SEA CLIFF HEALTHCARE CENTER
For profit - Corporation
182 Beds
THE ENSIGN GROUP
Data: November 2025
Trust Grade
65/100
#680 of 1155 in CA
Last Inspection: February 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Sea Cliff Healthcare Center in Huntington Beach, California, has a Trust Grade of C+, indicating it is slightly above average but not exceptional. It ranks #680 out of 1,155 facilities in California, placing it in the bottom half, and #48 out of 72 in Orange County, meaning there are only a few better local options. Unfortunately, the facility's trend is worsening, with issues doubling from 9 in 2024 to 18 in 2025. Staffing is a relative strength, with a turnover rate of 24%, significantly better than the state average of 38%, although RN coverage is concerning since it falls below 83% of California facilities. While the facility has not incurred any fines, which is positive, recent inspections revealed serious concerns about infection control practices and food safety, including improper hand hygiene and failures in following dietary protocols, which could impact residents' health.
- Trust Score
- C+
- In California
- #680/1155
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ✓ Good
- 24% annual turnover. Excellent stability, 24 points below California's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most California facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 17 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 96 deficiencies on record. Higher than average. Multiple issues found across inspections.
65/100
Bottom 42%
No red flags
9 → 18 violations
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 9 issues
2025: 18 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Low Staff Turnover (24%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (24%)
24 points below California average of 48%
Facility shows strength in quality measures, staff retention, fire safety.
The Bad
3-Star Overall Rating
Near California average (3.1)
Meets federal standards, typical of most facilities
Chain: THE ENSIGN GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 96 deficiencies on record
Jul 2025
1 deficiency
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Deficiency F0554
(Tag F0554)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and the facility P&P review, the facility failed to ensure one of four sampled residents (Resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and the facility P&P review, the facility failed to ensure one of four sampled residents (Resident 3) was assessed to determine if it was safe for the resident to self-administer the medications. * Resident 3 was observed with a medication cup filled with multiple medications at the bedside table. Resident 3 had no assessment, physician's order, and/or care plan problem addressing the self-administration of the medications. This failure had the potential for Resident 3 to administer medications inaccurately.Findings: Review of the facility's P&P titled Self-Administration of Medications (undated) showed the following:a. Residents will be informed that they have a right to self-administer drugs upon admission;b. if a resident requests to self-administer drugs the IDT will determine if the practice is safe before the resident may exercise this right;c. the IDT will determine who is responsible for the storage of the drugs and documentation of the administration of drugs, as well as the location of Drug Administration;d. these determinations need to be included in the residence care plan; e. the physicians order for such drugs will be clarified to include may keep at bedside; andf. residents who self-administer drugs will be periodically reevaluated based on any changes in the resident's status. Medical record review for Resident 3 was initiated on 7/24/25. Resident 3 was admitted to the facility on [DATE]. On 7/24/25 at 1108 hours, a concurrent observation and interview was conducted with Resident 3. A medication cup filled with multiple medications were present at the resident's bedside. When Resident 3 was asked if the medications inside the medication cup belong to him, Resident 3 stated Yes, then proceeded to self-administer the medications without the licensed nurse present. Review of Resident 3's Order Summary Report dated 7/24/25, failed to show a physician's order to self-administer the medications. Further review of Resident 3's medical record failed to show Resident 3 was assessed for the self-administration of the medications. Review of Resident 3's plan of care failed to show a care plan problem to address Resident 3's ability to self-administer the medications. On 7/24/25 at 1114 hours, an interview was conducted with LVN 1. LVN 1 was informed of the above findings. LVN 1 verified Resident 3 was not supposed to have the medications unattended at the bedside. LVN 1 stated the facility's process for the residents to self-administer the medications require an assessment from the physician to indicate the resident could self-administer the medications. On 7/24/25 at 1454 hours, a follow up interview was conducted with LVN 1. LVN 1 verified the medications inside the medication cup were Resident 3's scheduled at 0900 hours medications. When asked what medications were inside the medication cup, LVN 1 stated the following medications: folic acid (supplement), amlodipine (blood pressure medication), carvedilol (blood pressure medication), apixaban (blood thinner medication), aspirin (blood thinner), vitamin D (supplement), and lisinopril (blood pressure medication). On 7/25/25 at 1548 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the following medications were documented as administered to the resident on 7/24/25 at 0900 hours: amlodipine, aspirin, cyanocobalamin (vitamin b12 supplement), folic acid, Lasix (diuretic), lisinopril, thiamin (supplement), and apixaban. The DON verified Resident 3 had no assessment, physician's order, and/or a care plan problem addressing the self-administration of the medications. On 7/25/25 at 1617 hours, an interview was conducted with the Administrator and DON. The Administrator and the DON were informed and acknowledged the above findings.
Feb 2025
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to notify the resident and/or their repr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to notify the resident and/or their representative of the transfer and reasons for the transfer in writing and send a copy of the notice to the LTC Ombudsman when the resident was transferred to the acute care hospital for one of three final sampled residents (Resident 25) reviewed for hospitalization. This failure had the potential for the resident and their representative of not knowing about the appeal process and posed the risk of the LTC Ombudsman not being aware of the circumstances of the resident's transfer/discharge should the resident and their representative believe the transfer or discharge was inappropriate or involuntary.
Findings:
Medical record review for the Resident 25 was initiated on 2/11/25. Resident 25 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 25's H&P examination dated 1/4/25, showed Resident 25 had the capacity to understand and make decisions.
Review of Resident 25's Physician Order Summary showed following orders:
- dated 12/24/24, to send Resident 25 to the acute care hospital due to the altered laboratory result.
- dated 1/10/25, to send Resident 25 to the acute care hospital for decreased oxygen saturation level.
Review of the Resident 25's Progress Note dated 12/24/24 at 1808 hours, showed Resident 25 was transferred to the acute care hospital due to the abnormal laboratory result.
Review of Resident 25's eInteract Transfer Form V4.1 dated 1/10/25, showed Resident 25 was transferred to the acute care hospital.
Review of Resident 25's Notice of Proposed Transfer/discharge date d 12/24/24, showed the name of Resident 25's representative in the section for the resident/resident representative's signature. The Notice of Transfer/Discharge showed, If you believe that the proposed transfer/discharge is inappropriate in your case, and is involuntary, you have the right to appeal. The appeal can be filed in writing to, or by calling the following: DHCS Office of Administrative Hearing and Appeals, State Long-Term Care Ombudsman Office, State Agency for Persons with Mental Disorder. The Notice of Proposed Transfer/Discharge further showed the facility would not discharge/transfer the resident while the appeal was pending if the resident exercised the right of appeal unless the failure to discharge/transfer would endanger the resident's health or safety or that of other residents/other individual in the facility.
Further review of Resident 25's medical record failed to show if the notice of proposed transfer and discharge was provided in writing to Resident 25 or their representative and the copy of the The Notice of Transfer/Discharge was sent to the LTC Ombudsman, when Resident 25 was transferred to the acute care hospital on [DATE], and 1/10/25.
On 2/13/25 at 1043 hours, an interview was conducted with Resident 25. Resident 25 stated she was transferred to the acute care hospital on or around 12/24/24, and 1/10/25. Resident 25 was asked if the facility provided her the notice of transfer and discharge in writing when she was transferred to the acute care hospital on or around 12/24/24, and 1/10/25, Resident 25 stated she was notified verbally but did not remember if the notice of transfer was provided in writing.
On 2/14/25 at 0842 hours, an interview and concurrent medical record review for Resident 25 was conducted with RN 4. RN 4 verified the above findings. RN 4 verified Resident 25 was transferred to the acute care hospital on [DATE], and the Notice of Proposed Transfer/discharge on [DATE], showed the name of Resident 25's representative. RN 4 stated she was not able find documented evidence to show the Notice of Proposed Transfer/Discharge was provided to Resident 25 or their representative and the copy was sent to the LTC Ombudsman when Resident 25 was transferred to the acute care hospital on [DATE] and 1/10/25.
On 2/14/25 at 0927 hours, an interview and concurrent medical record review for Resident 25 was conducted with the SSD. The SSD stated she sent the list of the residents who were transferred to the acute care hospital to the LTC Ombudsman weekly; however, she did not send the copy of the Notice of Proposed Transfer/Discharge for each of the residents. The SSD verified she did not send the copy of the Notice of Proposed Transfer /Discharge to the LTC Ombudsman when Resident 25 was transferred to the acute care hospital on [DATE] and 1/10/25.
On 2/14/25 at 0930 hours, an interview and concurrent medical record review for Resident 25 was conducted with the DON. The DON verified and acknowledged the above findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the resident and/or their repr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the resident and/or their representative were provided with the written information regarding the facility's bed-hold policy when the resident was transferred to the acute care hospital for one of three final sampled residents (Resident 25) reviewed for hospitalization. This failure had the potential for Resident 25 and/or their representative to be unaware of their rights to request a bed hold and return to the first available bed should the resident's hospital stay exceed the seven-day bed-hold period.
Findings:
Review of the facility's P&P titled Bed-Holds and Returns revised 12/2023 showed it is the policy of the facility to inform the resident or resident's representative in writing of their right to exercise the bed hold provision of seven days upon admission and provide a second notice before transfer to a general acute care hospital or before the resident goes on a therapeutic leave. In the event of an emergency transfer, the second notice will be provided within 24 hours.
Medical record review for the Resident 25 was initiated on 2/11/25. Resident 25 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 25's H&P examination dated 1/4/25, showed Resident 25 had the capacity to understand and make decisions.
Review of Resident 25's Physician Order Summary showed the following physician's orders:
- dated 12/24/24, to send Resident 25 to the acute care hospital due to altered laboratory results.
- dated 1/10/25, to send Resident 25 to the acute care hospital for decreased oxygen saturation level.
Review of the Resident 25's Progress Notes dated 12/24/24 at 1808 hours, showed Resident 25 was transferred to the acute care hospital due to abnormal laboratory results.
Review of the Resident 25' s eInteract Transfer Form V4.1 dated 1/10/25, showed Resident 25 was transferred to the acute care hospital.
Review of the Resident 25's Bed Hold Informed Consent dated 12/24/24, showed the document was sent with the resident at the time of the transfer. The Bed Hold Informed Consent showed, You have the option of requesting a seven days bed hold to keep a bed vacant and available for return to this facility. Non-medical beneficiaries are responsible for reasonable cost not to exceed the beneficiaries monthly room rate. Insurance may or may not cover such charges. Medi-Cal will cover the cost of the bed hold if the resident's share of cost has been satisfied for the month, unless we receive written notice from the attending physician that the stay in the acute hospital is expected to exceed seven days. If you desire this option, facility must be notified within 24 hours of transfer. However, further review of the Bed Hold Informed Consent did not show Resident 25's signature acknowledging the receipt of the bed hold information.
Further review of Resident 25's medical record did not show if the written information regarding the facility's bed hold policy was provided when Resident 25 was transferred to the acute care hospital on [DATE] and 1/10/25.
On 2/13/25 at 1043 hours, an interview was conducted with Resident 25. Resident 25 stated she was transferred to the acute care hospital on or around 12/24/24, and 1/10/25. Resident 25 was asked if the facility provided her the facility's bed hold policy in writing when she was transferred to the acute care hospital on or around 12/24/24, and 1/10/25. Resident 25 stated she did not receive information regarding the facility's bed hold policy in writting.
On 2/13/25 at 1606 hours, an interview and concurrent medical record review for Resident 25 was conducted with RN 1. RN 1 verified Resident 25 was transferred to the acute care hospital on [DATE], and the Bed Hold Informed Consent on 12/24/24, showed the document was sent with the resident at the time of the transfer, however, the Bed Hold Informed Consent did not show Resident 25's signature. RN 1 was not able to show documented evidence Resident 25 or their representative was provided with written information regarding the facility's bed hold policy when Resident 25 was transferred to the acute care hospital on [DATE]. RN 1 stated she did not provide the copy or mailed the facility's bed hold policy to the resident representative. RN 1 stated the Bed Hold Informed Consent was sent with the resident at the time of the transfer to the acute care hospital.
On 2/14/25 at 0842 hours, an interview and concurrent medical record review for Resident 25 was conducted with RN 4. RN 4 verified the above findings. RN 4 verified Resident 25 was transferred to the acute care hospital on [DATE] and 1/10/25. RN 4 stated she was not able to find the documented evidence to show Resident 25 or their representative was provided with the facility's bed hold policy in writing when Resident 25 was transferred to the acute care hospital on [DATE] and 1/10/25.
On 2/14/25 at 0930 hours, an interview and concurrent medical record review for Resident 25 was conducted with the DON. The DON verified and acknowledged the above findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility's P&P Enteral Feeding Administration revised 5/2020 showed to check the enteral feeding tube placement...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility's P&P Enteral Feeding Administration revised 5/2020 showed to check the enteral feeding tube placement before initiating the feeding.
Medical record review for Resident 87 was initiated on 2/11/25. Resident 87 was readmitted to the facility on [DATE].
Review of Resident 87's Order Summary Report showed the following physician's orders:
- dated 8/23/24, to administer Glucerna 1.5 (enteral feeding) at 50 ml/hr for 20 hours, staring at 1300 hours.
- dated 8/12/24, to check the tube placement and residuals before starting the tube feeding.
- dated 11/13/24, to administer enteral water flush at 40 ml/hr for 20 hours, starting at 1300 hours.
On 2/12/25 at 1301 hours, an observation and concurrent interview was conducted with LVN 4 at Resident 87's bedside. LVN 4 was observed starting Resident 87's enteral feeding and water flush. LVN 4 was then observed connecting the enteral feeding tubing and water flush tubing to the resident's GT and starting the enteral feeding and water flush. LVN 4 did not verify the GT placement and/or checked the gastric residuals. As LVN 4 started walking away, LVN 4 was asked if he verified the GT placement and checked the gastric residuals before starting the enteral feeding and water flush. LVN 4 verified he did not and stated he should have.
On 2/12/25 at 1340 hours, an interview was conducted with the DON. The DON stated prior to starting an enteral feeding, the nurse should verify the GT placement by injecting 5-10 ml of air bolus into the tubing while using a stethoscope to auscultate and verify the placement. The DON stated a residual check was done to ensure there was not a delay in gastric emptying; and if the residuals was more than 100 ml, the enteral feeding should be held for an hour.
Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services related to the GT per the facility's P&P for three of three final sampled residents (Residents 87, 111, and 152) reviewed for enteral feeding.
* Two of two licensed nurses administered the medications to Residents 111 and 152 by pushing the medications through the GT instead of gravity.
* One of two licensed nurses (LVN 4) did not check the tube placement and residual volume before the GT medication administration for Resident 111.
* Resident 87's GT placement and residual checks were not performed prior to starting the resident's enteral feeding.
These failures had the potential for the residents to develop complications related to the GT care and management, including tube dislodgement, infection of the GT site, delayed nutritional feeding, and trauma.
Findings:
1. Review of the facility's P&P titled Enteral Tube Medication Administration Procedures dated 1/28/25, showed the licensed nurse allows medication to flow down tube via gravity and give gentle boosts with the plunger (approximately 1 inch down) if the medication will not flow by gravity.
a. Medical record review for Resident 152 was initiated on 2/11/25. Resident 152 was admitted to the facility on [DATE], with a diagnosis of dysphagia (difficulty swallowing), following a cerebral infarction (stroke due to blockage of blood flow to the brain).
Review of Resident 152's Order Summary Report showed the following physician's order:
- dated 11/13/24, for the enteral feed order, to crush all crushable medications given via feeding tubes; and may slow push to facilitate consumption.
On 2/11/25 at 0815 hours, a medication pass observation was conducted with LVN 8. LVN 8 was observed administering six medications, including five medications via GT for Resident 152. Before administering the medications, LVN 8 placed the tip of a 60 ml syringe into a cup of water and withdrew about 15 ml of water by pulling back the plunger of the syringe with her left hand, while holding the GT with her right hand. Then, LVN 8 was observed attaching the syringe to the GT and administering the water by pushing the plunger into the syringe rapidly (over 3-5 seconds) to deliver the water into the GT. LVN 8 was observed using the same method of pushing the plunger into the syringe rapidly when administering each medication.
On 2/11/25 at 1228 hours, an interview was conducted with LVN 8. LVN 8 stated depending on the medications, some medications could be pushed, and some medications were administered by gravity. LVN 8 also stated she pushed the medications by following the physician's order for the GT medication administrations and showed the physician's order written on 11/13/24, with a direction to crush all crushable medication given via feeding tube. May slow push to facilitate consumption.
b. Medical record review for Resident 111 was initiated on 2/12/25. Resident 111 was admitted to the facility on [DATE], with a diagnosis of dysphagia.
Review of Resident 111's Order Summary Report showed the following physician's order:
- dated 9/6/24, for the enteral feed order, to crush all crushable medications given via feeding tubes; and may slow push to facilitate consumption.
On 2/12/25 at 0814 hours, a medication pass observation was conducted with LVN 4. LVN 4 was observed administering nine medications, including eight medications via the GT for Resident 111. LVN 4 withdrew the prepared medications from the first cup by pulling back the plunger of 60 ml syringe. LVN 4 started administering the first medication by pushing the plunger into the syringe rapidly (over 3-5 seconds) to deliver the medication into the GT. Before administering the second medication, LVN 4 stated he made a mistake and was supposed to use the gravity method to administer medications into the GT. LVN 4 was then observed using the gravity method to administer the remaining seven medications into the GT.
On 2/12/25 at 1110 hours, an interview was conducted with LVN 4. LVN 4 verified he did not use the gravity method when he administered the first medication into the GT.
On 2/13/25 at 0856 hours, an interview was conducted with the DON. The DON acknowledged when giving the medications through the GT, the licensed nurse was supposed to administer the medications by pouring the liquid into the syringe and let it go down by the gravity. The DON stated it was okay to push the medications with the syringe and plunger but very slowly and gently for about one inch only, when there was resistance to the flow.
2. Review of the facility's P&P titled Enteral Tube Medication Administration Procedures dated 1/28/25, showed it is the policy of the facility to check tube placement by unclamping tube and inserting a small amount of air into the tube with the syringe and listen to stomach with stethoscope for gurgling sound, and aspirate stomach contents with syringe.
Review of Resident 111's Order Summary Report showed the following physician's order:
- dated 9/6/24, for the enteral feed order, to check the tube placement and residuals before giving medications or starting the feeding.
On 2/12/25 at 0814 hours, a medication pass observation was conducted with LVN 4. LVN 4 was observed administering nine medications, including eight medications via the GT for Resident 111, one by one, through the syringe without first checking for the tube placement and assessing the gastric residual volume (the amount of fluid already in the stomach) to determine if it was safe to administer the medications.
On 2/12/25 at 1110 hours, an interview was conducted with LVN 4. LVN 4 verified he did not check the GT placement and residual volume, which were required before starting the medication administration.
On 2/13/25 at 0856 hours, an interview was conducted with the DON. The DON acknowledged when giving the medications through the GT, the licensed nurse should listen to the resident's stomach with a stethoscope for a gurgling sound to verify the GT placement and check for the residual volume prior to administering the medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and the facility P&P review, the facility failed to ensure the oxygen wa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and the facility P&P review, the facility failed to ensure the oxygen was administered as ordered by the physician for one of two final sampled residents (Resident 152) reviewed for oxygen use. This failure had the potential to affect the respiratory health and well-being of Resident 152.
Findings:
Review of the facility's P&P titled Oxygen Administration revised 2/2023 showed it is the policy of this facility that oxygen therapy was administered by the licensed nurse as ordered by the physician, or as a nursing measure and an emergency measure until the order can be obtained.
Medical record review for Resident 152 was initiated on 2/11/25. Resident 152 was admitted to the facility on [DATE].
Review of Resident 152's Order Summary Report showed a physician's order dated 11/13/24, to administer the oxygen at two liters per minutes via nasal cannula continuously to keep the oxygen saturation level more than 90%.
Review of Resident 152's MDS dated [DATE], showed Resident 152 was dependent on the staff for his activities of daily life, including repositioning in bed from lying on the back to sitting on the side of the bed, rolling to the left and right sides, and returning to lying on the back.
On 2/11/25 at 1048 hours, Resident 152 was observed lying in the bed. The oxygen was observed being on at two liters per minutes and connected to the nasal cannula tubing. However, the nasal cannula tubing was observed hanging on the feeding tube stand, not on Resident 152.
On 2/11/25 at 1050 hours, an observation and concurrent interview was conducted with RN 1. RN 1 verified the above observation and stated Resident 152 required a continuous oxygen administration. RN 1 further stated the nasal cannula should be on Resident 152's nose and not hanging on the feeding tube stand. RN 1 was then observed placing the nasal cannula on Resident 152's nose.
On 2/14/25 at 0930 hours, an interview and medical record review for Resident 152 was conducted with the DON. The DON verified and acknowledged the above findings.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the provision of pharmacy services met the needs of the residents in accordance with t...
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Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the provision of pharmacy services met the needs of the residents in accordance with the facility's P&P when:
* The licensed nurse left Resident 152's medications unattended on the resident's bedside table during the medication administration. This failure had the potential for misuse of the medications by the residents, facility staff and/or visitors.
* An opened container of the CII E-kit was not replaced timely within 72 hours after being opened. This failure had the potential for the emergency medications to be unavailable when needed.
* One tablet of Percocet (narcotic pain medication) was removed from CII E-kit and wasted due to the resident's refusal was not disposed of as per the facility's policy; instead the Percocet medication was kept inside the CII E-kit while waiting for the pharmacy to replace the opened E-kit. This failure had the potential to result in controlled medication abuse, diversion or unauthorized removal from the facility.
* A staff discarded the non-scheduled medication wastes into a regular trash bin during the preparation for the medication administration. This failure had the potential for the misuse of the medications and environmental harm.
Findings:
1. Review of the facility's P&P titled Administration Process dated 1/28/25, showed the prepared drugs are not left with the resident (unless the resident has asked for, and has had approved the right of self-administration).
On 2/11/25 at 0815 hours, a medication administration observation was conducted with LVN 8. LVN 8 was observed administering five medications via GT and an insulin medication via injection for Resident 152. During the medication administration, LVN 8 left the medications on Resident 152's bedside table and walked out of the resident's room to obtain supplies from the medication cart located in the hallway outside the resident's room. The following was observed:
- After LVN 8 disconnected the feeding tube from the GT, LVN 8 left the medications at the bedside when she went to get the stethoscope;
- Before starting the medication administration, LVN 8 left the medications at the bedside when she went to get a cup of water; and
- LVN 8 left the insulin pen at the bedside when she went to get the alcohol swab to clean the insulin injection site.
On 2/11/25 at 1228 hours, an interview was conducted with LVN 8. LVN 8 stated she had to get the supplies from the medication cart because she was not fully prepared for medication administration.
On 2/13/25 at 0856 hours, an interview was conducted with the DON. The DON stated the licensed nurse should be able to always secure the line of vision for the medications, otherwise they should take the medications with them.
2. Review of the facility's P&P titled Emergency Pharmacy Service and Emergency Kits dated 1/28/25, showed the opened kits are replaced 72 hours of opening.
On 2/11/25 at 1624 hours, an inspection of Medication Cart 1 and concurrent interview was conducted with LVN 9. Inside the medication cart, a CII E-kit was observed to be sealed with black locks. LVN 9 verified the black lock meant the CII E-kit had been opened by the nursing staff. During an inspection of the CII E-kit, two paper slips were observed inside the E-kit. The paper slips titled Emergency Drug Kit Slip showed the E-kit was opened twice on 2/7/25, as follows: one tablet of Norco (hydrocodone-acetaminophen medication, a potent controlled medication for pain) 5/325 mg was removed and one tablet of Percocet 5/325 mg medication was removed. LVN 9 verified the CII E-kit had not been replaced since 2/7/25, and acknowledged it should have been replaced.
On 2/13/25 at 0856 hours, an interview was conducted with the DON. The DON stated the facility had only one CII E-kit in the building. The DON further explained that once the E-kit was opened, the nursing staff sealed it with black tags and called the pharmacy to request for a replacement. The DON was aware the CII E-kit was not replaced in a timely manner, which should have been replaced within 72 hours in accordance with the facility's P&P.
3. Review of the facility's P&P titled Controlled Drugs dated 1/28/25, showed if a dose is prepared for administration, but is refused or held for any reason, the dose must be destroyed.
On 2/11/25 1624 hours, an inspection of the CII E-kit stored Medication Cart 1 and concurrent interview was conducted with LVN 9. One of the Emergency Drug Kit Slips inside the E-kit was observed stapled to a plastic bag containing one tablet of medication. The note on the slip showed a licensed nurse removed one tablet of Percocet 5/325 mg on 2/7/25, but the resident refused the medication and requested for the Norco medication instead, due to an allergy. LVN 9 verified the tablet in the plastic bag was Percocet 5/325 mg. LVN 9 stated the resident refused the Percocet medication and requested for the Norco medication due to an allergy, and the nursing staff stapled the bag with a pill of the Percocet medication onto the slip.
On 2/13/25 at 0856 hours, an interview was conducted with the DON. The DON stated the licensed nurse should have given the refused narcotic or discontinued controlled medication to the DON, so the DON could dispose the controlled medications properly according to the facility's P&P.
4. Review of the facility's P&P titled of General Procedures to Follow for All Medications dated 1/28/25, showed once removed from the package or containers, unused doses should be disposed of according to the facility policy.
On 2/12/25 at 0814 hours, a medication administration observation was conducted with LVN 4. LVN 4 was observed preparing nine medications, including five solid tablets, two capsules, one vial of solution for inhalation, and one liquid suspension for Resident 111. LVN 4 placed each tablet in a small plastic bag, crushed each medication individually by using a crushing device, and placed the crushed medication into small individual cups. LVN 4 opened the capsule form of medications and placed the contents inside the capsule into a small individual cups. Two cups out of the seven cups prepared by LVN 4 were observed containing very small amount of crushed medications. When asked which medications were in the two cups, LVN 4 stated it was the wastes from the preparation. LVN 4 then grabbed the two cups and wasted them into a regular trash bin attached to the medication cart. When asked the total number of medications due for the morning medication pass, he reviewed Resident 111's MAR and could not identify which medications were left in the remaining five cups and which medications he had to prepare. LVN 4 was observed discarding the remaining five cups containing crushed medications into the regular trash bin and re-prepared seven medications, including five tablets and two capsules.
On 2/12/25 at 1110 hours, an interview was conducted with LVN 4. LVN 4 stated he trashed all the cups containing crushed medications into the regular trash bin, but he should have transferred the medications from the cups into a drug disposing bottle. LVN 4 showed the liquid containing drug disposing bottle stored in his cart and stated he should have disposed the wasted medications into the bottle containing a solution so the medication could not be reused.
On 2/13/25 at 0856 hours, an interview was conducted with the DON. The DON stated the licensed nurse should dispose the crushed medication or regular medication into the drug disposal system, which was stored in each of the medication carts.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of five sampled residents ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of five sampled residents (Residents 47 and 57) reviewed for unnecessary psychotropic (drug that affects brain activities associated with mental processes and behaviors) medications were free from unnecessary psychotropic medications when:
* For Resident 57, the physician did not document the rationale and specified duration for the extended use of the as needed hydroxyzine (a psychotropic medication for anxiety and tension caused by nervous and emotional conditions. also used to relieve symptoms of allergic conditions) beyond 14 days.
* For Resident 47, the physician did not document the rationale for the extended use of the as needed lorazepam (a psychotropic medication for anxiety) beyond 14 days and did not have documented evidence of monitoring non-pharmacological interventions, target behaviors, and adverse side effects to assess effectiveness of psychotropic medication.
These failures had the potential to result in unnecessary use of psychotropic medications.
Findings:
Review of the facility's P&P titled Psychotropic Drug Use dated 1/28/25, showed, the facility ensures PRN orders for the psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN psychotropic medication order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. The facility's P&P showed the facility ensures the residents who use psychotropic drugs receive behavioral interventions, unless clinically contraindicated (condition that makes a treatment inadvisable because it could be harmful). The facility's P&P also showed the residents will be referred to the facility's Psychotropic Drug Review Committee and/or the Psychiatrist to ensure monitoring for adverse consequences, effectiveness of medications, PRN medications use within guidelines, and reviewing plan of care with individualized, person-centered care approaches to manage behavior with non-pharmacological interventions.
1. Medical record for Resident 57 was initiated on 2/13/25.
Review of Resident 57's admission Record showed the resident was admitted to the facility on [DATE], with diagnoses including anxiety, insomnia (difficulty sleeping), epilepsy (condition with recurring seizures), and dementia (loss of cognitive functioning, thinking, remembering and reasoning) without behavioral, psychotic, mood, and anxiety disturbances.
Review of Resident 57's physician's order dated 12/23/24, showed to administer hydroxyzine 25 mg one tablet by mouth every six hours as needed for itching.
Review of Resident 57's medical record showed there were no documentation of the psychoactive committee meeting in 12/2024 or 1/2025, to evaluate the resident's current psychotropic medication regimen including the PRN hydroxyzine medication ordered on 12/23/24, without a specified duration for extended use beyond 14 days.
Review of Resident 57's Progress Note dated 1/11/25, showed Resident 57's psychiatrist NP followed up on the resident's Ambien (sedative) medication for insomnia. However, there was no progress notes made by the psychiatrist NP in January 2025 assessing the resident's conditions with the current antiaxiety (drug to treat anxiety and panic issues) medication, hydroxyzine.
On 2/14/25 at 1048 hours, an interview was conducted with the DON. The DON stated the facility did not have the prescriber's documented rationale and specified duration for extended use of the PRN hydroxyzine beyond 14 days. The DON also stated the facility did not have the psychoactive committee meeting record for December 2024 and January 2025 regarding Resident 57's use of the antianxiety medication, hydroxyzine.
2. Medical record for Resident 47 was initiated on 2/14/25.
Review of Resident 47's admission Record showed the resident was admitted to the facility on [DATE], with diagnoses including anxiety, depression, dementia, Parkinson's disease (a progressive brain disorder that causes movement problems, including tremors, stiffness, and balance issues).
Review of Resident 47's physician's order dated 1/10/25, with an end date of 3/11/25, showed to administer lorazepam 0.5 mg one tablet by mouth every six hours as needed for anxiety manifested by verbalization of inability to relax related to Parkinson's disease for 60 days.
Review of Resident 47's Initial Visit Note dated 9/15/24, showed Resident 47's psychiatrist NP assessed and documented the resident exhibited anxiety, agitation, and insomnia. The psychiatrist NP recommended Ativan (brand name of lorazepam) 0.5 mg three times daily as needed for anxiety with a plan to monitor the mood and behavior.
However, there was no progress notes made by the psychiatrist NP evaluating the resident's current order of lorazepam 0.5 mg every six hours PRN for 60 days. In addition, there was no evidence the physician documented the rationale why the resident needed the lorazepam beyond 14 days.
Review of Resident 47's MAR and Order Summary Report showing the active orders as of 2/14/25, did not show the specific behaviors associated with the use of the antianxiety medication (lorazepam) was monitored and documented. In addition, there was no documented evidence in the resident's medical record ensuring the facility implemented the monitoring and documenting of the non-pharmacological interventions and adverse side effects to assess the effectiveness of Resident 47's antianxiety medication, lorazepam.
On 2/14/25 at 1418 hours, an interview and medical record review was conducted with the DON. The DON stated the facility did not have the prescriber's documented rationale for the extended 60 days use of the PRN lorazepam for Resident 47. The DON further stated any psychotropic medication for PRN use should be limited to 14 days unless the physician documented the rationale for the extended use. The DON also acknowledged the adverse effects of lorazepam and the non-pharmacological interventions, assessing the effectiveness of lorazepam were not monitored and documented for Resident 47's current order of lorazepam. The DON also stated the facility should monitor and assess the target behaviors, effectiveness of the non-pharmacological interventions, adverse consequences of the psychotropic medications as well as the effectiveness of the psychotropic medications as required per the facility's P&P.
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
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate during the medication administration observation was less than ...
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Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate during the medication administration observation was less than 5%.
* The facility had a cumulative medication error rate of 20%. Six medication errors occurred out of 30 opportunities during the medication administration for two out of four residents (final sample residents, Residents 111 and 152). This failure resulted in medications not given in accordance with the physician's orders and the facility's P&P, which had the potential for residents not receiving the full therapeutic effects of the medications and worsening of the residents' medical conditions.
Findings:
1. Review of the facility's P&P titled Administration Process dated 1/28/25, showed the medications are administered in accordance with written orders of the attending physicians.
Review of the facility's P&P titled General Procedures to Follow for All Medications dated 1/28/25, showed in part, .obtain and record any vital signs, as necessary, prior to mediation administration .
Medical record review for Resident 152 was initiated on 2/11/25.
Review of Resident 152's MAR showed the following physician's orders:
- dated 11/13/24, to administer amlodipine besylate (used to treat high blood pressure, lowering blood pressure) 10 mg one tablet via PEG-tube one time a day for HTN, hold for SBP less than 110 mmHg or heart rate less than 60 beats per minute;
- dated 11/13/24, to administer carvedilol (used to treat high blood pressure, lowering blood pressure) 25 mg one tablet via PEG-Tube two times a day for HTN, hold for SBP less than 110 mmHg or heart rate less than 60 beats per minute;
- dated 2/9/25, to administer aspirin (a drug that reduces pain, fever, inflammation, and blood clotting) 325 mg one chewable tablet via PEG-Tube one time a day for CVA prophylaxis; and
- dated 2/9/25, to administer Multivitamin & Mineral Oral Liquid 15 ml via PEG-Tube one time a day for supplement.
On 2/11/25 at 0815 hours, a medication administration observation was conducted with LVN 8. Prior to administering the medications, LVN 8 was observed assessing the resident's blood pressure using a stethoscope and a BP cuff but did not measure the resident's HR. After the BP assessment, LVN 8 was observed preparing the following six medications:
- amlodipine 10 mg one tablet;
- carvedilol 25 mg one tablet;
- aspirin 81 mg chewable one tablet;
- multivitamins with mineral one tablet;
- escitalopram (antidepressant) 10 mg one tablet; and
- Lantus (insulin) Solostar 10 units.
LVN 8 was observed placing each tablet in a small plastic pouch, crushed each medication individually by using a crushing device, and transferred the crushed medication into a small individual cups. Then, LVN 8 transferred the contents prepared in the small cups to the individual big cups, added water into each big cup, and stirred the mixture in the cups with unused spoon to dissolve. After LVN 8 finished preparing the medications and checking the GT placement with the residual volume, LVN 8 was observed administering the prepared medications through the resident's GT.
On 2/11/25, during the medical record review of Resident 152's MAR post medication administration observation, the following was identified:
- The physician's orders required the resident's HR to be checked/monitored/documented in addition to checking/documenting the SBP. The physician's orders for the amlodipine and carvedilol medications showed the two medications should be held when the SBP was less than 110 mmHg or the HR was less than 60 beats per minute. However, LVN 8 did not assess Resident 152's HR prior to administering the amlodipine and carvedilol medications. The HR was documented as 72 on Resident 152's MAR by LVN 8.
- LVN 8 administered one chewable tablet of aspirin 81 mg instead of the physician's order for aspirin 325 mg tablet; and
- LVN 8 administered one tablet of multivitamins with mineral instead of the physician's order for the liquid form of multivitamins with mineral.
On 2/11/25 at 1228 hours, an interview and concurrent medical record review was conducted with LVN 8. LVN 8 stated she did not check Resident 152's HR but documented the HR in the MAR. When asked about the physician's holding parameters for Resident 152's BP medications, LVN 8 stated the BP medications needed to be held if the SBP less than 110 mmHg and the DBP less than 60 mmHg. LVN 8 was asked to check the MAR to verify the physician's order for Resident 152. LVN 8 then verified Resident 152's physician's order instructed both the SBP and HR to be checked and followed before administering the amlodipine and carvedilol medications.
On 2/13/25 at 0856 hours, an interview was conducted with the DON. The DON stated the licensed nurses should read the physician's orders, including the holding parameter instructions. The DON further stated the LVN should have measured the HR in addition to the SBP prior to administering the amlodipine and carvedilol medication.
