the residents. RNA 1 stated Resident 2 said Resident 1 was asking for a cigarette from him, but Resident 2 said he did not have a cigarette, then, Resident 1 pushed Resident 2. During an interview on 7/9/2025 at 12:17 PM with RN 2, RN 2 stated Resident 1 would become verbally aggressively toward staff when the staff did not attend to his request immediately. RN 2 stated the charge nurses reported that Resident 1 would refuse to take medications, then, the nurse would educate the resident about the risk of refusing medication, informed the responsible party (RP) to convince the resident, and notify the physician. RN 2 stated she did not know how often and how many medications Resident 1 had refused since his admission, and she did not know if any interventions were developed and implemented to address Resident 1's behavior of refusing medications frequently. During an interview on 7/9/2025 at 1:40 PM with Licensed Vocational Nursing (LVN) 2, LVN 2 stated Resident 1 had refused his medication since the first day he was admitted into the facility. LVN 2 stated Resident 1's refusal of medications increased before Resident 1 was transferred to the GACH. LVN 2 stated she reported Resident 1's refusal of medication to the RN supervisor and the RN supervisor was responsible for assessing Resident 1 and reporting to and following up with the physician. During a telephone interview on 7/9/2025 at 3:50 PM with RN 1, RN 1 stated on 6/12/2025, the charged nurse informed her that Resident 1 refused to take medications, such as metformin, haloperidol and valproic acid, so RN 1completed the COC, and reported Resident 1's refusals of medications to the nurse practitioner (NP) of Resident 1's psychiatrist. RN 1 stated the NP stated she would come to the facility and visit with Resident 1, however RN 1 did not document NP's response or COC onto Resident 1's medical record. RN 1 stated she did not know if the NP or the psychiatrist came to see Resident 1 after informing NP of Resident 1 refusing medications. RN 1 stated she had not followed up with Resident 1's COC nor did RN 1 know if Resident 1's refusal of meds was followed up. RN 1 stated she did not know Resident 1 refused the prescribed medication haloperidol almost every day and RN 1 did not know how often Resident 1 refused another prescribed medication valproic Acid. During an interview on 7/9/2025 at 4:01 PM with LVN 3, LVN 3 stated Resident 1 often refused medications, and she remembered she called Resident 1's primary physician about it Resident 1's refusal of medications, however did not inform Resident 1's psychiatrist since Resident 1's primary provided stated they would reach out to the psychiatrist. LVN 3 could not state whether Resident 1's psychiatrist knew Resident 1 refused the prescribed psychotropic medications or if Resident 1 had been reevaluated by the psychiatrist. LVN 3 stated it was not her responsibility to follow up with the physician for further orders, instead, it was the RN supervisors' responsibility to do that. LVN 3 stated she did not know if the RN supervisors follow up with it. During a concurrent interview and record review on 7/9/2025 at 4:20 PM with the Director of Nursing (DON), Resident 1's MAR, dated 5/2025 and 6/2025 were reviewed. The DON stated Resident 1, who had the diagnosis of schizophrenia and bipolar disorder, exhibited behaviors of refusing the prescribed psychotropic medications, which was a COC for Resident 1. The DON stated she was unaware that Resident 1 was refusing medications. The DON stated Resident 1 had refused Haloperidol since the first day of his admission on [DATE], but there was no COC was done until 6/12/2025. The DON stated the licensed nurses did not follow up with Resident 1's COC for further instruction from the physician, and did not inform the DON about Resident 1's COC. The DON stated the facility did not conduct an IDT and did not develop a care plan to address Resident 1's COC of refusing medications. The DON stated it was important for the licensed nurses to monitor Resident 1's behavior of refusing psychotropic medication closely, and report Resident 1 refusal of medications to the physician, to manage and intervened Resident 1's mental condition timely and effectively. The DON stated the facility did not monitor, communicate, address and intervene regarding Resident 1's behavior of frequent refusal of psychotropic medications, which had resulted in Resident 1 not receiving medications as ordered by the physician. The DON stated since Resident 1 was not receiving the prescribed medications, this could have resulted in why Resident 1 allegedly pushed Resident 2, and Resident 1 being transferred to the GACH for 5150 on 6/20/25. During a review of the facility's policy and procedure (P&P) titled, Behavioral Assessment, Intervention and Monitoring, dated 3/2019, the P&P indicated the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance. The P&P indicated the staff will assess, evaluate and identify, document, and inform the physician and RP about changes in an individual's mental status, behavior and cognition, then, IDT will evaluate and identify the cause of the changes, and intervene and manage the condition. During a review of the facility's policy and procedure (P&P) titled, Requesting, Refusing and/or Discontinuing Care or Treatment, dated 2/2021, the P&P indicated If a resident/representative requests, discontinues or refuses care or treatment, an appropriate member of the interdisciplinary team (IDT) will meet with the resident/representative to a. determine why he or she is requesting, refusing or discontinuing care or treatment; b. try to address his or her concerns and discuss alternative options; and c. discuss the potential outcomes or consequences (positive and negative) of the decision, If the decision to refuse or discontinue treatment results in a significant change of condition, a reassessment will occur and appropriate changes will be made to the resident's care plan. The P&P indicated detailed information relating to the refusal of treatment are documented in the resident's medical record, including the practitioner's response. The P&P indicated the practitioner must be notified of refusal of treatment, in a time frame determined by the resident's condition and potential serious consequences of the request.
May 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a comprehensive, person-centered care plan was develope...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a comprehensive, person-centered care plan was developed for one of two sampled resident (Resident 1) who was assessed to be at risk of elopement (the act of leaving a facility unsupervised and without prior authorization) and wandering.
This deficient practice had the potential for Resident 1 to not receive care that would prevent the resident from wandering into other resident ' s rooms, which could be a violation of other resident ' s privacy and rights, and/or elope from the facility.
Findings:
During a review of Resident 1 ' s admission Record (AR), the AR indicated the resident was admitted on [DATE] with diagnoses that included Alzheimer ' s disease (a disease characterized by a progressive decline in mental abilities) and dementia (a progressive state of decline in mental abilities), and cognitive communication disease.
During a review of Resident 1 ' s History and Physical (H&P), dated 4/25/2025, the H&Pindicated the resident does not have the capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated 4/25/2025, the MDSindicated the resident has severe impaired cognition (the ability to process thoughts). The MDS also indicated the resident requires moderate assistance (helper does less than half the effort) on activities such as walking up to 50 feet and sitting to standing. The MDS also indicated the resident requires substantial assistance (helper does more than half the effort) for self-care activities such as putting on/taking off footwear, toileting, and personal hygiene.
During a review of Resident 1 ' s Elopement Evaluation (EE), dated 4/21/2025, the EE indicated Resident 1 wandered aimlessly or non-goal-directed. The EE indicated the resident was at risk for wandering or elopement.
During a review of Resident 1 ' s active care plans, there were no care plans for Resident 1 initiated to address Resident 1 ' s behavior of wandering or elopement.
During an interview on 5/28/2025 at 12:39 PM with Registered Nurse (RN) 1, RN 1 stated Resident 1 wandered around the facility and was at risk for elopement. RN 1 stated Resident 1 could walk by himself and wandered around the facility.
During a concurrent interview and record review on 5/28/2025 at 2:32 PM with Director of Nursing (DON), Resident 1 ' s active care plans and EE, dated 4/21/2025, were reviewed. DON stated Resident 1 did not have a care plan that addressed Resident 1 ' s behaviors of wandering and for being at risk for elopement. DON stated there should be a care plan for the resident ' s behavior since the care plan wasused to inform all staff on which specific interventions to implement for Resident 1. DON stated the care plan for the resident ' s behavior of wandering and risk of elopement should include interventions such as close monitoring or moving the resident to a room closer to the nurses ' station.
During a record review of the facility ' s policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, indicated the care plan interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. The P&P also indicated the comprehensive, person-centered care plan:
1. Includes measurable objectives and timeframes;
2. Describe the services that are to be furnished to attain or maintain the resident ' s highest practicable, mental, and psychosocial well-being, including:
a. services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including to refuse treatment;
3. builds on the resident ' s strengths; and
4. reflects currently recognized standards of practice for problem areas and conditions.
May 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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to report immediately and/or no later than two hours if t...
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 report immediately and/or no later than two hours if the alleged allegation involves abuse, the verbal and physical altercation that happened with two of two sampled residents (Resident 1 and Resident 6) on 5/3/2025. Resident 6 reported that on 5/3/2025 around 9AM, Resident 1 stopped him in the hallway in his wheelchair, and yelled profanity (offensive or vulgar language, often considered impolite, rude, or disrespectful) at him and while in his wheelchair, he was pushed fast, spun around and grabbed his shirt prior to the staff separating them.
As a result, Resident 6 verbalized feeling upset, sad and discouraged, which negatively affected his quality of life. Also, it had the potential for a recurrence resulting in harm to other residents and staff in the facility.
On the same day, 5/3/2025, approximately four hours after the altercation with Resident 6, the facility failed to report an incident of Resident 1 choking Certified Nurse Assistant (CNA) 1 on 5/3/2025, while CNA 1 was inside another resident ' s room (Resident 5).
Resident 1 was transferred to the General Acute Care Hospital (GACH 1) on 5/3/2025 via 5150 (temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others due to signs of mental illness).
Findings:
A review of Resident 1 ' s admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cognitive communication deficit (communication difficulties stemming from underlying cognitive impairments, rather than from speech or language deficits), schizoaffective disorder- bipolar type (a mental illness that combines symptoms of schizophrenia [like hallucinations and delusions) with those of bipolar disorder (like mania and depression)], and psychotic disorder (when you see reality very differently to people around you).
A review of Resident 1 ' s History and Physical Examination (HPE), dated 4/18/2024, indicated Resident 1 was alert to time, person and situation.
A review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment screening tool), dated 4/18/2025, indicated the Resident 1 ' s cognitively status (ability to think, remember, and reason) moderately impaired impaired. The MDS indicated Resident 1 required supervision or touching assistance (Helper provides verbal cues and or touching steadying) with eating, partial/moderate assistance (helper does less than half the effort) with personal hygiene, dressing, toileting and bathing.
A review of Resident 6 ' s admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included osteoarthritis (a degenerative joint disease where the cartilage cushioning the bones in your joints wears away over time) of both shoulders and both knees, diabetes mellitus (disease of inadequate control of blood levels of glucose), and hypertension (high blood pressure).
A review of Resident 6 ' s History and Physical Examination (HPE), dated 10/11/2024, indicated Resident 6 has the capacity to understand and make decisions.
A review of Resident 6 ' s Minimum Data Set (MDS – a resident assessment screening tool), dated 4/18/2025, indicated the Resident 6 ' s cognitively status (ability to think, remember, and reason) was intact. The MDS indicated Resident 6 required Setup and clean-up assistance (helper sets up and cleans up; resident completes activity) with eating and oral hygiene, substantial/maximal assistance (helper does more than half the effort) with dressing and personal hygiene, and dependent (helper does all the effort) with bathing and toileting.
A review of Resident 5 ' s admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer ' s disease (a progressive brain disorder that primarily affects memory and thinking skills, eventually leading to difficulty with everyday tasks and behavior changes), aortic aneurysm (a bulge that occurs in the wall of the body's main artery, called the aorta) and palliative care (focuses on improving the quality of life for people with serious illnesses by providing comfort and support, even when a cure isn't possible).
A review of Resident 5 ' s History and Physical Examination (HPE), dated 5/1/2024, indicated Resident 5 does not have the capacity to understand and make decisions.
A review of Resident 5 ' S Minimum Data Set (MDS – a resident assessment screening tool), dated 4/14/2025, indicated Resident 5 dependent with eating, oral hygiene, toileting, bathing, dressing and personal hygiene.
A review of Resident 1 ' s facility document titled, Progress Notes (PN), dated 5/3/2025 timed at 1:45 PM, indicated Resident 1 was aggressive and hurt Certified Nurse Assistant (CNA) 1 by putting his hands around CNA ' s 1 neck, and the police came and took Resident 1 to GACH 1 for physical aggression via 5150 (California law code for the temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others due to signs of mental illness).
During an interview on 5/7/2025 at 3:30 PM with Family 2 (Family of Resident 5), Fam 2 stated, on 5/3/2025 around 1 PM, while inside Resident 5 ' s room (which was adjacent to Resident 1 ' s room), she was talking to CNA 1, when Resident 1 came to Resident 5 ' s room and without warning attacked and started choking CNA 1. Fam 2 stated she helped CNA 1 and had to remove Resident 1 ' s hand around CNA 1 ' s neck. Fam 2 stated, the police came and took Resident 1 away. Fam 2 stated, she was concerned for Resident 5 ' s safety since Resident 5 is cognitively impaired, and other residents who cannot protect themselves from Resident 1. Fam 2 stated, she informed the Director of Social Services (DSS) and the facility leadership about her concern that same day.
During an interview on 5/7/2025 at 3:50 PM with CNA 1, CNA 1 stated, on 5/3/2025 around 1 PM she was talking to FAM 2 inside Resident 5 ' s room, when Resident 1 came inside Resident 5 ' s room and grabbed her neck and started choking her without warning. CNA 1 stated the staff came to help, and the police took Resident 1 away on 5/7/2025.
During a concurrent observation and interview on 5/7/2025 at 4:30 PM with Resident 6, in Resident 6 ' s room, Resident 6 was sitting at the side of the bed, next to his wheelchair, face was flushed, eyebrows drawn together, clenched teeth with teary eyes and would look up and down while being interviewed. Resident 6 stated, the incident with Resident 1 started with him, on 5/3/2025 around 9AM, he was in the hallway going towards the smoking area, when Resident 1 blocked his way and started yelling profanity, grabbed his wheelchair and pushed him in the hallway so fast, even touching his back and he almost fell. Resident 6 stated, he struggled, then Resident 1 turned his wheelchair around and grabbed his jacket, that ' s when the facility staff separated them. Resident 6 stated he reported the incident to the charge nurse, and there were other nurses there, but he does not remember their names. Resident 6 stated, he felt discouraged and sad and what upsets him the most was no one talked to him about the incident, and he felt he was nobody and no one cares for him.
During an interview on 5/8/2025 at 9:30 AM with Housekeeper (HSK) 1, HSK 1 stated., she worked on 5/3/2025, and around 9AM she saw Resident 6 wheeling himself in the hallway, when Resident 1 stopped him, and they yelled at each other. HSK 1 stated, Resident 1 then grabbed Resident 6 ' s wheelchair, pushed him hard and turned Resident 6 ' s wheelchair around. HSK 1 stated there were other people around and stopped the altercation, and she did not report it because she thought someone else would tell the administrator.
During an interview on 5/8/2025 at 9:45 AM with CNA 1, CNA 1 stated, on 5/3/2025 around 9 AM Resident 1 and Resident 6 were yelling at each other, then Resident 1 grabbed Resident 6 ' s wheelchair and pushed Resident 6 ' s wheelchair and turned him around and grabbed Resident 6 ' s jacket. CNA 1 stated, she does not know why it was not reported, since there were other staff there. CNA 1 stated, the incident should have been reported, and maybe the incident with her would not have happened.
During an interview on 5/8/2025 at 10:10 AM with CNA 4, CNA 4 stated, on 5/3/2025 around 9AM Resident 1 and Resident 6 were yelling at each other using profanity, Resident 1 yelled mother_____ to Resident 6. CNA 4 stated, he separated Resident 1 and resident 6 and escorted Resident 1 to his room while Resident 6 went to the nurse ' s station. CNA 4 stated, he did not see the physical abuse but saw the verbal abuse and it should have been reported to the abuse coordinator.
During an interview on 5/8/2025 at 10:20 AM with LVN (license Vocational Nurse) 4, LVN 4 stated, on May 3 she heard to commotion around 9 am, the staff was already separating Resident 1 and Resident 6. LVN 4 stated, Resident 6 told her that Resident 1 pushed him in his wheelchair and yelled at him profanity, and Resident 6 was concerned that he might get hurt. LVN 4 stated that the incident should have been reported because of verbal abuse and possible physical abuse, for patient safety and prevent recurrence. LVN stated the incident was not in the progress notes or change of condition (COC) documentation. LVN 4 stated, she reported it to RN (Registered Nurse) 3.
During an interview on 5/8/2025 at 10:35 AM with RN 3, RN 3 stated, no one told her about the incident between resident 1 and Resident 6. RN 3 stated, on 5/3/2025 in the morning, Resident 6 came to her very upset and told her Resident 1 yelled profanity at him and push his wheelchair while he was in it. RN 3 stated, she was unable to interview Resident 1 because he was still agitated. RN 3 stated, the incident should have been reported to the abuse coordinator, the ombudsman, police and California Department of Public Health (CDPH) as per policy. RN 3 stated that not reporting the incident had resulted in upsetting Resident 3 and had the potential for abuse to recur or escalate and could affect the safety of the other patients in the facility.
During an interview on 5/8/2025 at 11:00 AM with DON (Director of Nurses), the DON stated, any suspicion of abuse should be reported within 2 hours as indicated in the facility policy. The DON stated, any type of verbal or physical altercation should be reported, and should be investigated thoroughly, so the incident would be addressed and prevent from potential recurrence or harm to other residents. DON stated, yelling profanity to another Resident is considered abuse, grabbing a resident or pushing someone on a wheelchair against his will, is considered abuse and should be reported to PD, Ombudsman and CDPH. DON stated, not reporting the incident between Resident 1 and Resident 6 had the potential for recurrence and escalation of the problem that could potentially affect the safety of the residents in the facility.
A review of the facility ' s policy and procedure (P&P) titled, Abuse Prevention/ Prohibition, revised 11/2018, the P&P indicated; a) the facility does not condone any form of Resident abuse and/or mistreatment and develops a system in order to promote an environment free from abuse and mistreatment, b)Abuse is defined as a willful infliction of injury, involuntary seclusion, intimidation with resulting physical harm pain or mental anguish.
A review of the facility ' s policy and procedure (P&P) titled, Abuse Investigation and Reporting, revised 7/2017, the P&P indicated; a) all reports of residents abuse, mistreatment shall be promptly reported to local , state and federal agencies and thoroughly investigated by facility management, b) under reporting, all alleged violations of abuse or mistreatment will be reported by the facility administrator or his/her designee to the state licensing /certification agency, ombudsman, and law enforcement, c) an alleged abuse or mistreatment will reported immediately, but no later than two hours if the alleged allegation involves abuse.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
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 facility have sufficient and competent nur...
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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 facility have sufficient and competent nursing staff to address, and provide necessary services (behavior monitoring and management) and implement person centered care plans for the behavioral healthcare needs of one of three sampled residents (Resident 1) diagnosed with schizoaffective disorder- bipolar type (a mental illness that combines symptoms of schizophrenia [a serious mental health condition that affects how people think, feel and behave] with those of bipolar disorder (a mood disorder characterized by extreme mood swings)], and psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions), in accordance with the facility ' s policy and procedures on Behavioral Assessment, Intervention and Monitoring and Care Planning – Interdisciplinary Team. The facility failed to:
1. Ensure Resident 1 ' s aggressive behavior was addressed, monitored and managed after an incident of choking Certified Nurse Assistant (CNA) 1 on 5/3/2025 while CNA 1 was inside another resident ' s room (Resident 5). Resident 1 transferred to the General Acute Care Hospital (GACH 1) on 5/3/2025 via 5150 (temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others due to signs of mental illness). Resident 1 was readmitted back to the facility on 5/8/2025.
2. Ensure Resident 1 ' s behavioral aggressiveness was thoroughly evaluated and licensed staff develop individualized comprehensive care plan interventions and approaches that were communicated with all facility staff upon readmission to the facility on 5/8/2025 due to the resident ' s history of aggressive and violent behaviors with a recent choking incident on 5/3/2025.
As a result, Resident 1 displayed physically aggressive and violent behaviors when Resident 1 ran after the facility staff with a bread knife at the facility lobby while pointing the bread knife at the facility receptionist and made a gesture of slitting Registered Nurse (RN) 5 ' s neck with the same bread knife on 5/16/2025 at 3 AM, during the night shift (11 PM to 7 AM). Resident 1 was taken by the Police via another 5150-hold, 5/16/2025 and was taken to GACH 2 Psychiatric facility.
These deficient practices had the potential to result in facility staff getting physically hurt and injured, including other vulnerable residents that included Resident 1 ' s roommate (Resident 12) who is cognitively impaired and assistance with activities of daily living, and Resident 5 who is also cognitively impaired and resides adjacent to Resident 1 ' s room.
Findings:
During a review of Resident 1 ' s admission Record (AR), the AR indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cognitive communication deficit (communication difficulties stemming from underlying cognitive impairments, rather than from speech or language deficits), schizoaffective disorder- bipolar type (a mental illness that combines symptoms of schizophrenia [like hallucinations and delusions) with those of bipolar disorder (like mania and depression)], and psychotic disorder (when you see reality very differently to people around you).
During a review of Resident 1 ' s History and Physical Examination (HPE), dated 4/18/2024, the HPE indicated Resident 1 was alert to time, person and situation.
During a review of Resident 1 ' S Minimum Data Set (MDS – a resident assessment screening tool), dated 5/12/2025, the MDS indicated the Resident 1 ' s cognitively status (ability to think, remember, and reason) moderately impaired. The MDS indicated Resident 1 required supervision or touching assistance (Helper provides verbal cues and or touching steadying) with eating, partial/moderate assistance (helper does less than half the effort) with personal hygiene, dressing, toileting and bathing.
During a review of Resident 12 ' s AR, the AR indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cognitive communication deficit, schizophrenia, bipolar disorder, unsteadiness on feet and muscle weakness.
During a review of Resident 12 ' s History and Physical Examination (HPE), dated 5/15/2025, the HPE indicated Resident 12 does not have the capacity to understand and make decisions.
During a review of Resident 12 ' s MDS, dated [DATE], the MDS indicated the Resident 12 ' s cognitively status was severely impaired. The MDS indicated Resident 12 required Setup and clean-up assistance (helper sets up and cleans up; resident completes activity) with eating and oral hygiene, supervision or touching assistance with dressing, personal hygiene and walking, and partial/moderate assistance (helper does less than half the effort) with toileting and bathing.
During a review of Resident 5 ' s AR, the AR indicated the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer ' s disease (a progressive brain disorder that primarily affects memory and thinking skills, eventually leading to difficulty with everyday tasks and behavior changes), aortic aneurysm (a bulge that occurs in the wall of the body's main artery, called the aorta) and palliative care (focuses on improving the quality of life for people with serious illnesses by providing comfort and support, even when a cure isn't possible).
During a review of Resident 5 ' s HPE, dated 5/1/2024, the HPE indicated Resident 5 does not have the capacity to understand and make decisions.
During a review of Resident 5 ' s MDS, dated [DATE], the MDS indicated Resident 5 dependent with eating, oral hygiene, toileting, bathing, dressing and personal hygiene.
During a review of Resident 1 ' s facility document titled, Progress Notes (PN), dated 5/3/2025 timed at 1:45 PM, the PN indicated Resident 1 was aggressive and hurt Certified Nurse Assistant (CNA) 1 by putting his hands around CNA 1 ' s neck, and the police came and took Resident 1 to GACH 1 for physical aggression via 5150.
During a review of Resident 1 ' s GACH 1 record titled Transfer of Summary dated 5/8/2025, the GACH 1 record indicated Resident 1 ' s Reason for admission or Evaluation was due to involuntary hold for DTO (danger to others) initiated on 5/3/2025 through 5/6/2025 . The record further indicated Resident 1 was at risk for danger to others.
During a review of Resident 1 ' s facility document titled, Progress Notes (PN), dated 5/8/2025 at 9:06 PM, indicated Resident 1 was readmitted to the facility from GACH 1 at 3:40 PM.
During a review of Resident 1 ' s GACH 1 document titled Transfer of Care Summary dated 5/8/2025, indicated diagnosis was at risk for danger to others.
During a review of Resident 1 ' s IDT Conference Record dated 5/9/2025 (one day after facility readmission), the IDT Record attended by the Activity Assistant, Social Services Director (SSD), Dietary Services Director (DSS), Director of Rehabilitation (DOR), and RN MDS Coordinator, indicated the IDT met with Resident 1 ' s representative via telephone and discussed the resident ' s plan of care [NAME] included medical diagnosis, nursing care/services, medication management, health teachings, training therapy needs, dietary/activity preferences, discharge process, and code status. The IDT Record, including IDT interventions indicated in the IDT Record did not include recommendations for developing individualized comprehensive care plan interventions and approaches that were communicated with all facility staff upon Resident 1 ' s readmission to the facility on 5/8/2025 due to the resident ' s history of aggressive and violent behaviors and with a recent choking incident with CNA 1 on 5/3/2025 that resulted to a 5150 transfer to GACH 1.
During a review of Resident 1 ' s facility document titled, Progress Notes (PN), dated 5/12/2025 at 12:00 AM, the PN indicated Resident 1 had a sudden outburst of anger towards a CNA, and refuse to take PRN medication, the PN indicated the resident ' s physician was made aware and monitored. The PN did not indicate any other individualized behavioral interventions developed or implemented to prevent physical aggression towards others and protect other staff and residents from Resident 1.
During a review of Resident 1 ' s Progress Notes (PN), dated 5/12/2025 at 6:44 AM, the PN indicated Resident 1 noted with verbal and aggressive behavior towards staff and residents, yelling and screaming. The PN did not indicate any other individualized behavioral interventions developed or implemented to prevent physical aggression towards others and protect other staff and residents from Resident 1.
During a review of Resident 1 ' s Progress Notes (PN), dated 5/16/2025 at 5:11 PM, the PN indicated at around 3:07 AM, Resident 1 went out of his room towards the lobby and turned to the RN (RN 5) sitting at the Nurse Station and showed a silver knife in his hand. The PN indicated He (Resident 1) moved it towards his neck, acted like slitting it. The PN indicated [Resident 1] run towards RN 5 and other nurses in Station 1 pointing the knife towards them acted as if he will stab one. RN hurriedly called 911 for police assistance. The PN further indicated [Resident 1] went to the front desk area and pointed the knife at the receptionist. [Resident 1] got a folded metal chair, went to Station 1 and tried to slam it to a nurse who is trying to calm him down. When he [Resident 1] wasn ' t able to, he went inside his room with the bread knife and foldable chair. He [Resident 1] closed the door and locked it most probably with another chair. 2 police officers came and went inside his room, a banged (sic) was heard inside the room like a heavy object hitting the floor, one office was able to open the door. [Resident 1] was inside by his bed, while his roommate was inside too (Resident 12) on his own bed and was not hurt at all . The PN further indicated Resident 1 was taken via 5150 hold and GACH 2 psychiatric facility was notified.
During a review of a facility document (untitled) dated 5/17/2025 at 12 AM, the document indicated Resident [1] had a bread knife in his hand, and while in the [facility] lobby he moved the bread knife in his neck and acted like slitting it. He [Resident 1] also run after the nurses with a bread knife, he pointed a bread knife to the receptionist and almost hit a nurse with a folded metal chair. The document indicated law enforcement (police department) was notified and that there were no residents present in the facility hallway during that time.
During an interview on 5/7/2025 at 3:30 PM with Family 2 (Family of Resident 5), Fam 2 stated, on 5/3/2025 around 1 PM, while inside Resident 5 ' s room (which was adjacent to Resident 1 ' s room), she was talking to CNA 1, when Resident 1 came to Resident 5 ' s room and without warning attacked and started choking CNA 1. Fam 2 stated she helped CNA 1 and had to remove Resident 1 ' s hand around CNA 1 ' s neck. Fam 2 stated, the police came and took Resident 1 away. Fam 2 stated, she was concerned for Resident 5 ' s safety since Resident 5 is cognitively impaired, and other residents who cannot protect themselves from Resident 1. Fam 2 stated, she informed the Director of Social Services (DSS) and the facility leadership about her concern that same day.
During an interview on 5/7/2025 at 3:50 PM with CNA 1, CNA 1 stated, on 5/3/2025 around 1 PM she was talking to FAM 2 inside Resident 5 ' s room, when Resident 1 came inside Resident 5 ' s room and grabbed her neck and started choking her without warning. CNA 1 stated the staff came to help, and the police took Resident 1 away on 5/7/2025.
During an interview and record review on 5/20/2025 at 11:40 AM with the Medical Record Director (MRD) and the Director of Nurses (DON), Resident 1 ' s Electronic Health Records (EHR) dated 5/8/2025 (Resident 1 ' s admission date) until 5/20/2025 were reviewed. The EHR indicated the facility did not have an active care plan developed for Resident 1 ' s behavior or a behavior monitoring for Resident 1 ' s history of aggressive behavior/s, history of violence nor specific interventions for managing Resident 1 ' s behavior and protecting others against Resident 1 ' s aggressive/violent behaviors. During the concurrent record review, Resident 1 ' s IDT (Interdisciplinary Team - a group of professionals from different fields who work together to provide comprehensive care for a patient or resident) notes dated 5/9/2025 (day after readmission) did not indicate Resident 1 ' s aggressive behavior, history of violence nor specific plan for facility staff to manage/address Resident 1 ' s behavior was discussed during the IDT meeting. The MRD stated, Resident 1 should have a current/active care plan that addressed Resident 1 ' s behavior history with this current facility readmission. The MRD stated the previous care plans prior to the readmission cannot be used. The DON stated, Resident 1 ' s active care plans should include behavior monitoring and specific interventions regarding the resident ' s aggressive
behavior and history of violence, The DON stated the IDT notes did not indicate Resident 1 ' s aggressive behavior nor history of violence was discussed and there was no specific interventions to address Resident 1 ' s behavior history.
During an interview on 5/20/2025 at 1:40 PM with LVN (license Vocational Nurse) 6, LVN 6 stated she started her shift on 5/16/2025 around 3 AM and heard a commotion by the facility lobby. LVN 6 stated she saw Resident 1 yelling while at the facility lobby. LVN 6 stated Resident 1 was holding something but not sure what it was. LVN 6 stated, when she called for help from the other facility staff, Resident 1 started to chase the staff away and so the staff had to ran. LVN 6 stated, Resident 1 went back to his room while his roommate (Resident 12) was inside the same room, sleeping and closed the door.
During an interview on 5/20/2025 at 1:50 PM with RN (Registered Nurse) 5, RN 5 stated on 5/16/2025 around 3AM, she saw Resident 1 come out of his room, went to the facility lobby then looked at RN 5 while Resident 1 was holding a bread knife and made a gesture of slitting his neck. RN 5 stated she felt threatened and scared, and she does not know where Resident 1 got the bread knife. RN 1 stated, when she asked Resident 1 to put the knife down, Resident 1 pointed the knife at her while RN 1 remained about 15 feet away from Resident 1 ' s location. RN 1 stated, she ran away from Resident 1 and called the police, so as the sitter. RN 1 stated, Resident 1 ran back to his room, still holding on to the bread knife, closed the door of the room, while Resident 12 remained inside the same room, sleeping. RN 5 stated, she was not aware Resident 1 did not have a specific care plan for his aggressive behavior and history of violence. RN 5 was asked if the CNAs assigned to provide one to one monitoring to Resident 1 was provided with Resident 1 ' s behavior care plan or how to manage Resident 1 ' s specific behaviors and how to protect others against Resident 1. RN 5 stated, she just instructed the CNAs/sitter to ensure Resident 1 do not hurt himself or others.
During an interview on 5/20/2025 at 3:00 PM with CNA 6, CNA 6 stated, she sometimes works as a sitter for Resident 1. CNA 6 stated the instruction from the licensed nurses and RN supervisors when she was assigned as a sitter for Resident 1 was just to keep Resident 1 safe and does not get into fight with others. CNA 6 there was specific reason and care plan provided to her when she was assigned to supervise Resident 1 one-on-one.
During an interview on 5/20/2025 at 3:10 PM with CNA 7, CNA 7 stated, was assigned as a sitter for Resident 1 before and recalled the RN supervisor ' s instructions were to make sure if Resident 1 gets agitated to make sure he does not hurt himself or other residents. CNA 7 stated, he was not provided a specific plan of care of how to ensure Resident 1 does not hurt others.
During an interview and record review on 5/20/2025 at 3:15 PM with the Director of Social Services (DSS), Resident 1 ' s IDT notes dated 5/9/2025 (day after admission) was reviewed. the DSS stated, she is part of the IDT and the IDT notes did not have documented evidence that Resident 1 ' s specific aggressive behavior and history of violence was discussed, and there was no specific care plan interventions indicated in the IDT notes to prevent potential for abuse or harm to residents or staff.
During an interview on 5/20/2025 at 3:30 PM with CNA 8, CNA 8 stated on 5/16/2025 around 3AM, she saw Resident 1 in the lobby with a bread knife, he was screaming at RN 5, then he ran to his room with the bread knife and close the door, Resident 12 was in there sleeping. CNA 8 stated, everyone felt threatened and scared.
During an interview on 5/20/2025 at 3:55 PM with DON, DON stated, Resident 1 did not have a specific care plan nor intervention for his aggressive behavior and history of violence. DON stated, the care plan Resident 1 had was general and not specific enough. DON stated the IDT notes on 5/9/2025 had no documentation regarding the plan of care for Resident 1 ' s history of violent behavior. DON stated, not having a specific care plan for Resident 1 ' s aggressive behavior and history of violence and not having documentation on the plan of care on the IDT notes upon admission for Resident 1 ' s aggressive behavior and history of violence, had potentially led to an escalation of Resident 1 ' s behavior that could have resulted in abuse to residents and staff.
During a review of the facility ' s policy and procedure (P&P) titled, Abuse Prevention/ Prohibition, revised 11/2018, the P&P indicated; a) the facility does not condone any form of Resident abuse and/or mistreatment and develops a system in order to promote an environment free from abuse and mistreatment, b)Abuse is defined as a willful infliction of injury, involuntary seclusion, intimidation with resulting physical harm pain or mental anguish.
During a review of the facility ' s policy and procedure (P&P) titled, Care Planning – Interdisciplinary Team, revised 3/2022, the P&P indicated; a) the interdisciplinary team is responsible for the development of resident care plans, and b) comprehensive, person centered care plans are based of resident assessments and developed by an IDT.
During a review of the facility ' s policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated; a) A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet resident's physical, psychosocial and functional needs is developed and implemented for each resident, b) The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment, and c) The comprehensive, person-centered care plan includes measurable objectives and timeframes and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
During a review of the facility ' s policy and procedure (P&P) titled, Behavioral Assessment, Intervention and Monitoring, revised 3/2019, the P&P indicated; a) The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition, including: worsening of or complications related to other conditions and emotional, psychiatric and/or psychological stressors. b) Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for their behavior. The care plan will include, as a minimum, a description of the behavioral symptoms, including frequency, intensity, duration, outcomes, and precipitating factors or situations.
Dec 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0741
(Tag F0741)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide sufficient nursing staff who have the knowledge, training, ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide sufficient nursing staff who have the knowledge, training, and skills sets to address behavioral healthcare needs for one of four sampled residents (Resident 1), who was diagnosed with dementia and assessed at high risk for elopement, in accordance with the resident ' s care plan, the facility ' s policy and procedure on Behavioral Health Services, Dementia Care, and the Facility Assessment.
The facility staff failed to intervene when Resident 1, who was visibly agitated and refused to come back inside the facility upon returning from an out-on-pass with the family [FM 1] on 11/27/2024. Registered Nurse [RN] 1 failed to implement Resident 1 ' s care plan on Behavioral Problem. RN 1 did not address Resident 1 ' s agitated behavior and allowed Resident 1 to wander out of the facility and instructed FM 1 to follow the resident and for FM 1 to call law enforcement.
As a result of this deficient practice Resident 1 could not be found for two and half hours on 11/27/2024. On 11/27/2024, at around 8:10 PM, local law enforcement found Resident 1 and transferred to the general acute care hospital [GACH] and was placed on Welfare and Institutions Code 5150 hold (the code allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour when evaluated to be a danger to others, or to himself or herself, or gravely disabled).
Findings:
During a review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 6/20/2024 with diagnoses that included encephalopathy (a general term for a group of brain disorders or diseases that cause brain dysfunction) and unsteadiness on feet.
During a review of Resident 1 ' s Elopement Risk Assessment (ERA), dated 6/21/2024, indicated Resident 1 had elopement risk total score of 12 which indicated Resident 1 had a history of elopement and was at high risk for elopement. The ERA indicated Resident 1 had wander behavior and wander aimlessly. The potential interventions for elopement indicated frequent monitoring-check every two hours, identification bracelet, and staff aware of resident ' s wander risk.
During a review of Resident 1 ' s Care Plan, dated 6/21/2024, the Care Plan indicated Resident 1 was at risk for elopement and the interventions were to assist in re-orientation to room/facility, monitor resident location with visual check, monitor behavior and mood patterns, anticipate resident needs based upon wandering behavior.
During a review of Resident 1 ' s History and Physical Examination (H&P), dated 6/22/2024, indicated Resident 1 had a diagnosis of dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities) and Resident 1 does not have the capacity to understand and make decisions.
During a review of Resident 1 ' s Psychiatric Examination, dated 6/27/2024, indicated Resident ' s chief complaint and psychiatric history was anxiety (a feeling of fear, dread, and uneasiness that can be a normal reaction to stress).
During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 9/24/2024, indicated Resident 1 required supervision or touching assistance for eating, and partial/moderate assistance with oral hygiene, toileting hygiene, shower/bathe self, and personal hygiene, and chair/bed-to-chair transfer.
During a review of Resident ' s Care Plan, dated 10/8/2024, the Care Plan indicated Resident 1 has a behavior problem and the intervention was to intervene as necessary by approach/speak in a calm manner, divert attention, and remove from situation and take to alternate location as needed.
During a review of Resident 1 ' s Elopement Evaluation (EE), with effective date 11/26/2024 and timed at 12:18 PM, indicated Resident 1 had a history of elopement and was the risk for elopement and she had a pattern of wandering behavior. The EE indicated the intervention included notify staff of wandering and elopement risk and monitor location frequently.
During a review of Resident 1 ' s Change in Condition Evaluation (COC), dated 11/26/24 at 5:09 PM, the COC evaluation indicated Resident 1 attempted to leave the facility on 11/26/2024 [prior to the resident ' s out on pass with the family member on the same day].
During a review of Resident 1 ' s Progress Notes (PN), dated 11/27/2024, was reviewed. The PN indicated the Family Member (FM) took Resident 1 home out on pass on 11/26/2024 at 6 PM [an hour prior to Resident 1 ' s attempt to elope the facility on 11/26/2024 timed at 5:09 PM] and planned to bring Resident 1 back to the facility after the holiday celebration, but Resident 1 was showing aggressive behavior at home. Then, on 11/27/2024 at 6:30 PM, the FM came inside the facility and asked for help because she brought Resident 1 to the outside of the facility but Resident 1 refused to come inside and walked away. The PN indicated FM 1 did not want to force Resident 1 getting inside the facility. The facility staff followed up with the FM over the phone twice and asked about Resident 1 ' s whereabouts, then, the FM stated she did not know where Resident 1 was. The facility staff advised the FM to report to local police. On 11/27/2024 around 9:30 PM, Resident 1 was found by police.
During a review of the Police Report (PR), dated 11/27/2024, the PR indicated that on 11/27/2024, at approximately 8:10 PM assisted with a missing person report. The PR indicated Resident 1 walked away from the facility after she was dropped off by the FM. The PR indicated Resident 1 was located sitting on a bus bench, subsequently. The PR indicated that based on Resident 1 ' s conflicting statements and wanting to wander the streets of another city, Resident 1 was transported to the GACH and was placed on Welfare and Institutions Code 5150 hold by the GACH. The PR indicated Resident 1 was gravely disabled and a danger to herself.
During a review of Resident 1 ' s Order Summary Report, for December 2024, the Order Summary Report indicated physician order dated 6/21/2024, to monitor the resident ' s whereabouts every two hours, visual check due to high risk for elopement. The Order Summary Report also indicated another physician order dated 11/26/204, that Resident 1 may go out on pass with the FM for 48 hours.
During an interview on 12/3/2024 at 10:53 AM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was assigned to take care of Resident 1 regularly in the morning shift and she was familiar with Resident 1 ' s care. CNA 1 stated Resident 1 was confused, and she would get mad sometimes by yelling and screaming at the staff. CNA 1 stated she was not aware that Resident 1 was on the watch for elopement risk before the incident on 11/27/2024.
During an interview on 12/3/2024 at 11:15 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 was delusional sometimes and she could be aggressive sometimes by yelling and screaming at the staff. LVN 1 stated the facility identified Resident 1 was at risk for elopement before [could not recall date]. LVN 1 stated Resident 1 tried to go out the facility without the staff ' s supervision two times before [unable to recall dates], but the facility staff caught the resident before she could go out the facility.
During an interview on 12/3/2024 at 11:30 AM, with the Director of Nursing (DON), the DON stated the receptionist reported to her that Resident 1 was holding a bag and had the tendency of going out the facility on 11/26/2024 [prior to leaving out on pass with the FM], so the facility notified Resident 1 ' s physician and obtained an order to put a wander guard on the resident, and completed the COC. The DON stated Resident 1 was often out on pass with the family members and returns to the facility on the same day without any issue in the past. The DON stated Resident 1 did not have any history of an actual elopement from the facility, so the FM ' s request to take Resident 1 home for 48 hours for the holiday was approved even though it was the first time for Resident 1 to be out of the facility overnight. The DON stated the FM took Resident 1 home out on pass for 48 hours on 11/26/24 at 6 PM, but the FM decided to bring Resident 1 back to the facility on [DATE], because Resident 1 was showing aggressive behavior, and she could not control the resident at home. The DON stated the FM informed the staff that Resident 1 did not want to come inside the facility and Registered Nurse (RN) 1 offered that the staff could grab Resident 1 and bring the resident inside, but the FM did not want to forcefully bring Resident 1 back to the facility. The DON stated since the FM refused the staff ' s help at that time [on 11/27/24] and allowed Resident 1 kept walking away, the facility had to respect the FM ' s choice and followed up with the FM by phone to check the whereabouts of Resident 1. The DON stated the facility did not send a staff to follow Resident 1 because the staff could not follow Resident 1 wherever she was going to walk to. The DON stated when RN 1 knew about Resident 1 was missing, the facility did not report to the police, instead, RN 1 advised the FM to report to the police to find Resident 1.
During a telephone interview on 12/3/2024 at 12:52 PM, with RN 1, RN 1 stated on 11/27/2024 at 6:30 PM, the FM came inside the facility and said she brought Resident 1 back to the facility. The FM stated Resident 1 was still outside the facility, because the resident refused to come back inside the facility and walking away. RN 1 stated the FM said Resident 1 was acting out at home and yelling at the FM, and she could not control Resident 1 at home. RN 1 stated she did not see Resident 1 outside the facility lobby at that time. RN 1 stated she asked the FM if it was ok for the staff to grab Resident 1 and bring her in, but the FM did not want to force Resident 1 to go inside and wanted Resident 1 to be willing to go back to the facility. RN 1 stated she offered help, but the FM refused at that time. RN 1 stated she did not send any facility staff outside to check on Resident 1 because if Resident 1 would not listen to the FM, then, she would not listen to a facility staff who the resident was not familiar with. RN 1 stated she told the FM to follow Resident 1 and kept a visual on her, then, she called twice to follow up with the FM regarding the whereabouts of Resident 1. RN 1 stated 20 minutes later, she saw the FM was sitting in the car outside of the facility, and the FM said she did not know where Resident 1 was. RN 1 stated she advised the FM to report to the police. RN 1 stated Resident 1 was found around 9:30 PM. RN 1 stated Resident 1 was out on pass, the FM was responsible for the resident. RN 1 stated the facility would be responsible for Resident 1 until she was checked in back to the facility. RN 1 stated she was not sure or aware if Resident 1 was at risk for elopement.
During a telephone interview on 12/3/2024 at 2:36 PM, with the FM, the FM stated on 11/27/2024 morning, Resident 1 was getting more difficult and agitated as the day progressed and she could not control Resident 1 at home anymore, so she decided to bring Resident 1 back to the facility. The FM stated Resident 1 had dementia and was showing the symptoms of early stage of dementia, but the aggressive behavior at home was new to her and she did not know how to handle Resident 1 safety at home. The FM stated she drove Resident 1 to the facility, but when Resident 1 was 10 feet away from the facility ' s lobby door, Resident refused to go inside and started to walk away. The FM stated she tried to convinced Resident 1 but Resident 1 just kept walking further away. The FM stated she did not know what to do and went inside the facility to ask for help. The FM stated she could not get help from the facility staff at the front lobby until RN 1 came out and talked to her. The FM stated RN 1 asked if she agreed to have the staff to grab Resident 1, and she replied she did not want to force Resident 1 back to the facility and she did not know what to do. The FM stated RN 1 told her to follow Resident 1 and keep an eye on the resident. The FM stated she tried to follow Resident 1, but when Resident 1 saw her, Resident 1 turned around and walked away from her, so she decided to wait in the car, in hoping that Resident 1 would return on her own if Resident 1 did not see her following, but she did not see Resident 1 walked back to the facility. The FM stated when she told RN 1 that she did not know where Resident 1 was, RN 1 told her that she had to call the police herself. The FM stated she went inside the facility to ask for help because she did not know what to do when Resident 1 refused to go inside the facility and walked away. The FM stated she thought the facility staff would send someone outside to talk to Resident 1 and bring her in the facility calmly, but the facility did not send anyone outside to check on Resident 1. The FM stated she felt helpless at that time because she did not have the professional knowledge of dealing with a situation like this and she expected the facility staff to provide professional assistance to address Resident 1 ' s behavior and ensure the resident safety.
During an interview on 12/3/2024 at 3:55 PM, with the DON, the DON stated the facility had the responsibility for Resident 1 ' s safety when the resident was outside the facility. The DON stated Resident 1 had a diagnosis of dementia and was showing signs and symptoms of distress when the FM tried to bring Resident 1 back to the facility. The DON stated the staff should addressed Resident 1 ' s distress and provide professional assistance to check on Resident 1 right away, bring her back to the facility, and call the police as needed to ensure the resident ' s safety.
During an interview on 12/10/2024, at 3 PM, the DON stated as this time, the staff would receive dementia care training upon hire and regular dementia care in-service during facility huddle and daily rounding. The DON stated the facility did not have a competency checklist for each staff about dementia care. The DON stated dementia care was not included in the staff annual competency evaluation. The DON stated there were 14 residents residing at the facility assessed at risk for elopement.
During a review of the facility ' s Policy and Procedures (P&P), Behavioral Health Services, dated 2/2019, indicated Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care. The P&P indicated Staff must promote dignity, autonomy .and safety as appropriate for each resident and are trained in ways to support residents in distress.
During a review of the facility ' s Hand in Hand Dementia Training Acknowledgement, dated 4/23/2024, indicated Registered Nurse (RN) 1 certified that she was able to effectively listen and speak with a person with dementia and understand the actions and reactions of persons with dementia as forms of communication.
During a review of the facility ' s Facility Assessment (FA), dated 7/1/2024 to 9/1/2024, The FA indicated the facility would address the diagnosis and condition of dementia and would provide training in non-pharmacological interventions, dementia care, change of condition, baseline and care plan content and resident rights. The FA also indicated the facility would provide dementia training twice per year.
Nov 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide adequate monitoring and supervision to ensure one of two sampled resident (Resident 1), who had severely impaired cogn...
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Based on observation, interview and record review, the facility failed to provide adequate monitoring and supervision to ensure one of two sampled resident (Resident 1), who had severely impaired cognition and memory and was assessed at risk for elopement with diagnoses of dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities) did not elope from the facility on 11/14/2024.
The deficient practice had resulted in Resident 1 eloping from the facility on 11/14/2024. As of 11/15/2024, Resident 1 had not been found by the facility staff. Resident 1 had the potential for fall and injury from being struck by motor vehicles. Resident 1 also had the potential to be exposed to extreme weather and malnutrition (lack of proper nutrition.
Findings:
During a review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 10/23/2024 with diagnoses that included dementia and heart failure (a condition that the heart isn ' t pumping as well as it should).
During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/4/2024, indicated Resident 1 had severely impaired cognition (ability to think and reason) and memory. The MDS indicated Resident 1 required supervision or touching assistance for eating, chair/bed-to-chair transfer, walk 50 feet with two turns and walking 10 feet on uneven surfaces, and partial/moderate assistance with oral hygiene, toileting hygiene, shower/bathe self, and personal hygiene. The MDS also indicated Resident 1 had wander/elopement alarm.
During a review of Resident 1 ' s Elopement Evaluation, dated 10/30/2024, indicated Resident 1 was at high risk for elopement. The Elopement Evaluation indicated Resident 1 had a history of elopement or attempted leaving the facility without informing staff; Resident 1 verbally expressed the desire to go home, packed belongings o go home or stayed near an exit door; Resident 1 wanders; Resident 1 ' s wandering behavior is a pattern, goal-directed with specific destination in mind; Resident 1 ' s wandering behavior likely to affect the safety or well-being of self/others; and Resident 1 has been recently admitted and is not accepting the situation.
During a review of Resident 1 ' s Order Summary Report, dated 10/31/2024, indicated the physician order Resident 1 may have wander guard due to elopement risk score at six (high risk), starting on 10/30/2024.
During a review of Resident 1 ' s Care Plan, dated 10/30/2024, the Care Plan indicated the goal was the resident will not leave facility unattended and the resident ' s safety will be maintained. The Care Plan indicated to identify if there is a certain time of day wandering/elopement attempts occur.
During a review of Resident ' s with Wanderguard, dated 11/11/2024, indicated Resident 1 was on the list of Resident ' s with Wanderguard.
During a review of the Facility ' s Elopement Binder, Resident 1 ' s picture and information were in the Elopement Binder.
During an interview on 11/15/2024 at 11:52 AM, with the Licensed Vocational Nurse (LVN), the LVN stated Resident 1 always asked if he lived in the facility and he remembered the place where he used to live. The LVN stated Resident 1 was high risk for elopement and they put a wander guard on his wrist, and she checked his wander guard around 6:50 AM on 11/14/2024 which was working. The LVN stated the last time she saw Resident 1 was between 12 PM and 12:15 PM when she was passing medications to other residents. The LVN stated Resident 1 walked passing the medication cart and got some juice from her. The LVN stated it was between 12:50 PM and 1 PM, the Treatment Nurse (TXN) came to the nursing station and asking if someone saw Resident 1, then, everyone started to look for him and Code 10 (a code activated when a patient is missing) was called.
During an interview on 11/15/2024 at 12:24 PM, with the Receptionist, the Receptionist stated his responsibility was stay at the front desk in the lobby to monitor the residents in the lobby. The Receptionist stated Resident 1 hangs out in the lobby and the activity room which the door was facing the lobby, and Resident 1 has said he wanted to leave the facility. The receptionist stated Resident 1 always held a plastic bag packed with his belongs and trying to go out. The Receptionist stated he reported Resident1 ' s behavior to the nurses, and they put a wander guard on his wrist. The Receptionist stated it was around 12:30 PM on 11/14/2024, he needed to use the restroom, then, he checked with an activity staff who was supervising the dining room during lunch time and the nursing supervisor at the nursing station who was assisting a resident, but they were busy at that time, so he decided to leave his post and go to the restroom without making sure someone was monitoring the lobby. The receptionist stated he saw Resident 1 sitting inside the activity room, holding his plastic bag, and looking outside before he left his post. The Receptionist stated he returned to his post 40 seconds later and the wander guard alarm by the lobby entrance was not beeping and he did not notice Resident 1 had eloped. The Receptionist stated he was unsure if Resident 1 was wearing the wander guard. The Receptionist stated the facility did not pre-assign other staff to cover his post when he was on break, and he could not find coverage for his break sometimes because everyone was busy with their own work. The Receptionist stated he should find someone to monitor the lobby before he left his post yesterday to prevent Resident 1 from leaving the facility without supervision.
During a concurrent observation and interview on 11/15/2024 at 1:45 PM, with the Administration (ADM), the facility ' s video footage of the surveillance camera at the lobby was reviewed. The ADM stated the Receptionist left his post and disappeared from the footage at 12:31:07 PM on 11/14/2024, shortly after, Resident 1, who was holding a plastic bag came out from the activity room, walked towards the entrance door, and left the facility at 12:31:23 PM on 11/14/2024 without staff ' s supervision. The ADM stated the Receptionist returned his post at 12:32:15 PM on 11/14/2024. The ADM stated there was no staff monitoring the lobby area during the time Resident 1 eloped and there should be a staff at the front desk to always monitor the lobby.
During an interview on 11/15/2024 at 1:55 PM, with Resident 2, Resident 2 stated Resident 1 always said that he did not like here and he wanted to leave. Resident 2 stated he was looking for Resident 1 before lunch and he could not find him yesterday.
During an interview on 11/15/2024 at 2 PM, with the Acting Director of Nursing (ADON), the ADON stated the Receptionist was supposed to find coverage before he left the post to ensure resident ' s safety and she did not why the Receptionist did not ask someone to cover him.
During an interview on 11/15/2024 at 2:46 PM, with the Director of Nursing (DON), the DON stated Resident 1 ' s elopement on 11/14/2024 was because the Receptionist left his post without making sure someone was monitoring the lobby area. The DON stated the receptionist must find someone to cover the post and have staff available to help with coverage to ensure residents ' safety. The DON stated the facility did not provide adequate supervision to ensure Resident 1 ' s safety and Resident 1 was still not found at this time.
During a follow up telephone interview on 11/26/2024 at 2:08 PM, with the ADM, the ADM stated the police informed him that Resident 1 was located and placed under police custody. The ADM stated the police informed him it was not clear if Resident 1 would return to the facility at this time.
During a review of the facility ' s policy and procedure (P&P) titled, Receptionist, dated 10/2003, indicated the receptionist promotes a safe environment for residents, visitors, and staff at all times.
During a review of the facility ' s P&P titled, Safety and Supervision of Residents, dated 7/2017, indicated Resident supervision is a core component of the systems approach to safety.
During a review of the facility ' s P&P titled, Nursing-Wandering and Elopement, dated 6/2018, indicated the facility to enhance the safety of the residents, reinforce proper procedures for leaving the facility for residents assessed to be at risk for elopement, and provide extra monitoring on the residents ' whereabouts.
Oct 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0573
(Tag F0573)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the resident with access to personal and medical records pe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the resident with access to personal and medical records pertaining to him or herself, upon an oral or written request, in the form and format requested by one of two sampled residents (Resident 1), or in a readable hard copy form or such other form and format as agreed to by the facility and the resident, within 24 hours (excluding weekends and holidays), in accordance with the facility ' s Policy and procedure [P&P] titled Resident Rights and Release of Information.
This deficient practice violated the rights of Resident 1 to access personal and medical records pertaining to him or herself.
Findings:
A review of Resident 1 ' s the admission Record indicated Resident 1 was admitted to the facility on [DATE], with a primary diagnosis of polyneuropathies (disease affecting nerves).
A review of Resident 1 ' s History and Physical dated 7/27/2024, indicated Resident 1 had capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data set (MDS- a federally mandated resident assessment tool) dated 8/9/2024, indicated resident 1 has moderate cognitive impairment (may need extra assistance with daily activities).
During an interview on 10/10/2024 at 10:02AM with Resident 1, Resident 1 stated that she initially requested a copy of her medical records in August 2024 and had a discussion with the Administrator (ADM) regarding the process of requesting medical records. Resident 1 stated she had made multiple attempts to obtain her medical records from the facility but had not yet received the medical release form to obtain copies of her medical records.
During an interview on 10/10/2024 at 10:34 AM with the Administrator (ADM), the ADM stated he recalled Resident 1 requesting her medical records and had instructed Medical Records [MR] Staff to provide Resident 1 with the medical records release form. The ADM explained that after the request to medical records department was made, he did not follow up with Medical Records staff anymore to ensure Resident 1 received a copy of her records. The ADM stated it is important to allow residents to access to their personal medical records because it is their right as a resident.
During an interview on 10/10/2024 at 10:35 AM with Medical Records [MR] Staff, MR Staff stated she had received a text message from the ADM indicating that Resident 1 was requesting her medical records and required a release form to proceed. MR Staff stated that when she approached Resident 1 [unable to provide a date] to provide the medical release form, Resident 1 no longer wished to receive her medical records. MR Staff stated she did not document Resident 1 ' s wishes not to pursue receiving a copy of her medical records.
During an interview on 10/10/2024 at 10:51 AM with Resident 1, Resident 1 stated that MR Staff never offered her the opportunity to fill out a medical release form and denied ever having refused or changed her mind in regard to wishing to receive a copy of her medical records.
A review of the facility ' s policy and procedure (P&P) titled, Resident Rights, revision date of December 2016, the P&P indicated, Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident ' s right to access personal and medical records pertaining to him or herself.
A review of the Facility ' s policy and procedure (P&P) titled, Release of Information ' , revision date of November 2009, the P&P indicated, the resident may have access to his or her records within 5 days (excluding weekends or holidays) of the resident ' s written or oral request.
Oct 2024
20 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain an informed consent for psychotropic (any drug...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain an informed consent for psychotropic (any drug that affects behavior, mood, thoughts, or perception) drug for one of one sampled resident (Resident 99) who was prescribed Quetiapine (medication used to treat a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), and Zolpidem (medication used for used to treat insomnia (trouble sleeping) .
This deficient practice had violated Resident 99's rights to be informed when choosing the type of care or treatment to be received, make decisions on alternative measures the resident or responsible party preferred, which could negatively affect Resident 99 ' s quality of life.
Findings:
A review of the admission record indicated Resident 99 was admitted on [DATE] with diagnoses that included dementia (a group of related symptoms associated with an ongoing decline of the brain and its abilities), psychotic disorder (affect the mind, where there has been some loss of contact with reality), and cognitive communication deficit.
A review of Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 6/4/2024, indicated Resident 99 ' s cognitive status was severely impaired. The MDS indicated Resident 99 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guar assistance as resident completes activity) with eating, partial/moderate assistance (helper does less than half the effort) with toileting and substantial/maximal assist (helper does more than half the effort) with bathing and personal hygiene.
During an observation on 10/1/2024 at 10:03 AM in the facility dining room, Resident 99 on a wheelchair with activity staff verbalizing nonsensical (having no meaning; making no sense) words.
During a concurrent observation and interview on 10/3/2024 at 11:00 AM with certified nurse assistant (CNA) 3 Resident 99 was in bed asleep. CNA 3 stated, Resident 99 gets confused with episodes of agitation, and the staff would just redirect resident 99 ' s attention.
During an interview on 10/3/2024 at 11:15 AM with Director of Staff Development (DSD) stated, Resident 99 was receiving psychotropic medications, and it should have a consent obtained and signed by the physician as per policy. DSD stated, the physician needs to explain the cause and effect of the medication and other alternatives. DSD stated, not having consent for psychotropic medication, violates resident rights.
During a concurrent interview and record review, on 10/3/2024, at 11:30 AM, with Director of Nurses (DON), Resident 99 ' s Informed Consent for psychotropic drugs Quetiapine and Zolpidem, (undated) was reviewed. The documents did not have a date and a physician name or signature who obtained consent. DON stated, the psychotropic informed consent should have a signature of the doctor per policy. DON stated, she did not have any documented proof, consent for psychotropic drugs was obtained by the doctor from Resident 99 or responsible party. DON stated, it was important for the doctor to obtain the consent for psychotropic medication, so he can explain pros and cons of the medications and alternative options. DON stated, not having not having psychotropic medication consents violates Resident 99 ' s rights.
A review of Resident 99 ' s facility document Order Summary Report (OSR), dated 10/1/2024, , the document indicated order for: a) Quetiapine Fumarate 25 mg (unit of weight) to give 1 tablet at bedtime for schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves) ordered 5/31/2024, and b) Zolpidem Tartrate 10 mg to give 1 tablet at bedtime for insomnia manifested by inability to sleep, ordered 9/23/2024.
A review of the facility ' s policy and procedure (P&P) titled Informed Consent, dated 6/2019, indicated: a) to involve residents in their care decisions by facilitating information and obtaining consent for the use of psychotropic drugs, b) if resident is determined not to have the capacity to make informed decisions a surrogate decision maker is identified, c) when initiating a new order in psychotropic drugs the attending physician will obtain inform consent from resident or responsible party.
A review of the facility ' s policy and procedure (P&P) titled Resident Rights, dated 2/2021, indicated, federal and state law guarantee certain basic rights to all residents of the facility, these rights included rights to: a) be notified of his or her medical condition and of anu changes in his or her condition, and b) be informed of , and participate in, his or her care planning and treatment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide communication board (a sheet of symbols, pict...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide communication board (a sheet of symbols, pictures, or photos that one can use by point to, to help people who have limited spoken language ability to communicate with others.) to facilitate and help residents express and have their needs met for one of twenty-three sampled residents (Resident 23).
This failure had a potential to result in Resident 23's needs not met, feeling upset, potential decline in quality of care provided to her and her overall quality of life.
Findings:
During a review of Resident 23's admission Record indicated the facility initially admitted Resident 23 on 4/1/2015 and readmitted on [DATE] with diagnoses that included hemiplegia (a condition that causes partial or complete paralysis or weakness on one side of the body and hemiparesis (weakness or an inability to move on one side of the body) following cerebral infraction (stroke, a serious condition that occurs when blood flow to the brain is disrupted, causing brain tissue to die) affecting right dominant side, muscle weakness, cognitive communication deficit, aphasia (loss of the ability to understand or express spoken or written language), and dysphagia (difficulty swallowing).
During a review of Resident 23 ' s Speech Therapy SLP (Speech-Language Pathologist, a communication expert that assess and treat people who have speech, language, voice, and fluency disorders) Evaluation and Plan of Treatment, dated 7/15/2023, indicated Resident 23 had profound expressive language skills characterized by mostly nonverbal speech. The record indicated Resident 23 was able to express occasional yes/no answers to questions, follow directions, read written text but unable to write, and recommended interventions included implementation of simple communication boards to facilitate with wants/needs.
During a review of Resident 23's History and Physical, dated 8/12/2024, indicated Resident 23 had fluctuating capacity to understand and make decisions.
During a review of Resident 23's care plan (a document that outlines the facility ' s plan to provide personalized care to a resident based on the resident ' s needs), dated 3/6/2024, indicated Resident 23 was at risk of communicate her needs due to problems with inability to express self making self-understood by others. The goal was to use a form of communication to help Resident 23 effectively communicate with others and ensure all her needs anticipated and met by the facility. The interventions included to provide alternative means of communication, including use of communication board.
During a concurrent dining observation and interview on 10/1/2024 at 12:15 PM with Resident 23 in her room, Resident 23 was observed eating alone with no assistant and unable to cut up a piece of adult palm size chicken. Resident 23 pointed to her right arm to express that her right arm could not move and that she could not use her right hand to cut up the chicken to eat.
During a concurrent observation and interview on 10/1/2024 at 12:45 PM with Certified Assistant Nurse (CNA) 4 in Resident 23's room, Resident 23 was pointing at the lunch tray and making gesture with four fingers while CNA 4 was observed guessing what Resident 23 wanted for approximately 10 minutes. CNA 4 stated, she could not understand what Resident 23 wanted. When surveyor asked Resident 23 if she wanted to cut the chicken up in four pieces, Resident 23 nodded her head. CNA 4 stated, she usually guessed what Resident 23 wanted and she had never seen any communication board in the facility. CNA 4 stated, there should be a communication board with pictures to help understand the resident better because Resident 23 could read and understand when staff communicated with her.