2. Review of the facility's P&P titled Enteral Tube Medication Administration Procedure dated 1/28/25, showed in part, .Flush the tube with 30 ml of water prior to medication administration .Administer the medication and flush the tube with water .flush the tube with 30 ml of water or as directed .
Review of the facility's P&P titled Administration Process dated 1/28/25, showed in part, .Flush tube before and after medication administration with at least 30 ml or warm water .
a. Medical record review for Resident 152 was initiated on 2/11/25.
Review of Resident 152's MAR showed the following physician's order:
- dated 11/13/24, to flush the GT with 50 ml of water pre and post medication administration via tube.
On 2/11/25 at 0815 hours, a medication administration observation was conducted with LVN 8. LVN 8 was observed administering five medications through Resident 152's GT. Prior to administering the first medication, LVN 8 was observed flushing Resident 152's GT with 15 ml of plain water. After the first flushing with the water, LVN 8 proceeded to administer the five prepared medications through Resident 152's GT. However, LVN 8 did not flush the resident's GT with plain water in between the administration of each medications. After administering the fifth medication through Resident 152's GT, LVN 8 was observed rinsing one of the medication cups with water and administered it through Resident 152's GT. LVN 8 did not flush the GT with plain water at the end of the medication administration.
On 2/11/25 at 1228 hours, an interview was conducted with LVN 8. LVN 8 verified she flushed Resident 152's GT with 15 ml of water before giving medications. LVN 8 stated the reason why she did not flush the GT with water in between each medication was because each medication contained water, and thought it was okay to give the medications without flushing with water after administering each medication.
b. Medical record review for Resident 111 was initiated on 2/12/25.
Review of Resident 111's MAR showed the following physician's order:
- dated 9/6/24, to flush the tube (GT) with 50 cc (ml) of water pre and post mediation administration via tube.
On 2/12/25 at 0814 hours, a medication administration observation was conducted with LVN 4. LVN 4 was observed administering nine medications, including eight medications through Resident 111's GT. LVN 4 was not observed flushing the GT with water prior to administering the first medication, between the first and the second medication administration and after giving the last medication. LVN 4 was observed flushing Resident 111's GT with about 15-30 ml of plain water in between each medication administration after giving the second medication through the eighth medication.
On 2/12/25 at 1110 hours, an interview was conducted with LVN 4. LVN 4 verified he did not flush the resident's GT with plain water before and after administering the medications and between the first two medications.
On 2/13/25 at 0856 hours, an interview was conducted with the DON. The DON stated when administering medications through a GT, the licensed nurse should flush the resident's GT with 30 ml of plain water before and after administering medications and 5-10 ml of plain water between each medication to prevent clogging, with the exact amount depending on the physician's flushing order and instruction.
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 F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility P&P review, the facility failed to store and label the m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility P&P review, the facility failed to store and label the medications in accordance with the manufacturer's instructions and the facility's P&P when:
* An amber bottle of megestrol acetate (appetite stimulant) oral suspension was not properly labeled with
the specific instruction on preparation in Medication Cart 2.
* A bottle of Katerzia (amlodipine, use for treatment of hypertension, to lower blood pressure) oral suspension requiring refrigerated storage condition was stored at a room temperature in Medication Cart 2.
* An opened Levemir insulin vial was stored without an open date in Medication Cart 1.
* Three boxes of expired Tempa-DOT (single-use, disposable clinical thermometer for oral and axillary (armpit) use that measures body temperature, designed to be sanitary and prevent the spread of infection) supplies were stored in Medication Room A.
These failures had the potential for the residents to receive unsafe, ineffective medications and inaccurate medical device.
Findings:
1. Review of the manufacturer's package insert (detailed description of a drug's uses, storage, and more that is available to clinicians) for megestrol acetate oral suspension dated 10/2021 showed, shake container well before using.
On [DATE] at 1553 hours, an observation of Medication Cart 2 and concurrent interview was conducted with LVN 10. The pharmacy label on the provided amber bottle of megestrol acetate oral suspension 40 mg/ml was observed without the specific preparation instruction for the licensed nurses to shake the container well before using. No auxiliary label was observed on the amber bottle which could be used as a reminder for the licensed nurses to shake the container well before use. LVN 10 acknowledged the finding and stated the information of shake well was a special preparation instruction that the licensed nurses needed to know when they prepared the medication before administering it to the residents.
On [DATE] at 0856 hours, an interview was conducted with the DON. The DON stated any suspension medications required the proper and adequate shaking to produce a uniform preparation of the medication prior to each administration since the suspension medications had the potential to settle in the bottom of the medication bottle. The DON also stated if the suspension medication was not labeled to shake the bottle, the staff should have contacted the pharmacy to request a replacement of the medication with the appropriate labels.
2. Review of the facility's P&P titled Medication Storage in the Facility dated [DATE], showed medications requiring refrigeration temperatures between 2°C (36°F) and 8°C (46°F) are kept in a refrigerator with a thermometer to allow temperature monitoring.
Review of the manufacturer's package insert for Katerzia (amlodipine) oral suspension dated 4/2023 showed the Katerzia (amlodipine) oral suspension should be stored refrigerated (2°C to 8°C/36°F to 46°F).
Review of the manufacturer's box container in which the bottle of medication was stored showed, Must store refrigerated: 2°C - 8°C (36°F - 46°F).
On [DATE] at 1553 hours, an observation of Medication Cart 2 and concurrent interview was conducted with LVN 10. A manufacturer's bottle of Katerzia (amlodipine) oral suspension 1 mg/ml in a manufacturer's box container with attached pharmacy-applied label was observed stored inside Medication Cart 2 at a room temperature, instead of being stored in a refrigerator. LVN 10 acknowledged the finding and stated one of the licensed nurses might have used the medication for the resident and left it in the medication cart.
On [DATE] at 0856 hours, an interview was conducted with the DON. The DON was informed of the above findings. The DON stated the medication should be stored in accordance with the manufacturer's storage instruction. The DON also stated after the licensed nurses used the refrigerated medication for the resident, the licensed nurses should bring the medication back to the refrigerator in the medication room.
3. Review of the facility's P&P titled Medications Requiring Notation of Date Opened dated [DATE], showed all the medications requiring an open date will be dated immediately upon opening. Date will be applied using a Date Open label or written directly on the packaging by the charge nurse. To ensure potency, maintain efficacy and avoid cross contaminations, certain medications must be dated when first opened and discarded when the designated expiration time period or the manufacturer's expiration date elapses. The following expiration periods are based on currently accepted standards of practice and/or the manufacturer's recommendation:
- Expires 28 days after opening: All insulins.
On [DATE] at 1624 hours, an observation of Medication Cart 1 and concurrent interview was conducted with LVN 9. An opened vial of Levemir (insulin medication) 100 units/ml without an open date was observed in Medication Cart 1. LVN 9 verified the finding and stated the insulin vials should be discarded 28 days after the opened date. When asked about the expiration date of the opened Levemir insulin vial, LVN 9 stated she was unable to identify the expiration date of the medication without an open date.
On [DATE] at 0856 hours, an interview was conducted with the DON. The DON stated the insulin vials and pens should be dated when opened. The DON further stated the multi-dose vial would expire in 28 days.
4. On [DATE] at 0949 hours, an inspection of Medication Room A and concurrent interview was conducted with the Central Supply Staff. During the inspection of the medications and medical supplies in Medication Room A, three boxes of expired Tempa-DOT were observed. Review of the manufacturer's boxes of the Tempa-DOT showed one box with an expiration date of [DATE], and two boxes with an expiration date of [DATE]. The Central Supply Staff verified the findings and stated the expired supplies should have been removed.
On [DATE] at 0856 hours, an interview was conducted with the DON. The DON stated the facility staff working in the central supply room should be checking the expiration date of the medical supplies. The DON further stated if the expired supply delivered to the nursing units for resident use, the licensed nurses who received the supply should check the expiration date prior to using it for the resident. The DON stated the facility staff should dispose of any expired supplies.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed as evidenced by:
1. The froze...
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Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed as evidenced by:
1. The frozen meat was not thawed in a safe manner.
2. The food preparation equipment was not clean or in good working condition.
3. The dry bulk food was not stored properly.
4. The meal preparation equipment was not air dried.
5. Two floor drains did not have a backflow prevention.
6. The cleaning equipment was not stored in a sanitary manner.
These failures posed the risk for food borne illnesses in highly susceptible resident population of 157 facility residents who received food prepared in the kitchen.
Findings:
Review of the facility's Matrix dated 2/11/25, showed 157 of 166 residents who resided in the facility consumed food prepared in the kitchen.
1. Review of the facility's P&P titled Thawing of Meats dated 2023 showed thawing of the meat properly can be done by labelling defrosting meat with a pull date (date food put in refrigerator) and use by date.
On 2/11/25 at 1022 hours, during the initial kitchen walkthrough and concurrent interview with the DSS in the kitchen, seven bags of thawed raw chicken with a large amount of bloody liquid in a large plastic container dated 2/11 were found in the walk-in refrigerator. The chicken did not have a pull date. The DSS stated the chicken was to be used that day and was put in the refrigerator three days ago. The DSS verified the chicken did not have a date reflecting when the chicken was placed in the walk-in refrigerator. The DSS could not show when the chicken was placed in the walk-in refrigerator. The DSS stated the chicken should have a pull date listed on the container.
2. Review of the facility's P&P titled Sanitization dated 2023 showed all the utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas.
On 2/11/25 at 1022 hours, during the initial kitchen walkthrough and concurrent interview with the DSS and RD, a frying pan with heavy black residue was observed. The DSS and RD verified the frying pan was unusable and should be discarded.
3. Review of the facility's P&P titled Storage of Food and Supplies dated 2023 showed the dry bulk foods (flour, sugar, dry beans, food thickener, spices, etc.) should be stored in seamless metal or plastic containers with tight covers, or in bins which are easily sanitized. Scoops should not be left in the containers .
On 2/11/25 at 1022 hours, during the initial kitchen walkthrough and concurrent interview with the DSS and RD, a plastic scoop was found in the powdered thickener container. The DSS and RD verified the findings.
4. According to the USDA Food Code 2022, Section 4-901.11 (A) Equipment and Utensils, Air-Drying Required. After cleaning and sanitizing, equipment and utensils: (A) Shall be air-dried . before contact with food.
On 2/11/25 at 1022 hours, during the initial kitchen walkthrough and concurrent interview with the DSS and RD, a blender was observed stored wet with the lid on. The DSS and RD verified the findings.
5. According to the USDA Food Code 2022, Section 5-202.13 Backflow Prevention, Air Gap. An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (one inch).
On 2/11/25 at 0903 hours, during a kitchen walkthrough and concurrent interview was conducted with the Maintenance Director. The Maintenance Director was asked to check the drainage pipes of the juice machine and walk-in refrigerator. The Maintenance Director verified the juice machine and walk-in refrigerator drainage pipes did not have an air gap for backflow prevention.
6. According to the USDA Food Code 2022 Annex 3, Section 6-501.113 Storing Maintenance Tools. To prevent harborage and breeding conditions for the rodents and insects, the maintenance equipment must be stored in an orderly fashion to permit cleaning of the area.
On 02/11/25 at 1022 hours, during the initial kitchen walkthrough and concurrent interview with the DSS, a broom was observed stored on the floor in the utility closet. The DSS verified the broom should be stored off the floor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0836
(Tag F0836)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the RD completed or reviewed the MDS Nutritional Sta...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the RD completed or reviewed the MDS Nutritional Status assessment and the quarterly nutritional assessment for accuracy for one of 33 final sampled residents (Resident 87). This failure posed the risk for the residents' nutritional needs to not be met in the facility.
Findings:
The California Business and Professions Code (B&P Code) are a set of laws that govern businesses and licensed professions in California. The B&P Code 2586 governs the services of Registered Dietitians. These services include nutritional and dietary assessments.
Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2024 showed under Section K Nutritional Status: the assessor should collaborate with the dietitian and dietary staff to ensure that items in this section have been assessed and calculated accurately. If the resident is gaining a significant amount of weight, the facility should not wait for the 30- or 180-day timeframe to address the problem. Weight changes of 5% in 1 month, 7.5% in 3 months, or 10% in 6 months should prompt a thorough assessment of the resident's nutritional status.
a. Medical record review for Resident 87 was initiated on 2/11/25. Resident 87 was readmitted to the facility on [DATE].
Review of Resident 87's Quarterly MDS Section K Swallowing/Nutritional Status assessment dated [DATE], showed, no or unknown under the section to show if the resident had a weight gain of 5% or more in the last month, or 10% or more in the last 6 months. The dietary section was signed as completed by the DSS.
Review of Resident 87's Weight and Vitals Summary showed the following weights:
- on 7/3/24, a weight of 114 lbs.
- on 1/1/25, a weight of 130.8 lbs (an increase of 14%).
On 2/12/25 at 1430 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator reviewed Resident 87's weights and MDS data, and verified the MDS assessment on 1/15/25 was incorrectly coded. The MDS Coordinator stated the dietary section was completed by the DSS.
On 2/14/25 at 1116 hours, an interview and concurrent medical record review for Resident 87 was conducted with the RD . The RD verified the MDS Section K assessment completed by the DSS dated 1/1/25, showed Resident 87 weighed 131 lbs. The RD verified Resident 87 had a significant weight gain of 17 lbs, 13% in six months. The RD also verified the MDS Section K Significant Weight Gain of 5% or more in the last month or gain of 10% or more in last six months completed by the DSS was coded as No or unknown. The RD stated the MDS nurse had mentioned to the DSS the Section K of the MDS dated [DATE], was incorrect. The RD verified she was not involved in completing the MDS Section K assessment nor did she check the accuracy of the MDS Section K assessment.
Cross reference to F641, example #2.
b. On 2/14/25 at 1012 hours, an interview was conducted with the RD. When the RD was asked about the job duties of the RD and DSS, the RD stated the DSS was responsible to complete all quarterly nutritional assessment for the residents. The RD further stated she was not involved in completing the quarterly nutritional assessments and did not check the accuracy of the quarterly nutritional assessments completed by the DSS.
On 2/14/25 at 1116 hours, an interview and concurrent medical record review was conducted with the RD. The quarterly nutritional assessment for Resident 87 dated 1/14/25, showed the assessment was completed by the DSS and reviewed with the RD. The quarterly nutritional assessment showed Resident 87 weighed 130.8 lbs on 1/1/25. The section titled Weight History showed on 1/1/25, Resident 87 weighed 131 lbs; and on 7/3/24, Resident 87 weighed 114 lbs. The section titled Assessed Needs showed the resident's weight was stable and to continue with the current diet as ordered. The RD verified the quarterly nutritional assessment completed by the DSS dated 1/14/25, showed Resident 87's weight was stable. The RD verified Resident 87's weight was not stable but rather she had experienced a significant weight gain of 17 lbs, 13% in the past six months. The RD further verified the quarterly nutritional assessment dated [DATE], completed by the DSS was not accurate.
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, medical record review and the facility P&P review, the facility failed to ensure the medical records were co...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review and the facility P&P review, the facility failed to ensure the medical records were complete and accurately maintained for 12 of 33 final sampled residents (Residents 16, 25, 32, 37, 46, 47, 56, 57, 65, 87, 146, and 158).
* Resident 47's POLST incorrectly showed the resident had the advanced directive and health care agent (person listed in the advanced directive who can legally make health-care decisions for the resident).
* Resident 87's POLST failed to show the names of facility staff who reviewed and confirmed the form with the resident's responsible party.
* Resident 57's post fall eInteract Change in Condition Evaluation V4.2 showed the incorrect time for the physician and resident notification.
* Resident 158's POLST failed to show the physician's signature.
* Resident 146's POLST failed to show the physician's signature.
* The facility failed to ensure Resident 65's TARs regarding the treatment for xerosis and pruritus were completed.
* The facility failed to ensure Resident 16's LAL monitoring of the setting and functionality was done on 2/9/25, for the NOC shift.
* The facility failed to ensure accurate documentation of the meal consumption for Resident 25.
* The licensed nurses failed to ensure the documentation on the MARs were complete for Residents 32, 37, 46, and 56. In addition, the licensed nurses failed to ensure the documentation on the TAR for Residents 37 was complete.
These failures resulted in inaccurate medical records, which had the potential for the residents' care needs not being met as their medical information was inaccurate and incomplete.
Findings:
Review of the facility's P&P titled Advanced Directives revised 11/2019 showed once an advanced directive is received by the facility, it will be confirmed in the resident's medical record. The facility uses a POLST form to communicate medical interventions, procedures, and end-of-life decisions.
Review of the facility's P&P titled Charting and Documentation revised 2/2022 showed it is the policy of the facility to ensure that the resident record is concise and reflective of resident status. Resident record will be completed on all residents on a schedule basis and will be reflective of current care provided to the resident. The resident's clinical record is a concise account of treatment, care, response to care, signs, symptoms, and progress of the resident's condition. Is also necessary to include data needed for identification and communication with family and friends. Rules for Charting section showed the following:
1. Notes are to be written on all long term residents by day, evening, and night shifts; frequency is determined by the individual nursing service.
2. Daily notes are required as the necessary arises.
3. New admissions must have nurse's notes on all three shifts for the first seventy-two hour.
4. Changes of condition will be documented in resident chart for at least 72 hours.
5. The admitting nurse must write a complete physical and mental nursing assessment.
6. Continuous nurse's notes are required on all residents as the necessary arises.
Review of the facility's P&P titled Physician Documentation revised 11/2024 showed the following:
- Progress notes must be written, signed, and dated with each visit. They may be either paper, or electronic (at least every 30 days for the first 90 days after admission, and at least done once every 60 days thereafter).
- Each physician visit should include an evaluation of the resident's condition, treatment, and a review of, and a decision about, the continued appropriateness of the resident's condition and current medical regime.
Review of the facility's P&P titled Specific Medication Administration Procedures: Documentation revised 1/28/25, showed the individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off duty without first recording the administration of any medications. Current medication, except topicals used treatments, are listed on the resident's MAR. Topical medications used in treatments are; listed on the Treatment Administration record. The resident's MAR is initialed by the person administering the medication in the space provided under the date, and on the line for that specific medication dose administration.
1. Medical record review for Resident 47 was initiated on 2/11/25. Resident 47 was readmitted to the facility on [DATE].
Review of Resident 47's DPOA dated 4/26/24, showed, This document does not authorize anyone to make medical and other health-care decisions for the resident. There was no advanced directive located in the resident's medical record to show a health care agent had been selected.
Review of Resident 47's POLST dated 11/28/24, showed the resident had an advanced directive dated 4/26/24, which was reviewed and listed the resident's health care agent's information.
Review of Resident 47's Social Services Assessment/Evaluation - V 2 dated 12/30/24, showed the resident had a DPOA but had no advanced directive formulated.
On 2/13/25 at 1126 hours, an interview and concurrent medical record review was conducted with the Social Services Staff. The Social Services Staff stated Resident 47's provided a DPOA, but not an advanced directive. The Social Services Staff showed a scanned copy of Resident 47's POLST from the resident's medical record dated 8/2/24, which showed the resident had no advanced directive. The Social Services Staff was unsure if there was an updated POLST in the resident's paper medical record.
On 2/13/25 at 1136 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 reviewed Resident 47's POLST dated 11/28/24, located in the resident's paper medical record. LVN 5 stated the POLST showed the resident had an advance directive and listed a health care agent. LVN 5 stated if the resident was to be transferred out of the facility in an emergency, the POLST would be sent with the resident to show the selected treatment and health care agent.
On 2/13/25 at 1143 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD verified Resident 47's most recent POLST dated 11/28/24, incorrectly showed the resident had the advanced directive and health care agent.
2. Medical record review for Resident 87 was initiated on 2/11/25. Resident 87 was readmitted to the facility on [DATE].
Review of Resident 87's POLST dated 8/12/24, showed the resident had a legally recognized decision maker. In the section for the legally recognized decision maker, a box with signature (required), showed, verbal consent was obtained at 1906 hours. The form did not show the facility staff who had reviewed and confirmed the POLST information with the responsible party and witnessed the review and confirmation of the POLST.
On 2/13/25 at 1044 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated when the facility staff were getting verbal or telephone consent for a signature, the process was to have two facility staff present, one facility staff to obtain the consent and the other facility staff to witness the consent was obtained. The DON stated for Resident 87's POLST, two facility staff names should have been listed on the POLST, to show the staff member who obtained the telephone consent and the other staff member who witnessed the consent was obtained.
3. Medical record review for Resident 57 was initiated on 2/11/25. Resident 57 was readmitted to the facility on [DATE].
Review of Resident 57's eInteract Change in Condition Evaluation V4.2 dated 11/28/24 at 2343 hours, showed the resident had a fall. The evaluation showed the resident's physician was notified of the fall on 11/28/24 at 2228 hours, and the resident was notified at 2230 hours.
Review of Resident 57's post fall Neurological Assessment Flowsheet dated 11/28/24, showed the first neurological assessment was completed at 2330 hours.
Review of Resident 57's Post-Event IDT Review dated 12/2/24, showed the IDT met to discuss a fall incident that the resident had on 11/28/24 at 2330 hours.
On 2/13/25 at 1608 hours, an interview and concurrent medical record review was conducted with the DON. The DON reviewed Resident 57's medical record and was asked what time the resident had a fall on 11/28/24. The DON stated the medical record showed the fall occurred at 2330 hours. The DON verified the time of the physician and resident notifications were incorrectly documented as it was one hour before the resident's actual fall.
8. On 2/13/25 at 1206 hours, during the dinning observation, Resident 25 was observed eating her lunch in her room. The meal tray was observed with vegetable burger, rice, dessert, salad, a cup of chicken noodle soup, a cup of milk and a cup of water. Resident 25 was observed eating couple bites of the vegetable burger, some of the chicken noodle soup, and salad. Resident 25 was observed not touching the rice and milk.
On 2/13/25 at 1304 hours, an observation and concurrent interview was conducted with the CNA 3. CNA 3 was observed asking Resident 25 if she was done with her meal, Resident 25 stated yes. CNA 3 was then observed taking out the meal tray for Resident 25. CNA 3 verified Resident 25 ate around 25% of her meal tray.
Medical record review for the Resident 25 was initiated on 2/11/25. Resident 25 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of the Resident 25's Physician Order Summary dated 1/2/25, showed a physician's order to monitor the resident's meal percentage intake every meal.
Review of the Resident 25's Documentation Survey Report v2 dated February 2025 showed on 2/13/25 at 1251 hours, the percentage of the lunch eaten by Resident 25 was documented as 76-100%.
On 2/13/25 at 1606 hours, an interview and concurrent medical record review for Resident 25 was conducted with RN 1. RN 1 was informed of the observation of Resident 25's lunch meal intake of around 25% on 2/13/25. RN 1 verified the facility staff documented 76-100% for Resident 25's lunch meal intake on 2/13/25. RN 1 stated the facility staff should accurately document the percentage of amount eaten by the resident.
On 2/14/25 at 0930 hours, an interview and concurrent medical record review for Resident 25 was conducted with the DON. The DON verified and acknowledged the above findings.
9. Medical record review for Resident 32 was initiated on 2/12/25. Resident 32 was admitted to the facility on [DATE].
Review of Resident 32's MAR for December 2024 showed the following entries with missing documentation from the licensed nurse:
- to monitor the pain level using the following scale; 0 = no pain, 1-3 = mild, 4-6 = moderate, and 7-10 = severe every shift.
There was no documentation for the monitoring on 12/25/24, for the night shift and 1/21/25, for the morning shift.
- to administer multiple vitamins-minerals (supplement) one tablet by mouth one time a day for supplement.
There was no documentation the multiple vitamins-minerals medication was administered on 1/21/25.
- to provide nonpharmacological interventions for pain: 1 = Repositioning, 2 = Dim light/ quiet environment, 3 = relaxation 4 = distraction, 5 = music, and 6= massage every shift.
There was no documentation a nonpharmacological interventions were provided on 12/25/24, for the night shift.
- to administer Senna (stool softener) tablet 8.6 mg two tablets by mouth two times a day for constipation. There was no documentation the Senna medication was administered on 1/21/25, for the morning shift.
- to monitor/document/report to the MD for signs and symptoms of anticoagulant complications: blood tinged or frank blood in the urine, black tarry stools, dark or bright red blood in stools, sudden sever headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs every shift.
There was no documentation the above monitoring was performed on 1/21/25, for the morning shift.
- to administer tadalafil 5 mg one tablet by mouth one time a day for benign prostatic hypertrophy (enlarged prostate).
There was no documentation the tadalafil medication was administered on 1/21/25.
- to administer aspirin (pain medication) low dose 81 mg one chewable tablet by mouth one time a day for cerebrovascular disorder (conditions that affect the blood vessels in the brain and spinal cord) prophylaxis.
There was no documentation aspirin medication was administered on 1/21/25.
- to provide health shake 4 oz with meals for supplement.
There was no documentation the Healthshake was provided to the resident on 1/21/25, for the morning and evening shifts.
10.a. Medical record review for Resident 37 was initiated on 2/12/25. Resident 37 was admitted to the facility on [DATE].
Review of Resident 37's MAR for December 2024 showed the following entries with missing documentation from the licensed nurse:
- to monitor the vital signs and record any Covid-19 signs and symptoms: F=fever, C = cough, S=new shortness of breath/difficulty of breathing, Z=chills, repeated shaking with chills, M = muscle pain, H = Headache, T = sorethroat , L = New loss of taste or smell, O = Congestion, R - runny nose, FA = fatigue, G = GI symptoms; diarrhea/Nausea, and NA = Not applicable, every night shift.
There was documentation the monitoring was performed as ordered on 12/15/24, for the night shift.
- to monitor for the signs and symptoms of bleeding related to anticoagulation/antiplatelet therapy every shift. Notify the MD if any of the following signs and symptoms are present (passing blood in urine, passing blood when resident is having a bowel movement, sever bruising, prolonged nosebleeds (lasting longer than 10 minutes), bleeding gums, vomiting blood or coughing up blood, sudden severe back pain, or difficulty of breathing or chest pain every shift; and to monitor the pain level using the following scale: 0 = no pain, 1-3 = Mild, 4-6 = Moderate, and 7-10 = Severe, every shift.
There was no documentation for the monitoring for the above physician's orders on 12/25/24, for the night shift.
- to elevate the head of the bed to 30-45 degrees at all times on 12/25/24, for the night shift; to flush the GT tube with 50 cc of water pre and post medication administration every shift; to monitor for the signs and symptoms of pacemaker malfunction (syncope, dizziness, palpitations, slow or fast heart rate, hiccup) every shift; to observe the pacemaker site on for any signs and symptoms of infection, signs of pacemaker failure such as pulse below 60, bradycardia, syncope, palpitations, SOB, prolonged hiccups, chest pain , dizziness, weakness, swelling, discoloration, erosion of pacing wire and any pain every shift. Notify the MD if noted every shift; and to crush all crushable medications given via feeding tubes. May slow push to facilitate consumption every shift.
There were no documentation the above physician's orders were performed on 12/25/24, for the night shift.
b. Review of Resident 37's TAR for December 2024 showed the following entrries with missing documentation from the licensed nurse on 12/25/24, for the night shift:
- to monitor the left upper extremity skin discoloration for skin breakdown and increase in size, and notify the MD every shift.
- to monitor the setting and functionality of the low air loss mattress for wound management. May adjust the settings based on the weight or per the resident's comfort every shift.
11. Medical record review for Resident 46 was initiated on 2/12/25. Resident 46 was admitted to the facility on [DATE].
Review of Resident 46's MAR for December 2024 showed the following entries with missing documentation from the licensed nurse on 12/25/24, for the night shift:
- to monitor the vital signs and record any Covid-19 signs and symptoms: F = fever, C = cough, S = new shortness of breath/difficulty of breathing, Z = chills, repeated shaking with chills, M = muscle pain, H = Headache, T = sorethroat , L = New loss of taste or smell, O = Congestion, R - runny nose, FA = fatigue, G = GI symptoms; diarrhea/Nausea, and NA = Not applicable every night shift.
- to provide the nonpharmacological interventions for pain: 1 = Repositioning, 2 = Dim light/ quiet environment, 3 = relaxation 4 = distraction, 5 = music, and 6= massage every shift.
- to monitor the pain level using the following scale: 0 = no pain, 1-3 = Mild, 4-6 = Moderate, and 7-10 = Sever every shift.
12. Medical record review for Resident 56 was initiated on 2/12/25. Resident 56 was admitted to the facility on [DATE].
Review of Resident 46's MAR for December 2024 showed the following entries with missing documentation from the licensed nurse on 12/25/24, for the night shift:
- to monitor the vital signs and record any Covid-19 signs and symptoms: F = fever, C = cough, S = new shortness of breath/difficulty of breathing, Z = chills, repeated shaking with chills, M = muscle pain, H = Headache, T = sorethroat , L = New loss of taste or smell, O = Congestion, R - runny nose, FA = fatigue, G = GI symptoms; diarrhea/Nausea, and NA = Not applicable, every night shift.
- to monitor for the signs and symptoms of bleeding related to anticoagulation/antiplatelet therapy every shift. Notify the MD if any of the following signs and symptoms are present (passing blood in urine, passing blood when resident is having a bowel movement, sever bruising, prolonged nosebleeds (lasting longer than 10 minutes), bleeding gums, vomiting blood or coughing up blood, sudden severe back pain, or difficulty of breathing or chest pain every shift.
On 2/12/25 at 0942 hours, an interview and concurrent medical record review for Residents 32, 37, 46, and 56 was conducted with LVN 3. LVN 3 verified the missing documentation on the residents' MARs and TARs should have been completed by the assigned licensed staff. LVN 3 stated the physician's orders on the MARs and TARs for the above residents were performed, but the licensed nurse had just missed to document in the MARs and TARs.
On 2/14/25 at 1531 hours, an interview was conducted with the DON. The DON verified and acknowledged the above findings.
6. Medical record review for Resident 65 was initiated on 2/12/25. Resident 65 was admitted to the facility on [DATE].
Review of Resident 65's H&P examination dated 4/27/24, showed Resident 65 had the capacity to understand and make decisions.
Review of Resident 65's Order Summary Report dated 2/13/25, showed the following physician's orders:
- dated 11/5/24, to apply Eucerin external lotion (moisturizer) to the body topically every shift for xerosis; and
- dated 11/5/24, to apply triamcinolone acetonide (used to treat skin itching, redness, swelling, dryness, crusting, and scaling) cream 0.1% to the arms topically every shift for pruritus.
Review of Resident 65's TAR for February 2025 showed missing documentation for the Eucerin external lotion and triamcinolone acetonide cream application to the resident's skin on 2/9/25, for the NOC shift (1900-0700 hours).
On 2/12/25 at 1340 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified the above findings. LVN 3 stated complete documentation was important because it showed care provided to the residents.
On 2/14/25 at 1447 hours, an interview was conducted with the DON. The DON stated complete documentation was important to show proof of the services provided to the residents. The DON stated if the treatment or care was not documented, it was not done. The DON further stated the daily audits were done by the Medical Record Director, and the Unit Managers and RNs did random weekly checks of the residents' MARs and TARs. The DON was informed and acknowledged the above findings.
7. Review of the facility's P&P titled Skin and Wound Monitoring and Management (undated) showed the following:
- Use pressure relieving/reducing and redistributing devices (including but not limited to low air loss mattresses, wedges, pillows, etc;
- Licensed nurse to document presence of pressure reducing devices on TAR as ordered; and
- Monitoring daily via medication administration and treatment administration record.
Medical record review for Resident 16 was initiated on 2/13/25. Resident 16 was admitted to the facility on [DATE].
Review of Resident 16's H&P examination dated 10/29/24, showed Resident 16 had the capacity to understand and make decisions.
Review of Resident 16's MDS dated [DATE], showed Resident 16 had a BIMS score of 6 indicating severe cognitive impairment.
Review of Resident 16's Order Summary Report dated 2/13/25, showed the following physician's orders:
- dated 1/30/25, for LAL mattress for wound management, to monitor the setting and functionality every shift and may adjust the settings based on the weight and/or the resident's comfort, every day and night shift; and
- dated 1/31/25, for the sacrococcyx Kennedy terminal ulcer (a painful skin sore that appears in people who are near death) wound care treatment every shift.
Review of Resident 16's TAR for February 2025 showed missing documentation on 2/9/25, for the NOC shift, to show the resident's LAL mattress was monitored for the setting and functionality as ordered by the physician.
On 2/13/24 at 0938 hours, an interview and concurrent medical record review was conducted with LVN 7. LVN 7 verified the above findings.
On 2/14/25 at 1447 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.
4. Medical record review for Resident 146 was initiated on 2/11/25. Resident 146 was admitted to the facility on [DATE].
Review of the Resident 146's POLST dated 12/4/24, under Section D, failed to show the physician's signature.
5. Medical record review for Resident 158 was initiated on 2/12/25. Resident 158 was admitted to the facility on [DATE].
Review of the Resident 158's POLST dated 1/6/25, under Section D, failed to show the physician's signature.
On 2/14/25 at 1053 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the POLST for Residents 146 and 158 were not signed by the residents' physician and stated the residents' POLST should have been signed during the physician's follow-up visit.
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, medical record review, and facility P&P review, the facility failed to provide the necessary care and servic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for two of four final sampled residents (Residents 16 and 93) reviewed for hospice services
* The facility failed to ensure Residents 16 and 93 received HA visits two times a week per the hospice provider's calendar. This failure posed the risk for delays in the communication between the hospice provider and facility, which may affect the residents' care.
Findings:
Review of the facility's P&P titled End of Life Care: Hospice and/or Palliative Care revised on 12/2023 showed the following:
- Hospice services will be offered as appropriate and as ordered by the physician. These services will be integrated into the overall individualized, interdisciplinary care plan. Collaboration with Hospice will include processes for orienting staff to facility policies and procedures which may include resident's rights, documentation, and record keeping requirements; and
- However, the facility will continue to provide necessary care and services to assist the resident to achieve his or her highest practicable well-being.
1. Medical record review for Resident 16 was initiated on 2/13/25. Resident 16 was admitted to the facility on [DATE].
Review of Resident 16's Order Summary Report dated 2/13/25, showed a physician's order dated 1/15/25, to admit the resident under Hospice A with the diagnosis of heart failure.
Review of Resident 16's Hospice Visit Sign-in Monthly Calendar showed the HA visit frequency was two times a week.
Review of Resident 16's January to February 2025 Hospice Visit Sign-in Monthly Calendar during the weeks from 1/12 to 2/8/25, showed there were no HA visits conducted two times a week. In addition, during the week of 2/9 to 2/15/25, there were two scheduled HA visits on 2/11 and 2/14/25. However, there was no documented evidence of the HA visit on 2/11/25.
Reviewed Resident 16's Hospice Visit Sign-in Sheet for January and February 2025 did not show the entries or the hospice staff's names for the biweekly scheduled for the HA visits.
On 2/13/25 at 0949 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 stated the HA visit was scheduled two times a week and the RN Case Manager was scheduled weekly. LVN 3 verified the above findings. LVN 3 stated the hospice staff were supposed to sign the hospice monthly calendar and the visit sign in sheet. Furthermore, LVN 3 stated the facility licensed nurse assigned to the resident would call the hospice provider when the HA visits were not completed.
2. Medical record review for Resident 93 was initiated on 2/13/25. Resident 93 was admitted to the facility on [DATE].
Review of Resident 93's Order Summary Report dated 2/13/25, showed a physician's order dated 12/17/24, to admit the resident under Hospice B with the diagnosis of cerebral atherosclerosis.
Review of Resident 93's Vitas Personalized Visit Schedule for December 2024 and February 2025 showed the following:
- During the weeks from 12/15 to 12/28/24, there were no HA visits conducted during these weeks.
- During the week of 12/29/24 to 1/4/25, showed there was one HA visit scheduled. However, there was no documented evidence the HA visited during this week.
- During the weeks of 1/5 to 2/8/25, showed there were two HA visits scheduled. However, there was no documented evidence of the HA visits during these weeks.
On 2/13/25 at 0949 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified the above findings.