During a concurrent observation and interview on 10/3/2024 at 4:04 PM with CNA 9 in Resident 23 ' s room, Resident 23 was observed upset, lying on the right-hand side and making left hand gesture toward CNA 9, CNA 9 was observed guessing what Resident 23 wanted. CNA 9 stated, she was not Resident 23 ' s regular CNA so she did not understand what Resident 23 was trying to say. CNA 9 stated, she would come out and request help from her coworker. CNA 9 stated, she had never seen any communication board in the facility.
During a concurrent observation and interview on 10/3/2024 at 4:10 PM with CNA 10 in Resident 23 ' s room, CNA 10 stated, she came to help CNA 9 to understand what Resident 23 wanted. CNA 10 stated, she could not understand what Resident 23 wanted. CNA 10 stated, she had not seen any communication board with pictures and simple languages in the facility.
During an interview on 10/3/2024 at 6:08 PM with the Director of Nurses (DON), the DON stated, the facility had communication board with pictures to assist in helping staff communicate with the residents who had difficulty in expressing their needs. The DON stated, without communication board, the staff could neglect what Resident 23 ' s needs and not able to provide the services that she needed. The DON stated, the resident could feel upset for not able to communicate what she wanted, and her health could decline.
During a review of the facility ' s policy and procedure (P&P) titled, Accommodation of Needs, dated March 2021, the P&P indicated in order to accommodate individual needs and preferences, staffs are to interact with the residents in ways that accommodate the physical or sensory limitations of the residents, promote communication, and maintain dignity.
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
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement facility's written abuse (the willful infliction of injur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement facility's written abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) policy and procedure for two of three sampled residents (Resident 106 and Resident 29) by not conducting a thorough investigation when the two residents were involved in a resident-to-resident altercation.
Resident 106 allegedly physically abused by Resident 29 during a resident -to-resident altercation on 9/26/24. Resident 29 poured a cup of water on Resident 106, who was sleeping on his bed around 7:30 PM on 9/26/24. Resident 29 walked out the room with Resident 106 following behind him. Resident 29 and Resident 106 stopped and stood face to face about one foot away from each other in front of the nursing station #1. Resident 106 asked Resident 29 loudly why did you pour water me? Resident 29 stayed quiet and did not say anything.
These deficient practices resulted in the residents not protected from repeat abuse and residents at risks from injury from abuse, feeling of intimidation and neglect.
Findings:
During a review of Resident 106's admission Record indicated the facility admitted Resident 106 on 9/13/24 with diagnoses that include schizophrenia (a mental health condition that is marked by a mix of symptoms, such as hallucinations and delusions, mood disorder depression, and mania) and anxiety disorder (a mental illness that causes a person to experience excessive and uncontrollable feelings of fear or anxiety).
During a review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/17/24, indicated Resident 106 had moderately impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 106 required supervision or touching assistance with eating, and partial/moderate assistance with oral hygiene, toilet hygiene, shower/bathe self and personal hygiene, and chair/bed-to-chair transfer.
During a review of Resident 29's admission Record indicated the facility originally admitted Resident 29 on 2/13/24 and readmitted on [DATE] with diagnoses that include schizophrenia (a mental health condition that is marked by a mix of symptoms, such as hallucinations and delusions, mood disorder depression, and mania) and dementia (a chronic condition that causes a decline in cognitive abilities, such as thinking, remembering, and reasoning, that interferes with daily life).
During a review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/4/24, indicated Resident 29 had moderately impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 29 required supervision or touching assistance with eating, and partial/moderate assistance with oral hygiene, toilet hygiene, shower/bathe self and personal hygiene, and chair/bed-to-chair transfer.
During a review of Resident 106 ' s Progress Notes, dated from 9/26/24 to 10/4/24, the Progress Notes indicated there was no documentation and investigation related to the altercation between Resident 106 and Resident 29.
During a review of Resident 29 ' s Progress Notes, dated from 9/1/24 to 10/2/24, the Progress Notes indicated there was no documentation related to the altercation between Resident 106 and Resident 29.
During an interview on 10/1/24 at 3:20 PM, with Resident 106, Resident 106 stated, he remembered the day Resident 29 was transferred to his room, and they became roommates. Resident 106 stated it was at around 7:30 PM while he was sleeping on his bed, Resident 29 walked toward his bed suddenly poured a cup of water on him. Resident 106 stated Resident 29 immediately walked out their room right away, he then followed Resident 29 to the nursing station #1. Resident 106 stated he asked Resident 29 why he poured water on him, but Resident 29 did not answer and pretended he did not do it. Resident 106 stated Resident 29 had issues and he always tried to look for trouble. Resident 106 stated Resident 29 poured the water on him on purpose. Resident 106 stated the staff separated them immediately after the incident occurred. Resident 106 stated he was upset at that time, and he had to keep an eye on Resident 29 all the time to make sure he did not try to do something to him again.
During an interview on 10/2/24 at 4:25 PM, with Licensed Vocational Nurse (LVN) 4, LVN 4 stated he could not remember if it happened on 9/25/24 or 9/26/24 around 7:30 PM, he saw Resident 29 walked out the room with Resident 106 following behind him. LVN 4 stated Resident 29 and Resident 106 stopped and stood face to face about one foot away from each other in front of the nursing station #1. LVN 4 stated Resident 106 asked Resident 29 loudly why did you pour water me? LVN 4 stated Resident 29 stayed quiet and did not say anything. LVN 4 stated Resident 106 and Resident 29 got really close to each other, then, the staff separated the residents. LVN 4 stated he did not witness how Resident 29 pour water on Resident 106, but he saw Resident 106 ' s bed was wet, so the Certified Nursing Assistant (CNA) 3 changed the wet bed linens for Resident 106 and housekeeping came to clean the floor. LVN 4 stated he thought the altercation was reported and the DON was aware because the DON was in the facility at that time.
During an interview on 10/2/24 at 4:30 PM, with CNA 3, CNA 3 stated she did not witness Resident 29 poured water on Resident 106, but after the incident, she was sent to change Resident 106 ' s bed. CNA 3 stated she saw Resident 106 ' s bed was wet, and she changed the bed linens for Resident 106. CNA 3 stated she only remembered the altercation occurred sometime last week but could not remember the exact date.
During an interview on 10/4/24 at 11:20 AM, with the Director of Nursing (DON), the DON stated she did not know about the altercation between Resident 106 and Resident 29 occurred last week and no staff had reported it to her until the surveyor informed her. The DON stated she did not investigate since she did not know about it. The DON stated a resident-to-resident altercation between Resident 106 and Resident 29 should be investigated and intervene effectively to protect the residents in the facility.
During an interview on 10/4/24 at 1:08 PM, with Registered Nurse (RN) 4, RN 4 stated Resident 29 was transferred to Resident 106 ' s room on 9/26/24.
During an interview on 10/4/24 at 5:00 PM, with the Administrator (ADM), the ADM stated he and the DON did not know about the altercation between Resident 106 and Resident 29 until today. The ADM stated he did not know that the staff who were aware of the altercation on 9/26/24 did not report or document it. The AMD stated a thorough investigation should be conducted to prevent reoccurrence of the altercation and protect the residents.
During a review of Report of Suspected Dependent Adult/Elder Abuse (SOC 341, a form, as adopted by the California Department of Social Services CDSS, is required under Welfare and Institutions Code WIC. Use SOC 341 to report suspected dependent adult/elder abuse), dated 10/4/24, indicated the incident was reported to the Department on 10/4/24 at 2:02 PM via facsimile transmission.
During a review of the facility ' s policy and procedure (P&P) titled, Abuse Reporting and Investigation, dated 11/2018, indicated When the Abuse Prevention Coordinator receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, exploitation or injuries of an unknown source, the APC will initiate an investigation immediately. The P&P indicated to inform resident of results of investigation or Corrective Action and provide a written report of the results of all abuse investigations and appropriate action taken to the California Department of Public Health Licensing and Certification and others that may be required by state or local laws, within five working days for the reported allegation
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report immediately and within two hours an allegation or suspicion ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report immediately and within two hours an allegation or suspicion of physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) to the Administrator (the facility ' s Abuse Coordinator), state agency, responsible party, police department and ombudsman (state personnel that advocates for the residents in the facility) for one of three sampled residents (Resident 106) in accordance with the facility ' s policy Abuse Reporting and Investigation.
LVN 4 witnessed the confrontation between Resident 106 and Resident 29 in front of the nursing station #1 after Resident 106 allegedly poured water on Resident 29 while the resident was asleep, and did not report the incident to the Abuse Coordinator or designee within two hours.
CNA 3 changed Resident 106's wet bed linens and wet floor in the resident's floor and heard about the altercation, but did not report the incident immediately to the Abuse Coordinator.
The Social Services Director (SSD) reported the abuse incident to the enforcement agencies on 10/4/24 at 2:02 PM (eight days after the incident happened).
This deficient practice had the potential to result in repeat altercation and abuse between the residents and also result in unidentified abuse in the facility that could result in injury and psychosocial decline (emotional being).
Findings:
During a review of Resident 106's admission Record indicated the facility admitted Resident 106 on 9/13/2024 with diagnoses that include schizophrenia (a mental health condition that is marked by a mix of symptoms, such as hallucinations and delusions, mood disorder depression, and mania) and anxiety disorder (a mental illness that causes a person to experience excessive and uncontrollable feelings of fear or anxiety).
During a review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/17/2024, indicated Resident 106 had moderately impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 106 required supervision or touching assistance with eating, and partial/moderate assistance with oral hygiene, toilet hygiene, shower/bathe self and personal hygiene, and chair/bed-to-chair transfer.
During a review of Resident 106 ' s Progress Notes, dated 10/4/24, the Progress Notes indicated there was no documentation on the altercation-to-altercation between Resident 106 and Resident 29.
During a review of Resident 29's admission Record indicated the facility originally admitted Resident on 2/13/24 and readmitted on [DATE] with diagnoses that include schizophrenia (a mental health condition that is marked by a mix of symptoms, such as hallucinations and delusions, mood disorder depression, and mania) and dementia (a chronic condition that causes a decline in cognitive abilities, such as thinking, remembering, and reasoning, that interferes with daily life).
During a review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/4/24, indicated Resident 29 had moderately impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 29 required supervision or touching assistance with eating, and partial/moderate assistance with oral hygiene, toilet hygiene, shower/bathe self and personal hygiene, and chair/bed-to-chair transfer.
During a review of Resident 29 ' s Progress Notes, dated from 9/1/24 to 10/2/24, the Progress Notes indicated there was no documentation on the altercation-to-altercation between Resident 106 and Resident 29.
During a review of Report of Suspected Dependent Adult/Elder Abuse (SOC 341, a form, as adopted by the California Department of Social Services CDSS, is required under Welfare and Institutions Code WIC. Use SOC 341 to report suspected dependent adult/elder abuse), dated 10/4/24, indicated that the incident related to Residents 109 and 29 ' s altercation was reported to the Department on 10/4/24 at 2:02 PM via facsimile transmission.
During an interview on 10/1/24 at 3:20 PM, with Resident 106, Resident 106 stated he remembered the altercation occurred the day Resident 29 was transferred to his room, and they became roommates. Resident 106 stated at around 7:30 PM while he was asleep on his bed, Resident 29 suddenly walked toward his bed and poured a cup of water on him. Resident 106 stated Resident 29 walked out the room right away, and he followed Resident 29 to the nursing station #1. Resident 106 stated he asked Resident 29 why he poured water on him, but Resident 29 did not answer and pretended he did not pour water on him. Resident 106 stated Resident 29 had issues and he always tried to look for trouble. Resident 106 stated Resident 29 poured the water on him on purpose. Resident 106 stated the staff separated them immediately after the incident occurred. Resident 106 stated he was upset at that time, and he had to keep an eye on Resident 29 all the time to make sure he did not try to do something to him again.
During an interview on 10/2/24 at 4:25 PM, with Licensed Vocational Nurse (LVN) 4, LVN 4 stated he could not remember when, but he saw Resident 29 walked out the room with Resident 106 following behind him. LVN 4 stated Resident 29 and Resident 106 stopped and stood face to face about one foot away from each other in front of the Nursing Station #1. LVN 4 stated Resident 106 asked Resident 29 loudly why did you pour water me? LVN 4 stated Resident 29 stayed quiet and did not say anything. LVN 4 stated Resident 106 and Resident 29 got really close to each other, then, the staff separated the residents. LVN 4 stated he did not witness how Resident 29 pour water on Resident 106, but he saw Resident 106 ' s bed was wet, so the Certified Nursing Assistant (CNA) 3 changed the wet bed linens for Resident 106 and housekeeping came to clean the floor. LVN 4 stated he thought the altercation was reported and the DON was aware because the DON was in the facility at that time.
During an interview on 10/2/24 at 4:30 PM, with CNA 3, CNA 3 stated she did not witness Resident 29 poured water on Resident 106, but after the incident, she was sent to change Resident 106 ' s bed. CNA 3 stated she saw Resident 106 ' s bed was wet, and she changed the bed linens for Resident 106. CNA 3 stated she only remembered the altercation occurred sometime last week but could not remember the exact date.
During an interview on 10/4/24 at 11:20 AM, with the Director of Nursing (DON), the DON stated she did not know about the altercation between Resident 106 and Resident 29 occurred last week and no staff had reported it to her until the surveyor informed her. The DON stated the facility did not report since she did not know about it. The DON stated a resident-to-resident altercation between Resident 106 and Resident 29 should be reported immediately within two hours after the incident occurred.
During an interview on 10/4/24 at 1:08 PM, with Registered Nurse (RN) 4, RN 4 stated Resident 29 was transferred to Resident 106 ' s room on 9/26/24.
During an interview on 10/4/24 at 5PM, with the Administrator (ADM), the ADM stated he and the DON did not know about the altercation between Resident 106 and Resident 29 until today. The ADM stated he did not know that the staff who were aware of the altercation on 9/26/24 did not report or document it. The AMD stated the staff should reported to the DON or himself immediately, so they did not delay the reporting process.
During a review of the facility ' s policy and procedure (P&P) titled, Abuse Reporting and Investigation, dated 11/2018, indicated The facility will report ALL allegations of abuse as required by law and regulations to the appropriate agencies within 2 hours .Allegations of abuse, neglect, mistreatment, or exploitation are to be reported to the Abuse Prevention Coordinator immediately.
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 ensure assistance was provided ADLS (Activities of Da...
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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 assistance was provided ADLS (Activities of Daily Living- (routine tasks, activities such as eating, that a person performs daily to care for themselves) during mealtimes for one of twenty-three sampled residents (Resident 23).
This failure resulted in Resident 23's feeling upset, not able to eat her chicken during lunch on 10/1/2024, and a potential risk for malnutrition and weight loss. In addition, could result in a decline in the resident ' s ability to perform ADLS.
Findings:
During a review of Resident 23's admission Record indicated the facility initially admitted Resident 23 on 4/1/2015 and readmitted on [DATE] with diagnoses that included hemiplegia (a condition that causes partial or complete paralysis or weakness on one side of the body and hemiparesis (weakness or an inability to move on one side of the body) following cerebral infraction (stroke, a serious condition that occurs when blood flow to the brain is disrupted, causing brain tissue to die) affecting right dominant side, muscle weakness, cognitive communication deficit, aphasia (loss of the ability to understand or express spoken or written language), and dysphagia (difficulty swallowing).
During a review of Resident 23 ' s Speech Therapy SLP (Speech-Language Pathologist, a communication expert that assess and treat people who have speech, language, voice, and fluency disorders) Discharge Summary, dated 9/29/2023, indicated the treatment included utilization of safe swallow strategies such as small bites/sips.
During a review of Resident 23 ' s History and Physical, dated 8/12/2024, indicated Resident 23 had fluctuating capacity to understand and make decisions.
During a review of Resident 58 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/3/2024, indicated Resident 23 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating (ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident) and oral hygiene.
During a review of Resident 23 ' s care plan (a document that outlines the facility ' s plan to provide personalized care to a resident based on the resident ' s needs), dated 9/6/2024, indicated Resident 23 was at risk for weight loss, decline in functional status, and aspiration/choking during meals. The goals were to reduce/minimize risk of aspiration/choking during meals, and to receive adequate nutrition/hydration daily. The interventions included diet for mechanical soft diet with thin liquid, provide assist during meals as needed, and monitor tolerance with texture of food.
During a review of Resident 23's Nutritional Screening, dated 9/5/2024, indicated Resident 23 ' s diet order was Regular, mechanical soft texture, and supervision was needed during eating.
During a review of Resident 23's Order Summary Report, indicated Resident 23 had a physician order on 7/16/2023 for Regular diet with mechanical soft texture, regular/thin consistency.
During a concurrent dining observation and interview on 10/1/2024 at 12:15 PM with Resident 23 in her room, Resident 23 was observed in bed eating alone with no assistance. Resident 23 was observed using a spoon to cut up a piece of chicken that was close to 2x3 inches (unit of length) in size. A knife and a fork were observed on the right side of the lunch tray, and Resident 23 was observed unable to reach her left hand to the fork. When surveyor asked if she could reach to her fork, Resident 23 shook her head and pointed to her right arm expressing that her right arm could not move.
During an observation on 10/1/2024 at 12:35 PM in Resident 23's room, no staff was observed coming to check on Resident 23. Resident 23 was observed getting upset not able to use the spoon to cut and eat the chicken. Resident 23 nodded her head when the surveyor asked if Resident 23 needed assistance from the nurses during meals. Surveyor walked to the nurses ' station to request for assistance for Resident 23.
During a concurrent observation and interview on 10/1/2024 at 12:45 PM with Certified Assistant Nurse (CNA) 4 in Resident 23 ' s room, Resident 23's lunch tray was observed. CNA 4 stated, the chicken looked too big for the resident to eat. CNA 4 stated, the resident should be assisted to cut the chicken into bite size or grounded (meat that has been finely chopped using a meat grinder or chopping knife) to make it easy for Resident 23 to scoop the food and put in her mouth. CNA 4 stated, Resident 23 had right side weakness and used only her left hand to eat during meals time. CNA 4 stated, Resident 23 should have been assisted during meals time.
During an interview on 10/3/2024 at 6:15 PM with the Director of Nurses (DON), the DON stated, Resident 23 should have been assisted during mealtimes due to her right-side weakness. The DON stated, Resident 23 could be upset not able to eat her food and would be potential at risk for malnutrition and weight loss.
During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, dated March 2018, indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, including appropriate support and assistance with dining (meals and snacks).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents provide necessary care and services for skin break...
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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 provide necessary care and services for skin breakdown and pressure injuries (localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence or related to medical devices) to prevent skin breakdown for one of three sampled residents (Resident 4) by failing to ensure Resident 4 who uses a low air loss mattress (LAL Mattress -air filled mattress used to relieve pressure) was set according to resident's weight.
As a result of this deficient practice placed Resident 4 at additional risk for developing pressure injuries.
Findings:
During a review of Resident 4's admission Record (Face Sheet), dated 9/12/2023, the face sheet indicated the facility admitted Resident 4 on 9/12/2023, and readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary disease (COPD - lung disease which makes breathing difficult), muscle weakness and generalized osteoarthritis ( degenerative joint disease, in which the tissues in the joint break down over time).
During a review of Resident 4's Minimum Data Set (MDS-a federally mandated resident assessment tool.), dated 6/4/2024, indicated has severe cognitive impairment (the ability to think and process information). The MDS indicated the resident is totally dependent on staff for dressing, toilet use, personal hygiene, and bathing.
During a review of Resident 4's History and Physical (H&P), dated 6/24/2024, indicated, Resident 4 had the mental capacity to make medical decisions.
During a review of Resident 4's Order Summary Report, dated 8/2/2024 indicated to provide a low air loss mattress (LAL Mattress) to Resident 4 for wound management set mode for alternating and settings base on comfort and/or comfort and/or weight of the resident check setting and functionality every shift.
During a review of Resident 4's Weight Summary, dated 9/6/2024, indicated Resident 4' s weight 204 pounds (lbs.-unit of measurement).
During an observation on 10/2/2024 at 12:24 PM, Resident 4 was observed with a LAL Mattress was set for a person weighing 550 lbs.
During a concurrent interview and record review on 10/2/2024 AM 2:20 PM with Treatment Nurse (TN) 1, Resident 4's Weight Summary, dated 9/6/2024 was reviewed. The Weight Summary indicated Resident 4 weight was 204 lbs. TN1 stated the LAL Mattress getting goes by weight and Resident 4's LAL Mattress was not set correctly. TN 1 stated the LAL Mattress setting for Resident 4 should be at 250 since Resident 4's weigh is 204 lbs. TN 1 stated incorrect settings of LAL mattress places the resident at higher risk for further skin breakdown. TN 1 stated that setting the LAL Mattress was set at a weight higher than Resident 4's actual weight makes the mattress too hard which prevents the wounds from healing, therefore there was a potential to cause harm, when setting of LAL Mattress were incorrectly set.
A review of manufacturer's recommendation of Low Air Loss Mattress Owner's Manual, (undated), indicated, The Med Aire Edge Mattress Replacement System is a high-quality powered air support surface that is specifically designed for the prevention and treatment of pressure injuries while optimizing patient comfort. The owner ' s manual also indicated This digital control unit includes intuitive controls for adjusting the air pressure based on the patient ' s weight and comfort levels. Weight settings range from =250-1,000 lbs and can be used to adjust the pressure of the inflated cells based on the patient ' s weight and comfort level.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate device and appropriate rehabilita...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate device and appropriate rehabilitation services (assessment and evaluation of the residents to determine exercises or devices needed to improve or maintain mobility) to maintain or improve mobility for one of two sampled residents (Resident 58). with limited mobility and contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) on both arms was observed with towel between the arms.
This failure practice had a potential to result in Resident 58's worsened elbow contractures that could lead to pain, discomfort and high risk for fractures (broken bones).
Findings:
During a review of Resident 58's admission Record indicated the facility initially admitted Resident 58 on 4/27/2021 and readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thought), and anxiety disorder (a group of mental disorders characterized by significant feelings of fear that affect with daily activities).
During a review of Resident 58 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/9/2024, indicated Resident 58 ' s cognition (a term for the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) was severely impaired, and was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) in roll left and right, sit to lying, lying to sitting on side of bed, sit to stand.
During a review of Resident 58 ' s History and Physical, dated 1/13/2024, indicated Resident 58 was bed bound (confined to bed due to illness/weakness), his arms were contracted, and he did not have the capacity to understand and make decisions.
During a review of Resident 58 ' s care plan (a document that outlines the facility ' s plan to provide personalized care to a resident based on the resident ' s needs), dated 4/11/2024, indicated Resident 58 had limitation noted to shoulders, elbows and fingers, with the goal of minimizing the risk of further loss of ROM daily, and the interventions included to position resident to prevent further contractures with pillow or splints as needed.
During an observation on 10/1/2024 at 12:05 PM in Resident 58 ' s room, Resident 58 was lying in bed, left and right arms were bent at the elbow with stiffness and contracted. Four rolled towels were observed in the elbow between the bent contracted arms.
During a concurrent observation and interview on 10/3/2024 at 2:23 PM with Certified Nurse Assistant (CNA) 8 in Resident 58 ' s room, CNA 8 was placing one rolled towel in each of Resident 58 ' s contracted arm. CNA 8 stated, Resident 58 ' s arms had been severely contracted since admission to the facility and she usually place rolled towels between his upper and lower arms to help his arms to relax, prevent further contractures and pain if any.
During an interview on 10/3/2024 at 2:28 PM with Physical Therapist (PT) 1, PT 1 stated. The facility usually utilizes a splint to prevent the resident ' s further contractures. PT 1 stated, she would not recommend using a rolled towel to help prevent further contractures because it could fall off and will not be effective.
During a concurrent interview and observation on 10/3/2024 at 2:48 PM with Rehabilitation Director (RHD), RHD was able to flex Resident 58's arms to 45 degrees (unit of angle). RHD stated, the facility always utilizes a splint for residents with contracted arms who could flex more than 30 degree and based on her assessment, Resident 58 should already have a splint to prevent further contractures. RHD stated, rolled towels are not a standard of practice to use in preventing resident ' s worsen contractures because it ' s not therapeutic. RHD stated, he was not referred to Rehabilitation since 8/13/2021 for both arms with contractures to determine the device to use to prevent further decline. RHD stated, she would readmit Resident 58 to Rehabilitation for reassessment and evaluation.
During an interview on 10/4/2024 at 1:07 PM with the Director of Nurses (DON), the DON stated, the towels should not be used to prevent worsen arms and elbow contractures because they are too soft and not able to prevent any contracture. The DON stated, the resident should have been reevaluated. The DON stated, not using a proper device such as a splint, the resident is at risk for further arms and elbow contracture.
During a review of the facility ' s policy and procedure (P&P) titled, Resident Mobility and Range of Motion, dated July 2017, indicated: Residents with limited ROM will receive treatment and services to increase and/or prevent a further decrease in ROM. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 63's admission Record (Face Sheet), dated 2/18/2022, the face sheet indicated the facility admitt...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 63's admission Record (Face Sheet), dated 2/18/2022, the face sheet indicated the facility admitted Resident 63 on 2/18/2022, and readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary disease (COPD - lung disease which makes breathing difficult), and bronchiectasis (a condition where your airways widen or develop pouches).
During a review of Resident 63's History and Physical (H&P), dated 3/3/2024, indicated, Resident 63 had the mental capacity to make medical decisions.
During a review of Resident 63's Smoker's Risk Assessment, dated 7/21/2024, indicated Resident 63 was an independent smoker (no supervision needed).
During a review of Resident 63's Order Summary Report, dated 10/2/2024, the Order Summary Report indicated a physician order on 3/3/2024, ordered Resident 63 to receive oxygen at two (2) liters per minute (L/min) via nasal cannula (device use for delivery of oxygen) to maintain oxygen saturation (amount of oxygen carried in blood) at 92% (normal range 90-100%).
During a review of Resident 63's Minimum Data Set (MDS-a federally mandated resident assessment tool.), dated 8/15/2024, indicated the cognitive (the ability to think and process information) skills for daily decisions making was intact, and independent for activities of daily living.
During a concurrent observation and interview on 10/2/2024 at 11:30 a.m., Resident 63 was observed sitting at the edge of his bed in his room. Oxygen machine was observed in resident ' s room. A white grocery bag with a bag of tobacco a pipe at the resident ' s bedside. Resident 63 stated he makes his own cigarettes. Resident 63 stated the bag with tobacco pipe was bought by his family.
During an interview on 10/2/2024 at 9:05 a.m. with the Social Worker Designee (SSD) stated the resident was not allowed to have tobacco in his room. The SSD stated Resident 63 was non-compliant and had one bag of tobacco confiscated (taken away) previously. SSD stated she does not know how the Resident 63 was obtained to obtain the bag of tobacco.
During a concurrent observation and interview on 10/3/2024 at 9:30 a.m., with the Registered Nurse Supervisor 4 (RN 4), the RN4 confirmed that the resident had the bag of tobacco in his room, and he should not have tobacco inn his room because he has oxygen in his room. The RN 4 stated the bag will be confiscated.
During an interview on 10/4/2024 at 3:15 p.m. with the Director of Nursing (DON), DON stated it was not safe for Resident 63 to have tobacco in his room, We do not allow anyone to have cigarettes in the room. We inform the family as well that residents are not allowed to have cigarettes in their possession because the cigarettes need to be given to the activities staff. DON stated it is against the facility's policy for the resident to keep smoking materials in the room. The DON stated residents should not keep lighters or smoking materials with them or at the bedside due to safety reasons.
During a review of the facility ' s policy and procedure (P&P) titled, Smoking by Resident, released 9/2018, P&P indicated, Use of Oxygen of Oxygen in prohibited in Smoking areas. Residents who smoke and are on oxygen may not be allowed to retain smoking materials in the room and/or in their possession and smoking shall be prohibited in any room or other locations in the facility where combustible gases or oxygen is used or stored in other hazardous locations.
Based on observation, interview and record review, the facility failed to provide a safe and hazard free environment to two of three sampled residents (Resident 87 and 63) by failing to ensure:
1. Resident 87's bed alarm (a device used to monitor a patient's movements in bed) was monitored and in functioning condition.
This deficient practice placed Resident 87 at risk for falls or accidents when Resident 87 was getting out of bed without supervision.
2. Resident 63 who was a smoker and receives oxygen therapy via nasal cannula tubing (a device used to deliver supplemental oxygen placed directly on a resident's nostrils) retained bag of tobacco at the bedside.
As a result of this deficient practice, the potential for an accidental fire in the facility and can lead to injury to the residents and other people in the facility.
Findings:
During a review of Resident 87's admission Record indicated the facility originally admitted Resident 87 on 9/15/23 and readmitted on [DATE] with diagnoses that include dementia (a group of thinking and social symptoms that interferes with daily functioning) and muscle weakness.
During a review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/16/24, indicated Resident 87 had severely impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 87 required partial/moderate assistance with eating, oral hygiene, toilet hygiene, shower/bathe self, personal hygiene, chair/bed-to-chair transfer and sit to stand.
During a review of Resident 87's Order Summary Report (OSR), dated 9/30/24, the OSR indicated a physician order to apply bed alarm: monitor placement every shift for fall prevention to alert staff to respond quickly and assist residents.
During an observation on 10/1/24 at 9:29 AM, Resident 87 was lying on her bed awake, but she did not have eye contact and did not respond to the surveyor. A bed alarm monitor was observed hanging on the right bed siderail (barriers attached to the side of a bed to prevent falls and provide support) of Resident 87 ' s bed. Resident 87 ' s bed pad sensor (connects wirelessly with a handheld monitor and the alarm will sound when weight is removed from the pad) was observed not connected to the bed alarm monitor, and the light on the bed alarm monitor was off.
During a concurrent observation and interview on 10/1/24 at 9:38 AM, with Certified Nursing Assistant (CNA) 6, Resident 87 ' s bed alarm monitor was observed. CNA 6 stated the bed alarm was not in a working condition because the bed pad sensor connector was unplugged from the bed alarm monitor and there was no green light flash on the bed alarm monitor to indicate the bed alarm was functioning. CNA 6 stated Resident 87 was confused and attempted to get out of bed without assistance. CNA 6 stated if the bed alarm was not working properly, Resident 87 was at risk for falls.
During an interview on 10/1/24 at 9:47 AM, with CNA 7, CNA 7 stated checking on Resident 87 around 7:10 AM and 7:20 AM this morning. CNA 7 stated she did not pay attention to Resident 87 ' s bed alarm because she was too busy to care for other residents. CNA 7 stated she did not know for how long Resident 87 ' s bed alarm was not on and functioning. CNA 7 stated she should check the bed alarm to ensure it was working properly to prevent fall and injury to the resident.
During an interview on 10/2/24 at 3:10 PM, with the Director of Nursing (DON), the DON stated facility staff should check residents ' bed alarms to make sure they were in working condition so that when the residents were attempting to get out of the bed, the staff could respond quickly to prevent fall and accident to the residents.
During a review of the facility ' s policy and procedure (P&P) titled, Protekt Ultimate Alarm, dated 2024, the P&P indicated Top mounted flashing lights helps to verify that the monitor is armed (slow green flash) .
During a review of the facility ' s policy and procedure (P&P) titled, Fall Risk Assessment, dated 3/2018, the P&P indicated to identify and address fall risk factors and interventions to minimize the consequences of fall risk factors.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to verify one of seven sampled residents (Resident 89)'s identity before medication was administered to the resident in accordanc...
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Based on observation, interview and record review, the facility failed to verify one of seven sampled residents (Resident 89)'s identity before medication was administered to the resident in accordance with the facility's policy and procedure.
The deficient practice had put Resident 89 at risk of receiving the wrong and unnecessary medications that could cause the adverse effects (an undesired effect of a drug or other type of treatment).
Findings:
During a review of Resident 89's admission Record indicated the facility admitted Resident 89 on 9/29/23 with diagnoses that included diabetes mellitus (a group of diseases that affect how the body uses blood sugar) and hypertension (high blood pressure).
During a review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 7/10/24, indicated Resident 89 had moderately impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 89 required setup or clean-up assistance with eating, partial/moderate assistance with oral hygiene, substantial/maximal assistance with chair/bed-to-chair transfer, and was dependent with toilet hygiene, shower/bathe self and personal hygiene.
During a review of Resident 89 ' s Order Summary Report (OSR), dated 9/30/24, the OSR indicated physician ordered to administer multivitamin-minerals (a supplemental medication is used to support health needs) one tablet by mouth one time a day for supplement.
During a review of Resident 89's Medication Administration Record (MAR), dated 10/1/24 to 10/31/24, the MAR indicated Resident 89 received multivitamin-minerals one tablet by mouth at 9 AM on 10/2/24.
During an observation on 10/2/24 at 9:32 AM, Resident 89 was lying on his bed. Licensed Vocational Nurse (LVN) 1 went into Resident 89 ' s room and stood at the foot of Resident 89 ' s bed. Observed Resident 89 did not have identification (ID) band on his wrists. LVN 1 called Resident 89 ' s last name and told Resident 89 that she would administer his medication. Resident 89 stated OK. LVN 1 returned to the medication cart and checked Resident 89 ' s physician order on the electronic health record (HER). The EHR had no profile picture of Resident 89 on his EHR. LVN 1 prepared one tablet multivitamin-minerals and walked to Resident 89 ' s room. LVN 1 administered the medication to Resident 89 without confirming his name and date of birth to ensure Resident 89 ' s identity.
During a concurrent interview and record review on 10/2/24 at 9:35 AM, with LVN 1, Resident 89 ' s profile picture on EHR was reviewed. LVN 1 stated there was no picture of Resident 89 on the EHR and she could not identify if Resident 89 was right resident just by calling his last name.
During a concurrent observation and record review on 10/2/24 at 9:36 AM, with LVN 1, Resident 89 did not have a wrist ID band. LVN 1 stated the wrist ID band was important because it helped the staff to identify the residents correctly.
During an interview on 10/2/24 at 9:40 AM, with LVN 1, LVN 1 stated she only called Resident 89 ' s last name to verify his identity before she administered the medication to Resident 89. LVN 1 should use three identifiers, including the name, wrist band, e-MAR, birthday, picture, and room number, to verify the resident ' s identity to prevent administer the wrong medications to the wrong resident.
During a concurrent interview and record review on 10/2/24 at 3:07 PM, with the Director of Nursing (DON), the facility ' s policy and procedure (P&P) titled, Administering Medications, dated 4/2019, was reviewed. The DON stated according to the P&P, the nurse should verify the resident ' s identity before giving medications by checking identification band, checking photograph attached to medical record, and verifying resident identification with other facility personnel. The DON stated by calling only the resident ' s last name was not enough to identify the resident and could put the resident at risk of medication error and adverse consequences.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 4's admission Record (Face Sheet), dated 9/12/2023, the face sheet indicated the facility admitte...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 4's admission Record (Face Sheet), dated 9/12/2023, the face sheet indicated the facility admitted Resident 4 on 9/12/2023, and readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary disease (COPD - lung disease which makes breathing difficult), and muscle weakness.
During a review of Resident 4's Minimum Data Set (MDS-a federally mandated resident assessment tool.), dated 6/4/2024, indicated has severe cognitive impairment (the ability to think and process information). The MDS indicated the resident is totally dependent on staff for dressing, toilet use, personal hygiene, and bathing.
During a review of Resident 4's History and Physical (H&P), dated 6/24/2024, indicated, Resident 4 had the mental capacity to make medical decisions.
During a review of Resident 4's Order Summary Report, dated 10/3/2024, the Order Summary Report indicated an order dated 8/1/2024, to administer Lorazepam (Ativan) Tab (tablet) 0.5mg (milligram)- Give one tablet by mouth every six hours as needed for anxiety for 14 days m/b (manifested by) sudden outburst of anger with an order end date of 8/14/2024.
During a review of nursing notes dated 9/5/2024 at 9:15 PM, Lorazepam 0.5 mg tablet given p.o. (by mouth) PRN (as needed) to administer for anxiety.
During a review of nursing notes dated 9/5/2024 at 11:36 PM, Ativan 0.5 mg given at 9:15 PM and was effective at 11:30 PM, no anxiety noted.
During a review of nursing notes dated 9/14/2024 at 5:30 AM, Ativan 0.5 mg tablet 1 tablet given p.o. PRN anxiety m/b (manifested by): sudden outburst of anger.
During a review of nursing notes dated 9/14/2024 at 5:30 AM, Ativan given at 5:30 PM effective at 6:30 PM.
During a review of nursing notes dated 9/26/2024 at 5AM, Lorazepam 0.5 mg tablet 1 tablet given p.o. PRN anxiety, effective at 6PM
During a review of nursing notes dated 9/26/2024 at 5:50 AM, Late entry: Lorazepam 0.5 mg tablet 1 tablet given p.o. PRN anxiety, m/b agitation, effective at 7PM
During a review of Record of Controlled Substance indicated, Lorazepam was administered to Resident 4 as follow:
8/31/2024 at 9:30PM
9/5/2024 at 9:15PM
9/14/2024 at 5:30PM
9/26/2024 at 5PM
9/27/2024 at 5:50PM
During a concurrent interview and record review on 10/3/2024 at 4:38 PM, with the Registered Nurse Supervisor 4 (RN 4), Resident's 4 record of Controlled substances, was reviewed. The record of Controlled Substances indicated Resident 4 was administered Lorazepam on 8/31/24, 9/15/24, 9/14/24, 9/26/24, and 9/27/24 (a total of five times) without a physician's order. RN 4 stated that medication such as Ativan should not had been administered without the ordered and every medication needs some orders.
During an interview on 10/3/2024 at 4:55 PM with the DON stated the medication should had been given the Ativan to me after the medication was discontinue. DON stated that if the medication was discontinued and if the resident needs it, they need to call the doctor to obtain an order for the medication before administering the medication. The DON stated the nurse should not have administered the Ativan without a physician order. I understand that lorazepam is just ordered for 14 days and then the resident need to be reassessed for the need to Ativan.
During a concurrent interview and record review on 10/3/2024 at 5:18 PM, Licensed Vocational Nurse 2 (LVN 2) stated, she was aware that the Ativan was due for renewal. LVN 2 stated she thought the Ativan order was renewed. LVN 2 stated there is monitoring for the medication but no order to administer Lorazepam in the medication administration record (MAR). LVN 2 stated she could not remember where she documented that she administered the medication. LVN 2 confirmed there is no record of her administering the medication in the MAR.
During a review of the facility's policy and procedure (P&P) titled, Administering Medication, revised on 4/2019, P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required timeframe. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.
Based on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Resident 58 and 4) were free of unnecessary psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility's policy and procedureby [NAME] to ensure:
(any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure. Resident 58
1. Resident 58 with diagnoses of schizophrenia (a mental illness that is characterized by disturbances in thought) and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life) recieved specific indication for Risperidone (medication used to treat symptoms of schizophrenia) and Trazodone (medication used to treat depression), and behavior for the indication of use were monitored and documented from the period of 7/1/2024 to 10/4/2024.
These efficient practices had potential to result in placing Resident 58 at risk for significant adverse consequence (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic drug, which could result to impairment or decline in the residents' mental, physical condition, functional, and psychosocial status.
2. Resident 4 was administered Lorazepam (brand name Ativan, a medication to treat anxiety [fear of the unknown or extreme worry] disorders) without a physician order and clinical reason for use.
As a result of this deficient practice the resident was at risk for the use of unnecessary medication, or non-therapeutic use of psychotropic medication.
Findings:
During a review of Resident 58's admission Record indicated the facility initially admitted Resident 58 on 4/27/2021 and readmitted on [DATE] with diagnoses that included schizophrenia, depression, dementia (a progressive state of decline in mental abilities), and anxiety disorder (a group of mental disorders characterized by significant feelings of fear that affect with daily activities).
During a review of Resident 58 ' s Order Summary Report, indicated Resident had a physician order on 1/8/2024 for Trazodone HCl tab 50 mg (milligram, unit of weight) to give 0.5 tablet by mouth at bedtime for depression and a physician order on 1/10/2024 for Risperidone tab 3 mg to give 1 tablet by mouth two times a day for Schizophrenia manifested by mumbling to himself.
During a review of Resident 58 ' s History and Physical, dated 1/13/2024, indicated Resident 58 was aphasia (a disorder that makes it difficult to speak), bed bound (confined to bed due to illness/weakness), and did not have the capacity to understand and make decisions.
During a review of Resident 58 ' s care plan (a document that outlines the facility ' s plan to provide personalized care to a resident based on the resident ' s needs), titled Behavioral Symptoms, dated 4/11/2024, indicated Resident 58 had potential altered behavioral patterns manifested by mumbling to himself with the goals that minimize frequency of behavior exhibited, reduce risk for potential harm and ensure resident ' s safety and the interventions included to monitor behavior indicators as needed.
During a review of Resident 58 ' s care plan, titled Psychotherapeutic Medication Use, dated 4/11/2024, indicated resident has periods of psychosis manifested by mumbling to himself with medication used as Risperdal (brand name for Risperidone), and resident has periods of depression manifested by sad facial expression with medication used as Trazodone. The record indicated, the goals were to maximize resident ' s functional potential, reduce risk of potential adverse effects of medication usage and minimize noted behaviors. The interventions included to monitor and record episodes of behavior per facility policy/protocol.
During a review of Resident 58 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/9/2024, indicated Resident 58 ' s cognition (a term for the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) was severely impaired, and was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) in oral/personal hygiene, bathe self, upper and lower body dressing.
During a review of Resident 58 ' s Psychotropic Assessment, dated 1/8/2024, indicated Resident 58 was on Risperidone 3 mg BID (two times a day) for diagnosis of Schizophrenia with auditory hallucination, and no specific description of auditory hallucination was documented.
During a review of Resident 58 ' s Note to Attending Physician/Prescriber, dated 7/10/2024, documented by the facility ' s Consultant Pharmacist (CP) indicated Resident 58 has been receiving Risperidone 3 mg BID and Trazodone 25 mg QHS (at bedtime) to manage behavior, stabilize mood or treat a psychoactive condition. The record indicated the CP recommended for a review of the resident associated behaviors and monitoring parameters for worsening of behaviors to determine if the behaviors noted have been non to minimal. The record indicated, Federal nursing facility regulations require that gradual dosage reduction (GDR) be attempted in two separate quarters (with at least one month between attempts) within the first year in which a resident is admitted on a psychopharmacologic medication, or after the facility has initiated such medication, and then every 6 months thereafter unless clinically contraindicated. The record indicated, Resident 58 ' s physician disagreed with the CP ' s recommendations due to the benefits out-weight the risks with no explanation of benefits and risks were documented.
During an observation on 10/2/2024 at 10:15 AM in Resident 58 ' s room, Resident 58 was in bed and awake. Resident 58 did not answer, not nodding or shaking head with any questions asked by the surveyor.
During a concurrent observation and interview on 10/3/2024 at 2:23 PM with Certified Nurse Assistant (CNA) 8, Resident 58 was observed in bed, staring at the ceiling. CNA 8 stated, Resident 58 had been nonverbal and required total care since his admission on [DATE]. CNA 8 stated, she had not seen Resident 58 talking to himself and stated, Resident 58 ' s facial expression had been flat.
During a concurrent record review and interview on 10/4/2024 at 9:41 AM with Licensed Vocational Nurse (LVN) 1, Resident 58 ' s Psychotropic Assessment, and care plan were reviewed. LVN 1 stated, based on the records, Resident 58 was on Risperidone for hallucination manifested by mumbling to himself and Trazodone for depression manifested by sad face expression. LVN 1 stated, Resident 58 had been nonverbal and bedbound with total care upon admission on [DATE]. LVN 1 stated, when Resident 58 made a long argggg sound sometimes, she believed that was how he was mumbling to himself. LVN 1 stated, Resident 58 had been having a flat face with no expression.
During an interview on 10/4/2024 at 11:22 AM with Registered Nurse (RN) 4, RN 4 stated, Resident 58 had been nonverbal since admission on [DATE]. RN 4 stated, per policy, when a resident was on psychotropic medications with specific target behaviors, the LVNs are responsible to check the episodes of manifesting behavior and document them, then the RN would count the total number of episodes at the end of the month. RN 4 stated, they needed to count and monitor so that they could decrease or discontinue the medications if the resident did not have any episode of noted behaviors anymore.
During a concurrent record review and interview on 10/4/2024 at 12:05 PM with RN 4, Resident 58 ' s Psychotropic Summary Sheet was reviewed. RN 4 stated, the form was used to monitor monthly total number of episodes that Resident 58 exhibited behaviors of mumbling to himself and sad face expression and the RNs are responsible to count and document them. RN 4 stated, based on the record, there was no total count from the month of July 2024.
During a concurrent record review and interview on 10/4/2024 at 12:10 PM with RN 4, Resident 58 ' s electronic Medication Administration Record (eMAR) for August, September and October 2024 were reviewed. RN 4 stated, the eMAR indicated no numbers of episode of mumbling to self was documented since 8/1/2024. RN 4 stated, the LVNs had been documenting incorrectly or there must be a mistake from IT department that they could not document a number in the record. RN 4 stated, there was no episodes tracking since 8/1/2024. RN 4 stated, with no tracking, they could not assess the resident to initiate GDR, and they would not know if the resident still needed the medications or not, so the resident would be at risk for unnecessary psychotropic medications.
During a concurrent record review and interview on 10/4/2024 at 12:20 PM with RN 4, Resident 58 ' s Psychiatric notes, since admission on [DATE] were reviewed. RN 4 stated, there had been no GDR attempted in the past 9 months.
During an interview on 10/4/2024 at 12:33 PM with the Director of Nurses (DON), the DON stated, mumbling to himself should not be the indication of Risperidone use for schizophrenia and auditory hallucination is too general because it should specify what hallucinations, what he saw, what he heard. The DON stated, sad face alone should not be an indicator for Trazodone use to treat depression. The DON stated, a long sound arggg could not indicate that he was mumbling to himself. The DON stated, the facility ' s CP usually reviewed the medications record alone and send the recommendation to her, she would then review it and suggest it to the doctor. The DON stated, she did not review the suggestion from the pharmacist, which was documented in Resident 58 ' s Note to Attending Physician/Prescriber, dated 7/10/2024. The DON stated, she just brought the recommendation to the doctor and asked him to sign it. The DON stated, she should have reviewed the recommendation and assessed the resident for need to continue the medications or not and discuss with the doctor for possible GDR. The DON stated, the doctor should have explained in detail why he disagrees with GDR and wanted to continue Risperidone and Trazodone. The DON stated RNs are assigned to count the episodes every month and bring it to IDT meeting. The DON stated, the staffs did not properly monitor the resident ' s behaviors. The DON stated, they need to know how many episodes of hallucinations so that they know if the medication is effective, if it needed to be discontinued or decrease. The DON stated the indications for Risperidone and Trazodone were not accurate and should be more specific to use. The DON stated, Resident 58 is at risk for unnecessary psychotropic medications.
During a review of the facility ' s policy and procedure (P&P) titled, Psychoactive Drug Monitoring, dated March 2023, indicated the following:
-The continued need for the psychoactive medication shall be reassessed regularly by the prescriber and the care planning team. If continuation is deemed necessary, this is indicated in the medical record. Effects of the medications are documented as a part of the care planning process. Unless medically contraindicated, periodic dosage reductions shall be attempted, and the results documented.
-Conditions shall be satisfied prior to initiation and/or continuation of therapy included: long-term daily use has been accompanied by unsuccessful gradual dosage reductions.
-Residents receive antipsychotic medication only for behaviors that are quantitatively and objectively documented through the use of behavioral monitoring charts or a similar mechanism.
-Residents receive antipsychotic medication only for behaviors that are persistent, that are not caused by preventable reasons and are causing the resident to: present a danger to self or others, continuously screaming/yell/space, and experience psychotic symptoms.
During a review of the facility's P&P titled, Antipsychotic Medication Use, dated December 2016, indicated the following:
-Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for us. Re-evaluate the use of the antipsychotic medication at the time of admission to consider whether or not the medication can be reduced, tapered, or discontinued.
-Diagnoses alone do not warrant the use of antipsychotic medication. Antipsychotic medications will generally only be considered if the behavioral symptoms present a danger to the resident or others, and (1) the symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations); or (2) behavioral interventions have been attempted and included in the plan of care.
-The Physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication out-weight the risks or suspected or confirmed adverse consequences.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure drugs and biologicals used in the facility ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure drugs and biologicals used in the facility were, stored under proper temperature, are labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable in accordance with the facility's policy and procedures.
The facility failed to:
1. Ensure the medication room [ROOM NUMBER] ' s thermometer readings were monitored and recorded in the Daily Room Temperature Log to assure a safe temperature range for medication storage.
2. Label Resident 257's opened multi-dose medication bottles (a bottle of medication in the forms of liquid, tablet, or capsule, that contains more than one dose of medication) with the name in the Medication Cart #1 for:
a. Ascorbic acid (vitamin C, a dietary supplement) 500 milligram (mg, a unit of measurement)
b. Vitamin E (a dietary supplement) 400 unit (a unit of measurement)
c. Vitamin D3 (a dietary supplement) 25 micrograms (mcg, a unit of measurement)
3. Label the opened multi-dose medication bottle with the open date in the medication cart #2 for:
a. Pro-Stat (a medical food that is a concentrated liquid protein supplement) 15 grams (g, a unit of measurement) of protein in one fluid ounce (fl oz, a unit of measurement)
b. Bismuth subsalicylate (a medication to relieve upset stomach, gas, heartburn, and diarrhea) 525 mg/30 milliliter (ml, a unit of measurement)
c. Geri-Lanta (a medication is used to treat upset stomach, heartburn, and bloating) 355 ml
d. One battle of Sterile normal saline (a mixture of salt and water) 100 ml
This deficient practice had the potential for harm to residents due to the potential loss of strength of the drugs, the potential for the residents to receive ineffective drug dosages, and the potential to result in medication error.
Findings:
1. During a concurrent observation and interview on 10/3/24 at 10:52 AM, with Licensed Vocational Nurse (LVN) 6, the digital thermometer was attached to the wall, next to the Daily Room Temperature Log, in the medication room [ROOM NUMBER], but the thermometer display was blank. LVN 6 stated the night shift nurse was responsible to check the temperature and document it on the Daily Room Temperature Log every day, but the temperature for 10/3/24 was not documented. LVN 6 stated she did not know for how long the thermometer was not working.
During a concurrent interview and record review on 10/3/24 at 11AM, with the Director of Staff Development (DSD), the updated Daily Room Temperature Log was reviewed. The Daily Room Temperature Log indicated there was no documentation on the specific month and the location of the temperature log was monitoring. The DSD stated the updated Daily Room Temperature Log was the current log for October for the medication room [ROOM NUMBER]. The DSD stated the 3 on the log indicated the date for 10/3/24. The DSD stated the nurse, who worked the night shift last night, should check the temperature and documented it on the log before the end of her shift. The DSD stated the nurse only documented her signature and the shift 11-7 AM, but she did not document the temperature on the log. The DSD stated the night shift nurse might not be able to read the temperature because the thermometer was not working during her shift. The DSD stated it was important to monitor the temperature in the medication room to ensure the temperature was within the range and assure the potency of the medication stored in the medication room.
2. During a review of Resident 257's admission Record indicated the facility admitted Resident 257 on 9/20/24 with diagnoses that include hypertension (high blood pressure) and muscle weakness.
During a review of Resident 257 ' s MDS, dated [DATE], indicated Resident 257 had moderately impaired cognitive (ability to understand and make decisions) skills for daily decision making.
During a review of Resident 257 ' s Order Summary Report (OSR), dated 10/4/24, the OSR indicated the physician ordered to administer Ascorbic acid 500 mg give 500 mg by mouth in the morning for supplement and Vitamin E 400-unit one tablet by mouth in the morning for supplement.
During a concurrent observation and interview on 10/3/24 at 11:22 AM, with LVN 6, observed an opened multi-dose bottle of Ascorbic acid 500 mg, an opened multi-dose bottle of Vitamin E 400 unit, and an opened multi-dose bottle of Vitamin D3 25 microgram were stored in a drawer in the medication cart #1. Observed these opened bottles were only labeled with Resident 257 ' s room number without the resident ' s name on it. LVN 6 stated Resident 257 brought these medications to the facility, and they kept them in the medication cart. LVN 6 stated she should write Resident 257 ' s name on the bottles instead of the room number to prevent loss and/or administered it to the wrong resident if Resident 257 was transferred to a different room.
3. During a concurrent observation and interview on 10/3/24 at 4:13 PM, with LVN 7, observed an opened multi-dose bottle of liquid form of Pro-Stat 15 g of protein in one fluid ounce , an opened multi-dose bottle of liquid form of bismuth subsalicylate 525 mg/30 ml, an opened multi-dose bottle of liquid form of Geri-Lanta 355 ml, and an opened bottle of sterile normal saline were stored in a drawer in the Medication Cart #2. LVN 7 stated these four bottles of medication were not labeled with an opened date. LVN 7 stated these liquid medications were only good for 30 days after they were opened, and it was important to label the bottle on when it was opened so that the nurse will know when to discard the expired medications. LVN 7 stated the nurse, who opened the multi-dose bottle of medication, should label the date it was opened to ensure the potency of the medication and prevent infection from the overgrowth of the germs in these liquid medications.
During an interview on 10/4/24 at 10AM, with the Infection Preventionist (IP), the IP stated an opened bottle of an over the counter (OTC) liquid medication was good for three months after the date it was opened. The IP stated the nurse should label the open date of the medication when he or she opened it to ensure the medication potency and prevent infection which bacteria might overgrow in it.
During an interview on 10/4/24 at 11:17 AM, with the Director of Nursing (DON), the DON stated it was important to ensure the thermometers in the medication rooms were working, the staff monitor the temperature and document it in the log every day, and the staff label the opened bottles with the open date to prevent the loss of medication potency and infection. The DON stated the staff should label the resident ' s medication with his or her name on the bottle to prevent the loss of the medication and medication error.
During a review of the facility ' s policy and procedure (P&P) titled, Medication Labeling and Storage, dated 2/2023, the P&P indicated The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. The P&P indicated the medication label included resident ' s name. The P&P indicated multi-dose vials that have been opened are dated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
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 food prepared in a form designed to meet indi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide food prepared in a form designed to meet individual needs for one of twenty-three sampled residents (Resident 23) with dysphagia (difficulty swallowing) and was ordered by the physician to be served Regular diet (diet that does not include any restrictions) with mechanical soft texture (any foods that can be blended, mashed, pureed, or chopped using a kitchen tool such as a knife, a grinder, a blender, or a food processor) since 7/16/2024.
This failure resulted in Resident 23 received regular texture instead of mechanical soft texture as ordered from 7/16/2024 to 10/3/2024, which could place her at risk for aspiration (happens when food, liquid, or other material enters a person ' s airway by accident. It can happen as a person swallows) and choking.
Findings:
During a review of Resident 23's admission Record indicated the facility initially admitted Resident 23 on 4/1/2015 and readmitted on [DATE] with diagnoses that included hemiplegia (a condition that causes partial or complete paralysis or weakness on one side of the body and hemiparesis (weakness or an inability to move on one side of the body) following cerebral infraction (stroke, a serious condition that occurs when blood flow to the brain is disrupted, causing brain tissue to die) affecting right dominant side, muscle weakness, cognitive communication deficit, aphasia (loss of the ability to understand or express spoken or written language), and dysphagia .
During a review of Resident 23 ' s Speech Therapy SLP (Speech-Language Pathologist) Discharge Summary, dated 9/29/2023, indicated the treatment included utilization of safe swallow strategies such as small bites/sips.
During a review of Resident 23 ' s History and Physical, dated 8/12/2024, indicated Resident 23 had fluctuating capacity to understand and make decisions.
During a review of Resident 23 ' s care plan (a document that outlines the facility ' s plan to provide personalized care to a resident based on the resident ' s needs), dated 9/6/2024, indicated Resident 23 was at risk for weight loss, decline in functional status, and aspiration/choking during meals. The goals were to reduce/minimize risk of aspiration/choking during meals, and to receive adequate nutrition/hydration daily. The interventions included mechanical soft diet with thin liquid, assistance during meals as needed, and staffs to monitor resident ' s tolerance with food ' s texture.
During a review of Resident 23 ' s Nutritional Screening, dated 9/5/2024, indicated Resident 23 ' s diet order was Regular, mechanical soft texture, and supervision was needed during eating.
During a review of Resident 23 ' s Order Summary Report, indicated Resident 23 had a physician order on 7/16/2023 for Regular diet with mechanical soft texture.
During a concurrent dining observation and interview on 10/1/2024 at 12:15 PM with Resident 23 in her room, Resident 23 was observed in bed eating alone with no assistance. Resident 23 was observed using a spoon to cut up a piece of chicken that was close to 2x3 inches (unit of length) in size.
During a concurrent observation and interview on 10/1/2024 at 12:45 PM with Certified Assistant Nurse (CNA) 4 in Resident 23 ' s room, Resident 23 ' s lunch tray and tray card was observed. CNA 4 stated, Resident 23 ' s tray card indicated Regular diet with no indication for mechanical soft texture as ordered.
During a concurrent interview and record review on 10/3/2024 at 2:25 PM with the Dietary Service Supervisor (DSS), the facility ' s policy and procedure (P&P) titled, Regular Mechanical Soft Diet, dated 2023, was reviewed. The DSS stated, the facility only provided grounded meat for dysphagia residents who had diet order for mechanical soft texture to prevent aspiration and choking. The DSS stated, when a resident was admitted to the facility, the nurse would bring a slip with the resident ' s name and diet order to him. The DSS stated, he usually based on the information in the slip to transfer it to his computer and create a tray card for that resident. The DSS stated, he was not aware that Resident 23 had order for mechanical soft texture because Resident 23 ' s tray card only showed Regular diet. The DSS stated, they had been providing Resident 23 with regular texture diet since her admission on [DATE]. The DSS stated, Resident 23 ' s diet order could have been revised and he was not aware to update with the new texture. The DSS stated, there could be a risk that Resident 23 could aspirate or choke when the facility provided her with the wrong diet texture.
During a concurrent record review and interview on 10/3/2024 at 6:15 PM with the Director of Nurses (DON), Resident 23 ' s Order Summary Report was reviewed. The DON stated, Resident 23 ' s physician diet order had been mechanical soft texture since 7/16/2023. The DON stated, Resident 23 ' s tray card should have indicated mechanical soft texture. The DON stated, the DSS must have transferred Resident 23 ' s diet order incorrectly into his system. The DON stated, they have been providing Resident 23 with regular texture instead of grounded meat since 7/16/2023. The DON stated, Resident 23 could have aspirated or choked when provided with the wrong diet texture.
During a review of the facility ' s P&P titled, Diet Order, dated 2023, indicated diet orders prescribed by the Physician will be provided by the Food & Nutrition Services Department. Nursing will send a Diet Order Communication slip to the Food & Nutrition Services Department. The FNS Director or [NAME] in charge will make or adjust the diet profile and tray card as prescribed.
During a review of the facility ' s P&P titled, Regular Mechanical Soft Diet, dated 2023, indicated the mechanical soft diet is designed for residents who experience chewing or swallowing limitations. The regular diet is modified by mechanically altering, chopped or ground. Food including meats, poultry and fish are allowed in ground form, avoid whole. Chopped meat only allowed when ordered by Speech Therapist, and is recommended to chop in bite size, 0.5 inches moist.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
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 screen for the need of pneumococcal (PNA) vaccine (an administratio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to screen for the need of pneumococcal (PNA) vaccine (an administration of vaccine that stimulate the body's own immune system to protect the person against infection or disease) and offer the vaccine to one of five sampled residents (Resident 160) when the resident was initially admitted to the facility as indicated in the facility's policy and procedure titled, Pneumococcal Vaccine
The deficient practice had the potential to result in Resident 160 did not receive the PNA vaccine as recommended by the Department of Public Health and Centers of Disease Control and Prevention (CDC), which out the resident at risk for contracting pneumonia (a severe lung infection).
Findings:
During a review of Resident 160's admission Record indicated the facility admitted Resident 160 on 9/5/24 with diagnoses that include depression (a common mental disorder, involving a depressed mood or loss of pleasure or interest in activities for long periods of time) and low back pain.
During a review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/9/24, indicated Resident 160 had moderately impaired cognition (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 160 required supervision or touching assistance with eating, partial/moderate assistance with oral hygiene, personal hygiene and chair/bed-to-chair transfer, and substantial/maximal assistance with toileting hygiene and shower/bathe self.
During a concurrent interview and record review on 10/3/24 at 8:45 AM, with the Infection Preventionist (IP), Resident 160 ' s Informed Consent (a process that ensures a person has enough information to make an informed decision about a medical procedure, treatment, or clinical trial) for Pneumococcal Vaccine, dated 9/27/24, was reviewed. The IP stated she was responsible to screen the pneumococcal vaccine to all the residents upon their admission or couple days after the admission. The IP stated Resident 160 was admitted on [DATE] and she did not screen and offer Resident 160 the pneumococcal vaccine until 9/27/24 because she was busy with other tasks in the facility. The IP stated she should have screened the resident for the pneumococcal vaccine timely so that the resident was informed about the vaccine and how to protect herself from contracting pneumonia.
During an interview on 10/4/24 at 11:13 AM, with the Director of Nursing (DON), the DON stated the staff should screen the residents for the need to have pneumococcal vaccine when the resident was admitted into the facility to ensure the resident was informed about the vaccine and offered the vaccine to protect the residents from contracting pneumococcal infection.
During a review of the facility ' s policy and procedure (P&P) titled, Pneumococcal Vaccine, dated 3/2022, indicated Assessments of pneumococcal vaccination status are conducted within five working days of the resident ' s admission .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain a safe and sanitary environment for one of three sampled residents (Resident 160) who was observed with stained and ...
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Based on observation, interview, and record review, the facility failed to maintain a safe and sanitary environment for one of three sampled residents (Resident 160) who was observed with stained and soiled both upper bed siderails (one of the long narrow members connecting the headboard and footboard of a bed).
This deficient practice had the potential to result in Resident 160's discomfort and the spread of infection.
Findings:
During a review of Resident 160's admission Record indicated the facility admitted Resident 160 on 9/5/24 with diagnoses that include depression (a common mental disorder, involving a depressed mood or loss of pleasure or interest in activities for long periods of time) and low back pain.
During a review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/9/24, indicated Resident 160 had moderately impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 160 required supervision or touching assistance with eating, partial/moderate assistance with oral hygiene, personal hygiene and chair/bed-to-chair transfer, and substantial/maximal assistance with toileting hygiene and shower/bathe self.
During a concurrent observation and interview on 10/1/24 at 10:41 AM, with Resident 160, Resident 160 was observed lying in bed. Resident 160's siderails were observed with multiple brown stains and clumped accumulations of dust. Resident 160 stated since admission to the facility two weeks ago, Resident 160's siderails already had the brown stains and dust. Resident 160 stated informing the maintenance supervisor (MS) when Resident 160 was admitted to the facility regarding the dirty side rails, however no one came to clean Resident 160's siderails. Resident 160 stated utilizing siderails to move herself in bed and to get out of bed, but she did not want to touch the siderails because they were dirty. Resident 160 stated she did not feel comfortable staying in a bed with dirty bed siderails.
During a concurrent observation and interview on 10/1/24 at 10:45 AM, with Certified Nursing Assistant (CNA) 5, Resident 160 ' s side rails were observed. CNA 5 stated Resident 160 ' s siderails were dirty and that Resident 160 ' s side rails should be cleaned to provide a clean and sanitary environment. CNA 5 stated housekeeping was responsible for cleaning resident side rails.
During an interview on 10/1/24 at 10:58 AM, with Housekeeping (HK) 1, HK 1 stated the bed siderails were considered as the high touch area (those that people frequently touch with their hands) which required daily cleaning to prevent the spread of infection and provide a sanitary environment to the resident. HK 1 stated not cleaning Resident 160 ' s siderails. During an interview on 10/4/24 at 11:14 AM, with the Director of Nursing, the DON stated staff should clean the bed siderails daily to maintain a safe and sanitary environment for all residents in the facility.
During a review of the facility ' s policy and procedure (P&P) titled, Homelike Environment, dated 2/2021, the P&P indicated Resident are provided with a safe, clean, comfortable and homelike environment .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0577
(Tag F0577)
Could have caused harm · This affected multiple residents
Based on interview, observation and record review, the facility failed to ensure the facility ' s recent (last survey was on 10/5/2023) survey binder with past survey result (outcome of the survey tha...
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Based on interview, observation and record review, the facility failed to ensure the facility ' s recent (last survey was on 10/5/2023) survey binder with past survey result (outcome of the survey that were conducted to protect residents and to ensure that all residents receive the quality of care) were accessible and available for all the residents, including Resident 27, 102 and 106 who attended the facility ' s resident council meeting on 10/2/2024.
This deficient practice had the potential for the residents and their legal representatives to not fully informed of the facility's deficient practices and how they were corrected.
Findings:
During a review of Resident 27's admission Record indicated the facility admitted Resident 27 on 5/7/2024 with diagnoses that included diabetes mellitus (a group of diseases that result in too much sugar in the blood), malnutrition (inadequate intake of food as a source of protein, calories, and other essential nutrients), and lack of coordination.
During a review of Resident 27 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/9/2024, indicated Resident 27 was cognitively intact, had capacity to understand and make decisions.
During a review of Resident 102's admission Record indicated the facility admitted Resident 27 on 8/28/2024 with diagnoses that included malnutrition, hypertension (high blood pressure), and lack of coordination.
During a review of Resident 102 ' s MDS, dated 9/3/24, indicated Resident 102 was cognitively intact, had capacity to understand and make decisions.
During a review of Resident 106's admission Record indicated the facility admitted Resident 106 on 9/13/2024 with diagnoses that included lack of coordination, pain in right foot, and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life).
During a review of Resident 106 ' s MDS, dated 9/17/24, indicated Resident 106 was cognitively intact, had capacity to understand and make decisions.
During the facility ' s resident council meeting interview on 10/2/2024 at 10:55 AM with ten residents included Resident 27, Resident 102, and Resident 106, stated they were not aware of the availability and location of the survey report and how the facility corrected the deficiencies that were identified in the past survey. The residents stated they would like to know the facility's latest survey inspection results and the corrections that the facility put into place.
During a concurrent interview and observation on 10/2/2024 at 11:02 AM with the Director of Nurses (DON), the DON stated, the facility had a binder which content all past survey results. The DON stated, they have a designated table in the entrance area where they usually left the binder in the drawers. The DON was observed opening the designated table ' s drawers and could not find the survey binder. The DON stated, she could not locate the survey binder and would ask Medical Record (MR) where survey binder went.
During an interview on 10/2/2024 at 11:34 AM with the facility ' s MR, the MR stated, she took the survey binder to her office the day before and did not bring it back.
During an interview on 10/4/2024 at 1:22 PM with the DON, the DON stated, the survey binder should be accessible to the residents and visitors, because they had the right to know what was going on with the facility. The DON stated, if the binder was not available, the residents and their representatives could be frustrated not able to know the past deficiencies and how the facility corrected them. The DON stated, the residents and their representatives had the right to know facility ' s past deficient practices and how they were corrected.
During a review of the facility ' s policy and procedure (P&P) titled, Resident Rights, revised February 2021, the P&P indicated, Federal and state laws guarantee certain basic rights to all residents of this facility, these rights include the resident ' s right to examine survey results.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the quarterly Minimum Data Sets (MDS - a federally mandated ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the quarterly Minimum Data Sets (MDS - a federally mandated resident assessment tool) were completed within the required time frame for four out of four sampled residents (Residents 2, 30, 60, and 77).
This deficient practice had the potential to negatively affect the provision of necessary care and services for Residents 2, 30, 60, and 77.
Findings:
During a review of Resident 2's admission Record, indicated the facility initially admitted Resident 2 on 8/4/2020 and readmitted on [DATE].
During a review of Resident 30's admission Record, indicated the facility admitted Resident 30 on 2/21/2024.
During a review of Resident 60's admission Record, indicated the facility admitted Resident 60 on 11/10/2022.
During a review of Resident 77's admission Record, indicated the facility initially admitted Resident 77 on 2/13/2023 and readmitted on [DATE].
During an interview on 10/2/2024 at 3:52 PM with the MDS Nurse, the MDS Nurse stated, all residents were required to have MDS assessment quarterly after their admission date. The MDS Nurse stated, the system had a list of residents with their Assessment Reference Date (ARD-referring to resident assessments), and she had 14 days to complete the assessment after the ARD.
During a concurrent record review and interview on 10/2/2024 at 3:57 PM with the MDS Nurse, Resident 2's quarterly MDS was reviewed. The MDS Nurse stated, based on the record, Resident 2's most recent quarterly MDS assessment ' s ARD was 8/16/2024 and her deadline to complete the assessment was 8/30/2024. The MDS Nurse stated, she completed Resident 2's assessment on 10/1/2024, which was 33 calendar days late.
During a concurrent record review and interview on 10/2/2024 at 4:05 PM with the MDS Nurse, Resident 30's quarterly MDS was reviewed. The MDS Nurse stated, based on the record, Resident 30's most recent quarterly MDS assessment ' s ARD was 8/20/2024 and her deadline to complete the assessment was 9/3/2024. The MDS Nurse stated, she completed Resident 30's assessment on 10/2/2024, which was 29 calendar days late.
During a concurrent record review and interview on 10/2/2024 at 4:10 PM with the MDS Nurse, Resident 60's quarterly MDS was reviewed. The MDS Nurse stated, based on the record, Resident 60's most recent quarterly MDS assessment ' s ARD was 8/22/2024 and her deadline to complete the assessment was 9/5/2024. The MDS Nurse stated, she completed Resident 60 ' s assessment on 10/2/2024, which was 27 calendar days late.
During a concurrent record review and interview on 10/2/2024 at 4:20 PM with the MDS Nurse, Resident 77's quarterly MDS was reviewed. The MDS Nurse stated, based on the record, Resident 77's most recent quarterly MDS assessment's ARD was 8/15/2024 and her deadline to complete the assessment was 8/29/2024. The MDS Nurse stated, she completed Resident 77's assessment on 9/27/2024, which was 29 calendar days late.
During an interview on 10/2/2024 at 4:30 PM with the MDS Nurse, the MDS Nurse stated, she had been late for the residents assessment because there was a pilling of a number of residents assessment, and she did not have enough time to complete them all.
During an interview on 10/4/2024 at 1:12 PM with the Director of Nurses (DON), the DON stated, she was aware that residents assessment had been completed late. The DON stated, there was an MDS consultant that oversaw the MDS Nurses. The DON stated, if the residents assessment were late, there might be something wrong with the resident that we would not be able to assess and update the care plan timely. The DON stated, she would coordinate with the MDS consultant to make sure the residents are assessed and submitted timely.
During a review of the facility's policy and procedure (P&P) titled, MDS Completion and Submission Timeframes, revised July 2017, the P&P indicated, the facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes, timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument (RAI) Manual.
During a review of the facility's P&P titled, RAI OBRA-required (Omnibus Budget Reconciliation Act, federal law passed in 1987 that established standards for nursing home care and the rights of nursing home residents) Assessment Summary, dated October 2024, indicated for the non-comprehensive quarterly MDS assessment, the MDS completion date must be no later than 14 calendar days following the ARD.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During a review of Resident 63 ' s admission Record (Face Sheet), dated 2/18/2022, the face sheet indicated the facility admi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During a review of Resident 63 ' s admission Record (Face Sheet), dated 2/18/2022, the face sheet indicated the facility admitted Resident 63 on 2/18/2022, and readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary disease (COPD - lung disease which makes breathing difficult), and bronchiectasis (a condition where your airways widen or develop pouches).
During a review of Resident 63 ' s History and Physical dated 3/3/2024, indicated, Resident 63 had the mental capacity to make medical decisions.
During a review of Resident 63 ' s Order Summary Report, dated 10/2/2024, the Order Summary Report indicated an order on 3/3/2024, the order indicated may use oxygen at two (2) liters per minute (L/min) via nasal cannula (device use for delivery of oxygen) to maintain oxygen saturation (amount of oxygen carried in blood) at 92% (normal range 90-100%).
During a review of Resident 63's MDS, dated [DATE], indicated the cognitive (the ability to think and process information) skills for daily decisions making was intact, and independent for activities of daily living.
During a concurrent observation and interview on 10/1/2024 11:33 a.m., CNA 4 stated Resident 63 refuses to put the nasal cannula in a bag.
During a review of Resident 63's Care Plans did not indicate the resident refused to have nasal canula placed in a bag when not in use.
During a concurrent observation and interview on 10/4/2024 at 11:34PM with Resident 63 in resident's room. Resident 63 stated, he likes the tubbing just like it is. He does not like it in a bag.
During an interview on 10/4/2024 at 3:20 PM with the Director of Nursing (DON), stated the resident's behavior of not wanting the nasal canula in a bag should have been addressed and care planned accordingly.
During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated the comprehensive, person-centered care plan is developed for each resident within seven days of completion of required MDS assessment, and no more than 21 days after admission.
During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person- Centered, revised 4/2022, P&P indicated, a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed for each resident.
Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) for four of five sampled residents (Resident 58, 3, 70 and 63) by failing to:
1. Develop a care plan for dementia Resident 58 with dementia (a progressive state of decline in mental abilities)
2. Develop a plan of care for Resident 3 and Resident 70 while receiving psychoactive medications ( medications that affects mood and behavior).
3. Develop a plan of care for Resident 63 who refused to have the nasal canula (a device used to deliver supplemental oxygen placed directly on a resident's nostrils) placed in a bag when not in use.
These deficient practices had the potential for the residents not to recieve the necesary care and services to achieve their highest potential and/or in adverse side effects (undesired effect) from the use of psychoactive medications.
Findings:
1. During a review of Resident 58's admission Record indicated the facility initially admitted Resident 58 on 4/27/2021 and readmitted on [DATE] with diagnoses that included dementia, schizophrenia (a mental illness that is characterized by disturbances in thought), and anxiety disorder(a group of mental disorders characterized by significant feelings of fear that affect with daily activities).
During a review of Resident 58 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/9/2024, indicated Resident 58 ' s cognition (a term for the mental processes that take place in the brain, including thinking, attention, language, learning, memory and perception) was severely impaired.
During a review of Resident 58 ' s History and Physical, dated 1/13/2024, indicated Resident 58 did not have the capacity to understand and make decisions.
During a concurrent interview and record review on 10/4/2024 at 9:41 AM with Licensed Vocational Nurse (LVN) 1, Resident 58 ' s care plan was reviewed. LVN 1 stated, there was no care plan initiated for Resident 58 ' s dementia. LVN 1 stated, Resident 58 ' s diagnosis included dementia upon admission and there should have been a care plan for Resident 58 ' s dementia diagnosis. LVN 1 stated care plans were necessary for resident care, and not having a care plan for a resident ' s specific needs was a risk to resident ' s health and care, since staff would not know what interventions to implement or what to monitor. LVN1 stated the care plan was needed to ensure interventions were effective or not, and by implementing a care plan licensed nurses could monitor residents more effectively.
During an interview on 10/4/2024 at 12:57 PM with the Director of Nurses (DON), the DON stated, it was important to have a care plan addressing each of the diagnosis for Resident 58 including dementia so staffs would know how to take care of the resident and to discuss in the Interdisciplinary Team meeting (IDT, a coordinated group of experts from several different fields). The DON stated, Resident 58 would not have the right interventions for the specific behavior, and facility staff could not provide the care and services needed for Resident 58 ' s specific needs.
During a review of the facility ' s policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated March 2022, the P&P indicated, a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident.
2. During a review of Resident 3's admission Record indicated the facility admitted Resident 3 on 6/3/24 with diagnoses that include schizoaffective disorder (a mental health condition that is marked by a mix of symptoms, such as hallucinations [a perception of something that seems real but is not, and can involve any of the senses] and delusions [a false belief or judgement about external reality], mood disorder [a mental health condition that primarily affects the emotional state] and mania [a condition in which you have a period of abnormally elevated, extreme changes in your mood or emotions, energy level or activity level]) and dementia (a group of thinking and social symptoms that interferes with daily functioning).
During a review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/3/24, indicated Resident 3 had moderately impaired cognition (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 3 required partial/moderate assistance with eating and chair/bed-to-chair transfer, and required substantial/maximal assistance with oral hygiene, toilet hygiene, shower/bathe self and personal hygiene.
During a review of Resident 3's Order Summary Report (OSR), dated 9/30/24, the OSR indicated physician ordered the resident to receive Olanzapine (a medication that can treat several mental health conditions) 10 milligram (MG, a unit of measurement) one tablet by mouth at bedtime for psychosis (a condition that causes a person to lose touch with reality, making it difficult to distinguish what is real and what is not) manifested by delusional (holding a false belief or judgement about external reality).
During a review of Resident 3's Medication Administration Record (MAR), dated from 6/2024 to 10/2024, the MAR indicated Resident 3 received Olanzapine 10 MG one tablet by mouth at bedtime from 6/3/24 to 10/3/24.
During a concurrent interview and record review on 10/3/24 at 2:10 PM, with Licensed Vocational Nurse (LVN) 5, Resident 3's Care Plan (CP) was reviewed. LVN 4 stated Resident 3 was receiving psychotropic medication-Olanzapine. LVN 5 stated Resident 3 did not have a care plan to address interventions in the use of a psychotropic medication, there should have been a care plan developed to provide guidance to the staff how to care for the resident safely.
During a concurrent interview and record review on 10/3/24 at 2:15 PM, with Registered Nurse (RN) 3, Resident 3's CP was reviewed. RN 3 stated there was no CP to address the use of a psychotropic medication for Resident 3. RN 3 stated it was important to develop and implement the CP for Resident 3 regarding the use of olanzapine because the CP could guide staff what to monitor the side effects of olanzapine and how to intervene effectively to ensure Resident 3 ' s safety.
3. During a review of Resident 70's admission Record indicated the facility originally admitted Resident 70 on 6/1/23 and readmitted on [DATE] with diagnoses that include dementia and psychotic disorder (severe mental illnesses that cause abnormal thinking and perceptions, and a loss of touch with reality).
During a review of Resident 70 ' s MDS, dated [DATE], indicated Resident 70 had intact cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 70 required setup or clean-up assistance with eating and oral hygiene, partial/moderate assistance with personal hygiene, substantial/maximal assistance with chair/bed-to-chair transfer, and was dependent with toileting hygiene.
During a review of Resident 70's OSR, dated 10/3/24, the OSR indicated the physician ordered for Resident 70 to receive medications list below, started on 6/27/24:
a. Divalproex sodium (a medication is used to stabilize mood) 500 MG one tablet by mouth every 12 hours for mood stabilizer
b. Olanzapine 10 MG one tablet by mouth two times a day for striking out at staff and/or roommate
c. Paliperidone Palmitate (a medication is used to treat the symptoms of mental disorders) 235 MG/1.5 milliliter (ML, a unit of measurement) inject 0.5 ML intramuscularly one time a day starting on the 23rd and ending on the 23rd every month for rapid mood cycling sudden shifts in mood from pleasant to extreme anger as evidence by screaming and yelling
d. Risperidone (a medication is used to treat the symptoms of mental disorders) one MG one tablet by mouth one time a day for striking out at staff and/or roommate
e. Sertraline (a medication is used to treat the symptoms of a mental disorder) 100 MG one capsule by mouth one time a day for irritability manifested as verbal aggression
During a review of Resident 70 ' s MAR, dated from 6/2024 to 10/2024, the MAR indicated Resident 70 received Divalproex sodium 500 MG one tablet by mouth every 12 hours, Olanzapine 10 MG one tablet by mouth two times a day, Risperidone one MG one tablet by mouth one time a day, and Sertraline 100 MG one capsule by mouth one time a day from 6/28/24 to 10/2/24. The MAR indicated Resident 70 received Paliperidone Palmitate 235 MG/1.5 ML inject 0.5 ML intramuscularly one time a day on 7/23/24 and 8/23/24.
During a concurrent interview and record review on 10/3/24 at 2:12 PM, with Licensed Vocational Nurse (LVN) 5, Resident 70 ' s Care Plan (CP) was reviewed. LVN 4 stated Resident 70 s was receiving multiple psychotropic medications and the CP to address the intervention while receiving these psychotropic medications should be developed to provide guidance to the staff how to care for the resident safely. The LVN 5 stated the CP of the use of multiple psychotropic medications was not completely developed for Resident 70.
During a concurrent interview and record review on 10/3/24 at 2:17 PM, with Registered Nurse (RN) 3, Resident 70 ' s CP was reviewed. RN 3 stated the CP to address interventions to monitor the resident while receiving Divalproex, Risperdal and Olanzapine including their adverse effects and side effects, were not initiated on 6/27/24, but there was no intervention documented on the CP. RN 3 also stated there was no CP to address interventions to monitor the resident while receiving the use of Divalproex, Sertraline, and Paliperidone Palmitate for Resident 70. RN 3 stated it was important to develop and implement the complete CP for Resident 70 regarding the use of multiple psychotropic medications because the CP could guide staff what to monitor the side effects of her psychotropic medications and how to intervene effectively if the side effects occurred to ensure Resident 70 ' s safety.
During an interview on 10/4/24 at 11:16 AM, with the Director of Nursing (DON), the DON stated if a resident was on a psychotropic medication, the nurse should develop and implement the complete care plan regarding the use of the psychotropic medication to ensure safe care to the resident.
During a review of the facility ' s policy and procedure (P&P) titled, Behavior/Psychotropic Drug Management, dated 6/2019, the P&P indicated The Care Plan shall reflect .use of psychoactive medication(s), adverse reactions to psychoactive medication(s) .experienced by the resident and interventions taken.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of Resident 63 ' s admission Record dated 2/18/2022, the record indicated the facility admitted Resident 63 o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of Resident 63 ' s admission Record dated 2/18/2022, the record indicated the facility admitted Resident 63 on 2/18/2022 and readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary disease (COPD - lung disease which makes breathing difficult), and Bronchiectasis (a condition where your airways widen or develop pouches).
During a review of Resident 63 ' s History and Physical (H&P), dated 3/3/2024, indicated, Resident 63 had the capacity to make medical decisions.
During a review of Resident 63 ' s Order Summary Report, dated 10/2/2024, the Order Summary Report indicated an order on 3/3/2024, indicating may use oxygen at two (2) liters (a unit of measurement) per minute (L/min) via nasal cannula (device use for delivery of oxygen) to maintain oxygen saturation (amount of oxygen carried in blood) at 92%.
During a review of Resident 63's Minimum Data Set (MDS-a federally mandated resident assessment tool.), dated 8/15/2024, indicated the cognitive (the ability to think and process information) skills for daily decisions making was intact, and independent for activities of daily living.
During an observation on 10/2/2024 at 11:30 a.m., Resident 63 was observed sitting at the edge of his bed in his room. Resident 63 ' s oxygen machine was observed in resident ' s room. There was no precautionary signage posted on Resident 63 ' s door indicating oxygen was in used in the room or smoking was prohibited.
During a concurrent observation and interview on 10/1/2024 11:33 a.m. CNA 4 stated that there was no precautionary signage posted on Resident 63 ' s door indicating oxygen was in use, or smoking was prohibited.
During an interview on 10/3/2024 at 9:30 a.m., with the Registered Nurse Supervisor 4 (RN 4), RN4 stated smoking signage should be posted at the entrance door of residents receiving oxygen therapy to alert staff and visitors that oxygen was in use, and to avoid smoking for resident safety.
During a review of the facility ' s policy and procedure (P&P) titled, Oxygen Administration, revised 10/2010, P&P indicated, equipment and supplies are necessary when performing the procedure to place No smoking/Oxygen in Use signs.
2. A review of Resident 258's admission Record, indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure (a progressive condition in which the lungs cannot meet the body ' s oxygen demands)chronic obstructive pulmonary disease (COPD) (lung disease causing restricted airflow and breathing problems) and malignant neoplasm of upper lobe, right bronchus or lung (lung cancer).
A review of Resident 258's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 9/20/2024, the MDS indicated, Resident 258's cognitive status (ability to think and remember or thought process) was moderately impaired. The MDS indicated Resident 258 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guar assistance as resident completes activity) with eating, partial/moderate assistance (helper does less than half the effort) with personal hygiene, roll left and right , sit to stand, and required substantial/maximal assist (helper does more than half the effort) with toileting and bathing.
During an observation on 10/1/2024 at 9:30 AM in Resident 258's room, Resident 258 was asleep while continuously receiving oxygen at 2 liters per minute. The doorway of Resident 258 ' s room or in the room did not have an oxygen in use warning sign posted.
During an interview on 10/1/2024 at 9:45 AM with Licensed Vocational Nurse (LVN) 3 by Resident 258's room. LVN 3 stated, Resident 258's doorway should have a posted warning sign oxygen in use as per facility's policy, because the facility allows smokers in designated area, and smoking and oxygen had the potential to cause fire.
During an interview on 10/1/2024 at 10AM with Registered Nurse (RN) 3. RN 3 stated, Resident 258 had been receiving oxygen since admitted to the facility, and his doorway should have a warning sign of oxygen in use as per policy, because we have smokers in the building, to prevent potential accident or fire.
During a concurrent interview and record review, on 10/2/2024, at 4 PM, with Licensed Vocational Nurse (LVN) 2, Resident 258 ' s facility document titled Order Summary Report dated 10/2/2024 was reviewed. The document indicated, Resident 258 was admitted on [DATE] and the order to administer oxygen at 2 liters per minute via nasal cannula was just ordered 10/2/2024. LVN 2 stated, Resident 258 had been receiving oxygen since admission to the facility on 9/16/2024 without a physician ' s order.
During a concurrent interview and record review, on 10/2/2024 at 4:15 PM, with LVN 3, Resident 258 ' s documents titled ' Progress Notes (PN) dated 9/16/2024 and Medication Administration Record (MAR) for the month of September 2024 was reviewed. The PN indicated Resident 258 had been receiving oxygen at 2 liters per minute upon admission to the facility on 9/16/2024 and Resident 258 was receiving oxygen continuously without a physician ' s order since. LVN 3 stated, he missed getting an order for oxygen. LVN 3 stated, oxygen should have an order before administering because it could cause oxygen toxicity.
During a concurrent interview and record review, on 10/2/2024 at 4:25 PM, with Director of Nurses (DON), Resident 258 ' s facility document titled Order Summary Report dated 10/2/2024 was reviewed. DON stated, Resident 258 was receiving oxygen since admission to the facility on 9/16/2024, but did not have an order until today 10/2/2024. DON stated, the admitting nurse and the staff missed getting an order for oxygen until today. DON stated oxygen is a drug so it should have a physician order prior to administration because it has a potential to cause oxygen toxicity. DON also stated, Resident 258 who was receiving oxygen should have had a warning sign oxygen in use posted on the doorway because the facility allows smoking, and smoking and oxygen has a potential to cause fire.
A review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 10/2010, indicated: a) the purpose is to provide guidelines for safe oxygen administration, b) preparation includes to verify that there is a physician order for the procedure, c)equipment necessary when performing the procedure includes No Smoking/Oxygen in Use sign, and d) remove all potentially flammable items (smoking articles) from the immediate area where oxygen is to be administered.
A review of the facility's policy and procedure (P&P) titled, Physician Orders, (undated), indicated: a) ensure all physician orders are followed and documented as given without errors, and b) do not start any due medications if not yet verified from the physician or nurse practitioner.
Based on observation, interview, and record review, the facility failed to ensure residents who needs respiratory care were provided such care, consistent with professional standards of practice, care plan goals, and facility's policy and procedure for four of four sampled residents (Resident 258, 63, 26 and 55) by failing to ensure:
1. Resident 258, 63 who uses and was receiving oxygen in the room had an oxygen in use warning sign was posted on the resident's doorway.
2. Resident 258 does not receive oxygen therapy since 9/16/2024 without a physician ' s order.
3. Resident 26 and Resident 55 nebulizers (a small machine that turns liquid medicine into a mist that can be easily inhaled) were stored in a sanitary manner and changed according to facility's policy and procedure.
These deficient practices had the potential to cause a fire at the resident(s) in the facility that resulting in injuries and death. In addition, for Resident 258 could receive excessive oxygen that could result in oxygen toxicity (develop toxins in the body and result in lung damage due breathing in too much oxygen), and for Residents 26 and 55 had the potential for the transmission of bacteria and the risk for respiratory infection (any infectious disease of the parts of the body involved in breathing).
Findings:
1. During a review of Resident 26's admission Record indicated the facility initially admitted Resident 26 on 1/31/23 and readmitted on [DATE] with diagnoses that include respiratory failure (a serious condition that makes it difficult to breathe on your own) and dementia (a group of thinking and social symptoms that interferes with daily functioning).
During a review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/10/24, indicated Resident 26 had severely impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 26 required supervision or touching assistance with eating, and required partial/moderate assistance with oral hygiene, toilet hygiene, shower/bathe self, chair/bed-to-chair transfer.
During a review of Resident 26 ' s Order Summary Report (OSR), dated 9/30/24, the OSR indicated the physician ordered to administer albuterol sulfate (a medication is used to prevent and treat wheezing, difficulty breathing, chest tightness, and coughing) inhalation nebulizer solution (2.5 milligram [MG, unit of measurement]/3 milliliter (ML, unit of measurement]) 0.083 % [percent]) six ML inhale orally via nebulizer every four hours for shortness of breath and wheezing while awake, started on 9/6/24.
During a review of Resident 26 ' s Medication Administration Record (MAR), dated 9/1/24 to 9/30/24 and 10/1/24 to 10/31/24, the MAR indicated Resident 26 received Albuterol sulfate inhalation nebulizer solution inhale orally via nebulizer every four hours from 9/7/24 to 10/2/24.
During an observation on 10/1/24 at 10:52 AM, Resident 26 was sitting at the edge of her bed. Resident 26 had a nebulizer mask covering her nose and mouth with a blue head strap over her head, securing the nebulizer mask in place. Resident 26 was observed receiving breathing treatment via nebulizer mask.
During a concurrent observation and interview on 10/1/24 at 11:41 AM, in Resident 26 ' s room, Resident 26 ' s nebulizer mask was observed inside the top drawer of the nightstand on the right side of the Resident 26 ' s bed, not stored in a bag. A stained paper drawer liner was covering the bottom of the top drawer. Inside Resident 26 ' s drawer there were five disposable plastic cups lying on top of the stain of the paper drawer liner. One white dirty bottle cap, a hairbrush, one unopen paper straw, an undated mask, and a roll of plastic bags were observed inside the top drawer. The nebulizer mask had direct contact with the hairbrush, the straw and the paper liner.
During a concurrent observation and interview on 10/1/24 at 11:50 AM, with Licensed Vocational Nurse (LVN) 5, Resident 26 ' s nebulizer, kept in Resident 26 ' s nightstand was observed. LVN 5 stated Resident 26 ' s nebulizer mask should be kept inside a plastic bag with the date and the resident ' s name on the bag. LVN 5 stated not knowing how long Resident 26 ' s mask was stored, uncovered. LVN5 stated since Resident 26 ' s nebulizer mask was not stored in a bag while not in use, there was a risk for respiratory infection, due to inappropriate storage of the nebulizer mask.
During an interview on 10/2/24 at 3:09 PM, with the Director of Nursing (DON), the DON stated the nebulizer mask should be stored in a plastic bag, labeled with the resident ' s name and dated to ensure the nebulizer mask was clean, and to prevent infection.
During a review of the facility's policy and procedure (P&P) titled, Administering Medications through a Small Volume (Handheld) Nebulizer, dated 10/2010, the P&P indicated to store equipment, including mask, in a plastic bag with the resident ' s name and the date on it.
2. During a review of Resident 55's admission Record indicated the facility initially admitted Resident 55 on 1/28/21 and readmitted on [DATE] with diagnoses that include acute respiratory failure (a condition where there's not enough oxygen in your body) and diabetes mellitus (a group of diseases that result in too much sugar in the blood).
During a review of Resident 55's MDS, dated [DATE], indicated Resident 1 had severely impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 55 was dependent with eating, oral hygiene, toilet hygiene, shower/bath self, personal hygiene, and chair/bed-to-chair transfer.
During a review of Resident 55's OSR, dated 9/30/24, the OSR indicated the physician ordered to administer ipratropium (a medication that relaxes and opens the airways to help with breathing) albuterol inhalation nebulizer solution 0.5-2.5 MG/3 ML three ML inhale orally every four hours for shortness of breath and wheezing, and acetylcysteine (a medication is used to help with breathing) inhalation solution 10% two ML inhale orally every four hours for shortness of breath and wheezing, started on 7/24/24.
During a review of Resident 55's MAR, dated 10/1/24 to 10/31/24, the MAR indicated Resident 55 received ipratropium-albuterol inhalation nebulizer solution and acetylcysteine inhalation solution 10% inhale orally via nebulizer every four hours from 10/2/24 to 10/4/24.
During an observation on 10/4/24 at 9:14 AM, Licensed Vocational Nurse (LVN) 4 was holding Resident 55's nebulizer mask at bedside and squeezed a vial of ipratropium-albuterol inhalation nebulizer solution 0.5-2.5 MG/3 ML into the medication chamber of the nebulizer mask. Resident 55's nebulizer mask was labeled 9/25/24.
During a concurrent observation and interview on 10/4/24 at 9:15 AM, in Resident 55 ' s room, with the Infection Preventionist (IP) and LVN4, Resident 55's nebulizer treatment was observed. The IP stopped LVN 4 from placing the nebulizer mask on Resident 55 and instructed LVN 4 to obtain a new nebulizer mask. The IP stated the nebulizer mask should be changed every seven days. The IP stated Resident 55's nebulizer mask was dated 9/25/24. The IP stated the staff did not change the mask after 7 days and continued to use on Resident 55 for another three days, which put the resident at risk for infection.
During an interview on 10/4/24 at 11:12 AM, with the Director of Nursing (DON,) the DON stated nebulizer mask should be changed every seven days to prevent infection.
During a review of the facility's policy and procedure (P&P) titled, Administering Medications through a Small Volume (Handheld) Nebulizer, dated 10/2010, the P&P indicated to change equipment, including mask, every seven days.
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 ensure the food were stored prepared and distributed of food under sanitary conditions to all the residents in the facility b...
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Based on observation, interview, and record review, the facility failed to ensure the food were stored prepared and distributed of food under sanitary conditions to all the residents in the facility by failing to:
1.Ensuring to store food with label and open date.
2.Ensure expired food was not stored in the kitchen.
3.Monitoring and documenting Sanitization Bucket Log.
4.Monitoring and documenting Ice Machine cleaning log.
5.Monitoring and documenting cleaning and maintenance schedule log.
These deficient practices placed the residents at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).
Findings:
a. During a concurrent observation and interview on 10/1/2024 at 8:55 a.m., during an initial Kitchen tour in the presence of [NAME] (Cook) 1. There were several open items without label and open date. Those items were a liquid whole egg carton, three squeeze bottles containing apple sauce, cottage cheese container, a sliced watermelon covered with plastic wrap with no use by date, Buttermilk Ranch dressing container with no open date, Sliced potatoes in a container covered with plastic wrap with no used by date. [NAME] 1 stated that the items should have been labeled with open date and use by date.
During a review of the facility's policy and procedure (P&P) titled, Labeling and Dating of Foods , indicated newly opened food items will need to be closed and labeled with an open date and used by the date.
b. During a concurrent observation and interview on 10/1/2024 at 9:30 a.m. during the kitchen tour with the Dietary Service Supervisor (DSS) observed several items that were expired and stored in the kitchen. in the walk-in fridge Parmesan cheese with a use by date of 9/24/24, Turkey salad observed with a use by date of 9/30/24 were observed. The Dietary Service Supervisor (DSS) stated the food was no good and had to be discarded. The following condiments were observed Nutmeg ground expired 9/24/24 and Turmeric ground expiration date 6/2/24. DSS they should have been discarded.
During a review of the facility's policy and procedure (P&P) titled, Labeling and Dating of Foods , indicated No food will be kept longer than the expiration date on the product.
c. During a concurrent observation and interview on 10/1/2024 at 9:45 a.m. during an initial kitchen tour with the DSS, a review of the log for the month of September 2024 titled Sanitizer Bucket Log had missing dates with the test results from 9/19/2024 and 9/20/2024 from 1 p.m. to 7 pm. On 9/28/2024 and 9/30/2024 had missing test results for the entire day. DSS stated staff is supposed to fill out the log after each meal, after each use. The DSS verified that log entries were missing for the dates mentioned above. The DSS stated the sanitizing bucket is used to sanitize the food preparation area to reduce the number of bacteria on non-food contact surfaces. The incomplete log indicated the facility's kitchen was not sanitized according to the facility's policy. On 10/1/2024 at 9:45 a.m., during an initial tour of the kitchen with Dietary Services Supervisor (DSS), the Record of Sanitizer Bucket Log was reviewed. The form indicated to use Quaternary sanitizing solution: Concentration range 200ppm (parts per million or ppm means out of a million), immerse test strip for 10 seconds. The form had columns to enter the data eight times a day at 5 a.m., 7 a.m., 9 a.m., 11 a.m., 1 p.m., 3 p.m., 5 p.m., and 7 p.m. however, there were many blank columns. The last entry on the record was at 7 p.m., on 9/29/2024.
During an interview with the DSS on 10/1/2024 at 9:50 a.m., when asked about the procedure of completing the Record of Sanitizer Agent, DSS stated staff is supposed to fill out the log after each meal, after each use. Or if the PPM is not within acceptable range, make new sanitizer and retest. Change more often as needed. The DSS verified that log entries were missing from 9/19/2024 and 9/20/2024 from 1 p.m. to 7 pm, 9/28/2024 and 9/30/2024 had missing test results for the entire day.
During an interview with the DSS on 10/1/2024 at 9:50 a.m., DSS stated he is responsible making sure the log is filled out after each use of the test strip. When asked about the missing entries on the Record of Sanitizer bucket log. The DSS stated that every staff member of the kitchen is responsible for completing the log. The DSS stated he may have missed it. The DSS stated he would follow up and make sure everyone follows through. The DSS stated he would make sure the log is filled out accurately and consistently.
During a review of the facility's policy and procedure (P&P) titled, Quaternary Ammonium Log Policy, indicated the concentration of the ammonium in the quaternary sanitizer will be tested to ensure the effectiveness of the solution. Food and Nutrition Services staff will record the readings twice a day, once in the morning and once in the PM, to document the process was completed.
d. During a concurrent observation and interview on 10/1/2024 at 10:00 a.m., a review of the log for the month of September 2024 titled Ice Machine Cleaning Log had missing dates with staff initials for 9/20/2024, 9/21/2024, 9/27/2024 and 9/28/2024. DSS stated staff is supposed to fill out the log daily. It is the kitchen staff responsibility to clean the outside of the ice machine and scoop daily. DSS stated it is his responsibility to follow up with the staff, so they understand their duties, but I did not follow up.
e. During a concurrent observation, review and interview on 10/1/2024 at 10:10 a.m., a log titled Cleaning and maintenance Schedule for the month of July was observed posted in the Refrigerator 2, which was observed to have multiple missing entries. The DSS stated that the log is for the month of September 2024, but he forgot to change the month to September when he printed the log. The DSS provided the log for August and July logs that were incomplete. The DSS stated that this log was recently implemented in the month of July and the kitchen staff did complete the logs. The DSS stated it his responsibility to make sure the log is filled out accurately and consistently.
During a review of the facility's policy and procedure (P&P) titled, Sanitation, indicated The FNS (food & nutrition services) Director will write the cleaning schedule in which he designates by job title and/or employee who is to the task.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. During a review of Resident 43 ' s admission Record dated 1/27/2022, the record indicated the facility admitted Resident 43 o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. During a review of Resident 43 ' s admission Record dated 1/27/2022, the record indicated the facility admitted Resident 43 on 1/27/2022, and readmitted on [DATE] with diagnoses including Spinal Stenosis (abnormal narrowing of the spinal canal that may occur in any of the regions of the spine), Chronic Obstructive Pulmonary disease (COPD - lung disease which makes breathing difficult), and Dysphagia (difficulty swallowing).
During a review of Resident 43's Minimum Data Set (MDS-a federally mandated resident assessment tool.), dated 7/24/2024, indicated the cognitive (the ability to think and process information) skills for daily decisions making was moderately impaired, and required moderate assistance for activities of daily living.
During a review of Resident 43 ' s Order Summary Report, dated 10/03/2024, the Order Summary Report indicated an order on 6/02/2024 to provide the resident a consistent carbohydrate, No Added Salt Diet mechanical soft texture (a texture-modified diet that restricts foods that are difficult to chew or swallow), Regular/Thin consistency finely chopped.
During a review of Resident 257 ' s admission Record dated 9/20/2024, the record indicated the facility admitted Resident 43 on 9/20/2024, with diagnoses including Muscle weakness, and Hypertension (HTN - elevated blood pressure.
During a review of Resident 257's Minimum Data Set (MDS-a federally mandated resident assessment tool.), dated 9/24/2024, indicated the cognitive (the ability to think and process information) skills for daily decisions making was moderately impaired, and required moderate assistance for activities of daily living.
During a review of Resident 257 ' s Order Summary Report, dated 10/03/2024, the Order Summary Report indicated an order on 10/02/2024 to provide the resident a consistent carbohydrate diet, Regular/Thin consistency.
During an observation on 10/2/2024, at 12:30 p.m., Certified Nurse Assistant (CNA 4) was observed obtaining a meal tray from the meal tray cart and entered Resident 43 ' s room. CNA 4 was observed setting up the meal tray for Resident 43.CNA 4 was then observed exiting Resident 43 ' s room and then obtaining another meal tray from the meal tray cart for Resident 257. CNA 4 entered Resident 257 ' s room, CNA 4 was observed not performing hand hygiene in between meal tray distribution and set up for Resident 43 and Resident 257.
During an interview on 10/2/2024 at 12:35 p.m., CNA 1 stated not performing hand hygiene in between assisting Resident 43 and 257. CNA 1 stated she should have performed hand hygiene before and after entering or exiting any resident ' s room. CNA 1 stated it was important to performed hand hygiene to prevent cross contamination between residents.
During an interview on 10/4/2024 at 3:20 p.m. with the Director of Nursing (DON), the DON stated according to the facility's policy, all nursing staff were supposed to wash their hands prior to any physical contact or providing care and to wash their hands before and after the procedure.
During a review of the facility's policy and procedure (P&P) titled, Hand Hygiene indicated use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before and after assisting a resident with meals.
A review of the facility's policy and procedure (P&P) titled, [Departmental (Respiratory Therapy) - Prevention of Infection], dated 11/2011, indicated: a) the purpose is to guide prevention of infection associated with respiratory therapy task and equipment, among residents and staff, b) use distilled water for humidification per facility protocol, mark bottle with date and initials upon opening and discard after twenty-four (24) hours, b) change the oxygen cannula and tubing every seven (7) days, or as needed, c) infection control consideration related to medication nebulizers includes store the circuit in a plastic bag, marked with date and resident's name between uses, and discard the administration set-up every seven days.
A review of the facility's policy and procedure (P&P) titled, [Administering Medications through a small volume (Handheld) Nebulizer], dated 10/2010, indicated: a) when equipment is completely dry, store in a plastic bag with the resident's name and the date on it, b) change equipment and tubing every seven days, or according to facility protocol.
Based on observation, interview, and record review, the facility failed to implement the facility's infection control program (a system in preventing, controlling infections and communicable diseases) for six of six sampled residents (Residents 258, 86, 55, 95, 43 and 257).
The facility failed to:
1. Ensure for Resident 258 the nasal cannula (a device that delivers extra oxygen through a tube and into your nose), the hand held nebulizer (HHN- machine that turns liquid medication into a mist so that it can be breathed directly into the lungs mouthpiece) circuit were not labeled of the date of the initial use, the HHN circuit was not placed in a plastic bag and the humidifier bottle was not labeled with date and initials upon opening.
2. Ensure for Resident 86 the feeding syringe (a tool used to deliver small amounts of liquid into a person ' s [ gastric tube [G-tube, a tube that is inserted into the stomach to provide food, liquids, or drugs, or to remove substances from the stomach] was not changed every 24 hours.
3. Ensure for Resident 55 the blood pressure (BP, the force of the blood pushing against the walls of the arteries [tubelike structures transporting blood from the heart to the rest of the body) monitor was not Cleaned and disinfected (remove dirt or stains, and apply a chemical to a surface in order to destroy germs) a before and after each use.
4. Ensure the nasal cannula (NC, a flexible tube that provides oxygen through the nose) for Resident 95 was labeled when the NC will be changed.
5. Ensure facility staff performed hand hygiene while distributing resident meal trays for two sampled residents (Resident 43 and Resident 257) according to policy and procedure.
These deficient practices had the potential for the device to contact contaminated (containing disease causing organism) areas and cause the spread of infection (a process when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm) to the residents and others in the facility.
Findings:
1. A review of Resident 258's admission Record, indicated Resident 258 was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure (a condition in which the lungs have a hard time loading the blood with oxygen or removing carbon dioxide), chronic obstructive pulmonary disease (COPD) (lung disease causing restricted airflow and breathing problems) and malignant neoplasm of upper lobe, right bronchus or lung (lung cancer).
A review of Resident 258's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 9/20/2024, the MDS indicated, Resident 258 cognitive status was moderately impaired. The MDS indicated Resident 258 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guar assistance as resident completes activity) with eating, partial/moderate assistance (helper does less than half the effort) with personal hygiene, roll left and right , sit to stand, and required substantial/maximal assist (helper does more than half the effort) with toileting and bathing.
During an observation on 10/1/2024 at 9:30 AM in Resident 258's room, Resident 258 lying in bed with eyes close receiving oxygen at 2 liters per minute (a unit of measurement) the nasal cannula, oxygen humidifier, HHN circuit was not labeled of dated on when the tube was first used, also the HHN circuit was not stored inside the plastic bag to prevent the tube from contacting contaminated surface.
During an interview on 10/1/2024 at 9:45 AM with Licensed Vocational Nurse (LVN) 1 inside Resident 258's room, LVN 1 stated, Resident 258's had been receiving oxygen since admission to the facility on 9/16/2024 and his nasal cannula, oxygen humidifier and HHN circuit should have been labeled and dated of initial use, also the HHN circuit should be in a plastic bag. LVN 1 stated, not having a label of the date the device was initially used, would not let the nurses know the last time it was change. LVN 3 stated, if the oxygen equipment's are old it will harbor bacteria and virus and could cause and/or spread of infection and diseases.
During an interview on 10/1/2024 at 10 AM with Registered Nurse (RN) 1, RN 1 stated, Resident 258's nasal cannula and oxygen humidifier should be labeled of the dated it was initially used, and the HHN circuit should be placed in a plastic bag and should be labeled and dated it was initially used. RN 1 stated, nursing would not know the last time it was used and if it was old, and it could harbor bacteria and virus and can cause or even spread infection.
During an interview on 10/1/2024 at 10:15 AM with Infection Preventionist Nurse (IPN), IPN stated, Resident 258's nasal cannula, humidifier should be labeled and dated it was initially used and the HHN circuit should be in a plastic bag and dated of when it was initially used and labeled. IPN stated, otherwise it could be old equipment and could harbor bacteria or virus that can cause and spread infection.
A review of Resident 258's facility document titled 'Progress Notes (PN) dated 9/16/2024 was reviewed, the PN indicated Resident 258 was receiving oxygen at 2 liters per minute upon admission on [DATE].
A review of Resident 258's facility document titled Order Summary Report dated 10/2/2024 was reviewed. The document indicated a physician order for Albuterol Sulfate (medication used for to prevent and treat wheezing, difficulty breathing), inhalation nebulization solution 2.5mg/0.5 ML to be administered every four hours as needed via HHN.
4. During a review of Resident 95's admission Record indicated the facility initially admitted Resident 95 on 2/8/2024 and readmitted on [DATE] with diagnoses that included spondylosis (a condition in which there is abnormal wear on the cartilage [strong, flexible connective tissue supports and protects bones] and bones of the neck), disorder of the lung, and metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the blood that affects the brain's normal functioning).
During a review of Resident 95 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/9/2024, indicated Resident 95 ' s cognition (a term for the mental processes that take place in the brain, including thinking, attention, language, learning, memory and perception) was moderately impaired,
During a review of Resident 95 ' s Order Summary Report, indicated the physician ordered on 9/18/2024 for Resident 95 to receive oxygen at 2 liters per minute (LPM) via NC or face mask as needed for shortness of breath or oxygen saturation (measures how much oxygen blood carries in comparison to its full capacity) below 90% (normal range 90-100%)
During an observation on 10/1/2024 at 10:25 AM in Resident 95 ' s room, Resident 95 was observed lying in bed with oxygen in use at 2 LPM via NC without a date of when it was to be changed.
During a concurrent observation and interview on 10/1/2024 at 11:41 AM with Licensed Vocational Nurse (LVN) 1 in Resident 95 ' s room. LVN 1 stated, she could not find the label with date on when the NC was to be changed on the resident ' s NC. LVN 1 stated, the NC was required to be labeled with the date that the NC was last changed to track and make sure the NC was changed weekly to prevent infection per facility ' s policy.
During an interview on 10/4/2024 at 1:05 PM with the Director of Nurses (DON), the DON stated, it was in the facility ' s policy that all NCs to be dated so they could track and make sure to have them changed every 7 days to prevent infection, such as lung infection.
During a review of the facility ' s policy and procedure (P&P) titled, Departmental (Respiratory Therapy) - Prevention of Infection, revised November 2011, the P&P indicated, change the oxygen cannula and tubing every 7 days, as needed.
2.During a review of Resident 86's admission Record indicated the facility initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include dementia (a group of thinking and social symptoms that interferes with daily functioning) and dysphagia (difficulty swallowing foods or liquids).
During a review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/2/24, indicated Resident 86 had severely impaired cognition (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 86 required substantial/maximal assistance with eating, and was dependent with oral hygiene, toilet hygiene and personal hygiene.
During a review of Resident 86 ' s Order Summary Report (OSR), dated 8/29/24, indicated the physician ordered the resident to receive Jevity 1.5 (a liquid nutritional supplement that can be used for patients who are at risk of malnutrition or have altered taste perception) at 100 milliliter (ML, unit of measurement) per hour for 12 hours via pump per G-tube from 7 PM to 7 AM and to flush G-tube with 20-30 ML of water before and after administration of medication pass.
During a concurrent observation and interview on 10/1/24 at 9:56 AM, with the Director of Staff Development (DSD), in Resident 86 ' s room, Resident 86 was sitting on his bed and a G-tube feeding pump was secured on an intravenous (IV, a way of giving a drug or other substance through a needle or tube inserted into a vein) pole (a medical device to provide a secure place to hang bags of medicine or fluid for administration to a patient) next to his bed. The G-tube feeding pump was currently off. A feeding syringe was inside a pole bag, which was hung on a hook of the IV pole. The pole bag was labeled as 9/29/24 at 9 AM. The DSD stated the feeding syringe was used for flushing the G-tube, check placement of the G-tube and administering medications to the resident. The DSD stated the feeding syringe should be changed every 24 hours by the night shift nurse, but the nurse did not change the feeding syringe for 2 days which put the resident at risk of contracting an infection.
During an interview on 10/2/24 at 3:08 PM, the Director of Nursing (DON), the DON stated the night shift nurse should change the feeding syringe every 24 hours and label the bag with the date and time to prevent infection.
During a review of the facility ' s Policy and procedure (P&P) titled, Enteral Feedings-Safety Precautions, dated 11/18, the P&P indicated Change syringe every 24 hours during 11-7 shift and as needed.
During a review of Resident 1's admission Record indicated the facility initially admitted Resident 1 on 10/1/96 and readmitted on [DATE] with diagnoses that include sepsis (a life-threatening medical emergency that occurs when the body has an extreme response to an infection or injury) and diabetes mellitus (a group of diseases that result in too much sugar in the blood).
During a review of Resident 1 ' s MDS, dated [DATE], indicated Resident 1 had moderately impaired cognition (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 1 was dependent with eating, oral hygiene, toilet hygiene, shower/bath self, personal hygiene, and chair/bed-to-chair transfer.
3. During a review of Resident 55's admission Record indicated the facility initially admitted Resident 55 on 1/28/21 and readmitted on [DATE] with diagnoses that include acute respiratory failure (a condition where there's not enough oxygen in your body) and diabetes mellitus (a group of diseases that result in too much sugar in the blood).
During a review of Resident 55 ' s MDS, dated [DATE], indicated Resident 55 had severely impaired cognition (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 55 was dependent with eating, oral hygiene, toilet hygiene, shower/bath self, personal hygiene, and chair/bed-to-chair transfer.
During an observation on 10/3/24 at 9:10 AM, Registered Nurse (RN) 5 used a wrist (BP) monitor to check Resident 55 ' s BP, then, she placed the used wrist BP monitor on top of the medication cart without cleaning and disinfecting.
During an observation on 10/3/24 at 9:14 AM, RN 5 took the BP monitor that was not disinfected from the top of the medication cart and used it to check Resident 55 ' s BP.
During an interview on 10/3/24 at 9:16 AM, with RN 5, RN 5 stated she did not disinfect the BP monitor after using it on Resident 55 and did not disinfect it before using it on Resident 55. LVN 4 stated she should disinfect the BP monitor after and before each use to prevent the spread of infection to the residents.
During an interview on 10/4/24 at 11:15 AM, with the DON, the DON stated staff should disinfect the wrist BP monitor and other re-usable equipment before and after each to prevent infection spreading to other residents.
During a review of the facility ' s P&P titled, Cleaning and disinfection of Resident-Care Items and Equipment, dated 9/2022, the P&P indicated Reusable items are cleaned and disinfected .between residents (e.g., stethoscopes, durable medical equipment).
May 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure adequate supervision for one of three sampled ...
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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 adequate supervision for one of three sampled residents (Resident 1) by not escalating the process of finding Resident 1 ' s whereabout by not informing the Medical Doctor (MD), Director of Nurses (DON)] or the Social Worker (SW) for guidance when Resident 1 went out on pass (OOP) (temporary permission of a patient to leave the hospital in a specified time) on 5/23/2024 at 8:30 AM, and did not return to the facility the same day at 12:00 PM (which was Resident 1 ' s estimated time of return).
This incident delayed the notification of law enforcement and other appropriate agencies, who were notified more than 24 hours from the time of the incident.
Resident 1 returned to the facility on 5/25/2024 at 1:30 AM (more than 24 hours from the time resident went OOP), feeling tired, with untidy clothes and dirty hands and feet. Resident 1 also missed 2 days of due medications.
This deficient practice had the potential for Resident 1 to sustain accidents and physical injury while out of the facility.
Findings:
A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily), schizoaffective disorder, bipolar type (Episodes of mania {extreme highs} and sometimes major depression {severe lows}, and hypertension (high blood pressure).
A review of Resident 1 ' s History and Physical Examination, dated 2/27/2024, indicated Resident 1 had the capacity to understand and make decisions.
A review of Minimum Data Set (MDS, a standardized assessment and care screening tool), date 3/4/2024, indicated Resident 1 ' s cognitive skills (ability to make daily decisions) was moderately impaired. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guard assistance as resident completes activity) with eating and partial/moderate assistance (helper does less than half the effort) with personal hygiene.
A review of Resident 1 ' s physician order dated 3/9/24, indicated Resident 1 may go out on pass.
A review of Resident 1 ' s care plan (CP) titled Out on Pass, dated 3/9/2024, the CP indicated concern Resident may sustain injury going out on pass. The CP intervention included; if Resident is due for medication during the time that he or she will be out on pass, the Resident will be given medications that are due for that time and written and or oral instructions on when and how to administer the medications that are to be issued.
A review of Resident 1 ' s facility document titled Temporary Leave of Absence (TLA), dated 5/23/2024, indicated Resident 1 went OOP on 5/23/2024 at 8:30 AM with estimated time of return of 12:00 noon.
A review of Resident 1 ' s facility document titled Departmental Notes (DN), dated 5/24/2024 timed at 2:27 PM, indicated Primary Medical Doctor (PMD), and the Police was notified regarding Resident 1 have not returned from going OOP from 5/23/2024 at 8:30 AM (more than 24 hours from Resident 1 estimated time of return).
A review of Resident 1 ' s facility document titled Departmental Notes (DN), dated 5/25/2024 timed at 5:30 AM, indicated, Resident 1 returned to the facility around 1:30 AM clothes were untidy, hands and feet were dirty, overall appearance were disheveled (messy).
During an interview on 5/28/2024 at 12:20 PM with the Director of Nurses (DON), the DON stated, Resident 1 went OOP on 5/23/2024 at 8:30 AM and did not return until 5/25/24 at 1:30 AM. The DON stated Resident 1 missed two days of scheduled medications. The scheduled medications included Fluoxetine 10 mg daily for depression, Senna 8.6 mg daily for constipation, metoprolol 50 mg tablet twice daily for hypertension, quietapine 100 mg twice daily for schizophrenia, gabapentin 300 mg three times daily for neuralgia/seizure, another quietapine 200 mg at bedtime.
During a concurrent observation and interview on 5/28/2024 at 12:28 PM with Resident 1 in Resident 1 ' s room, Resident 1 stated, she usually goes OOP frequently. On 5/23/2024 Resident 1 stated, she went OOP to go to a pawnshop and get money to fix herself, manicure, and shopping. Resident 1 stated, she had trouble getting transportation to go back to the facility and her phone stopped working. Resident 1 stated, she stayed at a (Store 1) the whole time and random people and Store 1 owner did not let her use their phone to call the facility. Resident 1 stated she felt cold while outside the facility and her feet hurts. Resident 1 stated, on 5/25/2024 at around 1 AM, a good citizen (Citizen 1), called transportation for her to get back to the facility.
During an interview on 5/28/2024 at 1 PM with the Social Worker (SW), the SW stated, Resident 1 was gone for more than 24 hours (Resident 1 went OOP 5/23/2024), and Resident 1 whereabouts should have been addressed immediately when Resident 1 did not return from her expected time of return on 5/23/2024 at 12 noon. The SW stated, she was not informed of Resident 1 not returning from OOP until the next day, 5/24/2024. The SW stated, she informed the police, the ombudsman, and the Department of Health 5/24/2024, and it should be documented.
During an interview on 5/28/2024 at 1:15 PM with the DON, the DON stated, the OOP order was not complete, it should include the duration the resident is allowed to be OOP. The DON stated, she should have been notified when Resident 1 did return from OOP immediately, so she could have notified the Police earlier. The DON stated it is important to always know Resident 1 ' s whereabouts for her safety.
During an interview on 5/28/2024 at 1:45 PM with Licensed Vocational Nurse (LVN) 1, stated, if a resident did not return from going OOP at the expected time of return, and unable to contact the resident, it should be escalated to upper management for guidance. LVN 1 stated, regarding Resident 1 ' s incident, the PMD, the DON, and SW should have been notified immediately to alert authorities. LVN 1 stated, the facility is responsible for Resident 1 ' s safety.
During an interview on 5/28/2024 at 1:45 PM with Registered Nurse (RN) 1 (RN supervisor 7 to 3 shift 5/23/2024), stated, on 5/23/2024 when Resident 1 did not return from going OOP at 12 PM (estimated time of return), she should have escalated the concern and notify the MD, DON, and SW to alert the authorities.
During a concurrent interview and record review, on 5/28/2024, at 2:15 PM, with the DON, Resident 1 ' s Medication Administration Record (MAR) for the month of May 2024 indicated, for 5/22/2024 and 5/23/2024 medications were initialed N. The DON stated, N indicated the medications were not given for 2 days which included medication for high blood pressure. The DON stated, Resident 1 not getting her blood pressure medication and other scheduled medications had the potential for harm.
During an interview on 5/28/2024 at 3:25 PM with LVN 2 (worked on 5/23/2024 7 to 3 shift), stated, when Resident 1 did not return from going OOP she should have escalated the issue and notified the MD, DON, and SW for guidance. LVN 2 stated, it is important to know Resident 1 ' s whereabout because it is a safety issue and something bad might happen to her.
During an interview on 5/28/2024 at 3:25 PM with LVN 3 (worked on 5/23/2024 3 to 11 shift), stated, it was endorsed to her by the previous shift, that Resident 1 went OOP and had not returned yet. LVN 3 stated, she should have escalated the concern and inform the resident ' s physician, the DON, and the SW for guidance and alert authorities. LVN 3 stated, knowing Resident 1 whereabouts is a patient safety issue.
During an interview on 5/28/2024 at 4 PM with the DON, the DON stated, she expected the staff to inform her if a resident did not return at least within 4 hours from the time the resident is supposed to comeback from OOP so she can report it to the appropriate agencies as an unusual occurrence.
A review of the facility ' s policy and procedure (P&P) titled Signing Resident Out, revised 8/2006. The P&P indicated; a) unless otherwise prohibited by law, medications that must be administered while the resident is out will be given to the resident /person signing the resident out, b) written and/or oral instruction on when and how to administer the medication will be provided to the resident or to the person signing the resident out, and only medications that must be administered while the resident is out will be issued.
May 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to provide adequate supervision for one of five residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to provide adequate supervision for one of five residents (Resident 1) based on the resident ' s individual and assessed needs.
This lack of supervision has increased risk for falls and injuries due to resident ' s wandering (Going one location to another aimlessly, usually without a plan or definitive purpose).
This deficient practice had the potential for Resident 1 to sustain injuries and increases the risk of altercations with other residents.
Findings:
A review of Resident 1 ' s admission Record indicated the resident was admitted on [DATE], with diagnosis of, but not limited to, dementia (decline in mental ability server enough to interfere with daily function) and Alzheimer ' s disease (A progressive disease that destroys memory and other important mental functions).
A review of Resident 1 ' s History and physical dated 11/2/2023, indicates Resident 1 does not have the capacity to understand and make decisions with chief complaint of wondering behavior and Dementia.
A review of Resident 1 ' s Minimum Set Data (MDS - a standardized assessment and screening tool) dated 4/16/2024, indicated Resident 1 has severe cognitive impairment. The MDS also indicated the resident is dependent for all aspects of personal hygiene, dressing, bathing and indicated resident has presence of wandering behavior, occurring daily.
A review of Residents 1 ' s Physicians orders dated 12/10/2023, indicated to Monitor whereabouts of Resident every hour.
A review of Resident 1 ' s Medication Administration Record with a start date of 12/10/2023, indicated to monitor whereabouts of resident every hour. However, the MAR indicated documentation were completed every shift (8 hours - Day, Evening, Night).
A review of Resident 1 ' s Care plan dated 10/30/2023, indicated a problem/need, that showed Resident 1 was at risk for injuries secondary to wandering behavior with a goal of Resident 1 will have no injuries and interventions. The interventions indicated to monitor the resident ' s location with visual check at least every 2 hours.
A review of Resident 1 ' s records indicated Resident 1 was monitored hourly from 4/20/24 to 4/23/24 but no documentation found that Resident 1 was monitored every 2 hours after 4/24/24.
A review of Resident 1 ' s Care plan dated 4/20/2024, indicated the resident will have 1:1 supervision as needed. A review of Resident 1 ' s records indicated that Resident 1 had no 1:1 supervision from 4/20/2024 up to present. Resident 1 ' s records indicated Resident 1 was monitored hourly from 4/20/24 to 4/23/24 only.
A review of Resident 1 ' s record titled Renew SBAR dated 4/20/24 timed at 2:47 PM, indicated that an altercation happened between Resident 1 and Resident 2. Resident 2 physically assaulted Resident 1. Resident 2 punched Resident 1 on the left cheek because Resident 1 walked inside Resident 2 ' s room. The SBAR indicated, Resident 1 did not sustain injuries.
During an interview on 5/6/2024 at 9:45 am with the DON, when asked how the facility staff monitor Resident 1 as indicated in the care plan and physician orders. The DON stated the CNA assigned to the area where Resident 1 was, would be responsible for monitoring the location of the resident and document in the MAR every shift. The DON noted during a concurrent review of the Physician Order indicated to monitor the resident every hour.
During a concurrent record review and interview on 5/6/2024 at 10:40 am, with LVN 1, stated it was normal for Resident 1 to wander. LVN 1 stated Resident 1 does go into other resident ' s rooms occasionally. LVN 1 stated the facility staff make sure to make a visual check every 30 minutes and stated the physician order indicated Resident 1 should be monitored every hour, but the Medication Administration Record indicated to document every shift. This is the only documentation we do.
During an observation on 5/6/24 at 11 am, inside Resident 1 ' s room, Resident 1 was lying in bed and unable to verbalize needs and unable to respond to basic questions.
During an interview on 5/6/24 at 12:50 pm, the DON was asked how supervision was being provided to Resident 1. The DON stated that Resident 1 only had 72 hours monitoring after the altercation occurred on 4/20/24. The DON stated after that, Resident 1 had every shift monitoring. The DON stated Resident 1 had wandering behavior in the past but did not recall going inside other resident's rooms or displaying hostile behaviors.
On 5/6/2024 at 1:30 pm, during an observation, inside Resident 1 ' s room, Resident 1 was found on the floor, next to the resident ' s bed. Resident 1 ' s body was lying with head facing the foot of the bed with abdomen almost prone position on the floor. No visible signs of bleeding or lacerations noted. Observed resident not moving, no vocalization of being in pain or calling for help. No audible sound alarming from the bed. During the observation, and [NAME] Resident 1 was on the floor, CNA2 was inside the room in the next bed, assisting Resident 1 ' s roommate. CNA 2 was asked if he knew Resident 1 was on the floor. CNA 1 stated oh he is just crawling.
During the same concurrent observation and interview, on 5/6/24 at 1:35 pm, CNA 2 assisted Resident 1 back in bed. CNA 2 stated he did not see Resident 1 get out of bed, even if he is just in the next bed assisting the roommate. When asked if Resident 1 was able to walk independently, CNA 2 stated Resident 1 was able to walk when he wants to. When asked why Resident 1 was still in bed at 1:35 pm, CNA 2 had no answer. During the observation, Resident 1 was attempting to get out of bed with unsteady gait and requiring maximum assistance of CNA2 to walk.