On 2/13/25 at 1015 hours, an interview and concurrent medical record review was conducted with Hospice Case Manager. The Hospice Case Manager stated all hospice disciplines that visited the resident must sign the calendar and the visit description log. The Hospice Case Manager stated when the hospice discipline or hospice staff did not sign in on both the calendar and visit description log, the visit was not done. The Hospice Case Manager verified the above findings.
On 2/14/25 at 1447 hours, an interview was conducted with the DON. The DON stated all hospice staff must sign on the hospice calendar or visit log to show the visits were completed. Furthermore, the DON stated the facility licensed nurses were not required to document the visits done by the HA or aide, and only documented if there were orders received from hospice doctor. The DON was informed and acknowledged the above findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
Based on interview, medical record review, facility document review, and facility P&P review the facility failed to implement an antibiotic stewardship program to reduce the risk of unnecessary or ina...
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Based on interview, medical record review, facility document review, and facility P&P review the facility failed to implement an antibiotic stewardship program to reduce the risk of unnecessary or inappropriate antibiotic use when two nonsampled residents (Residents 127 and 159) were being treated for conditions which did not meet the McGeer's criteria. This failure had the potential of not accurately identifying true infections and exposing the residents to unnecessary antibiotic use.
Findings:
Review of the facility's P&P titled Infection Prevention and Control Program revised 9/2017 showed improving the use of antibiotics in healthcare to protect residents and reduce the threat of antibiotics resistance is a national priority, and disease caused by resistant bacteria are increasing in long term care facilities and contributing to higher rates of morbidity and mortality. The facility will promote appropriate antibiotic use while optimizing the treatment of infections, while reducing possible adverse events associated to antibiotic use.
On 2/14/25 at 0804 hours, an antibiotic stewardship review and concurrent interview was conducted with the IP. The IP stated the facility used the McGeers criteria to identify true infections. The IP stated for suspected infections that did not meet the McGeer's criteria and were treated with antibiotics, the process was to notify the physician to evaluate the antibiotic usage.
a. Review of the facility's Infection Prevention and Control Surveillance Log for November 2024, showed Resident 127 was prescribed an antibiotic medication on 11/11/24, for pneumonia and met the McGeer's criteria.
Review of Resident 127's Infection Surveillance - V2 dated 11/14/24, showed the criteria for pneumonia was met. However, review of Resident 127's medical record failed to show the resident's symptoms met criteria for a true infection.
The IP verified Resident 127's medical record failed to show the resident's symptoms met the McGeer's criteria. In addition, the resident's physician was not notified regarding the resident's antibiotic medication not meeting the McGeer's criteria and to re-evaluate the need for the use of the antibiotic medication.
b. Review of the facility's Infection Prevention and Control Surveillance Log for January 2025, showed Resident 159 was prescribed an antibiotic medication on 1/4/24, for other infection related to elevated WBCs and met the McGeer's criteria.
Review of Resident 159's Infection Surveillance - V2 dated 1/3/25, showed the McGeer's criteria was met. However, review of Resident 159's medical record failed to show the resident's symptoms met the McGeer's criteria for a true infection.
The IP stated the facility did not have a McGeer's criteria tool for the other infections. The IP verified the resident's symptoms did to meet the McGeer's criteria, and the resident's physician was not notified.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the essential equipment in the safe operating conditions.
* The facility's ice mach...
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Based on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the essential equipment in the safe operating conditions.
* The facility's ice machine was not cleaned and sanitized as per the manufacturer's instructions. This failure had the potential for the essential equipment not functioning in the way it was intended and in turn cause contamination of the food, leading to illnesses for the residents.
Findings:
Review of the facility's Matrix showed 157 of 166 residents consumed food prepared in the kitchen.
Review of the USDA Food Code 2022, Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment Food-Contact Surfaces and utensils shall be clean to sight and touch.
Review of the facility's P&P titled Ice Machine Cleaning Procedures dated 2023 showed the internal components are to be cleaned monthly per manufacturer's recommendations.
Review of the facility's ice machine manufacturer guidelines titled Cleaning and Sanitizing Procedure Instructions (undated) showed the following:
- Only use [Manitowac] approved ice machine cleaner and sanitizer for this application.
- Step 1: Ice must not be on the evaporator during the clean/sanitize cycle. Press the manual harvest button in the service menu and allow the ice to harvest. Once all of the ice falls from the evaporator, turn the machine off by pushing the power button.
- Step 2: Remove all ice from the bin/dispenser.
- Step 3: Press the clean button, follow the prompts, and select Turn off when complete. The unit does not start dumping until you select Off or Ice mode. Water will flow through the dump valve and down the drain. When water trough has refilled (approximately 1 minute) and the display indicates: Add the proper amount of ice machine cleaner. (See chart #1 for proper amount). Chart #1 showed five ounces of cleaner was to be added to the water trough.
- Step 4: Wait until the clean cycle is complete (approximately 24 minutes).
- Step 5: Remove parts for cleaning.
- Step 6: Mix a solution of the cleaner and warm water. Depending on the degree of mineral buildup. A large quantity of solution may be required. Use the table to mix enough solution to thoroughly clean all parts. Chart showed: use one gallon of water with 16 oz of cleaner solution.
- Step 7: Use half of cleaner mixture to clean all components. Soak parts for five minutes, 20 minutes for heavily scaled parts. The cleaner solution will foam when it contacts lime scale and mineral deposits. Once the foaming stops, use a soft-bristle nylon brush, sponge or cloth to thoroughly clean the following ice machine areas: side walls, base (area above the trough), evaporator plastic parts (top, bottom, and sides), bin or dispenser. Rinse all the components with clean water
- Step 8: While components are soaking, use half of the cleaner/water solution to clean all food zone surfaces of the ice machine and bin (or dispenser). Use nylon brush or cloth to thoroughly clean the following ice machine areas: side walls, base, evaporator plastic parts, bin, or dispenser. Rinse thoroughly with clean water.
- Step 9: Mix a solution of sanitizer and lukewarm water. Three gallon (12 liters) of water and two ounces of sanitizer.
- Step 10: Use half of the sanitizer/water solution to sanitize all removed components. Use a spray bottle to liberally apply the solution to all surfaces of the removed parts or soak the removed parts in the sanitizer/lukewarm solution. Do not rinse parts after sanitizing.
- Step 11: Use half of the sanitizer/water solution to sanitize all food zone surfaces of the ice machine and bin. Use a spray bottle to liberally apply the solution: side walls, base, evaporator plastic parts, bin or dispenser. Rinse all areas thoroughly with clean water.
- Step 12: Replace all removed components.
- Step 13: Wait 20 minutes.
- Step 14: Reapply power to the ice machine. Press the clean button and select make ice when complete.
- Step 15: When ice trough was refilled, and the display indicates: add the proper amount of ice machine sanitizer to the water trough by pouring between the water curtain and evaporator. (See chart #1 for proper amount.) Showed to use 3 oz of sanitizer.
On 2/11/25 at 0924 hours, an observation and concurrent interview was conducted with the Maintenance Director and MA for the ice machine located in the kitchen. The MA stated he cleaned the ice machine once a month. The MA was asked to explain the process he used to clean the ice machine. The MA stated he mixed five ounces of the ice machine cleaner/descaler with a pitcher of water. The mixture was poured into the machine and the clean cycle was started. The MA was asked how much water he mixed with the ice machine cleaner/descaler. The MA stated he filled the pitcher to the top with water. The MA verified he did not know how much water the pitcher held. The MA stated once the ice machine cleaner/descaler mixture ran through the machine, he removed the internal parts and soaked the parts in bleach in a large container. The MA then stated he put five ounces of ice machine sanitizer in the sink with water. The MA was not able to state how much water he mixed with the sanitizer in the sink. The MA stated he soaked the ice machine parts in the sanitizer/water mixture. The ice machine instructions located on the inside panel of the ice machine were reviewed with the Maintenance Director and MA. The Maintenance Director stated the MA was confused with the ice machine chemicals and the instructions were in English, which was difficult for the MA to understand.
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, medical record review, facility document review, and facility P&P review, the facility failed t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control program and practices to help prevent the development and transmission of diseases and infections.
* The laundry and clean linen rooms were not maintained to ensure a clean area, free from potential contamination.
* Resident 144 (final sampled resident)'s infection was not reported on the facility's monthly infection control log.
* Residents 127 and 159's infections (nonsampled residents) were incorrectly listed as meeting McGeer's Criteria on the facility's monthly infection control log.
* Two of four licensed nurses did not wear appropriate personal protective equipment (PPE) during the medication administrations for two of four residents (final sampled residents, Residents 111 and 152) who were on enhanced barrier precautions (EBP).
* Two of four licensed nurses did not sanitize the BP cuff and stethoscope before and after use for two of four residents (final sampled residents, Residents 111 and 152) on EBP.
* Three of four licensed nurses did not perform hand hygiene during the medication administration for three of four residents (final sampled residents, Residents 111 and 152; and nonsampled resident, Resident 68).
* One of four licensed nurses did not disinfect the feeding tube after dropping it on the floor and prior to attaching it to Resident 111's GT during the medication administration.
These failures resulted in inaccurate infection surveillance, which had the potential for spread of infection in the facility.
Findings:
1. On 2/13/25 at 1000 hours, a laundry room inspection was conducted with the Maintenance Director. The following was observed in the clean linen room located in the basement:
- Puddles of water were observed on the floor under and around the clean linen folding table, on the floor in and around two built in storage cabinets. The Maintenance Director stated the water had leaked in from the rain.
- The clean linen folding table had adhesive residue with threads on the laminate, resulting in an uncleanable surface.
- The clean linen room window perimeter, located above the clean linen folding table, had deteriorated and cracked paint and putty, with exposed wood and dark discoloration.
- The wall under the above window showed signs of damage with cracks and gaps between the wall and baseboard.
- The built-in wooden cabinets located along the outside wall, was filled with discharged residents' clothing and belongings. The items were stored on a wooden pallet on the floor. The pallet was sitting in a puddle of water, and the wood was warped and rotting with black and white staining. The base of one cabinet had black and dark brown discolorations at the base along the floor.
- The sink had blank stains and debris with white mineral-like residue.
In addition, the following was observed in the laundry room:
- The sink had blank stains and debris with white mineral-like residue.
-T he clothes dryer near the sink had metallic corrosion with brownish discoloration on the bottom frame.
The Maintenance Director verified the above findings and stated the conditions of the cabinets could cause mold formation and the white staining could be an indicator of mold.
On 2/13/25 at 1100 hours, a follow-up observation was conducted in the clean linen room. Laundry aides were observed folding clean clothes on the clean linen table, with the uncleanable surface, while a staff was wiping up the puddles of water still accumulating on the floor.
2. Review of the facility's P&P titled Infection Prevention - Surveillance of Infections and Reporting undated, showed it is the facility's policy to maintain an ongoing system of surveillance to identify possible communicable diseases or infections to ensure measures are taken to prevent any potential outbreak. An Infection Control Surveillance log will be maintained and reviewed to ensure all potential or actual infections are being identified. The Infection Control Committee will monitor these findings and report to the Quality Assurance Committee at least monthly.
On 2/14/25 at 0804 hours, an infection control and surveillance review was conducted with the IP. The IP stated the facility used the McGeer's criteria to identify true infections, and the information was listed on the monthly Infection Prevention and Control Surveillance Log to be reviewed monthly with the Quality Assurance program.
Review of Resident 144's Infection Surveillance - V 2 assessment dated [DATE], showed the resident was prescribed an antibiotic medication for an eye infection and the resident's symptoms met the McGeer's criteria.
Review of the facility's Infection Prevention and Control Surveillance Log for November 2024 failed to show Resident 144's infection was included on the log, to be reported to and reviewed by the facility's Quality Assurance Committee. The IP verified Resident 144's infection was not included on the log and should have been.
3. On 2/14/25 at 0804 hours, an antibiotic stewardship review was conducted with the IP.
a. Review of the facility's Infection Prevention and Control Surveillance Log for November 2024 showed Resident 127 was prescribed an antibiotic medication on 11/11/24, for pneumonia and the resident's symptoms met the McGeers criteria.
Review of Resident 127's Infection Surveillance - V2 dated 11/14/24, showed the criteria for pneumonia was met. However, Resident 127's medical record failed to show the resident's symptoms met the McGeer's criteria for a true infection.
The IP verified Resident 127's symptoms did not meet the McGeers criteria, resulting in incorrect data listing on the Infection Prevention and Control Surveillance Log for November 2024.
b. Review of the facility's Infection Prevention and Control Surveillance Log for January 2025 showed Resident 159 was prescribed an antibiotic medication on 1/4/24, for other infection related to elevated WBCs and met the McGeers criteria.
Review of Resident 159's Infection Surveillance - V2 dated 1/3/25, showed the McGeers criteria was met. However, review of Resident 159's medical record failed to show the resident symptoms met the McGeers criteria for a true infection.
The IP verified Resident 159's symptoms did not meet the McGeers criteria, resulting in incorrect data listing on the Infection Prevention and Control Surveillance Log for January 2025.
4. Review of the facility's P&P titled IPCP (infection prevention control program) Standard and Transmission-Based Precaution dated 1/28/25, showed in part, .wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. [NAME] PPE upon room entry, then doff and properly discard PPE and perform hand hygiene before exiting the patient room to contain pathogen . EBP is used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident (e.g., resident with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDRO). Indwelling medical devices include, but are not limited to central lines, PICC lines, urinary catheters, feeding tubes, and tracheostomies .
Review of the facility's P&P titled Infection Prevention-Employee Exposure dated 1/28/25, showed in parts, Protective Barriers .Gowns: Wear disposable gowns when entering room .and it is anticipated that clothing will become soiled with body fluids or when contact with soiled surfaces (such as side rails or bed linens of an infected resident) is anticipated. Remove gown when the procedure is complete and prior to leaving the resident's room .
a. Medical record review for Resident 152 was initiated on 2/11/25.
Review of Resident 152's MAR showed the following physician's order:
- dated 11/14/24, for Enhanced Barrier Precautions: PPE Required for high resident contact care activities. Indication: implanted feeding device.
On 2/11/25 at 0815 hours, a medication administration observation via GT was conducted with LVN 8. A sign/poster for EBP was observed on Resident 152's room door. LVN 8 was observed wearing a new pair of gloves at the medication cart and entering Resident 152's room without a gown, to assess the resident's BP. After LVN 8 prepared all the medications for GT administration at the medication cart, LVN 8 stated she would need to wear a gown since Resident 152 had a GT. LVN 8 was observed wearing a new pair of gloves and a gown during the medication administration observation.
On 2/11/25 at 1228 hours, an interview was conducted with LVN 8. LVN 8 stated she did not wear a gown while checking the Resident 152's BP. LVN 8 also stated a gown and gloves were required when checking the resident's BP and administering medications for the residents on EBP.
b. Medical record review for Resident 111 was initiated on 2/12/25.
Review of Resident 111's MAR showed the following physician's order:
- dated 9/6/24, for Enhanced Barrier Precautions: PPE Required for high resident contact care activities. Indication: implanted feeding device.
On 2/12/25 at 0814 hours, a medication administration observation via GT was conducted with LVN 4. A sign/poster for EBP was observed on Resident 111's room door. LVN 4 was observed wearing a new pair of gloves at the medication cart and entering Resident 111's room without a gown, to assess the resident's BP. While LVN 4 was measuring the resident's BP with the stethoscope and BP cuff, LVN 4's arms and clothing were observed touching the resident's linens and the resident's arm. Shortly after the BP assessment, LVN 4 returned to the mediation cart and started preparing nine medications for Resident 111. After preparing the medications, LVN 4 wore a new pair of gloves, returned to Resident 111's room again without a gown and proceeded to administer the medications through the resident's GT.
On 2/12/25 at 1110 hours, an interview was conducted with LVN 4. LVN 4 stated he did not wear a gown while checking the resident's BP and administering the resident's medications. LVN 4 also stated he realized after finishing the medication administration, he had to be gowned up. LVN 4 stated gown and gloves were required PPE when providing care to the residents on EBP, which included the BP assessment and medication administration.
On 2/13/25 at 0856 hours, an interview was conducted with the DON. The DON stated for the residents on EBP, the facility staff providing care such as BP measurement and medication administration, need to wear the gown and gloves before entering the room.
5. Review of the facility's P&P titled IPCP standard and Transmission-Based Precaution dated 1/28/25, showed in part, .patient-care equipment (e.g., blood pressure cuffs). If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient .
Review of the facility's P&P titled Infection Prevention-Employee Exposure dated 1/28/25, showed Environmental and Equipment Protection: Dedicated use of non-critical care equipment (i.e., sphygmomanometer, stethoscope and thermometer) will be provided to MDRO resident(s), when available. This equipment should be disinfected after each use whether dedicated to MDRO resident or shared.
a. On 2/11/25 at 0815 hours, a medication administration observation via GT was conducted with LVN 8. A sign/poster of EBP was observed on Resident 152's room door. LVN 8 was observed bringing an uncleaned stethoscope and BP cuff to Resident 152's room, to assess the resident's BP. After the BP assessment, LVN 8 brought out the stethoscope and BP cuff to the medication cart and disinfected only the earpieces of the stethoscope with the alcohol swab. LVN 8 did not sanitize the entire parts of the stethoscope and BP cuff with the sanitizing wipe before and after use.
On 2/11/25 at 1228 hours, an interview was conducted with LVN 8. LVN 8 verified she did not sanitize the BP cuff and stethoscope with the sanitizing wipe before and after use and sanitized only the earpieces of the stethoscope with the alcohol swab after use.
b. On 2/12/25 at 0814 hours, a medication administration observation via GT was conducted with LVN 4. A sign/poster of EBP was observed on Resident 111's room door. LVN 4 was observed sanitizing only the earpieces of the stethoscope without sanitizing the entire parts of the stethoscope and BP cuff. Then, LVN 4 was observed bringing the stethoscope and BP cuff to Resident 111's room, to assess the resident's BP. After the BP assessment, LVN 4 brought out the stethoscope and BP cuff to the medication cart and sanitized only the earpieces of the stethoscope with the alcohol swab. LVN 4 did not sanitize the entire parts of the stethoscope and BP cuff with the sanitizing wipe before and after use.
On 2/12/25 at 1110 hours, an interview was conducted with LVN 4. LVN 4 verified he did not sanitize the BP cuff and stethoscope before and after use. LVN 4 stated he should have cleaned the entire parts of stethoscope and BP cuff using the sanitizing wipe.
On 2/13/25 at 0856 hours, an interview was conducted with the DON. The DON stated the BP cuff and stethoscopes should be disinfected before and after use, sanitizing the whole stethoscope from the ear parts to the diaphragm, and it should be disinfected with bleach not with the alcohol swab.
6. Review of the facility's P&P titled Infection Prevention-Hand Hygiene dated 1/28/25, showed in part, 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 donning sterile glove .after removing glove .
a. On 2/11/25 at 0815 hours, a medication administration observation via GT was conducted with LVN 8. A sign/poster of EBP was observed on Resident 152's room door. After LVN 8 brought in all the prepared medications into Resident 152's room and placed it on the resident's bedside table, LVN 8 was observed walking out of the resident's room to the medication cart to get a cup of water for the GT administration. LVN 8 discarded the gloves she was wearing and prepared a cup of water. Before reentering to the resident's room, she wore a new pair of gloves without sanitizing her hands with the alcohol gel. After LVN 8 returned to the resident's room with a cup of water, she proceeded to administer the medications via GT.
On 2/11/25 at 1228 hours, an interview was conducted with LVN 8. LVN 8 stated she did not remember whether she sanitized her hands with the alcohol gel in between changing the gloves when she walked out of the resident's room to get a cup of water.
b. Review of the facility's P&P titled Administration Process dated 1/28/25, showed hands are to be washed with soap and water before and after administering injections, eye drops, eardrops, nasal sprays.
On 2/11/25 at 0903 hours, a medication administration observation was conducted with LVN 6. LVN 6 was observed preparing 10 medications, including eight tablets, one nasal spray and an insulin for injection for Resident 68. After administering the tablets to Resident 68, LVN 6 trashed the empty cups, washed her hands in the resident's restroom with soap and water. Then, LVN 6 was observed wearing a new pair of gloves to assess the resident's glucose level using a lancet, glucometer and a test strip. After LVN 6 assessed the resident's glucose level, LVN 6 was observed changing the gloves without performing hand hygiene. After LVN 6 wore a new pair of gloves, she proceeded to administer the nasal spray to Resident 68's nostrils.
On 2/11/25 at 1137 hours, an interview was conducted with LNV 6. LVN 6 stated she thought she cleaned her hands in between changing the gloves. However, two surveyors independently observed LVN 6 not performing hand hygiene in between changing the gloves before administering the last medication to the resident, which was the nasal spray.
c. On 2/12/25 at 0814 hours, a medication administration observation via GT was conducted with LVN 4. A sign/poster of EBP was observed on Resident 111's room door. After LVN 4 administered the third medication to Resident 111's GT, LVN 4 walked out of the resident's room to get more water for the remaining gloves. Then, LVN 4 returned to the resident's room with a cup of water wearing the same gloves. LVN 4 was not observed changing the gloves. After LVN 4 re-entered the resident's room, LVN 4 resumed administering the rest of the medications via the resident's GT.
On 2/12/25 at 1110 hours, an interview was conducted with LVN 4. LVN 4 stated he did not change the gloves when he walked out of the room to get more water. LVN 4 verified he came back to Resident 111's room with the same gloves on. LVN 4 stated hand hygiene was required before entering and after leaving the resident's room. LVN 4 verified he should have removed the gloves to prepare the cup of water, then donned a new pair of gloves before re-entering the resident's room.
On 2/13/25 at 0856 hours, an interview was conducted with the DON. The DON stated the facility staff must perform hand hygiene in between changing the gloves using alcohol gel or washing hands with soap and water.
7. Review of the facility's P&P titled IPCP Standard and Transmission-Based Precautions dated 1/28/25, showed standard precautions are infection prevention practices that apply to the care of all the residents, regardless of suspected or confirmed infection or colonization status. They are based on the principle that all blood, body fluids, secretions, and excretions (except sweat) may contain transmissible infectious agents. Standard precaution includes use of PPE based on the predicted staff interaction with residents and the potential for exposure to blood, body fluids, or pathogens), hand hygiene, environmental cleaning and disinfection and reprocessing of reusable medical equipment.
On 2/11/25 at 0815 hours, a medication administration observation via GT was conducted with LVN 8. A sign/poster of EBP was observed on Resident 152's room door. Prior to administering the medications to Resident 152, LVN 8 was observed disconnecting the feeding tube from the resident's GT and placing the feeding tube over the IV pole to hang it. After LVN 8 hung the GT tubing over the IV pole, the tubing was dropped on the floor. LVN 8 then grabbed the tubing from the floor and hung it again over the IV pole without disinfecting the tubing or replacing the tubing. Then, LVN 8 proceeded to administer the medications through the resident's GT. After finishing the medication administration, LVN 8 was observed grabbing the GT tubing from the IV pole and reattaching the tubing back to the resident's GT, without disinfecting the tubing or replacing the tubing.
On 2/11/25 at 1228 hours, an interview was conducted with LVN 8. LVN 8 verified the feeding tube was dropped on the floor, but she did not disinfect the tubing. LVN 8 stated she hung the tubing over the IV pole again and started administering the medications to Resident 152. LVN 8 also stated she did not disinfect the tubing before reattaching it to the resident's GT.
On 2/13/25 at 0856 hours, an interview was conducted with the DON. The DON stated the licensed nurse should have securely placed the tube in the holder attached to the feeding pump, instead of hanging the tubing over the IV pole. The DON also stated the licensed nurse should have disinfected the feeding tube after it dropped on the floor and before reattaching it to the resident's GT.
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Assessment Accuracy
(Tag F0641)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 87 was initiated on 2/11/25. Resident 87 was readmitted to the facility on [DATE].
Review ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 87 was initiated on 2/11/25. Resident 87 was readmitted to the facility on [DATE].
Review of Resident 87's Weight and Vitals Summary showed the following weights:
- on 7/3/24, a weight of 114 lbs.
- on 1/1/25, a weight of 130.8 lbs (an increase of 14%).
However, review of Resident 87's Quarterly MDS assessment dated [DATE], showed, no or unknown for the section showing if the resident had a weight gain of 5% or more in the last month, or 10% or more in the last six months. The dietary section was signed as completed by the DSS.
On 2/12/25 at 1430 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator reviewed Resident 87's weights and MDS data and verified the MDS assessment on 1/15/25, was incorrectly coded. The MDS Coordinator stated the dietary section was completed by the DSS.
Based on interview and medical record review, the facility failed to ensure the MDS was coded accurately for two of three final sampled residents (Residents 25 and 87) reviewed for nutrition.
* The facility failed to ensure the MDS was coded accurately when Resident 25 had a weight loss of more than 5% in a month.
* Resident 87's MDS was inaccurately coded to reflect the resident's weight gain.
These failures had the potential for the residents to not receive individualized plans of care to address their individual care needs and inaccurate data for quality measures.
Findings:
1. Medical record review for the Resident 25 was initiated on 2/11/25. Resident 25 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 25's admission MDS dated [DATE], showed Resident 25's weight as 153 lbs.
Review of Resident 25's Weights and Vitals Summary dated 2/13/25, showed the following weights:
- on 11/23/24, a weight of 156.6 lbs;
- on 11/25/24, a weight of 153 lbs;
- on 12/1/24, a weight of 147.4 lbs;
- on 12/9/24, a weight of 147.4 lbs;
- on 12/16/24, a weight of 143 lbs; and
- on 12/23/24, a weight of 139.6 lbs; (8.76 % weight loss in comparison to the weight of 153 lbs on 11/25/24 )
Review of Resident 25's Discharge Assessment- Return Anticipated MDS dated [DATE], showed Resident 25's weight as 140 lbs. However, the section for Weight Loss, Loss of 5% or more in the last month or loss of 10% or more in last six months showed, No or unknown.
On 2/13/25 at 1140 hours, an interview and concurrent medical record review for Resident 25 was conducted with the MDS Coordinator. The MDS Coordinator verified the above findings. The MDS Coordinator stated Resident 25 had more than 5% weight loss in a month, so the MDS on 12/24/24, should have been coded yes for the section for Loss of 5% or more in the last month or loss of 10% or more in last six months. The MDS Coordinator stated the dietary department was responsible to complete the MDS assessment of the residents' nutrition in the facility.
On 2/14/25 at 0930 hours, an interview and concurrent medical record review for Resident 25 was conducted with the DON. The DON verified and acknowledged above findings.
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Quality of Care
(Tag F0684)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review and facility P&P review, the facility failed to provide the necessary care and service...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for one of four final sampled residents (Resident 47) reviewed for accidents.
* Resident 47's post fall neurological evaluation was missing the hourly neurological assessments after the resident had an unwitnessed fall on 1/18/25. This failure had the potential for a delay in providing care to the resident.
Findings:
Review of the facility's P&P titled Neurological Evaluation revised 3/28/23, showed a neurological assessment will be done every 15 minutes for one hour, then every 30 minutes for four hours, then every hour for two hours, and then every shift for 72 hours.
Medical record review for Resident 47 was initiated on 2/11/25. Resident 47 was readmitted to the facility on [DATE].
Review of Resident 47's Nursing Note dated 1/18/25 at 2010 hours, showed at 2005 hours, Resident 47 had an unwitnessed fall and was found on the floor mat next to the wheelchair.
Review of Resident 47's Neurological Assessment Flowsheet initiated on 1/1/8/25 at 2010 hours, showed the neurological assessments should be completed every 15 minutes for one hour, then every 30 minutes for four hours, then every hour for two hours, and then every shift for 72 hours. Review of the flowsheet showed the first hourly assessment was completed on 1/19/25 at 0155 hours; however, there was no second hoursly assessment done at 0255 hours. The next assessment was performed two hours later at 0355 hours.
On 2/13/25 at 1605 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated for the unwitnessed falls, the post fall neurological assessments should be conducted per the frequency listed on the flowsheet. The DON reviewed Resident 47's Neurological Assessment Flowsheet and verified the scheduled neurological assessment for 1/19/25 at 0255 hours, was not completed. The DON stated it should have been done.
Sept 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to protect the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to protect the residents' rights to be free from the physical abuse for two of six sampled residents (Residents 1 and 2).
* Resident 2 allegedly called Resident 1 a bad word and scratched Resident 1's face. In response, Resident 1 bit Resident 2's hand and was found by staff with Resident 2's hand in her mouth. Resident 1 had a scratch mark on her face and Resident 2 had a bite mark on her right hand. This failure had the potential for Residents 1 and 2 to be seriously injured or have psychosocial harm.
Findings:
Review of the facility's P&P titled Abuse: Prevention of and Prohibition Against revised on 1/2021 showed in part, it is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility will provide oversight and monitoring to ensure that its staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, and exploitation .E. Identification. 2. Because some cases of abuse are not directly observed, understanding resident outcomes of abuse can assist in identifying whether abuse is occurring or has occurred. Possible indicators of abuse include, but are not limited to:
- Bruises, skin tears and injuries of unknown source;
- Extensive injuries;
- Injuries in an unusual location;
- Occurrences, patterns, and trends that may constitute abuse;
- Episodes of resident-to-resident altercation, willful or accidental, with or without injury.
- Sudden or unexplained changes in behaviors or activities (e.g., fear of a person or place, feelings of guilt or shame, etc.).
Review of the facility's P&P titled Resident Rights, source Federal Register amended 7/13/17, showed as a resident of this nursing facility, a resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A resident has the right to exercise their rights without interference, coercion, discrimination, or reprisal from the facility as a resident of the facility and as citizen or resident of the United States. A resident has a right to be treated with respect and dignity, including the right to a resident have a right to safe, clean, comfortable and homelike environment, and use of your personal belongings to the extent possible, including but not limited to receiving treatment and supports for daily living safely.
Review of the facility's SOC 341 dated 8/29/24, showed at around 1430 hours, the staff observed Resident 1 sitting in her wheelchair next to Resident 2's bed. Resident 2's hand was noted in Resident 1's mouth. Resident 1 stated she bit Resident 2's hand out of self-defense because Resident 2 had called her bitch and scratched her face. The residents were immediately separated. Resident 1 was assessed and noted with a scratch to the right side of her face. Resident 2 was assessed and noted with a bite mark to her right hand.
Review of the facility's Summary of Investigation letter dated 8/30/24, showed two employees heard noises coming from the residents' room. The staff observed Resident 1 had Resident 2's hand in her mouth. Resident 1 stated Resident 2 called her a derogatory name and scratched the right side of her face. In self-defense, Resident 1 bit Resident 2's hand. Resident 1 was assessed and noted with a scratch mark to the right side of her face. Resident 2 stated Resident 1 bit her. Resident 2 further stated she started it and stated she should have just stayed quiet. Resident 2 stated Resident 1 was being too loud and she told Resident 1 to keep it down. Resident 2 stated Resident 1 got mad and then they started arguing. Resident 2 was assessed and noted with a bite mark to her right hand. The facility substantiated the allegation of abuse between Residents 1 and 2.
a. Medical record review for Resident 1 was initiated on 9/4/24. Resident 1 was admitted to the facility on [DATE].
Review of Resident 1's MDS Section C dated 7/3/24, showed Resident 1 had a BIMS score of 12, indicating moderate cognitive impairment.
Review of Resident 1's Nurse Progress Note dated 8/29/24 at 1523 hours, showed Resident 1 found in a sitting position in her wheelchair. Resident 1 stated Resident 2 scratched the right side of her face. Scratch marks were noted on the resident's right side of face. Resident 1 stated in self-defense, she bit Resident 2's hand.
Review of Resident 1's Skin Evaluation- PRN/Weekly dated 8/29/24, showed Resident 1 was status post alleged altercation with another resident. Upon visualization, Resident 1 was noted to have dried diffused scratches around the right side of the face extending to the neck. No fresh bleeding was found, no redness. Scabbing noted upon assessment. The resident was noted to have dried dispersed scratches on the left side of the upper chest as well. When the resident was asked by this nurse what happened to it, the resident stated, Oh, I probably scratched it earlier.
b. Medical record review for Resident 2 was initiated on 9/4/24. Resident 2 was admitted to the facility on [DATE].
Review of Resident 2's MDS Section C dated 6/26/24, showed Resident 2 had a BIMS summary score of 6, indicating severe cognitive impairment.
Review of Resident 2's Nurse Progress Note dated 8/29/24 at 1525 hours, showed two CNAs went to the resident's room due to hearing commotion. The staff noted Resident 1 holding Resident 2's hand. Resident 2 stated Resident 1 bit her. Resident 2 was assessed and noted with a bite mark on the right hand.
Review of Resident 2's Skin Evaluation PRN/Weekly dated 8/29/24 at 1410 hours, showed Resident 2 was status post alleged altercation with another resident. Upon assessment, Resident 2 verbalized a new wound allegedly caused by roommate. Resident 2 was noted to have a deep laceration measuring 1.5 cm by 0.3 cm.
Review of the physician's orders showed an order dated 8/29/24, to cleanse the right hand bite with normal saline, apply triple antibiotic ointment, and cover with a dry dressing for 7 days.
On 9/4/24 at 1132 hours, an interview was conducted with LVN 4. LVN 4 verified Resident 1 mentioned Resident 2 scratched her and in response, she had bitten Resident 2 in self-defense.
On 9/4/24 at 1348 hours, a telephone interview was conducted with CNA 5. CNA 5 stated she heard loud noise and saw Resident 1 had bit Resident 2's hand. CNA 5 verified Resident 1 stated she bit Resident 2 in self-defense because Resident 2 scratched her (Resident 1) on the right side of her face.
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Comprehensive Care Plan
(Tag F0656)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review and facility P&P review, the facility failed to develop a plan of care to reflect the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review and facility P&P review, the facility failed to develop a plan of care to reflect the individual care needs for one of six sampled residents (Resident 3).
* The facility failed to develop a care plan problem to address Resident 3's refusal of taking medications. This posed the risk of not providing appropriate, consistent, and individualized care to the resident.
Findings:
Review of the facility's P&P titled Comprehensive Resident Centered Care Plan revised 1/2021 showed it is the policy of this facility that the interdisciplinary team shall develop and implement a comprehensive person - centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. A baseline care plan shall be developed within 48 hours of admission. A comprehensive care plan is developed within 7 days of completion of the Resident Minimum Data Set and will be updated as needed.
Medical record review for Resident 3 was initiated on 9/4/24. Resident 3 was admitted to the facility on [DATE].
Review of Resident 3's Nurse Progress Notes showed the following notes:
- dated 9/2/24 at 1554 hours, showed Resident 3 was refusing to take their medications at this time and was shouting random sentences.
- dated 9/2/24 at 2348 hours, showed Resident 3 again refused the medications and was yelling and calling out.
Review of Resident 3's care plans failed to show a care plan problem was developed for Resident 3's refusal to take medications.
On 9/6/24 at 1600 hours, an interview was conducted with the DON. The DON verified there was no care plan for refusal of medications.
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Deficiency F0836
(Tag F0836)
Minor procedural issue · This affected multiple residents
Based on observation, interview, and facility P&P review, the facility failed to comply with the State law when two staff (CNAs 2 and 6) were not wearing their name badges while on duty. This failure ...
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Based on observation, interview, and facility P&P review, the facility failed to comply with the State law when two staff (CNAs 2 and 6) were not wearing their name badges while on duty. This failure had the potential to place the residents at risk to be cared for by unidentified persons.
Findings:
According to Title 22, Article 5, Administration, §72501 (h), showed the licensee shall ensure that all employees serving patients, or the public shall wear name and title badges unless contraindicated.
Review of the facility's P&P titled Identification Badges revised 4/2004 showed all employees must wear identification badges. Further review of the policy showed all personnel are required to wear identification tags/badges during their work shifts.
On 9/4/24 at 1310 hours, a concurrent observation and interview was conducted with CNA 2. CNA 2 was observed wearing a visitor sticker badge. CNA 2 verified he was not wearing his employee name badge and stated it was important to wear it so the residents would know who he was.