On 5/6/24 at 1:36 pm, the DON stated that Resident 1 ' s behavior is at his baseline and that the facility would have to place a bed alarm to alert staff.
On 5/6/24 at 3:15 pm, the SSD stated that she interviewed Resident 2, after the altercation and Resident 2 informed him that Resident 1 came inside his room behaving agitated, that is why he hit Resident 1. The SSD stated that Resident 1 is a fall risk.
A review of Facility ' s policies and procedures titled Wandering and Elopement dated 7/2018, Indicated purpose: to enhance the safety of Residents, to help identify Resident who are at risk and to minimize possible injury.
A resident who are deemed to be high risk for elopement or wandering will have a photograph maintained in their medical record and IDT will develop a plan of care considering the individual risk factors of the Resident. Person- centered approach/ interventions to prevent elopement and /or divert wandering behavior will be included in the plan- of - Care.
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 F0744
(Tag F0744)
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 comprehensively assess the root cause of behavioral sy...
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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 comprehensively assess the root cause of behavioral symptoms and develop measurable goals and interventions to address care and treatment of a resident with dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning) for one of five sampled residents (Resident 1) with diagnosis of dementia with behaviors.
This deficient practice had the potential to negatively affect the safety, wellbeing, and the delivery of services.
Findings:
A Review of admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included but was not limited to Dementia (loss of memory, language, problem – solving and other thinking abilities) with behavioral disturbances, schizoaffective disorder (hallucinations or delusions, and symptoms of a mood disorder, such as depression), anxiety disorder( responds to situations with fear and dread), and Alzheimer ' s disease( loss of memory and thinking skills and, loss of ability to carry out simple tasks).
A review of Resident 1 ' s History and physical report completed on 11/2/2023, indicated resident 1 does not have the capacity to understand and make decisions with diagnosis of advanced Dementia (loss of memory, language, problem – solving and other thinking abilities).
A review of Resident 1 ' s Minimum Set Data (MDS – a standardized comprehensive assessment and care planning tool) dated 4/16/2024, indicated the resident displays wandering behavior daily with potential for hallucinations (Perceptual experiences in the absence of real external sensory stimuli).
A review of Resident 1 ' s Physician order dated 12/10/2023, indicated to monitor resident 1 ' s whereabouts every hour with diagnosis of Alzheimer ' s disease.
A review of Resident 1 ' s Medical Administration Records indicated resident 1 receives Donepezil 10mg tablet: every day at 9 pm for Dementia.
A review of Resident 1 ' s Care plan dated 10/30/2023, indicated a problem/need, that showed Resident 1 was at risk for injuries secondary to wandering behavior with a goal of Resident 1 will have no injuries and interventions. The interventions indicated to monitor the resident ' s location with visual check at least every 2 hours.
A review of Resident 1 ' s records indicated Resident 1 was monitored hourly from 4/20/24 to 4/23/24 but no documentation found that Resident 1 was monitored every 2 hours after 4/24/24.
A review of Resident 1 ' s Care plan dated 4/20/2024, indicated the resident will have 1:1 supervision as needed. A review of Resident 1 ' s records indicated that Resident 1 had no 1:1 supervision from 4/20/2024 up to present. Resident 1 ' s records indicated Resident 1 was monitored hourly from 4/20/24 to 4/23/24 only.
A review of Resident 1 ' s record titled Renew SBAR dated 4/20/24 timed at 2:47 PM, indicated that an altercation happened between Resident 1 and Resident 2. Resident 2 physically assaulted Resident 1. Resident 2 punched Resident 1 on the left cheek because Resident 1 walked inside Resident 2 ' s room.
During a concurrent record review and interview on 5/6/2024 at 10:40 am, with LVN 1, stated it was normal for Resident 1 to wander. LVN 1 stated Resident 1 does go into other resident ' s rooms occasionally.
During an observation on 5/6/24 at 11 am, inside Resident 1 ' s room, Resident 1 was lying in bed and unable to verbalize needs and unable to respond to basic questions.
During an interview on 5/6/24 at 12:50 pm, the DON was asked how supervision was being provided to Resident 1. The DON stated that Resident 1 only had 72 hours monitoring after the altercation occurred on 4/20/24. The DON stated after that, Resident 1 had every shift monitoring. The DON stated Resident 1 had wandering behavior in the past but did not recall going inside other resident ' s rooms or displaying hostile behaviors.
On 5/6/2024 at 1:30 pm, during an observation, inside Resident 1 ' s room, Resident 1 was found on the floor, next to the resident ' s bed. Resident 1 ' s body was lying with head facing the foot of the bed with abdomen almost prone position on the floor. No visible signs of bleeding or lacerations noted. Observed resident not moving, no vocalization of being in pain or calling for help. No audible sound alarming from the bed. During the observation, and [NAME] Resident 1 was on the floor, CNA2 was inside the room in the next bed, assisting Resident 1 ' s roommate. CNA 2 was asked if he knew Resident 1 was on the floor. CNA 1 stated oh he is just crawling.
During the same concurrent observation and interview, on 5/6/24 at 1:35 pm, CNA 2 assisted Resident 1 back in bed. CNA 2 stated he did not see Resident 1 get out of bed, even if he is just in the next bed assisting the roommate. When asked if Resident 1 was able to walk independently, CNA 2 stated Resident 1 was able to walk when he wants to. When asked why Resident 1 was still in bed at 1:35 pm, CNA 2 had no answer. During the observation, Resident 1 was attempting to get out of bed with unsteady gait and requiring maximum assistance of CNA2 to walk.
On 5/6/24 at 1:36 pm, the DON stated that Resident 1 ' s behavior is at his baseline and that the facility would have to place a bed alarm to alert staff.
On 5/6/24 at 3:15 pm, the SSD stated that she interviewed Resident 2, after the altercation and Resident 2 informed him that Resident 1 came inside his room behaving agitated, that is why he hit Resident 1. The SSD stated that Resident 1 is a fall risk.
During a concurrent record review and interview on 5/6/2024 at 4:00 pm with the DON, the DON stated Dementia care plan was not created or implemented for Resident 1.
During a concurrent record review and interview on 5/6/2024 at 4:00 the pm with DON, the DON stated there is no record of IDT meeting conducted for Resident 1 ' s dementia diagnosis and manifesting behaviors associated with dementia.
A review of the Facility ' s Policy Revised December 2016 Titled Care Plans indicated a plan of care shall be developed to assure that that the resident ' s needs are met and maintained including but not limited to goals, and Therapy services and to updated as necessary.
Mar 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to provide the resident's call light (device used to alert facility staff assistance as needed by residents) within reaxh as indi...
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Based on observation, interview, and record review the facility failed to provide the resident's call light (device used to alert facility staff assistance as needed by residents) within reaxh as indicated in the care plan, for one out of three sampled residents (Resident 2).
This deficient practice had the potential in a delay in meeting the resident ' s needs for assistance and can lead to frustration, unavoidable falls and accidents.
Findings:
A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 8/5/2023, with diagnoses including but not limited to cognitive communication deficit (difficulty with understanding information and knowledge), difficulty in walking, muscle weakness.
A review of Resident 2 ' s History and Physical dated 12/8/2023, indicated Resident 2 does not have the capacity to understand and make decisions.
A review of Resident 2 ' s Minimum Data Set (MDS – a comprehensive standardized assessment and screening tool) dated 2/7/2024, indicated moderate assistance is required for all transfers from chair/bed to chair and toilet transfers and walk 10 feet.
A review of resident 2 ' s Care plan titled At risk for injuries dated 12/8/2023, revised on 3/2024, indicated Resident 2 would have no injuries and anticipate the residents need based upon behaviors.
During an observation on 3/21/2024 at 11:15 am, Resident 2 was observed sitting in a wheelchair on the right side of the bed. During the observation, the resident's call light was observed on the floor and not within reach of Resident 2, as indicated in the care plan.
During an interview on 3/21/2024 at 11:15 am, with Certified Nursing Assistant (CNA) 3, CNA 3 stated if a resident does not have a call light within reach, they can not notify the staff if they need to be assisted.
During a review of the facility Policy titled Answering the Call light Nursing Services Policy and Procedure Manual for Long-Term Care Dated 2001, revised on 10/2010, indicated the purpose of this procedure is to respond to the resident ' s requests and needs. General Guidelines to include but not limited to when the resident is in bed or confined to a chair be sure that call light is within easy reach of the resident.
Feb 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of his individuality for one (1) of seven sampled residents (Resident 5).
The facility staff was observed removing Resident 5's shirt and exposing Resident 5's upper body in the facility's Activity Room, in the presence of Resident 6, Resident 7, and Resident 6's Family Member (FAM 1).
This deficient practice had the potential to affect Resident 5 's self-esteem and self-worth.
Findings:
A review of Resident 5 ' s admission Record, indicated Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), psychotic disorder (a collection of symptoms that affect the mind, where there has been some loss of contact with reality. During an episode of psychosis, a person's thoughts and perceptions are disrupted and they may have difficulty recognizing what is real and what is not), and seizures (a burst of uncontrolled electrical activity between brain cells (also called neurons or nerve cells) that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviors, sensations or states of awareness).
A review of Resident 5's History and Physical (H&P), dated 1/3/24, indicated Resident 5 does not have the capacity to understand and make decisions.
A review of Resident 5's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 11/24/2023, indicated the resident ' s cognition was severely impaired. The MDS indicated Resident 5 was dependent (helper does all the effort) for eating, oral hygiene, personal hygiene , upper body dressing, lower body dressing, rolling to the left and right, sit to stand, lying to sitting on the side of the bed, chair/bed-to chair transfer, toilet transfer, tub, shower transfer, toileting hygiene.
A review of Resident 6 ' s admission Record, indicated Resident 6 was admitted to the facility on [DATE], with diagnoses that included vascular atrial fibrillation (extremely fast and irregular beats from the upper chambers of the heart (usually more than 400 beats per minute), hypertension (high blood pressure), and dysphagia (difficulty swallowing).
A review of Resident 7 ' s admission Record, indicated Resident 7 was admitted to the facility on [DATE], with diagnoses that included failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol), and cognitive communication deficit (difficulty with thinking and how someone uses language).
During an observation on 2/02/2024 at 12:58 PM, at the facility's Activity Room, Resident 5 was observed sitting in the wheelchair, Resident 5's shirt was wet and dirty. During the observation, Certified Nurse Assistant (CNA) 3 removed Resident 5's shirt and exposed Resident 5's upper body inside the Activity Room, in the presence of two other residents (Resident 6) and (Resident 7), who were also in the Activity Room. During the observation, there was one family member (FAM 1) sitting with the resident inside the Activity Room.
During an observation and interview on 2/02/2024 at 1:02 PM, at the facility's Activity Room, Resident 5 was observed sitting in the wheelchair, with the upper body exposed and CNA 3 was observed assisting Resident 5 to put on his shirt. During the observation, the Director of Nursing (DON) approached CNA 3 and informed CNA 3 to cover up Resident 5 and take the resident back to his room. The DON stated CNA 3 should have not change Resident 5's clothes while in the Activity Room and exposed Resident 5 in public, to preserve the resident ' s dignity.
During an interview on 2/02/2024 at 2:01 PM, CNA 3 stated she should not have changed Resident 5's shirt in the Activity Room which is a public place. CNA 3 stated Resident 5 may have felt uncomfortable and humiliated. CNA 3 stated Resident 5 may not have want to show his body to anyone.
A review of the facility's policies and procedures titled Quality of Life - Dignity, revised in February 2020, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. Residents are treated with dignity and respect at all times. Staff inform and orient residents to their environment. Procedures are explained before they are performed and residents will be told in advance if they are going to be taken out of their usual or familiar surroundings. Staff personal promote, care and maintain during and treatment protect procedures. resident privacy, including bodily privacy during assistance with personal care and during treatment procedure.
Nov 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
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 Resident 1 was free from physical restraints by allowing eme...
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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 Resident 1 was free from physical restraints by allowing emergency medical technicians (EMT) to apply physical restraints attached in a gurney to Resident 1 ' s wrists and ankle on 11/15/2023 from 9:30 AM to 10:45 AM (one hour and 15 minutes) while waiting for Resident 1 to be evaluated by the Psychiatric Evaluation Team (PET), without a physician ' s order, on-going assessments and monitoring of the resident while on physical restraints, in accordance with the facility policy and procedure on Physical Restraint Application.
This failure resulted in Resident 1 ' s restriction of freedom of movement and had the potential to result in the resident ' s increased anxiety, agitation, and loss of dignity.
Findings:
A review of Resident 1 ' s Face Sheet (document that gives a patient ' s information such as contact details and brief medical history) indicated the facility admitted Resident 1 on 9/12/2023, with diagnoses that included major depressive disorder, severe with psych symptoms (a distinct type of depressive illness in which mood disturbance is accompanied by either delusions, hallucinations or both), generalized anxiety disorder (condition of excessive worry about everyday issues and situations) and schizoaffective disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucination or delusions, and mood disorder symptoms, such as depression or mania.)
A review of Resident 1 ' s Patient Care Plan: Behavior, dated 9/12/2023, indicated Resident 1 needed behavior management for the diagnosis of anxiety as manifested by restlessness. The care plan approach included giving Clonazepam (medication used to treat agitation) 0.5 mg as ordered to manage Resident 1 ' s behavior.
A review of Resident 1 ' s Order Summary Report for November 2023, indicated a physician order dated 11/11/2023, to administer Clonazepam 0.5 mg every 8 hours PRN (as needed) for agitation, for 14 days.
A review of Resident 1 ' s Minimum Data Set (MDS – a standardized assessment and care planning tool) dated 9/18/2023, indicated Resident 1 had moderately impaired cognition (ability to think, remember, and reason). The MDS indicated Resident 1 had behavioral symptoms not directed towards others (e.g., hitting or scratching self, screaming, disruptive sounds) and had a history of rejecting evaluation or care (e.g., bloodwork, taking medications, ADL assistance).
During a review of Resident 1 ' s Physician Telephone Orders, dated 11/15/2023 (no time), the Physician Telephone Orders indicated Resident 1 was to be transferred to GACH via 5150 (California Welfare and Institutions Code that allows for a 72 hours involuntary hold for treatment; criteria for hold includes a person exhibiting mental health issues that pose a threat to themselves or others, or are gravely disabled) for psychiatric evaluation, with bed hold for 7 days.
During a review of Resident 1 ' s Progress Notes, dated 11/15/2023 at 10:45AM and signed by the Registered Nurse Supervisor (RNS), the Progress Notes indicated Resident 1 left in the facility via ambulance (5150) in her usual self.
During an interview on 11/17/2023 at 10:49 AM with the RNS, the RNS stated Resident 1 ' s discharge plan to transfer to an acute hospital was initiated on 11/14/2023, but Resident 1 was not transferred until 11/15/2023, because the facility was waiting for the PET ' s evaluation and for transportation. The RNS stated the PET needed to determine if Resident 1 was a danger to self or others. The RNS stated that the EMTs (Emergency Medical Technicians – emergency response ambulance staff) arrived to the facility on [DATE] at 9:30 AM to pick up Resident 1, however, Resident 1 was not evaluated by the PET until around 10:08 AM, on 11/15/2023. The RNS stated that she did not transfer Resident 1 to the EMTs until she received the 5150 paperwork from the PET evaluation at around 10:30 AM. The RNS stated that Resident 1 was not transferred to the GACH until about 10:45 AM, on 11/152023, via ambulance.
During a concurrent interview and record review, on 11/17/2023, at 11:02 AM, with the RNS, Resident 1 ' s physician progress notes from Psychiatrist 1, [undated] was reviewed. The RNS stated Psychiatrist 1 ordered Resident 1 to be discharged on 11/14/2023, but the RNS wrote the order to transfer the resident on 11/15/2023. The RNS stated Psychiatrist 1 came to the facility on [DATE], but Resident 1 had already been transferred. The RNS stated she did not find notes from Psychiatrist 1 about Resident 1 ' s behavior and PET evaluation for 5150 transfer.
On 11/17/2023 at 12:05 PM, during a concurrent review and interview of the security camera surveillance footage of the facility lobby with the Administrator (ADM) and Maintenance Supervisor (MS), inside the ADM ' s office, the surveillance footage timestamped dated 11/15/2023, at 9:34 AM, showed two EMTs entering the facility ' s front lobby entrance with an empty gurney. The MS stated that the facility ' s security camera surveillance footage had about a 12-minute delay between the actual time and the time shown on the surveillance footage. During the continued review of the facility ' s security camera surveillance footage, timestamped at 10:54 AM, the surveillance footage showed Resident 1 leaving the facility with the two EMTs via gurney. The facility ' s security camera surveillance footage showed Resident 1 lying on the gurney with bilateral wrists and bilateral ankles soft restraints secured to the gurney. The ADM stated Resident 1 exhibited delusions that day, including believing there were cameras in her room and her roommate was somebody else (another name referred to a God). The ADM stated he believed Resident 1 ' s transfer took time because the EMTs were waiting for Resident 1 to agree with the transfer as ordered by the physician. The ADM stated the details of what transpired should be documented in Resident 1 ' s records.
During an interview on 11/17/2023 at 12:47 PM with the ADM, the ADM stated the facility does not use physical restraints with its residents. The ADM stated Psychiatrist 1 comes to the facility to evaluate residents once every two weeks, and leaves progress notes in the residents ' charts.
During an interview on 11/17/2023 at 1:24 PM with the facility ' s Receptionist (RCP), the RCP stated that in the morning of 11/15/2023, the RCP saw Resident 1 angrily banging on tables. The RCP stated when the EMTs arrived at the facility on 11/15/2023, Resident 1 was walking the hallways of the facility. The RCP stated she was not monitoring Resident 1 but believed Resident 1 was placed in the gurney when the EMTs arrived. The RCP stated Resident 1 was discharged out of the facility at around 10:45AM.
During an interview on 11/17/2023 at 1:53 PM with the RNS, the RNS stated the order for Resident 1 ' s transfer on 5150 was endorsed to her by the previous shift. The RNS stated there was a discussion on 11/14/2023, but she was not working that day; during that discussion, Psychiatrist 1 instructed the facility to call the PET for a 5150 hold for Resident 1. The RNS stated PET evaluation for Resident 1 was conducted via a phone call on 11/15/2023 at around 10:08AM. The RNS stated the facility received the 5150 transfer order form via fax at around 10:30 AM. The RNS stated the EMT ' s ambulance arrived at around 9:30 AM, and during that time, Resident 1 was walking around the facility. The RNS further stated the EMTs immediately placed Resident 1 on restraints because Resident 1 was fighting.
During an interview on 11/17/1023 at 2:09 PM with the Director of Nursing (DON), the DON stated that on 11/14/2023, Psychiatrist 1 instructed the facility to transfer Resident 1 to the GACH. The DON stated the licensed nurses should prepare the paperwork needed for the transfer and continue to observe the resident. The DON stated the facility practice was the facility ' s case manager arranges for the PET to come evaluate the resident, and arrange for the transportation. The DON stated the case manager called for an ambulance on 11/14/2023, but they did not come to the facility on [DATE], so the facility followed up again on 11/15/2023. The DON stated the ambulance arrived at the facility around on 11/15/2023 at around 9:30AM, and left at 10:45AM. The DON stated when the ambulance came, Resident 1 was paranoid and did not believe the ambulance was for her. The DON stated the facility did not have the 5150 evaluation and order form, so the EMTs could not take Resident 1. The DON stated the facility ' s case manager called the PET team to request for the required paperwork again. The DON stated that before the facility case manager called for the transportation or ambulance, the 5150 hold paperwork should had been ready.
During the same interview on 11/17/2023 at 2:18 PM with the DON, the DON stated when the two EMTs approached Resident 1, Resident 1 began cursing and yelling saying that was not her ambulance. The DON stated the facility staff assisted the EMTs in putting Resident 1 on the gurney because Resident 1 was kicking and screaming at the EMTs. The DON stated Resident 1 was strapped to the gurney for around one hour while the licensed nurses were obtaining the 5150-hold paperwork from the PET, because the EMTs could not leave without it. The DON stated the facility is restraint-free and it was not the facility ' s policy to put the residents in the gurney. The DON stated it was considered a physical restraint if the resident ' s wrists/ankles were strapped to the gurney. The DON stated that on 11/15/2023 Resident 1 was strapped in the EMT ' s gurney in front of the nurses ' station for about an hour. The DON stated that while Resident 1 was strapped in the gurney, Resident 1 was resisting and kicking the two EMTs. The DON stated that Resident 1 ' s attending physician was not notified while Resident 1 was combative and yelling during that time and there was no order to apply physical restraints while waiting to be transferred out of the facility. The DON stated Resident 1 was angry, trying to move her hands, and yelling You will be punished for this . [God] does not like what you ' re doing to me. The DON stated this was not a reason for Resident 1 to be physically restrained to the gurney. The DON stated Resident 1 was placed in front of the Nursing Station while lying on the gurney, for everyone in the facility to supervise. The DON stated there was no documented evidence that facility staff assessed and monitored Resident 1 for complications from physical restraints.
During a concurrent interview on 11/17/2023 at 2:56 PM with the Case Manager (CM), in the presence of the DON, the CM stated that she called for an ambulance to transport Resident 1 to the GACH. The CM stated the ambulance was from a private company. The CM stated she could not recall the time of her call to the ambulance company, but the ambulance company informed her that the ambulance was scheduled to arrive within two to three hours from the time of the call.
During a concurrent interview and record review on 11/17/2023 at 3:46 PM, with the DON, Resident 1 ' s Medication Administration Record (MAR) for November 2023 was reviewed. The DON stated that Resident 1 had an order for Clonazepam (medication used to treat agitation) as needed for agitation. The DON stated the MAR did not indicate that Clonazepam was administered to Resident 1 on 11/15/2023 for agitation. The DON stated the Clonazepam was not administered because Resident 1 was refusing medications. The DON stated the MAR did not indicate documented evidence that Resident 1 ' s physician was notified and refusing medication on 11/15/23 prior to the GACH transfer.
A review of the facility ' s policy and procedure titled, Physical Restraint Application, dated October 2010, indicated Physical Restraints are defined as any manual method, or physical, mechanical device, material or equipment attached or adjacent to the resident ' s body that the individual cannot remove easily which restricts freedom of movement. The policy and procedure further indicated to verify physician ' s order for the use of restraints and review the resident ' s care plan to assess for any special needs of the resident, including checking the resident every 30 minutes.
The policy and procedure indicated the following should be recorded in the resident ' s medical record:
1. Date and time restraints was applied
2. The name and title of the individual(s) who applied the restraint
3. The type of physical restraint applied
4. The specific reason the restraint was applied
5. The length of time the restraint will be used
6. Each time the device is released for resident exercise, toileting, and position change
7. Each time the resident is monitored.
8. All assessment data (e.g bruises, rashes, sores, etc.) observed during the procedure
9. If and how the resident participated in the procedure or any changes in the resident ' s ability to participate in the procedure
10. Any problems or complaints made by the resident related to the restraint application
11. If the resident refused treatment and the reason(s) why
12. The signature and title of the person recording the data
Oct 2023
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 38's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] and rea...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 38's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dysphagia following cerebral infarct (difficulty swallowing), polyneuropathy (when multiple peripheral nerves symptoms include problems with sensation, coordination, or other body functions), and depression (constant feeling of sadness).
A review of Resident 38's History and Physical (H&P) dated 8/24/23, indicated Resident 38 had fluctuating capacity to understand and make decision.
A review of Resident 38's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 7/12/23, indicated Resident 38 had severe cognitive impairment.
On 10/03/23 at 09:10 AM during a review of Resident 38's Physician Orders for Life-Sustaining Treatment Resident (POLST- a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency taking the patient's current medical condition into consideration). A POLST form form prepared on 1/05/21, indicated not to attempt resuscitation (DNR - medical order that directs healthcare providers not to administer cardiopulmonary resuscitation [CPR] in the event of cardiac or respiratory arrest. The POLST indicated the resident Refused to sign.
During an interview with the Social Services Director (SSD), on 10/03/23 at 9:15 AM, and review of Resident 38's POLST, the SSD stated the Resident 38's POLST indicated DNR facility consider Resident code DNR even though resident refused to sign.
During an interview with the Licensed Vocational Nurse (LVN )1, on 10/03/23 1:45 PM , and review of Resident 38's POLST, the LVN1 stated she is assigned to Resident 38 and POLST indicated Resident 38 refused to sign. LVN 1 stated she is not sure if Resident 38 is DNR or Full code. Stated the POLST is confusing since resident refused to sign. LVN stated if a document is not sign it is not valid. Stated the order should have been clarified with provided, stated it can lead to delay in care and Resident wish may not be respected.
During an interview with the Registered Nurse (RN)1 , on 10/03/23 2:03 PM , and review of Resident 38's POLST, the RN 1 stated even though the POLST indicated Resident 38 refused to sign since it has doctors signature she consider Resident 38 DNR and she will not provide CPR.
During an interview with the Director of Nursing (DON), on 10/03/23 2:34 PM , and review of Resident 38's POLST, the DON stated upon admission Resident 38 was able to make the decision and he decided to be DNR but refused to sign. DON stated Resident 38 is under interdisciplinary team (IDT- a group of experts from several different fields) meeting. The DON stated she was under impression the POLST was signed by Resident 38. DON stated Resident 38 Code status should have should been discussed during IDT meeting with physician.
A review of the facility's policies and procedures titled Advance Directives, revised in December 2016, indicated Advance directives will be respected in accordance with state law and facility policy. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. The Attending Physician will provide information to the resident and legal representative regarding the resident's health status, treatment options and expected outcomes during the development of the initial comprehensive assessment and care plan.
A review of the facility's policy and procedure, titled Physician Orders for Life Sustaining Treatments (POLST) indicated the facility will advise residents about their rights to make healthcare decisions and the facility will honor those wishes. The California POLST form will be utilized for end of life planning based on the resident's values, beliefs and goals for care and tbe health care professional presents then resident/patient's diagnosis, prognosis, and treatment alternatives. The POLST will be honored if received on adtnission and signed by both the resident and a physician in accordance with the guidelines. Advanced Directives complement the POLST.
Based on interview and record review, the facility failed to determine on admission and/or offer the resident or the responsible party to formulate an Advance Directives (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated), and ensure the DNR (Do Not Resuscitate- any medical intervention used to restore circulatory and/or respiratory function that has ceased) code status (level of medical interventions a person wishes to have started if their heart or breathing stops) was clearly indicated for two of 24 sampled residents (Residents 38 and Resident 60) clinical records in accordance with the facility's policy and procedures.
The facility failed to ensure:
1. Resident 60's representative was offered and given an Advance Directives information.
2. The licensed staff clarified with Resident 38's physician the code status or DNR status of the resident's code status of the resident which indicated the refused to sign the provision of CPR-cardiopulmonary resuscitation (CPR -method of reviving the heart and lungs when it ceased.
This deficient practice had the potential for Resident 38 not to receive care and services including a delay in provision of emergency services. In addition Resident 38 had the potential to result in the resident not to receive care according to his wishes. This deficient practice also resulted in the potential for Resident 60 representative not to exercise the right to formulate an advanced directive.
Findings:
1. A review of Resident 60's Face Sheet indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of, but not limited to, gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), quadriplegia (paralysis that the body from the neck down, including arms, legs), and dementia (is a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). The Face Sheet indicated Resident 60 had one responsible party (Family 2).
A review of Resident 60's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 7/19/2023, indicated the resident had severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making.
A review of Resident 60's History and Physical dated 2/23/2023 indicated the resident did not have the capacity to make decisions.
A review of a facility document titled Advance Directive Acknowledgement Form dated 11/2/2022, indicated Resident 60 does not have an Advanced Directive and declined to execute an advanced directive. The Advance Directive Acknowledgement Form indicated it was signed by the facility's Social Services Designee (DSD). The Advance Directive Acknowledgement Form did not indicate the name or signature of Resident 60's surrogate decision maker which was a court ordered conservator.
During an interview and concurrent record review of Resident 60's Advance Directive Acknowledgement form on 10/5/2023 at 8:05 am, the Director of Nursing (DON) stated that the Advance Directive Acknowledgement form was a required document to be completed by facility staff upon all resident's admission. The DON stated that Resident 60's Advance Directive Acknowledgement form was incomplete because Resident 60's responsible party did not fill out and sign the form.
During an interview and concurrent record review of Resident 60's Advance Directive Acknowledgement form on 10/5/2023 at 10:22 am, the Social Services Designee (SSD) stated that the Advance Directive Acknowledgement form was part of the admission process to show that the resident or the resident's responsible party received information about the right to have an advanced directive.
A review of the facility's policy and procedure, titled Advance Directives, dated 12/2016 indicated that, Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical surgical treatment and to formulate an advance directive if he or she chooses to do so.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment by not repairing a leaking flushometer of a toilet (a metal water...
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Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment by not repairing a leaking flushometer of a toilet (a metal water-diverter that uses an inline handle to flush tankless toilets or urinals) for one of four residents (Resident 17).
The failure had the potential to result in Resident 17 falling and sustaining an injury from the slipping on the wet restroom floor.
Findings:
During a review of Resident 17's Face Sheet indicated the facility admitted Resident 17 on 9/23/2022 with diagnoses that included dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally) and difficulty in walking.
During a review of Resident 17's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 6/29/2023, indicated the resident had moderately impaired cognition (ability to think and reason) for daily decision making. The MDS indicated Resident 17 required supervision (oversight, encouragement or cueing) with bed mobility, transfer, walking in room, dressing, eating, toilet use and personal hygiene.
During a review of Resident 17's History and Physical Examination (H&P), dated 9/21/2023, indicated Resident 17 has fluctuating capacity to understand and make decisions.
During a review of Resident 17's Care Plan, dated on 9/26/2022, indicated Resident 17 was at risk for fall and the intervention was to maintain safe environment.
During an observation and concurrent interview on 10/2/2023 at 9:58 AM, with Resident 78's family member (FM 1) who was in the room of Resident 78 stated the floor in the shared restroom in the room was dirty and wet. FM 1 stated she did not see any staff check or clean the floor.
During an observation on 10/2/2023 at 9:58 AM, Resident 17 was walking out from the restroom in his room. Resident 17 nodded his head when asking him if he used the restroom.
During an observation on 10/2/2023 at 10:00 AM, in the shared restroom of Resident 78 and 17's room had two areas with puddle of water on the restroom floor around the base of toilet. The flushometer of the toilet was observed leaking water dripping on the floor.
During an interview on 10/2/2023 at 10: 05 AM, FM 1 stated, she visited Resident 78 every day and observed the water in the restroom floor. FAM 1 stated Resident 78 stays in bed at all times and does not use the restroom.
During a concurrent observation and interview on 10/2/2023 at 10:23 AM, with the Housekeeping (HK), HK stated the flushometer was leaking water to the floor in Resident 17 and Resident 78's restroom. The HK stated he did not check the restroom today and did not know for how long the flushometer had been leaking. HK stated the flushometer should not be leaking because the wet floor could put Resident 17 at risk for slipping and falling.
During a concurrent observation and interview on 10/2/2023 at 10:43 AM, with the Maintenance Direction (MD), MD stated the flushometer was leaking and causing the puddles of water in the restroom floor. MD stated he did not know for how long the flushometer had been leaking. MD stated he will make sure the flushometer was working properly because the wet floor could cause residents to slip and fall.
During a current interview and record review on 10/2/2023 at 2:30 PM with MD, the Maintenance Log (ML), dated 5/4/2023 to 10/1/2023, indicated there was no documentation that the flushometer was reported leaking. The MD stated he did not know the flushometer was leaking until the notification from the surveyor today.
During an interview on 10/3/2023 at 2:38 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 17 used the restroom to urinate and defecate which put him at risk of slipping and falling.
During a review of the facility's policy and procedure titled, Quality of Life-Homelike Environment, dated 5/2017, indicated Residents are provided with a safe, clean, comfortable and homelike environment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to receive care consistent with professional standards of practice (sp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to receive care consistent with professional standards of practice (specialty practice guidelines or protocols of care for specific populations) to prevent worsening of pressure injury/ulcers (a skin injury resulting from prolonged unrelieved pressure or being in one position in the bony areas of the body) and/or does not develop new pressure ulcers that were unavoidable by ensuring one of three sampled residents (Resident 21) received and documented the skin treatment as ordered by the physician for skin redness on both heels on 10/1/23.
This deficient practice had the potential for the Resident 21 and other potential residents with pressure ulcer to develop worsened pressure injury/ulcer.
Findings:
During a review of Resident 21's Face Sheet, an admission record, Resident 21 admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included hypertension (high blood pressure) and muscle weakness.
During a review of Resident 21's History and Physical Examination (H&P), dated 5/25/2023, indicated Resident 21 does not have the capacity to understand and make decisions.
During a review of Resident 21's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/24/2023, indicated the resident had severely impaired cognition (ability to think and reason) for daily decision making. The MDS indicated Resident 21 required supervision (oversight, encouragement or cueing) with eating, and extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transfer, dressing, toilet use and personal hygiene.
During a review of Resident 21's Wound Assessment Report, dated 9/23/2023, indicated Resident 21 had non-blanchable (skin remained with skin discoloration or redness when pressed) that measured 2.5-centimeter (cm) x 1.5 cm x UTD (unable to determined) on the right heel and non-blanchable redness measured 3.0cm x 1.5 cm x UTD on the left heel.
During a review of a Physician Orders indicated on 9/24/2023 the physician ordered to treat Resident 21's right heel and left heel redness with NS, pat dry, apply A&D (Vitamin A and D) ointment (an ointment to treat diaper rash or redness and protects and soothes dry, irritated skin) and leave open to air daily for 30 days.
During a concurrent interview and record review of the Treatment Record and Progress notes for October 2023 on 10/4/2023 at 10:41 AM, with the Treatment Nurse (TXN), indicated Resident 21's right and left heel on 10/1/2023 treatments were not documented in the Treatment Record and Department Notes to indicate the treatment was provided. The TXN stated she was off on 10/1/2023 and the licensed nursed who performed the treatment for Resident 21 should have document on the treatment for Resident 21. The TXN stated it was important to document treatment on the Treatment Record, so the other staff would know what and when a treatment Resident 21 received.
During an interview on 10/4/2023 at 11:48 AM, the Licensed Vocational Nurse (LVN) 1 stated, she provided treatment for Resident 21 on 10/1/2023 because there was no Treatment Nurse assigned to work on 10/1/23, but she did not document the treatment provided in the Resident 21's clinical records. LVN 1 stated she did not know how to document it on the TR. LVN 1 stated she asked other licensed staff working that day, and no one knew how to document it on the TR. LVN 1 stated it was important to document the wound treatment when administred so that the next shift nurse and other staff could know what treatment and when the resident received to avoid confusion on the residents' care.
During an interview on 10/4/2023 at 11:55 AM, LVN 2 stated she worked on 10/1/2023 and there was no treatment nurse working on that day. LVN 2 stated important to document the administration of wound treatment correctly in residents' medical record.
During an interview and concurrent record review on 10/4/2023 at 2:30 PM, with the Director of Nursing (DON), the DON stated there was no documentation in Resident 21's medical record indicating Resident 21 received wound treatment to her left and right heel on 10/1/2023. The DON stated it was important to document the administration of wound care treatment correctly to avoid confusion in the resident's care and to ensure consistency and continuation of care.
During a review of the facility's policy and procedure titled, Wound Care, dated 10/2010, indicated information including the type of wound care given and the date and time the wound care was given should be recorded in the resident's medical record.
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 interview, observation, and record review, the facility failed to follow its policy and procedure on Oxygen Administration for one of 3 sampled residents (Resident 67) who had a was receiving...
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Based on interview, observation, and record review, the facility failed to follow its policy and procedure on Oxygen Administration for one of 3 sampled residents (Resident 67) who had a was receiving oxygen therapy (a supplemental delivery of oxygen) without a physician's order.
This deficient practice had the potential for Resident 67 and other residents receiving oxygen therapy to develop complications associated with oxygen therapy such as oxygen toxicity (also called oxygen poisoning is a lung damage due to receiving too much (supplemental) oxygen that can cause coughing, trouble breathing and in severe cases leads to death).
Findings:
A review of Resident 67's Face sheet (admission Record) indicated the facility initially admitted Resident 67 to the facility on 2/18/22 and readmitted date of 3/30/23 with the diagnoses that included, emphysema (gradual damage of lung tissue or alveoli [tiny air sacs] this damage causes the air sacs to rupture and traps air in the damaged tissue and prevents oxygen from moving through the bloodstream that causes the lungs to overfill with air and makes breathing more difficult), hepatic failure (failure of the liver to function that can cause serious complications such as bleeding and increased pressure in the brain) and schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly which involve false beliefs and seeing or hearing things that don't exist).
A review of Resident 67's History and Physical (H&P) dated 3/30/23, indicated Resident 67 does not have capacity to understand and make decision.
A review of Resident 67's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 8/22/23, indicated Resident 67 had no impairment in memory and cognitive (ability to reason) level for daily decision making.
During an observation on 10/4/23 at 12:10 P.M., Resident 67 was observed lying in bed while receiving oxygen therapy at 2 liters per minute (L/min) via nasal cannula (a device used to deliver supplemental oxygen that should be placed directly on the resident's nostrils) from the oxygen concentrator (a medical device that concentrates oxygen from environmental air used for supplemental oxygen) located at the bedside.
During an observation and concurrent interview with Certified Nursing Assistant (CNA) 2 on 10/4/23 at 12:12 PM, CNA 2 stated Resident 67 was receiving oxygen 2 L/min oxygen.
During an interview on 10/4/23 at 12:20 P.M., the License Vocational Nurse (LVN ) 1 stated, Resident 67 uses oxygen therapy as needed for comfort.
During an interview and concurrent record review of the Physician's order for October 2023, conducted with LVN 3 on 10/5/23 at 8AM, LVN 3 stated, Resident 67 had no physician's order to receive oxygen therapy at 2 L/min for comfort as needed. LVN 3 stated there should be a physician's order if the resident receives oxygen therapy. LVN 3 stated the resident could develop oxygen toxicity if the resident received oxygen if they do not need oxygen.
During an interview and record review of Resident 67 Physician's order for the month of October 2023 with the Director of Nursing (DON) on 10/05/23 at 8:14 AM, the DON stated there should be a physician's order for Resident 67 to receive oxygen therapy. The DON stated, to ensure the residents receive the right amount of oxygen therapy, because without the physician's order, the residents could receive more or less oxygen than needed.
A review of the facility's undated policy and procedure titled Oxygen Administration, revised on 10/2010, indicated the facility will provide guidelines for safe oxygen administration by verifying if there was a physician's order for the procedure and the facility staff will review the physician's orders or facility protocol for oxygen administration.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
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 monitor and review their hospice communication binder for 2 of 2 s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to monitor and review their hospice communication binder for 2 of 2 sampled residents (Resident 63 and Resident 342) which contains hospice nurse sign-in sheet, weekly calendar visits and hospice nurses notes that include treatment recommendations.
This deficient practice had the potential to negatively affect the delivery of care and services related to the resident's change of health (including but not limited to pain, shortness of breath, spiritual and psychosocial needs related to dying) and may put at risk the personal needs that are particular to end of life issues not being met.
Finding:
A review of Resident 63's admission Record indicated the resident was readmitted to the facility on [DATE] with the diagnosis of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and human immunodeficiency virus (HIV -virus that attacks the body's immune system).
A review of Resident 63's Minimum Data Set (MDS, a standardize assessment and care screening tool), dated 7/13/2023, indicated Resident 63 had severe impaired cognition (the ability or mental action or process of acquiring knowledge and understanding).
A review of Resident 63's History and Physical, dated 9/14/2023, indicated Resident 63 did not have the capacity to understand and make decisions.
A review of Resident 63's undated Hospice Weekly Staff Visit Sheet, indicated two (2) dates, 4/4/2021 and 4/18/2021, indicating dates the
hospice nurse visited Resident 63.
A review of Resident 63's Hospice Residents Calendar, dated 9/2023 indicated hospice visits were every Monday, Wednesday, Thursday and every other Fridays.
A review of Resident 342's admission Record, indicated Resident 342 admission to the facility was on 8/26/2022, with the diagnosis of paranoid schizophrenia (a severe mental health condition that can involve delusions and paranoia) and human immunodeficiency virus (HIV -virus that attacks the body's immune system).
A review of Resident 342's MDS, dated [DATE], indicated Resident 342 had moderately impaired cognition (the ability or mental action or process of acquiring knowledge and understanding).
A review of Resident 342's Hospice Weekly Staff Visit Sheet, indicated no date and staff name with no signature for all designated lines.
A review of Resident 342's Hospice Residents Calendar, indicated no scheduled hospice nurse visits, and no indication specifying which days the hospice nurses would visit.
During a concurrent interview and record review of Resident 63's Hospice Binder, with Registered Nurse (RN1), on 10/3/2023 at 2:38 PM, RN1 stated there were no hospice nurses notes indicated in Resident 63's hospice binder. RN1 stated the binder did not indicate days the hospice nurse was to visit Resident 63. RN1 stated the hospice nurse communicated with RN1 through text message and did not enter the information in the binder for Resident 63. RN1 stated since notes were not indicated on Resident 63's hospice binder, any change in care could be missed, and could have a negative affect when providing end-of life care for Resident 63.
During a concurrent interview and record review of Resident 342's Hospice Binder on 10/3/2023 at 2:58 PM with RN1, RN1 stated the hospice nurse for Resident 342 communicated with RN1 through text message. RN 1 stated the hospice binder did not indicate notes regarding Resident 342's hospice visits, no sign-in sheets, and no indication on the days a hospice nurse would visit Resident 342. RN1 stated since the hospice binder did not have nurses notes to indicate care was given or treatment recommendations, it could have a negative impact on Resident 342's care while on hospice.
During a concurrent interview and record review of Resident 63 and 342's Hospice binder on 10/4/2023 at 1:55 PM, with the Director of Nursing (DON), the DON stated that Resident 63 and Resident 342 hospice binders were not completed by the hospice nurses and the binder was not being monitored by RN1. The DON stated the hospice binder was important since it was used to communicate care between hospice staff and the facility. The [NAME] stated using the hospice binder ensures that residents who are on hospice get the specialized care for end-of-life issues so they are not in pain.
A review of the facility's policy titled, Hospice Program revised 7/2017, indicated in general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including: determining the appropriate hospice plan of care, changing the level of services provided when it is deemed appropriate, providing medical direction, nursing and clinical management of the terminal illness and providing spiritual, bereavement and/or psychosocial counseling and social services as needed. The policy further indicated, in general, it is the responsibility of the facility to meet the residents personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs which includes communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. A review of Resident 46's admission Record indicated the resident was initially admitted to the facility on [DATE] with the d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. A review of Resident 46's admission Record indicated the resident was initially admitted to the facility on [DATE] with the diagnosis of paranoid schizophrenia (a severe mental health condition that can involve delusions and paranoia) and encephalopathy (damage or disease that affects the brain).
A review of Resident 46's Minimum Data Set (MDS a standardized assessment and care screening tool), dated 8/30/2023, indicated that Resident 46 had moderate impaired cognition (the ability or mental action or process of acquiring knowledge and understanding).
During a concurrent interview and record review of Resident 46's Care Plan, with the Director of Nursing (DON), on 10/4/2023, at 11:35 AM, the DON stated there was no care plan in Resident 46's medical records for elopement. The DON stated Resident 46 had a history of elopement on 3/17/2022 from the facility. The DON stated the care plan for elopement should have been in Resident 46's medical records. The DON stated the elopement care plan was important for Resident 46 to monitor his behavior and to protect him from wandering outside the facility and getting injured.
5. A review of Resident 342's admission Record indicated the resident was initially admitted to the facility on [DATE] with the diagnosis of paranoid schizophrenia (a severe mental health condition that can involve delusions and paranoia) and human immunodeficiency virus (HIV-virus that attacks the body's immune system).
A review of Resident 342's MDS, dated [DATE], indicated that Resident 342 had moderate impaired cognition (the ability or mental action or process of acquiring knowledge and understanding).
During a interview and record review of Resident 342's Care plans, with Registered Nurse 1 (RN1), on 10/3/2023 at 2:28 PM, Registered Nurse (RN1) stated that Resident 342 did not have a care plan in his chart indicating he was on hospice care, therefore, RN1 stated she would initiate a hospice care plan for Resident 342.
During an interview on 10/4/2023 at 1:55 PM, the DON stated there should have been a care plan initiated for Resident 342 hospice care The DON stated initiating a care plan for Hospice for Resident 342 was not only the responsibility of the hospice nurse, but facility staff since the facility also provided end of life care.
A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered revised 12/2016, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident.
Based on interview, and record review, the facility failed to develop and/or implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the resident's needs for 5 of 10 sampled residents (Resident 46, Resident 47, Resident 60, Resident 70 and Resident 342).
1. Resident 47 did not have a comprehensive, resident specific care plan for Gastrostomy Tube (GT- gastrostomy an opening into the stomach from the abdominal wall, made surgically for the introduction of food) care that included cleansing the GT site daily, in accordance with the physician's order.
2. Resident 60 did not have a comprehensive, resident specific care plan for RNA decreased range of motion (how far and in what direction a person can move a joint or muscle) that included objectives in measurable outcomes, in accordance with the facility's policy on Care Plans, Comprehensive Person-Centered.
3. Resident 70 did not have a comprehensive care plan for RNA care plan: Decrease in ROM initiated on 11/16/2022, the intervention for gentle passive range of motion (PROM) exercised to be performed on both lower extremities (BLE). The care plan did not indicate the frequency to perform PROM exercises to BLE that included daily five times a week, as indicated in the physician's order.
4. Resident 46 did not have a care plan for history of elopement (leaving the facility without permission).
5. Resident 342 did not have a care plan for hospice care (focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life).
These deficient practices had the potential to delay care and services specific to Resident 46, 47, 60, 70 and Resident 342's needs.
Findings:
1. A review of Resident 47's Face Sheet indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of, but not limited to, gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), paraplegia (Paralysis that affects all or part of the trunk, legs, and pelvic organs), contracture of the right ankle (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and schizoaffective disorder (a mental health disorder that is marked by a combination of symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania).
A review of Resident 47's comprehensive admission Minimum Data Set (MDS - a standardized assessment and screening tool) dated 9/25/2023, indicated the resident had severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making. The MDS indicated the resident was extensively dependent to totally dependent on staff for activities of daily living (ADLs - term used in healthcare to refer to daily self-care activities).
A review of Resident 47's History and Physical dated 9/10/2022 indicated that the resident does not have the capacity to make decisions.
A review of Resident 1's Physician's Order dated 9/9/2022, indicated enteral feed order: cleanse GT site with normal saline, pat dry, cover with dry dressing every shift, notify MD (physician) for signs and symptoms of infection.
A review of Resident 47's care plan for GT Site initiated on 12/2022 indicated approaches/plan included to check GT site as needed to prevent odors, and monitor site for discharge, swelling, pain or redness. The care plan did not include to cleanse GT site with normal saline, pat dry, cover with dry dressing every shift as ordered by the physician.
During an interview and concurrent record review of Resident 47's care plans and physician orders on 10/05/2023 at 7:54 am, the DON stated the care plan for Res 47 should be specific and resident centered. The DON stated that the care plan approaches to check and cleanse GT site should indicate that it is checked every shift, as per physician's orders and reflected what the resident needs.
2. A review of Resident 60's Face Sheet indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of, but not limited to, gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), quadriplegia (paralysis that the body from the neck down, including arms, legs), and dementia (is a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment).
A review of Resident 60's MDS dated [DATE], indicated the resident had severely impaired cognitive skills for daily decision-making. The MDS indicated the resident was extensively dependent to totally dependent on staff for activities of daily living.
A review of Resident 60's History and Physical dated 11/2/2022 indicated that the resident does not have the capacity to understand and make decisions.
A review of Resident 60's Physician Orders dated 1/26/23 indicated RNA to provide PROM exercises on right upper extremities (RUE) and left upper extremities (LUE) every day, five times a week as tolerated.
A review of Resident 60's care plan titled RNA care plan: Decreased Range of Motion (ROM) initiated on 11/20/2022, showed a goal that indicated Review every month. The care plan did not indicate a goal that was specific to Resident 60's desired outcome for having a decreased in ROM.
During an interview and concurrent record review of Resident 60's RNA care plan: Decreased Range of Motion (ROM) on 10/05/2023 at 8:08 am, the DON stated that the goal of Resident 60's care plan is for the facility to review the care plan every three months. The DON stated the care plan did not indicate a goal that was specific to Resident 60's desired outcome for having a decreased in ROM.
3. A review of Resident 70's Face Sheet indicated the resident was admitted to the facility on [DATE], with diagnoses of, but not limited to, dementia, heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and adult failure to thrive (a syndrome of weight loss, decreased appetite and poor nutrition, and inactivity).
A review of Resident 70's MDS dated [DATE], indicated the resident had severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making. The MDS indicated the resident was extensively dependent to totally dependent on staff for activities of daily living (ADLs - term used in healthcare to refer to daily self-care activities).
A review of Resident 70's History and Physical dated 11/3/2022, indicated the resident did not have the capacity to make decisions.
A review of Resident 70's Physician Orders dated 11/16/2022, indicated RNA for BLE PROM exercises everyday, five times a week as tolerated.
A review of Resident 70's care plan titled RNA care plan: Decrease in ROM initiated on 11/16/2022, the intervention for gentle passive range of motion (PROM) exercised to be performed on both lower extremities (BLE). The care plan did not indicate the frequency to perform PROM exercises to BLE that included daily five times a week, as indicated in the physician's order.
During an interview and concurrent record review of Resident 70's RNA care plan: Decrease in ROM on 10/05/2023 8:10 am, the DON stated the care plan did not indicate the frequency to perform PROM exercises to Resident 70's BLE that included daily five times a week, as indicated in the physician's order.
During an interview on 10/05/2023 at 8:15 am, the DON stated the purpose of the care plan is to guide the resident's care so the facility staff can provide the proper care to meet the resident's needs. The DON stated that resident care plans should not be general and must be specific to the resident's needs.
A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated 12/2016, indicated that, The comprehensive person-centered care plan will include measurable objectives and timeframes; describe the services that are to be furnished, and reflect treatment goals, timetables and objectives in measurable outcomes.
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 and interview and record review the facility failed to follow its policy and procedure on food storage, preparation, distribution and serving food in accordance with professional ...
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Based on observation and interview and record review the facility failed to follow its policy and procedure on food storage, preparation, distribution and serving food in accordance with professional standards for food service safety by failing to:
1. Label the cut-up cantaloupe, ham slices and cheese sandwiches with the date of when the food were prepared and when to be consumed by.
2. Remove an egg carton with white liquid from the storage refrigerator.
3. Store two uncracked eggs with other uncracked eggs in the same egg carton.
These deficient practices had the potential to result in food contamination, growth of microorganisms (disease causing organism) that could cause foodborne illness (food poisoning or food illness due to pathogens (harmful organism that cause illness such as bacteria, viruses, or parasites) and toxins that contaminate food.
Findings:
1. During an initial kitchen observation conducted with the Dietary Manager (DM) on 10/2/2023 at 8:38 AM, the walk-in refrigerator had a cut-up cantaloupe was wrapped in a clear plastic wrapper and stored in a clear plastic food storage box with three uncut honeydews. The cut-up cantaloupe had no label of the date the cantaloupe was cut-up. In a concurrent interview, the DM stated the staff did not label the date that the cantaloupe was cut-up or when to be used by or for how long the cantaloupe was left cut-up in the refrigerator. The DM stated he does not know if the cantaloupe was still safe for the residents to consume, and consuming the cantaloupe might put residents at risk for foodborne illnesses.
During concurrent observation and interview on 10/2/2023 at 8:40 AM with the DM, the walk-in refrigerator shelf had 10 pieces of half-cut ham and cheese sandwiches that were on a food tray. The sandwiches were not labeled with the date of when the sandwiches were prepared or when to be used (consumed) by. The DM stated the 10 sandwiches were not properly labeled, and the staff should have labeled the date the sandwiches were prepared of used by. The DM stated without the proper labeling of the food, the staff would not know when the sandwiches were prepared and for how long these sandwiches would be safe to consume. The ADM stated consuming the sandwiches could put residents at risk for foodborne illnesses.
2. During a concurrent observation and interview on 10/2/2023 at 8:42 AM with the DM, the walk-in refrigerator had murky white liquid at the bottom of empty egg carton slots (divider in the carton) and the egg carton had two cracked raw eggs and five other uncracked raw eggs in it. The DM stated the murky white liquid was the residual of egg white from the cracked raw eggs which were disposed. The DM stated the dirty egg carton should be removed from the storage refrigerator because bacteria could grow in it and cause contamination to other food stored in the refrigerator.
3. During a concurrent observation and interview on 10/2/2023 at 8: 43 AM with DM, in the walk-in refrigerator, two cracked raw eggs were in the same egg carton with five other uncracked raw eggs. The DM stated the cracked raw eggs should be disposed immediately and should not be stored in the refrigerator with other produce because bacteria could grow in them quickly and put residents at risk for foodborne illness if consumed.
During an interview on 10/2/2023 at 8: 44 AM, the [NAME] stated she did not know when the two eggs were cracked and for how long the eggs had been in the refrigerator. The [NAME] stated she was too busy and did not dispose the two cracked eggs this morning. The [NAME] stated she should dispose the cracked raw eggs and not to use them for meal preparation to prevent foodborne illness.
During a review of the facility's policy and procedure titled, Food Receiving and Storage, dated 7/2014, indicated all foods stored in the refrigerator will be covered, labeled, and dated ('use by' date). The policy indicated Food services, or other designated staff, will maintain clean food storage areas at all times. The policy indicated Foods shall be received and stored in a manner that complies with safe hood handing practices.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement the facility's policy and procedure for infe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement the facility's policy and procedure for infection control practices by failing to:
1. Implement the facility's policy and procedure titled Departmental (Respiratory Therapy) Prevention of Infection by ensuring the oxygen nasal cannula (NC) tubing (a device used to deliver supplemental oxygen placed directly on a resident's nostrils) was labeled when first used for one of 3 sampled residents (Resident 67).
2.Implement the facility's policy and procedure titled Legionella Water Management Program related to prevention, detection and control of water-borne (recreational or drinking water contaminated by disease-causing organisms) contaminants, including Legionella (a bacteria that can cause Legionellosis, a serious type of pneumonia (lung infection) that can lead to severe respiratory failure (failure of the lungs to oxygenate the body), septic shock (a life threatening condition due to severe infection) and multi-organ failure (failure of the major organs in the body to meet the body's demand) for 86 of 86 residents in the facility and the staffs and visitors.
These deficient practices had the potential to result in a widespread infection of Legionellosis and other water-borne diseases throughout the facility. In addition Resident 67 and other potential residents had the potential to develop an infection associated with the use of NC that was not labeled to when it was last changed.
Findings:
1. A review of Resident 67's Face sheet (admission Record) indicated the facility initially admitted Resident 67 to the facility on 2/18/22 and readmitted date of 3/30/23 with the diagnoses that included, emphysema (gradual damage of lung tissue or alveoli [tiny air sacs] this damage causes the air sacs to rupture and traps air in the damaged tissue and prevents oxygen from moving through the bloodstream that causes the lungs to overfill with air and makes breathing more difficult), hepatic failure (failure of the liver to function that can cause serious complications such as bleeding and increased pressure in the brain) and schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly which involve false beliefs and seeing or hearing things that don't exist).
A review of Resident 67's History and Physical (H&P) dated 3/30/23, indicated Resident 67 does not have capacity to understand and make decision.
A review of Resident 67's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 8/22/23, indicated Resident 67 had no impairment in memory and cognitive (ability to reason) level for daily decision making.
During an observation on 10/4/23 at 12:10 P.M., Resident 67 was observed lying in bed while receiving oxygen therapy at 2 liters per minute (L/min) via nasal cannula (a device used to deliver supplemental oxygen that should be placed directly on the resident's nostrils) connected to the oxygen concentrator (a medical device that concentrates oxygen from environmental air used for supplemental oxygen) located at the bedside. The nasal cannula tubing did not have a date or label, and the nasal cannula had yellow discoloration around the nostrils.
During an observation and concurrent interview with Certified Nursing Assistant (CNA) 2 on 10/4/23 at 12:12 PM, CNA 2 stated Resident 67 was receiving oxygen 2 L/min oxygen.
During an interview on 10/04/23 at 12:20 P.M., License Vocational Nurse (LVN )1, stated the nasal cannula tubing must be labeled with the date when it was first removed from the package so that the staff know when it should be changed which is every 7 days per facility's policy and procedure to prevent infection. LVN 1 stated if the nasal cannula was not labeled with the date the staff will not know when it will need to be changed or the last time it was changed.
During an interview with Director of Nursing (DON), on 10/5/23 at 8:14 AM, the DON stated Resident 67 uses oxygen 2 L for comfort as needed, DON stated nasal cannula tubing must have a date and needs to be changed every 7 days to prevent infection per facility policy.
A review of the facility's policy revised November 2011, titled Departmental (Respiratory Therapy) -Prevention of Infection, indicated the purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff, change the oxygen cannula and tubing every seven (7) days, or as needed.
2. During an interview with the Infection Preventionist (IP) Nurse, 10/4/2023 at 2:16 PM, the IP Nurse stated the Maintenance Supervisor was responsible to check the water system in the facility for the presence of Legionella.
During an interview with the Maintenance Supervisor, 10/4/23 at 2:30 PM, he stated Legionella is an infection which can cause harm. The Maintenance Supervisor stated he does not know how to check the water system at the facility for the presence of. The MS stated facility he did not have any system or method to check the water for presence of Legionella prior to 10/2/23.
During an interview with the Director of Nursing (DON) on 10/4/23 at 3:04 PM, she stated,
prior to 10/2/2023, the facility did not have Legionella Water Management Program. The DON stated she already discussed with the IP nurse, maintenance supervisor, and Administrator to check the water system for Legionella.
During an interview with the IP Nurse on 10/5/23 at 9:48 AM, the IP Nurse stated Legionella is a bacterium that can be found in the pipe, especially older pipe, and most people catch the infection by inhaling the Legionella bacteria from the water and cause lung infection that could lead to pneumonia which is manifested by flu like symptoms, fever, chills, that could lead to harm. The IP Nurse stated checking the water system for Legionella must be done annually (yearly). The IP Nurse stated prior to 10/2/2023, the facility did not have a system to check the water system for Legionella and she does not have any documentation that shows the water system was checked for Legionella prior to 10/02/2023.
A review of the facility's policy and procedure titled Legionella Water Management Program, revised on September 2022, indicated the facility was committed to the prevention, detection and control of water-borne contaminants, including Legionella. As part of the infection prevention and control program, the facility has a water management program, which is overseen by the water management team. The water management team consists of at least the following personnel: The infection preventionist; The administrator. The medical director (or designee);d. The director of maintenance; and e. The director of environmental services.
The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. The water management program used by the facility is based on the Centers for Disease Control and Prevention and ASH [NAME] recommendations for developing a Legionella water management program. The water management program includes the following elements: a. An interdisciplinary water management team (see above); b. A detailed description and diagram of the water system in the facility, including the following:(1) Receiving;(2)Cold water distribution; (3)Heating; (4)Hot water distribution; and (5)Waste.
The water management program is reviewed at least once a year, or sooner if any of the following occur:
a. The control limits are consistently not met;
b. There is a major maintenance or water service change;
c. There are any disease cases associated with the water system; or
d. There are changes in laws, regulations, standards or guidelines.
Aug 2023
2 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Pharmacy Services
(Tag F0755)
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 maintain a system-wide method of accountability for c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a system-wide method of accountability for controlled medications (medication with a high risk of abuse or theft) and maintain a system to ensure accountability of controlled medications to track compliance with its policy on Controlled Substances. The Controlled Drug-Count Records (the title of the document the facility uses for the controlled medication reconciliation [a process of counting all the controlled medication in the medication cart between the nurse leaving and the nurse coming on duty to determine if there are any discrepancies]) were not signed by two nurses during shift change between 6/3/23 and 8/2/23 totaling 102 times, in accordance with the facility's policy and practice to have licensed nurses sign the Controlled-Drug-Count Records as a documentation that controlled medication reconciliation had been performed between two nurses during shift change, for three of three sampled medication carts (Medication Carts 1, 2, and 3).
In addition, the facility licensed nurses failed to follow proper procedures in accordance with the facility's practice and policy to ensure that controlled medications are counted at the end of each shift, between the licensed nurses coming on duty and the licensed nurses going off duty, on 8/1/23 and 8/2/23 while working on their respective nursing shifts. The Director of Nurses (DON) failed to maintain adequate oversight of Resident 1's Norco 5/325 mg Record of Controlled Substances (a log containing the date, time, and nurse's signature for all administered doses of a specific supply of a controlled medication) corresponding to the facility's pharmacy delivered supplies of Resident 1's Norco 5/325 mg dated 7/16/23 during the licensed nurses daily controlled medication reconciliation between 7/16/23 to 8/2/23. As a result, the facility was unable to account for 28 doses of Norco (a controlled medication used to treat pain) 5/325 milligrams (mg - a unit of measure for mass) for one of three sampled residents (Resident 1).
These deficient practices increases the risk of diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of controlled medications, staff working in an impaired state, increases the risk that medications are not available to residents when needed, and potential for accidental exposure to controlled substances for 94 of 94 total residents (facility census on 8/4/23) possibly resulting in respiratory depression (the inability to breathe) leading to hospitalization or death.
On 8/4/23 at 3:34 PM, the Department of Public Health (Department) called an Immediate Jeopardy (IJ) situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM), Director of Nursing (DON), and Assistant Administrator (AADM).
On 8/5/23 at 1:13 PM, the facility provided the Department with an IJ Removal Plan that included the following summarized actions:
1. On 8/4/23, the AADM visited and assessed Resident 1 in her room. Resident had no complaints of pain. Per Resident 1, pain medication is effective. No signs and symptoms of adverse effects noted.
2. On 8/4/23, the DON conducted an immediate in-service (used to describe training done during time at work) to Licensed Nurses regarding the facility's policies and procedures titled Controlled Medication Storage and Medication Administration - General Guidelines. All narcotic (a controlled medication or other substance that affects mood or behavior) medication will be kept in the medication cart narcotic drawers for each respective nursing station and are double-locked. The DON emphasized the failure of maintaining accountability of controlled substances and potential impact to residents. The DON further stressed that when as needed medications are administered, the licensed nurse shall sign the electronic Medication Administration Record (eMAR - an electronic record of all medications a resident receives). The DON will continue until all licensed nurses have received in-services with an expected completion date of 8/14/23.
3. On 8/4/23, the DON initiated an in-service to licensed nurses regarding timeliness in arriving to the facility for duty and proper endorsement between licensed nurses coming off duty and licensed nurses coming on duty. Licensed nursing coming off duty are not to leave the facility until the relieving licensed nurse coming on duty is present to receive endorsement. In the event of an emergency, and the licensed nurse coming off duty or the licensed nurse coming on duty are unable to endorse to each other, the Licensed Nurse supervisor coming on duty will receive endorsement from the licensed nurse coming off duty. When the Licensed Nurse coming on duty arrived, he/she will receive endorsement from the licensed nurse supervisor, the DON, or another designated licensed nurse shall be present during the accountability of narcotic medications. These nurses shall sign off on the Controlled Drugs - Count Record. The DON will continue until all licensed nurses have received in-services with an expected completion date of 8/14/23.
4. On 8/5/23, the Pharmacy Consultant (PC) will also provide additional mandatory in-service to licensed nurses regarding the facility's policies and procedures titled Controlled Medication Storage and Medication Administration - General Guidelines and conduct medication pass observation. The PC will also check narcotic medication for all nursing station for accurate reconciliation and account for all controlled medications.
5. On 8/4/23, the DON initialed skills competency evaluation for all licensed nurses, focusing on medication administration which includes accountability of controlled substances and documentation of PRN medication administration.
6. On 8/4/23, Situation Background Assessment Recommendation (SBAR - a nursing communication tool used to monitor for a resident's possible change in health status) and care plan were initiated for Resident 1 to monitor for signs and symptoms of pain and decline in the ability to perform Activities of Daily Living (ADL).
7. On 8/4/23, SBAR and care plans were initiated by licensed nurses for all current residents to monitor for respiratory depression (a breathing disorder characterized by slow and ineffective breathing) related to possible exposure of narcotic consumption, which will be continued every shift for 72 hours through 8/7/2023.
8. During change of shift, two licensed nurses, which include the nurse coming on duty and the nurse going off duty for each station, will count the narcotic medications in the medication cart narcotic drawer in the presence of the Licensed Nurse Supervisor coming on duty. The two licensed nurses and the licensed nurse supervisor coming on duty will sign the Controlled Drug-Count Record revised on 8/5/2023 to acknowledge that the licensed nurse coming on duty and the licensed nurse coming off duty have counted the controlled drug on hand and have found that the quantity of each medication counted is in agreement (matched) with the quantity stated on the Controlled Drug-Count Record. The revised Controlled Drug - Count Record shall include the written names and signatures of the licensed nurse coming on duty, the licensed nurse coming off duty, and the Licensed Nurse Supervisor coming on duty. The licensed nurse coming off duty will endorse the medication cart keys which included the narcotic drawer key to the licensed nurse coming on duty under the supervision of the Licensed Nurse Supervisor.
9. Licensed nurses will provide a copy of any new physician's orders for controlled substances, a copy of the pharmacy receipt for those controlled substances, and a copy of the controlled substance count sheets (a log containing the date, time, and nurse's signature for all administered doses of a specific supply of a controlled medication) to the DON which will be kept in a designated binder in the DON's office for accurate reconciliation and accounting for all controlled medications.
10. A triple check (means to check again with extra caution/attention) will be conducted monthly by two (2) facility-designated licensed nurses and licensed pharmacy nurse for each medication cart, including narcotic/controlled substances to ensure accurate reconciliation and accounting for all controlled medications by validating medications through each residents' physician orders, medication administration record, and the actual medication on hand. An audit of the Controlled Drug-Count Record will be conducted Monday through Friday for 7 am to 3 pm shift and 3 pm to 11 pm shift by the Medical Records Director/Designee utilizing the Audit Tool Controlled/Medication to the Medication Administration Record (MAR) Form. The Licensed Nurse Supervisor will audit the Controlled Drug-Count Record Monday through Friday 11 pm - 7 am shift and Saturday and Sunday 7 am to 3 pm shift, 3 pm to 11 pm shift, and 11 pm to 7 am shift utilizing the Audit Tool Controlled/Medication, Pro Re Nata (PRN - refers as needed medications) medication to MAR form to acknowledge that the incoming licensed nurse and outgoing licensed nurse have counted the controlled drug on hand and have found that the quantity of each medication counted is in agreement with the quantity stated on the Controlled Drug-Count Record. Additionally, the Medical Record Director/Designee will conduct an audit of the Controlled Drug-Count Record form Monday through Friday to ensure that the correct licensed nurses are signing the form by checking the signatures against the licensed nurses' floor schedule as written on Nursing Staffing Assignment and Sign-In Sheet. Findings will be reported and discussed by the Medical Records Director/Designee.
11. Any deficient practices will be immediately reported to the DON/Designee who will investigate and make every reasonable effort to reconcile (resolve) all reported discrepancies. Discrepancies which cannot be immediately resolved shall be documented by the DON/Designee in a report to the Administrator. If a major discrepancy or pattern of discrepancies occurs or if there is apparent criminal activity, the DON/Designee shall notify the ADM and PC immediately. A determination shall be made by the ADM, the PC, and the DON/Designee concerning possible notification of police or other enforcement agencies and any other actions to be taken.
12. The DON/Designee will discuss and review findings of accountability of controlled substances to the monthly Quality Assurance Performance Improvement (a structured approach in to evaluating the performance of systems in an organization) meetings to ensure corrective actions are sustained.
On 8/5/23 at 3:24 PM, while onsite and after confirming the facility's implementation of the IJ Removal Plan by observation, interview, and record review, the Department accepted the IJ removal plan and removed the Immediate Jeopardy, in the presence of the ADM, AADM, DON, and Senior [NAME] President (SVP).
Cross-referenced with F760
Findings:
A review of Resident 1's Face Sheet, dated 8/3/23, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including essential hypertension (high blood pressure) and muscle weakness.
A review of Resident 1's Minimum Data Set (MDS - a comprehensive resident assessment tool) section C (Cognitive Patterns) indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a interview tool used to determine cognitive impairment) score of 12 (moderately impaired.)
A review of Resident 1's History and Physical note (H&P - the formal document that physicians produce through the interview with the patient, the physical exam, and the summary of the testing either obtained or pending) dated 6/3/23, indicated Resident 1 had the capacity to understand and make decisions.
A review of Resident 1's physician order dated 6/9/23 indicated the physician prescribed Norco 5/325 mg to take one tablet by mouth every six hours as needed for moderate pain (pain score 4 to 6).
A review of Resident 1's eMAR, for the month of August 2023 and printed 8/3/23, indicated one dose of Norco 5/325 mg was given to Resident 1 on 8/1/23 at 10:58 PM and no additional doses were given on 8/2/23.
A review of Resident 1's Care Plan, dated 6/1/23, indicated Resident 1 was at risk for chronic pain due to neuropathy (nerve pain), arthritis (inflammation of the joint) in her left knee and bursitis (inflammation of tissue that cushions bones, tendons, and muscles near joints) in her left knee with targeted interventions to monitor for pain every shift and administer Norco 5/325 mg every 6 hours as needed.
A review of a pharmacy delivery receipt, dated 7/16/23, indicated a recent previous delivery was made to the facility for 60 tablets of Norco 5/325 mg on 7/16/23 timed at 1:23 AM for Resident 1.
A review of the pharmacy delivery receipt dated 8/2/23, indicated 30 tablets of Norco 5/325 mg (replacement supply) was delivered to the facility on 8/2/23 timed at 10:30 PM for Resident 1.
On 8/3/23 at 3:29 PM, during an interview, the DON stated LVN 1 was the nurse assigned on the morning shift (7 AM to 3 PM) on 8/2/23 and LVN 2 was the nurse assigned on the preceding night shift of 8/1/23 (11 PM to 7 AM) to Station 2, Medication Cart 2. The DON stated that at the start of LVN 1's morning shift on 8/2/23 (7 AM to 3 PM shift) around 9 AM, LVN 1 notified her that there were 14 tablets of Norco 5/325 mg missing from Resident 1's controlled medications supply. The DON stated that she looked for Resident 1's Norco 5/325 mg medications in Medication Cart 2, all other medication carts, and medication storage rooms in the facility but could not locate the medications. The DON stated she contacted the pharmacy to provide a replacement supply of Norco 5/325 mg, on 8/2/23. The DON stated the facility's pharmacy authorized one dose of Norco 5/325 mg from the controlled medication emergency kit (e-kit) and advised that the facility pharmacy would provide a replacement supply of Resident 1's Norco 5/325 mg. The DON stated the newly ordered replacement supply of Norco 5/325 mg was delivered to the facility on 8/2/23 at around 11 PM.
During the same interview, on 8/3/23 at 3:29 PM, the DON stated that the facility's pharmacy had delivered Norco 5/325 mg supplies with pharmacy delivery receipt dated 7/16/23. The DON stated Resident 1's Record of Controlled Substances (a log containing the date, time, and nurse's signature for all administered doses of a specific supply of a controlled medication) that corresponds to the missing supply of Resident 1's Norco 5/325 mg delivered on 7/16/23 was also missing.
During the same interview, on 8/3/23 at 3:29 PM, the DON stated LVN 1 (7 AM to 3 PM shift) and LVN 2 stated they signed the Controlled Drugs - Count Record but did not perform the controlled medication reconciliation for Medication Cart 2 together, as indicated in the facility's policy, during LVN 1 and 2's shift change (8/2/23 at 7 AM).
During the same interview, on 8/3/23 at 3:29 PM, the DON stated LVN 3 administered the last known dose of Norco 5/325 mg from the missing supply (pharmacy delivery dated 7/16/23) on 8/1/23 at around 9 PM. The DON stated LVN 3 worked on 8/1/23 during the 3 PM to 11 PM shift and was also assigned to Medication Cart 2. The DON stated on 8/1/23 at around 11 PM, when LVN 3 was ready to leave the facility, LVN 2 who was scheduled to work the 11 PM to 7 AM shift, had not yet arrived at the facility. The DON stated LVN 3 performed a controlled medication reconciliation with another licensed nurse scheduled during the same 3 PM to 11 PM shift, Registered Nurse (RN) 1, on 8/1/23 at around 11 PM. The DON stated RN 1 later (unknown time) performed a controlled medication reconciliation for Medication Cart 2 with LVN 4 who was assigned as a charge nurse team leader during the 11 PM to 7 AM shift on 8/1/23. The DON stated LVN 4 (11 PM to 7 AM shift) and LVN 2 (11 PM to 7 AM shift) performed a controlled medication reconciliation for Medication Cart 2 at some point prior to leaving the facility at approximately 7 AM on 8/2/23.
On 8/3/23 at 4:20 PM, during an interview, LVN 3 stated she was assigned to Medication Cart 2 on 8/1/23 for the 3 PM to 11 PM shift. LVN 3 stated that on 8/1/23, LVN 3 performed a controlled medication reconciliation with RN 1 around 10:50 PM because her shift was nearing its end, and LVN 2 (11 PM to 7 AM shift LVN) had not yet arrived at the facility. LVN 3 stated she provided one dose of Norco 5/325 mg to Resident 1 around 10:45 PM on 8/1/23. LVN 3 stated, after arriving on her shift (3 PM to 11 PM) the next day, on 8/2/23 around 3:20 PM, LVN 3 performed a controlled medication reconciliation with the DON because Resident 1's Norco 5/325 mg had been reported missing earlier that day. LVN 3 stated there was no Norco 5/325 mg available for Resident 1 during her shift that day, on 8/2/23. LVN 3 stated she assessed Resident 1 for pain during her shift around 4 PM or 5 PM and Resident 1 indicated her pain level was 4 to 5/10 (pain score on a scale from 0 to 10 where 0 is no pain and 10 is the worst possible pain).
On 8/4/23 at 10:08 AM, during another interview with the DON, the DON stated interviewing LVN 1 again regarding what happened with Resident 1's Norco 5/325 mg when it was discovered missing on 8/2/23. The DON stated LVN 1 informed her that she assessed Resident 1's pain the morning of 8/2/23 and LVN 1 indicated it was 2/10 pain. The DON stated LVN 1 determined Tylenol (over the counter medication for mild pain) was sufficient at that time but tried to locate the Norco 5/325 mg in case the Tylenol was not effective later. The DON stated LVN 1 was unable to find Resident 1's Norco 5/325 mg available on 8/2/23. The DON stated LVN 1 informed her LVN 1 failed to make a progress note log entry regarding Resident 1's missing Norco 5/325 mg-controlled medications supply.
On 8/4/23 at 10:39 AM, during a telephone interview with the Pharmacy Manager (RXM), RXM stated LVN 1 called the facility pharmacy at around 9 AM on 8/2/23 and stated Resident 1's Norco 5/325 mg was missing. RXM stated the pharmacy processed a refill of the Norco 5/325 mg which was delivered later that evening and provided the access code to the controlled medication e-kit for immediate use. RXM stated he was unaware whether the facility utilized any Norco 5/325 mg from the e-kit.
On 8/4/23 at 10:52 AM, during a telephone interview, LVN 1 stated she worked on 8/2/23 during the 7 AM to 3 PM shift, but did not arrive until right before 8 AM. LVN 1 stated LVN 2 (previous shift [11 PM to 7 AM]) had already left by the time she arrived at the facility, so LVN 1 did not count the controlled medications with any other nurse as indicated in the facility policy. LVN 1 stated she counted the controlled medications of other residents using the Record of Controlled Substances when she arrived at the facility by herself and did not find discrepancies (inconsistencies). LVN 1 stated she would not have known at that time if Resident 1's controlled medication supply of Norco 5/325 mg for Resident 1 was missing because the corresponding Record of Controlled Substances document was also missing. LVN 1 stated she assessed Resident 1's pain around 9 AM and determined Resident 1 had 2/10 pain. LVN 1 stated she administered Tylenol, as the pain rating was not sufficient to administer Norco at that time. LVN 1 stated she then searched Medication Cart 2 to determine whether the Norco 5/325 mg was available in case the Tylenol was ineffective. LVN 1 stated she could not find Resident 1's Norco medications. LVN 1 stated she immediately informed the DON that Resident 1's Norco 5/325 mg controlled medications were missing. LVN 1 stated the DON proceeded to search her Medication Cart and all other facility carts and medication storage rooms but was unable to locate the medication. LVN 1 stated she contacted the pharmacy for a replacement supply . LVN 1 stated she failed to document that Resident 1's Norco 5/325 mg was missing in Resident 1's progress note. LVN 1 stated she performed a controlled medication reconciliation with LVN 3 before leaving from her shift around 3 PM on 8/2/23. LVN 1 stated she failed to follow facility policy of performing controlled medication reconciliation with LVN 2 when she started her shift in the morning, on 8/2/23. LVN 1 stated it was important to ensure controlled medication counts are correct to ensure the availability of the medications for the residents. LVN 1 stated if controlled medications are missing, there is a chance residents could experience medical complications like increased pain or accidental exposure which could cause decreased quality of life.
On 8/4/23 at 12 PM, during a concurrent observation and interview in Resident 1's room, Resident 1 was observed sitting up on her bed. Resident 1 stated that on 8/2/23 she requested Norco 5/325 mg for severe pain at 4:45 PM and 11 PM. Resident 1 stated she was told by the licensed nurses (could not recall which licensed nurse) at both times the facility was out of the Norco. Resident 1 stated she did not remember which specific licensed nurse attended to her at those times. Resident 1 stated her pain was worsened because she did not receive her pain medication at those times, and she was supposed to be able to get the Norco every six hours. Resident 1 stated she would describe her pain at that time as severe. Resident 1 stated she never asks the licensed nurses for only Tylenol. Resident 1 stated sometimes licensed nurses tell her they will have to come back with her Norco because we keep them in a different place.
A review of Medicare Skilled Daily Note (a daily nursing progress note), dated 8/2/23, authored by LVN 1, included no entry concerning missing Norco 5/325 mg, pain score ratings, attempts to follow up with the pharmacy regarding the missing Norco 5/325 mg, e-kit usage.
A review of the facility's Controlled Drug - Count Record for Medication Cart 1 indicated the document was not signed according to facility policy a total of 28 times between 6/1/23 to 8/2/23.
A review of Resident 1's eMARs (printed 8/3/23) dated July and August 2023, indicated the following information:
1. A review of Resident 1's July 2023 MAR indicated Resident 1 received a total of 31 doses of Norco 5/325 mg between 7/16/23 (the date the most recent previous supply of Norco 5/325 mg was received from the pharmacy) to 7/31/23.
2. A review of Resident 1's August 2023 MAR indicated Resident 1 received a total of 1 dose of Norco 5/325 mg on 8/1/23 to 8/2/23 (the date the Norco 5/325 mg goes missing).
3. A review of Resident 1's July and August 2023 MARs indicated that between 7/16/23 (the date the most recent previous supply of Norco 5/325 mg was received from the pharmacy) to 8/2/23 (the date the Norco 5/325 mg goes missing) indicated a total of 28 doses out of the 60 doses of Norco 5/325 mg supply of Resident 1's Norco 5/325 mg were unaccounted for.
A review of the facility's Controlled Drug - Count Record for Medication Cart 2 indicated the document was not signed according to facility policy a total of 13 times between 6/1/23 to 8/2/23.
A review of the Controlled Drug - Count Record for Medication Cart 3 indicated the document was not signed according to facility policy a total of 61 times between 6/1/23 to 8/2/23.
A review of the Controlled Drug - Count Record for Medication Carts 1, 2, and 3 indicated the documents were not signed according to facility policy a total of 102 times, facility-wide between 6/1/23 to 8/2/23.
On 8/4/23 at 12:48 PM, during a telephone interview, LVN 2 stated her assignment was a charge nurse on Station 2, Medication Cart 2 on the night shift, of 8/1/23 during the 11 PM to 7 AM shift. LVN 2 stated that she arrived at the facility for her shift around 12:10 AM and did not count the controlled medications with anyone at that time. LVN 2 stated LVN 3 who was assigned to Medication Cart 2 for the previous shift (3 PM to 11 PM) had already left the facility. LVN 2 stated she counted everything that was in her lockbox inside Medication Cart 2 by herself but did not count any of Resident 1's Norco. LVN 2 stated all of Resident 1's supplies of Norco in Medication Cart 2 had been removed from Medication Cart 2 and relocated inside Medication room [ROOM NUMBER] and put into a lock box there. LVN 2 stated this change occurred about a month ago at the direction of the DON. LVN 2 stated she was unclear on why the Norco supplies for residents in Medication Cart 2 was moved in a lockbox inside Medication room [ROOM NUMBER]. LVN 2 stated she was unclear if there was a different controlled medication reconciliation process for the Norco controlled medications that had been relocated to Medication room [ROOM NUMBER]. LVN 2 stated she had not been reconciling the medication counts for any of the Norco since the Norco supplies were relocated from Medication Cart 2 to a lockbox in Medication room [ROOM NUMBER].
During the same interview, on 8/4/23 at 12:48 PM, LVN 2 stated that in the morning of 8/2/23, at around 7 AM before leaving the facility, she counted all the controlled medications in Medication Cart 2 with LVN 4. LVN 2 stated LVN 4 (11 PM to 7 AM) was also leaving from night shift at that time and was not the nurse taking over accountability of the controlled medications in Medication Cart 2 for oncoming shift (7 AM to 3 PM) on 8/2/23. LVN 2 stated LVN 1 was scheduled to relieve her for the next shift, on 8/2/23 at 7 AM but had not yet arrived at the facility, by the end of her shift.
On 8/4/23 at 1:20 PM, during a telephone interview, RN 1 stated she was scheduled to work on 8/1/23 for 3 PM to 11 PM shift. RN 1 stated that on 8/1/23, LVN 3 left around 11 PM and was unable to perform a controlled medication reconciliation with LVN 2 because LVN 2 had not yet arrived at the facility. RN 1 stated she counted the controlled medications with LVN 3 so LVN 3 could go home. RN 1 stated LVN 2 arrived around 12:10 AM, but RN 1 did not count the controlled medications with LVN 2 when she took over Medication Cart 2. RN 1 stated she also did not count the controlled medications with LVN 4 at any time prior to leaving the facility, on 8/1/23. RN 1 stated all the Norco supplies from Medication Cart 2 had been removed from Medication Cart 2 and placed in a lockbox inside Medication room [ROOM NUMBER]. RN 1 stated the keys to the lockbox were kept hanging on the side of the lockbox inside Medication room [ROOM NUMBER]. RN 1 stated anyone with keys to Medication room [ROOM NUMBER] could have accessed the Norco in the lockbox that was supposed to be in Medication Cart 2. RN 1 stated she was unsure why the DON made the decision to move the Norco to Medication room [ROOM NUMBER]. RN 1 stated if controlled medications are in two different places and people other than the responsible licensed staff have access to the controlled medications, the risk for diversion or accidental exposure to residents are increased.
On 8/4/23 at 1:34 PM, during a concurrent interview and record review of Resident 1's MAR and pharmacy delivery receipts, the DON stated and acknowledged that it was a total of 28 doses of Norco 5/325 mg missing instead of 14 tablets mentioned previously.
During the same interview, on 8/4/23 at 1:34 PM, the DON stated about a month ago she decided to move all the Norco from Medication Cart 2 into a lockbox in Medication room [ROOM NUMBER]. The DON stated she made this decision because in the past, Resident 1 and licensed staff disagreed on whether Resident 1 received her Norco. The DON stated her intent for doing this was to ensure at least two licensed nurses would need to be involved in administering Resident 1's Norco for verification that the medication administration occurred. The DON stated she failed to consider that by removing the Norco from Medication Cart 2, there would be no way to ensure the accountability of the controlled substances from shift to shift between licensed nurses when performing controlled medication reconciliation. The DON stated she failed to address the potential with which the Controlled Drugs - Count Record would not be signed for the Norco supplies according to facility policy by the oncoming and outgoing nurse between 6/1/23 to 8/2/23 if the controlled medications were on a separate location. The DON stated if one nurse is late, the nurse who was scheduled to leave should not leave before the next nurse arrives.
During the same interview, on 8/4/23 at 1:34 PM, the DON stated the facility did not have a policy to address what licensed nurses needed to do to endorse over the accountability of controlled medications in the case that two licensed nurses' shifts on duty do not overlap. The DON stated if both the incoming and outgoing nurses do not sign off on the Controlled Drugs - Count Record then there would be a break in the chain of accountability for the controlled medications. The DON stated if a licensed nurse counts the medications themselves or if two nurses who are both leaving from the same shift, count the controlled medications together it does not serve the purpose of continuous accountability. The DON stated because the facility failed to maintain adequate oversight on the controlled medication reconciliation process and because controlled medications are now missing, the facility's residents are at risk of accidental exposure possibly leading to hospitalization or death, increased pain, ADL decline, and quality of life decline. The DON stated that failure to maintain oversight of the controlled medications such as leaving the key hanging by the lockbox inside Medication room [ROOM NUMBER] and the licensed nurses controlled medication reconciliation process further increased the risk of medication diversion, misappropriation of resident property, or staff providing resident care in an impaired state.
A review of the facility's policy Controlled Substances, revised April 2019, indicated The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled substances . Access to controlled medications remains locked at all times and access is recorded . Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift ., Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together .
A review of the facility's policy Administering Medication, revised April 2019, indicated Medications are administered in a safe and timely manner, and as prescribed . Medications are administered in accordance with prescriber orders, including any required time frame . The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones .
CONCERN
(D)
📢 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 F0760
(Tag F0760)
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 administer two doses of Norco (a medication used to t...
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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 administer two doses of Norco (a medication used to treat pain) 5/325 milligrams (mg - a unit of measure for mass) on 8/2/23 for one of three sampled residents (Resident 1).
Failure to administer pain medication according to the physician ' s order increased the risk that Resident 1 could have experienced increased pain resulting in a decline in ability to perform activities of daily living (ADLs - everyday activities like brushing teeth or bathing) and quality of life.
Findings:
A review of Resident 1 ' s Face Sheet, dated 8/3/23, indicated she was admitted to the facility on [DATE] with diagnoses including essential hypertension (high blood pressure) and muscle weakness.
A review of Resident 1 ' s Minimum Data Set (MDS - a comprehensive resident assessment tool) section C (Cognitive Patterns) indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a interview tool used to determine cognitive impairment) score of 12 (moderately impaired.)
A review of Resident 1 ' s History and Physical note (H&P - the formal document that physicians produce through the interview with the patient, the physical exam, and the summary of the testing either obtained or pending) dated 6/3/23, indicated Resident 1 had the capacity to understand and make decisions.
A review of Resident 1 ' s physician order dated 6/9/23 indicated the physician prescribed Norco 5/325 mg to take one tablet by mouth every six hours as needed for moderate pain (pain score 4 to 6).
A review of Resident 1 ' s eMAR, dated August 2023 and printed 8/3/23, indicated one dose of Norco 5/325 mg was given to Resident 1 at 10:58 PM on 8/1/23 and no additional doses were given on 8/2/23.
A review of Medicare Skilled Daily Note (a daily nursing progress note), dated 8/2/23, authored by LVN 1, included no entry concerning missing Norco 5/325 mg, pain score ratings, attempts to follow up with the pharmacy regarding the missing Norco 5/325 mg, e-kit usage, etc.
A review of Resident 1 ' s Care Plan, dated 6/1/23, indicated she was at risk for chronic pain due to neuropathy (nerve pain), arthritis (inflammation of the joint) in her left knee and bursitis (inflammation of tissue that cushions bones, tendons, and muscles near joints) in her left knee with targeted interventions to monitor for pain every shift and administer Norco 5/325 mg every 6 hours as needed.
On 8/3/23 at 3:29 PM, during an interview, the DON stated LVN 1 was the nurse assigned on the morning shift (7 AM to 3 PM) on 8/2/23 and LVN 2 was the nurse assigned on the preceding night shift of 8/1/23 (11 PM to 7 AM) to Station 2, Medication Cart 2. The DON stated that at the start of LVN 1 ' s morning shift on 8/2/23 (7 AM to 3 PM shift) around 9 AM, LVN 1 notified her that there were 14 tablets of Norco 5/325 mg missing from Resident 1 ' s controlled medications supply. The DON stated that she looked for Resident 1 ' s Norco 5/325 mg medications in Medication Cart 2, all other medication carts, and medication storage rooms in the facility but could not locate the medications. The DON stated she contacted the pharmacy to provide a replacement supply of Norco 5/325 mg, on 8/2/23. The DON stated the facility ' s pharmacy authorized one dose of Norco 5/325 mg from the controlled medication emergency kit (e-kit) and advised that the facility pharmacy would provide a replacement supply of Resident 1 ' s Norco 5/325 mg. The DON stated the newly ordered replacement supply of Norco 5/325 mg was delivered to the facility on 8/2/23 at around 11 PM.
During the same interview, on 8/3/23 at 3:29 PM, the DON stated LVN 1 (7 AM to 3 PM shift) and LVN 2 stated they signed the Controlled Drugs - Count Record but did not perform the controlled medication reconciliation for Medication Cart 2 together, as indicated in the facility ' s policy, during LVN 1 and 2 ' s shift change (8/2/23 at 7 AM). The DON stated LVN 1 administered one dose of Norco 5/325 mg to Resident 1 from the facility ' s e-kit on 8/2/23 around 11:00 AM after the medication was discovered missing.
During the same interview, on 8/3/23 at 3:29 PM, the DON stated LVN 3 administered the last known dose of Norco 5/325 mg from the missing supply (pharmacy delivery dated 7/16/23) on 8/1/23 at around 9 PM. The DON stated LVN 3 worked on 8/1/23 during the 3 PM to 11 PM shift and was also assigned to Medication Cart 2. The DON stated on 8/1/23 at around 11 PM, when LVN 3 was ready to leave the facility, LVN 2 who was scheduled to work the 11 PM to 7 AM shift, had not yet arrived at the facility. The DON stated LVN 3 performed a controlled medication reconciliation with another licensed nurse scheduled during the same 3 PM to 11 PM shift, Registered Nurse (RN) 1, on 8/1/23 at around 11 PM. The DON stated RN 1 later (unknown time) performed a controlled medication reconciliation for Medication Cart 2 with LVN 4 who was assigned as a charge nurse team leader during the 11 PM to 7 AM shift on 8/1/23. The DON stated LVN 4 (11 PM to 7 AM shift) and LVN 2 (11 PM to 7 AM shift) performed a controlled medication reconciliation for Medication Cart 2 at some point prior to leaving the facility at approximately 7 AM on 8/2/23.
On 8/3/23 at 4:20 PM, during an interview, LVN 3 stated she was assigned to Medication Cart 2 on 8/1/23 for the 3 PM to 11 PM shift. LVN 3 stated that on 8/1/23, LVN 3 performed a controlled medication reconciliation with RN 1 around 10:50 PM because her shift was nearing its end, and LVN 2 (11 PM to 7 AM shift LVN) had not yet arrived at the facility. LVN 3 stated she provided one dose of Norco 5/325 mg to Resident 1 around 10:45 PM on 8/1/23. LVN 3 stated, after arriving on her shift (3 PM to 11 PM) the next day, on 8/2/23 around 3:20 PM, LVN 3 performed a controlled medication reconciliation with the DON because Resident 1 ' s Norco 5/325 mg had been reported missing earlier that day. LVN 3 stated there was no Norco 5/325 mg available for Resident 1 during her shift that day, on 8/2/23 andthat Resident 1 did not ask her for it at any time during her shift. LVN 3 stated she assessed Resident 1 for pain during her shift around 4 PM or 5 PM and Resident 1 indicated her pain level was 4 to 5/10 (pain score on a scale from 0 to 10 where 0 is no pain and 10 is the worst possible pain). LVN 3 stated she administered Tylenol (a medication used to treat mild pain) for that pain score but does not remember whether she documented any of Resident 1 ' s pain ratings in the medical record.
On 8/3/23 at 5:35 PM, during an observation of Medication room [ROOM NUMBER] on Nursing Station 1, the controlled medication e-kit was observed sealed with intact green plastic seals and combination pad lock. No apparent doses of any medication were observed missing. No accompanying written record of any recent usage was available. The e-kit was observed with a pharmacy fill date of 6/26/23 on the prescription label. The e-kit was observed to contain extra red plastic seals.
On 8/3/23 at 5:40 PM, during a concurrent observation of Medication room [ROOM NUMBER] on Nursing Station 2 with LVN 3, no controlled medication e-kit was observed in Medication room [ROOM NUMBER]. During a concurrent interview, LVN 3 stated the facility has two total medication rooms and three total medication carts. LVN 3 stated the facility only has one controlled medication e-kit and it is kept in Medication room [ROOM NUMBER].
On 8/3/23 at 5:45 PM, during an interview with the DON, the DON acknowledged it appears as if the controlled medication e-kit had not been used or replaced. The DON stated it is possible that LVN 1 was not truthful that she administered one dose of Norco 5/325 mg to Resident 1 from the facility ' s e-kit as she previously stated. The DON stated there is no record of any controlled medication being utilized from the controlled medication e-kit. The DON stated there is no record of any licensed staff administering Norco 5/325 mg to Resident 1 on 8/2/23 in the eMAR. The DON stated it appears LVN 1 failed to note anywhere in Resident 1 ' s clinical record that controlled medications were missing or e-kit doses were given noted in the skilled daily nursing note.
On 8/4/23 at 10:08 AM, during an interview with the DON, the DON stated she contacted LVN 1 regarding what happened the day Resident 1 ' s Norco 5/325 mg was discovered missing. The DON stated LVN 1 informed her that she assessed Resident 1 ' s pain the morning of 8/2/23 and LVN 1 indicated it was 2/10. The DON stated LVN 1 determined Tylenol was sufficient at that time but tried to locate the Norco 5/325 mg in case it was not effective later. The DON stated LVN 1 was unable to find the Norco 5/325 mg available at that time. The DON stated LVN 1 informed her she failed to sign the eMAR for medication administrated or make a progress note log entry regarding the missing medications.
A review of a pharmacy delivery receipt, dated 7/16/23, indicated a previous delivery was made to the facility for 60 tablets of Norco 5/325 mg on 7/16/23 timed at 1:23 AM for Resident 1.
A review of the pharmacy delivery receipt dated 8/2/23, indicated 30 tablets of Norco 5/325 mg (replacement supply) was delivered to the facility on 8/2/23 timed at 10:30 PM for Resident 1.
A review of Resident 1 ' s eMARs (printed 8/3/23) dated July and August 2023, indicated the following information:
1. A review of Resident 1 ' s July 2023 MAR indicated Resident 1 received a total of 31 doses of Norco 5/325 mg between 7/16/23 (the date the most recent supply of Norco 5/325 mg was received from the pharmacy) to 7/31/23.
2. A review of Resident 1 ' s August 2023 MAR indicated Resident 1 received a total of 1 dose of Norco 5/325 mg on 8/1/23 to 8/2/23 (the date the Norco 5/325 mg goes missing). The MAR indicated one dose of Norco 5/325 mg was given to Resident 1 on 8/1/23 at 10:58 PM and no additional doses were given on 8/2/23.
3. A review of Resident 1 ' s July and August 2023 MARs indicated that between 7/16/23 (the date the most recent supply of Norco 5/325 mg was received from the pharmacy) to 8/2/23 (the date the Norco 5/325 mg goes missing) indicated a total of 28 doses out of the 60 doses of Norco 5/325 mg supply of Resident 1 ' s Norco 5/325 mg were unaccounted for.
On 8/4/23 at 10:39 AM, during a telephone interview with the Pharmacy Manager (PM), PM stated LVN 1 called the pharmacy around 9 AM on 8/2/23 stating Resident 1 ' s Norco 5/325 mg was missing. PM stated the pharmacy processed a refill of the Norco 5/325 mg which was delivered later that evening and provided the access code to the controlled medication e-kit for immediate use. PM stated he was unaware whether the facility utilized any Norco 5/325 mg from the e-kit. PM stated the pharmacy dispenses the e-kit with green seals and if the facility uses any doses from the e-kit it is resealed with the red seals. PM stated the facility then needs to call the pharmacy to request the e-kit be replaced. PM stated there had been no request from the facility to replace the facility ' s current controlled medication e-kit.
On 8/4/23 at 10:52 AM, during a telephone interview, LVN 1 stated she worked on 8/2/23 during the 7 AM to 3 PM shift, but did not arrive until right before 8 AM. LVN 1 stated LVN 2 (previous shift [11 PM to 7 AM]) had already left by the time she arrived at the facility, so LVN 1 did not count the controlled medications with any other nurse as indicated in the facility policy. LVN 1 stated she counted the controlled medications of other residents using the Record of Controlled Substances when she arrived at the facility by herself and did not find discrepancies (inconsistencies). LVN 1 stated she would not have known at that time if Resident 1 ' s controlled medication supply of Norco 5/325 mg for Resident 1 was missing because the corresponding Record of Controlled Substances document was also missing. LVN 1 stated she assessed Resident 1 ' s pain around 9 AM and determined Resident 1 had 2/10 pain. LVN 1 stated she administered Tylenol, as the pain rating was not sufficient to administer Norco at that time. LVN 1 stated she then searched Medication Cart 2 to determine whether the Norco 5/325 mg was available in case the Tylenol was ineffective. LVN 1 stated she did not administer anything from the e-kit because the resident did not complain of pain at a high enough severity at that time or during the remainder of her shift to warrant it. LVN 1 stated she failed to document Resident 1 ' s pain rating in the clinical record, failed to document the administration of Tylenol in the eMAR, and failed to document that the resident ' s Norco 5/325 mg was missing in the clinical progress note. LVN 1 stated she could not find Resident 1 ' s Norco medications. LVN 1 stated she immediately informed the DON that Resident 1 ' s Norco 5/325 mg controlled medications were missing. LVN 1 stated the DON proceeded to search her Medication Cart and all other facility carts and medication storage rooms but was unable to locate the medication. LVN 1 stated she contacted the pharmacy for a replacement supply . LVN 1 stated she failed to document that Resident 1 ' s Norco 5/325 mg was missing in Resident 1 ' s progress note. LVN 1 stated she performed a controlled medication reconciliation with LVN 3 before leaving from her shift around 3 PM on 8/2/23. LVN 1 stated she failed to follow facility policy of performing controlled medication reconciliation with LVN 2 when she started her shift in the morning, on 8/2/23. LVN 1 stated it was important to ensure controlled medication counts are correct to ensure the availability of the medications for the residents. LVN 1 stated if controlled medications are missing, there is a chance residents could experience medical complications like increased pain or accidental exposure which could cause decreased quality of life.
On 8/4/23 at 12 PM, during a concurrent observation and interview in Resident 1 ' s room, Resident 1 was observed sitting up on her bed. Resident 1 stated that on 8/2/23 she requested Norco 5/325 mg for severe pain at 4:45 PM and 11 PM. Resident 1 stated she was told by the licensed nurses (could not recall which licensed nurse) at both times the facility was out of the Norco. Resident 1 stated she did not remember which specific licensed nurse attended to her at those times. Resident 1 stated her pain was worsened because she did not receive her pain medication at those times, and she was supposed to be able to get the Norco every six hours. Resident 1 stated she would describe her pain at that time as severe. Resident 1 stated she never asks the licensed nurses for only Tylenol. Resident 1 stated nursing staff never ask her to rate her pain on a scale from 0 to 10. Resident 1 stated she usually must ask for her pain medication rather than it being offered Resident 1 stated sometimes licensed nurses tell her they will have to come back with her Norco because we keep them in a different place.
On 8/4/23 at 12:45 PM, during an observation of Medication Cart 2 on Nursing Station 2, Resident 1 ' s supply of Norco 5/325 mg showed five doses missing. Observation of the Record of Controlled Substances corroborated a total of five doses administered and indicated staff administered the first dose from this supply on 8/3/23 at 11 AM and the second at 3:45 PM.
A review of Resident 1 ' s August 2023 eMAR, printed 8/3/23 at approximately 5 PM, did not indicate any doses of Norco 5/325 mg were administered to Resident 1 on 8/2/23 or 8/3/23.
A review of the facility ' s policy Administering Medication, revised April 2019, indicated Medications are administered in a safe and timely manner, and as prescribed . Medications are administered in accordance with prescriber orders, including any required time frame . The individual administering the medication initials the resident ' s MAR on the appropriate line after giving each medication and before administering the next ones .
A review of the facility ' s policy Pain - Clinical Protocol, revised March 2018, indicated The staff will reassess the individual ' s pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. Review should include frequency, duration and intensity of pain, ability to perform activities of daily living (ADLs), sleep pattern, mood, behavior, and participation in activities.
May 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the resident and/or Responsible Party (RP, a person responsible for a resident who are unable to make decisions for themself) was in...
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Based on interview and record review, the facility failed to ensure the resident and/or Responsible Party (RP, a person responsible for a resident who are unable to make decisions for themself) was informed prior to the administration of psychotropic (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior) medication for one of three sampled residents (Resident 1).
This deficient practice violated the resident's right to make an informed decision regarding the use of psychotropic medications, including the risk and benefits.
Findings:
A review of Resident 1's Face Sheet indicated the facility admitted Resident 1 on 4/21/23, with diagnoses that included psychosis (severe mental disorder that cause abnormal thinking and perceptions) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).
A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 4/26/23, indicated Resident 1 had moderately impaired memory and cognition (ability to think and reason). Resident 1 exhibited symptoms including feeling down, depressed, or hopeless, trouble falling or staying asleep, or sleeping too much, poor appetites or overeating, and trouble concentrating on things, such as reading the newspaper or watching television. Resident 1 had received medications including antipsychotic, antianxiety, antidepressant and hypnotic since admission.
During a review of Resident 1 ' s History and Physical (H&P), dated on 4/21/23, indicated Resident 1 had diagnoses of psychosis and cognitive impairment. The H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1 ' s Physician Orders, for the month of April 2023, indicated to give Resident 1 the following medications starting on 4/21/23:
1. Risperdal (antipsychotic, treat certain mental/mood disorders) 1 milligram (mg) tablet (tab) twice a day (BID) for psychosis disorder manifested by paranoia (An unrealistic distrust of others or a feeling of being persecuted, harassed, or betrayed by others).
2. Risperdal 2 mg tab every day at 9 PM for psychosis disorder manifested by paranoia.
3. Remeron (antidepressant, treat depression) 15 mg tab every day at 9 PM for depression manifested by feeling sad.
4. Zolpidem (sedative, treat sleeping problems) 10 mg tab at bedtime for insomnia oral every day as needed.
5. Ativan (antianxiety, treat anxiety) 1 mg tablet every 6 hours as needed for anxiety manifested by agitation.
During a review of Resident 1 ' s Medication Administration Record (MAR, legal record of medication administration to a resident at a facility by a health care professional), for the month of April 2023, indicated Resident 1 received Risperdal 1 mg BID oral from 4/21/23 to 4/26/23, Risperdal 2 mg and Remeron 15 mg oral at bedtime from 4/21/23 to 4/25/23, Zolpidem 10 mg oral at bedtime from 4/23/23 to 4/24/23 and Ativan 1 mg oral one time on 4/24/23.
During a concurrent interview and record review on 5/11/23 at 4:49 PM, Registered Nurse (RN 1) stated there was no documented evidence that informed consent was obtained from Resident 1 prior to the administration of the psychotropic medications (Risperdal 1 mg, Risperdal 2 mg, Remeron, Zolpidem, and Ativan) on 4/21/23. RN 1 stated Resident 1 ' s MAR indicated Resident 1 received psychotropic medications from 4/21/23 to 4/26/23 (6 days). RN 1 stated it was important to inform the residents and/or RP about the purpose, risks, and benefits of using psychotropic medication.
During an interview on 5/11/23, at 5:10 PM, the Director of Nursing (DON) stated an informed consent for psychotropic medication should be signed and dated before administering the medications. DON stated it was important to inform the residents about the use, risks, and benefits of psychotropic medications so that they could participate in and make decisions on their care.
During a review of the facility ' s policy and procedure titled, Informed Consent-Psychotherapeutic Medications and Restraint Devices, dated 12/14/17, indicated informed consent should be obtained from the resident/surrogate decision maker prior to receipt of the medication when a psychotherapeutic medication is ordered throughout the resident ' s stay in the facility.
Apr 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on observation, interviews and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) and other officials immediately, but not l...
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Based on observation, interviews and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) and other officials immediately, but not later than two hours for one of three sampled residents (Resident 1) in accordance with the facility's policy on Abuse Reporting and Investigation.
A facility reported incident received on 4/20/2023 indicated an allegation of verbal abuse that occurred on 4/11/2023 (9 days after the abuse allegation).
This deficient practice had the potential for the facility to under report allegations of abuse, which could lead to failure to investigate alleged abuse in a timely manner.
Findings:
A review of Resident 1's Face Sheet indicated an admission date on 11/6/2019 with diagnoses including Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar [glucose] where the body either doesn't produce enough insulin) with hyperglycemia (high blood sugar), generalized osteoarthritis (the cartilage in several joints is slowly breaking down), and schizoaffective disorder (a mental health condition that includes features of both schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly) and mood disorder) bipolar type (associated with episodes of mood swings ranging from depressive lows to manic highs).
A review of Resident 1's History and Physical Examination dated 11/30/2022, indicated Resident 1 did not have the capacity to understand and make decisions.
A review of Resident 1's Minimum Data Set (MDS, an assessment and screen tool) dated 2/3/2023 indicated Resident 1 had intact cognition and required supervision (oversight, encouragement or cueing) with bed mobility and transfer.
During an interview with the Administrator (ADM) on 4/28/2023 at 1:44 PM, the ADM stated the allegation was that the Director of Nursing (DON) called Resident 1 the N word. The ADM stated it was reported by Certified Nursing Assistant (CNA 1) and that the incident was in the past. The ADM stated once the allegation was reported to him on 4/20/2023, he immediately reported it to the necessary authorities. The ADM stated he did not know the exact date the DON allegedly said the N word to Resident 1. The ADM stated the staff should have told him right away. The ADM stated he wrote up CNA 1 and CNA 2 because they did not report it right away. The ADM stated the abuse allegation was escalated to the corporate level and Human Resources (HR) were at the facility conducting confidential interviews with staff.
During an interview with CNA 3 on 4/28/2023 at 2:20 PM, CNA 3 stated on 4/12/2023, he was told by CNA 1 and CNA 2 about the alleged verbal abuse that happened on 4/11/2023. CNA 3 stated he made the report to Human Resources.
During an interview with Resident 1 on 4/28/2023 at 3:14 PM, Resident 1 could not recall if the DON or any other staff yelled or mistreated her.
During a telephone interview with CNA 1 on 4/28/2023 at 3:54 PM, CNA 1 stated she knows she should have reported the verbal abuse allegation right away, but did not at the time. CNA 1 stated she and CNA 2 discussed the allegation and instead reported it to CNA 3 the next day, who then reported the allegation to Human Resources. CNA 1 stated it should have been reported to the ADM, CDPH, Ombudsman, and the local authorities within 2 hours or immediately.
During a telephone interview with CNA 2 on 4/28/2023 at 4:09 PM, CNA 2 stated she did not report the incident right away, she told CNA 3 who reported it to Human Resources. CNA 2 stated she knew she was supposed to report to the ADM right away or immediately. CNA 2 stated she told CNA 3 about the alleged verbal abuse on 04/12/23.
A review of facility's policy and procedure titled Abuse Reporting and Investigation, dated 11/2018 indicated the facility will report all allegations of abuse as required by law and regulations to the appropriate agencies within 2 hours.
Feb 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain an accurate documentation of medical records in accordance...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain an accurate documentation of medical records in accordance with accepted professional standards and practices when the facility documented colon cancer (cancer that forms in the tissues of the colon) and Tramadol (a narcotic used to treat moderate to severe pains) use for one (1) of three
(3) sampled residents (Resident 1).
This deficient practice had the potential to cause improper treatment and unnecessary psychosocial harm to Resident 1.
Findings:
A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] with a diagnoses of adjustment disorder (a short -term condition that happens when you have great difficulty managing with or adjusting to a particular source of stress such as major life event) anxiety, and contusion of the right ascending colon (bruised second part of the large intestine).
A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/7/22, indicated Resident 1 has moderately impaired cognitive status.
A review of Resident 1 ' s care plan dated 5/3/22 indicated colon cancer was one of the identified problem/concerns for the resident instead of contusion of ascending colon (injury to the colon).
A review of Resident 1 ' s nurses notes dated 5/27/22 indicated Resident 1 was on Tramadol 50 mg (milligrams-unit of measurement) by mouth every six (6) hours for pain management.
A review of resident 1 ' s history and physical with dated of 5/27/22 indicated Resident 1 has contusion of unspecified part of the colon.
A review of the physician ' s order indicated Resident 1 was on Oxycodone (medication used to relieve pains severe enough to require opioid treatment) 5 mg 1 tab by mouth every four (4) hours as needed for severe pain. The physician ' s order did not indicate Resident 1 was started on Tramadol.
During an interview on 2/2/23 at 2:30 PM, Registered Nurse 2 (RN 2), she stated to make sure the care plan is accurate, the staff should interview residents for any medical history.
During an interview on 2/2/23 at 3 PM, Medical Records Director (MRD) stated Resident 1 does not have any documented diagnosis for colon cancer but does have colon contusion based on his Face Sheet (a document that gives a resident ' s information at a quick glance). MRD also stated Resident 1 has history of breast cancer not colon cancer.
During an interview on 2/2/23 at 5 PM, RN 3 stated Resident 1 was not on Tramadol but Oxycodone. RN 3 validated an error was made in the written orders stating the resident was not on Tramadol and would not be able to give the medication to the resident if no order.
During an interview on 2/2/23 at 3:50 PM, the Administrator (ADM) stated the facility verifies and validate complaints related to medical records inaccuracies. ADM also stated if inaccuracies are proven to be true, they notify and investigate the person who is documenting on the resident ' s medical records and inquire what happened. ADM stated whenever he finds errors in documentation, he asks the consultant to make the correction. ADM stated he was not aware of the tramadol documentation error and the colon cancer documentation on the care plan.
A review of the facility ' s policy and procedure titled, Charting and Documentation, revised April 2008, indicated that all observations, medications administered, services performed, etc., must be documented in the residents ' clinical records accurately.
Oct 2022
24 deficiencies
2 IJ (2 affecting multiple)
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Resident Rights
(Tag F0550)
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 nine out of nine (Residents 79, 40, 292, 14, 4...
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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 nine out of nine (Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86) justice involved residents (residents currently in custody and held involuntarily through operation of law enforcement authorities in an institution, which is the responsibility of a governmental unit or over which a governmental unit exercises administrative control) residing in the facility were treated with respect and dignity and were able to exercise the same basic rights as all other residents in the facility in accordance to the facility's policy and procedure on Resident's Rights.
This failure resulted in the facility imposing conditions (practices) which included restricting indoor and outdoor visitations, receiving telephone calls, receiving mails, participating in activities of their choice, moving around within the facility, communicating with outside agencies which included the State Long-term care Ombudsman (OMB; an individual who advocates for long-term care facility residents, defends their rights, and ensures they are protected from verbal abuse, neglect, and assault) and Department of Public Health (DPH) State Surveyors, which violated the resident's rights of Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86. All decisions were made by the Federal Law Enforcement and Private Security Officers who were present with each justice involved resident.
These deficient practices had the potential to affect Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86's dignity and self-worth that could lead to severe negative psychosocial outcome such as fear, depression, agitation, isolation, suicidal ideation, and suicide.
On 10/19/22 at 12:25 PM, during the facility's annual recertification survey, the Department of Public Health (DPH) called an Immediate Jeopardy (IJ-a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident), in the presence of the Administrator (ADM) and Director of Nurses (DON), in regard to the nine justice involved residents residing in the facility that were unable to exercise the same basic rights as all other residents in the facility. The facility was found to imposed conditions on the nine justice involved residents which resulted in restricting and violating the rights of the nine justice involved residents that included communicating with and access to persons inside and outside the facility, that includes visitation, without interference, discrimination, and fear of reprisal.
On 10/20/22 at 6:10 PM, the DPH removed the IJ while onsite after the surveyor verified the facility implemented the IJ Removal Plan (a detailed plan to address the IJ findings) given by the ADM which included:
1. On 10/19/22, the DON and Social Services Director (SSD) interviewed the nine justice involved residents regarding their care, how staff treats them, and if they have experienced any adverse psychosocial effect as a result.
2. On 10/19/22, the DON notified the attending physician of all nine justice involved residents and the attending physician ordered for all nine justice involved residents to be transferred to the acute hospital because the facility cannot meet the residents' needs. The DON and Marketing Director (MKD) notified all justice involved residents regarding the attending physician's order for their transfer to the acute hospital due to the facility's inability to meet residents' needs, particularly the nine residents being able to exercise the same rights as all other residents in the facility which involves communicating with and access to persons inside and outside the facility, that includes visitation, sending and receiving mail, receiving, and making telephone calls, without interference, discrimination, and fear of reprisal.
3. All nine justice involved residents signed the Notice of Proposed Transfer and Discharge. The attending physician from the acute hospital, which the nine residents were transferred to, coordinated with the DON and MKD regarding the transfer. The MKD will coordinate with all nine justice involved residents' responsible parties to ensure proper placement.
4. On 10/20/22, the DON followed up with the nine Justice Involved Resident's attending physician at the acute hospital and physician informed that all nine Justice involved Residents are stable and doing well. All nine justice involved residents are still in the acute hospital. The responsible party of all nine justice involved residents are still working on proper placement with facilities that they work with.
5. On 10/19/22, the ADM was provided in-service education and training from the [NAME] President of Operations (VPO) regarding the facility's policy and procedure regarding, but not limited to, Resident's Rights.
Findings:
A review of a formal referral letter from the long-term care ombudsman dated 10/14/22, indicated the OMB was at the facility on 10/11/22. The letter indicated the OMB was not allowed to see or interview the nine justice involved residents in their rooms. The letter indicated that the DON stated the facility had been instructed to follow a different set of rules and were told that the justice involved residents did not have the same rights as all other residents in the facility. The letter indicated that on 10/12/22, the OMB spoke to the Federal Law Enforcement (Justice Department agency charged with carrying out all law enforcement activities relating to the federal justice system) Supervisor and explained to the OMB that the justice involved residents were supervised by the Federal Law Enforcement while in the facility. The letter indicated that the Federal Law Enforcement Supervisor informed the OMB that the justice involved residents residing in the facility have all the rights to keep them alive. The letter indicated the justice involved residents were not allowed to have phone calls, outside snacks, were not allowed to walk around the facility and have visitors without the Federal Law Enforcement Supervisor permission. The letter indicated that on 10/12/22, the facility's administrator shared with the OMB that the facility was following a separate protocol (policy) for the justice involved residents according to the facility's corporate guidance and the Federal Law Enforcement Agency.
A review of a Memorandum (a short note designating something to be remembered, especially something to be done or acted upon in the future) addressed to the facility and MKD, titled Policy and Procedures for Inmates in Nursing Home Facilities, dated 8/20/2021, signed by the Federal Law Enforcement Deputy and written in the Federal Law Enforcement letterhead indicated the following information:
- Clients (Inmates [residents of the facility]) who are residing in a nursing home facility are not allowed any outside food, clothing or any other item that is not medically necessary unless it is pre-approved by (Federal Law Enforcement Agency).
- Every client (inmate) that resides in a nursing home facility will be always accompanied by security staff (24 hours).
- Clients (inmates) are allowed phone calls only when pre-approved by (Federal Law Enforcement Agency). Calls will be initiated and monitored by security staff onsite.
- Clients (inmates) are not allowed to have family visitations or phone calls. If unannounced visitor arrives, notify (Federal Law Enforcement Agency) immediately.
- For a client (inmate) to participate in an extra activity, it must be pre-approved by the (Federal Law Enforcement Agency). Clients will not be able to participate in any activity which involved non-custodial (a person found guilty of a crime or offense and punishment does not involve going to prison) members of the Skilled Nursing Facility.
On 10/18/22 at 8:32 AM, during the initial tour of the facility, concurrent interview and review of the facility's residents census dated 10/17/22 with the DON, the DON stated the facility had 92 residents residing in the facility. The DON stated Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86 were under a fictitious (not real or true) name to protect the resident's identity and for confidentiality. The DON stated Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86 admitted in the facility were all justice involved residents.
On 10/18/2022 at 9:26 AM, Private Security Officer (PSO) 2 stated that two PSOs were assigned to supervise each of the nine justice involved residents in the facility. PSO 2 stated there were three working shifts per day, 8 hours per shift. PSO 2 stated Justice Involved Residents needs 24-hour supervision, to keep an eye on Justice Involved Residents daily activities. PSO 2 stated the justice involved residents were not allowed to receive any visitors and mails, no telephone calls, and they were not allowed to eat in the facility's dining room. PSO 2 stated the justice involved residents can only eat inside their own rooms.
During an interview on 10/18/22 at 9:35 AM, Licensed Vocational Nurse (LVN) 1 stated the Department of Public Health (DPH) surveyors were not allowed to go inside all justice involved residents' rooms due to Federal Law Enforcement policy. LVN 1 stated the DPH surveyors were not also allowed to check the justice involved resident electronic chart including the justice involved resident's name. LVN 1 stated all justice involved residents were on physical restraints, eat inside their rooms, not allowed to have visitors, receive mails and telephone calls. LVN 1 stated charge nurses give Justice Involved Residents medication but anything else, Justice Involved Residents need to talk and/or ask US Marshals
On 10/18/2022 at 12:16 PM, the DON stated the DPH state surveyors were not allowed to access all justice involved residents' paper resident's records and physical charts without the Federal Law Enforcement Agency Supervisor's approval.
During an interview on 10/18/22 at 2:42 PM, the Business Office Manager (BOM) stated all justice involved residents were not allowed to receive mails. BOM stated if she would receive the resident's mails, the BOM would notify the DON and ADM first, then give the mails to the PSOs. The BOM stated she does not go inside the justice involved residents' rooms, and when these residents need anything, they must talk to the PSOs.
During an interview on 10/18/22 at 2:47 PM, the DON stated the DPH surveyors and ombudsman, including the justice involved resident's attorneys were not allowed to go inside the justice involved residents' room without Federal Law Enforcement Supervisor's permission.
During the same interview, the DON stated the justice involved residents were not allowed to receive mails from the facility staff. The DON stated if the facility receives mails, the DON will give it to the Federal law Enforcement Supervisor who comes once a week (Thursdays). The DON stated if the facility receives the mail other than Thursday, the justice involved residents would need to wait until the next Thursday. The DON stated that PSOs were private security personnel, contracted by Federal Law Enforcement Agency. The DON stated the justice involved residents were not allowed to go to the facility's common areas and join other residents for safety reasons. The DON stated justice involved residents were only allowed to eat inside their rooms using only disposable spoons and containers.
1. A review of Resident 86's Face Sheet indicated an admission to the facility on 9/17/22 with diagnoses including suicidal ideations (thinking about or planning suicide), muscle weakness and traumatic subcutaneous (applied under the skin), emphysema (a condition in which air becomes trapped under the subcutaneous layer of the skin). The Face Sheet did not indicate a responsible party for Resident 86.
A review of Resident 86's H&P dated 9/20/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 86's MDS dated [DATE] indicated Resident 86 required limited assistance with transfers, toilet use and required total dependence (full staff performance every time during entire 7-day period) with dressing, required limited assistance with transfer and toilet use. The MDS indicated Resident 86 required supervision with bed mobility, eating and personal hygiene.
A review of Resident 86's Resident Transfer Record dated 10/19/22 indicated Resident 86 as the Responsible Party ([RP]decision maker).
During an observation outside Resident 86's room and interview with PSO 1 on 10/18/22 at 9:20 AM, PSO 1 stated the DPH surveyors were not allowed to go inside Resident 86's room without permission coming from Federal Law Enforcement Supervisor. PSO 1 stated justice involved residents were federal inmates and under the custody and property of the Federal Law Enforcement Agency. PSO 1 stated they were working as a private security contracted with Federal Law Enforcement Agency and need to stay with the justice involved residents at all times.
2. A review of Resident 87's Face Sheet indicated an admission to the facility on 9/27/22 with diagnoses including anemia (a condition in which the body does not have enough healthy red blood cells that provide oxygen to body tissues), emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness), secondary malignant neoplasm of bone (cancer [a disease in which abnormal cells divide uncontrollably and destroy body tissue] started in another part of the body but spread to the bone). The Face Sheet did not indicate a responsible party for Resident 87.
A review of Resident 87's undated H&P indicated the resident had the capacity to understand and make decisions.
A review of Resident 87's MDS dated [DATE] indicated Resident 87 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) with bed mobility, transfer, toilet use, personal hygiene and required supervision with dressing and eating.
A review of Resident 87's Resident Transfer Record dated 10/19/22 indicated Resident 87 as the RP.
On 10/18/22 at 9:26 AM, during an observation inside Resident 87's room and interview with PSO 2 in the presence of PSO 3 and Resident 87, PSO 2 stated that Resident 87's contact with the public was very limited. PSO 2 stated Resident 87 does everything inside Resident 87's room. PSO 2 stated Resident 87 was only allowed to go outside Resident 87's room during rehabilitation therapy. PSO 2 stated Resident 87 was handcuffed and shackled with steel iron chain connected to Resident 87's bed and the only time PSOs would disconnect the chain is when Resident 87 go to the bathroom, shower and during therapy.
During an interview on 10/18/22 at 9:29 AM, Resident 87 stated he was not allowed to receive any visitors and mails. Resident 87 stated that telephone calls were not allowed. Resident 87 stated he was not allowed to go outside except during therapy and shower.
3. A review of Resident 79's Face Sheet (admission record) the resident was admitted to the facility on [DATE] with diagnoses including insomnia (persistent problems falling and staying asleep) and personal history of COVID-19 ([Coronavirus] a disease that can triggers a respiratory [lung] tract infection affecting the upper respiratory tract [sinuses, nose, and throat] and/or lower respiratory tract [windpipe and lungs] the virus spreads mainly through person-to-person contact). The Face Sheet did not indicate a responsible party for Resident 79.
A review of Resident 79's History and Physical (H&P) dated 6/15/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 79's Minimum Data Set (MDS- a care area screening and assessment tool) dated 9/16/22 indicated Resident 79 required supervision (oversight, encouragement or cueing) during bed mobility, transfer, dressing, eating, toilet use and personal hygiene.
A review of Resident 79's care plan for psychosocial dated 6/14/22 indicated Resident 79 had alterations in psychosocial functions as manifested by changes in roles/status/relocation and feeling of isolation from family and community friends with an intervention to encourage loved ones to visit/telephone/write if possible and to encourage to participate, attend activities of choice There was no documented evidence from the resident's records that from 6/14/22 to 10/19/22 indicating interventions were implemented in accordance with Resident 79's care plan such as encouraging loved ones to visit/telephone/write and encouraging Resident 79 to participate, attend activities of choice.
A review of Resident 79's Resident Transfer Record dated 10/19/22 indicated Resident 79 as the RP.
4. A review of Resident 40's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including Type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), chronic kidney disease (gradual loss of kidney function) and epilepsy (a disorder of the brain; disorder in which the brain activity becomes abnormal, causing seizures [sudden, uncontrolled electrical disturbance in the brain] or periods of unusual behavior, sensations and sometimes loss of awareness). The Face Sheet did not indicate a responsible party for Resident 40.
A review of Resident 40's H&P dated 8/31/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 40's MDS dated [DATE] indicated Resident 40 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) with bed mobility, transfer, dressing, toilet use, personal hygiene and required supervision during eating.
A review of Resident 40's care plan for Activities of Daily Living (ADL) dated 8/1/22 indicated Resident 40 had self-care deficits related to unsteady gait and weakness with an intervention to maintain Resident 40's privacy and respect their rights.
A review of Resident 40's Resident Transfer Record dated 10/19/22 indicated Resident 40 as the RP.
5. A review of Resident 292's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements such as shaking, stiffness, and difficulty with balance and coordination), essential hypertension (high blood pressure that does not have a known secondary cause) and anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) disorder. The Face Sheet did not indicate a responsible party for Resident 292.
A review of Resident 292's H&P dated 10/13/22 indicated the resident had the capacity to understand and make decisions.
6. A review of Resident 14's Face Sheet indicated an admission to the facility on 7/15/22 with diagnoses including essential hypertension, spinal stenosis (occurs when one or more bony openings within the spine begin to narrow and reduce space for the nerves) and depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). The Face Sheet did not indicate a responsible party for Resident 14.
A review of Resident 14's H&P dated 8/31/22 indicated the resident has the capacity to understand and make decisions.
A review of Resident 14's MDS dated [DATE] indicated Resident 14 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transfer, dressing, toilet use, personal hygiene and required supervision during eating.
A review of Resident 14's care plan for depression dated 8/20/22 indicated Resident 14 had diagnosis of depression manifested by verbalization of depression with an intervention to encourage family to visit resident frequently.
A review of Resident 14's care plan for psychosocial dated 8/20/22 indicated Resident 14 had alterations in psychosocial functions as manifested by changes in roles/status/relocation and feeling of isolation from family and community friends. The care plan interventions indicated to provide emotional support/encourage expression of feelings, redirect behavior, utilize active listening techniques, encourage to verbalize feelings and concerns. From 8/20/22 to 10/19/22 there were no documented evidence indicating interventions were implemented in accordance with the resident's care plan that indicated Resident 14's family/friends were encouraged to visit, activities of choice were offered to avoid decline in psychosocial functions.
A review of Resident 14's Resident Transfer Record dated 10/19/22 indicated Resident 292 as the RP.
7. A review of Resident 42's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including anxiety disorder, chronic pain syndrome (pain that carries on for longer than 12 weeks despite medication or treatment) and malignant (destructive; cancerous) neoplasm (any growth that develops inside or on the body) of oropharynx (a disease in which malignant [cancer] cells form in the tissues of the oropharynx [middle part of the throat, behind the mouth]). The Face Sheet did not indicate a responsible party for Resident 42.
A review of Resident 42's H&P dated 5/10/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 42's MDS dated [DATE] indicated Resident 42 required supervision with bed mobility, transfer, dressing, eating, toilet use and personal hygiene.