On 9/5/24 at 1312 hours, a concurrent observation and interview was conducted with CNA 6. CNA 6 was wearing a visitor sticker badge. CNA 6 verified she was not wearing her employee name badge and stated it was important to wear it so the residents would know who she is.
On 9/6/24 at 1600 hours, an interview was conducted with the DON. The DON stated the facility ran out of the temporary sticker name badge. The DON verified it was important to wear an employee identification badge so the residents would know who the employees were and it would be easier to direct to the staff when the family member and/or visitors needed something.
Jun 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and servic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for two of seven sampled residents (Residents 2 and 5).
* Resident 2 did not receive Marinol (medication to stimulate appetite) as ordered from 2/2 - 2/7/24, and the physician was not notified. Additionally, there was no follow up with the pharmacy about the medication not being delivered timely.
* Resident 5 complained of numbness and feeling like having a stroke; however, the physician was not notified until six hours and 11 minutes later.
These failures had the potential to negatively affect the residents'health conditions and well-being.
Findings:
1. Review of the facility's P&P titled Medication Administration (undated) showed the medications are to be administered within one hour before or one hour after the prescribed time.
Medical record review for Resident 2 was initiated on 5/31/24. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 2's Order Recap Report showed the following orders:
- dated 2/2 - 2/7/24, showed Marinol 2.5 mg one capsule by mouth two times a day for appetite stimulant.
- dated 2/7 - 5/8/24, showed Marinol 5 mg one capsule by mouth two times a day for appetite stimulant.
Review of Resident 2's February 2024 MAR showed Resident 2 was not administered Marinol 2.5 mg one capsule by mouth two times a day from 2/2 - 2/7/24, as ordered with the reason documented as 7 (other, see progress notes).
Review of Resident 2's Progress Notes eMAR Medication Administration Note for Marinol 2.5 mg one capsule by mouth two times a day showed the following dates and times with comments:
- 2/2/24 at 1853 hours, pending delivery and MD paged for possible dosage change
- 2/3/24 at 0919 hours,not available at this time.
- 2/3/24 at 1917 hours,not available at this time.
- 2/4/24 at 1000 hours, no additional notes shown.
- 2/4/24 at 1739 hours, no additional notes shown.
- 2/5/24 at 0952 hours, no additional notes shown.
- 2/5/24 at 1728 hours, no additional notes shown.
- 2/6/24 at 1817 hours, the pharmacy follows up in progress.
- 2/7/24 at 1043 hours, new order (clarified).
On 6/13/21 at 1415 hours, an interview was conducted with the ADON. The ADON stated thepharmacy delivered themedications within the day that they were ordered. In addition, a follow-up with the pharmacy wouldbe done if the medications were not delivered. The ADON stated there was a nationwide shortage of Marinol, and the ADON verified there was no follow up with the pharmacy regarding the delay of thismedication delivery until 2/8/24, six days after the order was obtained. The ADON verified there was no documented evidence the physician was notified Resident 2 was not administered Marinol on these days.
On 6/13/24 at 1613 hours, the DON was informed and acknowledged the above findings.
2. Review of the facility's P&P titled Change of Condition Reporting dated 5/2019 showed it is the policy of this facility that all changes in a resident's condition will be communicated to the physician. The purpose is to clearly define the guidelines for the timely notification of a change in the resident condition.
According to the National Institute of Neurological Disorders and Stroke titled Stroke Overview-What is Stroke dated 4/20/24, showed signs of stroke can range from mild weakness to paralysis, or numbness on one side of the face or body. A stroke is a serious medical emergency and requires immediate medical attention, just like a heart attack. Stroke is the fifth leading cause of death in the United States. It is the most common cause of adult disability. With stroke, the sooner treatment begins, the better. Knowing the signs of stroke and calling 911 immediately can help save the person from death or disability. Timely treatment can save brain cells and greatly reduce or even reverse the damage. Healthcare professionals also use a variety of brain imaging techniques to assess stroke risk, diagnose stroke, determine stroke type (and the extent and exact location of damage), and evaluate individuals for clinical studies and beast treatment, including CT (computed tomography, MRI (magnetic resonance imaging), and catheter-based angiography.
According to the CDC's guidelines titled Risk Factors for Stroke dated 5/14/24, conditions that can increase risks are high blood pressure, high cholesterol, heart disease, and obesity.
According to the CDC's guidelines titled Signs and Symptoms of Stroke dated 5/15/24, sudden numbness or weakness in the face, arm, or leg, especially on one side of the body, and to call 911 right away.
Medical record review for Resident 5 was initiated on 5/31/21. Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 5 [NAME] medical history of hypertension, congestive heart failure, hyperlipidemia, and obesity.
Review or Resident 5's Weights and Vital Summary dated 5/14/24, showed two documented sets of vital signs for Resident 5 dated 5/14/24 at 0921 and 1535 hours.
Review of Resident 5's Progress Notes dated 5/14/24 at 0932 hours, showed Resident 5 complained of feeling numb and stated, I feel like I'm having a stroke.
Review of Resident 5's Progress Notes dated 5/14/24, showed no documented evidence the resident's physician was contacted when Resident 5 complained of numbing and feeling like he was having a stroke until 5/14/23 at 1543 hours (six hours and 11 minutes later), when Resident 5 was being sent out to an acute care hospital.
Review of Resident 5's Progress Notes dated 5/14/24 at 1550 hours, showed Resident 5 was transferred to the acute care hospital via 911 due to the uneven smile and left-side numbness.
Review of Resident 5's Discharge Summary Final Report from the acute care hospital dated 5/17/24, showed Resident 5 was brought in by the ambulance and had a tingling sensation on the left side of the body. Resident 5 stated the feeling started fromhis foot, then went tohis lungs and brain. Resident 5 thought his speech wasa little altered. In addition, the differential diagnoses (possible causes) listed stroke.
On 5/31/24 at 1125 hours, an interview was conducted with Resident 5. Resident 5 stated he had an incident when he was not treated right and stated he could barely talk; had weakness, progressive numbness, and tingling; and thought he was having a stroke. Resident 5 stated when he told the overnight CNA, she did not alert anyone until theshift change, and it took a while to get to the acute care hospital on the following day.
On 6/7/24 at 1147 hours, an interview was conducted with the ADON. When asked if a resident stated, I feel like I'm having a stroke if an RN should have assessed the resident, the ADON stated, yes, they should have.
On 6/7/24 at 1417 hours, an interview was conducted with LVN 4. LVN 4 stated the physician and nursing supervisor should have been notified when Resident 5 stated, I feel like I'm having a stroke .
On 6/7/24 at 1453 hours, a follow-up interview was conducted with LVN 4. LVN 4 stated a message was sent to the physician on 5/14/24 at 1225 hours, stating Resident 5 complainedof numbing on the left side and worried about a stroke.
On 6/7/24 at 1532 hours, an interview was conducted with the DON. When asked if LVN 4 should have notified the RN or physician to assess the resident, the DON stated, yes.
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and servic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to one of two sampled residents (Resident 1) as ordered by the physician.
* The facility failed to order and administerResident 1's aspirin (a medication used to thin the blood) and atorvastatin (a medication to treat high cholesterol) according to the discharge medication orders from the hospital. This failure had the potential to negatively affect the residents' health condition and well-being.
Findings:
Review of the facility's P&P titled Medication Orders (undated) showed under the section for Written Transfers Orders (sent with the resident by an acute care hospital or other health care facility) the following:
- implement a transfer order without further validation if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete or the date is different from the date of admission;
- if the order is unsigned, signed by another prescriber, or the date is other than the date of admission, the receiving nurse verifies the order with the current attending physician before medications are administered; and
- the nurse documents verification by entering the time, date, and signature on the admission order.
Medical record review for Resident 1 was initiated on 4/26/24. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of CVA, pneumonia, and potential stroke.
Review of Resident 1's Patient Discharge Instructions from the acute care hospital dated 4/26/24, showed a physician's order to administer the following new medications:
- aspirin 81 mg enteric coated tablet, give one tablet by mouth daily; and
- atorvastatin 40 mg oral tablet, give one tablet by mouth daily.
However, review of Resident 1's Order Summary Report dated 5/1/24, did not show the orders to administer the aspirin and atorvastatin medications.
Review of Resident 1's MARs for April and May 2024 showed no documented evidence of Resident 1 receiving the ordered aspirin and atorvastatin medications according to the discharge instructions from the acute care hospital.
On 5/10/24 at 0836 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified the aspirin and atorvastatin were the new prescribed medications for Resident 1 according to the acute care hospital's discharge orders. The LVN verified the medication orders were not followed through or carried out upon Resident 1's readmission to the facility. LVN 3 further stated the aspirin and atorvastatin were the medications that should have been carried out for the residents that had a diagnosis ofCVA. LVN 3 stated if the facility's physician did not agree with the new orders, it should have been documented. LVN 3 verified there was no documentation to show the facility's physician was notified of thenew medications.
On 5/10/24 at 0927 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the admitting nurse was responsible for reconciling the final medication ordersfrom the acute care hospital's discharge medication list. The DON further stated the nurse did not see the new orders. The DON acknowledged the above findings.
Jan 2024
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency 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, medical record review, and facility P&P review, the facility failed to promote dignity and resp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to promote dignity and respect for eightof 14 sampled residents (Residents 2, 3, 7, 8, 9, A, B, and C)
* The facility failed to ensure the resident's call lights were answered in a timely manner for Residents 3, 7, 8, 9, A, B, and C.
* The facility failed to ensure the call light was within the reach of Resident 2.
These failures posed the risk to negatively affect the residents' physical and emotional well-being.
Findings:
Review of the facility's P&P titled Call Light/Bell revised 5/2020 showedit is the policy of the facility to provide the resident a means of communication with nursing staff. Under the procedure sectionshowed following:
- Answer the call light/bell within a reasonable time;
- Turn off the call light/bell;
- Listen to the resident request/need;
- Respond to the request. If the item is not available or unable to assist, explain to the resident and notify the charge nurse for further instructions; and
- Leave the resident comfortable. Place the call device within resident's reach before leaving room. If the call light/bell is defective, immediately report this information to the unit supervisor.
1.a. On 12/27/23 at 1430 hours, a concurrent observation and interview was conducted with Resident 7. Resident 7 was observed lying in the bed. Resident 7 stated she needed the staff's assistance for her activities of daily living. Resident 7 further stated the facility staff usually took more than an hour to respond to her call light. When asked how she knew the time Resident 7 stated she looked at the clock in front of her to check the time. Resident 7 further stated at the nighttime, she usually had to wait for more than 2 hours to get staff assistance to change her diaper. Resident 7 stated she felt uncomfortable to wait for the staff for hours on a wet diaper.
Medical record review for Resident 7 was initiated on 12/27/23. Resident 7 was admitted to the facility on [DATE].
Review of Resident 7's History and Physical examination dated 2/6/23, showed Resident 7 had the capacity to understand and make decisions.
Review of Resident 7's MDS dated [DATE], showed Resident 7 was cognitively intact and Resident 7 required maximum assistance for her toileting needs.
b. On 12/7/23 at 1438 hours, a concurrent observation and interview was conducted with the Resident 8. Resident 8 was observed lying in the bed. Resident 8 stated the facility staff took more than an hour to respond to her call light. Resident 8 stated that happened most of the time when she called.
Medical record review for Resident 8 was initiated on 12/27/23. Resident 8 was admitted to the facility on [DATE].
Review of Resident 8's MDS dated [DATE], showed Resident 8 was cognitively intact and Resident 8 had impairment to both sidesof her upper and lower extremity. Further review of the MDS showed Resident 8 required moderate assistance for her activities of daily living.
c. On 12/28/23 at 1000 hours, a concurrent observation and interview was conducted with Resident 3. Resident 3 was observed standing by the bedside. Resident 3 stated sometimes during the night shift, she pressed the call light for assistance for water, ice, or medication. Resident 3 stated she was feeling upset because they came in and turned off the call light without attending to her needs. Resident 3 stated she had witnessed her roommate using the call light to be changed after having a bowel movement, but the staff did not come for a long time. Resident 3 stated she would have to walk outside to find the nurse.
Medical record review for Resident 3 was initiated on 12/28/24. Resident 3 was admitted to the facility on [DATE].
Review of Resident 3's History and Physical examination dated 4/15/23, showed Resident 3 had capacity to understand and make decisions.
d. On 12/28/23 at 0930 hours, a concurrent observation and interview was conducted with Resident 9. Resident 9 was observed sitting up in bed with head of bed elevated 60 degrees. Resident 9 stated sometimes at night shift, she had waited about one hour after pressing the call light and the nurse came in and turned the call light off before attending her needs. Resident 9 felt upset about it and stated she needed assistance to be changed and cleaned after a bowel movement.
Medical record review for Resident 9 was initiated on 12/28/24. Resident 9 was admitted to the facility on [DATE].
Review of Resident 9's MDS dated [DATE] showed for toileting hygiene, Resident 9 was dependent. Helper did all the effort and Resident 9 did none of effort to complete the activity.
e. On 1/3/24 at 1400 hours, a concurrent observation and interview was conducted with Resident A. Resident A was observed sitting upright in the bed with both heels elevated with the pillow.
Resident A stated when they called the nurse for assistance, Resident A would have to wait more than an hour during the night shift to be changed because the nurse was busy taking care of another resident.
Medical record review for Resident A was initiated on 1/3/24. Resident A was admitted to the facility on [DATE].
Review of Resident A's MDS dated [DATE] showed for toileting hygiene, Resident A needed substantial or maximal assistance. The helper did more than half the effort.
f. On 1/3/24 at 1500 hours, a concurrent observation and interview was conducted with Resident B. Resident B was sitting up in the wheelchair in front of the room. Resident B stated once a while, she turned on the call light because she needed help to change diaper in bed or assistance to go to the bathroom and would need to wait 30 minutes or more for assistance.
Medical record review for Resident B was initiated on 1/3/24. Resident B was admitted to the facility on [DATE].
Review of Resident B's care plan dated 4/16/21 showed a care plan problem addressing at risk for bowel/bladder incontinence related to disease process, impaired mobility, and advance age. The intervention included to encourage fluids during the day, to promote prompted voiding responses, and ensure an unobstructed path to the bathroom.
g. On 1/3/24 at 0930 hours, a concurrent observation and interview was conducted with Resident C and Resident C's family member. Resident C was observed lying on her back in bed and had a suprapubic catheter. Resident C and Resident C's family member stated during the night shift, Resident C needed help getting their diaper changed or the catheter emptied but sometimes waited 30 minutes to one hour. Resident C stated feeling sad about it because the nurse was so busy with other residents.
Medical record review for Resident C was initiated on 1/3/24. Resident C was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident C's care plan dated 11/30/23 showed the resident's risk for bowel/bladder incontinence related to activity intolerance, confusion, dementia, impaired mobility, medication side effects, and benign prostate hyperplasia (enlargement of prostate gland). The intervention included the use of disposable briefs; change every 2hrs and as needed; check as required for incontinence; and wash, rinse and dry perineum.
On 1/4/24 at 1515 hours, an interview was conducted with LVN 10. LVN 10 stated during the night shift on the weekend, sometimes the facility was short of CNAs because they called in sick or the registry CNA did not come. LVN 10 acknowledged if multiple residents pressed their call lights at the same time, it could be overwhelming for the CNA to attend to all the resident needs. There was a time when a CNA spend long time with one resident who needed total assistance.
On 1/4/24 at 1530 hours, an interview was conducted with CNA 3. CNA 3 stated there were a couple times when they were short at night because the registry CNA did not come in. There was a challenging time when one resident called for medicine, another resident called for a diaper change, and another resident needed other assistance at same time.
2. On 1/5/24 at 0954 hours, a concurrent observation and interview was conducted with Resident 2. Resident 2's call light was observed hanging on the wall towards the head of the bed. When asked if Resident 2 could reach the call light, Resident 2 was observed attempting to reach the call light. Resident 2 then stated he was not able to reach the call light.
Resident 2 further stated he had a concern with the facility's call light response time. He stated the facility staff took 20 minutes to 2 hours to respond to the call light. When asked how Resident 2 knew the time, Resident 2 stated he looked at the clock on the wall to check the time. Resident 2 stated he needed staff assistance for his activities of daily living and felt frustrated when the staff did not answer the call light timely.
On 1/5/24 at 1004 hours, a concurrent observation and interview was conducted with LVN 2. LVN 2 verified the above observation and stated Resident 2's call light was not within reach of Resident 2. LVN 2 stated Resident 2 required staff assistance for his activities of daily living so the call light should have been within reach.
Review of Resident 2's medical record was initiated on 1/5/24. Resident 2 was admitted to the facility on [DATE].
Review of Resident 2's History and Physical examination dated 12/8/23, showed Resident 2 had the capacity to understand and make decisions.
Review of Resident 2's MDS dated [DATE], showed Resident 2 was cognitively intact and required moderate to maximum assistance for his activities of daily living.
On 1/5/24 at 1203 hours, an interview with the DON was conducted. The DON was informed and acknowledged the above findings.
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, medical record review, and facility P&P review, the facility failed to develop the comprehensive plan of car...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plan of care to reflect the individual activity needs for one of 14 sampled residents (Resident 2). This failure posed the risk of not providing individualized activities to the residents.
Findings:
Review of the facility's P&P titled Comprehensive Resident Centered Care Plan revised 1/2021 showed it isthe policy of the facility that the IDTshall develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Under the procedure section showed the care plan is developed by the IDT which included but not limited to following professionals:
a. Attending physician;
b. Registered nurse responsible for resident;
c. Dietary supervisor/dietitian;
d. Social services staff member responsible for the resident;
e. Activity staff member responsible for the resident;
f. Rehabilitation specialist physical occupational, and/or speech therapist as indicated;
g. Consultants (as appropriate);
h. Director of Nursing services;
i. Nursing assistant responsible for resident care; and,
j. Others as necessary or indicated.
On 1/5/24 at 0954 hours, a concurrent observation and interview was conducted with Resident 2. Resident 2 was observed lying in bed with the television on. Resident 2 stated he was bored watching television the whole day and almost every day. Resident 2 stated he did not want to go to the group activities and was not provided the activities he could do in his room other than watching television.
Medical record review for Resident 2 was initiated on 1/5/24. Resident 2 was admitted to the facility on [DATE].
Review of Resident 2's MDS dated [DATE], showed Resident 2 was cognitively intact and required moderate to maximum assistance for his activities of daily living. The MDS further showed it was very important for Resident 2 to participate in his favorite activities.
Review of Resident 2's Care Plan showed no documented evidence of a care plan problemto address the activity needs of Resident 2.
On 1/5/24 at 1049 hours, a concurrent interview and medical record review of Resident 2 was conducted with the Activity Director. The Activity Director verified a care plan problemaddressing activity needs of Resident 2 was not initiated. The Activity Director stated she did the activity needs assessment for Resident 2; however, she did not get chance to initiate the care plan. The Activity Director stated a personalized care plan addressing the activity needs for Resident 2 should have been initiated.
On 1/5/24 at 1203 hours, a concurrent interview and medical record review for Resident 2 was conducted with the DON. The DON verified and acknowledged the above findings.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and service...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to one of 14 sampled residents (Resident 9).
* The facility failed to ensure Resident 9 received the protein supplement as ordered by the physician two times a day. This had potential for not providing necessary care and services to meet the care needs for this resident and medical complication.
Findings:
Review of the facility's P&P titled Medication Administration, undated, showed if a dose of a regularly scheduled medication is held, refused, or given at a time other than the prescribed time, that particular dose on the medication sheet is to be circled, and an explanation is to be offered on the back of the medication sheet. If doses of any medication are refused for more than three (3) consecutive days, or if the refusal of one dose could cause or has caused further deterioration in the resident's clinical condition, the attending physician is to be notified.
Medical record review for Resident 9 was initiated on 12/28/24. Resident 9 was admitted to the facility on [DATE].
Review of Resident 9's Physician Order Summary Report dated 11/6/23, showed to give Prostat (protein supplement) 30 ml with med pass as part of fluid restriction two times a day.
Review of Resident 9's MAR for November 2023 showed Resident 9 did not receive Prostat on 11/6, 11/8, 11/10, 11/13, 11/15, 11/17, 11/22, 11/23, 11/24, and 11/30/23 at 1700 hours.
Review of Resident 9's MAR for December 2023 showed Resident 9 did not receive Prostat on 12/4, 12/6, 12/8, 12/11, 12/13, 12/15, 12/18, 12/22, 12/24, and12/27/23 at 1700 hours.
Review of Resident 9's care plan problem dated 10/28/23, showed the resident'snutritional problem or potential nutritional problem related to on a therapeutic diet, admitted with multiple wounds and pressure injury, edema, infection, on dialysis and increase needs (Kilocalories/Protein) related to end stage renal disease or hemodialysis, risk of alternate skin integrity. The intervention included to administer the medications as ordered.
On 12/28/23 at 0930 hours, an interview was conducted with Resident 9. Resident 9 stated sometimes she was getting the protein supplement one time a day but knew she should get two times a day. She could not recall what day she was getting once a day.
On 1/9/23 at 1330 hours, a concurrent medical record review and interview with the DON was conducted. The DON was asked if the Prostat was given for those dates at 1700 hours. TheDON stated the resident went out to dialysis and the supplement was heldor not administered. The DON was asked if the nurse informed the physician if they hadbeen held or not administered the supplement due to the resident out to dialysis. The DON was unable to provide the documentation and verified the finding.
On 1/9/23 at 1400 hours, a concurrent medical record review and interview was conducted with LVN 4. LVN 4 was asked if Resident 9 received the Prostat on dialysis days at 1700 hours. LVN 4 stated sometimes Resident 9 came back from the dialysis center around 1900 hours, and LVN 4 had already been off work. LVN 4 stated the medication was being held or not administered because not within the range of one hour after 1700 hours. LVN 4 stated if Resident 9 came back fromdialysis around 1800 hours, she would administerthe Prostat. LVN 4 was asked if the physician had been informed Resident 9 might miss the dose scheduled at 1700 hours due to dialysis. LVN 4 stated she was not sure about it. LVN 4 verified the finding.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the RNA services...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the RNA services to seven of 14 sampled residents (Residents 2, 9, 10, 11, 12, 13,and 14) as ordered by the physician. This failure had the potential for the resident's decline in ROM functions and deterioration in their ability to perform ADL care.
Findings.
Review of the facility's P&P titled ROM (range of motion) and Contracture Prevention revised 5/2019 showed the facility is to ensure that resident receive services, care, and equipment to assure that every resident maintains, and/or improves to his/her highest level of range of motion and mobility, unless reduction is clinically unavoidable. Under the procedure section showed an interdisciplinary care plan is developed to maintain or increase joint mobility, the implementation of the program was carried out by the appropriate personnel in skilled rehab, routine therapy, restorative nursing, or CNA staff.
1. Medical record review for Resident 2 was initiated on 1/5/23. Resident 2 was admitted to the facility on [DATE].
Review of Resident 2's MDS dated [DATE], showed Resident 2 had impairment to one side of upper extremity (shoulder, elbow, wrist, and hand).
Review of Resident 2's Physician Order Summary showed an order dated 12/6/23, for RNA to perform the AROM and AAROM exercisesto the BUE/LUE three times a week as tolerated.
Review of Resident 2's Care Plan dated 12/6/23, showed a care plan problem addressing Resident 2's limited physical mobility. The interventions included for the RNAs to perform the AROM/AAROM exercises three times a week as tolerated.
Review of Resident 2's Documentation Survey Report from 12/22/23 to 1/5/24, for RNA services showed Resident 2 received RNA services on 12/22, 12/27,and 1/5/24. Further review of the document showed Resident 2 did not receive the RNA services on 12/25, 12/29/23, and 1/1/24.
On 1/5/24 at 1128 hours, an interview with RNA 4 was conducted. RNA 4 stated some days, the facility was short of RNAs and sometimes, they got reassigned to be CNAs to care for the residents. RNA 4 stated when the facility was short of RNAs, she could not provide the RNA services to the residents in the facility.
On 1/5/24 at 1203 hours, a concurrent interview and medical record review was conducted with the DON. The DON verified the above findings and stated Resident 2 had missed three RNA services from 12/22/23 to 1/5/24.
2. On 12/28/24 at 0930 hours, Resident 9 was observed sitting up in bed. Resident 9 stated she did not get the exercise all the time and they had been missing her exercise.
Medical record review for Resident 9 was initiated on 12/28/24. Resident 9 was admitted to the facility on [DATE].
Review of Resident 9's Physician Order Summary Report showed an order dated 11/4/23, showed the RNAs to assist the resident with the AROM exercises to the BUE and BLE three times per week as tolerated.
Review of Resident 9's Documentation Survey Report for December 2023 and January 2024 for RNA services showed Resident 9 did not receive the RNA services on 12/7,12/16, 12/23, 12/30/23 and 1/2/24.
Review of Resident 9's Care Plan dated 10/28/23, showed a care plan problem addressing Resident 9's ADL self-care performance deficits related to impaired mobility, disease process, bilateral hand deformities. The interventions included the RNAs to assist the resident with the AROM BUE/BLE exercises three times per week as tolerated.
3. Medical record review for Resident 10 was initiated on 12/28/24. Resident 10 was admitted to the facility on [DATE].
Review of Resident 10's Documentation survey Report for December 2023 and January 2024 for RNA services showed Resident 10 did not receive the RNA services on 12/30/23 and 1/2/24.
Review of Resident 10's Order Summary Report showed an order dated 12/27/23, for the RNAs to assist the resident with the AAROM exercises to the BUE/BLE three times a week as tolerated.
Review of Resident 10's care plan dated 11/22/23 showed a care plan problem addressing Resident 10's ADL self-care performance deficits related to impaired mobility, infection, disease process. The intervention included the RNAs to assist the resident with the AAROM exercises to the BUE/BLE three times a week as tolerated.
On 1/2/23 at 1130 hours, Resident 10 was observed sitting upright in bed on the air loss mattress. Resident 10 verbalized his concerns regarding exercises. He was aware he would not get the physical therapy services due to his insurance. He would like to receive the exercises routinely. He did not get exercises regularly and did not know what his schedule for the exercises was.
4. Medical record review for Resident was initiated on 1/3/24. Resident 11 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 11's Physician Order Summary Report showed an order dated 11/16/23, for the RNAs to assist the resident with ambulation three times per week as tolerated with the Pivot Front Walker.
Review of Resident 11's Documentation Survey Report for December 2023 and January 2024 for the RNA services showed Resident 11 did not receive the RNA services on 12/17, 12/24, 12/31/23, and 1/2/24.
On 1/4/24 at 1015 hours, Resident 11 was sitting upright in bed. Resident 11 had verbalized the concerns regarding his RNA services. Resident 11 stated they had been missing coupled times last month and did not do it because the staff told him that they were understaff.
5. Medical record review for Resident 12 was initiated on 1/3/24. Resident 12 was admitted to the facility on [DATE].
Review of Resident 12's Documentation survey Report for December 2023 and January 2024 for the RNA services showed Resident 12 did not receive the RNA services on 12/12, 12/17, 12/24, 12/31/23, and 1/2/24.
Review of Resident 12's Physician Order summary report showed an order dated 6/10/23, for the RNAs to assist the resident with ambulation with a front wheel walker three times per week as tolerated.
Review of Resident 12's care plan showed a care plan problem addressing Resident 12's ADL self-care performance deficits related to disease process, impaired mobility, impaired cognition, weakness. The intervention included the RNAs to assist the resident with ambulation with a front wheeled walker three times per week as tolerated.
6. Medical record review for Resident 13 was initiated on 1/3/24. Resident 13 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 13's Documentation Survey Report for December 2023 and January 2024 for the RNA services showed Resident 13 did not receive the RNA services on 12/17, 12/24, 12/31/23 and 1/2/24.
Review of Resident 13's Physician Order Summary report showed an order dated 1/4/24, for the RNAs to assist the resident with the AAROM exercises to the BUE/BLE three times per week as tolerated.
Review of Resident 13's care plan dated 11/9/23, showed a care plan problem addressing ADL self-care performance deficits related to impaired mobility, infection, disease process. The intervention included the RNAs to assist the resident with the AAROM exercises to the BUE/BLE three times per week as tolerated.
7. Medical record review for Resident 14 was initiated on 1/3/24. Resident 14 was admitted to the facility on [DATE].
Review of Resident 14's Documentation Survey Report December 2023 and January 2024 for the RNA services showed Resident 14 did not receive the RNA services on 12/16, 12/30/23 and 1/2/24.
Review of Resident 14's Physician order summary report showed an order dated 2/8/23, for the RNAs to assist the resident with the PROM exercises to the BUE/BLE three times per week as tolerated.
Review of Resident 14's MDS dated [DATE], showed Resident 14 had impairment to the BUE and BLE.
Review of Resident 14's care plan dated 2/8/23 showed a care plan problem addressing ADL self-care performance deficits related to medical condition. The intervention included the RNAs to assist the resident with the PROM exercises to the BUE/BLE three times per week as tolerated.
An interview and concurrent medical record review was conducted with RNA 3 on 1/3/23 at 0900 hours. RNA 3 stated on Monday 1/1/23, RNA 3 knew there were no RNAs. RNA 3 stated they only had one RNA, but they pulled her to work on the floor as a CNA. RNA 3 stated there were no RNAs on 12/30 and 12/31/23. RNA 3 was asked if they provided the RNA services for those dates for Residents 9, 10, 11, 12, 13, and 14. RNA 3 acknowledged there were no RNA services on those dates and verified the findings.
An interview was conducted with RNA 1 on 1/3/24 at 1530 hours. RNA 1 stated on 1/2/23, RNA 1 was only one RNA on the floor for 46 residents. RNA 1 stated she was trying to catch up for doing the weekly or monthly weights and the PT helped her with the residents needing the RNA services for ambulation. RNA 1 stated there was not enough time to do the RNA services for all scheduled residents. RNA 1 stated they worked eight hours shifts and must provide the RNA services to 46 residents, each service needing 10 to 15 minutes for each exercise.
An interview and concurrent medical record was conducted with RNA 2 on 1/4/24 at 1250 hours. RNA 2 stated they did not have RNAs on 12/5, 12/30, 12/31/23, 1/1, and 1/2/24. RNA 2 also stated there were no RNAs on 12/16, 12/17, 12/24, and 12/25/23. RNA 2 was asked regarding the missing entries for the RNA services for Residents 9, 10, 11, 12, 13, and 14. RNA 2 acknowledged RNA services was not provided. If the residents refused, they should have documented it. RNA 2 verified the findings.
Sept 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one sampled resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one sampled resident (Resident 1) wasassessed to determine if it was safe to self-administer their medications prior to self-administration of the medications as per the facility's P&P.
* LVN 3 left Resident 1's oral medications at the Resident 1's bedside unattended for Resident 1 to self-administer medications without LVN 3's supervision. However, Resident 1 was not assessed to safely self-administer the medications. This failure put Resident 1 at risk for unsafe self-administration of the medications.
Findings:
Review of the facility's P&P titled Self-Administration/Bedside Medication Order, undated, showed the residents may self-administer medications when a desire is expressed and when the center's Inter-Disciplinary Team (IDT- a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the resident)grants approval.
On 9//21/23 at 1000 hours, an observation was conducted for Resident 1. A medication cup with nine tablets was observed on Resident 1's bedside table.
On 9/21/23 at 1015 hours,a concurrent medical record review and interview was conducted with RN 1. R N 1 stated it was not the facility's policy to allow the residents to self-administer medication unless a Self-Administration tool was completed, and the resident was found to be safe to do so. During the review of Resident 1's medical record, RN 1 was unable to locate a completed Self-Administration tool for Resident 1.
On 9/21/23 at 1030 hours,an interview was conducted with LVN 3. LVN 3 stated Resident 1 was not approved for self-administration of medications and the medications should not have been left unattended at Resident 1's bedside.
Medical Record Review for Resident 1 was initiated on 9/20/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 1's Initial admission Record, dated 7/11/23 under section 1, number 7, Self-Administration of Drugs, showed Resident 1 did not have the desire to self-administer medications.
Further review of Resident 1's medical record showed no documented evidence the facility's IDT had assessed Resident 1 for self-administration of medication as per the facility's P&P. There was no documented evidence of a physician's order allowing Resident 1 to self-administer medications.
On 9/21/23 at 1445 hours,an interview was conducted with the DON. When asked, the DON acknowledged Resident 1 had not been assessed to self-administer medications and had no order in place to self-administer medications. The DON also acknowledged Resident 1 should have taken their medications with the supervision of a licensed nurse.
Sept 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to maintain a safe, clean, comfortable, and homelike environment for one of three sampled residents (Resident 3).
* The baseboards and walls by ...
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Based on observation and interview, the facility failed to maintain a safe, clean, comfortable, and homelike environment for one of three sampled residents (Resident 3).
* The baseboards and walls by the baseboards in Resident 3's bathroom (in Room A) were observed in a state of disrepair: the walls and baseboards were unclean, stained, had exposed plaster, holes in some areas, and had peeling paint. The toilet seat was also observed with yellow stains. This failure had the potential to negatively impact the resident's safety, right to a dignified existence, and quality of life.
Findings:
Review of the written complaint, Family Member 2 reported several concerns with Room A. These included the room's worn-out condition, a non-functional paper towel dispenser in the adjacent bathroom, inadequate lighting, an unpainted white patch on the wall from a previously incomplete repair, the need for room painting, and the view outside the closed curtains which revealed a lack of landscaping and a view of dirt.
On 9/1/23 at 1120 hours, an observation of Room A was conducted with the Maintenance Assistant. The baseboards and walls by the baseboards in Resident 3's bathroom (in Room A) were observed in a state of disrepair: the walls and baseboards were unclean and stained brown, some areas had exposed plaster, there were holes in some areas of the wall, and there was peeling paint throughout the wall. The toilet seat was also observed with yellow stains. The Maintenance Assistant verified the findings and stated the walls required repair, patching, and sanding; and both the walls and baseboards required cleaning and painting.
On 9/1/23 at 1158 hours, a telephone interview was conducted with Family Member 2. Family Member 2 stated the facility was the pits and resembled a pigsty. Family Member 2 stated the facility's website photos looked totally different than the actual condition of the place as it was dirty and required cleaning, patching, and painting at the least. Family Member 2 stated he did not feel right about leaving Resident 3 there and had expected a more dignified environment where his wife could stay and recover. Family Member 2 stated as a result, he took Resident 3 home within an hour and a half of arriving at the facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0776
(Tag F0776)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to obtain radiology services for one of three sampled resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to obtain radiology services for one of three sampled residents (Resident 1).
* The facility failed to obtain a chest x-ray for Resident 1 as ordered. This had the potential to result in delayed diagnosis and treatment for Resident 1.
Findings:
On 8/29/23 at 1505 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated Resident 1 was admitted at the facility from 2/14 to 2/19/23. Family Member 1 explained Resident 1 had developed an increasingly productive cough but did not receive the scheduled chest x-ray at the facility. Subsequently, Resident 1 was transferred to the acute care hospital after a fall and diagnosed with pneumonia. Family Member 1 expressed the belief that if the facility had addressed the resident's symptoms promptly, he might not have become weak and suffered a fall.
Medical record review for Resident 1 was initiated on 8/29/23. Resident 1 was admitted to the facility on [DATE].
Review of Resident 1's Change in Condition Evaluation dated 2/17/23 at 1255 hours, showed Resident 1 had increased coughing and congestion with noted bilateral wheezing in the lungs. Under the Respiratory Evaluation section, Resident 1's documented respiratory changes included a recently progressive or persistent minor shortness of breath, cough, self-limited wheezing that was more extensive and less responsive to treatment than usual, and increased congestion with difficulty while lying down. The evaluation showed the nurse practitioner was notified and ordered a chest x-ray.
Review of Resident 1's Progress Note dated 2/17/23 at 1218 hours, showed the nurse practitioner was notified of the resident's persistent cough and a chest x-ray was ordered for 2/18/23.
Review of Resident 1's Order Summary Report showed an order dated 2/17/23, to obtain a chest x-ray for Resident 1 on 2/18/23.
Review of Resident 1's electronic health record and closed medical record (paper) did not show a chest x-ray was obtained for Resident 1.