A review of Resident 42's care plan for psychosocial dated 8/22/22 indicated Resident 42 had alterations in psychosocial functions as manifested by changes in roles/status/relocation and feeling of isolation from family and community friends. There was no care plan developed specific for the resident's diagnosis of anxiety.
A review of Resident 42's Resident Transfer Record dated 10/19/22 indicated Resident 42 as the RP.
8. A review of Resident 342's Face Sheet indicated an initial admission to the facility on [DATE] with diagnoses including post-traumatic (a mental health condition that's triggered by a terrifying event) stress disorder, borderline personality (a mental health disorder that impacts the way you think and feel about yourself and others) disorder, and bipolar (a mental condition marked by alternating periods of elation and depression) disorder. The Face Sheet did not indicate a responsible party for Resident 342.
A review of Resident 342's H&P dated 10/13/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 342's care plan for psychotropic medication dated 10/14/22 indicated Resident 342 required the use of psychoactive medication with an intervention to encourage family visits.
There was no documentation from 10/14/22 to 10/19/22 indicating interventions were implemented in accordance with Resident 342's care plan such as respecting 342's rights and encouraging family visits.
A review of Resident 342's Resident Transfer Record dated 10/19/22 indicated Resident 342 as the RP.
9. A review of Resident 76's Face Sheet indicated an initial admission to the facility on 6/29/22 with diagnoses including unspecified part of neck of femur (region just below the ball of the hip joint), phalanx (bone located between the first joint and center knuckle) of right mid finger, shaft of right tibia (middle of right big bone between knee and ankle), fracture (broken bone). The Face Sheet did not indicate a responsible party for Resident 76.
A review of Resident 76's H&P dated 10/13/22, indicated the resident had the capacity to understand and make decisions.
A review of Resident 76's MDS dated [DATE] indicated Resident 76 required supervision with bed mobility, transfer, dressing, toilet use, and personal hygiene.
A review of Resident 76's Resident Transfer Record dated 10/19/22 indicated Resident 76 as the RP.
During an interview on 10/18/22 at 9 AM, PSO 6 stated that DPH state surveyors cannot enter the justice involved resident's rooms and would not answer any more questions about the justice involved residents.
During an interview with PSO 1, on 10/18/22 at 9:20 AM, PSO 1 stated for all the other needs of the justice involved residents, the facility staff need to go through the Federal Law Enforcement Agency approval which included visitations, receiving mails, activities, and other special requests.
A review of facility's Resident Council Minutes from the month of June 2022 to October 2022 indicated there were no justice involved residents' attendees during the facility's Resident Council Meetings.
During an interview on 10/18/22 at 2:51 PM, Activities Director (AD) stated all justice involved residents were not allowed to go to the facility's Dining and Activity Room. The AD stated justice involved residents were not allowed to have visitors, receive mails and phone calls. The AD stated in the past (not able to remember when and who the resident was), one of the justice involved residents received a telephone call but the PSOs denied their right to take the phone call. The AD stated justice involved residents were not offered and allowed to join the facility's Resident Council Meeting. The AD stated she asked the Federal Law Enforcement agent what the justice involved residents can do aside from watching TV inside their rooms, and the response AD received was nothing (no other activities). The AD stated activity staff would need to obtain approval from the PSOs if the Justice Involved resident asks for basic items such as toothpaste.
During an observation on 10/18/22 between the hours of 8:23 AM to 5 PM, all justice involved residents were observed inside their rooms with their doors closed with two security personnel (Federal Law Enforcement agent or PSOs) watching and monitoring each resident. The nine justice involved residents were not observed coming outside their rooms or going inside the facility's Dining and Activity Rooms.
During an interview on 10/19/22 at 7:02 AM, Certified Nurse Assistant (CNA) 1 stated all justice involved residents were not allowed to have visitors except their attorneys. CNA 1 stated all justice involved residents eat inside their rooms and only allowed to use disposable utensils and dishware. CNA 1 stated all justice involved residents were not allowed to smoke. CNA 1 stated justice involved residents cannot have razors and clippers thus, staff need to ask permission from the PSOs before grooming the resident. CNA 1 further stated that facility staff cannot give personal items directly to the justice involved residents.
On 10/19/22 at 9:43 AM, during a concurrent interview of the ADM and review of the memorandum provided by the Federal Law Enforcement Agency to the facility titled, Policy and procedures for inmates in nursing home facilities dated 8/20/21 the ADM stated the memo from Deputy of the Federal Law Enforcement served as a resource for the facility staff. The ADM stated the facility has their own justice involved residents' policy, and whenever they develop policies, the facility needed resources. The ADM stated justice involved residents can exercise rights, but restricted and required an approval from the Deputy Representative of the Federal Law Enforcement Agency.
A review the facility's policy and procedure titled Residents Involved with the Criminal Justice System (no date), indicated the following:
- Clients (Inmates [residents of the facility]) who are residing in a nursing home facility are not allowed any outside food, clothing or any other item that is not medically necessary unless it is pre-approved by (Federal Law Enforcement Agency).
- Every client (inmate) that resides in a nursing home facility will be always accompanied by security staff (24 hours).
- Clients (inmates) are allowed phone calls only when pre-approved by (Federal Law Enforcement Agency). Calls will be initiated and monitored by security staff onsite.
- Clients (inmates) are not allowed to have family visitations or phone calls. If unannounced visitor arrives, notify (Federal Law Enforcement Agency) immediately.
- For a client (inmate) to participate in an extra activity, it must be pre-approved by the (Federal Law Enforcement Agency). Clients will not be able to participate in any activity which involved non-custodial (a person found guilty of a crime or offense and punishment does not involve going to prison) members of the Skilled Nursing Facility.
During an interview on 10/19/22 at 9:43 AM and concurrent interview of the facility's undated facility's policy and procedure titled Residents Involved with the Criminal Justice System, the ADM stated the undated policy was developed by the facility around September 2022 and used the Federal Law Enforcement Agency Memorandum provided by the Federal Law Enforcement Supervisor titled, Policy and procedures for inmates in nursing home facilities dated 8/20/21 as the facility's policy reference.
During an interview on 10/19/22 at 3:39 PM, the DON stated that DPH state surveyors were still not allowed to interview and review all the medical records of the nine justice involved residents per the Federal Law Enforcement Agency Supervisor's instruction.
During a conference meeting via TEAMS (allows users to communicate via text, chat, voice or video call from home or office) on 10/20/22 at 10:10 AM, attended by Los Angeles County Department of Public Health (LAC-DPH) Health Facilities Investigation Division (HFID) supervision team, the facility's ADM, DON, VPO, Quality Assurance Consultant (QA Consultant) and MKD. The VPO stated the DPH state surveyors were not allowed to access the justice involved resident's medical records since the residents were discharged from the facility on 10/19/22 and will not be coming back. The VPO stated the facility was trying to discuss with the Federal Law Enforcement Supervisor to allow the DPH state surveyors to continue to review and release the medical records of the nine justice involved residents with the Federal Law Enforcement Agency Supervisor.
A review of another policy and procedure for justice involved residents provided by the facility titled Residents Involved with the Criminal Justice System, revised in March 2019 indicated, Residents involved in the justice system are entitled to the same rights as all other residents in the facility. The facility does not impose any restrictions on justice-involved residents that violate their resident rights. The P&P also indicated the following:
a. All residents, including justice-involved residents, have the right to a dignified existence, self-determination, communication and access to persons and services inside and outside the facility.
b. Justice involved residents include residents under the care of (taken into custody by) law enforcement
c. Law enforcement jurisdiction is not integrated with facility operations. This facility maintains control over the conditions under which the resident receives care.
A review of the facility's policy and procedure titled Residents Rights revised in December 2016, indicated Federal and state laws guarantee certain basic rights to all residents of this facility. These rights included the resident's right to:
a. Be treated with respect and existence.
b. Be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms.
c. Communication with and access to people and services, both inside and outside the facility.
d. Exercise his or her rights as a resident of the f
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0604
(Tag F0604)
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 that nine out of nine (Residents 79, 40, 292, 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 that nine out of nine (Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86) justice involved residents (residents currently in custody and held involuntarily through operation of law enforcement authorities in an institution, which is the responsibility of a governmental unit or over which a governmental unit exercises administrative control) residing in the facility were free from physical restraints with a locking device (any device attached or adjacent to the body that cannot be easily removed and restricts freedom of movement) for the purpose of discipline and not required to treat the resident's medical condition. There was no physician's order, medical justification, and reevaluation for continued use of the physical restraints used on all nine residents.
These deficient practices resulted in Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86's rights being violated, held against each resident's will, and had the potential to result in serious physical injury, and psychosocial harm that may lead to hospitalization and/or death.
On 10/19/22 at 12:38 PM, during the facility's annual health recertification survey, the Department of Public Health (DPH) called an Immediate Jeopardy (IJ-a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident), in regard to nine (9) justice involved residents residing in the facility that were physically restrained with a locking device as directed by a Federal Law Enforcement Agency, in the presence of the Administrator (ADM) and Director of Nursing (DON).
On 10/20/22 at 6:10 PM, the Department of Public Health removed the IJ while onsite after the surveyor verified the facility implemented the facility's IJ Removal Plan (a detailed plan to address the IJ findings) given by the ADM which included:
1. On 10/19/22, the nine Justice involved Residents were interviewed by the Director of Nursing (DON), Activity Staff, and Social Services Director (SSD) regarding their care, how staff treats them, and if they have experienced any adverse psychosocial effect as a result. Per interview with the nine residents, none were identified to be affected.
2. On 10/19/22, treatment nurses conducted body/skin assessments on all nine residents and no skin breakdown/impairment had results from the use of locking device.
3. On 10/19/22, the Administrator (ADM) was provided in-service education and training from the [NAME] President of Operations (VPO) regarding facility's policy and procedure regarding, but not limited to, Restraints.
4.On 10/19/22, all nine justice involved residents were transferred to acute hospital because the facility cannot meet the residents' needs, particularly being free from physical restraints with a locking device.
5.On 10/20/22, the DON followed up with the nine justice involved residents' attending physician at the acute hospital and physician informed that all nine residents are stable and doing well. All nine residents are still in the acute hospital. The Responsible Party (RP) of all nine residents are still working on proper placement with facilities that they work with.
Cross referenced to F550.
Findings:
A review of a formal referral letter from the long-term care ombudsman dated 10/14/22, indicated the OMB (OMB; an individual who advocates for long-term care facility residents, defends their rights, and ensures they are protected from verbal abuse, neglect, and assault) was at the facility on 10/11/22. The letter indicated the OMB was not allowed to see or interview the nine justice involved residents in their rooms. The letter indicated that the DON stated the facility had been instructed to follow a different set of rules and were told that the justice involved residents did not have the same rights as all other residents in the facility. The letter indicated that on 10/12/22, the OMB spoke to the Federal Law Enforcement Supervisor and explained to the OMB that the justice involved residents were supervised by the Federal Law Enforcement while in the facility. The letter indicated that the Federal Law Enforcement Supervisor informed the OMB that the justice involved residents residing in the facility have all the rights to keep them alive. The letter indicated the justice involved residents were not allowed to have phone calls, outside snacks, were not allowed to walk around the facility and have visitors without the Federal Law Enforcement Supervisor permission. The letter indicated that on 10/12/22, the facility's administrator shared with the OMB that the facility was following a separate protocol (policy) for the justice involved residents according to the facility's corporate guidance and the Federal Law Enforcement Agency.
A review of a Memorandum (a short note designating something to be remembered, especially something to be done or acted upon in the future) addressed to the facility and the facility's Marketing Director (MKD), titled Policy and Procedures for Inmates in Nursing Home Facilities, dated 8/20/2021, signed by the Federal Law Enforcement Deputy and written in the Federal Law Enforcement letterhead indicated, Every client (inmate) that resides in a nursing home facility will be always accompanied by security staff (24 hours).
During the facility's initial tour and observation at the facility's hallway on 10/18/22 at 8:05 AM, and a concurrent interview with Private Security Officer (PSO) 4, stated that all justice involved residents were always chained to the bed, with either handcuffs or shackle (something that confines the legs or arms; one of a pair of metal rings connected by a chain and fastened to a person's wrists or the bottoms of the legs to prevent the person from escaping), except when these residents are going for physical therapy (PT-evaluate and treat abnormal physical function related to an injury, disability, or other health condition to improve residents' range of movement, quality of life and prevent further injury or disability) or to the bathroom.
During an interview on 10/18/22 at 8:10 AM, PSO 5 stated all justice involved residents were physically restrained to their beds.
On 10/18/22 at 8:32 AM, during the initial tour of the facility, concurrent interview and review of the facility's residents census dated 10/17/22 with the DON, the DON stated the facility had 92 residents residing in the facility. The DON stated Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86 were under a fictitious (not real or true) name to protect the resident's identity and for confidentiality. The DON stated Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86 admitted in the facility were all justice involved residents.
On 10/18/2022 at 9:26 AM, PSO 2 stated that two PSOs were assigned to supervise each of the nine justice involved residents in the facility. PSO 2 stated there were three working shifts per day, 8 hours per shift. PSO 2 stated justice involved residents needs 24-hour supervision, to keep an eye on justice involved residents' daily activities. PSO 2 stated all nine justice involved residents were restrained to the bed.
On 10/18/2022 at 12:16 PM, the DON stated the DPH state surveyors were not allowed to access all justice involved residents' paper resident's records and physical charts without the Federal Law Enforcement Agency Supervisor's approval.
1. During an observation on 10/18/22 at 8:35 AM, Resident 86's room door was open, and Resident 86 was visible from outside the residents' room. Resident 86 was observed with a right-handcuff restraint attached to the bed.
During an interview on 10/18/22 at 9:20 AM, while outside Resident 86's room, PSO 1 stated all justice involved residents walk around in the facility accompanied by two PSOs when they go to physical therapy. PSO 1 stated all justice involved residents were restrained to their bed with hand cuffs two metal rings, joined by a short chain, that are locked around wrist(s) to prevent free movement. PSO 1 stated every justice involved residents were different when it comes to the number of hand cuffs is applied. PSO 1 stated he was not allowed to tell the DPH state surveyors on how many handcuffs Resident 86 had.
A review of Resident 86's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] with diagnoses including suicidal ideations (thinking about or planning suicide), muscle weakness and traumatic subcutaneous (applied under the skin), emphysema (a condition in which air becomes trapped under the subcutaneous layer of the skin).
A review of Resident 86's History and Physical (H&P) dated 9/20/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 86's Minimum Data Set (MDS- a care area screening and assessment tool) dated 9/21/22 indicated Resident 86 required limited assistance with transfers, toilet use and required total dependence (full staff performance every time during entire 7-day period) with dressing, required limited assistance with transfer and toilet use. The MDS indicated Resident 86 required supervision with bed mobility, eating and personal hygiene.
A review of Resident 86's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints while in the facility.
A review of Resident 86's care plan for restraints dated 10/14/22 indicated Resident 86 was at risk for injury and needs physical restraint due to the [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy and 3. Hand cuffs per [Federal Law Enforcement Agency] policy.
On 10/18/22 at 12:33 PM, during a concurrent interview and record review of Resident 86's medical records (nurses notes, care plans, progress notes, medication administration records), the DON stated there were no documented evidence of ongoing monitoring and reevaluation for the continued use of restraints for Resident 86.
2. A review of Resident 79's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including insomnia (persistent problems falling and staying asleep) and personal history of COVID-19 ([Coronavirus] a disease that can triggers a respiratory [lung] tract infection affecting the upper respiratory tract [sinuses, nose, and throat] and/or lower respiratory tract [windpipe and lungs] the virus spreads mainly through person-to-person contact).
A review of Resident 79's History and Physical (H&P) dated 6/15/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 79's MDS dated [DATE] indicated Resident 79 required supervision (oversight, encouragement, or cueing) during bed mobility, transfer, dressing, eating, toilet use and personal hygiene.
A review of Resident 79's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints while in the facility.
A review of Resident 79's care plan for restraints dated 10/14/22 indicated Resident 79 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy and 3. Hand cuffs per [Federal Law Enforcement Agency] policy.
On 10/18/22 at 12:33 PM, during a concurrent interview and record review of Resident 79's medical records (nurses notes, care plans, progress notes, medication administration records), the DON stated there were no documented evidence of ongoing monitoring and reevaluation for the continued use of restraints for Resident 79.
3. A review of Resident 87's Face Sheet indicated an admission to the facility on 9/27/22 with diagnoses including anemia (a condition in which the body does not have enough healthy red blood cells that provide oxygen to body tissues), emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness), secondary malignant neoplasm of bone (cancer [a disease in which abnormal cells divide uncontrollably and destroy body tissue] started in another part of the body but spread to the bone)
A review of Resident 87's undated H&P indicated the resident had the capacity to understand and make decisions.
A review of Resident 87's MDS dated [DATE] indicated Resident 42 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) with bed mobility, transfer, toilet use, personal hygiene and required supervision with dressing and eating.
A review of Resident 87's MDS dated [DATE] indicated Resident 42 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) with bed mobility, transfer, toilet use, personal hygiene and required supervision with dressing and eating.
A review of Resident 87's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints while in the facility.
A review of Resident 87's care plan for restraints dated 10/14/22 indicated Resident 87 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy and 3. Hand cuffs per [Federal Law Enforcement Agency] policy.
On 10/18/22 at 9:26 AM, during a concurrent observation and interview with PSO 2, in the presence of PSO 3, Resident 87 was lying on his bed with a metal locking leg cuffs applied to both legs and secured to the foot part of the bed. PSO 2 stated Resident 87 was restrained on both legs with steel iron chain that is secured to the bed. PSO 2 stated justice involved residents wears handcuffs but since Resident 87 was very fragile, they do not apply it to Resident 87 all the time. PSO 2 stated they would remove both physical restraints to both legs during Resident 87's shower, toileting, and physical therapy.
On 10/18/22 at 12:33 PM, during a concurrent interview and record review of Resident 87's medical records (nurses notes, care plans, progress notes, medication administration records), the DON stated there were no documented evidence of ongoing monitoring and reevaluation for the continued use of restraints for Resident 87.
4. A review of Resident 40's Face Sheet indicated an admission to the facility on 7/29/22 with diagnoses including Type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), chronic kidney disease (gradual loss of kidney function) and epilepsy (a disorder of the brain; disorder in which the brain activity becomes abnormal, causing seizures [sudden, uncontrolled electrical disturbance in the brain] or periods of unusual behavior, sensations and sometimes loss of awareness).
A review of Resident 40's H&P dated 8/31/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 40's MDS dated [DATE] indicated Resident 40 required limited assistance with bed mobility, transfer, dressing, toilet use, personal hygiene and required supervision during eating.
A review of Resident 40's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints while in the facility.
A review of Resident 40's care plan for physical device dated 8/1/22 indicated Resident 40 has handcuffs when in bed and out of bed with an intervention to review need for device. restraint possible discontinuation, reduction, less restrictive measures, or continuation of use regularly.
A review of Resident 40's care plan for restraints dated 10/14/22 indicated Resident 40 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] and 3. Hand cuffs per [Federal Law Enforcement Agency] policy.
On 10/18/22 at 12:33 PM, during a concurrent interview and record review of Resident 40's medical records (nurses notes, care plans, progress notes, medication administration records), the DON stated there were no documented evidence of ongoing monitoring and reevaluation for the continued use of restraints for Resident 40.
5. A review of Resident 292's Face Sheet indicated an admission to the facility on [DATE] with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements such as shaking, stiffness, and difficulty with balance and coordination), essential hypertension (high blood pressure that does not have a known secondary cause) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).
A review of Resident 292's H&P dated 10/13/22 indicated the resident had the capacity to understand and make decisions
A review of Resident 292's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints while in the facility.
A review of Resident 292's care plan for restraints dated 10/14/22 indicated Resident 292 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy and 3. Hand cuffs per [Federal Law Enforcement Agency] policy.
On 10/18/22 at 12:33 PM, during a concurrent interview and record review of Resident 292's medical records (nurses notes, care plans, progress notes, medication administration records), the DON stated there were no documented evidence of ongoing monitoring and reevaluation for the continued use of restraints for Resident 292.
6. A review of Resident 14's Face Sheet indicated an admission to the facility on 7/15/22 with diagnoses including essential hypertension, spinal stenosis (occurs when one or more bony openings within the spine begin to narrow and reduce space for the nerves) and depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.)
A review of Resident 14's H&P dated 8/31/22 indicated the resident has the capacity to understand and make decisions.
A review of Resident 14's MDS dated [DATE] indicated Resident 40 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transfer, dressing, toilet use, personal hygiene and required supervision during eating.
A review of Resident 14's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints while in the facility.
A review of Resident 14's care plan for restraints dated 10/14/22 indicated Resident 14 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy and 3. Hand cuffs per [Federal Law Enforcement Agency] policy.
On 10/18/22 at 12:33 PM, during a concurrent interview and record review of Resident 14's medical records (nurses notes, care plans, progress notes, medication administration records), the DON stated there were no documented evidence of ongoing monitoring and reevaluation for the continued use of restraints for Resident 14.
7. A review of Resident 42's Face Sheet indicated an initial admission to the facility on 6/2/22 with diagnoses including anxiety disorder, chronic pain syndrome (pain that carries on for longer than 12 weeks despite medication or treatment) and malignant (destructive; cancerous) neoplasm (any growth that develops inside or on the body) of oropharynx (a disease in which malignant [cancer] cells form in the tissues of the oropharynx [middle part of the throat, behind the mouth]).
A review of Resident 42's H&P dated 5/10/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 42's MDS dated [DATE] indicated Resident 42 required supervision with bed mobility, transfer, dressing, eating, toilet use and personal hygiene.
A review of Resident 42's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints while in the facility.
A review of Resident 42's care plan for restraints dated 10/14/22 indicated Resident 42 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy and 3. Hand cuffs per [Federal Law Enforcement Agency] policy.
During an interview on 10/18/22 at 8 AM in the presence of three (3) PSOs, Resident 42 stated that his attending physician (AP) 1 ordered for Resident 42 to be chained to the bed. Resident 42 stated the reason why he was not chained to the bed that time was because he was going to an outside appointment. Resident 42 stated he was always chained on bed and the PSOs will remove it during physical therapy and bathroom breaks.
On 10/18/22 at 12:33 PM, during a concurrent interview and record review of Resident 42's medical records (nurses notes, care plans, progress notes, medication administration records), the DON stated there were no documented evidence of ongoing monitoring and reevaluation for the continued use of restraints for Resident 42.
8. A review of Resident 342's Face Sheet indicated an initial admission to the facility on [DATE] with diagnoses including post-traumatic (a mental health condition that's triggered by a terrifying event) stress disorder, borderline personality (a mental health disorder that impacts the way you think and feel about yourself and others) disorder, and bipolar (a mental condition marked by alternating periods of elation and depression) disorder.
A review of Resident 342's H&P dated 10/13/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 342's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints while in the facility.
A review of Resident 342's care plan for restraints dated 10/14/22 indicated Resident 342 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy and 3. Hand cuffs per [Federal Law Enforcement Agency] policy.
A review of Resident 342's care plan for psychotropic medication dated 10/14/22 indicated Resident 342 requires the use of psychoactive medication with an intervention to encourage family visits.
On 10/18/22 at 12:33 PM, during a concurrent interview and record review of Resident 342's medical records (nurses notes, care plans, progress notes, medication administration records), the DON stated there were no documented evidence of ongoing monitoring and reevaluation for the continued use of restraints for Resident 342.
9. A review of Resident 76's Face Sheet indicated an initial admission to the facility on 6/29/22 with diagnoses including unspecified part of neck of femur (region just below the ball of the hip joint), phalanx (bone located between the first joint and center knuckle) of right mid finger, shaft of right tibia (middle of right big bone between knee and ankle), fracture (broken bone).
A review of Resident 76's H&P dated 10/13/22, indicated the resident had the capacity to understand and make decisions.
A review of Resident 76's MDS dated [DATE] indicated Resident 76 required supervision with bed mobility, transfer, dressing, toilet use, and personal hygiene.
A review of Resident 76's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints while in the facility.
A review of Resident 76's care plan for restraints dated 10/14/22 indicated Resident 76 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy and 3. Hand cuffs per [Federal Law Enforcement Agency] policy.
On 10/18/22 at 12:33 PM, during a concurrent interview and record review of Resident 76's medical records (nurses notes, care plans, progress notes, medication administration records), the DON stated there were no documented evidence of ongoing monitoring and reevaluation for the continued use of restraints for Resident 76.
During an interview on 10/18/22 at 9:35 AM, Licensed Vocational Nurse (LVN) 1 stated the DPH surveyors were not allowed to go inside all justice involved residents' rooms due to Federal Law Enforcement policy. LVN 1 stated all justice involved residents were on physical restraints, eat inside their rooms, not allowed to have visitors .
During an interview on 10/18/22 at 9:35 AM, LVN 2 stated justice involved residents were all restrained with physical restraints. LVN 2 stated all justice involved residents need to be always restrained for the safety of other residents and facility staff. LVN 2 stated there were no clinical indication for the use of the physical restraints on the nine justice involved residents.
On 10/18/22 at 12:16 PM, during a concurrent interview with the DON and record review of all justice involved residents' electronic medical records, the DON stated handcuffs, leg cuffs, and shackles were considered as physical restraints. The DON stated that application of physical restraints to all residents needs a physician's order. The DON stated she could not find physician orders for physical restraints use for all the nine justice involved residents' electronic medical records.
During the same interview on 10/18/22 at 12:16 PM, the DON stated that physical restraints were applied to all justice involved residents, some in the arms, some in the legs. The DON stated the PSOs would rotate the sites of the physical restraints. The DON stated the physical restraints were chains, approximately two feet long attached to the resident's bed. The DON stated the restraints would be removed when justice involved residents would go to the bathroom. The DON stated that PSOs who were under contract with the Federal Law Enforcement Agency were the only persons that had access to remove the resident's physical restraints. The DON stated no one from the facility staff had access/and or keys to all the justice involved residents locked physical restraints. The DON stated all justice involved residents need physical restraints because They are inmates, they might run and do something, they are criminals. The DON stated upon review of the resident's records, there were no clinical indication for the use of physical restraints to all the justice involved residents.
During a concurrent interview with the DON and record review of all nine-justice involved resident's physician orders, care plans, and MDS on 10/18/22 at 12:33 PM, the DON stated that physician orders, care plans and the MDS coding for physical restraints were only initiated and documented on 10/14/22 in the resident's paper medical records, which were a few days before the DPH state surveyors arrived in the facility on 10/18/22.
During the same interview on 10/18/22 at 12:33 PM, the DON stated the facility did not consider the handcuffs, leg cuffs, and shackles as physical restraints upon admission of the justice involved residents in the facility. The DON stated the facility recently discussed that the facility would consider the handcuffs, leg cuffs, and shackles as physical restraints moving forward. The DON stated the physician's orders for physical restraints should be indicated and reflect in the electronic medical records of all the justice involved residents.
During an interview on 10/19/22 at 7:02 AM, Certified Nurse Assistant (CNA) 1 stated facility staff do not have access or keys to all justice involved resident's locked physical restraints. CNA 1 stated the handcuffs' chain were long and all the justice involved residents can move around their beds, CNA 1 stated the PSOs removes the physical restraints during showers.
During an interview on 10/19/22 at 7:11 AM, CNA 2 stated all justice involved residents have metal handcuffs and leg cuffs applied to them and attached to their beds. CNA 2 stated those physical devices were not considered as physical restraints since the residents could still move. CNA 2 stated the facility staff does not have keys to the locked physical restraints. CNA 2 stated justice involved residents wears the hand cuffs even when they are eating.
During an interview on 10/19/22 at 7:22 AM, Treatment Nurse (TXN) 1 stated facility staff do not have keys to all justice involved residents including treatment and/or wound nurses. TXN 1 stated Resident 86 was handcuffed and shackled. TXN 1 stated Resident 87 was handcuffed. TXN 1 stated she does not see all justice involved residents regularly if there are no wound/skin issues. TXN 1 stated We do not do such thing and most justice involved residents were alert and able to verbally report to the staff if they have skin problems and issues caused by physical restraints. TXN 1 stated there were no order for regular skin monitoring or evaluation of skin breakdown for use of physical restraints. TXN 1 stated she could not find documented evidence of skin monitoring for physical restraints use in the Treatment Administration Records (TAR) for the nine justice involved residents.
A review of an undated policy and procedure titled Residents Involved with the Criminal Justice System that was provided by the ADM, indicated All residents, including justice-involved residents, have the right to dignified existence, self-determination, and will be provided provisions that are clinically necessary. The policy indicated that Law enforcement jurisdiction and facility operations maintain control over the conditions under which the resident receives care. The policy indicated that If a justice-involved individual is admitted , the following measures are taken:
a.Reviewing the medical records and other pertinent documentation from correctional providers.
b.Conducting a comprehensive assessment and resident centered care plan by the interdisciplinary team.
c.Ensuring that the safety, rights, and quality of care are maintained for all residents and staff.
The policy did not indicate the use of physical restraints such as handcuffs and shackles.
On 10/19/22 at 9:43 AM, during a concurrent interview and record review of the facility's undated policy and procedure titled Residents Involved with the Criminal Justice System the ADM stated physical restraints were not mentioned in the facility's policy and procedure.
A review of facility's policy and procedure titled Use of Restraints revised in April 2017, indicated Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints should only be used to treat the resident's medic[TRUNCATED]
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide access to personal funds over the weekend for one out of 45...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide access to personal funds over the weekend for one out of 45 sampled residents (Resident 6) in accordance with facility's policy and procedure.
This deficient practice has the potential to negatively impact the psychosocial well being of the residents.
Findings:
During an interview on 10/21/22 at 11:52 AM, the Business Office Manager (BOM) stated the residents can access their money only on weekdays.
During an interview on 10/21/22 at 12:15 PM, the Director of Nursing (DON) stated she informed the licensed nurses to anticipate how much money the residents financial need for the weekend and provide them to the BOM by Friday. The DON also stated the BOM was supposed to give the money to each resident from their personal funds according to the list provided by licensed nurses with anticipated need for that coming weekend.
During an interview on 10/21/22 at 12:20 PM, the DON stated the facility did not have a policy that indicated residents must have access to their personal funds including the weekend. The DON stated, it was important for the residents to have access with their personal funds including weekends because it was theirs and to meet their needs if they needed to purchase something over the weekend. The DON further stated it should be added into their policy.
During an interview on 10/21/22 at 1:16 PM, the administrator (ADM) stated personal funds were not available on the weekend because business office was closed.
During an interview on 10/21/22 at 1:28 PM, the Director of Staff Development (DSD) stated there was no way the residents can access money over the weekend. DSD also stated, the residents will have to wait until Monday or the next business day.
During an interview on 10/21/22 at 1:32 PM, LVN 8 stated the residents goes to the SSD office before Friday to get money if they needed them over the weekend.
A review of Resident 6's admission Record indicated Resident 6 was admitted on [DATE] for hypertensive heart disease with heart failure (a long-term condition that develops over many years in people who have high blood pressure resulting in their hearts inability to pump enough blood for the body's needs).
A review of Resident 6's History and Physical (a shorthand for the formal document that physicians produce through interview with the resident, physical examination and the summary of testing either obtained or pending) dated 04/14/22, indicated the resident has fluctuating capacity to understand and make decisions.
A review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/20/22, indicated Resident has severe impairment in cognitive skills (ability to make daily decisions) and required limited assistance with activities of daily living.
During an observation and interview on 10/21/22 at 1:52 PM, Resident 6 shook his head and stated he was not able to get money from his account (personal funds kept by the facility) during the weekends when he needed to purchase something. Resident 6 stated he felt horrible then stepped away refusing to talk about it further.
A review of the following facility's policy and procedure did not indicate residents have ready access to their personal funds managed by the facility including the weekend titled:
1)
Accounting and Records of Residents Funds revised in April 2017
2)
Resident Trust Account Policy dated 11/01/17
3)
Residents Rights revised in December 2016
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to support the rights of one of one sampled resident (Resident 42) to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to support the rights of one of one sampled resident (Resident 42) to file a complaint against his doctor.
This deficient practice had the potential for the resident to not feel heard and for his needs not to be met.
Cross reference with F745.
Findings:
A review of Resident 42's Face Sheet (a record of admission), indicated the resident was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses that included malignant (cancerous, in which abnormal cells divide uncontrollably and destroy body tissue) neoplasm (a new and abnormal growth of tissue in some part of the body) of oropharynx (the middle part of the throat), hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood), and anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities).
A review of Resident 42's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 8/12/22, indicated the resident had no impairment in cognitive skills (ability to understand and make decision) and required supervision from staff for transferring, dressing, eating, and toileting.
During an interview, on 10/19/22 at 8:00 AM, Resident 42 stated he had been trying to file a complaint against his Attending Physician (AP) 1 because he had only seen AP 1 once since being admitted to the facility. Resident 42 stated, staff (unknown) told him they did not know how he can file a complaint against AP 1.
During an interview, on 10/20/22 at 11:55 PM, Marketing Director (MKD) stated, she was never made aware that Resident 42 had complaints about AP 1. MKD stated, she would have filed a grievance (a complaint, either written or oral, expressing dissatisfaction with the services provided) for Resident 42 if she had been aware of his complaints against AP 1.
During an interview, on 10/20/22 at 12:05 PM, Social Services Designee (SSD) stated, Resident 42 complained to her many times that he wanted to see AP 1. SSD stated, she did not file a grievance because Resident 42 was under the responsibility of the US Marshals (law enforcement agency). SSD stated, she informed Resident 42 that she would notify MKD of his concerns and that MKD was responsible to coordinate with AP 1 and the US Marshals.
A review of the facilities Grievance Binder dated from January 2022 to 10/20/22, it did not indicate grievance filed for Resident 42.
A review of the facility's policy revised December 2016, titled, Resident Rights, indicated the residents had the right to voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal; have the facility respond to his or her grievances.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for 1 of 6 sampled r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for 1 of 6 sampled residents (Residents 5) who has a diagnosis of dysphagia (difficulty swallowing), who prefers to eat lying down flat in bed.
These deficient practices had the potential for Resident 5 to not receive appropriate care and monitoring for his safety while still able to honor his preference.
Findings:
A review of Resident 5's admission Record indicated Resident 5 was admitted on [DATE] dysphagia, oropharyngeal phase (difficulty transferring food from the mouth into the pharynx and esophagus to initiate an involuntary swallowing process), and gastro-esophageal reflux disease (when stomach contents come back up into the esophagus) without esophagitis (inflammation that damages the tube running from the throat to the stomach).
A review of Resident 5's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/20/22, indicated Resident has moderate impairment in cognitive skills (ability to make daily decisions).
During an observation on 10/18/22 at 8:50 AM, Resident 5 was seen eating breakfast while lying flat in bed without a staff supervising.
During an interview on 10/21/22 at 8:22 AM, LVN 7 stated Resident 5 is always eating flat in bed and is more comfortable in that position.
During a concurrent interview and record review on 10/21/22 at 10:45 AM with the DON, stated the resident did not have a care plan prior to 10/18/22 on his preference eating lying down.
A review of the facility's Policy and Procedure titled Care Plans - Comprehensive, revised in September 2010, indicated that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the residents medical, nursing, mental and psychological needs is developed for each resident. The policy indicated that comprehensive care plans is designed to incorporate identified problem areas and risk factors associated with the identified problem.
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, interviews and record reviews, the facility failed to ensure one of 6 sampled residents (Resident 5) who i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure one of 6 sampled residents (Resident 5) who is assessed with difficulty swallowing is provided necessary care and services with eating while lying flat in bed.
This deficient practice has a potential to result in Resident 5 aspirating (accidental breathing in of food or fluid into the lungs).
Findings:
A review of Resident 5's admission Record indicated Resident 5 was admitted on [DATE] dysphagia, oropharyngeal phase (difficulty transferring food from the mouth into the pharynx and esophagus to initiate an involuntary swallowing process), gastro-esophageal reflux disease (when stomach contents come back up into the esophagus) without esophagitis (inflammation that damages the tube running from the throat to the stomach) and idiopathic peripheral neuropathy (damage of the peripheral nerves where cause cannot be determined).
A review of Resident 5's History and Physical (a shorthand for the formal document that physicians produce through interview with the resident, physical examination and the summary of testing either obtained or pending) dated 7/28/22, indicated that the resident has the capacity to understand and make decisions.
A review of Resident 5's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/20/22, indicated the resident has moderate impairment in cognitive skills (ability to make daily decisions) and required supervision with eating.
During an observation and interview on 10/18/22 at 8:50 AM, Resident 5 was observed eating breakfast while lying flat in bed without a staff supervising. Resident 5 was also observed as having a Fentanyl patch on his right chest.
During an interview on 10/19/22 at 9:18 AM, the CNA 5 stated Resident 5 prefers to eat lying down and they are monitoring him every 10 - 15 minutes when he is eating.
During a concurrent observation and interview on 10/20/22 at 1:04 PM, Resident 5 was seen eating again lying flat. CNA 6 states she tries to stay with the resident as much as she can but has other residents to watch for. CNA 6 stated she goes to see residents in room [ROOM NUMBER] and 22 and comes back to check on Resident 5. CNA 6 stated the resident could possibly choke if not supervised while eating lying flat.
During an interview on 10/21/22 at 8:22 AM, LVN 7 stated a staff is supposed to sit down and supervise Resident 5 while eating to make sure the resident does not choke.
During a concurrent observation and interview on 10/21/22 at 8:33 AM, CNA 1 was observed standing by the doorway with the curtain divider inside the room halfway drawn preventing from visibly seeing Resident 5. CNA 1 stated she was assigned to watch the Resident 5 while eating.
During the same observation on 10/21/22 at 8:33 AM, Resident 5 was seen inside the resident's room eating while lying flat in bed with plate of food on top of the resident.
During a concurrent interview and record review on 10/21/22 at 10:45 AM, the DON stated Resident 5 did not have a care plan prior to 10/18/22 on his preference eating lying down.
A review of Resident 5's activities of daily living care plan dated 7/20/22, indicated the resident needed eating supervision.
A review of the facility's policy titled, Assisting the Resident with In-Room Meals, revised in December 2013 indicated, to review residents care plan and provide for any special needs of the resident. The policy also indicated that the resident should be positioned so his head and upper body are as upright as possible and with the head tipped slightly forward. If the resident is served his meal in bed, use wedges and pillows to achieve a nearly upright position.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 16) wa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 16) was provided with appropriate services and equipment to maintain resident's mobility and prevent decrease in range of motion (ROM, refers to how far you can move or stretch a part of your body, such as a joint or a muscle) in accordance with facility's policy and procedure by:
1. Failure to ensure Resident 16 has regular joint mobility assessment to monitor and check resident's ROM was declining
2. Failure to revise Resident 16's care plan to initiate a treatment plan/ exercise and/or devices for resident's both hands to prevent further contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).
This deficient practice had the potential for the resident to have worsening contractures and/or a decrease in the ability to care for himself.
Finding:
A review of Resident 16's Face Sheet (a record of admission), indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), and chronic kidney disease (a condition characterized by a gradual loss of kidney function over time).
A review of Resident 16's Joint Mobility Assessment, dated 4/28/22, indicated the resident's fingers on both hands had moderate to severe limitation in ROM. The joint mobility assessment did not indicate any
A review of Resident 16's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 8/2/22, indicated the resident was moderately impaired in cognitive skills and required extensive assistance (resident involved in activity, staff provided weight bearing assistance) from staff for transferring, dressing, toileting, and personal hygiene. The MDS indicated that Resident 16 had functional limitations (does not have the ability to perform routine activities of daily living) in ROM to both upper extremities (shoulder, elbow, wrist, hand).
A review of Resident 16's Occupational Therapy Treatment Careplan, dated 10/9/22, did not indicate interventions to prevent contracture or further contracture formation/deformity.
During an observation of Resident 16 and interview, on 10/18/22, at 12:48 PM, Resident 16's fingers on both hands were in a curled position. Resident 16 stated, both hands were stiff, and it was difficult for him to move them to an open position. Resident 16 stated, he stretches his fingers because no one at the facility stretches his fingers for him. Resident 16 stated, the facility staff could have done a better job if they were stretching his fingers.
During an interview, on 10/20/22, at 01:38 PM, Physical Therapy Director (PTD) stated, Resident 16 had limited ROM to his hands. PTD stated, Resident 16 had contractures to both of his hands. PTD stated, the facility did not treat Resident 16's hands with stretching or splints (used to immobilize a body part).
During an interview and observation of Resident 16, on 10/21/22, at 10:56 AM, Resident 16 demonstrated that his fingers were in a claw like position, unable to open both hands in a flat position and resident was unable to stretch his fingers. Resident 16 stated, the facility did not stretch or massage his fingers. Resident 16 stated he feels helpless because he cannot open containers due to his fingers being in that condition. Resident 16 stated, the physical therapists needed to exercise and stretch his fingers but facility never did.
During an interview and observation in Resident 16's room, on 10/21/22, at 11:15 AM, PTD tried to stretch and open Resident 16's fingers on both hands. PTD stated she was not able to stretch the resident's fingers to open the hands. PTD stated according to her assessment Resident 16's ROM on both hands and fingers have moderate to severe (fingers able to stretch open 25 - 50%) limitations. PTD stated the resident should have treatment consisting of stretching to loosen the fingers to prevent contractures from getting worst. PTD further stated, Resident 16 should have a resting hand splint (a device used to properly position the hand) for both hands.
During an interview and observation of Resident 16, on 10/21/22, at 11:20 AM, Resident 16's fingers on both hands were in a claw like position. The Director of Nursing (DON) stated, Resident 16's hands were contracted when he was admitted to the facility. The DON stated Resident 16 needed stretching treatment for his hand and it was not provided by the facility since resident was admitted in the facility.
A review of the facility's policy and procedure titled, Resident Mobility and Range of Motion, revised July 2017, indicated residents with ROM will receive treatment and services to increase and/or prevent a further decrease in ROM. The policy indicated residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure provisions with social service-related assistance was provid...
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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 provisions with social service-related assistance was provided for two of two sampled residents (Residents 5 and 42) in accordance with the facility's policies and procedures by:
1. 1. Failing to ensure Resident 5 was provided an accounting of his financial records and purchases used out of his personal funds by the Social Services Director (SSD).
2. Failing to ensure Resident 42, who had expressed to Social Services Director (SSD) that he needed assistance with contacting attending physician (AP) 1 and requested assistance in filing a complaint against DR 1, was provided with services to meet his needs.
These deficient practices had the potential for the residents to not receive care and/or treatment services which could lead to unnecessary stress, and serious illness.
Findings:
1. A review of Resident 5's admission Record indicated Resident 5 was admitted on [DATE] for dysphagia, oropharyngeal phase (difficulty transferring food from the mouth into the oropharyngeal phase (difficulty transferring food from the mouth into the hollow tube inside the neck that starts behind the nose and ends at the top of the windpipe and the tube that goes to the stomach to initiate an involuntary swallowing process), gastro-esophageal reflux disease (when stomach contents come back up into the esophagus) without esophagitis (inflammation that damages the tube running from the throat to the stomach) and idiopathic peripheral neuropathy (damage of the peripheral nerves where cause cannot be determined).
A review of Resident 5's History and Physical (a shorthand for the formal document that physicians produce through interview with the resident, physical examination and the summary of testing either obtained or pending) dated 7/28/22, indicated the resident has the capacity to understand and make decisions.
A review of Resident 5's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/20/22, indicated resident has moderate impairment in cognitive skills (ability to make daily decisions) and required supervision with eating.
During an interview and concurrent record review of Resident 5's Statement Landscape dated on 10/18/22 at 12:48 PM, Resident 5 stated someone used his account or personal funds kept by the facility and withdrew money out from it. Resident 5 stated, about 2 years ago he bought two (2) Burton Jackets and one (1) flannel shirt at Vendor 1 worth approximately $400.00 and the remaining balance of the $5,000.00 was given to the front desk for safe keeping. Resident 5's statement of account from Resident Fund Management Service indicated, Resident 5 has a current balance of $2,367.03 as of 10/03/22. Resident 5 stated he felt robbed after finding out somebody used his account to purchase television and other items besides the jackets and flannel shirts. Resident 5 stated, he was left hanging by the facility when he asked what happened to his money because he did not ask the facility to purchase the television and other items besides the jacket and flannel shirt.
A review of Resident 5's records titled, Inventory List, dated 8/17/20, the records did not show any personal belongings acquired nor purchased from resident's personal funds after admission.
During an interview on 10/20/21 at 1:58 PM, SSD stated she did not document the items purchased for Resident 5 from Vendor 2. SSD also stated Resident 5's clothes was in the social services office and forgot to give them to the resident. SSD was unable to provide accounting or receipt of the purchases.
During the same interview on 10/20/22 at 1:58 PM, SSD stated she was supposed to document purchases made for Resident 5 and what was received but she did not. SSD stated it was her responsibility to ensure Resident 5 was provided his right to know what was being bought out of his personal funds and should have received a copy of the invoice, but she did not.
During an interview on 10/20/21 at 1:58 PM, SSD stated she did not document the items purchased for Resident 5 from Vendor 2. SSD also stated Resident 5's clothes was in the social services office and forgot to give them to the resident. SSD was unable to provide accounting or receipt of the purchases.
During the same interview on 10/20/22 at 1:58 PM, SSD stated she was supposed to document purchases made for Resident 5 and what was received but she did not. SSD stated it was her responsibility to ensure Resident 5 was provided his right to know what was being bought out of his personal funds and should have received a copy of the invoice, but she did not.
2. A review of Resident 42's Face Sheet (a record of admission), indicated the resident was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses that included malignant (cancerous, in which abnormal cells divide uncontrollably and destroy body tissue) neoplasm (a new and abnormal growth of tissue in some part of the body) of oropharynx (the middle part of the throat), hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood), and anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities).
A review of Resident 42's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 8/12/22, indicated the resident had no impairment in cognitive skills (ability to understand and make decisions) and required supervision from staff for transferring, dressing, eating, and toileting.
During an interview, on 10/19/22 at 8:00 AM, Resident 42 stated he had been trying get a hold of AP
1. Resident 42 stated he had only seen AP 1 once since being admitted at the facility.
During an interview, on 10/20/22 at 11:55 PM, Marketing Director (MKD) stated, she was never made aware that Resident 42 had complaints about AP 1.
During an interview, on 10/20/22 at 12:05 PM, Social Services Designee (SSD) stated, Resident 42 complained to her many times that he wanted to see AP 1. SSD stated, she informed Resident 42 that she would notify MRK of his concerns and that MRK was responsible to coordinate with AP 1.
A review of the facilities job description dated May 2008, titled Social Services Designee, indicated the purpose of the job position was to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. The SSD's following job functions are:
a. Promotes/protects resident rights.
b. Maintains grievance (complaint) process - maintains all appropriate follow-up documentation.
c. Uses chain of command to communicate problems or grievances.
A review of the facility's policy revised December 2016, titled, Resident Rights, indicated the residents had the right to communication with and access to people and services, both inside and outside the facility and to be supported by the facility in exercising his or her rights.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:
1. Ensure that psychotropic medications (medications...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:
1. Ensure that psychotropic medications (medications that affect brain activities associated with mental processes and behaviors), such as temazepam (a medication used to treat the inability to sleep) are used to treat specific condition(s) as diagnosed and documented in the physician's order/clinical record for one out of 5 residents taking psychotropic medications (Residents 1.)
2. Ensure that PRN (as needed - not given on a regular schedule) orders for psychotropic medications are limited to a duration of only 14 days for one out of 5 residents taking psychotropic medications (Residents
1). Temazepam did not indicate a stop date since it was ordered on 7/7/22.
3. Monitor for adverse effects (unwanted or dangerous medication side effects) of temazepam in one of five sampled residents (Resident 1)
4. Monitor for behaviors tied to temazepam use in one of five sampled residents (Resident 1.)
5. Ensure individualized care plan for temazepam was revised and updated for one of five sampled residents (Resident 1).
These deficient practices increased the risk that Resident 1 to experience adverse effects of psychotropic medication therapy including, but not limited to, dizziness, drowsiness, leading to an overall negative impact on her physical, mental, and psychosocial well-being.
Findings:
On 10/18/22 at 10:15 AM, during the initial tour of the facility, Resident 1 was observed inside her room sleeping.
A review of Resident 1's Face Sheet (admission record) indicated an admission to the facility on 7/7/22 with diagnoses including major depressive disorder (a mood disorder that interferes with daily life), anorexia (an emotional disorder characterized by an obsessive desire to lose weight by refusing to eat), and type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar).
A review of Resident 1's History and Physical (H&P) dated 7/12/22 indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 1's MDS dated [DATE] indicated Resident 1 required total dependence (full staff performance every time during entire 7-day period) with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene).
A review of Resident 1's Physician's Order for the month of October 2022, indicated on 7/7/22, the physician ordered temazepam 30 milligrams (mg - a unit of measure for mass) by mouth every day as needed at bedtime, may repeat 1 cap as needed after midnight. The Physician's Order indicated the facility did not indicate a stop date or specify a duration for the PRN order for temazepam. The Physician Order did not indicate an indication and/or diagnosis for the administration of temazepam.
A review of Resident 1's care plan for behavior dated 7/7/22, indicated Resident 1 needs behavior management related to Resident 1's diagnosis of agitation and haloperidol (antipsychotic-can treat certain types of mental disorders) medication. The care plan indicated an intervention to give medication as ordered and monitor episodes of behavior every shift (7 AM to 3 PM, 3 Pm to 11 PM, and 11 PM to 7 AM). The haloperidol medication was discontinued on 8/5/22 as reflected in Resident 1's electronic Physician's Order.
A review of Resident 1's care plan for psychotropic medication dated 7/7/22, indicated Resident 1 requires the use of psychoactive medications such as antipsychotic haloperidol and hypnotic (used to treat insomnia and sleep disorders) temazepam. The care plan included interventions such as 1. Pharmacy audit of medication monthly, monitor adverse side effects, notify medical doctor for any adverse side effects 2. Monitor behavior/ hashmark every shift 3. monthly psychotropic summary review.
A review of Resident 1's care plan for mood state dated 7/11/22, indicated Resident 1 has sleep cycle issue with an intervention to assess sleep cycle and monitor mood status every shift.
A review of Resident 1's Medication Administration Record (MAR - a record of medications, behaviors, and adverse effect monitoring done by licensed nursing staff) for October 2022 indicated the facility was not monitoring for behavior of inability to sleep tied to the use of temazepam.
A review of Resident 1's MAR for October 2022 also indicated the facility was not monitoring for adverse effects common to temazepam. Further review of Resident 1's MAR for October 2022 indicated the facility was also not tracking Resident 1' number of hours of sleep each night tied to Resident 1's use of the temazepam but instead tracking Resident 1's episodes of anxiety behavior manifested by agitation.
On 10/21/22 at 11:09 AM, during a concurrent interview and observation of Resident 1 inside the resident's room, Licensed Vocational Nurse (LVN) 5 stated that Resident 1 was still sleeping at that time (11:09 AM). LVN 5 stated she works usually during the night shift (11 PM to 7 AM), and during LVN 5's shift, she observed Resident 1 was awake on and off during nighttime.
On 10/21/22 at 11:10 AM, during a concurrent interview and record review of Resident 1's electronic medical record, stated there was an order to administer temazepam PRN at nighttime to help Resident 1 sleep at night. LVN 5 stated there was no documentation of monitoring Resident 1's inability to sleep in the MAR. LVN 5 stated when asked if Resident 1 needs monitoring for inability to sleep, I don't know, since there were no orders to monitor behaviors tied to her psychotropic medication therapy and no order to monitor for the adverse effects of temazepam. LVN 5 stated licensed nurses were monitoring Resident 1 for agitation but Resident 1 was not taking any antianxiety (drug used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) medication. LVN 5 stated Resident 1 was taking haloperidol before it was discontinued on 8/5/22. LVN 5 stated it was Minimum Data Set (MDS) Nurses' responsibility to complete and document the monthly summary of the monitoring behaviors of residents on psychotropic medications. LVN 5 stated there was no stop date for Resident 1's temazepam PRN order.
On 10/21/22 at 11:27 AM, during concurrent interview and record review of Resident 1's electronic medical records, Registered Nurse (RN) 1 stated there was no stop date for Resident 1's temazepam order and no monitoring for temazepam's adverse effects. RN 1 stated Resident 1's inability to sleep should be monitored to determine if the temazepam was effective or not.
On 10/21/22 at 11:32 AM, during a concurrent interview and record review of Resident 1's Physician Orders and MAR for the month of October 2022, the Director of Nursing (DON) stated that diagnosis and indication for temazepam should be documented in Resident 1's Physician Orders. The DON stated the facility to add a stop date or duration to the resident's order for PRN temazepam. The DON stated temazepam like other psychotropic medication ordered as PRN need to be renewed every 14 days, must be seen and evaluated by resident's attending physician before renewing the PRN psychotropic medications. The DON stated the facility did not monitor behaviors and adverse effects of Resident 1's temazepam as specified in the Resident 1's plan of care. The DON stated it is important to monitor behaviors associated with psychotropic medication use to determine if the medications are effective or not at controlling the resident's behaviors. The DON stated that monitoring side effects of psychotropic medications is important to ensure that the medications don't cause significant side effects that can diminish a resident's quality of life such as drowsiness, and dizziness. The DON stated pharmacy review were done monthly by the pharmacy consultant but Resident 1's temazepam's adverse effect and behavior monitoring were missed. The DON stated care plan should be updated and revised in order to implement resident's care plan accurately.
A review of facility's policy and procedures (P&P) titled Behavior/Psychotropic Drug Management dated June 2019, indicated the following:
1. Any order for psychoactive medications must include the name of drug and dosage, route, frequency, diagnosis for its use and specific behavior manifested.
2. Resident should be observed and/or monitored for side effects and adverse effects while on any specific classification of psychotropic medication regimen. If the resident experiences any side effects, the License Nurse documents the occurrence in the resident's record and notifies Attending Physician/Prescriber.
3. Occurrences of behavior and side effects will be tallied and entered on the Monthly Psychoactive Drug Management Form in addition to any occurrence of adverse reaction.
4. Any psychoactive medication prescribed on a PRN basis must be ordered not to exceed 14 days. If the physician feels the medication needs to be continued, the reason (s) for the continued usage must be documented in the clinical record.
A review of facility's P&P titled Care plans-Comprehensive revised in September 2010, indicated assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
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's dietary staff failed to follow the Fall menu cooks spreadsheet...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility's dietary staff failed to follow the Fall menu cooks spreadsheet, approved by the registered dietician for residents requiring large portion meals for one of 21 sampled residents (Resident 47).
This deficient practice place Resident 47 at risk for potential weight loss and/or weight gain.
Findings:
During an observation on 10/20/22 at 7:33 AM, Dietary [NAME] (DC) prepared a large portion breakfast tray with a request for sausage for Resident 47. The tray included one sausage patty, 2 omelet pieces, and one slice of toast cut into two triangle pieces.
During an interview with Dietary Supervisor (DS) on 10/20/22 at 7:50 AM, DS stated, Resident 47 lost weight and is on weekly weights. DS stated, large portion should be two sausages.
During a concurrent interview and record review of the Fall Menus with the Regional Registered Dietician Consultant (RRDC) on 10/20/22 at 1:42 PM, RRDC stated, staff need to follow the menu; for example's breakfast, 1 slice of bread is 1 square slice or if cut up 2 triangles and for large portion is 2 slices of bread equivalent to 4 triangles.
A review of the facility's document titled Fall Menus dated for 10/3/22 to 11/28/22 indicated Toast given 1 slice for small and regular portion; for large portion should be 2 slices.
A review of Resident 47's Face Sheet (a record of admission) indicated the resident admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included generalized muscle weakness, chronic obstructive pulmonary disease (COPD- disease that causes obstructed airflow from the lungs), schizoaffective disorder (a mental illness that causes loss of contact with reality), Gastro-Esophageal Reflux Disease (GERD - a digestive disease in which stomach acid or contents irritates the food pipe lining).
A review of Resident 47's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/4/22 indicated the resident was able to make self-understood and understood others and did not have impairment in cognitive skills. The MDS indicated Resident 47 required extensive assistance (resident involved in activity, staff provided weight-bearing support) from staff for dressing, and personal hygiene.
A review of Resident 47's monthly weight record indicated the following information:
a. On 7/6/22 resident weight was 155 lbs.
b. On 8/4/22 resident weight was 206 lbs
c. On 9/8/22 resident weight was 209 lbs
d. On 10/6/22 resident weight 200 lbs.
A review of Resident 47's nutritional assessment dated on 9/16/22 indicated resident with significant weight gain before discharged to hospital with 54 lbs. with a weight gain times one month. Registered dietician recommendation included to encourage resident to be weighted and continue to monitor.
A review of Resident 47's Interdisciplinary Team (IDT, group of healthcare professionals from diverse fields who work in a coordinated manner toward a common goal for the resident) conference record dated 10/6/22 indicated recommendation of weekly weight times four weeks.
A review of Resident 47's care plan for risk for dehydration and malnutrition due to weight loss dated 10/6/22 indicated the resident will gain at least 3 lbs. per month to target ideal body weight range. The approaches included to encourage of diet and nourishment as ordered.
A review of Resident 47's weekly weights record for the month of September and October of 2022 indicated as follows:
a. On 9/12/22 resident's weight 209 lbs.
b. On 9/21/22 resident refused to be weighed.
c. On 9/28/22 resident refused to be weighed.
d. On 10/6/22 resident's weight 200 lbs.
e. On 10/12/22 resident's weight 201 lbs.
f. On 10/19/22 resident's weight 200 lbs.
A review of Resident 47's physician order dated 9/12/22 indicated for Resident 47 to be weighed weekly times four on admission.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have a functioning call light (a device used by a res...
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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 have a functioning call light (a device used by a resident to signal his or her need for assistance) system for two out of ten sampled resident's bathrooms (rooms [ROOM NUMBERS]).
This failure had the potential to prevent residents residing and staff assisting in rooms [ROOM NUMBERS] to receive bathroom assistance for needs in a prompt and timely manner.
Findings:
During an observation in the bathroom in room [ROOM NUMBER] and interview, on 10/19/22 at 7:35 AM, Maintenance Director (MTD) stated, the cord for the bathroom call light in room [ROOM NUMBER] was missing. MTD stated the residents in room [ROOM NUMBER] needed the cord to be able to pull and activate the call light when they need assistance while in the bathroom. MTD stated it was unsafe for the resident to not be able to pull the cord for assistance.
During an observation in the bathroom in room [ROOM NUMBER] and interview, on 10/19/22 at 7:45 AM, MTD stated, the cord for the bathroom call light in room [ROOM NUMBER] was missing. MTD stated the bathroom call light cannot be activated without the cord and so resident in room [ROOM NUMBER] were not able to call for assistance when they need it while in the bathroom.
A review of Resident 23's Face Sheet (a record of admission), indicated the resident was admitted to the facility on [DATE] with diagnoses that included Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) , Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and Chronic kidney disease (a condition characterized by a gradual loss of kidney function over time).
A review of Resident 23's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 7/22/22, indicated the resident was moderately impaired in cognitive skills and required extensive assistance (resident involved in activity, staff provided weight bearing assistance) from staff for transferring, dressing, toileting, and personal hygiene.
During an interview, on 10/20/2022 at 9:08 AM, Certified Nursing Assistant (CNA) 8 stated, they would take Resident 23 to the bathroom (room [ROOM NUMBER]) when he needed to use the toilet. CNA 8 stated they would leave resident 23 on the toilet by himself and wait outside the bathroom until he was finished. CNA 8 stated Resident 23 would knock on the bathroom door when he finished. CNA 8 further stated, if the call light cord was present and was working, we could have prevented Resident 23 from knocking to be able to call for the staff's help while he's in the bathroom.
During an interview, on 10/20/2022 at 9:12 AM, Resident 23 stated he knocked on the door when he was done using the bathroom, because the call light cord was missing, and call button did not work. Resident 23 further stated the call light cord was missing from the bathroom for room [ROOM NUMBER] (unable to recall since when) and it was difficult for resident to call for the staff's help when he's in the bathroom.
A review of the facility's policy and procedure titled, Answering the Call Light, revised October 2010, indicated the purpose of the procedure is to respond to the resident's requests and needs. Staff are to explain to the resident that a call system is also located in his/her bathroom and to demonstrate how it works. Staff are to report defective call lights to the nurse supervisor promptly.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0562
(Tag F0562)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to provide immediate access to nine out of nine (Reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to provide immediate access to nine out of nine (Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86) justice involved residents (residents currently in custody and held involuntarily through operation of law enforcement authorities in an institution, which is the responsibility of a governmental unit or over which a governmental unit exercises administrative control) residing in the facility by representatives of the Secretary and/or State which included the long-term care Ombudsman (OMB; an individual who advocates for long-term care facility residents, defends their rights, and ensures they are protected from verbal abuse, neglect, and assault) and Department of Public Health (DPH) State Surveyors.
This deficient practice violated all nine justice involved residents' (Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86) rights to communicate with outside agencies including, but not limited to OMB and DPH State Surveyors any matter concerning the residents' health, safety, care, treatment, and other issues. This deficient practice had the potential to negatively affect all nine justice involved residents' psychosocial well-being.
Findings:
A review of a formal referral letter from the long-term care ombudsman dated 10/14/22, indicated the OMB was at the facility on 10/11/22. The letter indicated the OMB was not allowed to see or interview the nine justice involved residents in their rooms. The letter indicated that the DON stated the facility had been instructed to follow a different set of rules and were told that the justice involved residents did not have the same rights as all other residents in the facility. The letter indicated that on 10/12/22, the OMB spoke to the Federal Law Enforcement (Justice Department agency charged with carrying out all law enforcement activities relating to the federal justice system) Supervisor and explained to the OMB that the justice involved residents were supervised by the Federal Law Enforcement while in the facility.
On 10/18/22 at 8:32 AM, during the initial tour of the facility, concurrent interview and review of the facility's residents census dated 10/17/22 with the DON, the DON stated the facility had 92 residents residing in the facility. The DON stated Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86 were under a fictitious (not real or true) name to protect the resident's identity and for confidentiality. The DON stated Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86 admitted in the facility were all justice involved residents.
During an interview on 10/18/22 at 9 AM, PSO 6 stated that DPH/state surveyors cannot enter the justice involved resident's rooms and would not answer any more questions about the justice involved residents.
1.During an interview on 10/18/22 at 9:20 AM, while outside Resident 86's room, PSO 1 stated all justice involved residents were only allowed to go outside the resident's room when they go to physical therapy accompanied by two PSOs. PSO 1 stated all justice involved residents were not allowed to have visitors including state surveyors without United States (US) Marshal Supervisor. PSO 1 stated state surveyors were not allowed to go inside the justice involved residents' room to observe and conduct interviews even after explaining state surveyor's reason and authority to have immediate access to all residents in the facility.
A review of Resident 86's Face Sheet (admission record) indicated an admission to the facility on 9/17/22 with diagnoses including suicidal ideations (thinking about or planning suicide), muscle weakness and traumatic subcutaneous (applied under the skin), emphysema (a condition in which air becomes trapped under the subcutaneous layer of the skin). The Face Sheet did not indicate a responsible party for Resident 86.