Review of Resident 1's Progress Notes dated 2/20/23 at 0010 hours, showed Resident 1 was admitted to the acute care hospital for pneumonia.
On 9/1/23 at 1041 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings including Resident 1's Change in Condition Evaluation dated 2/17/23, and the order to obtain a chest x-ray for Resident 1 on 2/18/23. After reviewing Resident 1's electronic health record and closed (paper) medical record, the DON verified the chest x-ray was not obtained as ordered.
On 9/1/23 at 1135 hours, a follow-up interview and concurrent medical record review was conducted with the DON. The DON stated a radiology examination request form was found for the chest x-ray. However, the DON stated after calling the radiology services provider, they confirmed that a chest x-ray was not obtained for Resident 1 as ordered.
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 medical record review, the facility failed to ensure the medical record for one of three sampled resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the medical record for one of three sampled residents (Resident 1) was accurate. The facility failed to ensure Resident 1's Fall Risk Evaluation was completed accurately. This had the potential for the resident's care needs not being met as their medical information was inaccurate.
Findings:
Medical record review for Resident 1 was initiated on 8/29/23. Resident 1 was admitted to the facility on [DATE].
Review of Resident 1's Fall Risk Evaluation dated 2/14/23 at 2017 hours, showed Resident 1 had one to two falls in the past three months.
Review of Resident 1's Change in Condition Evaluation dated 2/18/23 at 1859 hours, showed Resident 1 suffered a fall on 2/18/23, resulting in a left elbow skin tear measuring 1.5 cm, left eyebrow bruising and cuts, and pain level of 8 (on a pain scale of 0 to 10, 0 is no pain and 10 is excruciating pain). Resident 1's responsible party and physician were notified at 1800 hours.
However, review of Resident 1's Fall Risk Evaluation dated 2/18/23 at 1933 hours, showed Resident 1 had no falls in the past three months. This Fall Risk Evaluation failed to reflect the fall Resident 1 had suffered earlier in the day and directly contradicted Resident 1's Fall Risk Evaluation dated 2/14/23, conducted four days earlier, which showed Resident 1 had one to two falls in the past 3 months.
On 9/1/23 at 1041 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings and stated not including a fall or an inaccurate assessment could change the resident's fall risk category and score.
Aug 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to ensure one of three sampled resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to ensure one of three sampled residents (Resident 1) was free from the physical abuse when Resident 2 hit Resident 1 with his cane. This resulted in multiple injuries to Resident 1's right arm and shoulder, which had the potential to negatively impact the resident's well-being.
Findings:
Review of the facility's P&P titled Abuse: Prevention of and Prohibition Against revised January 2021 showed it is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.
Review of SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 8/12/23, showed Resident 2 hit Resident 1 with his cane after getting into a verbal argument, causing a laceration to Resident 1's right hand.
a. Medical record review for Resident 1 was initiated on 8/15/23. Resident 1 was admitted to the facility on [DATE].
Review of Resident 1's MDS dated [DATE], showed Resident 1 had moderate cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life).
Review of Resident 1's Progress Notes dated 8/14/23 at 1447 hours, showed the IDT met and the RN supervisor was informed by the staff that Resident 1 had a physical altercation with another resident (Resident 2) on 8/12/23 at approximately 1330 hours. Per staff, Resident 1 was struck by Resident 2 with a wooden cane. The IDT note also showed Resident 1 was noted with skin tears to the right lateral hand, right wrist, and right frontal shoulder abrasion.
Review of the skin evaluation note dated 8/12/23 at 1630 hours, showed Resident 1 had the following wounds:
- Right lateral hand skin tear (a wound that happens when the layers of skin separate or peel back) measuring 2 cmin length, 1.2 cm in width, and 0.7 cm in depth.
- Right lateral wrist skin tear, 5.5 cm in length, 1.8 cm in width and 0.2 cm in depth.
- Right frontal shoulder abrasion, 6 cm in length and 4 cm in width.
- Right upper quadrant (right upper part of the abdomen) discoloration, 6 cm in length and 6 cm in width.
b. Medical record review for Resident 2 was initiated on 8/15/23. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 2's MDS dated [DATE], showed Resident 2 was cognitively intact.
On 8/15/23 at 1330 hours, an interview was conducted with Resident 1. Resident 1 stated inthe afternoon of 8/12/23, the resident was seated in his wheelchair in the hallway when Resident 2 began to curse and yell at him to get out of the way of the PT who was wheeling another resident in the hallway at the time. A verbal altercation then occurred between Residents 1 and 2. Resident 2 told Resident 1, All you white guys think you run everything. Resident 2 then went to his room, returned to the hallway with his cane, and struck Resident 1two times to his right arm and wrist, causing the wooden cane to break and lodge a piece of wood in Resident 1's right wrist. Resident 1 also stated Resident 2 also attempted to stab himwith the cane to the right upper portion of his stomach.
On 8/15/23 at 1415 hours, an interview was conducted with PT 1. PT 1 stated in the afternoon of 8/12/23, the PT was wheeling a resident down the hallway for therapy when Resident 2 began to yell at the other residents in the hallway to move out of the way. Resident 2 then began to yell and curse at Resident 1. PT 1 then observed Resident 2 strike Resident 1 twice to their right arm with Resident 2's cane. PT 1 stated they then saw Resident 1 bleeding from their right wrist.
On 8/15/23 at 1550 hours, an interview was conducted with the DON. The DON stated Resident 1 had opted to press charges against Resident 2. Resident 2 was arrested by the law enforcement officials and was taken to jail.
Aug 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to notify one of two sampled residents' (Resident 1) represent...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to notify one of two sampled residents' (Resident 1) representative or responsible party of Resident 1's nephrology (a specialty within the internal medicine field related to kidney care) appointment. This failure had the potential for Resident 1's representative or responsible party of not being involved in resident's plan of care.
Findings:
Review of the SOC 341 dated 7/18/23, showed Family Member 1 stated Resident 1 was dropped off at a nephrologist's (a medical doctor who specializes in kidney care) office, and she was not aware of the appointment until Resident 1's family member received a call from the nephrologist office.
Medical record review for Resident 1 was initiated on 7/28/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 1's History and Physical examination dated 9/27/22, showed Resident 1 had fluctuating capacity to understand and make medical decisions. Further review of the medical record showed Resident 1's diagnosis included dementia (a condition characterized by progressive or persistent loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).
Review of Resident 1's admission Record showed Family Member 1 was listed as Resident 1's contacts.
Review of Resident 1's Order Summary Report showed an order dated 5/19/23, to follow up with the nephrologist on 5/24/23 at 1115 hours. Further review of Resident 1's medical record failed to show any documentation Resident 1's family member was informed of the appointment.
Review of the nephrologist progress notes dated 5/24/23, showed Resident 1 had a follow-up visit for telemedicine on 6/14/23.
On 8/1/23 at 1528 hours, a concurrent interview and medical record review was conducted with LVN 1. LVN 1 stated any orders for consults/appointments would be communicated to the social services staff or case manager for scheduling. LVN 1 stated Resident 1's nephrology appointment was scheduled by thesocial services. LVN 1 verified and acknowledged the above findings.
On 8/1/23 at 1610 hours, a concurrent interview and medical record review was conducted with the Case Manager. The Case Manager verified and acknowledged the above findings.
On 8/2/23 at 0920 hours, a concurrent interview and medical record review was conductedwith the Social Services Assistant. The Social Services Assistant verified and acknowledged the above findings. The Social Services Assistant further stated Resident 1 needed someone when going to his appointments due to his cognition.
On 8/2/23 at 1624 hours, a concurrent interview and medical record review was conducted with the DON. The DON was informed and acknowledged the above findings. The DON stated no documentation of Resident 1's family member was informed regarding his Nephrology appointment on 5/24/23. The DON further stated Resident 1 was cognitively impaired and needed to have someone for his appointments.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to provide the necessary care and services for one of two samp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to provide the necessary care and services for one of two sampled residents (Residents 1) to maintain their highest physical well-being. The facility failed to follow the physician's order for a nephrology (a specialty within the internal medicine field related to kidney care) consult for Resident 1. This failure posed the risk for delayed care and necessary interventions to Resident 1.
Findings:
Medical record review for Resident 1 was initiated on 7/28/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 1's Order Summary Report showed an order dated 12/1/22, to have a nephrology consult.
Further review of Resident 1's medical record failed to show documentation Resident 1 was seen by a nephrologist as recommended by the physician.
On 8/1/23 at 1528 hours, a concurrent interview and medical record review was conducted with LVN 1. LVN 1 stated any orders for consults/appointments would be communicated to the social services staff or case manager for scheduling. LVN 1 verified there was an order for a nephrology consult and no documented evidence Resident 1 was seen by a nephrologist.
On 8/1/23 at 1610 hours, a concurrent interview and medical record review was conducted with the Case Manager. The Case Manager was informed and acknowledged the above findings. The Case Manager further stated to follow the physician's order for a nephrology consult so that Resident 1 could get the necessary treatment.
On 8/2/23 at 0920 hours, a concurrent interview and medical record review was conducted with the Social Services Assistant. The Social Services Assistant verified and acknowledged the above findings.
On 8/2/23 at 1624 hours, a concurrent interview and medical record review was conducted with the DON. The DON was informed and acknowledged the above findings. The DON stated no one could validate Resident 1's nephrology consult ordered on 12/1/22, was scheduled. The DON further stated the physician's order should have been followed to meet Resident 1's needs.
Jul 2023
1 deficiency
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Deficiency F0657
(Tag F0657)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to revise the plan of care for one of tw...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to revise the plan of care for one of two sampled residents (Resident 1).
* Resident 1's care plan problem was not updated to address the unwitnessed fall on 9/9/22. This failure had the potential to affect the provision of care for Resident 1.
Findings:
Review of the facility's P&P titled Nursing Administration dated 5/2019 showed to Document resident change of condition and response in Change of Condition Evaluation and in nursing progress notes, and update resident care plan, as indicated.
Review of the facility's P&P titled Comprehensive Resident Centered Care Plan dated 1/2021 showed It is the policy of this facility that the interdisciplinary team (IDT) shall develop and implement a comprehensive person-centered care plan for each resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.
Review of Resident's 1 medical record was initiated on 6/30/23. Resident 1 was admitted to the facility on [DATE].
Review of Resident 1's Progress Note dated 9/9/22, showed Resident 1 had a non-injury fall in room while ambulating without assistance.
Review of Resident 1's MDS dated [DATE], showed Resident 1 had a BIMS (a cognitive screening that evaluates memory and orientation) score of five (which meant to have severely impaired cognition).
Review of Resident 1's medical record failed to show a change of condition evaluation was completed and the care plan was updated to address Resident 1's unwitnessed fall on 9/9/22.
On 7/19/23 at 1410 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the change of condition evaluation and the updated care plan were not completed for Resident 1's unwitnessed fall on 9/9/22.
Jul 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide personal privacy...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide personal privacy for one of six sampled residents (Resident 3).
* LVN 2 failed to completely close Resident 3's privacy curtain when she provided wound care. Resident 3's sacrococcyx area was exposed during the procedure. This failure had the potential to expose Resident 3's uncovered body parts to the public view and affect self-esteem and self-worth.
Findings:
Review of the facility's P&P titled Dignity and Privacy dated 11/2021 showed the residents shall be examined and treated in a manner that maintains the privacy of their bodies. The P&P further showed a closed door or drawn curtains shields the resident from passers-by.
Medical record review for Resident 3 was initiated on 6/22/23. Resident 3 was admitted to the facility on [DATE].
Review of Resident 3's MDS assessment dated [DATE], showed Resident 3 had memory problem and totally dependent on staff for ADL care.
On 6/22/23 at 1043 hours, a wound care observation was conducted with LVN 2. LVN 2 was observed exposing Resident 3's sacrococcyx area and providing wound care. LVN 2 did notcompletely close the privacy curtain of Resident 3, which allowed the staff and visitors passing by the hallway to see Resident 3 during the wound care.
On 6/22/23 at 1102 hours, an interview was conducted with LVN 2. LVN 2 verified the above observation and stated the privacy curtain should have been completely closed before exposing Resident 3 for the wound care.
On 6/22/23 at 1549 hours, an interview was conducted with the DON. The DON was informed and acknowledged above findings.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure monitoring for neurological st...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure monitoring for neurological status and physician notification were conducted in a timely manner when one of six sampled residents (Resident 5) had unwitnessed fall resulting in periorbital (area surrounding the eye) swelling and bruise. This failure had the potential for Resident 5 to not receive the appropriate care and services in timely manner.
Findings:
Review of the facility's P&P titled Neurological Evaluation revised 3/28/23,showed any residents who had an injury involving the head or an unobserved fall shall have neuro checks and vital signs taken at least every eight hours. Further review of the P&P showed a comprehensive neurological assessment to be done on the following frequencies:
- Every 15 minutes for 1 hour;
- Every 30 minutes for 4 hours;
- Every 1 hour for 2 hours; and,
- Every shift for 72 hours.
On 6/23/23 at 0937 hours, a telephone interview was conducted with the RR. The RR stated Resident 5 had a fall on 6/12/23 around 0100 hours, that resulted in swelling and bruising of her eyes. The RR stated Resident 5 was transferred to the acute care hospital on 6/12/23 around 0600 to 0700 hours. The RRstated he wondered why it took so long to transfer Resident 5 to the acute care hospital after the fall. The RR stated he was worried because Resident 5 was on blood thinner medication.
Medical record review for Resident 5 was initiated on 6/23/23. Resident 5 was admitted to the facility on [DATE].
Review of Resident 5's Physician Order dated 4//28/23 showed to administer Eliquis (blood thinner) 2.5 mg one tablet by mouth two times a day.
Review of the Resident 5's Progress Note showed following:
- The fall committee IDT note dated 6/12/23 at 1324 hours, Resident 5 was found on the floor next to her bed on 6/12/23 at 0130 hours, noted with swelling and bruising around the left eye on 6/12/23 around 0530 hours, and transferred to the acute care hospital.
- Thechange of condition evaluation dated 6/12/23 at 0400 hours, the physician was notified of the incident at 0500 hours, three and half hours after the fall incident.
Review of Resident 5's Neurological Assessment showed the neuro checks were initiated on 6/12/23 at 0530 hours (4 hours after the fall incident).
On 6/23/23 at 1556 hours, an interview was conducted with LVN 3. LVN 3 stated on 6/12/23 around 0130 hours, CNA 1 reported to her that Resident 5 was out of bed, and LVN 3 did not know Resident 5 was witnessed sitting on the floor. LVN 3 stated on 6/12/23 at 0530 hours, CNA 1 reported Resident 5 had swelling and bruising on her left eye. After aneurological evaluation was initiated, LVN 3 notified the physician and Resident 5 was transferred to the acute care hospital.
On 7/11/23 at 1500 hours, a telephone interview was conducted with CNA 1. CNA 1 stated on around 6/12/23 at or around 0130 hours, he witnessed Resident 5 sitting on the floor. CNA 1 stated with the help of other staff, he transferred Resident 5 to the bed, then he reported incident to LVN 3. CNA 1 stated same night at around 0530 hours, during rounding, he noticed Resident 5 had swelling and bruising on her left eye, then he reported the incident to the RN supervisor.
On 7/11/23 at 1531 hours, a concurrent interview and record review was conducted with the DON. The DON verified theabove findings and stated the neurological evaluation should have been initiated immediately after the unwitnessed fall to monitor the resident for head injury. The DON stated the physician should have been notified promptly. The DON stated Resident 5 had unwitnessed fall and there was a miscommunication between CNA 1 and LVN 3.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the staff perform...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the staff performed hand hygiene during the wound care treatment for one of six sampled residents (Resident 3). This failure posed the risk of infection and the transmission of disease-causing microorganisms.
Findings:
Review of the facility's P&P titled Handwashing/Hand Hygiene (undated) showed to use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations:
- Before handling clean or soiled dressings, gauze pads, etc.;
- After handling used dressings, contaminated equipment, etc.; and,
- After removing gloves.
Further review of the facility's P&P showed the use of gloves does not replace hand washing/hand hygiene. Integration of gloves use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.
Medical record review for Resident 3 was initiated on 6/22/23. Resident 3 was admitted to the facility on [DATE].
Review of Resident 3's Physician's Order dated 5/25/23, showed to cleanse the coccyx pressure injury with normal saline, pat dry, apply medihoney, add collagen, pack lightly with the calcium alginate to wound bed, miconazole (antifungal) cream and zinc oxide (moister barrier cream) to peri wound (tissue surrounding a wound) and cover with dry dressing daily.
On 6/22/23 at 1043 hours, a wound care observation for Resident 3 was conducted with LVN 2. Resident 3 was observed being awake in bed. LVN 2 was observed washing her hands with soap and water and donning a clean pair of gloves. LVN 2 was observed removing the dressing from Resident 3's sacrococcyx area. LVN 2 was then observed changing her gloves without performing hand hygiene and proceeded to clean Resident 3's wound with normal saline, then patted it dry with a gauze. LVN 2 then changed to a clean pair of gloves without performing hand hygiene and proceeded to apply medihoney and collagen to the wound. LVN 2 then lightly packed dressing with calcium alginate and used a cotton swab to apply miconazole and zinc oxide at peri wound to Resident 3's wound. Finally, LVN 2 covered and secured Resident 3's wound with a gauze dressing.
On 6/22/23 at 1103 hours, an interview was conducted with LVN 2. LVN 2 verified above observation and stated she should have performed hand hygiene before donning each pair of clean gloves.
On 6/22/23 at 1549 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.
Jun 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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to establish and maintain t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to establish and maintain the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections for one of two sampled residents (Resident 2).
* LVN 1 failed to perform hand hygiene after removing gloves during wound care treatment for Resident 2. This failure had the potential for increased infection and compromising Resident 2's medical condition.
Findings:
Review of the facility's P&P titled Infection Prevention - Hand Hygiene (undated) showed it is the facility's policy that hand hygiene is considered the primary means to prevent the spread of infections. Further review of the policy showed to use an alcohol-based hand rub containing at least 62% alcohol or alternatively soap (antimicrobial or non-microbial) and water after removing the gloves.
Review of Resident 2's medical record was initiated on 6/13/23. Resident 2 was admitted to the facility on [DATE].
Review of Resident 2's Order Summary Report showed the following wound care treatment orders:
- dated 6/15/23, cleanse the coccyx pressure injury with normal saline solution (a solution of salt and water), pat dry, apply iodosorb (an antimicrobial gel that can be used to treat skin wounds and ulcers) gel, and cover with a dry dressing daily.
- dated 6/22/23, cleanse the right gluteal fold pressure injury with normal saline solution, pat dry, apply iodosorb gel, and cover with a dry dressing daily.
- dated 6/15/23, cleanse the right leg wound with normal saline, pat dry, paint with betadine (antiseptic solution) solution, air dry, and cover with a rolled gauze.
On 6/22/23 at 1024 hours, a wound care observation for Resident 2 was conducted with LVN 1. LVN 1 cleaned Resident 2's coccyx and right gluteal fold pressure injuries with normal saline solution, pat dry with a clean gauze. LVN 1 proceeded to change gloves without washing her hands and was then observed applying iodosorb gel to the coccyx and right gluteal fold pressure injuries. LVN 1 proceeded to cover the areas with the dry dressings. LVN 1 removed the old dressing from Resident 2's right leg wound, changed gloves without washing hands, and took the measurements of the right leg wound.
On 6/22/23 at 1124 hours, LVN 1 was informed of the above observation during wound care treatment for Resident 2. LVN 1 acknowledged the above findings and further stated hand washing was important between changing gloves for infection control purposes.
On 6/22/23 at 1412 hours, an interview was conducted with the Infection Control Preventionist. The Infection Control Preventionist acknowledged the above findings and further stated hand hygiene between changing of gloves is the best practice to prevent cross contamination
Jun 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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to en...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to ensure two of three sampled residents (Residents 2 and 3) maintained their highest practicable physical well-being.
* The facility failed to apply Resident 2's right lateral trunk support with wide arm rest while in the wheelchair as per the physician's order.
* Resident 3 had one floor mat in place instead of bilateral floor mats as per the physician's order and IDT recommendation. In addition, Resident 3 had bilateral grab bars attached to her bed instead of bilateral 1/4 bed side rails as per the physician's order and IDT recommendation.
These failures had the potential for adverse outcomes to the residents.
Findings:
1. Medical record review for Resident 2 was initiated on 5/17/23. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 2's History and Physical Examination dated 3/22/23, showed Resident 2 did not have the capacity to understand and make decisions.
Review of Resident 2's Order Summary Report for May 2023 showed an order dated 5/26/19, for Resident 2 to have the right lateral trunk support with wide arm rest in wheelchair one time a day.
Review of Resident 2's care plan revised on 4/28/19, showed the care plan problem addressing ADL self-care performance deficit (a shortfall or loss). The resident had the right lateral upright support for sitting up in the wheelchair to increase ability to self-feed and participate in ADL care. One of the interventions or tasks included the resident to have the right lateral upright trunk support in the wheelchair.
On 5/17/23 at 1412 hours, an observation and concurrent interview was conducted with CNA 2. Resident 2 was observed in her room sitting in her wheelchair with no device or equipment attached to her wheelchair. When asked about Resident 2's right lateral trunk support with wide arm rest while in wheelchair, CNA 2 stated she was not aware of a special device or equipment to be applied when Resident 2 was up in a wheelchair.
On 5/17/23 at 1420 hours, a concurrent observation, interview, and medical record review was conducted with the Unit Manager. Resident 2 was observed in her room sitting in her wheelchair with no device or equipment attached to her wheelchair. When asked about Resident 2's right lateral trunk support with wide arm rest while in wheelchair, the Unit Manager acknowledged Resident 2 had an order to have a right lateral trunk support with wide arm rest in wheelchair. However, Resident 2 did not have the trunk support applied. The unit manager stated she would need to double check with the rehabilitation department.
On 5/17/23 at 1435 hours, an interview was conducted with the DOR. When asked about Resident 2's right lateral trunk support with wide arm rest while in wheelchair, the DOR stated the right lateral trunk support with wide arm rest was to increase Resident 2's ability to self-feed. However, Resident 2 currently required staff to feed her during meals and did not require the right lateral trunk support with wide arm rest. The DOR stated the order should have been discontinued.
On 5/17/23 at 1600 hours, the DON was informed and verified the above findings.
2. Medical record review for Resident 3 was initiated on 5/17/23. Resident 3 was admitted to the facility on [DATE], had a fall on 4/18/23, and was readmitted on [DATE], with diagnosis of displaced intertrochanteric fracture of the right femur status post right hip replacement.
Review of Resident 3's MDS dated [DATE], showed Resident 3 had severely impaired cognition.
a. Review of Resident 3's Order Summary Report for May 2023 showed an order dated 4/28/23, for a low bed with bilateral floormats for safety.
Review of Resident 3's progress note dated 4/28/23, under the fall committee IDT section, showed the IDT recommended a low bed with bilateral floormats for safety.
During an observation on 5/17/23 at 0830 hours, Resident 3 was observed asleep in bed with one floor mat to the right side of the bed.
On 5/17/23 at 1300 hours, an observation and concurrent interview was conducted with CNA 1. Resident 3 was observed in her room, in bed with one floor mat to the right side of the bed. When asked about Resident 3's floor mat, CNA 1 stated Resident 3 should have two floor mats in place, one on the right side of the bed and another one on the left side of the bed.
On 5/17/23 at 1402 hours, a concurrent interview and medical record review was conducted with the Unit Manager. When asked about Resident 3's bilateral floor mats, the Unit Manager stated Resident 3 had a fall few weeks ago and had a physician's order for bilateral floor mats. The Unit Manager acknowledged the above findings and stated Resident 3 should have two floor mats in place, one on each side of the bed.
On 5/17/23 at 1600 hours, the DON was informed and verified the above findings.
b. During an observation on 5/17/23 at 0830 hours, Resident 3 was observed asleep in bed with bilateral 1/2 bed side rails elevated.
During an observation and concurrent interview on 5/17/23 at 1145 hours, Resident 3 was sitting in a wheelchair while the Maintenance Director was detaching the 1/2 bed side rails from Resident 3's bed and attaching the bilateral grab bars. When asked about the grab bars, the Maintenance Director stated he was instructed to attach the 1/4 bed side rails.
Review of Resident 3's Order Summary Report for May 2023 showed an order dated 5/12/23, for bilateral 1/4 bed side rails.
Review of Resident 3's Therapy Notes dated 5/12/23, under the siderail assessment, showed the use of siderails was recommended by the IDT.
Review of Resident 3's Restraint/ Enabling Device/ Safety Device Evaluation dated 5/12/23, under the device recommended section,showed to use the 1/4 bed side rails up for positioning and easy mobility.
On 5/17/23 at 1435 hours, an observation and concurrent interview was conducted with the DOR. When asked about Resident 3's current siderails, the DOR stated Resident 3 was assessed and recommended to have the 1/4 bed side rails by the IDT. When asked what the difference between a grab bar and a 1/4 bed side rails was, the DOR stated both the grab bars and 1/4 side rails were to assist Resident 3 with positioning and mobility; however, the grab bars were shorter than the 1/4 side rails. The DOR verified Resident 3 currently had bilateral grab bars attached to her bed and stated Resident 3 should have the bilateral 1/4 side rails instead.
On 5/17/23 at 1600 hours, the DON was informed and verified the above findings. The DON stated Resident 3 should have the bilateral 1/4 bed side rails as per the IDT recommendation and physician's order.
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
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to discontinue and remove the IV li...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to discontinue and remove the IV line (a device places in a vein to allow repeated and long-term access to the bloodstream for frequent or regular administration of drugs) for one of two sampled residents (Resident 2) when the resident was discharged from the facility. This failure had the potential to put the resident at risk for adverse reactions at the IV insertion site.
Findings:
Closed medical record review for Resident 2 was initiated on 3/30/23. Resident 2 was admitted to the facility on [DATE] and discharged to the community on 3/12/23.
Review of Resident 2's Order Summary Report dated 3/30/23, showed the following physician's orders:
- On 3/9/23, to start an IV line and change the IV site as needed for infiltration or soiling.
- On 3/9/23, for ceftriaxone sodium (an antibiotic) 1 GM daily for 10 days, to be administered intravenously.
- On 3/9/23, for maintenance flushes, 10 cc every 12 hours.
- On 3/9/23, to discontinue the IV line when the IV therapy is complete.
- On 3/9/23, to monitor the IV site and report any abnormalities (i.e. redness, warmth, swelling, pain) to the physician.
Review of Resident 2's Progress Notes dated 3/9/23 at 1150 hours, showed theIV access was obtained from Resident 2's left upper arm.
Review of Resident 2's IV Medication Administration Recordfor March 2023 showed the following orders were discontinued on 3/10/23 at 0736 hours:
- start an IV and change the site as needed for infiltration
- ceftriaxone sodium 1 gm daily for 10 days, to be administered intravenously
- maintenance flushes, 10 cc every 12 hours
- monitor the site and report any abnormalities (i.e. redness, warmth, swelling, pain) to the physician
However, further review of Resident 2's medical record failed to show when the IV line was discontinued and removed from the resident's arm.
On 4/18/23 at 1458 hours, a telephone interview was conducted with the Home Health Nurse Manager. The Home Health Nurse Manager stated the Home Health Agency provided services to Resident 2. The Home Health Nurse Manager reviewed Resident 2's medical record and stated it appeared the resident was discharged home with their IV linestill in place. The skilled nursing facility faxed the Home Health Agency with a physician's order dated 3/10/23, to discontinue the IV line. And on 3/13/23, the documentation showed the home health nurse went to remove the IV line, noted the cannula was no longer inserted, but the cannula was still taped on Resident 2's arm.
On 4/19/23 at 1224 hours, a telephone interview was conducted with RN 1. RN 1 stated at the time of Resident 2's discharge, they did not recall seeing Resident 2's IV line, and Resident 2's electronic medical record did not show the resident had an IV line.
Review of Resident 2's Home Health Agency OASIS-E (Outcome and Assessment Information Set-a standardized assessment) Resumption of Care assessment dated [DATE], showed Resident 2 was discharged home from the skilled nursing facility with an IV line still in placeand the home health nurse removed the IV line.
On 4/20/23 at 1053 hour, an interview and concurrent record review were conducted with the DON. The DON reviewed Resident 2's physician orders and verified the orders showed to discontinue the resident IV access once the antibiotics were complete. The DON stated the IV MAR showed on 3/10/23 at 0736 hours, the IV orders were discontinued and the IV should have been removed at that time. The DON verified there was no documentation to show when Resident 2's IV access was removed. The DON stated Resident 2 should not have been discharged with an IV device still in place.
Mar 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 medical record review, the facility failed to ensure the comprehensive care plan was implem...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the comprehensive care plan was implemented for one of two sampled residents (Residents 1).
* The facility failed to ensure the bilateral floor mats were implemented and the resident's call light was within the resident's reach as care planed. This failure placed the resident at risk of not being provided appropriate, consistent, and individualized care.
Findings:
Medical record review for Resident 1 was initiated on 2/23/23. Resident 1 was admitted to the facility on [DATE].
Review of Resident 1's Fall Risk Evaluation dated 1/1/23 at2309 hours, showed Resident 1 was at high risk for falls.
Review of Resident 1's care plan titled At Risk for Falls initiated 1/2/23, showed the interventions included to implement the bilateral floor mats for safety (initiated 2/13/23) and ensure Resident 1's call light was within his reach (initiated 1/2/23).
On 2/23/23 at 1443 hours, an observation of Resident 1's room and concurrent interview was conducted with CNA 1. CNA 1 stated Resident 1 utilized his call light to request staff assistance. Resident 1's call light was observed on the floor underneath the head of Resident 1's bed, and outside of Resident 1's reach. CNA 1 verified the findings. CNA 1 then picked up Resident 1's call light from the floor and placed in on Resident 1's bed within his reach.
On 2/23/23 at 1453 hours, an observation of Resident 1's room and concurrent interview was conducted with RN 1. RN 1 stated Resident 1 utilized his call light and could call out for staff assistance when needed. RN 1 stated Resident 1 had episodes of confusion and forgetfulness. RN 1 stated Resident 1 had a history of falls in the facility, with Resident 1 having fallen at least twice. RN 1 verified Resident 1's bed had only one floor mat in place adjacent to his bed.
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 medical record review, the facility failed to ensure one of two sampled residents (Resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure one of two sampled residents (Resident 1) with a history of falls in the facility remained free from accident hazards.
* The facility failed to ensure the bilateral floor mats were implemented as per the physician's order and the resident's call light was within the resident's reach. This failure had the potential to place the resident at risk for serious injury.
Findings:
Medical record review for Resident 1 was initiated on 2/23/23. Resident 1 was admitted to the facility on [DATE].
Review of Resident 1's Fall Risk Evaluation dated 11/18/22 at 2333 hours, showed Resident 1 was at medium risk for falls. Resident 1's Fall Risk Evaluation showed Resident 1 had a history of falls in the past 3 months.
Review of Resident 1's History and Physical Examination dated 11/22/22, showed Resident 1 sustained a left acetabulum (socket of the hipbone, into which the head of the femur fits) fracture as a result of a fall.
Review of Resident 1's Nursing Progress Note dated 12/18/22 at1950 hours, showed Resident 1 had an unwitnessed fall in the facility. Resident 1 was found lying on his left side with the pillow and sheets underneath him on the floor.
Review of Resident 1's Fall Risk Evaluation dated 1/1/23 at 2309 hours, showed Resident 1 was at high risk for falls.
Review of Resident 1's care plan titled At Risk for Falls initiated 1/2/23, showed the interventions included to implement the bilateral floor mats for safety (initiated 2/13/23) and ensure Resident 1's call light was within his reach (initiated 1/2/23).
Review of Resident 1's readmission Progress Note dated 1/19/23 at 1508 hours, showed Resident 1 was brought to the acute care hospital's emergency room from the facility for an evaluation of a fall. Resident 1 tried to reach for a remote and fell on his left side. Resident 1 stated he fell and hit his head.
Review of Resident 1's Nursing Progress Note dated 2/10/23 at0501 hours, showed the nurse was making rounds and found Resident 1 lying on the floor on his right lateral side. Resident 1 stated he was trying to get something from the floor. Resident 1 sustained a skin tear to his right forearm and a bump on his forehead. Resident 1's call light was on the bed within his reach. Resident 1 was re-educated on how to use the call light.
Review of Resident 1's Order Summary Report showed a physician's order dated 2/13/23, for bilateral floor mats for safety.
On 2/23/23 at 1330 hours, an observation and concurrent interview was conducted with Resident 1. Resident 1 was observed lying in his bed. Resident 1's bed was observed with only one floor mat in place adjacent to Resident 1's bed. The opposite side of Resident 1's bed did not have a floor mat in place. Resident 1's call light was observed on the floor, underneath the head of Resident 1's bed, and outside of Resident 1's reach. Resident 1 was asked if he had sustained a fall while residing in the facility, to which he replied he knew he fell in the past.
On 2/23/23 at 1443 hours, an observation of Resident 1's room and concurrent interview was conducted with CNA 1. CNA 1 was asked if Resident 1 had a history of falls in the facility. CNA 1 stated she was unaware of Resident 1 having fallen in the facility. CNA 1 stated Resident 1 utilized his call light to request staff assistance. Resident 1's call light was observed on the floor underneath the head of Resident 1's bed, and outside of Resident 1's reach. CNA 1 verified the findings.
On 2/23/23 at 1453 hours, an observation of Resident 1's room and concurrent interview was conducted with RN 1. RN 1 stated Resident 1 utilized his call light and could call out for staff assistance when needed. RN 1 stated Resident 1 had episodes of confusion and forgetfulness. RN 1 stated Resident 1 had a history of falls in the facility, with Resident 1 having fallen at least twice. RN 1 verified Resident 1 had only one floor mat in place adjacent to his bed, and the physician had ordered a floor mat to be in place on both sides of Resident 1's bed, for safety.
Cross reference to F656.
Dec 2022
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the comprehensive plan of care for one of two sampled residents (Resident 1).
* The facility failed to implement Resident 1's care plan of having two staff members present during care for Resident 1. This failure posed the risk of not providing appropriate, consistent, and individualized care to Resident 1.
Findings:
Review of the facility's P&P titled Care Planning revised 5/2019 showed the IDT shall develop a comprehensive care plan for each resident.
Medical record review for Resident 1 was initiated on 12/14/22. Resident 1 was admitted to the facility on [DATE].
Review of Resident 1's H&P examination dated 10/2/22, showed Resident 1 did not have the capacity to understand and make decisions.
Review of Resident 1's comprehensive plan of care created on 12/18/20, and revised on 8/6/22, showed a care plan problem regarding the resident having episodes of making false accusations towards the staff. The care plan intervention dated 8/6/22, showed during care, there should always be two staff members, with one staff member to serve as a witness.
On 12/20/22 at 1025 hours, CNA 1 was observed carrying the towels to Resident 1's bed and closing the curtain.
On 12/20/22 at 1040 hours, an interview was conducted with CNA 1. CNA 1 stated CNA 1 just bathed and shaved the resident by themselves. CNA 1 stated the nurses would let them know if the resident needed two staff members. CNA 1 further stated the CNA was not sure if the CNA could review the care plan interventions.
On 12/20/22 at 1057 hours, an interview and concurrent review of the facility's staffing matrix report for 12/20/22, was conducted with LVN 2. LVN 2 pointed to the staffing matrix report and stated there were two staff members assigned to Resident 1.
On 12/20/22 at 1400 hours, an interview and concurrent medical record was conducted with RN 1. RN 1 stated the care plan specifically showed when providing care to this resident, there should be two staff members. RN 1 stated they must have two staff members taking care of Resident 1. RN 1 stated all staff should know the resident's behavior because the resident had been in the facility for a long time.
On 12/20/22 at 1425 hours, an interview was conducted with the DON. The DON stated the expectation is for staff to follow the care plan and have two people take care of Resident 1.
Nov 2022
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, medical record review, and facility P&P review, the facility failed to provide supervision to R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide supervision to Resident 1 to prevent the fall.