A review of Resident 86's History and Physical (H&P) dated 9/20/22 indicated the resident had the capacity to understand and make decisions.
2. On 10/18/22 at 9:26 AM, during an observation inside Resident 87's room and interview with PSO 2 in the presence of PSO 3 and Resident 87, PSO 2 stated that Resident 87's contact with the public was very limited. PSO 2 stated justice involved residents were not allowed to receive visitors and receive phone calls.
During an interview on 10/18/22 at 9:29 AM, Resident 87 stated he was not allowed to receive any visitors and mails. Resident 87 stated that telephone calls were not allowed. Resident 87 stated he was not allowed to go outside except during therapy and shower.
A review of Resident 87's Face Sheet indicated an admission to the facility on 9/27/22 with diagnoses including anemia (a condition in which the body does not have enough healthy red blood cells that provide oxygen to body tissues), emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness), secondary malignant neoplasm of bone (cancer [a disease in which abnormal cells divide uncontrollably and destroy body tissue] started in another part of the body but spread to the bone).
A review of Resident 87's undated H&P indicated the resident had the capacity to understand and make decisions.
3. A review of Resident 79's Face Sheet the resident was admitted to the facility on [DATE] with diagnoses including insomnia (persistent problems falling and staying asleep) and personal history of COVID-19 ([Coronavirus] a disease that can triggers a respiratory [lung] tract infection affecting the upper respiratory tract [sinuses, nose, and throat] and/or lower respiratory tract [windpipe and lungs] the virus spreads mainly through person-to-person contact).
A review of Resident 79's H&P dated 6/15/22 indicated the resident had the capacity to understand and make decisions.
4. A review of Resident 40's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including Type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), chronic kidney disease (gradual loss of kidney function) and epilepsy (a disorder of the brain; disorder in which the brain activity becomes abnormal, causing seizures [sudden, uncontrolled electrical disturbance in the brain] or periods of unusual behavior, sensations and sometimes loss of awareness). The Face Sheet did not indicate a responsible party for Resident 40.
A review of Resident 40's H&P dated 8/31/22 indicated the resident had the capacity to understand and make decisions.
5. A review of Resident 292's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements such as shaking, stiffness, and difficulty with balance and coordination), essential hypertension (high blood pressure that does not have a known secondary cause) and anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) disorder.
A review of Resident 292's H&P dated 10/13/22 indicated the resident had the capacity to understand and make decisions.
6. A review of Resident 42's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including anxiety disorder, chronic pain syndrome (pain that carries on for longer than 12 weeks despite medication or treatment) and malignant (destructive; cancerous) neoplasm (any growth that develops inside or on the body) of oropharynx (a disease in which malignant [cancer] cells form in the tissues of the oropharynx [middle part of the throat, behind the mouth]).
A review of Resident 42's H&P dated 5/10/22 indicated the resident had the capacity to understand and make decisions.
7. A review of Resident 42's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including anxiety disorder, chronic pain syndrome (pain that carries on for longer than 12 weeks despite medication or treatment) and malignant (destructive; cancerous) neoplasm (any growth that develops inside or on the body) of oropharynx (a disease in which malignant [cancer] cells form in the tissues of the oropharynx [middle part of the throat, behind the mouth]).
A review of Resident 42's H&P dated 5/10/22 indicated the resident had the capacity to understand and make decisions.
8. A review of Resident 342's Face Sheet indicated an initial admission to the facility on [DATE] with diagnoses including post-traumatic (a mental health condition that's triggered by a terrifying event) stress disorder, borderline personality (a mental health disorder that impacts the way you think and feel about yourself and others) disorder, and bipolar (a mental condition marked by alternating periods of elation and depression) disorder.
A review of Resident 342's H&P dated 10/13/22 indicated the resident had the capacity to understand and make decisions.
9. A review of Resident 76's Face Sheet indicated an initial admission to the facility on 6/29/22 with diagnoses including unspecified part of neck of femur (region just below the ball of the hip joint), phalanx (bone located between the first joint and center knuckle) of right mid finger, shaft of right tibia (middle of right big bone between knee and ankle), fracture (broken bone).
A review of Resident 76's H&P dated 10/13/22, indicated the resident had the capacity to understand and make decisions.
During an interview on 10/18/22 at 9:35 AM, Licensed Vocational Nurse (LVN) 1 stated the DPH state surveyors were not allowed to go inside all justice involved residents' rooms due to Federal Law Enforcement policy. LVN 1 stated the DPH surveyors were not also allowed to check the justice involved resident electronic chart including the justice involved resident's name.
During an interview on 10/18/22 at 1:28 PM, the DON stated the facility was not able to provide the DPH state surveyors the copies of the nine justice involved residents' medical records as requested. The DON stated the facility was still asking and waiting for the Federal Law Enforcement Agency Supervisor's approval/permission for the DPH surveyors to obtain copies of the justice involved residents' medical records.
During an interview on 10/18/22 at 2:47 PM, the DON stated the DPH state surveyors and ombudsman, including the justice involved resident's attorneys were not allowed to go inside the justice involved residents' room without Federal Law Enforcement Supervisor's permission.
During an interview on 10/19/22 at 3:39 PM, the DON stated that the DPH state surveyors were still not allowed to interview and review all the medical records of the nine justice involved residents per the Federal Law Enforcement Agency Supervisor's instruction.
During a conference meeting via TEAMS (allows users to communicate via text, chat, voice or video call from home or office) on 10/20/22 at 10:10 AM, attended by Los Angeles County Department of Public Health (LAC-DPH) Health Facilities Investigation Division (HFID) supervision team, the facility's Administrator (ADM), DON, [NAME] President of Operations (VPO), Quality Assurance Consultant (QA Consultant) and Marketing Director (MKD). The VPO stated the state surveyors were not allowed to access the justice involved resident's medical records since the residents were discharged from the facility on 10/19/22 and will not be coming back. The VPO stated the facility was trying to discuss to allow the state surveyors to continue to review and release the medical records of the nine justice involved residents with the Federal Law Enforcement Agency Supervisor.
A review of a Memorandum (a short note designating something to be remembered, especially something to be done or acted upon in the future) addressed to the facility and MKD, titled Policy and Procedures for Inmates in Nursing Home Facilities, dated 8/20/2021, signed by the Federal Law Enforcement Deputy and written in the Federal Law Enforcement letterhead indicated the following information: Clients (inmates) are not allowed to have family visitations or phone calls. If unannounced visitor arrives, notify (Federal Law Enforcement Agency) immediately.
A review of the facility's policy and procedure titled Residents Rights revised in December 2016, indicated Federal and state laws guarantee certain basic rights to all residents of this facility. These rights included the resident's right to:
a. Communication with and access to people and services, both inside and outside the facility.
b. Exercise his or her rights as a resident of the facility and as a resident or citizen of the United States.
c. Be supported by the facility in exercising his or her rights.
d. Exercise his or her rights without interference, coercion, discrimination or reprisal from the facility.
Voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal;
e. Communicates with outside agencies (e.g., local, state, or federal officials, state and federal surveyors, state long-term care ombudsman, protection or advocacy organizations, etc.) regarding any matter.
f. Visit and be visited by others from outside the facility.
g. Access to a telephone, mail and email.
h. Communicate in person and by mail, email and telephone with privacy.
A review of a Memorandum from the Centers for Medicare & Medicaid Services (CMS-a federal agency within the United States Department of Health and Human Services) titled Updated Guidance to Surveyors on Federal Requirements for Providing Services to Justice Involved Individuals revised in 12/23/16 indicated, Skilled Nursing Facilities (SNFs) and Nursing Facilities (NFs), as residential environments, must permit residents to have autonomy and choice, to the maximum extent practicable regarding how they wish to live their everyday lives and receive care. Federal statutes and regulations establish an array of individual rights and safeguards. Nursing homes cannot impose conditions or restrictions that undetermined resident rights and protections required by federal law .Resident rights in the nursing home include but are not limited to the right to: 1. Interact with members of the community both inside and outside the facility; and 2. Immediate access to any resident by the following: subject to the resident's right to deny or withdraw consent at any time, immediate family, or other relatives of the resident; and subject to reasonable restrictions and the resident's right to deny or withdraw consent at any time, others who are visiting with the consent of the resident; Also, nursing home residents must not only be able to exercise their rights as residents of the facility and as citizens of the United Sates, but also have the right to be free of interference, coercion, discrimination, or reprisal from the facility in exercising those rights. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0563
(Tag F0563)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to respect the rights of the residents to receive/deny...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to respect the rights of the residents to receive/deny visitors of nine out of nine (Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86) justice involved residents (residents currently in custody and held involuntarily through operation of law enforcement authorities in an institution, which is the responsibility of a governmental unit or over which a governmental unit exercises administrative control) residing in the facility.
This deficient practice restricted and violated the nine justice involved residents' (Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86) rights and had the potential to negatively affect the resident's psychosocial wellbeing.
Findings:
A review of a formal referral letter from the long-term care ombudsman dated 10/14/22, indicated the OMB was at the facility on 10/11/22. The letter indicated the OMB was not allowed to see or interview the nine justice involved residents in their rooms. The letter indicated that the DON stated the facility had been instructed to follow a different set of rules and were told that the justice involved residents did not have the same rights as all other residents in the facility. The letter indicated that on 10/12/22, the OMB spoke to the Federal Law Enforcement (Justice Department agency charged with carrying out all law enforcement activities relating to the federal justice system) Supervisor and explained to the OMB that the justice involved residents were supervised by the Federal Law Enforcement while in the facility. The letter indicated that the Federal Law Enforcement Supervisor informed the OMB that the justice involved residents residing in the facility have all the rights to keep them alive. The letter indicated the justice involved residents were not allowed to have visitors without the Federal Law Enforcement Supervisor permission. The letter indicated that on 10/12/22, the facility's administrator shared with the OMB that the facility was following a separate protocol (policy) for the justice involved residents according to the facility's corporate guidance and the Federal Law Enforcement Agency.
A review of a Memorandum (a short note designating something to be remembered, especially something to be done or acted upon in the future) addressed to the facility and MKD, titled Policy and Procedures for Inmates in Nursing Home Facilities, dated 8/20/2021, signed by the Federal Law Enforcement Deputy and written in the Federal Law Enforcement letterhead indicated the following information: Clients (inmates) are not allowed to have family visitations or phone calls. If unannounced visitor arrives, notify (Federal Law Enforcement Agency) immediately.
On 10/18/22 at 8:32 AM, during the initial tour of the facility, concurrent interview and review of the facility's residents census dated 10/17/22 with the DON, the DON stated the facility had 92 residents residing in the facility. The DON stated Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86 were under a fictitious (not real or true) name to protect the resident's identity and for confidentiality. The DON stated Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86 admitted in the facility were all justice involved residents.
During an interview on 10/18/22 at 9 AM, Private Security Officer (PSO) 6 stated that DPH State Surveyors cannot enter the justice involved resident's rooms and would not answer any more questions about the justice involved residents.
1. A review of Resident 87's Face Sheet (admission record) indicated an admission to the facility on 9/27/22 with diagnoses including anemia (a condition in which the body does not have enough healthy red blood cells that provide oxygen to body tissues), emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness), secondary malignant neoplasm of bone (cancer [a disease in which abnormal cells divide uncontrollably and destroy body tissue] started in another part of the body but spread to the bone).
A review of Resident 87's undated History and Physical (H&P) indicated the resident had the capacity to understand and make decisions.
A review of Resident 87's Minimum Data Set (MDS- a care area screening and assessment tool) dated 9/30/22 indicated Resident 87 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) with bed mobility, transfer, toilet use, personal hygiene and required supervision (oversight, encouragement or cueing) with dressing and eating.
On 10/18/22 at 9:26 AM, during an observation inside Resident 87's room and interview with PSO 2 in the presence of PSO 3 and Resident 87, PSO 2 stated that Resident 87's contact with the public was very limited. PSO 2 stated all nine justice involved residents were not allowed to receive visitors.
During an interview on 10/18/22 at 9:29 AM, Resident 87 stated he was not allowed to receive any visitors and mails.
2. A review of Resident 86's Face Sheet indicated an admission to the facility on 9/17/22 with diagnoses including suicidal ideations (thinking about or planning suicide), muscle weakness and traumatic subcutaneous (applied under the skin), emphysema (a condition in which air becomes trapped under the subcutaneous layer of the skin).
A review of Resident 86's History and Physical (H&P) dated 9/20/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 86's MDS dated [DATE] indicated Resident 86 required limited assistance (with transfers, toilet use and required total dependence (full staff performance every time during entire 7-day period) with dressing, required limited assistance with transfer and toilet use. The MDS indicated Resident 86 required supervision with bed mobility, eating and personal hygiene.
3.A review of Resident 79's Face Sheet the resident was admitted to the facility on [DATE] with diagnoses including insomnia (persistent problems falling and staying asleep) and personal history of COVID-19 ([Coronavirus] a disease that can triggers a respiratory [lung] tract infection affecting the upper respiratory tract [sinuses, nose, and throat] and/or lower respiratory tract [windpipe and lungs] the virus spreads mainly through person-to-person contact).
A review of Resident 79's H&P dated 6/15/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 79's MDS dated [DATE] indicated Resident 79 required supervision during bed mobility, transfer, dressing, eating, toilet use and personal hygiene.
4. 4. A review of Resident 40's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including Type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), chronic kidney disease (gradual loss of kidney function) and epilepsy (a disorder of the brain; disorder in which the brain activity becomes abnormal, causing seizures [sudden, uncontrolled electrical disturbance in the brain] or periods of unusual behavior, sensations and sometimes loss of awareness). The Face Sheet did not indicate a responsible party for Resident 40.
A review of Resident 40's H&P dated 8/31/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 40's MDS dated [DATE] indicated Resident 40 required limited assistance with bed mobility, transfer, dressing, toilet use, personal hygiene and required supervision during eating.
5. A review of Resident 292's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements such as shaking, stiffness, and difficulty with balance and coordination), essential hypertension (high blood pressure that does not have a known secondary cause) and anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) disorder.
A review of Resident 292's H&P dated 10/13/22 indicated the resident had the capacity to understand and make decisions.
6. A review of Resident 42's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including anxiety disorder, chronic pain syndrome (pain that carries on for longer than 12 weeks despite medication or treatment) and malignant (destructive; cancerous) neoplasm (any growth that develops inside or on the body) of oropharynx (a disease in which malignant [cancer] cells form in the tissues of the oropharynx [middle part of the throat, behind the mouth]).
A review of Resident 42's H&P dated 5/10/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 42's MDS dated [DATE] indicated Resident 42 required supervision with bed mobility, transfer, dressing, eating, toilet use and personal hygiene.
7. A review of Resident 42's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including anxiety disorder, chronic pain syndrome (pain that carries on for longer than 12 weeks despite medication or treatment) and malignant (destructive; cancerous) neoplasm (any growth that develops inside or on the body) of oropharynx (a disease in which malignant [cancer] cells form in the tissues of the oropharynx [middle part of the throat, behind the mouth]).
A review of Resident 42's H&P dated 5/10/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 42's MDS dated [DATE] indicated Resident 42 required supervision with bed mobility, transfer, dressing, eating, toilet use and personal hygiene.
8. A review of Resident 342's Face Sheet indicated an initial admission to the facility on [DATE] with diagnoses including post-traumatic (a mental health condition that's triggered by a terrifying event) stress disorder, borderline personality (a mental health disorder that impacts the way you think and feel about yourself and others) disorder, and bipolar (a mental condition marked by alternating periods of elation and depression) disorder.
A review of Resident 342's H&P dated 10/13/22 indicated the resident had the capacity to understand and make decisions.
9. A review of Resident 76's Face Sheet indicated an initial admission to the facility on 6/29/22 with diagnoses including unspecified part of neck of femur (region just below the ball of the hip joint), phalanx (bone located between the first joint and center knuckle) of right mid finger, shaft of right tibia (middle of right big bone between knee and ankle), fracture (broken bone).
A review of Resident 76's H&P dated 10/13/22, indicated the resident had the capacity to understand and make decisions.
A review of Resident 76's MDS dated [DATE] indicated Resident 76 required supervision with bed mobility, transfer, dressing, toilet use, and personal hygiene.
During an interview on 10/18/22 at 2:47 PM, the Director of Nursing (DON) stated justice involved residents were not allowed to receive visitors without Federal Law Enforcement Supervisor's permission. The DON stated the Department of Public Health (DPH) surveyors and ombudsman, including the justice involved resident's attorneys were not also allowed to go inside the justice involved residents' room without Federal Law Enforcement Supervisor's permission.
During an interview on 10/18/22 at 2:51 PM, Activities Director (AD) stated all justice involved residents were not allowed to have visitors.
During an interview on 10/19/22 at 7:02 AM, Certified Nurse Assistant (CNA) 1 stated all justice involved residents were not allowed to have visitors except their attorneys.
During an interview on 10/19/22 at 9:43 AM, the Administrator (ADM) stated visitation were allowed to all resident's residing in the facility including all justice involved residents if residents have prior clearance and Federal Law Enforcement Supervisor's permission due to safety reasons.
A review of the facility's policy and procedure titled Residents Rights revised in December 2016, indicated Federal and state laws guarantee certain basic rights to all residents of this facility. These rights included the resident's right to:
a. Communication with and access to people and services, both inside and outside the facility.
b. Exercise his or her rights as a resident of the facility and as a resident or citizen of the United States.
c. Be supported by the facility in exercising his or her rights.
d. Exercise his or her rights without interference, coercion, discrimination or reprisal from the facility.
e. Communicates with outside agencies (e.g., local, state, or federal officials, state and federal surveyors, state long-term care ombudsman, protection or advocacy organizations, etc.) regarding any matter.
f. Visit and be visited by others from outside the facility.
A review of facility's policy and procedure titled Residents Involved with the Criminal Justice System revised in March 2019 indicated Residents involved in the justice system are entitled to the same rights as all other residents in the facility. The facility does not impose any restrictions on justice-involved residents that violate their resident rights. The P&P also indicated the following:
a. All residents, including justice-involved residents, have the right to a dignified existence, self-determination, communication and access to persons and services inside and outside the facility.
b. Justice involved residents include residents under the care of (taken into custody by) law enforcement
c. Law enforcement jurisdiction is not integrated with facility operations. This facility maintains control over the conditions under which the resident receives care.
A review of a Memorandum from the Centers for Medicare & Medicaid Services (CMS-a federal agency within the United States Department of Health and Human Services) titled Updated Guidance to Surveyors on Federal Requirements for Providing Services to Justice Involved Individuals revised in 12/23/16 indicated, Skilled Nursing Facilities (SNFs) and Nursing Facilities (NFs), as residential environments, must permit residents to have autonomy and choice, to the maximum extent practicable regarding how they wish to live their everyday lives and receive care. Federal statutes and regulations establish an array of individual rights and safeguards. Nursing homes cannot impose conditions or restrictions that undetermined resident rights and protections required by federal law .Resident rights in the nursing home include but are not limited to the right to: 1.Interact with members of the community both inside and outside the facility; and 2. Immediate access to any resident by the following: subject to the resident's right to deny or withdraw consent at any time, immediate family, or other relatives of the resident; and subject to reasonable restrictions and the resident's right to deny or withdraw consent at any time, others who are visiting with the consent of the resident; Also, nursing home residents must not only be able to exercise their rights as residents of the facility and as citizens of the United Sates, but also have the right to be free of interference, coercion, discrimination, or reprisal from the facility in exercising those rights. The memorandum indicated The facility must promote care for its residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Examples of prohibited facility restrictions include but are not limited to: The facility makes a determination as to which visitors a resident may or may not see. The resident has the right to choose his or her own visitors.https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0571
(Tag F0571)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 5's admission Record indicated Resident 5 was admitted on [DATE] for unspecified schizophrenia (a seriou...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 5's admission Record indicated Resident 5 was admitted on [DATE] for unspecified schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and persistent mood disorder (the general emotional state of a person is inconsistent with the circumstances and interferes with their ability to function).
A review of Resident 5's History and Physical (a shorthand for the formal document that physicians produce through interview with the resident, physical examination and the summary of testing either obtained or pending) dated 7/28/22, indicated, the resident has the capacity to understand and make decisions.
A review of Resident 5's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/20/22, indicated resident has moderate impairment in cognitive skills (ability to make daily decisions).
During an interview and concurrent record review of Resident 5's Statement Landscape on 10/18/22 at 12:48 PM, Resident 5 stated someone used his account or personal funds kept by the facility and withdrew money out from it. Resident 5 stated, about 2 years ago he bought two (2) Burton Jackets and one (1) flannel shirt at online store 1 worth approximately $400.00 and the remaining balance of the $5,000.00 was given to the front desk for safe keeping. Resident 5's statement of account from Resident Fund Management Service indicated, Resident 5 has a current balance of $2,367.03 as of 10/03/22. Resident 5 stated he felt robbed after finding out somebody used his account to purchase television and other items besides the jackets and flannel shirts. Resident 5 stated, he was left hanging by the facility when he asked what happened to his money because he did not ask the facility to purchase the television and other items besides the jacket and flannel shirt.
A review of Resident 5's Resident Statement Landscape (financial statement itemizing posted transactions in the trust account) dated from 1/3/22 to 10/3/22, indicated the following:
a. On 3/11/22, an amount of $1,533.00 was debited (deducted from the trust account as payment for services or goods) for Clothing and paid to Online Store 2.
b. On 6/29/22, an amount of $1,403.79 was debited for Personal Needs Items and paid to Online Store 2.
A review of Resident 5's invoice amounting to $1,533, dated 2/22/22, indicated the purchase of the following:
a. Television (TV) - one (1) totaling in the amount of $440
b. TV wall mount - 1 totaling in the amount of $90
c. Slip on shoes (size 9.5 inches [in, unit of measurement]) - 1 totaling in the amount of $45
d. Regular socks (six [6] pack) - two (2) totaling in the amount of $80
e. Non-skid socks (6 pack) - 1 totaling in the amount of $40
f. Men's sweatsuit set (XL) - five (5) totaling in the amount of $325
g. T-Shirt (XL) - 5 totaling in the amount of $75
h. Men's Hat (Beanie) - 2 totaling in the amount of $30
i. Shampoo with conditioner - 2 totaling in the amount of $30
j. Body wash - 2 totaling in the amount of $30
k. Deodorant (2 pack) - 1 totaling in the amount of $15
l. summer blanket - 2 totaling in the amount of $70
A review of Resident 5's invoice amounting to $1,403.79 dated 6/22/22, indicated the purchase of the following:
a. Variety of chips (Doritos) - 1 totaling in the amount of $30
b. Variety of chocolate - 1 totaling in the amount of $30
c. Soda (Vernor's Ginger Ale; 24 cans/case) - 1 totaling in the amount of $50
d. Soda (Canada Dry Ginger Ale; 36 cans/case) - 1 totaling in the amount of $30
e. Extra sour sourdough [NAME] bread - 1 totaling in the amount of $15
f. Lotion - 2 totaling in the amount of $36
g. Shampoo/Conditioner (Dove) - 2 totaling in the amount of $36
h. Pillow with case (2 packs) - 1 totaling in the amount of $45
i. Men's adaptive T-Shirt (Printed; Large) - 5 totaling in the amount of $275
j. Men's adaptive pants (Large) - 5 totaling in the amount of $300
k. Wrap back adaptive nightgown (Large) - 2 totaling in the amount of $110
l. Hot rod magazine (Latest Edition) - 2 totaling in the amount of $70
m. National Hot Rod Association (NHRA) Magazine (Latest Edition) - 2 totaling in the amount of $70
n. Cars Magazine (Latest Edition) - 2 totaling in the amount of $70
During an interview and record review on 10/18/22 at 1:01 PM, Social service Director (SSD) stated Resident 5's TV was in the conference room and the clothes and other items purchased were in her office. The SSD stated resident's personal belongings inventory did not show the lists of belongings acquired after admission and was not in the resident's closet.
During a record review on 10/20/22 at 1:29 PM there was no documentation that the items purchased was requested by Resident 5.
During an interview on 10/20/22 at 1:58 PM, the SSD stated she was not able to find any documentation that Resident 5 requested to purchase a TV.
During the same interview on 10/20/22 at 1:58 PM, SSD stated she was supposed to document purchases made for Resident 5 and what was received by the resident but did not. The SSD stated it was her responsibility to ensure Resident 5 and 50 were provided their right to know what was being bought out of their personal funds and should have received a copy of the invoice. The SSD further stated, she failed to provide resident's right.
A review of the facility's job description dated May 2008, titled Social Services Designee, indicated the purpose of the job position was to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. The SSD's following job functions included:
a. Promoting/protecting resident rights.
d. Assisting in coordination of resident's financial affairs.
A review of the facility's policy revised December 2016, titled, Resident Rights, indicated the residents had the right to communication with and access to people and services, both inside and outside the facility and to be supported by the facility in exercising his or her rights. The policy also indicated that residents have the right to be free from misappropriation of property.
A review of the facility's policy revised April 2017, titled Accounting of Records of Residents Funds, indicated records will include copies of the resident's or representative's written permission for any non-covered items or services charged.
Based on observation, interview, and record review, the facility failed to limit charges on the personal funds of two of twelve sampled residents (Residents 50 and 5) by failing to:
1.
Ensure Resident 50 was informed and agreed to the facility staff to use Resident 50's personal funds prior to purchasing resident's personal clothing.
2.
Ensure the facility purchased items for Resident 5 were related to the necessary care for the resident, assess the personal needs of Resident 5 and determine the reasonable costs of items purchased in excessive amounts, prior to the facility staff purchasing items using the residents' personal funds without resident's consent to purchase such items.
These deficient practices violated the residents' rights related to the misuse of residents' personal funds by the facility due to the absence of any requests and consents of the residents and/or the responsible parties and may result to psychosocial harm.
Findings:
1. A review of Resident 50's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) disorder, major depressive order (a mood disorder that interferes with daily life), and anemia (a condition in which the body does not have enough healthy red blood cells that provide oxygen to body tissues).
A review of Resident 50's History and Physical (H&P) dated 9/23/21 indicated the resident had the capacity to understand and make decisions.
A review of Resident 50's Minimum Data Set (MDS- a care area screening and assessment tool) dated 8/10/22 indicated Resident 50 required limited assistance with transfers, toilet use and required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transfer, dressing, toilet use, personal hygiene and required supervision (oversight, encouragement or cueing) with eating.
During an interview on 10/18/22 at 2:10 PM, Resident 50 stated when he was residing in Facility 1 few years ago, Resident 50 was receiving monthly funds or money in the amount of $60.00. Resident 50 stated since he was admitted to the facility, he did not know if he was currently receiving any funds/money or not.
During a concurrent interview and record review of Resident 50's Resident Fund Statement (statement of account) dated from 1/1/22 and 3/31/22, on 10/20/22 at 11:20 AM, the Business Office Manager (BOM) stated Resident 50 was not receiving petty cash nor monthly allowance. The BOM stated Resident 50 has ending balance of $1.03 as of 9/30/22.
During a concurrent interview and record review of Resident 50's Resident Statement Landscape (financial statement itemizing posted transactions in the trust account) dated from 12/23/20 to 10/3/22, on 10/20/22 at 11:23 AM, the BOM stated Resident 50 received a one-time money allowance on 12/23/20 in the amount of $325.09. The BOM stated, on 5/25/21, an amount of $324.12 was debited (deducted from the trust account as payment for services or goods) for Clothing and paid to Vendor 2. The BOM stated, the facility just found on 10/19/22 that Resident 50's clothing/belongings that was purchased on 5/25/21 were missing. The BOM stated they replaced the missing clothing and belongings on 10/19/22 and placed it inside Resident 50's closet.
A review of Resident 50's invoice amounting to $324.12, dated 6/1/22, indicated the purchase of the following:
a. Four (4)- T-Shirts (4XL)
b. Three (3)Lightweight Sweatpants (4XL)
c. Six (six)6-Socks, size 13 (per pair)
d. One (1)-Men's surge running shoes, size 12
During an interview on 10/20/22 at 1:51 PM, Resident 50 stated he was not aware he has clothing until the facility replaced those clothing on 10/19/22. Resident 50 stated, he did not ask and was not aware that the facility purchased clothing items for him using his funds/money. Resident 50 stated he was surprised and frustrated that he was not able to use his own clothing right after it was purchased.
During an interview on 10/21/22 12:03 PM, the BOM stated, the clothing was purchased in 2021, and possibly misplaced and got lost during room changes. The BOM stated Social Services Director (SSD) checked Resident 50's closet on 10/18/22 and did not find the clothing that were listed in Resident 50's inventory list and were purchased using Resident 50's money on 5/25/21. The BOM stated it was SSD responsibility if there were resident's clothes or belongings missing. The BOM stated the facility would be responsible in replacing resident's belongings that were lost in the facility. The BOM stated SSD will accept, handle the belongings and document it in the resident's inventory list during admission and need to be updated whenever there were new belongings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the Notice of Proposed Transfer/Discharge at least 30 days ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the Notice of Proposed Transfer/Discharge at least 30 days before the resident was discharged to the General Acute Care Hospital (GACH), when the facility initiated an immediate transfer/discharge to nine (9) out of nine (Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86) justice involved residents (residents currently in custody and held involuntarily through operation of law enforcement authorities in an institution, which is the responsibility of a governmental unit or over which a governmental unit exercises administrative control) for placement purposes, on 10/19/2022.
The facility's Discharge Summaries indicated the facility discharged nine residents (Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86) to the GACH on the night of 10/19/2022 for evaluation. The facility's Departmental Notes indicated the nine residents (Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86) discharged to GACH were facility-initiated discharges (facility-initiated transfer or discharge is a transfer or discharge which the resident objects to, did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences), due to intent deficiency issued by the DPH State Surveyors. As of 10/31/2022, all nine residents remained in the GACH waiting for facility placement under the skilled nursing level of care.
This deficient practice did not allow Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86 enough time to submit an appeal or demonstrate that the residents and their representatives understand the risks of initiating discharge that may potentially affect the resident's quality of life.
As a result, all nine residents incurred prolonged stay in the GACH, pending the acceptance to another facility to accept Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86 for skilled nursing facility level of care placement.
Findings:
On 10/18/22 at 8:32 AM, during the initial tour of the facility, concurrent interview and review of the facility's residents census dated 10/17/22 with the Director of Nurses (DON), the DON stated the facility had 92 residents residing in the facility. The DON stated Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86 were under a fictitious (not real or true) name to protect the resident's identity and for confidentiality. The DON stated Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86 admitted in the facility were all justice involved residents.
During the same interview, the VPO stated the facility will try to discharge all nine justice involved residents on 10/19/22.
On the next day, 10/20/22 at 6:24 AM, during an interview with the Assistant Administrator (AADM), AADM stated all nine justice involved residents (Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86) were transferred on the evening of 10/19/22 to the GACH for evaluation.
On 10/20/22 at 6:50 AM, during a concurrent interview and record review of the facility's resident census dated 10/20/22, the DON stated the facility had 82 in-house residents and 5 bed holds. The DON stated all nine justice involved residents were transferred to the GACH. When asked about the diagnosis and medical necessity for GACH transfer/discharge of Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86, the DON stated the nine residents were transferred for further evaluation and proper placement. The DON stated when asked if it was appropriate to transfer all nine justice involved residents to the GACH, the DON responded yes since all nine justice involved residents were all discharged from the same GACH prior to being admitted to their facility for skilled nursing care.
1. A review of Resident 79's Face Sheet (admission record) indicated an admission to the facility on 6/13/22 with diagnoses including insomnia (persistent problems falling and staying asleep) and personal history of COVID-19 ([Coronavirus] a disease that can triggers a respiratory [lung] tract infection affecting the upper respiratory tract [sinuses, nose, and throat] and/or lower respiratory tract [windpipe and lungs] the virus spreads mainly through person-to-person contact). The Face Sheet did not indicate a responsible party for Resident 79.
A review of Resident 79's History and Physical (H&P) dated 6/15/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 79's care plan for discharge planning dated 6/14/22 indicated a Short term care. Under care of Federal Law Enforcement Agency with the following goals: 1. Long term care: Resident unable to perform activities of daily living (ADLs), 2. To return to prior level of independent functioning, and 3. Short term care: Resident will be discharged to a lower level of care when independent in ADLs.
A review of Resident 79's Physician's Telephone Order dated 10/19/22 timed at 3:04 PM indicated Transfer to GACH for further evaluation.
A review of Resident 79's Notice of Proposed Transfer/Discharge indicated that the notice was provided to the resident on the day of the Physician's Telephone Order to transfer to the GACH on 10/19/22. The Notice indicated a Notification Date of 10/19/22 and an Effective Date of 10/19/22 indicated Resident 79 was transferred to GACH on 10/19/22 with the following reason: The transfer or discharge is necessary for your welfare and your need cannot be met in the facility. The Notice indicated If you intent to file an appeal of this transfer/discharge, it is important to do so within 10 calendar days of being notified. The decision regarding an appeal will normally be made within 30 days from the date of this Notice . The Notice further indicated The facility may not transfer or discharge the resident while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility.
A review of Resident 79's handwritten Discharge summary dated [DATE], indicated Resident 79's Date of Discharge was 10/19/22. The Discharge Summary indicated the resident was transferred to GACH in fair
condition for evaluation. The physician signature of Resident 79's Discharge Summary was left blank.
A review of Resident's 79's Departmental Notes dates 10/20/22 timed at 12:10 AM indicated Resident transferred to GACH for evaluation and treatment. Informed state surveyor Team Coordinator due to intent deficiency issued.
2. A review of Resident 40's Face Sheet indicated an admission to the facility on 7/29/22 with diagnoses including Type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), chronic kidney disease (gradual loss of kidney function) and epilepsy (a disorder of the brain; disorder in which the brain activity becomes abnormal, causing seizures [sudden, uncontrolled electrical disturbance in the brain] or periods of unusual behavior, sensations and sometimes loss of awareness). The Face Sheet did not indicate a responsible party for Resident 40.
A review of Resident 40's H&P dated 8/31/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 40's care plan for discharge planning dated 7/29/22 indicated a Short term care. Under care of Federal Law Enforcement Agency with the following goals: 1. To return to prior level of independent functioning, and 2. Short term care: Resident will be discharged to a lower level of care when independent in ADLs.
A review of Resident 40's Interdisciplinary Team (group of people from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) Conference Summary dated 10/13/22 indicated the discharge goal for Resident 40 was to go back to the Detention Center (DC-secure facility for inmates) when medically stable.
A review of Resident 40's Physician's Telephone Order dated 10/19/22 at 3:17 PM indicated Transfer to GACH for further evaluation.
A review of Resident 40's Departmental Notes dates 10/19/22 at 10:52 PM indicated Resident transferred to GACH for evaluation and treatment. Informed state surveyor Team Coordinator due to intent deficiency issued.
A review of Resident 40's handwritten Discharge summary dated [DATE], indicated Resident 40's Date of Discharge was 10/19/22. The Discharge Summary indicated the resident was transferred to GACH in fair condition for evaluation. The physician signature of Resident 40's Discharge Summary was left blank.
A review of Resident 40's Notice of Proposed Transfer/Discharge indicated that the notice was provided to the resident on the day of the Physician's Telephone Order to transfer to the GACH on 10/19/22. The Notice indicated a Notification Date of 10/19/22 and an Effective Date of 10/19/22. indicated Resident 40 was transferred to GACH on 10/19/22 with the following reason: The transfer or discharge is necessary for your welfare and your need cannot be met in the facility. The Notice indicated If you intent to file an appeal of this transfer/discharge, it is important to do so within 10 calendar days of being notified. The decision regarding an appeal will normally be made within 30 days from the date of this Notice . The Notice further indicated The facility may not transfer or discharge the resident while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility.
3. A review of Resident 292's Face Sheet indicated an admission to the facility on [DATE] with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements such as shaking, stiffness, and difficulty with balance and coordination), essential hypertension (high blood pressure that does not have a known secondary cause) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). The Face Sheet did not indicate a responsible party for Resident 292.
A review of Resident 292's H&P dated 10/13/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 292's Physician's Telephone Order dated 10/19/22 at 3:11 PM indicated Transfer to GACH for further evaluation.
A review of Resident 292's Interdisciplinary Team Care Conference Summary dated 8/3/22 indicated discharge goal for Resident 292 was to go back to the DC when medically stable.
A review of Resident 292's care plans did not indicate a discharge planning care plan in the resident's records.
A review of Resident 292's Notice of Proposed Transfer/Discharge indicated that the notice was provided to the resident on the day of the Physician's Telephone Order to transfer to the GACH on 10/19/22. The Notice indicated a Notification Date of 10/19/22 and an Effective Date of 10/19/22. indicated Resident 292 was transferred to GACH on 10/19/22 with the following reason: The transfer or discharge is necessary for your welfare and your need cannot be met in the facility. The Notice indicated If you intent to file an appeal of this transfer/discharge, it is important to do so within 10 calendar days of being notified. The decision regarding an appeal will normally be made within 30 days from the date of this Notice . The Notice further indicated The facility may not transfer or discharge the resident while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility.
A review of Resident 292's handwritten Discharge summary dated [DATE], indicated Resident 292's Date of Discharge was 10/19/22. The Discharge Summary indicated the resident was transferred to GACH in fair condition for evaluation. The physician signature of Resident 292's Discharge Summary was left blank.
A review of Resident 292's Departmental Notes dates 10/20/22 timed at 12:05 PM indicated Resident transferred to GACH for evaluation and treatment. Informed state surveyor Team Coordinator due to intent deficiency issued.
4. A review of Resident 14's Face Sheet indicated an admission to the facility on 7/15/22 with diagnoses including essential hypertension, spinal stenosis (occurs when one or more bony openings within the spine begin to narrow and reduce space for the nerves) and depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.) The Face Sheet did not indicate a responsible party for Resident 14.
A review of Resident 14's H&P dated 8/31/22 indicated the resident has the capacity to understand and make decisions.
A review of Resident 14's care plan for discharge planning dated 8/22/22 indicated a Short term care. Under care of Federal Law Enforcement Agency with the following goals: 1. Resident will move to an appropriate level of care without complication and 2. To return to prior level of independent functioning.
A review of Resident 14's Physician's Telephone Order dated 10/19/22 at 2:59 PM indicated Transfer to GACH for further evaluation.
A review of Resident 14's Notice of Proposed Transfer/Discharge indicated that the notice was provided to the resident on the day of the Physician's Telephone Order to transfer to the GACH on 10/19/22. The Notice indicated a Notification Date of 10/19/22 and an Effective Date of 10/19/22. indicated Resident 14 was transferred to GACH on 10/19/22 with the following reason: The transfer or discharge is necessary for your welfare and your need cannot be met in the facility. The Notice indicated If you intent to file an appeal of this transfer/discharge, it is important to do so within 10 calendar days of being notified. The decision regarding an appeal will normally be made within 30 days from the date of this Notice . The Notice further indicated The facility may not transfer or discharge the resident while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility.
A review of Resident's 14's Departmental Notes dates 10/19/22 timed at 9:45 PM indicated Resident transferred to GACH for evaluation and treatment. Informed state surveyor Team Coordinator due to intent deficiency issued.
A review of Resident 14's handwritten Discharge summary dated [DATE], indicated Resident 86's Date of Discharge was 10/19/22. The Discharge Summary indicated the resident was transferred to GACH in fair condition for evaluation. The physician signature of Resident 14's Discharge Summary was left blank.
5. A review of Resident 42's Face Sheet indicated an initial admission to the facility on 6/2/22 with diagnoses including anxiety disorder, chronic pain syndrome (pain that carries on for longer than 12 weeks despite medication or treatment) and malignant (destructive; cancerous) neoplasm (any growth that develops inside or on the body) of oropharynx (a disease in which malignant [cancer] cells form in the tissues of the oropharynx [middle part of the throat, behind the mouth]). The Face Sheet did not indicate a responsible party for Resident 42.
A review of Resident 42's H&P dated 5/10/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 42's Interdisciplinary Team Care Conference Summary dated 8/12/22 indicated discharge goal for Resident 42 was to go back to the DC when medically stable.
A review of Resident 42's care plan for discharge planning dated 8/12/22 indicated a Short term care. Under care of Federal Law Enforcement Agency with a goal for Resident 42 to move to an appropriate level of care without complication.
A review of Resident 42's Physician's Telephone Order dated 10/19/22 at 3:01 PM indicated Transfer to GACH for further evaluation.
A review of Resident 42's Notice of Proposed Transfer/Discharge indicated that the notice was provided to the resident on the day of the Physician's Telephone Order to transfer to the GACH on 10/19/22. The Notice indicated a Notification Date of 10/19/22 and an Effective Date of 10/19/22. indicated Resident 42 was transferred to GACH on 10/19/22 with the following reason: The transfer or discharge is necessary for your welfare and your need cannot be met in the facility. The Notice indicated If you intent to file an appeal of this transfer/discharge, it is important to do so within 10 calendar days of being notified. The decision regarding an appeal will normally be made within 30 days from the date of this Notice . The Notice further indicated The facility may not transfer or discharge the resident while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility.
A review of Resident 342's handwritten Discharge summary dated [DATE], indicated Resident 86's Date of Discharge was 10/19/22. The Discharge Summary indicated the resident was transferred to GACH in fair condition for evaluation. The physician signature of Resident 342's Discharge Summary was left blank.
A review of Resident's 42's Departmental Notes dates 10/19/22 timed at 10:48 PM indicated Resident transferred to GACH for evaluation and treatment. Informed state surveyor Team Coordinator due to intent deficiency issued.
6. A review of Resident 342's Face Sheet indicated an initial admission to the facility on [DATE] with diagnoses including post-traumatic (a mental health condition that's triggered by a terrifying event) stress disorder, borderline personality (a mental health disorder that impacts the way you think and feel about yourself and others) disorder, and bipolar (a mental condition marked by alternating periods of elation and depression) disorder. The Face Sheet did not indicate a responsible party for Resident 342.
A review of Resident 342's H&P dated 10/13/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 342's Interdisciplinary Team Care Conference Summary dated 10/17/22 indicated discharge goal for Resident 292 was to go back to the jail when medically stable.
A review of Resident 342's Physician's Telephone Order dated 10/19/22 at 3:19 PM indicated Transfer to GACH for further evaluation.
A review of Resident 342's Notice of Proposed Transfer/Discharge indicated that the notice was provided to the resident on the day of the Physician's Telephone Order to transfer to the GACH on 10/19/22. The Notice indicated a Notification Date of 10/19/22 and an Effective Date of 10/19/22. indicated Resident 342 was transferred to GACH on 10/19/22 with the following reason: The transfer or discharge is necessary for your welfare and your need cannot be met in the facility. The Notice indicated If you intent to file an appeal of this transfer/discharge, it is important to do so within 10 calendar days of being notified. The decision regarding an appeal will normally be made within 30 days from the date of this Notice . The Notice further indicated The facility may not transfer or discharge the resident while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility.
A review of Resident 342's handwritten Discharge summary dated [DATE], indicated Resident 342's Date of Discharge was 10/19/22. The Discharge Summary indicated the resident was transferred to GACH in fair condition for evaluation. The physician signature of Resident 342's Discharge Summary was left blank.
A review of Resident 342's Departmental Notes dates 10/20/22 at 11:47 PM indicated Resident transferred to GACH for evaluation and treatment. Informed state surveyor Team Coordinator due to intent deficiency issued.
7. A review of Resident 87's Face Sheet indicated an admission to the facility on 9/27/22 with diagnoses including anemia (a condition in which the body does not have enough healthy red blood cells that provide oxygen to body tissues), emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness), secondary malignant neoplasm of bone (cancer [a disease in which abnormal cells divide uncontrollably and destroy body tissue] started in another part of the body but spread to the bone) The Face Sheet did not indicate a responsible party for Resident 87.
A review of Resident 87's undated H&P indicated the resident had the capacity to understand and make decisions.
A review of Resident 87's Interdisciplinary Team Care Conference Summary dated 9/29/22 indicated discharge goal for Resident 87 was to go back to the DC when medically stable.
A review of Resident 87's care plan for discharge planning dated 9/29/22 indicated a Short term care. Under care of Federal Law Enforcement Agency with the following goals: 1. Resident will move to an appropriate level of care without complication and 2. Short term care: Resident will be discharged to a lower level of care when independent in ADLs.
A review of Resident 87's Physician's Telephone Order dated 10/19/22 at 3:14 PM indicated Transfer to GACH for further evaluation.
A review of Resident 87's Notice of Proposed Transfer/Discharge indicated that the notice was provided to the resident on the day of the Physician's Telephone Order to transfer to the GACH on 10/19/22. The Notice indicated a Notification Date of 10/19/22 and an Effective Date of 10/19/22. indicated Resident 87 was transferred to GACH on 10/19/22 with the following reason: The transfer or discharge is necessary for your welfare and your need cannot be met in the facility. The Notice indicated If you intent to file an appeal of this transfer/discharge, it is important to do so within 10 calendar days of being notified. The decision regarding an appeal will normally be made within 30 days from the date of this Notice . The Notice further indicated The facility may not transfer or discharge the resident while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility.
A review of Resident's 87's Departmental Notes dates 10/19/22 timed at 7:52 PM indicated Resident transferred to GACH for evaluation and treatment. Informed state surveyor Team Coordinator due to intent deficiency issued.
A review of Resident 87's handwritten Discharge summary dated [DATE], indicated Resident 87's Date of Discharge was 10/19/22. The Discharge Summary indicated the resident was transferred to GACH in fair condition for evaluation. The physician signature of Resident 87's Discharge Summary was left blank.
8. A review of Resident 76's Face Sheet indicated an initial admission to the facility on 6/29/22 with diagnoses including unspecified part of neck of femur (region just below the ball of the hip joint), phalanx (bone located between the first joint and center knuckle) of right mid finger, shaft of right tibia (middle of right big bone between knee and ankle), fracture (broken bone). The Face Sheet did not indicate a responsible party for Resident 76.
A review of Resident 76's H&P dated 10/13/22, indicated the resident had the capacity to understand and make decisions.
A review of Resident 76's care plan for discharge planning dated 10/12/22 indicated a Short term care. Under care of Federal Law Enforcement Agency without goals and interventions specified.
A review of Resident 76's Interdisciplinary Team Care Conference Summary dated 10/13/22 indicated discharge goal for Resident 76 was to go back to the DC when medically stable.
A review of Resident 76's Physician's Telephone Order dated 10/19/22 at 3:08 PM indicated Transfer to GACH for further evaluation was ordered by DR 1.
A review of Resident's 76's Departmental Notes dates 10/19/22 timed at 9:54 PM indicated Resident transferred to GACH for evaluation and treatment. Informed state surveyor Team Coordinator due to intent deficiency issued.
A review of Resident 76's Notice of Proposed Transfer/Discharge indicated that the notice was provided to the resident on the day of the Physician's Telephone Order to transfer to the GACH on 10/19/22. The Notice indicated a Notification Date of 10/19/22 and an Effective Date of 10/19/22. indicated Resident 76 was transferred to GACH on 10/19/22 with the following reason: The transfer or discharge is necessary for your welfare and your need cannot be met in the facility. The Notice indicated If you intent to file an appeal of this transfer/discharge, it is important to do so within 10 calendar days of being notified. The decision regarding an appeal will normally be made within 30 days from the date of this Notice . The Notice further indicated The facility may not transfer or discharge the resident while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility.
A review of Resident 76's handwritten Discharge summary dated [DATE], indicated Resident 76's Date of Discharge was 10/19/22. The Discharge Summary indicated the resident was transferred to GACH in fair condition for evaluation. The physician signature of Resident 76's Discharge Summary was left blank.
9. A review of Resident 86's Face Sheet indicated an admission to the facility on 9/17/22 with diagnoses including suicidal ideations (thinking about or planning suicide), muscle weakness and traumatic subcutaneous (applied under the skin), emphysema (a condition in which air becomes trapped under the subcutaneous layer of the skin). The Face Sheet did not indicate a responsible party for Resident 86.
A review of Resident 86's H&P dated 9/20/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 86's care plan for discharge planning dated 9/21/22 indicated a Short term care. Under care of Federal Law Enforcement Agency with the following goals: 1. Resident will move to an appropriate level of care without complication and 2. To return to prior level of independent functioning.
A review of Resident 86's Physician's Telephone Order dated 10/19/22 at 2:54 PM indicated Transfer to GACH for further evaluation.
A review of Resident 86's Notice of Proposed Transfer/Discharge indicated that the notice was provided to the resident on the day of the Physician's Telephone Order to transfer to the GACH on 10/19/22. The Notice indicated a Notification Date of 10/19/22 and an Effective Date of 10/19/22. indicated Resident 86 was transferred to GACH on 10/19/22 with the following reason: The transfer or discharge is necessary for your welfare and your need cannot be met in the facility. The Notice indicated If you intent to file an appeal of this transfer/discharge, it is important to do so within 10 calendar days of being notified. The decision regarding an appeal will normally be made within 30 days from the date of this Notice . The Notice further indicated The facility may not transfer or discharge the resident while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility.
A review of Resident's 86's Departmental Notes dates 10/19/22 timed at 9:22 PM indicated Resident transferred to GACH for evaluation and treatment. Informed state surveyor Team Coordinator due to intent deficiency issued.
A review of Resident 86's handwritten Discharge summary dated [DATE], indicated Resident 86's Date of Discharge was 10/19/22. The Discharge Summary indicated the resident was transferred to GACH in fair condition for evaluation. The physician signature of Resident 86's Discharge Summary was left blank.
During a conference meeting via TEAMS (allows users to communicate via text, chat, voice or video call from home or office) on 10/20/22 at 9:41 AM, attended by Department of Public Health (DPH), the ADM, the DON, the VPO, Quality Assurance Consultant (QA Consultant) and the Marketing Director (MKD), MKD stated all nine justice involved residents were transferred to the GACH on 10/19/22 at around 6:30 PM. MKD stated all nine justice involved residents will not return to the facility. MKD stated the Federal Law Enforcement Agency signed the transfer paperwork (discharge papers), but all nine justice involved residents were informed.
During the same conference meeting, MKD stated the reason for discharge the GACH was due to resident's rights and physical restraints (any device attached or adjacent to the body that cannot be easily removed and restricts freedom of movement) findings for the nine justice involved residents. MKD stated due to the Federal Law Enforcement Agency's policy and procedures, the facility was not able to provide and follow the Centers for Medicare & Medicaid Services (CMS-a federal agency within the United States Department of Health and Human Services) regulations and guidelines. MKD stated the facility was not allowed and cannot remove the nine resident's hand cuffs and shackles for safety reasons. MKD stated the discharge of the nine residents would be better and safer for all residents and staff in the facility.
During the same conference meeting, MKD stated all nine justice involved residents were given the Notice of Transfer/Discharge forms three (3) to four (4) hours before all nine justice involved residents were transferred to the GACH. MKD stated, the residents would not be on bed hold since the nine residents were paying privately.
During an interview on 10/20/22 at 2:46 PM, the Social Services Director (SSD) stated for facility initiated discharges, residents and/or responsible parties (RP) should be given enough time to appeal. The SSD stated MKD would be the one involved with the justice involved residents' discharge planning. The SSD stated she was not in the facility during the time of the discharges of the nine justice involved residents that is why nothing were documented in the SSD notes about the discharge on [DATE].
During an interview on 10/20/22 at 5:58 PM with the ADM and the DON, in the presence of the VPO and AADM, VPO stated during non-emergency transfer and discharge, resident can always appeal the discharge and should be given enough time to appeal. ADM stated upon admission, justice involved residents were informed that they were admitted for physical therapy (PT-evaluate and treat abnormal physical function related to an injury, disability, or other health condition to improve residents' range of movement, quality of life and prevent further injury or disability), once their condition improved, Justice Involved Residents will go back to jail. The VPO stated that Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86's transfer to GACH was considered as discharge since the facility was aware that all the nine justice involved residents were not coming back to the facility.
A review of an email communication from the GACH representative dated 10/31/22
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 interview and record review, the facility failed to ensure that the Minimum Data Set (MDS, a standardized assessment an...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the Minimum Data Set (MDS, a standardized assessment and care-screening tool) was coded accurately for seven (7) out of 44 sampled residents (Residents 79, 40, 14, 42, 87, 76, and 86).
During the facility's Annual Health Recertification Survey, the facility applied physical restraints (any device attached or adjacent to the body that cannot be easily removed and restricts freedom of movement) with a locking device (handcuffs, leg cuffs and shackles) to seven justice involved residents (Residents 79, 40, 14, 42, 87, 76, and 86) as directed by a Federal Law Enforcement Agency upon admission to the facility but were not accurately reflected in Residents 79, 40, 14, 42, 87, 76, and 86's MDS transmitted to the Center of Medicare and Medicaid Service (CMS).
This deficient practice had the potential for the resident not to receive treatment, plan of care and/or care services.
Findings:
During the facility's initial tour and observation at the facility's hallway on 10/18/22 at 8:05 AM, and a concurrent interview with Private Security Officer (PSO) 4, stated that all justice involved residents were always chained to the bed, with either handcuffs or shackle (something that confines the legs or arms; one of a pair of metal rings connected by a chain and fastened to a person's wrists or the bottoms of the legs to prevent the person from escaping), except when these residents are going for Physical Therapy or to the bathroom.
During an interview on 10/18/22 at 8:10 AM, PSO 5 stated all justice involved residents were physically restrained to their beds.
On 10/18/22 at 8:32 AM, during the initial tour of the facility, concurrent interview and review of the facility's residents census dated 10/17/22 with the DON, the DON stated the facility had 92 residents residing in the facility. The DON stated Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86 were under a fictitious (not real or true) name to protect the resident's identity and for confidentiality. The DON stated Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86 admitted in the facility were all justice involved residents.
1. During an observation on 10/18/22 at 8:35 AM, Resident 86's room door was open, and Resident 86 was visible from outside the residents' room. Resident 86 was observed with a right-handcuff restraint attached to the bed.
During an interview on 10/18/22 at 9:20 AM, while outside Resident 86's room, PSO 1 stated all justice involved residents walk around in the facility accompanied by two PSOs when they go to physical therapy. PSO 1 stated all justice involved residents were restrained to their bed with hand cuffs (two metal rings, joined by a short chain, that are locked around wrist(s) to prevent free movement). PSO 1 stated every justice involved residents were different when it comes to the number of hand cuffs is applied. PSO 1 stated he was not allowed to tell the DPH state surveyor on how many handcuffs Resident 86 had.
A review of Resident 86's Face Sheet (admission record) indicated an admission to the facility on 9/17/22.
A review of Resident 86's electronic admission Minimum Data Set (MDS- a care area screening and assessment tool) dated 9/21/22 indicated Resident 86 required limited assistance with transfers, toilet use and required total dependence (full staff performance every time during entire 7-day period) with dressing, required limited assistance with transfer and toilet use. The MDS indicated Resident 86 required supervision with bed mobility, eating and personal hygiene. The MDS indicated under Section P (Restraints), P0100, Physical Restraints, Used in bed and Used in Chair or Out of Bed, was coded 0 (not used), meaning Resident 86 did not have/use any limb restraint.
A review of Resident 86's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints while in the facility.
A review of Resident 86's care plan for restraints dated 10/14/22 indicated Resident 86 was at risk for injury and needs physical restraint due to the [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy and 3. Hand cuffs per [Federal Law Enforcement Agency] policy.
2. A review of Resident 79's Face Sheet indicated an admission to the facility on 6/13/22.
A review of Resident 79's electronic quarterly MDS dated [DATE] indicated Resident 79 required supervision (oversight, encouragement or cueing) during bed mobility, transfer, dressing, eating, toilet use and personal hygiene. The MDS indicated under Section P (Restraints), P0100, Physical Restraints, Used in bed and Used in Chair or Out of Bed, was coded as 0 (not used), meaning Resident 79 did not have/use any limb restraint.
A review of Resident 79's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints while in the facility.
A review of Resident 79's care plan for restraints dated 10/14/22 indicated Resident 79 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy and 3. Hand cuffs per [Federal Law Enforcement Agency] policy.
3. On 10/18/22 at 9:26 AM, during a concurrent observation and interview with PSO 2, in the presence of PSO 3, Resident 87 was lying on his bed with a metal locking leg cuffs applied to both legs and secured to the foot part of the bed. PSO 2 stated Resident 87 was restrained on both legs with steel iron chain that is secured to the bed. PSO 2 stated justice involved residents wears handcuffs but since Resident 87 was very fragile, they do not apply it to Resident 87 all the time. PSO 2 stated they would remove both physical restraints to both legs during Resident 87's shower, toileting, and physical therapy.
A review of Resident 87's Face Sheet indicated an admission to the facility on 9/27/22.
A review of Resident 87's electronic admission MDS dated [DATE] indicated Resident 87 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) with bed mobility, transfer, toilet use, personal hygiene and required supervision with dressing and eating. The MDS indicated under Section P (Restraints), P0100, Physical Restraints, Used in bed and Used in Chair or Out of Bed, was coded 0 (not used), meaning Resident 87 did not have/use any limb restraint.
A review of Resident 87's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints while in the facility.
A review of Resident 87's care plan for restraints dated 10/14/22 indicated Resident 87 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy and 3. Hand cuffs per [Federal Law Enforcement Agency] policy.
4. A review of Resident 40's Face Sheet indicated an admission to the facility on 7/29/22.
A review of Resident 40's electronic admission MDS dated [DATE] indicated Resident 40 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) with bed mobility, transfer, dressing, toilet use, personal hygiene and required supervision during eating. The MDS indicated under Section P (Restraints), P0100, Physical Restraints, Used in bed and Used in Chair or Out of Bed, was coded 0 (not used), meaning Resident 40 did not have/use any limb restraint.
A review of Resident 40's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints while in the facility.
A review of Resident 40's care plan for physical device dated 8/1/22 indicated Resident 40 has handcuffs when in bed and out of bed with an intervention to review need for device. restraint possible discontinuation, reduction, less restrictive measures, or continuation of use regularly.
A review of Resident 40's care plan for restraints dated 10/14/22 indicated Resident 40 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] and 3. Hand cuffs per [Federal Law Enforcement Agency] policy.
5. A review of Resident 14's Face Sheet indicated an admission to the facility on 7/15/22.
A review of Resident 14's electronic admission MDS dated [DATE] indicated Resident 14 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transfer, dressing, toilet use, personal hygiene and required supervision during eating. The MDS indicated under Section P (Restraints), P0100, Physical Restraints, Used in bed and Used in Chair or Out of Bed, was coded 0 (not used), meaning Resident 14 did not have/use any limb restraint.
A review of Resident 14's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints while in the facility.
A review of Resident 14's care plan for restraints dated 10/14/22 indicated Resident 14 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy and 3. Hand cuffs per [Federal Law Enforcement Agency] policy.
6. During an interview on 10/18/22 at 8 AM in the presence of three (3) Private Security Officers (PSOs), Resident 42 stated that his AP ordered for Resident 42 to be chained to the bed. Resident 42 stated the reason why he was not chained to the bed that time was because he was going to an outside appointment. Resident 42 stated he was always chained on bed and the PSOs will remove it during physical therapy (PT-evaluate and treat abnormal physical function related to an injury, disability, or other health condition to improve residents' range of movement, quality of life and prevent further injury or disability) and bathroom breaks.
A review of Resident 42's Face Sheet indicated an initial admission to the facility on 6/2/22.
A review of Resident 42's electronic admission MDS dated [DATE] indicated Resident 42 required supervision with bed mobility, transfer, dressing, eating, toilet use and personal hygiene. The MDS indicated under Section P (Restraints), P0100, Physical Restraints, Used in bed and Used in Chair or Out of Bed, was coded 0 (not used), meaning Resident 42 did not have/use any limb restraint.
A review of Resident 42's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints while in the facility.
A review of Resident 42's care plan for restraints dated 10/14/22 indicated Resident 42 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy and 3. Hand cuffs per [Federal Law Enforcement Agency] policy.
7. A review of Resident 76's Face Sheet indicated an initial admission to the facility on 6/29/22.
A review of Resident 76's electronic admission MDS dated [DATE] indicated Resident 76 required supervision with bed mobility, transfer, dressing, toilet use, and personal hygiene. The MDS indicated under Section P (Restraints), P0100, Physical Restraints, Used in bed and Used in Chair or Out of Bed, was coded 0 (not used), meaning Resident 76 did not have/use any limb restraint.
A review of Resident 76's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints while in the facility.
A review of Resident 76's care plan for restraints dated 10/14/22 indicated Resident 76 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy and 3. Hand cuffs per [Federal Law Enforcement Agency] policy.
On 10/18/22 at 12:33 PM, during a concurrent interview and review of seven (7) justice involved resident's MDS, the DON stated the MDS were not coded accurately in seven (7) justice involved residents (Residents 79, 40, 14, 42, 87, 76, and 86) since the facility did not consider the handcuffs, leg cuffs, and shackles as physical restraints upon admission of justice involved residents in the facility. The DON stated the facility recently discussed that the facility would consider the handcuffs, leg cuffs, and shackles as physical restraints moving forward.
During the same interview on 10/18/22 at 12:33 PM, during a concurrent interview and review of all justice involved residents' electronic medical records, the DON stated that all seven (7) nine justice involved residents' MDS coding for physical restraints were only initiated and documented between 10/14/22 and 10/17/22, which were a few days before the state surveyors arrived in the facility.
During an interview on 10/18/22 at 12:43 PM, the DON stated physical restraints were considered as part of the resident's status assessment and should be coded in the MDS.
During an interview on 10/18/22 at 1:28 PM, the DON stated the facility was not able to provide the Department of Public Health (DPH) surveyors copies of MDS transmitted to CMS for the seven (7) justice involved residents as requested. The DON stated the facility was still asking and waiting for the Federal Law Enforcement Agency Supervisor's approval/permission for the DPH surveyors to obtain copies of the justice involved residents' medical records.
During an interview on 10/20/22 at 2:16 PM, MDS Nurse stated he was the one who answered and completed all justice involved residents' MDS sections and the DON signed it off. The MDS stated hand cuffs, leg cuffs and shackles that can restrict resident's movement were applied by the Federal Law Enforcement Agency officers for federal reasons. The MDS stated he would have coded the restraints as 2 (used daily) and not 0 but the MDS Nurse was told by the facility consultants that it was not supposed to be coded since justice involved residents' physical restraints were not a necessity but for federal reasons. The MDS Nurse stated it was not until the facility staff reviewed the real definition of restraints and concluded hand cuffs, leg cuffs and shackles used by the seven (7) justice involved residents whose MDS were already completed and transmitted, were considered as a physical restraint. The MDS stated he amended, modified, and coded the MDS for the seven (7) justice involved residents on 10/17/22 to 10/18/22, then re-submitted it to the Centers for Medicare and Medicaid Services (CMS-a federal agency within the United States Department of Health and Human Services).
A review of the facility's policy and procedure titled Resident Assessments revised in November 2018 indicated the following:
1. The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriate resident assessments and reviews according to the following requirements:
a. Omnibus Budget Reconciliation Act (OBRA-Nursing Reform Act, set forth specific health and safety rules that nursing homes and nursing home staff members must follow to protect nursing home residents) required assessments-conducted for all residents in the facility:
(1) Initial Assessment (Comprehensive)-Conducted within fourteen (14) days of the resident's admission to the facility.