* After lunch, Resident 1 was wheeled to the reception area. Resident 1 was not supervised, tried to stand up from the wheelchair, and fell. Resident 1 sustained a subarachnoid hemorrhage (bleeding in the space that surrounds the brain).
Findings:
Review of facility's P&P titled Fall Management System revised 6/2013 showed each resident is assisted in attaining their highest level of function by providing the resident with adequate supervision. The residents who are considered high risks based on their fall risk evaluations will have the care plans developed to prevent falls and consider the particular elements of the assessments that put the residents at risk.
Closed medical record review for Resident 1 was initiated on 10/27/22. Resident 1 was admitted to the facility on [DATE].
Review of Resident 1's History and Physical examination dated 9/23/22, showed Resident 1 did not have the capacity to understand and make medical decisions due to diagnosis of dementia.
Review of Resident 1's MDS dated [DATE], showed the following:
- Section C Cognitive Patterns showed Resident 1 had a BIMS (Brief Interview of Mental Status) score of 7 which meant to have severe cognitive impairment.
- Section G Functional Status showed Resident 1 needed extensive assistance of one person with transfer, bed mobility, locomotion, dressing, toilet use, personal hygiene, and bathing. Resident 1 was not steady and able to stabilize only with staff assistance with moving from seated to standing position, walking, turning around, moving on and off the toilet, and surface-to-surface transfer.
- Section H Bowel and Bladder showed Resident 1 was always incontinent of bowel.
- Section J Health Conditions showed Resident 1 had a previous fall within one month prior to admission.
Review of the Fall Risk Evaluation dated 9/22/22, showed Resident 1 was medium risk for falls due to balance problem while standing/walking. The evaluation also showed the following:
- Resident 1 was alert/oriented; however, the History and Physical examination showed Resident 1 had a diagnosis of dementia and the MDS showed Resident 1 had severe cognitive impairment.
- Resident 1 had no falls in the past three months; however, the MDS showed Resident 1 had a previous within one month prior to admission to the facility.
- Resident 1 had no noted drop in systolic blood pressure (the top number of the blood pressure which measures the force the heart exerts on the walls of the arteries each time it beats); however, the face sheet showed a diagnosis of orthostatic hypotension (a sudden fall in blood pressure that occurs when a person assumes a standing position).
- Resident 1 required assistance with elimination; however, the MDS showed Resident 1 was always incontinent of bowel.
The Fall Risk Evaluation was not updated to include the risk factors identified above.
Review of Resident 1's plan of care showed a care plan problem initiated on 9/23/22, addressing self-care deficits related to a history of falls and orthostatic blood pressure. The interventions included to provide supervision, cueing, encouragement, and physical assistance with transfers.
Review of the Progress Note dated 10/24/22 at 1320 hours, showed Resident 1 tried to stand up from her wheelchair and fell at the reception area. The facility staff did not move her, called 911, and transferred to the acute care hospital emergency department.
Review of the Progress Note dated 10/24/22 at 1927 hours, showed the acute care hospital staff called the facility to inform them that Resident 1 would be admitted to the acute care hospital with a diagnosis of subarachnoid hemorrhage.
Review of Resident 1's Fall Risk Evaluation dated 10/24/22 showed Resident 1 was high risk for falls.
The evaluation showed the resident's mental status was disoriented with a history of one to two episodes of falls in the past three months, regularly incontinent, and with balance problem while standing.
On 10/27/22 at 0930 hours, an interview was conducted with RN 1. RN 1 stated she was supervising Resident 1 at the dining room and encouraging to eat her meal. RN 1 stated Resident 1 was confused and would get distracted often. RN 1 further stated she would supervise Resident 1 whenever the resident was placed at the nurses' station. RN1 stated she had observed Resident 1 trying to get up unassisted from her wheelchair and had to intervene to prevent her from falling. RN 1 stated Resident 1 was at risk for falls and needed adequate supervision. RN 1 stated Resident 1 could not walk with an assistive device such as a walker and required one-person extensive physical assistance with ADL care.
On 10/27/22 at 1000 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 1 was at risk for falls because she was confused, often distracted, and would stand up unassisted from her wheelchair. CNA 1 stated she wheeled Resident 1 from the dining room to the outside of the resident's room next to the reception area. However, CNA 1 verified she did not alert LVN 1 when she placed Resident 1 outside of the resident's room, in the hallway.
On 10/27/22 at 1100 hours, an interview was conducted with the PTA. The PTA stated she had worked with Resident 1. The PTA further stated Resident 1 was confused, had difficulty following directions, and was unaware of safety protocols. The PTA stated Resident 1 was at risk for falls because she often tried to stand up from her wheelchair unassisted. The PTA stated Resident 1 required one-person physical assistance for standing up from a seating position. The PTA stated Resident 1 could not walk without supervision, support, and an assistive device.
Further review of the clinical record failed to show documented evidence the care plan problem addressing the risk for falls was revised to include the appropriate interventions and preventive measures to address Resident 1's behaviors of trying to stand up from the wheelchair unassisted to prevent further falls.
On 10/27/22 at 1200 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 1 was at risk for falls because she was confused and often distracted. LVN 1 further stated Resident 1 was placed at the nurse's station for adequate supervision. LVN 1 stated he was at the hallway of the nurses' station passing the residents' medications. LVN 1 denied being informed that Resident 1 was placed in front of the resident's room. LVN 1 stated he heard a thud noise and observed Resident 1 falling on the floor, close to the reception area. LVN 1 further stated he assumed the activity staff was supervising Resident 1 since she was at the common area between her room and dining room.
On 10/27/22 at 1230 hours, an interview was conducted with LVN 2. LVN 2 stated Resident 1 was at risk for falls because she was confused and often distracted. LVN 2 further stated Resident 1 was placed at the nurses' station for adequate supervision. LVN 2 stated he was sitting at the nurses' station when the incident occurred. LVN 2 stated he was not aware Resident 1 was placed outside the resident's room, near the reception area.
On 10/27/22 at 1400 hours, an interview was conducted with LVN 3. LVN 3 stated Resident 1 required supervision due to trying to stand up from wheelchair without support, was confused, and had difficulty following directions and remembering directions or to ask for the facility staff for assistance. LVN 3 stated Resident 1 was placed at the nurses' station so the resident could be supervised and was also taken to activity room to keep her occupied with games or coloring.
Nov 2022
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to notify the responsible party when one...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to notify the responsible party when one of three sampled residents (Resident 1) had a change in condition. This failure had the potential for the responsible party to not be able to make appropriate decisions in the care and treatment of Resident 1.
Findings:
Review of the facility's P&P titled Change of Condition Reporting dated 5/2019 showed the responsible party will be notified that there has been a change in the resident's condition and what steps are being taken. All attempts to reach the responsible party will be documented in the nursing progress noted. Documentation will include time and response.
Medical record review for Resident 1 was initiated on 10/31/22. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of the Change in Condition Evaluation form dated 8/18/22, showed Resident 1 was tested positive for COVID 19 on 8/17/22. The form also showed one of the family members on the emergency contact list was notified on 8/18/22 at 1530 hours; however, the family member was not the responsible party. There was no documented evidence Resident 1's responsible party was notified of Resident 1's change in condition as per the facility's P&P.
On 11/7/22 at 1302 hours, a telephone interview and concurrent medical record review was conducted with the ADON. When asked if Resident 1's responsible party was notified when Resident 1 was tested positive for COVID 19, the ADON replied she was not sure. The ADON was informed and verified Resident 1's medical record failed to show documented evidence Resident 1's responsible party was notified of Resident 1's change in condition.
On 11/16/22 at 1620 hours, a telephone interview was conducted with the DON. The DON stated it was important to notify the resident's responsible party if there was a change in condition because they were responsible and in charge of the care of the resident.
Nov 2022
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three samp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 3) was assessed to self-administer their medications. This had the potential for Resident 3 to have medication administration errors.
Findings:
Review of thefacility's P&P titled Preparation and General Guidelines: Self-Administration of Medications dated 2/23/15, showed the self-administration assessment will be completed by the facility's IDT to determine if the resident has the cognitive, physical, and visual ability to safely self-administer their own medications.
Medical record review for Resident 3 was initiated on 10/24/22. Resident 3 was admitted to the facility on [DATE].
Review of the H&P examination dated 7/31/22,showed Resident 3 has the capacity to understand andmake decisions.
On 10/10/22 at 0955 hours, Resident 3's bedside table was observed with a bottle of eye drops, a bottle of nasal spray, a bottle of Albuterol (to treat difficulty breathing), and a medicine cup with multiple pills in it. Resident 3 stated the nurse left them here for the resident. The resident further stated the nurse told Resident 3 that she was late and in a hurry.
On 10/10/22at 1003 hours, an interview was conducted with LVN 1. LVN 1 stated, we are supposed to watch them take their medications. LVN 1 stated, usually I watch them, but I am busy today.
On 10/10/22 at 1020 hours, an interview was conducted with the DON. The DON stated they were supposed to watch the residents take their medications.
On 10/20/22 at 1152 hours, a concurrent interview and medical record review was conducted with the ADON. The ADON stated the self-administration of medications evaluation wasdone upon admission. The ADON stated no self-administration of medications assessment was found in Resident 3's medical record. The ADON stated for a resident to self-administer their medications, it requiredan MD order. The ADON confirmed no MD order was found in the resident's medical record. The ADON stated the expectation was for them to watch the resident taking their medications.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to maintain a clean, sanitary, and homelike environment for one of two sampled residents (Resident 2) and one of eight nonsampled residents (Res...
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Based on observation and interview, the facility failed to maintain a clean, sanitary, and homelike environment for one of two sampled residents (Resident 2) and one of eight nonsampled residents (Resident G).
* Residents 1 and 2 were roommates and shared a bathroom. Resident 1's blood was visible on the toilet and floor. Resident 2 had to use the bathroom with blood stain.
* Anold oxygen tubing was on the bedside table outside the patio door of Room C. The patio door screens in Room C were covered with dirt. Resident G lived in Room C.
These failures affected the health and well-being of the residents residing in the rooms.
Findings:
1. On 9/26/22 at 1420 hours, the bathroom in Room B was observed. Resident 1's blood was visible on the toilet and floor of the bathroom which was shared by Residents 1 and 2. The bathroom had an odor. Resident 1 stated the blood was visible on the toilet and floor. Resident 1 stated the resident had wounds that were bleeding. Resident 1 stated the room was cleaned several days ago.
On 9/26/22 at 1437,an interview was conducted with CNA 1. CNA 1 stated Resident 2 used that bathroom, and it was not fair that other resident had to use the bathroom with blood stain. CNA 1 stated the bathroom was covered with blood this weekend. CNA 1 stated there was no housekeeper this weekend.
On 9/26/22 at 1538 hours, an interview was conducted with Resident 2. Resident 2 stated it stank. Resident 2 stated the blood was from Resident 1. Resident 2 stated, every time I go in the bathroom it's there. Resident 2 stated, it makes me feel unpleasant. Resident 2 stated, sometimes it makes me sick to my stomach.
Cross reference to F880, example #1.
2. On 9/26/22 at 1337 hours, outside the patio door in Room C, an oxygen tubing dated 4/25/22, was observed on the bedside table. The patio door screens were covered with dirt.
On 9/26/22 at 1346 hours, an interview was conducted with Resident G. Resident G stated, our room (Room C) hasn't been cleaned in about a week. Resident G stated, it makes me feel like I'm in a dirty room. Resident G stated it was uncomfortable.
On 9/26/22 at 1432 hours, an observation and concurrent interview was conducted with the IP. The IP stated the oxygen tubing wassupposed to be thrown in the trash, not outside the resident patio door.
On 9/26/22 at 1458 hours, an observation and concurrent interview was conducted with the Maintenance Director. The Maintenance Director pointed to the oxygen tubing and stated that should not be there. The Maintenance Director confirmed the screens were dirty.
Cross reference to F880, example #3.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on observation, interview, and CDC guidance review, the facility failed to ensure all nursing staff possessed the competencies and skill sets necessary to respond to a blood spill.
* LVNs 2 and ...
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Based on observation, interview, and CDC guidance review, the facility failed to ensure all nursing staff possessed the competencies and skill sets necessary to respond to a blood spill.
* LVNs 2 and 3 were unable to demonstrate competency in cleaning up a blood spill. This failure had the potential to put the residents at risk for blood borne illnesses.
Findings:
Review of the CDC's guidelines for the management of blood spills reviewed 4/15/20, showed any spill of blood or body fluids should be cleaned up immediately or as soon as possible.
On 9/26/22 at 1420 and 1619 hours, the bathroom in Room B was observed with blood visible on the toilet and floor.
On 9/26/22at 1432 hours, an observation and concurrent interview was conducted with the IP. Blood was observed on the toilet and bathroom floor. The IP stated they needed to clean it up immediately. The IP stated there might be an infection in the blood that could be given to other residents or staff, or it could be trailed throughout the facility. The IP stated they had a blood spill kit at every station. The IP stated whoever found it should do the initial cleaning because it was blood, then thehousekeeping would follow up.
On 9/26/22 at 1621 hours, an interview was conducted with LVN 2. LVN 2 stated the facility had a kit that they could spray on the area that had blood. LVN 2 stated not sure where it would be. LVN 2 stated, I can't find it. LVN 2 was observed walking into the utility room. LVN 2 stated, it's not there, let me go ask them. LVN 2 walked over to LVN 3 for assistance. LVN 3 stated, they did train me, but I forgot, and I do not know where it is. LVN 3 further stated they showed me a few months ago. LVN 2 stated they would call the maintenance. LVN 2 stated theywould clean it up right away and put a yellow cone on it until the maintenance comes.
On 9/26/22 at 1627 hours, an observation and concurrent interview was conducted with LVNs 2 and 3. LVN 2 walked down the stairs to the infectious waste biohazard storage room and stated no kit was to be found. LVN 2 returned to the nurses' station, called the IP, and stated it was on the wall. TheBloodborne Pathogen Personal Protection Kit was observed hanging on the wall at the nurses' station. LVN 3 stated, I am not sure if that is what would be used to clean up the blood.
On 9/26/22 at 1636 hours an observation and concurrent interview was conducted with the IP. The IP opened the kit, removed the supplies, and explained to LVN 3 how to use the kit. The IP stated anyone coulddo it.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide a safe, sanitary environment and prevent the transmission of infection and diseases was implemented as evidenced by:
* One of two sampled residents (Resident 2) had to use a bathroom which was contaminated with Resident 1's blood. This posed the risk for Resident 2 to be exposed to blood borne pathogens.
* Three of three nonsampled residents (Residents A, B, and C)' rooms had medical waste and trash on the floor.
* Trash was left outside the patio door of Room C.
* Trash was observed in the hallway.
These failures posed the risk of spreading infection and the transmission of disease-causing microorganisms.
Findings:
Review of the facility's P&P titled Infection Prevention and Control Program revised 7/22/22, showed all blood or body fluids should always be considered potentially infectious. Routine cleaning and disinfection should be performed daily, including resident rooms to prevent the spread of communicable diseases and conditions.
1. On 9/26/22 at 1420 hours, the bathroom in Room B was observed. Resident 1's blood was visible on the toilet and floor which was shared by Residents 1 and 2. The room had an odor. Resident 1 stated the resident had wounds that were bleeding. Resident 1 stated the red substance visible on the toilet and floor were blood.
Medical record review for Resident 1 was initiated on 10/10/22. Resident 1 was readmitted to the facility on [DATE].
Medical record review for Resident 2 was initiated on 11/10/22. Resident 2 was admitted to the facility on [DATE].
On 9/26/22 at 1437 hours,an interview was conducted with CNA 1. CNA 1 stated Resident 2 used that bathroom, and it was not fair for Resident 2 to use it with Resident 1's blood on it.
On 9/26/22 at 1432 hours, a concurrent observation and interview was conducted with the IP. When the IP opened the bathroom door in Room B, a sickening smell poured out from the bathroom. Blood was observed on the toilet and bathroom floor. The IP stated, I have to get out of here, I just had lunch. The IP stated they needed to clean it up immediately. The IP stated there might be an infection in the blood that could be given to other residents or staff, or it could be trailed throughout the facility.
On 9/26/22 at 1538 hours,an interview was conducted with Resident 2. Resident 2 stated it stank. Resident 2 stated the blood was from Resident 1. Resident 2 stated, every time I go in the bathroom it's there.
Cross reference to F584, example #1.
2. On 9/26/22 at 1315 hours, Room A was observed with trash and a used blood test strip on the floor.
On 9/26/22 at 1432 hours, an observation of Room A and concurrent interview was conducted with the IP. The IP confirmed there was a used glucose test strip on the floor. The IP stated this was a medical waste and should have been disposed of in the medical waste bag. The IP further stated there were wet paper towel, skin prep, and something sticky on the floor. The IP stated the rooms were supposed to be cleaned daily and as needed. The IP confirmed the floors did not look clean.
3. On 9/26/22 at 1337 hours, an oxygen tubing dated 4/25/22, was observed on a bedside table outside the patio door in Room C.
On 9/26/22 at 1432 hours, a concurrent observation and interview was conducted with the IP. The IP stated the oxygen tubing was supposed to be thrown in the trash, not out in the patio.
Cross reference to F584, example #2.
4. On 9/26/22 at 1335 hours, there was trash observed in the hallway.
On 9/26/22 at 1300 hours, an interview was conducted with CNA 1. CNA 1 stated the facility did not have a housekeeper that day or yesterday.
On 9/26/22 at 1432 hours,a concurrent observation and interview was conducted with the IP. The IP stated the rooms were supposed to be cleaned daily and as needed.
On 9/26/22 at 1458 hours, a concurrent observation, interview, and facility document review was conducted with the Maintenance Director and Maintenance Assistant. The Maintenance Director stated each of the rooms was supposed to get cleaned daily. The Maintenance Director stated the housekeeper who normally worked at the facility had been gone for a week. The Maintenance Director stated, I cannot confirm the rooms have been cleaned since the housekeeper left. The maintenance assistant stated, the last time this area was cleaned was last Thursday (9/22/22). The Maintenance Director stated each of the rooms were supposed to be deep cleaned once per month. Review of the housekeeping deep cleaning checklist showed no documentation of deep cleaning since 7/29/22. The Maintenance Director stated he could not confirm the deep cleanings had been done since that date.
Nov 2022
26 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure care was provided in a manner which pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure care was provided in a manner which promoted respect and dignity for two of 33 final sampled resident (Residents 39 and 526).
* Resident 39 had to wait 40 minutes to an hour to have her soiled diaper changed by the facility staff. This had the potential of not maintaining or enhancing the resident's self-esteem and self-worth.
* The facility failed to ensure privacy during the delivery of personal care and services by pulling the privacy curtains closed and providing clothing or a cover to prevent exposure of body parts for Resident 526. This failure posed the potential to negatively impact the resident's psychosocial well-being.
Findings:
1. On 11/3/22 at 1006 hours, an interview was conducted with Resident 39. Resident 39 described an incident when CNA 8 left her waiting for hours in her soiled diaper which caused her to develop a rash.
On 11/4/22 at 1555 hours, a follow-up interview was conducted with Resident 39. Resident 39 stated the incident occurred one month prior, and she was sitting in her bowel movement for 40 minutes to an hour before another CNA came to change her. Resident 39 stated sitting in her soiled diaper made her feel disrespected, unheard, like a child.
On 11/4/22 at 1422 hours, an interview was conducted with CNA 8. CNA 8 stated the specific incident occurred on 10/14/22. CNA 8 stated the resident was not changed for approximately 40 minutes.
On 11/7/22 at 1148 hours, an interview was conducted with Resident 39's family member. Resident 39's family member stated he arrived to the facility daily at 1100 hours. He stated about two times a week, he assisted Resident 39 with calling a nurse to assist with diaper change. Resident 39's family member further stated they had to wait around an hour for Resident 39 to be changed.
On 11/8/22 at 1044 hours, an interview was conducted with LVN 16. LVN 16 stated that resident had no skin breakdown the week prior.
On 11/8/22 at 1220 hours, a wound observation was conducted with CNA 2 and LVN 16. Resident 39 had an incontinence episode of bowel and bladder. After incontinence care was provided by CNA 2, LVN 16 reported that Resident 39 had new moisture associated skin damage (MASD, skin damage caused by prolonged exposure of skin to moisture) to the right buttock.
Medical record review for Resident 39 was initiated 11/8/22. Resident was admitted to the facility on [DATE].
Review of the History and Physical Examination dated 11/4/22, showed Resident 39 had the capacity to understand and make decisions. 2. Review of the facility's P&P titled Dignity and Respect dated 9/2019 showed the residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the resident from passer-by. Staff members shall knock before entering the Resident's room.
Medical record review for Resident 526 was initiated on 11/1/22. Resident 526 was admitted to the facility on [DATE].
Review of Resident 526's MDS dated [DATE], showed a BIMS score of 15.
Review of Resident 526's History and Physical examination dated 10/32/22, showed the resident had a stroke on 10/26/22.
Review of Resident 526's Care Plan dated 10/31/22, showed the care plan problem addressing ADL-Self Care Performance Deficit and the resident required assistance due to limited physical mobility, weakness, activity intolerance, and stroke.
On 11/1/22 at 1000 hours, an observation in Resident 526's room showed the privacy curtain was not fully drawn around the bed for privacy when Resident 526 was receiving personal care. Resident 526 was observed sitting on the side of his bed in his underwear, and both the upper and lower half of the body were exposed. CNA 9 was observed performing ADL care of shaving Resident 526's face. CNA 10 was present and witnessed the privacy curtain not drawn during Resident 526's ADL care.
On 11/2/22 at 1005 hours, an interview was conducted with CNA 10. When asked if the privacy curtain should have been drawn closed all the way around the bed when CNA 9 was delivering personal care to Resident 526, CNA 10 stated yes.
On 11/2/22 at 1040 hours, and interview was conducted with CNA 9. When asked if the privacy curtain should have been drawn closed all the way around the bed when she was delivering personal care to Resident 526, she stated yes.
On 11/2/22 at 1630 hours, an interview was conducted with Resident 526. When asked if the privacy curtain was left open while he was receiving personal care and he was sitting in his underwear, he stated yes, it was open. When asked how it made him feel, Resident 526 stated he felt embarrassed and sad.
On 11/2/22 at 1100 hours, an interview was conducted with LVN 12. When asked what the procedure was to ensure privacy during the delivery of personal care, LVN 12 stated the CNA was to knock on the door, introduce themselves, and explain the procedure. LVN 12 stated the CNA was to completely close the privacy curtain all the way around the bed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
Based on interview, medical record review, and facility P&P review, the facility failed to obtain an informed consent (process in which a health care provider educates a patient about the risks, benef...
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Based on interview, medical record review, and facility P&P review, the facility failed to obtain an informed consent (process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention to obtain agreement or permission for care, treatment, or services) for the psychotropic medications for one of 33 sampled residents (Resident 99). This failure had the potential to compromise the right of the residents or responsible parties (persons designated to make decisions on behalf of the residents) to be fully informed regarding care and treatment to make health care decisions.
Findings:
Review of the facility's P&P titled Informed Consent dated 4/2013 showed the physician's orders related to the use of psychotherapeutic drug should not be initiated until an informed consent is obtained.
Medical record review for Resident 99 was initiated on 11/4/22.
Review of the March and June 2022 MDS showed Resident 99 had a BIMS score of 4 (meaning severe impairment of mental status).
Review of Resident 99's medication order dated 4/11/22, showed mirtazapine 7.5 mg (medication used to treat depression) by mouth at bedtime for sleep and increased appetite and Seroquel 25 mg (medication used to treat schizophrenia and bipolar disorder) by mouth twice a day for disturbance behavior.
Review of Resident 99's medication order dated 6/22/22, showed an order to change the Seroquel dosage to 25 mg by mouth daily for psychosis/mood disorder.
Review of Resident 99's medication order dated 10/20/22, showed an order for mirtazapine 7.5 mg by mouth at bedtime for depression manifested by poor appetite.
Review of Resident 99's MAR showed resident has been receiving mirtazapine and Seroquel from 4/11/22 through 11/4/22.
Review of Resident 99's medical record showed no documentation of informed consent were obtained from the resident's responsible party. Further review of Resident 99's medical record showed the verification of informed consent forms were filled out and signed by the provider on 10/14/22, (for Seroquel and mirtazapine) but the confirmation of informed consent section was not completed as required on the form.
On 11/4/22 beginning at 0835 hours, several attempts were made to verify with Resident 99's responsible party (using the contact information provided by the facility) regarding the informed consent for the use of psychotropic medications, however there was no response.
On 11/4/22 at 0919 hours, an interview was conducted with MD 1. MD 1 was unable to answer whether an informed consent was obtained from Resident 99's responsible party. MD 1 stated his NP was responsible for the resident and the NP was on vacation.
On 11/4/22 at 1012 hours, an interview was conducted with LVN 8. LVN 8 stated the facility's policy was to get a consent from the resident or responsible party prior to administration of the psychotropic medication.
During an interview on 11/4/22 at 1430 hours, the DON acknowledged there was no documented evidence the informed a consent was obtained for the psychotropic medications prior to administration. The DON stated the confirmation of informed consent should be documented on the form by the nursing staff prior to the initiation of the psychotropic medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the facility's P&...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the facility's P&P addressing self administration of the medications was implemented for one nonsampled resident (Resident 5).
* LVN 11 left Resident 5's oral medications at the resident's bedside unattended and Resident 5 took the oral medications without LVN 11's supervision. However, Resident 5 was not a candidate to safely self-administer the medications. This failure put Resident 5 at risk for unsafe self-administration of the medications.
Findings:
Review of the facility's P&P titled Preparation and General Guidelines, Medication Administration-General Guidelines dated 2/23/15, showed the residents are allowed to self-administer medications when specifically authorized by attending physician and in accordance with procedures for self-administration of medications.
Review of the facility's P&P titled Preparation and General Guidelines, Self-Administration of Medications dated 2/23/15, showed the IDT determines the resident's ability to self-administer medications by means of a skill assessment on a quarterly basis.
On 11/1/22 at 0916 hours, an observation of medication administration was conducted with LVN 11. LVN 11 was observed leaving a medicine cup containing Resident 5's medications on top of Resident 5's bedside table and exiting the room. Resident 5 was then, observed to self-administering the medications orally without the supervision of LVN 11. LVN 11 returned to Resident 5's bedside and asked Resident 5 if the resident took his medications, Resident 5 acknowledged he took the medications.
On 11/1/22 at 0945 hours, an interview was conducted with LVN 11. When asked, LVN 11 acknowledged Resident 5 was not approved for self-administration of the medications.
Medical record review for Resident 5 was initiated on 11/2/22. Resident 5 was admitted to the facility on [DATE].
Review of Resident 5's MDS dated [DATE], showed Resident 5's cognition was moderately impaired.
Further review of the clinical record failed to show documented evidence the IDT had assessed Resident 5 for self-administration of medication. There was no documented evidence of a physician's order allowing Resident 5 to self-administer his medications as per the facility's P&P.
On 11/08/22 at 1049 hours an interview was conducted with the facility's DON. When asked, the DON acknowledged the IDT must assess the resident for self-administration of medication and determine that the resident was capable of self-administering his/her medications prior to allowing the resident to self-administer his/her medications. The DON further acknowledged the residents who could not self-administer their medications should take their medications with the supervision of a licensed nurse.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to provide information on how to formulate an advance directiv...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to provide information on how to formulate an advance directive for four of 33 final sampled residents (Residents 82, 95, 121, and 471). This had the potential for the residents' decision regarding their healthcare and treatment options not being honored.
Findings:
1. Medical record review for Resident 471 was initiated on 11/1/22. Resident 471 was admitted to the facility on [DATE].
Review of Resident 471's H&P examination dated 10/23/22, showed Resident 471 had the capacity to understand and make decision.
Review of Resident 471's POLST dated 10/22/22, under Section D Information and Signatures, did not show advance directive was discussed with Resident 471.
Review of the Social Services Assessment/Evaluation V.2 dated 10/26/22, did not show Resident 471 was provided information on how to formulate an advance directive.
Further review of Resident 471's medical record did not show documentation Resident 471 was provided information on how to formulate an advance directive.
On 11/3/22 at 1017 hours, an interview was conducted with Resident 471. When asked about the advance directive, Resident 471 stated he had an advance directive form at home, but it was not completed. Resident 471 stated he did not remember being asked about advance directive nor being given information on how to formulate an advance directive. Resident 471 stated he wanted to formulate an advance directive.
2. Medical record review for Resident 95 was initiated on 11/1/22. Resident 95 was readmitted to the facility on [DATE].
Review of Resident 95's Physician's Progress Notes readmission H&P examination dated 9/16/22, showed Resident 95 had the capacity to understand and make decision.
Review of Resident 95's POLST dated 7/29/21, under Section D Information and Signatures, did not show an advance directive was discussed with Resident 95.
Review of the Social Services Assessment/valuation V.2 dated 9/23/22, did not show Resident 95 was provided information on how to formulate an advance directive.
Further review of Resident 95's medical record did not show documentation Resident 95 was provided information on how to formulate an advance directive.
On 11/3/22 at 1010 hours, an interview was conducted with Resident 95. When asked about advance directive, Resident 95 stated she was not given information on how to formulate an advance directive. Resident 95 stated she wanted to formulate an advance directive.
3. Medical record review for Resident 121 was initiated on 11/1/22. Resident 121 was admitted to the facility on [DATE].
Review of Resident 121's H&P examination dated 9/18/22, showed Resident 121's decision-making capabilities as capable and independent.
Review of Resident 121's POLST dated 9/13/22, under Section D Information and Signatures, showed Resident 121 did not have an advance directive.
Review of the Social Services Assessment/Evaluation V.2 dated 9/20/22, did not show Resident 121 was provided information on how to formulate an advance directive.
Further review of Resident 121's medical record did not show documentation Resident 121 was provided information on how to formulate an advance directive.
On 11/3/22 at 0957 hours, an interview was conducted with Resident 121. When asked about advance directive, Resident 121 stated she spoke with the SSD but was not given information on how to formulate an advance directive. Resident 121 stated she wanted information on how to formulate an advance directive.
On 11/3/22 at 1444 hours, an interview and concurrent medical record review for Residents 95, 121, and 471 were conducted with the SSD. The SSD verified the above findings. The SSD stated upon admission, the residents were asked if they had an advance directive or if they were interested in formulating an advance directive. The SSD stated the social services department was to provide the information regarding advance directives to the residents who were interested and was to contact the Long-Term Care Ombudsman to assist with the completion of an advance directive for the residents. The SSD stated the social services department was to document this in the admission, readmission, quarterly social services assessments, and progress notes. The SSD verified there were no documentation to show Residents 95, 121, and 471 were provided information on how to formulate an advance directive.
4. Medical record review for Resident 82 was initiated on 11/1/22. Resident 82 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 82's Social Services Assessment/Evaluation dated 9/8/22, showed Resident 82 was alert and oriented, and had not formulated an advanced directive.
On 11/3/22 at 1020 hours, an interview was conducted with Resident 82. Resident 82 stated he was interested in receiving information specific to formulating an advance directive for health care. Resident 82 stated in the event he became incapacitated, he wanted to ensure his decisions specific to his healthcare were followed. Resident 82 stated he would also like to include his family member in the process of formulating his advance directive.
On 11/3/22 at 1422 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD was asked to describe the process in which the facility assisted the residents formulating an advance directive. The SSD stated upon admission to the facility, the facility would determine whether a resident had formulated an advance directive. If a resident had not formulated an advance directive, the facility would then educate the resident and/or resident representative regarding formulating an advance directive. If the resident wished to formulate an advance directive, the facility would then assist the resident with formulating an advance directive. The SSD stated discussions with the resident as to whether the resident wished to formulate an advance directive would be documented in the residents' medical record.
Review of Resident 82's medical record failed to show documentation specific to whether Resident 82 wished to formulate an advance directive. The SSD verified the findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to protect Resident 526's right to be free from physical abuse...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to protect Resident 526's right to be free from physical abuse by Resident 60. This had the potential for physical abuse to continue for Resident 526.
Findings:
Medical Record Review for Resident 60 was initiated on 11/1/22. Resident 60 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of the Facility Reported Incident dated 11/1/22, showed Residents 60 and 526 share a room. At 0425 hours, the RN reported Resident 60 climbed into Resident 526's bed and grabbed and shook Resident 526's wrist while Resident 526 was lying in his bed.
Review of the facility's P&P for Abuse titled Abuse: Prevention of and Prohibition Against (undated) showed each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish and Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.
Review of Resident 60's H&P examination dated 10/27/22, showed the resident could make needs known but could not make medical decisions.
Review of Resident 60's MDS dated [DATE], under Section D showed the resident's mood was being short tempered and easily annoyed. The MDS dated [DATE], under Section E showed the resident had physical behaviors directed toward others (hitting, kicking, pushing, and grabbing).
Review of Resident 60's nurse progress notes dated 9/8 to 9/10/22, showed the resident was monitored for increase agitation/restlessness/verbally abusive towards staff, the resident was noted wandering into other resident room and demanding them to get out of bed and shouting at the staff who attempting to redirect him, and attempting to kick a CNA while trying to give the resident a blanket to cover up.
Review of Resident 60's nurse progress note dated 9/29/22, showed the resident was transferred to an acute care hospital due to increased agitation.
Review of Resident 60's nurse progress note dated 11/1/22, showed the resident was noted with episodes of going to another resident's bed and holding the other resident's wrist; and had history of aggressive behavior towards staff.
On 11/2/22 at 1300 hours, an interview was conducted with the maintenance staff. He stated at 1600 hours on 11/1/22, he heard yelling and screaming coming from Residents 60 and 526's room. The maintenance staff stated when he walked into the room, he observed Resident 60 lying in Resident 526's bed. He stated Resident 60 was holding and shaking Resident 526's wrist. The maintenance staff stated Resident 60 had an angry expression on his face and looked like he may hit Resident 526. He stated no other staff were in the room at the time of the incident.
On 11/2/22 at 1330 hours, an interview was conducted with the caregiver assigned to Resident 60. The caregiver stated she was the one-to-one caregiver assigned to Resident 60. She observed, assisted, and redirected Resident 60 as needed. She stated her shift begins at 1630 hours and she was not in the room when Residents 60 and 526 had the altercation. She stated she arrived at 1630 hours, and the incident had already occurred. The caregiver stated she observed Resident 60 using the bathroom and the resident did try to go outside the room. She stated she would redirect Resident 60 and ask him what he needs. The caregiver stated she would go get water and snacks for Resident 60 and the resident would stand at the doorway.
On 11/3/22 at 1000 hours, an interview was conducted with RN 1. RN 1 stated she heard a sound coming from the room of Residents 60 and 526. RN 1 stated she went into the room and saw Resident 60 was lying in Resident 526's room and holding on to Resident 526's wrist. RN 1 stated she told Resident 60 to go back into his bed and he followed her directions. RN 1 stated Resident 526 was scared because he thought Resident 60 was going to punch him. RN 1 stated the caregiver was not in the room at the time of the incident. RN 1 stated Resident 60 had a history of aggressive behavior with staff, such as striking out, yelling, and screaming. RN 1 stated Resident 60 wandered out of his room and went into other rooms to use their bathroom or lie down in their beds.
On 11/3/22 at 1100 hours, an interview was conducted with Resident 526. Resident 526 stated Resident 60 came to the side of his bed and touched him. Resident 526 stated, I told Resident 60 his bed was on the other side of the room. Resident 526 stated he was afraid of Resident 60 because he didn't know what Resident 60 was going to do. Resident 526 stated Resident 60 sat down and laid on his bed. He stated he tried to use the call light and could not reach it. He stated he yelled and screamed for help because Resident 60 had grabbed his wrist and began shaking him. Resident 526 stated he was scared because he thought Resident 60 was going to punch him. Resident 526 stated he was immediately transferred to another room, and he feels safe and comfortable. He stated he had not seen Resident 60 since the incident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 144's medical record review was initiated on 11/2/22. Resident 144 was admitted on [DATE], and readmitted ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 144's medical record review was initiated on 11/2/22. Resident 144 was admitted on [DATE], and readmitted on [DATE].
Review of Resident 144's MDS dated [DATE], showed under Section K0300 (Weight Loss - loss of 5% or more in the last month or loss of 10% or more in the last 6 months), it was coded as zero meaning Resident 144 had no weight loss.
Review of Resident 144's MDS dated [DATE], showed under Section K0300 (Weight Loss - loss of 5% or more in the last month or loss of 10% or more in the last 6 months), it was coded as 2 meaning Resident 144 had weight loss, not on the physician-prescribed weight-loss regimen.
On 11/3/22 at 1450 hours, a concurrent interview and medical record review was conducted with RN 1. RN 1 verified Resident 144 had weight loss of 12.94% from 5/5/22 to 6/2/22.
Based on interview, medical record review, and facility P&P review, the facility failed to ensure accurate assessment and coding of MDS for two of 33 sampled residents (Residents 99 and 144) as evidenced by:
* The facility failed to accurately assess Resident 99 when the quarterly assessment dated [DATE], showed Resident 99 did not receive any antipsychotic medication the last seven days. The MAR showed Resident 99 received antipsychotic medication from 6/15/22 through 6/21/22.
* The facility failed to accurately code Resident 144's weight loss in the MDS.
These failures resulted in inaccurate assessment which could delay appropriate therapy leading to poor resident outcomes.
Findings:
1. Review of the facility's P&P titled Comprehensive assessment dated 12/2021 showed it is the policy of this facility to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity which are based on the state's specific Resident Assessment instrument (RAI) and the facility's interdepartmental assessment forms.
Medical record review was initiated for Resident 99 on 11/4/22.
Review of Resident 99's medication order dated 4/11/22, showed Seroquel 25 mg (medication used to treat schizophrenia and bipolar disorder) by mouth twice a day for disturbance behavior.
Review of Resident 99's medication order dated 6/22/22, showed a new order to change the Seroquel dosage to 25 mg by mouth daily for psychosis/mood disorder.
Review of the quarterly MDS assessment on 6/22/22, showed Resident 99 did not receive any antipsychotic medication during the last seven days prior to 6/22/22.
However, review of the MAR for June 2022 showed Resident 99 received Seroquel 25 mg by mouth two times a day from 6/15/22 to 6/21/22.
Review of the quarterly MDS assessment on 9/22/22, also showed Resident 99 did not receive any antipsychotic medication since admission/entry.
However, review of the MAR for April to October 2022 showed Resident 99 had been receiving Seroquel from April through October 2022.
During an interview on 11/4/22 at 1520 hours, LVN 9 acknowledged the above MDS assessments were inaccurate.
During an interview on 11/4/22 at 1430 hours, the DON acknowledged the inaccuracies of the MDS assessments.
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 medical record review, the facility failed to develop the plans of care to reflect the indi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to develop the plans of care to reflect the individual care needs for six of 33 final sampled residents (Resident 98, 99, 123, 138, 140, and 144).
* The facility failed to develop a comprehensive person-centered care plan to address Resident 123's indwelling urinary catheter.
* The facility failed to develop a comprehensive person-centered care plan to address Resident 140's Trazodone use.
* The facility failed to develop a comprehensive person-centered care plan to address Resident 144's refusal of meals and weight loss.
* The facility failed to implement bilateral floor mats for Resident 138.
* The facility failed to implement bilateral floor mats for Resident 98 to prevent injury if fall occurred, and failed to develop a care plan to address Resident 98's left first toe wound.
* The facility failed to have a person centered and individualized care plan developed for Resident 99's uncontrolled crying, yelling out and poor appetite.
These failures posed the risk of not providing appropriate, consistent, and individualized care to Residents 98, 99, 123, 138, 140, and 144.
Findings:
Review of the facility's P&P titled Care Planning dated 1/2021 showed it is the policy of the facility that the IDT shall develop and implement a comprehensive person-centered care plan for each resident, consistent with resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.
1. Review of Resident 123's medical record was initiated on 11/3/22. Resident 123 was admitted to the facility on [DATE].
On 11/3/22 at 0850 hours, Resident 123 was observed lying in bed. Resident 123 had an indwelling urinary catheter with a urinary drainage bag hanging on the right side of the bed.
However, there was no documented evidence of a physician's order to use an indwelling urinary catheter.
Further review of Resident 123's medical record failed to show documented evidence a care plan was developed to address Resident 123's use of an indwelling urinary catheter.
During an interview and concurrent medical record review with RN 1 on 11/4/22 at 1500 hours, RN 1 was informed and verified a care plan was not developed to address the use of an indwelling urinary catheter.
2. Review of Resident 140's medical record review was initiated on 11/3/22. Resident 140 was admitted to the facility on [DATE].
Review of Resident 140's physician orders dated 10/12/22, showed an order to administer trazodone (antidepressant medication) HCl 50 mg by mouth at bedtime for depression/not being able to sleep manifested by feeling sad/difficulty sleeping.
However, further review of Resident 140's medical record failed to show documented evidence a care plan was developed addressing Resident 140's use of antidepressant medication.
On 11/8/22 at 1430 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 was informed and verified there was no care plan developed addressing the use of antidepressant for Resident 140.
3. Review of Resident 144's medical record was initiated on 11/3/22. Resident 144 was admitted to the facility on [DATE].
a. Review of Resident 144's meal intake record showed the resident refused at least one meal on 5/15, 6/7 to 6/9/22, 6/13 to 6/17/22, and 6/19 to 6/28/22.
However, there was no documented evidence a care plan was developed addressing Resident 144's refusal of meal which put the resident at risk of unplanned weight loss.
On 11/8/22 at 1500 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 was informed and acknowledged there was no care plan addressing the resident's refusal of meals.
b. Review of Resident 144's weight log showed that the resident had a weight loss of 12.94% from 5/5/22 to 6/2/22.
On 11/3/22 at 1450 hours, an interview and concurrent medical record review was conducted with RN. RN 1 was informed and verified the resident had weight loss; however, there was no care plan developed addressing the resident's weight loss.
4. Medical record review for Resident 138 was initiated on 6/8/21. Resident 138 was readmitted to the facility on [DATE].
Review of the MDS dated [DATE], showed Resident 138 was cognitively impaired and needed extensive assistance from a staff for his ADL care. Resident 138 had balance problems and needed assistance during transfers.
Review of Resident 138's nurses progress note dated 7/5/22, showed Resident 138 was found on the floor, laying vertically, with his legs flex under his bed. Resident 138 had no change in mentation, no other obvious injury noted, only having redness to the right shoulder. Resident 138 was assisted back to bed which was in low position. Resident 138 was a poor historian and nonverbal but able to make needs known. The MD was called and provided an order to do the skull and right shoulder x-ray, and neuro checks.
Review of Resident 138's care plan showed a care plan problem dated 7/5/22, addressing the resident's actual fall related to weakness, impaired mobility, gait balance problem, and history of falls. An intervention dated 7/5/22, showed to apply bilateral floor mats.
Review of the IDT progress note dated 7/12/22, showed Resident 138 had an unwitnessed fall on 7/5/22. The IDT's recommendations included the use for bilateral floor mats.
Review of Resident 138's Physician Order Summary Report dated 7/12/22, showed a physician's orders for bilateral floor mats at bedside.
On 11/3/22 at 0900 hours, Resident 138 was observed lying in bed. There were no bilateral floor mats at the bedside.
On 11/3/22 at 1003 hours, an observation, interview, and concurrent medical record review was conducted with LVN 12. LVN 12 acknowledged there were no bilateral floor mats at the bedside. LVN 12 acknowledged the resident fell on 7/5/22. LVN 12 verified there was a physician's order and care plan for the use of bilateral floor mats at bedside. LVN 12 verified the bilateral floor mats at the bedside were not implemented. LVN 12 stated she would call maintenance to get floor mats placed in the resident's room because Resident 138 needed it for his history of fall.
5. Medical record review for Resident 98 was initiated on 11/1/22. Resident 98 was admitted to the facility on [DATE], and readmitted on [DATE].
a. Review of Resident 98's care plan addressing the risk for falls dated 11/23/22, showed Resident 98 was at risk for falls related to poor balance control, unsteadiness, pain, medication side effects, and poor safety awareness. The care plan interventions included the implementation of floor mats at Resident 98's bedside.
On 11/1/22 at 1105 hours, an observation and concurrent interview was conducted with LVN 10. Resident 98 was observed lying in bed without floor mats in place at Resident 98's bedside. LVN 10 verified the findings and stated as per Resident 98's care plan, the floor mats should be in place at Resident 98's bedside as Resident 98 was at risk for falls related to poor balance control, unsteadiness, and poor safety awareness.
b. On 11/4/22 at 0929 hours, an observation, interview, and concurrent medical record review was conducted with the treatment nurse (LVN 17). LVN 17 observed Resident 98's left first toe and stated Resident 98 had what appeared to be a diabetic ulcer on his left first toe.
Review of Resident 98's medical record was then conducted with LVN 17. LVN 17 reviewed Resident 98's medical record and verified Resident 98 was readmitted to the facility on [DATE]; however, Resident 98's medical record failed to show documentation of assessment of Resident 98's left first toe wound. LVN 17 was unable to determine the date of onset for Resident 98's left first toe wound and whether Resident 98's left first toe wound was improving or worsening.
Further review of Resident 98's medical record failed to show the facility initiated a care plan for Resident 98's left first toe wound. LVN 17 verified the above findings. Cross reference to F684, exmaple #1.
6. Medical record review was initiated for Resident 99 on 11/4/22. Resident 99 was admitted to the facility on [DATE].
Review of Resident 99's medication order dated 2/11/22, showed an order for Nuedexta 20 mg/10 mg by mouth every 12 hours for Pseudobulbar affect manifested by uncontrolled crying.
Review of Resident 99's medication order dated 6/22/22, showed an order for Seroquel 25 mg by mouth daily for psychosis/mood disorder manifested by yelling out.
Review of Resident 99's medication order dated 10/20/22, showed an order for mirtazapine 7.5 mg by mouth at bedtime for depression manifested by poor appetite.
Review of the Resident 99's care plan addressing the use of Nuedexta for Pseudobulbar affect manifested by uncontrolled crying showed the non-pharmacological interventions included back rub, redirection, speak to/approach in a calm manner, reposition, offer snacks/fluid/milk, assess for pain, provide a quite environment, encourage to express feelings, take to activities, and provide reassurance.
Review of the Resident 99's care plan addressing antipsychotic medication use manifested by yelling out showed the non-pharmacological interventions included back rub, redirection, speak to/approach in a calm manner, reposition, offer snacks/fluid/milk, assess for pain, provide a quite environment, encourage to express feelings, take to activities, and provide reassurance.
Review of the Resident 99's care plan for mirtazapine use manifested by poor appetite showed the non-pharmacological interventions included back rub, redirection, speak to/approach in a calm manner, reposition, offer snacks/fluid/milk, assess for pain, provide a quite environment, encourage to express feelings, take to activities, and provide reassurance.
During an interview on 11/4/22 at 1039 hours, RN 3 acknowledged developing the above care plans. RN 3 also acknowledged the non-pharmacological interventions documented in the care plan for yelling out, uncontrolled crying and poor appetite were the same, they were generalized and not for the resident's specific behaviors exhibited.
During an interview on 11/4/22 at 1430 hours, the DON acknowledged the care plans developed for Resident 99's behaviors (uncontrolled crying, yelling out and decrease appetite) were generic and not specific to the resident's behaviors.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the comprehensive plan of care for one of 33 final s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the comprehensive plan of care for one of 33 final sampled residents (Resident 95) was revised to reflect the resident's current care needs and interventions. This posed the risk of not providing Resident 95 with individualized and person-centered care.
Findings:
Medical record review for Resident 95 was initiated on 11/1/22. Resident 95 was readmitted on [DATE].
Review of the Order Summary Report dated 11/8/22, showed the following physician's orders:
- dated 9/17/22, to monitor neck area for skin integrity secondary to the use of the soft collar every shift;
- dated 9/17/22, to put on the soft collar at all times and may remove during ADL care every shift;
- dated 9/17/22, to administer ipratropium-albuterol solution 0.5-2.5 mg/3 ml one dose every four hours as needed for shortness of breath or wheezing; and
- dated 10/10/22, to administer oxygen two liters per minute via nasal cannula continuous, may titrate to five liters to keep oxygen saturation above 92% every shift
Review of Resident 95's plan of care showed the following care plan problems dated 9/17/22:
- addressing the risk for potential or actual impairment to skin integrity related to surgical wound - scalp incision status post shunt status revision. The interventions did not include the physician's order to apply the soft collar on at all times, may remove during ADL care, and to monitor neck area for skin integrity secondary to use of soft collar every shift; and
- addressing oxygen therapy as needed for shortness of breath. The care plan problem and interventions did not include the physician's order for continuous oxygen therapy.
On 11/8/22 at 0929 hours, an interview and concurrent medical record review for Resident 95 was conducted with LVN 15. LVN 15 verified the care plan problem addressing Resident 95's skin integrity related to surgical wound - scalp incision status post shunt status revision did not include applying a soft collar on at all times, except for ADLs and monitoring the skin integrity of the neck while the soft collar was applied. LVN 15 acknowledged the application of the soft collar should have been included under the interventions. In addition, LVN 15 verified the care plan problem addressing Resident 95's oxygen therapy showed the oxygen therapy was for as needed. LVN 15 acknowledged the oxygen therapy should have been revised to show continuous use of oxygen.
Cross reference to F684, example #2.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 11/3/22 at 1010 hours, Resident 95 was observed in bed without having the soft neck collar on.
Medical record review was i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 11/3/22 at 1010 hours, Resident 95 was observed in bed without having the soft neck collar on.
Medical record review was initiated on 11/1/22. Resident 95 was readmitted to the facility on [DATE].
Review of Resident 95's Radiology Prescription dated 9/20/22, showed Resident 95 had a diagnosis of cervical spine fusion (a surgery that joins two or more of the vertebrae in the neck).
Review of the Order Summary Report dated 11/8/22, showed the following physician's orders dated 9/17/22:
- To monitor neck area for skin integrity secondary to use of soft collar every shift; and
- To put on soft collar at all times and may remove during ADL care every shift.
On 11/8/22 at 0900 hours, Resident 95 was observed in bed without having the soft neck collar on.
On 11/8/22 at 0929 hours, an observation, interview, and concurrent medical record review for Resident 95 was conducted with LVN 15. LVN 15 verified Resident 95 was observed in bed without having the soft neck collar on. LVN 15 stated Resident 95 had a cervical shunt placed on her scalp and the physician ordered the soft neck collar to minimize the movement of her neck. LVN 15 acknowledged the soft neck collar should have been placed as per the physician's order.
Cross reference to F657.
Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services provided to meet care needs related to wound assessments and soft neck collar (cervical collar or neck brace, a medical device worn around the neck to help provide stability and support) application for two of 33 final sampled residents (Residents 95 and 98).
* Resident 98 was observed with a wound on the tip of his left first toe; however, Resident 98's medical record failed to show documentation the facility conducted an assessment of the wound. This posed the risk for a delay in the identification of a wound and the implementation of treatments and interventions necessary to promote wound healing.
* The facility failed to ensure the soft neck collar was applied to Resident 95 as per the physician's order. This posed the potential for poor health outcomes for this resident.
Findings:
1. Review of the facility's P&P titled Change of Condition Reporting dated 5/2019 showed any change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician. Document the change of condition and response in the resident's progress notes, change of condition form, and update resident care plan, as indicated.
Review the facility's P&P titled Skin Management System dated 5/2019 showed a plan of care will be initiated to address areas of actual skin breakdown. The plan of care will be reviewed and revised as needed. Residents will have ongoing head to toe assessments done weekly. A report of all wounds and their progress will be updated by the treatment nurse weekly.
Medical record review for Resident 98 was initiated on 11/1/22. Resident 98 was admitted to the facility on [DATE], and readmitted on [DATE].
On 11/1/22 at 1053 hours, an observation and concurrent interview was conducted with Resident 98. Resident 98 was observed lying in bed. The tip of Resident 98's left first toe was observed with a black discolored wound. Resident 98 stated he had no feeling in his left foot and was unable to see his feet and unaware of the wound.
On 11/4/22 at 0929 hours, an observation, interview, and concurrent medical record review was conducted with the treatment nurse (LVN 3). LVN 3 was asked to describe the facility's practice specific to the assessment of the resident's wounds. LVN 3 stated when a resident presented with a wound, an initial assessment of the wound would be performed and weekly assessments would be done thereafter. LVN 3 stated the purpose of the initial and weekly assessments was to track the progress of the resident's wound, in order to determine if the wound was improving or worsening. If the resident's wound worsened, the resident's physician would then be notified to obtain necessary treatment orders.
LVN 3 observed Resident 98's left first toe and stated Resident 98 had what appeared to be a diabetic ulcer on his left first toe. Review of Resident 98's medical record was then conducted with LVN 3. LVN 3 reviewed Resident 98's medical record and verified Resident 98 was readmitted to the facility on [DATE]; however, Resident 98's medical record failed to contain documentation of an assessment of Resident 98's left first toe wound. LVN 3 was unable to determine the date of onset for Resident 98's left first toe wound and whether Resident 98's left first toe wound was improving or worsening.
Cross reference to F656, example #5.b.
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. Medical record review for Resident 138 was initiated on 6/8/21. Resident 138 was readmitted to the facility on [DATE].
Revie...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 138 was initiated on 6/8/21. Resident 138 was readmitted to the facility on [DATE].
Review of the MDS Section C dated 9/17/22, showed Resident 138 was not able to be interviewed for Mental Status; and the resident's BIMS score was 0. The MDS Section J dated 9/17/22, showed Resident 138 had one fall since admission.
Review of Resident 138's History and Physical Examination dated 6/10/22, showed the resident was alert, oriented x 0.
Review of Resident 138's Nurses Progress note dated 7/5/22, showed Resident 138 was found on the floor, laying vertically, with legs under his bed flex. The resident had no change in mentation and no other obvious injury noted. The resident noted to have redness on the right shoulder. The resident was assisted back to the bed. The resident's bed was maintained in low position. The resident was poor historian, nonverbal, but able to make needs known. The physician was called with order for the skull and right shoulder x-ray, and neuro checks.
Review of Resident 138's care plan showed a care plan problem dated 7/5/22, addressing the resident's actual fall related to weakness, impaired mobility, gait balance problem, and history of falls. An intervention dated 7/5/22, showed to apply bilateral floor mats.
Review of the IDT Progress Note dated 7/12/22, showed Resident 138 had an unwitnessed fall on 7/5/22. The IDT's recommendations included to use bilateral floor mats for Resident 138
Review of Resident 138's Physician Order Summary Report dated 7/12/22, showed the physician's order to use bilateral floor mats at bedside for Resident 138.
On 11/1/22 at 0830 and 1500 hours, Resident 138 was observed being alert and lying in the bed. There were no bilateral floor mats at bedside.
On 11/2/22 at 0900 and 1600 hours, Resident 138 was observed lying in bed. There were no bilateral floor mats at bedside.
On 11/3/22 at 0900 hours, Resident 138 was observed lying in bed. There were no bilateral floor mats at bedside
On 11/3/22 at 1003 hours, an observation., interview, and concurrent review of Resident 138's medical record was conducted with LVN 12. LVN 12 acknowledged there were no bilateral floor mats at bedside for Resident 138. LVN 12 acknowledged the resident fell on 7/5/22. LVN 12 verified there was the physician's order and care plan for the use of bilateral floor mats at bedside. LVN 12 stated she would call the maintenance to get the floor mats placed in the resident's room because Resident 138 needed it due to the history of fall.
Based on observation, interview, and medical record review, the facility failed to provide floor mats for three of 33 final sampled residents (Residents 95, 98, and 138) as per the physician's orderd and the plans of care. This failure posed the risk for additional falls and injury to the residents.
Findings:
1. On 11/1/22 at 0935 hours, during the initial tour of the facility, Resident 95 was observed in bed with no floor mats in place. Resident 95 stated she had a fall three weeks ago. Resident 95 stated she fell from the bed and hit her head. Resident 95 stated she was transferred to the acute care hospital.
Medical record review for Resident 95 was initiated on 11/1/22. Resident 95 was readmitted to the facility on [DATE].
Review of Resident 95's Fall Risk Evaluation dated 9/17/22, showed Resident 95 was at high risk for falls.
Review of Resident 95's plan of care showed a care plan problem dated 9/17/22, to address the risk for falls. The interventions included to provide floor mats at bedside.
Review of Resident 95's Progress Note showed a nursing entry dated 10/20/22, showing at approximately 0245 hours, Resident 95 was found lying on the floor. The progress note showed Resident 95 was transferred to the acute care hospital via 911.
Review of Resident 95's eInteract Change in Condition Evaluation V4.2 dated 10/20/22, showed Resident 95 had a fall. Under the Pain Evaluation, the evaluation form showed Resident 95 had pain with the pain level of 10 out of 10 and had a right front forehead right parietal laceration.
Further review of Resident 95's plan of care showed a care plan problem dated 9/17/22, to address actual fall with head injury - lacerations to scalp. The interventions included to continue interventions on the at-risk care plan.
On 11/3/22 at 1010 hours and on 11/8/22 at 0900 and 0929 hours, Resident 95 was observed in bed with no floor mats in place.
On 11/8/22 at 0900 hours, an interview was conducted with CNA 5. CNA 5 verified there were no floor mats in place for Resident 95. CNA 5 stated she heard Resident 95 had a fall and the resident was transferred to the hospital. When asked about the floor mats, CNA 5 stated Resident 95 did not have floor mats before or even after Resident 95 had a fall.
On 11/8/22 at 0929 hours, an observation, interview, and concurrent medical record review for Resident 95 was conducted with LVN 15. LVN 15 verified the above findings. LVN 15 verified Resident 95's plan of care showed a care plan problem to address the risk for and actual fall included to provide floor mats. LVN 15 verified there were no floor mats in place. LVN 15 stated the floor mats should have been put in place for Resident 95.
3. Medical record review for Resident 98 was initiated on 11/1/2022. Resident 98 was admitted to the facility on [DATE], and readmitted to the facility on [DATE].
Review of Resident 98's care plan titled At Risk for Falls with the target date as of 11/23/22, showed Resident 98 was at risk for falls related to poor balance control, unsteadiness, pain, medication side effects, and poor safety awareness. The care plan interventions include the implementation of floor mats at Resident 98's bedside.
On 11/1/22 at 1105 hours, an observation and concurrent interview was conducted with LVN 10. Resident 98 was observed lying in bed without floor mats in place at Resident 98's bedside. LVN 10 verified the findings and stated as per Resident 98's At Risk for Falls care plan, the floor mats should be in place at Resident 98's bedside as Resident 98 was at risk for falls related to poor balance control, unsteadiness, and poor safety awareness.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary services and care for t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary services and care for the use of an indwelling urinary catheter for one of 33 final sampled residents (Resident 123) when there was no documented evidence showing an indication for the indwelling urinary catheter use for Resident 123. This posed the risk for infection related to unnecessary catheter use.
Findings:
On 11/3/22 at 0850 hours, Resident 123 was observed lying in bed. Resident 123 had an indwelling urinary catheter with the drainage bag hanging on the right side of the bed.
Review of Resident 123's medical record was initiated on 11/3/22. Resident 123 was admitted to the facility on [DATE].
Review of the Progress Notes *NEW showed the Laboratory/Radiology Note dated 9/13/22 at 1942 hours, showing Resident 123 had an order to insert an indwelling urinary catheter; the order was noted and carried out.
However, there was no documented evidence to show an indication for the use of the indwelling urinary catheter for Resident 123.
An interview was conducted with LVN 6 on 11/3/22 at 1426 hours. When asked about the indication of the indwelling urinary catheter use for Resident 123, LVN 6 stated he did not know.
During an interview and concurrent review of Resident 123's medical record with RN 1 on 11/4/22 at 1500 hours, RN 1 verified there was no documentation showing the reason why the indwelling urinary catheter was used for Resident 123. RN 1 verified there was no diagnosis for the use of an indwelling urinary catheter. RN 1 acknowledged the risks of an unnecessary indwelling urinary catheter including, trauma and risk for infection.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0691
(Tag F0691)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure one of 33 final sampled residents (Res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure one of 33 final sampled residents (Resident 523) received the appropriate and necessary services for the care of a colostomy bag.
* The staff failed to ensure proper care for Resident 523's colostomy bag by pricking a hole in the colostomy bag due to the initial improper application of the colostomy bag to the resident's lumbar region. This failure had the potential to result in leakage of gas and fecal matter and made the resident feel embarrassed and frustrated.
Findings:
Medical record review for Resident 523 was initiated on 11/1/22. Resident 523 was admitted to the facility on [DATE].
Review of Resident 523's History and Physical examination dated 11/4/22, showed the resident has the capacity to understand and make decisions.
Review of Resident 523's Order Summary Report dated 10/31/22, showed an order for colostomy care in the lumbar region every shift; and colostomy appliance change or flange as needed for leakage.
Review of Resident 523's Care Plan dated 11/1/22, showed a problem to address the resident's alteration in gastrointestinal status related to Colostomy diagnosis: Colon Cancer. The care plan showed the goal for resident to remain free from discomfort, complications, or signs/symptoms related to colostomy use. The care plan showed the interventions included to change colostomy bag or flange as needed for leakage and provide colostomy care in the left lumbar region every shift.
On 11/1/22 at 1000 hours, an observation and concurrent interview was conducted with Resident 523. Resident 523 was observed lying in bed with the head of the bed elevated. Resident 523 was alert. Resident 523 stated his colostomy bag was changed last night and the LVN improperly applied the colostomy bag. Resident 523 stated the colostomy bag should be placed so that it faced the the left side and could be emptied out; however, the nurse placed it facing the right side. Resident 523 stated at 0920 hours, CNA 11 pricked a hole in the colostomy bag to allow the gas to escape. Resident 523 stated the colostomy bag was full and he could smell the gas escaping from the bag. Resident 523 stated the CNA 11 should not have pricked a hole in the colostomy bag and now he was afraid at his next bowel movement, the fecal matter would leak out of the bag onto his stomach and made a mess. Resident 523 stated he was frustrated and embarrassed with his roommates and staff entering the room as they could smell the gas and possible leakage. Resident 523 stated he had been waiting for LVN 13 to replace the colostomy bag with a new one in the proper direction so it could be emptied out properly. Resident 523 stated he was frustrated when the colostomy bag was applied improperly and he was waiting for 40 minutes for it to be changed.
On 11/1/22 at 1030 hours, an observation and concurrent interview was conducted with CNA 11. Resident 523's colostomy bag was observed with full of fecal matter. CNA 11 verified it was full of fecal matter and should be emptied out now. CNA 11 stated the colostomy bag was facing the wrong direction and she could not empty it out due to the potential of fecal matter to be spilled over the resident's abdomen. CNA 11 stated she took pointy sharp instrument and pricked the colostomy bag so the gas building up in the colostomy bag could be escaped to prevent the colostomy bag from bursting open. CNA 11 stated she used a sharp instrument to prick the colostomy bags of other residents who had colostomy bags as well.
On 11/1/22 at 1100 hours, an observation and concurrent interview was conducted with LVN 13. LVN 13 observed the colostomy bag and verified it was placed incorrectly. LVN 13 stated CNA 11 had informed her of the resident's complaint forty minutes ago. LVN 13 stated CNA 11 should not have pricked a hole in the colostomy bag, and it was not the standard of colostomy care. LVN 13 stated CNA 11 should have emptied the fecal matter and gas from the colostomy bag due to the potential of leakage and bursting of the colostomy bag.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 33 final sampled reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 33 final sampled residents (Resident 144) received the appropriate services to meet their nutritional needs and maintain desirable weight.
* The facility failed to notify the physician regarding Resident 144's weight loss and develop a plan to address the resident's weight loss. These failures had the potential for further weight loss and not meeting the nutrition needs for Resident 144.
Findings:
Review of the facility's P&P titled Nutrition revised 5/19 showed, The nurse will notify physician, family, and/or resident of weight loss/gain with interventions.
Review of Resident 144's medical record was initiated on 11/3/22. Resident 144 was admitted on [DATE].
Further review of Resident 144's medical record showed the resident had a weight loss of 15.4 pounds from 5/5/22 to 6/2/22. However, there was no documented evidence the physician was notified regarding the significant weight loss.
On11/4/22 at 1104 hours, a concurrent interview and medical record review was conducted with the RD. The RD verified the IDT meeting was done with the DON, ST, and treatment nurse attending the meeting, but not the physician. The RD verified a care plan to include the interventions from the IDT meeting was not developed for Resident 144.
On 11/4/22 at 1133 hours, a concurrent interview and medical record review was conducted with RN 1. RN 1 acknowledged the assessment for the significant weight loss was not done for Resident 144.
During an interview with RN 1 on 11/8/22 at 1500 hours, RN 1 stated her expectations was that physician should be notified immediately and implement the interventions for the significant weight loss for Resident 144.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
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 necessary care and services related to GT were...
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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 necessary care and services related to GT were provided for two of 33 final sampled residents (Residents 50 and 138).
* The licensed nurse failed to check the GT (a flexible tube surgically inserted into the abdomen to the stomach for feeding and medication administration) placement correctly before medication administration for Resident 138.
* The facility failed to ensure Resident 35's head of bed was elevated at 30-45 degrees during GT feeding administration as ordered.
These failures had the potential for complication related to GT including aspiration.
Findings:
1. Review of the facility's P&P titled Policy/Procedure-Nursing Clinical, Gastrostomy Tube, undated, showed under the Administering Medications through feedings tubes, to check for placement.
Medical record review for Resident 138 was initiated on 11/1/22. Resident 138's admission Record showed Resident 138 was admitted to the facility on [DATE], with a diagnosis of dysphagia (difficulty swallowing).
Review of Resident 138's MDS dated [DATE], showed Resident 138 was totally dependent on staff for eating and had a diagnosis of dysphagia following nontraumatic intracerebral hemorrhage.
Review of the physician's orders showed Resident 138 had an order dated 9/2/22, to check tube placement/and residuals before giving medications or starting feeding.
During a concurrent observation and interview with LVN 12 on 11/1/2022 at 0830 hours, LVN 12 was observed administering the medications via GT to Resident 138. Prior to administering the medications, LVN 12 did not check for proper placement of Resident 138's GT. During an interview, LVN 12 acknowledged checking proper placement of GT was not done prior to administering the medications to Resident 138.
On 11/8/22 at 1049 hours, an interview was conducted with the DON. The DON acknowledged when giving medications thru GT, the nurse should verify placement prior to administering the medications.
2. Medical record review for Resident 50 was initiated on 11/1/22. Resident 50 was admitted to the facility on [DATE].
Review of Resident 50's Order Summary Report showed the following physician's orders:
- dated 10/6/22, to provide continuous GT feeding of Jevity 1.2 (fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding) at 85 ml per hour for 20 hours; and
- dated 10/16/22, for enteral feed order, to elevate head of bed to 30 to 45 degrees at all times.
On 11/3/22 at 0803 and 0841 hours, Resident 50 was observed in bed asleep with his head of the bed almost lying flat. The head of the bed was not elevated at 30 to 45 degrees as ordered. Resident 50's GT feeding was observed infusing via a feeding pump at 85 ml per hour.
On 11/3/22 at 0844 hours, an observation and concurrent interview was conducted with CNA 6. Resident 50 was observed in bed asleep with his head of the bed almost lying flat while the GT feeding was infusing. The head of the bed was not elevated at 30 to 45 degrees as ordered. CNA 6 verified the findings.
On 11/3/22 at 0849 hours, an observation and concurrent interview was conducted with RN 4. Resident 50 was observed in bed asleep with his head of the bed almost lying flat while the GT feeding was infusing. The head of the bed was not elevated at 30 to 45 degrees as ordered. RN 4 verified the findings. RN 4 was observed repositioning and elevating Resident 50's head of the bed.
On 11/3/22 at 0954 hours, an interview and concurrent medical record review was conducted with LVN 13. When asked about the proper positioning of the residents with GT, LVN 13 stated Resident 50 should be positioned properly, and the head of the bed should be elevated to prevent him from aspirating (breathing in a foreign object into the airway).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure one of 33 final sampled residents (Resident 50) rece...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure one of 33 final sampled residents (Resident 50) received appropriate care for peripheral IV (intravenous, infusion of substances such as an antibiotic directly into a vein).
* Resident 50's IV site was on the left wrist, and Resident 50's left hand was observed swollen while IV fluid was infusing. In addition, the IV site dressing was undated. Furthermore, the IV administration was not documented and the IV monitoring was incomplete.
These failures posed the risk for Resident 50 to develop complications related to the use of the peripheral IV catheter.
Findings:
Review of the facility's P&P titled Continuous Infusion of Medications and Solutions updated 1/2021 showed while in the facility, the nurse will monitor the access device every one to two hours for signs and symptoms of complications. The flow rate and condition of the intravenous catheter site will be documented at least every four to eight hours with consideration given to therapy and the condition of the resident. Under the Documentation section showed to document medication/ solution, flushing agents, date, time, and nurse administering on the Medication Administration Record as appropriate.
a. On 11/3/22 at 0803 and 0841 hours, Resident 50 was observed in bed. A bag of Sodium Chloride 0.9% was observed infusing at 60 ml per hour. The bag was labeled NS 0.9% at 60 ml/hr. 2nd liter of 3 liters, started at 6:45 AM. A peripheral IV line was observed on Resident 50's left wrist, covered by a transparent dressing. The transparent dressing was observed with illegible marking. Resident 50's left hand was observed swollen.
Medical record review for Resident 50 was initiated on 11/1/22. Resident 50 was admitted to the facility on [DATE].
Review of Resident 50's Order Summary Report showed the following physician's orders:
- dated 10/27/22, to monitor site and report to the physician for any abnormalities such as redness, warmth and swelling;
- dated 10/27/22, to observe for any reactions during infusion;
- dated 10/27/22, to observe for reactions during infusion;
- dated 10/27/22, to observe for signs and symptoms of infiltration (occurs when fluid leaks out of the vein into surrounding soft tissue) or phlebitis (inflammation of a vein) pre/post administration during shift;
- dated 10/27/22, to start IV and change site every 72 hours and as needed for infiltration or soiling;
- dated 10/27/22, may extend site beyond 72 hours due to poor venous access;
- dated 10/29/22, ceftriaxone sodium (antibiotic, a drug used to treat infection) two grams one time a day for UTI (urinary tract infection, an infection in any part of the urinary system) for ten days; and
- dated 11/2/22, sodium chloride 0.9% (a solution used to supply water and salt to the body) at 60 ml per hour IV every shift for elevated BUN (blood urea nitrogen, a blood test to determine how well the kidneys function) and creatinine (a blood test to measure of how well the kidneys filter waste from the blood) for five days, three liters total.
b. Review of Resident 50's IV MAR for November 2022 did not show the administration of the first liter of sodium chloride 0.9% was documented.
On 11/3/22 at 0849 hours, an observation, interview, and concurrent medical record review for Resident 50 was conducted with RN 4. Resident 50 was observed in bed, and a bag of sodium chloride 0.9% was observed infusing at 60 ml per hour via IV. RN 4 verified the date on the IV site was illegible, and hard to see. When asked about Resident 50's IV site on the left wrist and swollen left hand, RN 4 also verified Resident 50's left hand was swollen. RN 4 was observed stopping the IV infusion. When asked about Resident 50's IV, RN 4 stated she hung the second liter of sodium chloride 0.9% at 0645 hours. When asked for the documentation of the first liter of sodium chloride 0.9%, RN 4 verified it was not documented in Resident 50's IV MAR.
c. Review of Resident 50's IV Medication Administration Record for October 2022 showed the following:
- a physician's order dated 10/7/22, to administer dextrose solution 50% at 50 ml per hours IV for elevated BUN for three days. This was administered to Resident 50 on 10/7 to 10/10/22; and
- a physician's order dated 10/25/22, to administer dextrose solution 50% at 50 ml per hours IV for hypernatremia until 10/29/22. The MAR did not show Resident 50 was administered the medication on the day shift of 10/27/22, and night shift of 10/28/22.