(2) Quarterly Assessment-Conducted not less frequently than three (3) months following the most recent OBRA assessment of any type.
(3) Significant Change in Status Assessment (Comprehensive)-Conducted when there has been a significant change in the resident's condition.
(4) Annual Assessment (Comprehensive)-Conducted not less than once every twelve (12) months.
2. A comprehensive assessment includes:
a. Completion of the Minimum Data Set (MDS)
3.All resident assessment completed within the previous 15 months are maintained in the resident's active clinical record. The results of the assessment are used to develop, review and revise the resident's comprehensive care plan.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
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, facility failed to provide an activity program to support the residents in th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility failed to provide an activity program to support the residents in their choice of activities, that can support resident's physical, emotional and psychosocial well- being, and promote self- esteem for nine (Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86) out of 10 sampled residents.
This deficient practice violated resident's rights and had the potential for Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86 a decreased quality of life causing boredom, withdrawal, frustration resulting in distress, agitation and suicidal ideation.
Findings:
On 10/18/22 at 8:32 AM, during the initial tour of the facility, concurrent interview with the DON and review of the facility's residents census dated 10/17/22, the DON stated the facility had 92 residents residing in the facility. The DON stated Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86 were under a fictitious (not real or true) name to protect the resident's identity and for confidentiality. The DON stated Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86 admitted in the facility were all justice involved residents (residents currently in custody and held involuntarily through operation of law enforcement authorities in an institution, which is the responsibility of a governmental unit or over which a governmental unit exercise administrative control).
On 10/18/2022 at 9:26 AM, Private Security Officer (PSO) 2 stated that two PSOs were assigned to supervise each of the nine justice involved residents in the facility. PSO 2 stated there were three working shifts per day, 8 hours per shift. PSO 2 stated Justice Involved Residents needs 24-hour supervision, to keep an eye on Justice Involved Residents daily activities. PSO 2 stated the justice involved residents were not allowed to eat in the facility's dining room and do everything inside the resident's room. PSO 2 stated justice involved residents' contact with the public were very limited and were only allowed to go outside the resident's room during physical therapy (PT-evaluate and treat abnormal physical function related to an injury, disability, or other health condition to improve residents' range of movement, quality of life and prevent further injury or disability).
1. On 10/18/22 at 9:29 AM, during a concurrent observation and interview with Resident 87, in the presence of PSO 2 and PSO 3, Resident 87 was observed lying on his bed with a metal locking leg cuffs applied to both legs and secured to the foot part of the bed. Resident 87 stated he was not allowed to receive visitors or go outside of the room except during PT.
A review of Resident 87's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] with diagnoses including anemia (a condition in which the body does not have enough healthy red blood cells that provide oxygen to body tissues), emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness), secondary malignant neoplasm of bone (cancer [a disease in which abnormal cells divide uncontrollably and destroy body tissue] started in another part of the body but spread to the bone)
A review of Resident 87's undated History and Physical (H&P) indicated the resident had the capacity to understand and make decisions.
A review of Resident 87's Minimum Data Set (MDS- a care area screening and assessment tool) dated 8/23/22 indicated Resident 42 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) with bed mobility, transfer, toilet use, personal hygiene and required supervision with dressing and eating.
A review of Resident 87's untitled care plan dated 9/28/22, indicated facility cannot provide activity to inmates per US Marshals (Federal law enforcement) policy with an intervention to provide care as per US Marshals policy as long as it does not interfere with daily function and time, and monitor for signs and symptoms of anxiety and report to medical doctor if behavior interferes with daily function.
A review of Resident 87's care plan for activity/psychosocial wellbeing dated 9/28/22, indicated As per US Marshal; policy, resident under their care are not allowed for social activities. The care plan indicated an intervention to post activity calendar within resident site.
2. A review of Resident 86's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including suicidal ideations (thinking about or planning suicide), muscle weakness and traumatic subcutaneous (applied under the skin), emphysema (a condition in which air becomes trapped under the subcutaneous layer of the skin).
A review of Resident 86's H&P dated 9/20/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 86's MDS dated [DATE] indicated Resident 86 required limited assistance with transfers, toilet use and required total dependence (full staff performance every time during entire 7-day period) with dressing, required limited assistance with transfer and toilet use. The MDS indicated Resident 86 required supervision with bed mobility, eating and personal hygiene.
A review of Resident 86's untitled care plan dated 10/10/22, indicated facility cannot provide activity to inmates (a person confined to an institution such as a prison or hospital) per US Marshals policy with an intervention to provide care as per US Marshals policy as long as it does not interfere with daily function and time, and monitor for signs and symptoms of anxiety and report to medical doctor if behavior interferes with daily function.
A review of Resident 86's care plan for cognitive loss/communication dated 9/20/22, indicated the resident has cognitive and communication deficit manifested by modified independence decision making, problem understanding others related to his diagnosis of schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly). The care plan indicated an intervention to provide resident activities that enhance abilities, reinforce strengths and maximize deficits.
A review of Resident 86's care plan for psychotropic medication (a drug that affects behavior, mood, thoughts, or perception) dated 9/20/22, indicated Resident 86 requires the use of antipsychotic medication (drug used to treat psychotic disorders) with an intervention for regular, predictable routines with pleasant activities.
A review of Resident 86's care plan for behavior dated 9/20/22, indicated Resident 86 needs behavior management related to Resident 86's diagnosis of depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) manifested by suicidal ideation. The care plan indicated an intervention to encourage Resident 86 to participate in activities.
3. A review of Resident 79's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including insomnia (persistent problems falling and staying asleep) and personal history of COVID-19 ([Coronavirus] a disease that can triggers a respiratory [lung] tract infection affecting the upper respiratory tract [sinuses, nose, and throat] and/or lower respiratory tract [windpipe and lungs] the virus spreads mainly through person-to-person contact).
A review of Resident 79's H&P dated 6/15/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 79's MDS dated [DATE] indicated Resident 79 required supervision (oversight, encouragement, or cueing) during bed mobility, transfer, dressing, eating, toilet use and personal hygiene.
A review of Resident 79's untitled care plan dated 6/14/22, indicated facility cannot provide activity to inmates per US Marshals policy with an intervention to provide care as per US Marshals policy as long as it does not interfere with daily function and time, and to monitor for signs and symptoms of anxiety and report to medical doctor if behavior interferes with daily function.
A review of Resident 79's care plan for psychosocial dated 6/14/22 indicated Resident 79 had alterations in psychosocial functions as manifested by changes in roles/status/relocation and feeling of isolation from family and community friends with an intervention to attend activities of choice.
4. A review of Resident 40's Face Sheet indicated an admission to the facility on 7/29/22 with diagnoses including Type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), chronic kidney disease (gradual loss of kidney function) and epilepsy (a disorder of the brain; disorder in which the brain activity becomes abnormal, causing seizures [sudden, uncontrolled electrical disturbance in the brain] or periods of unusual behavior, sensations and sometimes loss of awareness).
A review of Resident 40's H&P dated 8/31/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 40's MDS dated [DATE] indicated Resident 40 required limited assistance with bed mobility, transfer, dressing, toilet use, personal hygiene and required supervision during eating.
A review of Resident 40's untitled care plan dated 8/1/22, indicated facility cannot provide activity to inmates per US Marshals policy with an intervention to provide care as per US Marshals policy as long as it does not interfere with daily function and time, and to monitor for signs and symptoms of anxiety and report to medical doctor if behavior interferes with daily function.
A review of Resident 40's care plan for cognitive loss/communication dated 8/1/22, indicated Resident 40 has cognitive and communication deficits as manifested by modified independence with decision-making with Activities of Daily Livings (ADLs) and at risk for further decline/needs not being met with an intervention to encourage choice of care, clothes, and activity as capable, and place resident in activities that enhance his/her abilities, reinforce strengths, and maximize deficits,
5. A review of Resident 292's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements such as shaking, stiffness, and difficulty with balance and coordination), essential hypertension (high blood pressure that does not have a known secondary cause) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).
A review of Resident 292's H&P dated 10/13/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 292's untitled care plan dated 10/12/22, indicated facility cannot provide activity to inmates per US Marshals policy with an intervention to 1. Provide care as per US Marshals policy as long as it does not interfere with daily function and time, and to monitor for signs and symptoms of anxiety and report to medical doctor if behavior interferes with daily function.
6. A review of Resident 14's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including essential hypertension, spinal stenosis (occurs when one or more bony openings within the spine begin to narrow and reduce space for the nerves) and depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.)
A review of Resident 14's H&P dated 8/31/22 indicated the resident has the capacity to understand and make decisions.
A review of Resident 14's MDS dated [DATE] indicated Resident 40 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transfer, dressing, toilet use, personal hygiene and required supervision during eating.
A review of Resident 14's untitled care plan dated 8/19/22, indicated facility cannot provide activity to inmates per US Marshals policy with an intervention to provide care as per US Marshals policy as long as it does not interfere with daily function and time, and to monitor for signs and symptoms of anxiety and report to medical doctor if behavior interferes with daily function.
7. A review of Resident 42's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including anxiety disorder, chronic pain syndrome (pain that carries on for longer than 12 weeks despite medication or treatment) and malignant (destructive; cancerous) neoplasm (any growth that develops inside or on the body) of oropharynx (a disease in which malignant [cancer] cells form in the tissues of the oropharynx [middle part of the throat, behind the mouth]).
A review of Resident 42's H&P dated 5/10/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 42's MDS dated [DATE] indicated Resident 42 required supervision with bed mobility, transfer, dressing, eating, toilet use and personal hygiene.
A review of Resident 42's untitled care plan dated 6/6/22, indicated facility cannot provide activity to inmates per US Marshals policy with an intervention to provide care as per US Marshals policy as long as it does not interfere with daily function and time, and to monitor for signs and symptoms of anxiety and report to medical doctor if behavior interferes with daily function.
8. A review of Resident 342's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including post-traumatic (a mental health condition that's triggered by a terrifying event) stress disorder, borderline personality (a mental health disorder that impacts the way you think and feel about yourself and others) disorder, and bipolar (a mental condition marked by alternating periods of elation and depression) disorder.
A review of Resident 342's H&P dated 10/13/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 342's untitled care plan dated 10/14/22, indicated facility cannot provide activity to inmates per US Marshals policy with an intervention to provide care as per US Marshals policy as long as it does not interfere with daily function and time, and to monitor for signs and symptoms of anxiety and report to medical doctor if behavior interferes with daily function.
A review of Resident 342's care plan for behavior dated 10/14/22, indicated Resident 342 needs behavior management due to Resident 342's diagnosis of depression with an intervention to involve Resident 342 in daily activity of choice or needed, as allowed.
9. A review of Resident 76's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including unspecified part of neck of femur (region just below the ball of the hip joint), phalanx (bone located between the first joint and center knuckle) of right mid finger, shaft of right tibia (middle of right big bone between knee and ankle), fracture (broken bone).
A review of Resident 76's H&P dated 10/13/22, indicated the resident had the capacity to understand and make decisions.
A review of Resident 76's MDS dated [DATE] indicated Resident 76 required supervision with bed mobility, transfer, dressing, toilet use, and personal hygiene.
A review of Resident 76's untitled care plan dated 10/13/22, indicated facility cannot provide activity to inmates per US Marshals policy with an intervention to provide care as per US Marshals policy as long as it does not interfere with daily function and time, and to monitor for signs and symptoms of anxiety and report to medical doctor if behavior interferes with daily function.
A review of Resident 76's care plan for activity/psychosocial wellbeing dated 10/17/22, indicated As per US Marshal; policy, resident under their care are not allowed for social activities. The care plan indicated an intervention to post activity calendar within resident site.
During an interview on 10/18/22 at 9 AM, PSO 6 stated that state surveyors cannot enter the justice involved resident's rooms and would not answer any more questions about the justice involved residents.
During an interview with PSO 1, on 10/18/22 at 9:20 AM, PSO 1 stated for all the other needs of the justice involved residents, the facility staff need to go through the Federal Law Enforcement Agency approval which included visitations, activities, and other special requests.
During an interview on 10/18/22 at 2:47 PM, the DON stated all justice involved residents were not allowed to go in the facility's common area like patios, dining room and activity room for the safety of other residents and staff.
During an interview on 10/18/22 at 2:51 PM, Activities Director (AD) stated all justice involved residents were not allowed to go to the facility's Dining and Activity Room. The AD stated she was not allowed to offer and provide justice involved residents with books or anything that can harm themselves and other people in the facility. The AD stated she asked the Federal Law Enforcement agent what the justice involved residents can do aside from watching TV inside their rooms, and the response AD received was nothing (no other activities).
During an observation on 10/18/22 between the hours of 8:23 AM to 5 PM, all justice involved residents were observed inside their rooms with their doors closed with two security personnel (Federal Law Enforcement agent or PSOs) watching and monitoring each resident. The nine justice involved residents were not observed coming outside their rooms or going inside the facility's Dining and Activity Rooms.
A review of a Memorandum (a short note designating something to be remembered, especially something to be done or acted upon in the future) addressed to the facility and MKD, titled Policy and Procedures for Inmates in Nursing Home Facilities, dated 8/20/2021, signed by the Federal Law Enforcement Deputy and written in the Federal Law Enforcement letterhead indicated the following information:
- Every client (inmate) that resides in a nursing home facility will be always accompanied by security staff (24 hours).
- For a client (inmate) to participate in an extra activity, it must be pre-approved by the (Federal Law Enforcement Agency). Clients will not be able to participate in any activity which involved non-custodial (a person found guilty of a crime or offense and punishment does not involve going to prison) members of the Skilled Nursing Facility.
A review of a Memorandum from the Centers for Medicare & Medicaid Services (CMS-a federal agency within the United States Department of Health and Human Services) titled Updated Guidance to Surveyors on Federal Requirements for Providing Services to Justice Involved Individuals revised in 12/23/16 indicated, Skilled Nursing Facilities (SNFs) and Nursing Facilities (NFs), as residential environments, must permit residents to have autonomy and choice, to the maximum extent practicable regarding how they wish to live their everyday lives and receive care. Federal statutes and regulations establish an array of individual rights and safeguards. Nursing homes cannot impose conditions or restrictions that undetermined resident rights and protections required by federal law .Resident rights in the nursing home include but are not limited to the right to choose activities, schedules, and health care consistent with his or her interests, assessments and plans of care. Also, nursing home residents must not only be able to exercise their rights as residents of the facility and as citizens of the United Sates, but also have the right to be free of interference, coercion, discrimination, or reprisal from the facility in exercising those rights. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide the necessary care and treatment for nine out of nine (Res...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide the necessary care and treatment for nine out of nine (Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86) justice involved residents (residents currently in custody and held involuntarily through operation of law enforcement authorities in an institution, which is the responsibility of a governmental unit or over which a governmental unit exercises administrative control) residing in the facility in accordance with the facility's policy and procedures (P&P) by failing to:
1. Ensure facility staff assessed and monitored nine (Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86) justice involved residents for any possible skin breakdown and injury while on physical restraints (any device attached or adjacent to the body that cannot be easily removed and restricts freedom of movement) upon admission to the facility, which included handcuffs and shackles applied to the wrists and ankles.
2. Ensure a comprehensive care plan for the nine (Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86) justice involved residents were developed to prevent skin breakdown and circulation impairment were developed upon application and due to the use of the physical restraints in the facility.
These deficient practices had the potential to cause serious skin breakdown, injuries, and circulatory impairment to the nine residents with physical restraints applied while in the facility.
Findings:
During the facility's initial tour and observation at the facility's hallway on 10/18/22 at 8:05 AM, and a concurrent interview with Private Security Officer (PSO) 4, stated that all justice involved residents were always chained to the bed, with either handcuffs or shackle (something that confines the legs or arms; one of a pair of metal rings connected by a chain and fastened to a person's wrists or the bottoms of the legs to prevent the person from escaping), except when these residents are going for Physical Therapy or to the bathroom.
During an interview on 10/18/22 at 8:10 AM, PSO 5 stated all justice involved residents were physically restrained to their beds.
On 10/18/22 at 8:32 AM, during the initial tour of the facility, concurrent interview and review of the facility's residents census dated 10/17/22 with the DON, the DON stated the facility had 92 residents residing in the facility.
The DON stated Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86 were under a fictitious (not real or true) name to protect the resident's identity and for confidentiality. The DON stated Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86 admitted in the facility were all justice involved residents.
On 10/18/2022 at 12:16 PM, the DON stated the DPH state surveyors were not allowed to access all justice involved residents' paper resident's records and physical charts without the Federal Law Enforcement Agency Supervisor's approval.
1. During an observation on 10/18/22 at 8:35 AM, Resident 86's room door was open, and Resident 86 was visible from outside the residents' room. Resident 86 was observed with a right-handcuff restraint attached to the bed.
During an interview on 10/18/22 at 9:20 AM, while outside Resident 86's room, PSO 1 stated all justice involved residents walk around in the facility accompanied by two PSOs when they go to physical therapy. PSO 1 stated all justice involved residents were restrained to their bed with hand cuffs (two metal rings, joined by a short chain, that are locked around wrist(s) to prevent free movement). PSO 1 stated every justice involved residents were different when it comes to the number of hand cuffs is applied. PSO 1 stated he was not allowed to tell the DPH state surveyor on how many handcuffs Resident 86 had.
A review of Resident 86's Face Sheet indicated an admission to the facility on 9/17/22.
A review of Resident 86's History and Physical (H&P) dated 9/20/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 86's Minimum Data Set (MDS- a care area screening and assessment tool) dated 9/21/22 indicated Resident 86 required limited assistance with transfers, toilet use and required total dependence (full staff performance every time during entire 7-day period) with dressing, required limited assistance with transfer and toilet use.
A review of Resident 86's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints and skin monitoring while on physical restraints.
A review of Resident 86's Physician's Telephone Order dated 10/18/22, indicated attending physician (AP) 1 ordered to monitor Resident 86's skin integrity and circulation due to use of shackles/handcuffs and notify medical doctor for any signs of skin breakdown.
A review of Resident 86's care plan for restraints dated 10/14/22 indicated Resident 86 was at risk for injury and needs physical restraint due to the [Federal Law Enforcement Agency] policy with the following interventions:
1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy, 3. Hand cuffs per [Federal Law Enforcement Agency] policy, and 4. Monitor skin integrity every shift, notify medical doctor for any sign of skin breakdown.
A review of Resident 86's Treatment Administration Record (TAR) and Medication Administration Record (MAR) for the month of October 2022, indicated there was no monitoring of Resident 86's skin integrity and circulation and was only initiated on 10/18/22 when the DPH state surveyors arrived.
On 10/18/22 at 12:33 PM, during a concurrent interview and record review of Resident 86's medical records (nurses notes, care plans, progress notes, medication administration records), the DON stated there were no documented evidence of ongoing monitoring and reevaluation for the continued use of restraints for Resident 86. The DON stated, there were no physician's order for physical restraints and monitoring for skin integrity and circulation while the resident was on physical restraints.
2. A review of Resident 79's Face Sheet (admission record) indicated an admission to the facility on 6/13/22.
A review of Resident 79's History and Physical (H&P) dated 6/15/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 79's MDS dated [DATE] indicated Resident 79 required supervision (oversight, encouragement or cueing) during bed mobility, transfer, dressing, eating, toilet use and personal hygiene.
A review of Resident 79's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints and skin monitoring while on physical restraints.
A review of Resident 79's Physician's Telephone Order dated 10/18/22, indicated AP 1 ordered to monitor Resident 86's skin integrity and circulation due to use of shackles/handcuffs and notify medical doctor for any signs of skin breakdown.
A review of Resident 79's care plan for restraints dated 10/14/22 indicated Resident 79 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy, 3. Hand cuffs per [Federal Law Enforcement Agency] policy and 4. Monitor skin integrity every shift, notify medical doctor for any sign of skin breakdown.
A review of Resident 79's TAR and MAR for the month of October 2022, indicated there was no monitoring of Resident 76's skin integrity and circulation and was only initiated when the state surveyors arrived on 10/18/22.
On 10/18/22 at 12:33 PM, during a concurrent interview and record review of Resident 76's medical records (nurses notes, care plans, progress notes, medication administration records), the DON stated there were no documented evidence of ongoing monitoring and reevaluation for the continued use of restraints for Resident 76. The DON stated, there were no physician's order for physical restraints and monitoring for skin integrity and circulation while the resident was on physical restraints.
3. On 10/18/22 at 9:26 AM, during a concurrent observation and interview with PSO 2, in the presence of PSO 3, Resident 87 was lying on his bed with a metal locking leg cuffs applied to both legs and secured to the foot part of the bed. PSO 2 stated Resident 87 was restrained on both legs with steel iron chain that is secured to the bed. PSO 2 stated justice involved residents wears handcuffs but since Resident 87 was very fragile, they do not apply it to Resident 87 all the time. PSO 2 stated they would remove both physical restraints to both legs during Resident 87's shower, toileting, and physical therapy.
A review of Resident 87's Face Sheet indicated an admission to the facility on 9/27/22.
A review of Resident 87's undated H&P indicated the resident had the capacity to understand and make decisions.
A review of Resident 87's MDS dated [DATE] indicated Resident 42 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) with bed mobility, transfer, toilet use, personal hygiene and required supervision with dressing and eating.
A review of Resident 87's MDS dated [DATE] indicated Resident 87 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) with bed mobility, transfer, toilet use, personal hygiene and required supervision with dressing and eating.
A review of Resident 87's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints and skin monitoring while on physical restraints.
A review of Resident 87's Physician's Telephone Order dated 10/18/22, indicated AP 1 ordered to monitor Resident 87's skin integrity and circulation due to use of shackles/handcuffs and notify medical doctor for any signs of skin breakdown.
A review of Resident 87's care plan for restraints dated 10/14/22 indicated Resident 87 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy, 3. Hand cuffs per [Federal Law Enforcement Agency] policy and 4. Monitor skin integrity every shift, notify medical doctor for any sign of skin breakdown.
A review of Resident 87's TAR and MAR for the month of October 2022, indicated there was no monitoring of Resident 87's skin integrity and was only initiated when the state surveyors arrived on 10/18/22.
On 10/18/22 at 12:33 PM, during a concurrent interview and record review of Resident 87's medical records (nurses notes, care plans, progress notes, medication administration records), the DON stated there were no documented evidence of ongoing monitoring and reevaluation for the continued use of restraints for Resident 87. The DON stated, there were no physician's order for physical restraints and monitoring for skin integrity and circulation while the resident was on physical restraints.
4. A review of Resident 40's Face Sheet indicated an admission to the facility on 7/29/22.
A review of Resident 40's H&P dated 8/31/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 40's MDS dated [DATE] indicated Resident 40 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) with bed mobility, transfer, dressing, toilet use, personal hygiene and required supervision during eating.
A review of Resident 40's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints and skin monitoring while on physical restraints.
A review of Resident 40's Physician's Telephone Order dated 10/18/22, indicated DR 1 ordered to monitor Resident 40's skin integrity and circulation due to use of shackles/handcuffs and notify medical doctor for any signs of skin breakdown.
A review of Resident 40's care plan for physical device dated 8/1/22 indicated Resident 40 has handcuffs when in bed and out of bed with an intervention to: 1. Do visual check at least every shift for circulation, 2. Provide protective skin care, 3. Monitor skin condition, and 4. Monitor for potential adverse effects/complications with device/restraint use, report to medical doctor if noted.
A review of Resident 40's care plan for restraints dated 10/14/22 indicated Resident 40 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1.
Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy, 3. Hand cuffs per [Federal Law Enforcement Agency] policy and 4. Monitor skin integrity every shift, notify medical doctor for any sign of skin breakdown.
A review of Resident 40's TAR and MAR for the month of October 2022, indicated there was no monitoring of Resident 40's skin integrity and circulation due to the use of physical restraints and was only initiated when the state surveyors arrived on 10/18/22.
On 10/18/22 at 12:33 PM, during a concurrent interview and record review of Resident 40's medical records (nurses notes, care plans, progress notes, medication administration records), the DON stated there were no documented evidence of ongoing monitoring and reevaluation for the continued use of restraints for Resident 40. The DON stated, there were no physician's order for physical restraints and monitoring for skin integrity and circulation while the resident was on physical restraints.
5. A review of Resident 292's Face Sheet indicated an admission to the facility on [DATE].
A review of Resident 292's H&P dated 10/13/22 indicated the resident had the capacity to understand and make decisions
A review of Resident 292's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints and skin monitoring while on physical restraints.
A review of Resident 292's Physician's Orders for the month of October 2022, indicated there were no physician orders for skin monitoring, circulation, skin and wound treatment due to the use of physical restraint.
A review of Resident 292's Physician's Telephone Order dated 10/18/22, indicated AP 1 ordered to monitor Resident 292's skin integrity and circulation due to the use of shackles/handcuffs and notify medical doctor for any signs of skin breakdown.
A review of Resident 292's care plan for restraints dated 10/14/22 indicated Resident 292 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy, 3. Hand cuffs per [Federal Law Enforcement Agency] policy and 4. Monitor skin integrity every shift, notify medical doctor for any sign of skin breakdown.
A review of Resident 292's Shower Day Inspection form dated 10/19/22, indicated Resident 292 had shackles placed on Resident 292's right leg. The form indicated Resident 292's both lower extremities had redness spots.
A review of Resident 292's TAR and MAR for the month of October 2022, indicated there was no monitoring of Resident 40's skin integrity and circulation due to the use of physical restraints and was only initiated when the state surveyors arrived on 10/18/22.
On 10/18/22 at 12:33 PM, during a concurrent interview and record review of Resident 292's medical records (nurses notes, care plans, progress notes, medication administration records), the DON stated there were no documented evidence of ongoing monitoring and reevaluation for the continued use of restraints for Resident 292. The DON stated, there were no physician's order for physical restraints and monitoring for skin integrity and circulation while the resident was on physical restraints.
6. A review of Resident 14's Face Sheet indicated an admission to the facility on 7/15/22.
A review of Resident 14's H&P dated 8/31/22 indicated the resident has the capacity to understand and make decisions.
A review of Resident 14's MDS dated [DATE] indicated Resident 14 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transfer, dressing, toilet use, personal hygiene and required supervision during eating.
A review of Resident 14's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints and skin monitoring while on physical restraints.
A review of Resident 14's Physician's Telephone Order dated 10/18/22, indicated DR 1 ordered to monitor Resident 14's skin integrity and circulation due to use of shackles/handcuffs and notify medical doctor for any signs of skin breakdown.
A review of Resident 14's care plan for restraints dated 10/14/22 indicated Resident 14 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy, 3. Hand cuffs per [Federal Law Enforcement Agency] policy and 4. Monitor skin integrity every shift, notify medical doctor for any sign of skin breakdown.
A review of Resident 14's TAR and MAR for the month of October 2022, indicated there was no monitoring of Resident 14's skin integrity and circulation due to the use of physical restraints and was only initiated when the state surveyors arrived on 10/18/22. not until 10/18/22 when the state surveyors arrived.
On 10/18/22 at 12:33 PM, during a concurrent interview and record review of Resident 14's medical records (nurses notes, care plans, progress notes, medication administration records), the DON stated there were no documented evidence of ongoing monitoring and reevaluation for the continued use of restraints for Resident 14. The DON stated, there were no physician's order for physical restraints and monitoring for skin integrity and circulation while the resident was on physical restraints.
7. A review of Resident 42's Face Sheet indicated an initial admission to the facility on 6/2/22.
A review of Resident 42's H&P dated 5/10/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 42's MDS dated [DATE] indicated Resident 42 required supervision with bed mobility, transfer, dressing, eating, toilet use and personal hygiene.
A review of Resident 42's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints and skin monitoring while on physical restraints.
A review of Resident 42's Physician's Telephone Order dated 10/18/22, indicated DR 1 ordered to monitor Resident 42's skin integrity and circulation due to use of shackles/handcuffs and notify medical doctor for any signs of skin breakdown.
A review of Resident 42's care plan for restraints dated 10/14/22 indicated Resident 42 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy, 3. Hand cuffs per [Federal Law Enforcement Agency] policy and 4. Monitor skin integrity every shift, notify medical doctor for any sign of skin breakdown.
During an interview on 10/18/22 at 8 AM in the presence of three (3) Private Security Officers (PSOs), Resident 42 stated that his AP ordered for Resident 42 to be chained to the bed. Resident 42 stated the reason why he was not chained to the bed that time was because he was going to an outside appointment. Resident 42 stated he was always chained on bed and the PSOs will remove it during physical therapy (PT-evaluate and treat abnormal physical function related to an injury, disability, or other health condition to improve residents' range of movement, quality of life and prevent further injury or disability) and bathroom breaks.
A review of Resident 42's TAR and MAR for the month of October 2022, indicated there was no monitoring of Resident 42's skin integrity and circulation due to the use of physical restraints and was only initiated when the state surveyors arrived on 10/18/22.
On 10/18/22 at 12:33 PM, during a concurrent interview and record review of Resident 42's medical records (nurses notes, care plans, progress notes, medication administration records), the DON stated there were no documented evidence of ongoing monitoring and reevaluation for the continued use of restraints for Resident 42. The DON stated, there were no physician's order for physical restraints and monitoring for skin integrity and circulation while the resident was on physical restraints.
8. A review of Resident 342's Face Sheet indicated an initial admission to the facility on [DATE].
A review of Resident 342's H&P dated 10/13/22 indicated the resident had the capacity to understand and make decisions.
A review of Resident 342's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints skin monitoring while on physical restraints.
A review of Resident 42's Physician's Telephone Order dated 10/18/22, indicated DR 1 ordered to monitor Resident 42's skin integrity and circulation due to use of shackles/handcuffs and notify medical doctor for any signs of skin breakdown.
A review of Resident 42's TAR and MAR for the month of October 2022, indicated there was no monitoring of Resident 42's skin integrity and circulation due to the use of physical restraints and was only initiated when the state surveyors arrived on 10/18/22.
A review of Resident 342's care plan for restraints dated 10/14/22 indicated Resident 342 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy, 3. Hand cuffs per [Federal Law Enforcement Agency] policy and 4. Monitor skin integrity every shift, notify medical doctor for any sign of skin breakdown.
A review of Resident 342's TAR and MAR for the month of October 2022, indicated there was no monitoring of Resident 342's skin integrity and circulation due to the use of physical restraints and was only initiated when the state surveyors arrived on 10/18/22.
On 10/18/22 at 12:33 PM, during a concurrent interview and record review of Resident 342's medical records (nurses notes, care plans, progress notes, medication administration records), the DON stated there were no documented evidence of ongoing monitoring and reevaluation for the continued use of restraints for Resident 342. The DON stated, there were no physician's order for physical restraints and monitoring for skin integrity and circulation while the resident was on physical restraints.
9. A review of Resident 76's Face Sheet indicated an initial admission to the facility on 6/29/22.
A review of Resident 76's H&P dated 10/13/22, indicated the resident had the capacity to understand and make decisions.
A review of Resident 76's MDS dated [DATE] indicated Resident 76 required supervision with bed mobility, transfer, dressing, toilet use, and personal hygiene.
A review of Resident 76's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints skin monitoring while on physical restraints.
A review of Resident 76's Physician's Telephone Order dated 10/18/22, indicated DR 1 ordered to monitor Resident 76's skin integrity and circulation due to use of shackles/handcuffs and notify medical doctor for any signs of skin breakdown.
A review of Resident 76's care plan for restraints dated 10/14/22 indicated Resident 76 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy and 3. Hand cuffs per [Federal Law Enforcement Agency] policy.
A review of Resident 76's TAR and MAR for the month of October 2022, indicated there was no monitoring of Resident 76's skin integrity and circulation due to the use of physical restraints and was only initiated when the state surveyors arrived on 10/18/22.
On 10/18/22 at 12:33 PM, during a concurrent interview and record review of Resident 76's medical records (nurses notes, care plans, progress notes, medication administration records), the DON stated there were no documented evidence of ongoing monitoring and reevaluation for the continued use of restraints for Resident 76. The DON stated, there were no physician's order for physical restraints and monitoring for skin integrity and circulation while the resident was on physical restraints.
On 10/18/22 at 12:33 PM, during the concurrent interview and review of all nine justice involved residents' electronic medical records, the DON stated skin monitoring were only initiated between few days ago (10/14/18) and when the state surveyors arrived in the facility (10/18/22). The DON stated there were no monitoring for skin integrity due to the use of physical restraints in all nine justice involved residents' TAR and MAR. The DON stated residents on physical restraints should have skin monitoring and must be documented in MAR or TAR.
During the same interview on 10/18/22 at 12:33 PM, the DON stated the facility did not consider the handcuffs, leg cuffs, and shackles as physical restraints upon admission of justice involved residents in the facility. The DON stated the facility recently discussed that the facility would consider the handcuffs, leg cuffs, and shackles as physical restraints moving forward. The DON stated skin monitoring should be documented and reflect in either TAR and/or MAR regardless of if the physician's order was on paper or electronic chart/medical records.
During an interview on 10/19/22 at 7:02 AM, CNA 1 stated justice involved residents were cuffed/restrained. CNA 1 stated it was the treatment nurses who checks justice involved resident's skin and treatment nurses would sometimes put bandages on justice involved resident's skin with physical restraint. CNA 1 stated the facility staff does not have keys to the locked physical restraints.
During an interview on 10/19/22 at 7:11 AM, CNA 2 stated all justice involved residents have metal handcuffs and leg cuffs applied to them and attached to their beds. CNA 2 stated she does not check justice involved resident's skin, sometimes justice involved resident's does not want CNA 2 to check justice involved resident's skin. CNA 2 stated she does not check justice involved resident's wrist or foot area; it was the treatment nurse who does the skin monitoring. CNA 2 stated the facility staff does not have keys to the locked physical restraints.
During an interview on 10/19/22 at 7:22 AM, Treatment Nurse (TXN) 1 stated she does skin assessment to all residents and assessed for skin discoloration, skin injury and other reportable skin issues. TXN 1 stated some justice involved residents had dermatology (skin) issues like itchiness that needed treatment, wound consult and some justice involved residents had existing wounds that been resolved before discharged . TXN 1 stated Resident 86 was handcuffed and shackled. TXN 1 stated Resident 87 was handcuffed. TXN 1 stated facility staff do not have keys to all justice involved residents including treatment and/or wound nurses. TXN 1 stated shackles rubbed the resident's skin and if TXN 1 noticed some redness, TXN 1 would apply foam dressing (wound dressing) but will need permission from Federal Law Enforcement since TXN 1 did not have keys to justice involved resident's physical restraints and was not allowed to remove the physical restraints. TXN 1 stated she will notify the AP and/or the dermatologist (a medical doctor who specializes in conditions that affect the skin, hair and nails) for any skin issues that needs treatment. TXN 1 stated she does not see all justice involved residents regularly if there are no wound/skin issues. TXN 1 stated there were no order for regular skin monitoring or evaluation of skin breakdown for use of physical restraints. TXN 1 stated We do not do such thing and most justice involved residents were alert and able to verbally report to the staff if they have skin problems and issues caused by physical restraints. TXN 1 stated she could not find documented evidence of skin monitoring for physical restraints use in the TAR for the nine justice involved residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the safe storage of medications for one of two ...
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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 safe storage of medications for one of two medication rooms (Medication room [ROOM NUMBER]) inspected. The facility had multiple expired medications not destructed and one opened bottle of vitamin not labeled when it was opened.
These deficient practices had the potential for residents to receive expired medications and experience adverse reactions.
Findings:
During an inspection of Medication room [ROOM NUMBER] with the Director of Nursing (DON) on 10/19/22 at 9:17 AM, the following were observed:
a.One erythromycin (medication used to treat infection) ophthalmic (relating to the eye) ointment, expiration date of 1/3/21
b.One E-Kit with the following expired medications:
i.one lorazepam intensol (medication used to treat anxiety) oral spray 2 milligram (mg, a unit of measurement)/milliliter (ml, unit of measurement), expiration date of 4/2022
ii.one atropine sulfate 1% solution [used before eye examinations to dilate (open) the pupil, the black part of the eye through which you see], expiration date of 10/2021,
iii.one bisacodyl (medication used to treat constipation) 10 mg suppository (rectally), expiration date of 3/2022.
c.One bottle of haloperidol (medication used to treat mental illness) 2 mg/ml concentration 120 ml, expiration date of 6/30/22
d.One nitroglycerine (medication used to treat episodes of chest pain) 0.4 mg/tablet, expiration date of 6/2018
e.one bottle of Ultra B-100 Complex (nutritional supplement) 100 tablets, opened with no date when it was opened.
During an interview on 10/19/22 at 9:46 AM, DON stated all expired medications need to be destructed and should not be kept in the medication room.
A review of facility's policy and procedure (P&P) titled, Storage of Medications, revised 4/2019, indicated discontinued or outdated (expired) medications were returned to the dispensing pharmacy or destroyed.
A review of facility's P&P titled, Administering Medications, revised 4/2019, indicated when opening a multi-dose container, the date opened was recorded on the container.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to prepare and serve food according to the facility's menu. The facility's menu indicated to add a garnish to make the meal attr...
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Based on observation, interview, and record review, the facility failed to prepare and serve food according to the facility's menu. The facility's menu indicated to add a garnish to make the meal attractive (refers to the appearance of the food when served to residents) and appetizing to the residents.
This deficient practice had a potential for residents to not want to eat the food served which could lead to weight loss.
Findings:
During a tray line observation for breakfast on 10/20/22 at 7:09 AM, the breakfast trays were observed presented with two (2) slices of toast and an omelet. There were no garnishes as indicated on the meal menu on the residents' breakfast plates.
During an interview on 10/20/22 at 7:09 AM, a Dietary [NAME] (DC) stated they had no parsley or fruits to garnish the meals because the facility ran out and had not received any new delivery.
During a follow up interview on 10/20/22 at 7:47 AM, DC stated she liked to garnish residents' food because the plate looked better and would appeal to the residents to eat more, when the plate looked nice.
A review of the facility's Fall Menu Cook's Spreadsheet for week 3 of 9/22/22, 10/20/22 and 11/17/22, indicated for a parsley sprig garnish.
A review of the facility's policy and procedure titled, Fall Menus Cooks Spreadsheet, indicated a parsley sprig garnish for regular diets.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected multiple residents
Based on observation, interview, record review, the facility failed to follow proper sanitation and food handling practices as indicated in the facility's policies and procedures when:
1)Lemonade spo...
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Based on observation, interview, record review, the facility failed to follow proper sanitation and food handling practices as indicated in the facility's policies and procedures when:
1)Lemonade spout nozzle prepared on 10/18/22 was observed touching the kitchen counter.
2)Dietary cook (DC) failed to perform hand hygiene when plating residents' meal after stepping away to do another task.
These deficient practices have the potential to result in food borne illness (infection or irritation of the gastrointestinal tract caused by food or beverages that contain harmful bacteria, parasites, viruses, or chemicals; symptoms include vomiting, diarrhea, abdominal pain, fever, and chills) to 92 Residents in the facility, which could lead to other serious medical complications and hospitalizations.
Findings:
(1) During a kitchen observation on 10/18/22 at 8 am, a clear container full of prepared lemonade was seen sitting on top of the kitchen counter with the spout touching the countertop.
During an interview on 10/18/22 at 8:10 am, the Dietary Supervisor (DS) stated it will need to be discarded because the spout dispenser was touching the counter and should not be used anymore to prevent food borne illness.
During an interview on 10/18/22 at 8:10 am, the tray liner personnel confirmed the lemonade was prepared on 10/18/22 as shown on the sticker attached to the container.
(2) During an observation and interview on 10/20/22 at 7:46 am, DC was seen plating residents' breakfast during tray line wearing gloves. DC was observed stepping away to obtain Styrofoam bowl in the dry storage room and returned using the same gloves. DC was not observed removing the gloves, perform hand washing, or putting on a new pair of gloves while she resumed plating the remaining plates.
During the same observation and interview on 10/20/22 at 7:46 am, the DC did not to perform hand hygiene or change her gloves between tasks in the presence of the DS.
During an interview on 10/20/22 at 7:50 am, DS stated it is important to perform handwashing and put a new pair of gloves between tasks to avoid cross contaminating (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) resident's food.
A review of the facility's Policy and Procedure (P&P) titled, Food Preparation and Services, revised in April 2019, indicated that food and nutrition service employees are to prepare and serve food in a manner that complies with safe food handling practices. The P&P indicated food preparation staff to adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. The P&P also indicated food and nutrition service staff are to wash their hands before serving food to the residents and to wear gloves when handling food directly and to change them between tasks.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
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 address and update the facility-wide assessment (tool ...
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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 address and update the facility-wide assessment (tool to evaluate its resident population and identify the resources needed to provide the necessary care and services the residents require) to include the Justice Involved Residents' population currently admitted in the facility since Year 2021.
This deficient practice failed to identify factors that would require a change in assessment, thus potentially unable to provide the necessary person-centered care and services the Justice Involved Residents required, placing the residents at risk for physical, mental, and psychological harm.
Findings:
During an entrance conference on 10/18/22 at 8:12 AM, with the Administrator (ADM) and the Director of Nursing (DON), the facility assessment was requested as part of the recertification survey requirements and process. The ADM and DON was made aware that the requested document was needed in four (4) hours from entrance conference time as reflected in the Entrance Conference Worksheet, facility copy.
On 10/18/22 at 8:32 AM, during the initial tour of the facility, concurrent interview and review of the facility's residents census dated 10/17/22 with the DON, the DON stated the facility had 92 residents residing in the facility. The DON stated Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86 were under a fictitious (not real or true) name to protect the resident's identity and for confidentiality. The DON stated Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86 admitted in the facility were all justice involved residents.
On 10/18/22 at 11:27 AM, during a concurrent interview and record review of the facility's Facility assessment dated [DATE], the DON stated there was no indication or documentation of the facility admitting and caring for Justice Involved Residents population. The DON stated the Federal Law Enforcement personnel in charge of the security of these resident population were also not included and documented in the Facility Assessment as facility resources needed to provide care for facility's resident population every day and during emergencies. The DON stated training and in-service on how to provide care for Justice Involved Residents should had been included in the Facility Assessment.
During a conference meeting via TEAMS (allows users to communicate via text, chat, voice or video call from home or office) on 10/20/22 at 9:41 AM, attended by Los Angeles County Department of Public Health (LAC-DPH) Health Facilities Investigation Division (HFID) supervision team, the facility's ADM, DON, VPO, Quality Assurance Consultant (QA Consultant) and the Marketing Director. The VPO stated the facility did not have a contract with the Federal Law Enforcement Agency. The VPO stated there was only email agreements for the facility to admit Justice Involved Residents. The VPO stated training and in-service on how to provide care for Justice Involved Residents were provided by the Federal Law Enforcement Agency for one to two hours in the facility.
During an interview on 10/20/22 at 2:38 PM, the ADM stated he was hired by the facility as ADM on 2/1/22 and there were Justice Involved Residents already residing in the facility that time. The ADM stated Facility Assessment was last revised on [DATE], and admitting Justice Involved Residents in the facility was mislooked, not addressed and included in the Facility Assessment. The ADM stated the Facility Assessment should be updated and must reflect and include Justice Involved Residents. The ADM stated that the DON, Quality Assurance Consultant (QA Consultant), Minimum Data Set (MDS) Nurse were all part of the Facility Assessment review and the governing body which included the VPO, and Medical Director oversees the process. The ADM stated Facility Assessment was the overall assessment of the facility, including the services provided and the resident population taken care by the facility.
On 10/21/22 at 8:42 AM, during a concurrent interview and record review of Federal Law Enforcement Agency in-service sign in sheet dated 9/23/22, the DON stated the facility could not find and provide the first in-service sign-in sheet. The DON stated that all in-services sign in sheet together with the lesson plan should be filed in the Director of Staff Development Binder, but since the ADM, DSD and DON were all newly hired (6 months-1 year), they do not know where it was placed/filed. The DON stated that the previous staff should have endorsed it and should be readily available.
A review of facility's policy and procedure (P&P) titles Facility Assessment revised in October 2018, indicated A facility assessment tis conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. The P&P indicated the following:
1. Once a year, and as needed, a designated team conducts a facility-wide assessment to ensure that the resources are available to meet the specific needs of our residents.
- The facility assessment includes a detailed review of the resident population. This part of the assessment includes:
- Resident census data from the previous 12 months
2. Factors that affect the overall acuity of the residents, such as the number and percentage of residents with:
- Need for assistance with ADLs;
- Mobility impairments
- Incontinence (bowel and bladder);
- Cognitive or behavioral impairments; and
- Conditions or diseases that require specialized care (e.g. dialysis (process of purifying the blood of a person whose e kidneys are not working normally, ventilators (life support machines) , wound care).
3. The facility assessment also includes a detailed review of the resources available to meet the needs of the resident population. This part of the assessment includes:
- The contracts or agreements with third parties to provide services, equipment and supplies to the facility during normal operations and in the event of an emergency.
All personnel, including Contracted staff (full and part time)
A breakdown of the training, licensure, education, skill level and measures of competency for all personnel.
4. The facility assessment is intended to help our facility plan for and respond to changes in the needs of our resident population and helps to determine budget, staffing, training, equipment and supplies needed.
5. The facility assessment is reviewed, and updates annually and as needed. Facility or resident changes or modifications that may prompt a reassessment sooner include a significant change in the resident census and/or overall acuity of our residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately document resident's care of the supra pubic catheter (a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately document resident's care of the supra pubic catheter (a hollow flexible tube that is inserted into the bladder through a cut in the stomach to drain urine from the bladder) for one of five sampled residents (Resident 242).
This deficient practice resulted in inaccuracy of medical records which had the potential for confusion in the care and services being provided for the resident.
Findings:
1. A review of Resident 242's Face Sheet (a record of admission) indicated the resident admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included speech and language deficit following cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), muscle wasting, and atrophy (loss of muscle tissue).
A review of Resident 242's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 9/21/22, indicated the resident had severe impairment in cognitive skills (ability to make daily decisions).
A review of Resident 242's physician's order, dated 10/14/22, indicated the following orders:
a.Supra pubic catheter may insert 16 French (Fr, measurement of size of the catheter)/10 cubic centimeter (cc, a unit of measurement) as needed (PRN) if soiled, blocked, or leaking.
b.Supra pubic catheter change catheter bag PRN if soiled or leaking.
c.Supra pubic catheter may irrigate with 60 cc of normal saline (NS, mixture of salt and water similar to the body's fluid used to clean wounds and/or replenish fluid in the body) PRN if soiled, blocked or leaking.
A review of Resident 242's Treatment Administration Record (TAR) for the month of October 2022, indicated that the supra pubic catheter was inserted, changed catheter bag, and irrigated every shift from 10/16/22 to 10/20/22.
During an interview on 10/20/22 at 4:28 PM, Treatment Nurse 1 (TXN 1) stated she did not insert, change catheter bag, or irrigate the supra pubic catheter for Resident 242 on her shift on 10/18/22, 10/19/22, and 10/20/22. TXN 1 stated facility had a new electronic charting system which was very confusing. TXN 1stated she was documenting because the system prompted her as a task that was due so she signed the TAR as done because she thought she was acknowledging the order. TXN 1 stated she was the one who entered the orders for Resident 242 and admitted she entered the orders for the supra pubic catheter to be done every shift instead of PRN.
During an interview on 10/21/22 at 7:30 AM, a Licensed Vocational Nurse 4 (LVN 4) stated she did not insert, change the bag or irrigate the supra pubic catheter on 10/19/22 or 10/20/22 for Resident 242 during her shift. LVN 4 stated she thought by clicking on the task, it was an acknowledgement of the orders. LVN 4 stated it should not be charted if the task was not performed. LVN 4 stated, I guess it would be an error then.
During an interview on 10/21/22 at 8:05 AM, LVN 5 stated she did not insert, change the catheter bag or irrigate for the supra pubic catheter for Resident 242 on 10/18/22 during her shift. LVN 5 stated she was completing the task on the TAR since it was populating as a task that was due. LVN 5 stated she thought it was an acknowledgement of the order for her to check the catheter. LVN 5 stated she did not know that it was indicating the task (inserting, changing the bag, and irrigating the supra pubic catheter) was performed. LVN 5 stated the facility had a new electronic system for charting, so she got confused. LVN 5 stated it was an error of documentation.
During an interview on 10/21/22 at 8:10 AM, LVN 6 stated she did not insert, change the catheter bag or irrigate the supra pubic catheter on 10/17/22 during her shift as documented on Resident 242's TAR. LVN 6 stated, I thought it was an acknowledgment of the order, and the task was due, so I was just completing the task. LVN 6 stated the facility had a new electronic charting system, so she got confused how to document on the resident's TAR. LVN 6 stated, It was an error of documentation.
During an interview and record review on 10/21/22 at 8:10 AM, the Director of Nursing (DON) stated Resident 242's TAR for October 2022 had errors in documentation on dates from 10/16/22 to 10/20/22 for supra pubic catheter care. The DON stated staff were expected to document accurately in the resident's medical records.
A review of facility's policy and procedure (P&P) titled, Charting and Documentation, dated 7/2017, indicated treatment or services performed information was to be documented in the resident medical record. The P&P indicated the documentation in the medical record would be objective, complete, and accurate.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Quality Assessment and Assurance (QAA) committee failed to include in the facility-wid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Quality Assessment and Assurance (QAA) committee failed to include in the facility-wide assessment, identify systemic issues, establish priorities for its improvement activities, and monitor practices involving justice involved residents (residents currently in custody and held involuntarily through operation of law enforcement authorities in an institution, which is the responsibility of a governmental unit or over which a governmental unit exercises administrative control) admitted by the facility and ensure nine of nine (Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86) of these type of residents received the same basic rights as other residents in the facility including freedom to be free from physical restraints.
This deficient practice caused the facility not to develop and implement action plans to correct identified quality deficiencies which created a situation where some residents were likely to experience serious physical injury, psychosocial harm and/or impairment.
Findings:
A review of a formal referral letter from the long-term care ombudsman dated 10/14/22, indicated the OMB was at the facility on 10/11/22. The letter indicated the OMB was not allowed to see or interview the nine justice involved residents in their rooms. The letter indicated that the DON stated the facility had been instructed to follow a different set of rules and were told that the justice involved residents did not have the same rights as all other residents in the facility. The letter indicated that on 10/12/22, the OMB spoke to the Federal Law Enforcement Supervisor and explained to the OMB that the justice involved residents were supervised by the Federal Law Enforcement while in the facility. The letter indicated that the Federal Law Enforcement Supervisor informed the OMB that the justice involved residents residing in the facility have all the rights to keep them alive. The letter indicated the justice involved residents were not allowed to have phone calls, outside snacks, were not allowed to walk around the facility and have visitors without the Federal Law Enforcement Supervisor permission. The letter indicated that on 10/12/22, the facility's administrator shared with the OMB that the facility was following a separate protocol (policy) for the justice involved residents according to the facility's corporate guidance and the Federal Law Enforcement Agency.
A review of a Memorandum (a short note designating something to be remembered, especially something to be done or acted upon in the future) addressed to the facility and the facility's Marketing Director (MKD), titled Policy and Procedures for Inmates in Nursing Home Facilities, dated 8/20/2021, signed by the Federal Law Enforcement Deputy and written in the Federal Law Enforcement letterhead indicated, Every client (inmate) that resides in a nursing home facility will be always accompanied by security staff (24 hours).
During an interview on 10/18/22 at 8:10 AM, Private Security Officer (PSO) 5 stated all justice involved residents were shackled unless their attending physician (AP 1) ordered not to apply shackle on the justice involved residents.
On 10/18/22 at 8:32 AM, during the initial tour of the facility, concurrent interview and review of the facility's residents census dated 10/17/22 with the Director of Nursing (DON), the DON stated the facility had 92 residents residing in the facility. The DON stated Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86 were under a fictitious (not real or true) name to protect the resident's identity and for confidentiality. The DON stated Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86 admitted in the facility were all justice involved residents.
A review of Resident 86's Face Sheet indicated an admission to the facility on 9/17/22 with diagnoses including suicidal ideations (thinking about or planning suicide), muscle weakness and traumatic subcutaneous (applied under the skin), emphysema (a condition in which air becomes trapped under the subcutaneous layer of the skin).
During an observation on 10/18/22 at 8:35 AM, Resident 86's room door was open, and Resident 86 was visible from outside the residents' room. Resident 86 was observed with a right-hand metal restraint attached to the bed.
A review of Resident 86's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints while in the facility.
During an interview on 10/18/22 at 9:20 AM, while outside Resident 86's room, PSO 1 stated all justice involved residents walk around in the facility accompanied by two PSOs when they go to physical therapy. PSO 1 stated all justice involved residents were restrained to their bed with hand cuffs. PSO 1 stated every justice involved residents were different when it comes to the number of hand cuffs. PSO 1 stated he was not allowed to tell the state surveyor on how many handcuffs Resident 86 had.
A review of Resident 87's Face Sheet indicated an admission to the facility on 9/27/22 with diagnoses including anemia (a condition in which the body does not have enough healthy red blood cells that provide oxygen to body tissues), emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness), secondary malignant neoplasm of bone (cancer [a disease in which abnormal cells divide uncontrollably and destroy body tissue] started in another part of the body but spread to the bone).
On 10/18/22 at 9:26 AM, during a concurrent observation and interview with PSO 2, in the presence of PSO 3, Resident 87 was lying on his bed with a metal locking leg cuffs applied to both legs and secured to the foot part of the bed. PSO 2 stated Resident 87 was restrained on both legs with steel iron chain that is secured to the bed. PSO 2 stated justice involved residents wears handcuffs but since Resident 87 was very fragile, they do not apply it to Resident 87 all the time. PSO 2 stated they would remove both physical restraints to both legs during Resident 87's shower, toileting, and physical therapy.
A review of Resident 87's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints while in the facility.
On 10/18/2022 at 9:26 AM, PSO 2 stated that two PSOs were assigned to supervise each of the nine justice involved residents in the facility. PSO 2 stated there were three working shifts per day, 8 hours per shift. PSO 2 stated justice involved residents needs 24-hour supervision, to keep an eye on justice involved residents' daily activities. PSO 2 stated the justice involved residents were not allowed to receive any visitors and mails, no telephone calls, and they were not allowed to eat in the facility's dining room. PSO 2 stated the justice involved residents can only eat inside their own rooms.
During an interview on 10/18/22 at 9:35 AM, Licensed Vocational Nurse (LVN) 1 stated the Department of Public Health (DPH) surveyors were not allowed to go inside all justice involved residents' rooms due to Federal Law Enforcement policy .LVN 1 stated all justice involved residents were on physical restraints, eat inside their rooms, not allowed to have visitors, receive mails and telephone calls. LVN 1 stated charge nurses give Justice Involved Residents medication but anything else, Justice Involved Residents need to talk and/or ask Federal Law Enforcement Agency.
During an interview on 10/18/22 at 9:35 AM, LVN 2 stated justice involved residents were all restrained with physical restraints. LVN 2 stated all justice involved residents need to be always restrained for the safety of other residents and facility staff. LVN 2 stated there were no clinical indication for the use of the physical restraints on the nine justice involved residents.
On 10/18/22 at 12:16 PM, during a concurrent interview and record review of all justice involved residents' electronic medical records, the DON stated handcuffs, leg cuffs, and shackles were considered as physical restraints. The DON stated that application of physical restraints to residents needs a physician's order. The DON could not find physician orders for all the nine justice involved residents' electronic medical records.
During the same interview on 10/18/22 at 12:16 PM, the DON stated that physical restraints were applied to all justice involved residents, some in the arms, some in the legs. The DON stated the PSOs would rotate the sites of the physical restraints. The DON stated the physical restraints were chains, approximately two feet long attached to the resident's bed. The DON stated the restraints would be removed when justice involved residents would go to the bathroom. The DON stated that PSOs who were under contract with the Federal Law Enforcement Agency were the only persons that had access to remove the resident's physical restraints. The DON stated no one from the facility staff had access/and or keys to all the justice involved residents locked physical restraints. The DON stated all justice involved residents need physical restraints because They are inmates, they might run and do something, they are criminals. The DON stated upon review of the resident's records, there were no clinical indication for the use of physical restraints to all the justice involved residents.
On 10/18/22 at 11:27 AM, during a concurrent interview and record review of the facility's Facility assessment dated [DATE], the DON stated there was no indication or documentation of the facility admitting and caring for justice involved residents' population. The DON stated the Federal Law Enforcement personnel in charge of the security of these resident population were also not included and documented in the Facility Assessment as facility resources needed to provide care for facility's resident population every day and during emergencies. The DON stated training and in-service on how to provide care for justice involved residents should had been included in the Facility Assessment.
On 10/18/22 at 12:33 PM, during a concurrent interview and record review of all the nine justice involved residents' electronic medical records, the DON stated that physician orders, care plans and the MDS coding for physical restraints were only initiated and documented on 10/14/22 in the resident's paper medical records, which were a few days before the state surveyors arrived in the facility.
During the same interview on 10/18/22 at 12:33 PM, the DON stated the facility did not consider the handcuffs, leg cuffs, and shackles as physical restraints upon admission of justice involved residents in the facility. The DON stated the facility recently discussed that the facility would consider the handcuffs, leg cuffs, and shackles as physical restraints moving forward. The DON stated the physician's orders for physical restraints should be indicated and reflect in the electronic medical records of all the justice involved residents.
On 10/20/22 at 2:30 PM, during a concurrent interview and record review of facility's Quality Assurance Schedule 2022 and Quality Assurance and Performance Improvement (QAPI) meeting topic, the DON was unable to provide documentation and/or evidence that the QAA committee and the QAPI review was able to identify and discussed pertinent issues about the justice involved residents admitted in the facility.
During an interview on 10/20/22 at 2:38 PM, the Administrator (ADM) stated he was hired by the facility as ADM on 2/1/22 and there was justice involved residents already residing in the facility. The ADM stated the facility's Quality Assurance (QA) Committee mislooked the issues and practices involving the facility's admission and care of the justice involved residents.
On 10/21/22 at 8:42 AM, during a concurrent interview and record review of inservices conducted by the Federal Law Enforcement Agency and the facility's in-service sign in sheet dated 9/23/22, the DON stated the facility could not find and provide the first in-service sign-in sheet. The DON stated that all in-services sign in sheet together with the lesson plan should be filed in the Director of Staff Development (DSD) Binder, but since the ADM, DSD and DON were all newly hired (6 months-1 year), they do not know where it was placed/filed. The DON stated that the previous staff should have endorsed it and should be readily available.
During the QAA/QAPI review on 10/21/22 at 1:16 PM in the presence of the ADM and the DON, the ADM and DON stated that the facility's QAA committee meets every fourth Thursday of the month. The DON stated the facility's QAA committee consists of the medical director, the ADM, the DON, Infection Preventionist (IP), Minimum Data Set Coordinator (MDS), Activities Director (AD), Rehabilitation Director (DOR), Social Services Designee (SSD), Dietary Supervisor (DS), DSD, Maintenance Director (MTD), Registered Nurse (RN) Supervisor and other members as needed. The DON stated the last QAA meeting was on 9/22/22.
During an interview on 10/21/22 at 1:19 PM, the DON stated, QAA committee did not include and correct issues and practices involving the care that the justice involved residents receives in the facility since the facility staff did not recognize it was a problem before. The DON stated it was only around 10/14/22 that they discussed issues and concerns regarding the justice involved residents residing in the facility.
A review of the facility's policy and procedure titled Quality Assurance and Performance Improvement (QAPI) Program-Governance and Leadership revised in March 2020, indicated the following:
1. The Administrator, whether a member of the QAPI Committee or not, is ultimately responsible for the QAPI Program, and for interpreting its results and findings to the governing body.
2. The governing body is responsible for ensuring that the QAPI program:
a. Is implemented and maintained to address identified priorities.
b. Is sustained through transitions of leadership and staffing.
c. Is adequately resourced and funded, including the provisions of money, time, equipment, training and staff coverage sufficient to conduct the activities of the program.
d. Is based on data, resident and staff input, and other information that measures performance, and
e. Focuses on problems and opportunities that reflect processes, functions, and services provided to the residents.
2. The responsibilities of the QAPI Committee are to:
a. Collect and analyze performance indicator data and other information.
b. Identify, evaluate, monitor and improve facility systems and processes that support the delivery of care and services.
c. Identify and help to resolve negative outcomes and/or care quality problems identified during the QAPI process.
d.Utilize root cause analysis to help identify where identified problems point to underlying systematic problems.
3.The following individulas serve on the committee:
a.Administrator, or a designee who is in a leadership role.
b.Director of Nursing Services
c.Medical Director
d.Infection Preventionist
e.Representatives of the following departments, as requested by the Administrator:
(1)Pharmacy
(2)Social Services
(3)Activity Services
(4)Environmental Services
(5)Human Resources
(6)Medical Records.
4. The committee has the full authority to oversee the implementation of the QAPI Program, including but not limited to the following:
a. Establishing performance and outcome indicators of quality care and services delivered in the facility.
5. The committee meets at least quarterly (or more often as necessary).
6. Specializes meetings maybe called by the ADM as needed to present issues that need to be addresses before the next regularly scheduled meeting.
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
- • 23% annual turnover. Excellent stability, 25 points below California's 48% average. Staff who stay learn residents' needs.
Concerns
- • Multiple safety concerns identified: 3 life-threatening violation(s). Review inspection reports carefully.
- • 70 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $13,385 in fines. Above average for California. Some compliance problems on record.
- • Grade F (17/100). Below average facility with significant concerns.
Bottom line: This facility has 3 Immediate Jeopardy findings. Serious concerns require careful evaluation.
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About This Facility
What is Chestnut Ridge Post Acute Llc's CMS Rating?
CMS assigns CHESTNUT RIDGE POST ACUTE LLC an overall rating of 2 out of 5 stars, which is considered below average nationally. Within California, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Chestnut Ridge Post Acute Llc Staffed?
CMS rates CHESTNUT RIDGE POST ACUTE LLC's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 23%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Chestnut Ridge Post Acute Llc?
State health inspectors documented 70 deficiencies at CHESTNUT RIDGE POST ACUTE LLC during 2022 to 2025. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 67 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Chestnut Ridge Post Acute Llc?
CHESTNUT RIDGE POST ACUTE LLC is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 106 certified beds and approximately 99 residents (about 93% occupancy), it is a mid-sized facility located in GLENDALE, California.
How Does Chestnut Ridge Post Acute Llc Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, CHESTNUT RIDGE POST ACUTE LLC's overall rating (2 stars) is below the state average of 3.1, staff turnover (23%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Chestnut Ridge Post Acute Llc?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Chestnut Ridge Post Acute Llc Safe?
Based on CMS inspection data, CHESTNUT RIDGE POST ACUTE LLC has documented safety concerns. Inspectors have issued 3 Immediate Jeopardy citations (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 Chestnut Ridge Post Acute Llc Stick Around?
Staff at CHESTNUT RIDGE POST ACUTE LLC tend to stick around. With a turnover rate of 23%, the facility is 23 percentage points below the California average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 29%, meaning experienced RNs are available to handle complex medical needs.
Was Chestnut Ridge Post Acute Llc Ever Fined?
CHESTNUT RIDGE POST ACUTE LLC has been fined $13,385 across 1 penalty action. This is below the California average of $33,213. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Chestnut Ridge Post Acute Llc on Any Federal Watch List?
CHESTNUT RIDGE POST ACUTE LLC is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.