Further review of Resident 50's IV MAR for October 2022 did not show documented evidence Resident 50' s peripheral IV site was monitored for any abnormalities such as redness, warmth, swelling, and pain every shift, for reactions during infusion, and for signs and symptoms of infiltration and phlebitis pre/post administration on 10/12/22, and the night shift on 10/28/22
On 11/8/22 at 1445 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings. The DON stated the licensed nursing staff were responsible in monitoring Resident 50's IV. The DON stated the licensed nurses labeled the date and time when inserting the peripheral IV catheter. The DON verified there was no documented evidence Resident 50' s peripheral IV site was monitored on 10/12 and 10/28/22. The DON also verified the IV administration was not documented on 10/27 and 10/28/22.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the facility's P&P titled Oxygen Administration (Mask, Cannula, Catheter) revised 05/2007 showed oxygen humidifier ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the facility's P&P titled Oxygen Administration (Mask, Cannula, Catheter) revised 05/2007 showed oxygen humidifier bottles should be changed when empty or essentially empty.
On [DATE] at 1546 hours, during the resident rounds, Resident 88 was observed asleep in bed with a nasal cannula tubing on her face. The nasal cannula was attached to the oxygen machine which showed 3 liters flow of oxygen. An empty oxygen humidifier bottle dated 10/24 was observed attached to the oxygen machine.
Medical record review for Resident 88 was initiated on [DATE]. Resident 88 was admitted to the facility on [DATE], with the diagnosis of asthma.
Review of Resident 88's History and Physical examination dated [DATE], showed a diagnosis of Asthma.
Review of Resident 88's Physician Order Summary showed an order with the start date of [DATE], to change oxygen tubing every night shift every Sunday.
On [DATE] at 0812 hours, during a follow-up observation, Resident 88 was observed awake in bed with her nasal cannula tubing on. The nasal cannula was attached to the oxygen machine and the humidifier bottle dated 10/24 remained emptied.
On [DATE] at 1600 hours, LVN 4 was shown the empty humidifier bottle attached to Resident 88's oxygen machine and LVN 4 verified it was empty. When asked to describe her process for assessing a resident on oxygen, LVN 4 stated she assessed both the oxygen tubing and machine. When asked what the purpose was of the humidifier bottle, she stated it provided humidity to the residents when they breathe.
When asked how often the humidifier bottle should be changed, she stated it should be changed every 7 days at the same time as the oxygen tubing. When asked why the humidifier bottle dated 10/24 was not changed, she stated it was the night shift's responsibility to change the humidifier bottle.
On [DATE] at 1530 hours, the DON was informed acknowledged the above findings.
4. Medical record review for Resident 521 was initiated on [DATE]. Resident 521 was admitted to the facility on [DATE].
Review of Resident 521's Physician Order Summary Report dated [DATE], showed administer oxygen via nasal cannula at 4 liters per minute continuous every shift for oxygen supplementation, change oxygen tubing every week and if soiled one time a day every Sunday.
Review of Resident 521's Progress Notes dated [DATE] showed the resident had conditions effecting the respiratory system, respiratory treatment was oxygen therapy, and to use continuous oxygen at 2.5 liters via nasal cannula.
On [DATE] at 0810 hours, an observation and concurrent interview was conducted with Resident 521. Resident 521 was observed lying in bed receiving oxygen via nasal cannula. Resident 521 stated she was administered with oxygen continuously. Resident 521's oxygen tubing was observed undated.
On [DATE] at 0820 hours, an observation and interview with LVN 12 was conducted. LVN 12 verified the nasal cannula oxygen tubing for oxygen administration for Resident 521 was not dated upon admission on [DATE]. LVN 1 stated the facility's P&P required the nasal cannula oxygen tubing to be changed once every week. LVN 12 stated Resident 521's nasal cannula oxygen tubing was not dated.
Based on observation, interview, medical record review and facility's P&P, the facility failed to provide the necessary treatment to five of 33 final sampled residents (Residents 15, 27, 88, 95, and 521) receiving oxygen therapy and receiving medication through a nebulizer (a device which delivers medicated mist to a person via a mouth piece or a face mask).
* The facility failed to change the nebulizer mask and tubing for Residents 15, 27, and 95 as per the facility's P&P. In addition, the facility failed to ensure Resident 95's humidifier bottle was dated.
* The facility failed to ensure Residents 15, 95, and 521's oxygen tubing were dated.
* The facility failed to change the emptied and expired oxygen humidifier bottle for Resident 88.
These failures had the potential to negatively impact the residents' medical conditions.
Findings:
Review of the facility's P&P titled Oxygen Administration (mask, cannula, catheter) revised 5/2007, under the Instructions for Tubing and Humidifier Changes, showed oxygen tubing is to be replaced every seven days. Oxygen masks or nasal prongs are to be replaced every seven days.
1. On [DATE] at 0935 hours, during the initial tour of the facility, Resident 95 was observed in bed receiving oxygen at 3.5 liters per minute via nasal cannula. There was no date observed on the oxygen tubing. A bag attached to the concentrator was dated [DATE]. An oxygen humidifier bottle attached to the oxygen concentrator was observed quarter-full and was undated. A bag with the date of [DATE], contained the nebulizer mask and tubing attached to a machine was observed on Resident 95's bedside table.
Medical record review for Resident 95 was initiated on [DATE]. Resident 95 was readmitted to the facility on [DATE].
On [DATE] at 1241 hours, an observation, interview, and concurrent medical record review for Resident 95 was conducted with LVN 11. LVN 11 verified the above findings. LVN 11 stated the nasal cannula tubing and nebulizer tubing should be changed every two days. LVN 11 stated she would change the nasal cannula tubing, nebulizer mask and tubing, and humidifier.
On [DATE] at 1010 hours, Resident 95 was observed in bed receiving oxygen at 2.5 liters per minute via nasal cannula. A bag with the date of [DATE], contained the nebulizer mask and tubing attached to a machine was observed on Resident 95's bedside table.
Review of Resident 95's Order Summary Report showed the following physician's orders dated:
- [DATE], to administer ipratropium-albuterol solution 0.5 - 2.5 mg/3 ml one dose via mask every four hours as needed for shortness of breath or wheezing; and
- [DATE], to administer oxygen at two liters per minute via nasal cannula continuous, may titrate to 5 liters per minute to keep oxygen saturation level above 92%.
Review of Resident 95's MAR showed Resident 95 received oxygen daily from 10/10 to [DATE]. In addition, Resident 95 was administered ipratropium-albuterol solution (a combination of two drugs to keep airways open and to decrease inflammation in the lungs) via nebulizer mask on 10/7, 10/8, 10/9, 10/11, 10/12, 10/13, 10/14, 10/15, 10/18, 10/19, 10/21, 10/27, 10/27, 10/28, 10/29, 11/1, 11/2, 11/3, 11/4, and [DATE]
On [DATE] at 0900 and 0929 hours, Resident 95 was observed in bed receiving oxygen at 2 liters per minute via nasal cannula. A bag with the date of [DATE], contained two nebulizer masks was observed on Resident 95's bedside table. The two nebulizer masks inside the bag were observed to be dirty.
On [DATE] at 0929 hours, an observation, interview, and concurrent medical record review for Resident 95 was conducted with LVN 15. LVN 15 verified the above findings. LVN 15 was observed taking the bag containing the two dirty nebulizer masks. LVN 15 stated the nasal cannula tubing and nebulizer masks and tubing should be changed every Sunday.
2. On [DATE] at 0917 hours, during the initial tour of the facility, Resident 27 was observed in bed. A bag with the date of [DATE], contained the nebulizer mask and tubing attached to a machine was observed on Resident 27's bedside table. Resident 27 stated she was administered breathing treatment twice a day.
Medical record review for Resident 27 was initiated on [DATE]. Resident 27 was admitted to the facility on [DATE].
On [DATE] at 1239 hours, an observation, interview, and concurrent medical record review for Resident 27 was conducted with LVN 11. LVN 11 verified the above findings. LVN 11 stated the nebulizer tubing should be changed every two days. LVN 11 stated she would change the nebulizer mask and tubing.
On [DATE] at 1119 hours, Resident 27 was observed in bed. The bag with the date of [DATE], contained the nebulizer mask and tubing was still on Resident 27's bedside table.
Review of Resident 27's Order Summary Report showed a physician's order dated [DATE], to administer ipratropium-albuterol solution 0.5 - 2.5 mg/3 ml one dose every four hours as needed for shortness of breath or wheezing via a nebulizer.
Review of Resident 27's MAR showed Resident 27 was administered ipratropium-albuterol solution via nebulizer mask on 10/1, 10/3, 10/5, 10/7, 10/9, 10/11, 10/12, 10/13, 10/14, 10/15, 10/19, 10/24, 10/26, 10/27, 10/28, and [DATE]
On [DATE] at 0847 hours, Resident 27 was observed sitting in the wheelchair inside the room. The bag with the date of [DATE], contained the nebulizer mask and tubing were still on Resident 27's bedside table. The nebulizer mask inside the bag was observed to be dirty.
On [DATE] at 0929 hours, an observation, interview, and concurrent medical record review for Resident 95 was conducted with LVN 15. LVN 15 verified the above findings. LVN 15 was observed taking the bag containing the dirty nebulizer mask. LVN 15 stated the nebulizer mask and tubing should be changed every Sunday.
3. On [DATE] at 1033 hours, during the initial tour of the facility, Resident 15 was observed in bed receiving oxygen at two liters per minute via nasal cannula. There was no date observed on the oxygen tubing. A bag attached to the concentrator was dated [DATE]. A bag with the date of [DATE], contained a nebulizer mask and tubing attached to a machine was observed on Resident 15's bedside table.
Medical record review for Resident 15 was initiated on [DATE]. Resident 15 was admitted to the facility on [DATE].
Review of Resident 15's Order Summary Report showed the followings physician's orders dated:
- [DATE], to administer oxygen at two liters per minute via nasal cannula continuous, may titrate to five liters per minute to keep oxygen saturation above 92%; and
- [DATE], to administer ipratropium-albuterol solution 0.5 - 2.5 mg/3 ml one dose every six hours as needed for shortness of breath or wheezing via a nebulizer.
Review of Resident 15's MAR showed Resident 15 was administered oxygen daily from 10/1 to [DATE]. In addition, Resident 15 was administered ipratropium-albuterol solution via nebulizer mask on 10/2 and [DATE].
On [DATE] at 1601 hours, an observation, interview, and concurrent medical record review was conducted with RN 1. RN 1 verified the above findings. RN 1 stated the nasal cannula tubing, humidifier, nebulizer mask and tubing should be changed every Sunday or as needed. RN 1 stated the charge nurses were expected to change the nasal cannula tubing, nebulizer mask and tubing, and humidifier, but everybody was responsible to monitor and check if these have been changed. RN 1 stated the infection control and unit managers were supposed to do their rounds and this was part of what they were supposed to check. They were expected to check if the nasal cannula tubing, nebulizer mask and tubing, and humidifier were changed, labeled, and dated.
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 interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure accurate reconciliation of controlled medications for one sampled resident (...
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Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure accurate reconciliation of controlled medications for one sampled resident (Resident 421) and one nonsampled resident (Resident 621). The facility failed to ensure administration of controlled medications for Residents 421 and 621 were accurately documented to ensure accurate reconciliation and to prevent medication administration errors. This posed the risk for diversion of controlled medications and medication administration errors.
Findings:
Review of the facility's P&P titled Medication storage in the facility dated 2/23/15, showed under the procedures, any discrepancy in controlled substance medication counts is reported to the director of nursing immediately. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. The director of nursing documents irreconcilable discrepancies in a report to the administrator. The medication regimen of residents using medications that have such discrepancies are reviewed to assure the resident has received all medications ordered and the goal of therapy is met (example: a resident receiving a pain medication complains of unrelieved pain).
On 11/2/22 at 1026 hours, an inspection of Medication Cart 2 at Nursing Station 1 was conducted with LVN 13. Review of the Controlled Drug Record for Resident 621 showed one tablet of hydrocodone/acetaminophen 5-325 mg (controlled narcotic pain medication) was removed on 10/24/22 at 1230 hours, and 10/24/22 at 1706 hours. However, review of Resident 621's MAR for October 2022 showed no documented evidence the doses administered on 10/24/22 at 1230 hours, and 10/24/22 at 1706 hours.
On 11/2/22 at 1110 hours, an inspection of Nursing Station 3's medication cart and concurrent interview with LVN 7 was conducted. LVN 7 was asked what the facility's policy was regarding the administration and documentation of the controlled medications. LVN 7 stated the process for administering the controlled medications was to document the removal of the controlled medication on the Controlled Drug Record (Accountability Record) after removing the medication from the bubble pack (a card where medications are placed in individual, clear, and sealed compartments), administer the medication to the resident, and document the medication administration on the MAR.
Review of the Controlled Drug Record for Resident 421 showed one tablet of hydrocodone/acetaminophen 5-325, was removed on 10/2/22 at 1000 hours, 10/2/22 at 1500 hours, 10/5/22 at 2100 hours, 10/5/22 at 2104 hours, 10/20/22 at 0820 hours, 10/21/22 at 0610 hours, and 10/26/22 at 2100 hours. However, review of Resident 421's MAR for October 2022 showed no doses administered on 10/2/22 at 1000 hours, 10/2/22 at 1500 hours, 10/5/22 at 2100 hours, 10/5/22 at 2104 hours, 10/20/22 at 0820 hours, 10/21/22 at 0610 hours, and 10/26/22 at 2100 hours.
On 11/8/22 at 1049 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the process for administering the controlled medications was to document the removal of the controlled medication on the Controlled Drug Record immediately after removing the medication from the supply and document the medication administration on the MAR with the licensed nurse's initial and time of administration after administering the medication to the resident. The DON verified the above findings and stated the nurses should have documented the administration of the medication on the MAR.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one of 33 sampled residents (Resident 99) was free from unnecessary medication when the facility failed to ensure Resident 99's beha...
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Based on interview and record review, the facility failed to ensure one of 33 sampled residents (Resident 99) was free from unnecessary medication when the facility failed to ensure Resident 99's behavior manifested for pseudobulbar affect was being monitored for effectiveness of Nuedexta (medication used to treat pseudobulbar affect) and non-pharmacological approach to care was not implemented for this behavior.
This failure had the potential for increased risks associated with medication use that include but are not limited to diarrhea, peripheral edema, and dizziness and may result in poor resident outcome.
Findings:
Review of Resident 99's medication order dated 2/11/22, showed Nuedexta 20 mg/10 mg by mouth every 12 hours for Pseudobulbar affect manifested by uncontrolled crying.
Review of Resident 99's MAR from February to October 2022 showed there was no behavior monitoring for Pseudobulbar affect.
During an interview on 11/3/22 at 1435 hours, LVN 7 acknowledged she had not been monitoring the uncontrolled crying and had not implemented non-pharmacological approach to care for this behavior.
During an interview on 11/8/22 at 1120 hours, the DON stated her expectation was that staff would monitor the resident's behavior of uncontrolled crying every shift when Nuedexta was initiated. The DON also acknowledged the non-pharmacological intervention was not implemented to control behavior.
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. Review of Resident 140's medical record review was initiated on 11/3/22. Resident 140 was admitted on [DATE].
Review of the p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 140's medical record review was initiated on 11/3/22. Resident 140 was admitted on [DATE].
Review of the physician's orders dated 10/12/22, showed an order for Trazodone HCl 50mg tablet, give 1 tablet by mouth at bedtime for depression/not being able to sleep m/b feeling sad/difficulty sleeping.
However, there was no documented evidence the non-pharmacological intervention was not implemented prior to initiating the Trazodone medication administration as per the facility's P&P. In addition, there was no documented evidence of the adverse effects monitoring for the use of Trazadone as per the facility's P&P.
On 11/8/22 at 1430 hours, a concurrent interview and medical record review was conducted with RN 1. RN 1 acknowledged the adverse effects of Trazodone was not being monitored as required.
Based on interview, record review, and facility's P&P review, the facility failed to ensure two of 33 final sampled residents (Residents 99 and 140) were free from unnecessary psychotropic medications when:
* The facility failed to ensure Resident 99's Seroquel was used to treat a specific diagnosed and documented condition.
* The facility failed to document the behaviors and implement non-pharmacological approach for yelling out behavior prior to Resident 99's Seroquel being ordered.
* The facility failed to monitor the behaviors specific to Resident 99's Seroquel and mirtazapine use.
* The facility failed to monitor adverse consequences for Resident 99's psychotropic medications.
* The facility failed to monitor the behaviors specific to the use of trazadone and side effects of trazadone for Resident 140.
These failures had the potential for the residents to receive unnecessary medications and not effectively evaluate the effectiveness of the psychotropic medications.
Findings:
1. Review of the facility's P&P titled Psychotropic Drug Use dated 8/2017 showed in part, it is the policy of the facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record Based on a comprehensive assessment of a resident, the facility will ensure that: Residents who use psychotropic drugs . receive behavioral interventions . These drugs are to be administered only when required to treat the resident's medical symptoms and will be considered only after non-pharmacological interventions have failed . These residents will be referred to facility's psychotropic Drug Regimen Review Committee and/or Psychiatrist to ensure: psychotropic medication was prescribed to treat a specific diagnosed condition, as documented in the clinical record. Monitoring for adverse consequences and effectiveness of medications are in place.
Review of Resident 99's admission Record showed the resident was admitted to the facility in March 2019 with diagnoses including dementia, atrial fibrillation, presence of artificial left hip joint, anemia, pseudobulbar affect, and abnormalities of gait and mobility.
Review of Resident 99's medication order dated 4/11/22, showed mirtazapine 7.5 mg by mouth at bedtime for sleep and increased appetite and Seroquel 25 mg by mouth twice a day for disturbance behavior.
Review of Resident 99's medication order dated 6/22/22, showed an order for Seroquel 25 mg by mouth daily for psychosis/mood disorder manifested by yelling out.
Review of Resident 99's medication order dated 10/20/22, showed mirtazapine 7.5 mg by mouth at bedtime for depression manifested by poor appetite.
a. Review of the physician's progress notes between March and October 2022 did not show any documentation for diagnosis of psychosis/mood disorder.
Review of the MDS completed in March and June 2022 showed Resident 99 did not exhibit any behavior and no documented evidence for diagnosis of psychosis or mood disorder.
During an interview on 11/4/22 at 0919 hours, MD 1 stated his NP was responsible for the resident and the NP was on vacation. MD 1 was unable to answer questions regarding why Seroquel was ordered for Resident 99.
During an interview with the DON on 11/4/22 at 1430 hours, the facility was unable to show documented evidence of diagnosis for Seroquel in the medical record.
b. Review of Resident 99's MAR from February to October 2022 showed Resident 99 had been receiving Seroquel from 4/11/22 through 11/4/22. There was no documented evidence non-pharmacological approach to care was not implemented for Resident 99's behavior (yelling out) as per the facility's P&P, and the behavior was not monitored prior to initiating the use of Seroquel.
During an interview on 11/8/22 at 1120 hours, the DON stated her expectation was that LN would monitor the resident's behaviors for yelling out every shift before starting Seroquel. The DON also acknowledged non-pharmacological intervention was not implemented.
c. Review of Resident 99's MAR from April to October 2022, showed no documented evidence of the behaviors monitoring for depression and psychosis/mood disorder as required.
During an interview on 11/3/22 at 1435 hours, LVN 7 acknowledged not monitoring the resident's behaviors manifested for depression and psychosis/mood disorder.
During an interview on 11/8/22 at 1120 hours, the DON stated her expectation was that LN would monitor the resident's behaviors for yelling out and poor appetite every shift.
d. Review of Resident 99's MAR from April to October 2022 also failed to show the adverse effects of Seroquel and mirtazapine were monitored as per the facility's P&P.
During an interview on 11/3/22 at 1435 hours, LVN 7 acknowledged not monitoring the adverse effects of mirtazapine and Seroquel as required.
During an interview on 11/8/22 at 1120 hours, the DON stated her expectation was that LN would monitor the adverse effects of mirtazapine and Seroquel every shift.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 14.29%. Three of four licensed nurses (LVNs 10, 12, and 14) had performed the medication errors during the medication administration observation.
* LVN 12 failed to properly administer the medication via the GT (a flexible tube surgically inserted into the abdomen to the stomach for feeding and medication administration) to Resident 138.
* LVN 14 failed to properly administer the eye drops to Resident 67.
* LVN 10 failed to properly administer insulin to Resident 65.
These failures had the potential to negatively affect the residents' health.
Findings:
1. Review of the facility's P&P titled Policy/Procedure-Nursing Clinical, Gastrostomy Tube undated, showed
under the Administering Medications through Feedings Tubes section, never mix medications. Mixing medications can cause them to interact in a way that will result in a clogged tube. Administer all medications individually.
On 11/1/22 at 0816 hours, a medication administration observation for Resident 138 was conducted with LVN 12. LVN 12 was observed crushing Hydroxyzine (medication to control itching) 25 mg and removing the contents of a Probiotic capsule (live microorganisms (usually bacteria that are similar to beneficial microorganisms found in the human gut) and placing them in the same medication cup with water and administering them to Resident 138 via the GT.
On 11/1/22 at 1206 hours, an interview was conducted with LVN 12. LVN 12 acknowledged the medications that are administered through the GT should be given individually and realized the mistake after the medications were administered.
2. Review of the facility's P&P titled Specific Medication Administration Procedures, Eye Drop Administration, dated 1/5/18, showed to wait 3-5 minutes between administration of all eye drops, including multiple drops of the same medication.
On 11/1/22 at 0844 hours, a medication administration observation for Resident 67 was conducted with LVN 14. LVN 14 was observed administering 1 drop of Prednisolone eye drops (medicine used to treat mild to moderate non-infectious eye allergies and inflammation) to Resident 67's left and right eyes at 0850 hours. LVN 14 was then observed administering 1 drop of Ketorolac eye drops (medicine used to treat itchy eyes caused by allergies) to Resident 67's left and right eyes at 0851 hours.
On 11/1/22 at 1200 hours, an interview was conducted with LVN 14. LVN 14 acknowledged five minutes should be taken between administration of two different eye drops. When asked how long LVN 14 waited to instill the second eye drop, LVN 14 stated about a minute. LVN 14 stated she did not wait to instill the second eye drop because Resident 65 was impatient and did not want to wait for the second drop to be administered.
3. Review of the facility's P&P titled Specific Medication Administration Procedures: Insulin injection dated 2/23/15, showed prepare injection as follows: hold insulin syringe with correct calibration and withdraw ordered dosage of insulin.
On 11/1/22 at 1128 hours, a medication administration observation for Resident 65 was conducted with LVN 10. LVN 10 was observed pulling the plunger (part of the syringe that is pulled back to measure a presice amount of medication) of the insulin syringe past the 100 unit marking in an attempt to withdraw 110 units of insulin (medicine that allows glucose [sugar] to enter the body's cells to provide energy) into a 100-unit syringe.
Review of Resident 65's medical record was iniitated on 11/1/22. Resident 65's medical record showed the resident was admitted to the facility on [DATE].
Review of the Order Summary Report dated 11/3/22, showed to administer 110 unit of insulin glargine subcutaneous one time a day, starting on 8/30/22.
On 11/1/22 at 1150 hours, an interview was conducted with LVN 10, where they stated they were trained by their preceptor (an experienced licensed clinician who supervises and orients newly hired and licensed staff) to withdraw 110 units of insulin by using a single 100-unit insulin syringe.
On 11/8/22 at 1049 hours, an interview was conducted with the DON. The DON acknowledged the medications administered through GT should not be mixed and should be given individually. The DON also acknowledged when multiple eye drop medications were administered, 3-5 minutes should pass before administering the second eye drop medication. The DON also acknowledged the insulin doses over 100 units should not be withdrawn into a single 100-unit syringe.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manne...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner.
* Two expired bottles of Aspirin tablets (medication used to reduce fever and to relieve mild to moderate pain) were observed in Medication room [ROOM NUMBER].
* One open bottle of Antacid tablets extra strength (medicine that counteracts (neutralize the acid in stomach to relieve indigestion and heartburn) with no open date was found in Medication Cart 2 at Nursing Station 4.
* One open tube of Medi-Honey (An ointment used to treat wounds) with no open date was observed in the Main Treatment Cart.
* Multiple open medication containers with no open date were found in Nursing Station 3's medication cart.
These failures had the potential for unsafe administration of medications.
Findings:
Review of the facility's P&P titled Medication storage in the facility dated 2/23/15, showed under the procedures section, M. outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists.
* On 11/1/22 at 1522 hours, an inspection of Medication room [ROOM NUMBER] and concurrent interview was conducted with RN 1. Two bottles of Aspirin 325 mg tablets were found with an expiration date of September 2022. RN 1 verified the medications had expired and acknowledged the expired medications should not be stored in the medication room.
* On 11/1/22 at 1538 hours, an inspection of Medication Cart 2 at Nursing Station 4 and concurrent interview was conducted with LVN 2. An opened bottle of Antacid tablets had no open date on the container. LVN 2 verified the container was open with no open date and acknowledged those medication bottles should be dated when first opened.
* On 11/2/22 at 0840 hours, an inspection of the Main Treatment Cart and concurrent interview was conducted with RN 4. An open tube of Medi-Honey 1.5 ounces was found with no open date. RN 4 verified the Medi-Honey tube was opened and acknowledged that open tubes of medication should be dated when first opened.
* On 11/2/22 at 1110 hours, and inspection of the medication cart at Nursing Station 3 and concurrent interview was conducted with LVN 7. The following medications were open with no open date.
-Amazon brand severe cold and flu elixir.
-Ferrous Gluconate (medication used to treat low levels of iron) 324 mg tablets.
-Geri-dryl 25 mg (medication used to treat allergy symptoms).
-Oyster shell calcium 500 mg with vitamin D (a combination medication that is used to treat prevent low calcium levels).
-Amlodipine 1 mg/ml (medication to control high blood pressure).
LVN 5 acknowledged the above five listed medications were open with no open dates on their containers.
On 11/08/22 at 1049 hours, an interview was conducted with the DON. The DON stated the nurses were expected to date all multi-dose medication containers when first opened.
CONCERN
(D)
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** 2. Medical record review for Resident 57 was conducted on 11/7/22. Resident 57 was admitted to the facility on [DATE].
Review of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 57 was conducted on 11/7/22. Resident 57 was admitted to the facility on [DATE].
Review of the resident's LN - Skin Pressure Ulcer Weekly dated 5/6/22, showed Resident 57 developed a newly acquired unstageable pressure injury to the coccyx on 5/3/22. It was recommended the resident would be seen by the wound care MD for ongoing treatment.
Medical record review showed the wound care consult was ordered on 5/10/22.
Review of the resident's LN - Skin Pressure Ulcer Weekly dated 10/11, 10/14, 10/21, 10/27, and 11/3/22, showed Resident 57 continued to receive the weekly visits from the wound care MD.
Review of the Order Summary Report for Resident 57 dated 11/9/22, showed the order for the coccyx pressure injury as follows: to cleanse with NS, pat dry, apply honey, collagen calcium alginate, and cover with a dry dressing every day shift ordered as of 10/21/22 with the start date of 10/22/22.
On 11/07/22 at 0910 hours, an interview was conducted with LVN 16 who stated the wound care MD saw Resident 57 weekly, and the weekly measurements of wound were done with the wound care MD. LVN 16 verified the wound care MD's progress notes were sent to the treatment nurses via email. LVN 16 stated the treatment nurses integrated the wound care MD's notes into the weekly skin update. LVN 16 verified the wound care MD's progress notes were not in the medical record under the weekly update for Resident 57.
On 11/09/22 at 1022 hours, an interview was conducted with the wound care MD. When asked where the wound care MD's progress notes were located in Resident 57's medical record, the wound care MD stated she emailed the staff her progress notes weekly.
Based on interview and medical record review, the facility failed to ensure the medical record was accurate for two of 33 final sampled residents (Residents 57 and 99).
* Resident 99's Weekly Nursing Summaries showed no antipsychotic medications were used; however, Resident 99 received Seroquel (antipsychotic medication) in September and October 2022.
* The facility failed to ensure the wound care's MD progress notes were included in Resident 57's medical record.
These failures had the potential for the residents' care needs not being met as the medical information was inaccurate, incomplete, and not readily available.
Findings:
1. Medical record review for Resident 99 was initiated on 11/1/22. Resident 99 was admitted to the facility on [DATE].
Review of Resident 99's Weekly Nursing Summary dated 9/27/22 and 10/18/22, showed Resident 99 did not take antipsychotic medication.
However, Review of Resident 99's Medication Administration Record for September and October 2022 showed Resident 99 received Seroquel 25 mg orally once a day during the months of 9/22 and 10/22.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to ensure the freezer compartment inside the resident's refrigerator was free of ice buildup. This had the potential for the refrigerator not be...
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Based on observation and interview, the facility failed to ensure the freezer compartment inside the resident's refrigerator was free of ice buildup. This had the potential for the refrigerator not being maintained in safe operating condition.
Findings:
Review of the owner's manual for Upright Reach-Ins Bottom Mounted Condensing Unit (undated), under the Operation, showed the unit is preset to defrost every five to six hours with a duration of 45 minutes or less depending on the evaporator coil temperature. Changing the preset outside of the default range will result in cooling issues and advanced component failure.
On 11/1/22 at 0800 hours, an inspection of the freezer in the kitchen was conducted with the DSS. The bottom area of the freezer compartment was observed with a build-up of ice. The DSS verified the above findings.
On 11/2/22 at 1215 hours, an interview and concurrent product manual and facility document review was conducted with the Maintenance Director and DSS present. The Maintenance Director stated he cleaned the outside of freezer but did not clean the inside of freezer. The Maintenance Director stated the freezer had an automatic defroster so there should be no ice build-up. The DSS stated the refrigerator technician came last month and only unplugged the freezer when an ice build-up was observed inside the freezer.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, interview, facility P&P review, facility document review, the facility failed to follow the menu for 19 residents who were on a pureed diet. The facility failed to ensure the kit...
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Based on observation, interview, facility P&P review, facility document review, the facility failed to follow the menu for 19 residents who were on a pureed diet. The facility failed to ensure the kitchen staff used the correct scoop size when serving pureed broccoli. This failure had the potential of not following the menu and not meeting the residents' nutritional needs which could lead to nutritional-related health complications.
Findings:
Review of the facility's P&P titled Menu Planning 2020 showed the menus are planned to meet nutritional needs of residents in accordance with established national guidelines, physician's orders, and to the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences.
Review of the facility's document titled Fall Menus for Week 1 Thursday for 9/8, 10/6, 11/3, and 12/1/22, showed the seasoned broccoli would be served with #12 scoop for the pureed diet.
Review of the facility's document showing the scoop measurements frequently found on menus (undated) showed a #10 scoop was equivalent to six tablespoons and a #12 scoop was equivalent to five tablespoons.
Review of the facility's Order Listing Report showed there were 19 residents on a pureed diet, with no restrictions to broccoli.
On 11/3/22 at 1128 hours, during the tray line observation, the dietary aid was observed using #10 scoop to serve pureed broccoli. The DSS verified the above findings. The DSS verified the serving size was more than what on the spreadsheet for pureed diet. When asked about the portion size for broccoli for a pureed diet, the DSS stated it should have been #12 scoop.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the facility's P&P titled, Food Safety Standards revised 1/2021 showed food must be distributed according to the pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the facility's P&P titled, Food Safety Standards revised 1/2021 showed food must be distributed according to the professional standards for food from the US Food And Drug Administration (FDA) Food Code and Centers for Disease Control and Prevention (CDC).
According to the US FDA 2017, 3-306.14, Returned Food and Re-Service or Sale, disease agents can be transferred person-to-person through food. Food that has been served to a consumer and not eaten can become a vehicle for pathogenic microorganisms to the next consumer if the food is served again.
Findings:
On 11/1/22 at 1117 hours, during the resident rounds, Resident 42 was observed asleep in his room. On Resident 42's bedside table were a cup of thickened water covered with a plastic wrap dated 10/31/22, with Resident 3's name and a peanut butter sandwich in a plastic sandwich bag dated 10/31/22, with Resident's 53's name.
However, during a follow-up observation on 11/1/22 at 1218 hours, Resident 42 was observed sitting up in his wheelchair awake with his bedside table in font of him. On the bedside table, the cup of thickened water was empty and the peanut butter sandwich dated 10/31/22, with Resident 53's name was partially eaten.
On 11/1/22 at 1252 hours, an interview was conducted with CNA 2. CNA 2 was shown the peanut butter sandwich partially eaten by Resident 42 and verified the peanut butter sandwich was labeled with Resident 53's name.
Upon further interview, CNA 2 stated if a resident refused a food, the staff would re-serve that food to another resident. When asked to explain their process for redistributing food, he stated the staff did not check the resident's medical record prior to reallocating food. However, CNA 2 stated they should be checking the resident's medical record because it would be safer.
On 11/8/22 at 1124 hours, an interview was conducted with the DSS. When asked to explain the facility's process for the returned food items, the DSS stated that food was always labeled with the resident's name. She stated food that was refused could be saved and redistributed only to the resident's name on the label. When asked if it was appropriate for the staff to reallocate food from one resident to another, she stated no because of the risk of spreading infection between the residents.
Medical record review for Resident 42 was initiated on 11/1/22. Resident 42 was admitted to the facility on [DATE].
Review of Resident 42's Physician Order Summary Report showed a diet order with the start date of 10/12/22, for a controlled carbohydrate (CCHO) diet, dysphagia mechanical soft texture, nectar thick consistency, and soft sandwich.
Review of the MDS dated [DATE], showed Resident 42 had severe cognitive impairment with a BIMS of 2.
On 11/9/22 at 1530 hours, the DON was informed acknowledged the above findings.
Based on observation, interview, and facility document review, the facility failed to ensure the food safety and sanitation requirements were met.
* The facility failed to air dry equipment.
* The facility failed to ensure the upper plate domes and bottom plates were free from chip and cracks.
* The facility failed to ensure the chlorine strips and pH sanitizer strips were not expired.
* The facility failed to ensure Resident 53's food items were not served to Resident 42.
These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.
Findings:
Review of CMS-672 Resident Census and Conditions of Residents completed by the facility dated 11/1/22, showed 160 of 168 residents residing in the facility received food prepared in the kitchen.
1. According to the USDA Food Code 2017, 4-901.11, Equipment and Utensils, Air- Drying Required, items must be allowed to drain and air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganism can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms.
On 11/2/22 at 1045 hours, a pureed food preparation observation and concurrent interview was conducted with the Cook, with the DSS present. After blending the beef, the [NAME] was observed washing the blender. Then, the [NAME] placed the wet blender into the machine. The [NAME] stated he would prepare the pureed spinach. The [NAME] and DSS verified the blender was still wet. The [NAME] was observed air drying the blender. The DSS stated the [NAME] usually air dried the blender, but they were running out of time today.
2. According to the USDA Food Code 2017, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.
Review of the facility's P&P titled Sanitation dated 2018 showed all utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas. Plastic ware, chin and glassware that becomes unsightly, unsanitary or hazardous because of chips, cracks, or loss of glaze shall be discarded.
On 11/3/22 at 1135 hours, during the trayline observation, the following was observed:
a. Plate domes were observed stack in a drying rack and on the shelf near the trayline area. Several plate domes were observed with melted jagged edges;
b. Bottom plates were observed on the shelf near the trayline area. Several bottom plates were observed with chipped edges; and
c. A used spatula was observed with burned handle.
The DSS verified the above findings. The DSS stated she had ordered the plate domes, but their vendor had a shortage. The DSS stated she told her staff not to place the bottom plates, plate domes or any items near the oven so they would not melt. The kitchen staff were observed taking out several plate domes, and bottom plates out of the trayline area.
3. According to the USDA Food Code 2017, 4-501.18, Warewashing Equipment, Clean Solutions, failure to maintain clean wash, rinse, and sanitizing solutions adversely affects the warewashing operation. Equipment and utensils may not be sanitized, resulting in subsequent contamination of food.
Review of the Product Technical Fact Sheet for the chlorine test papers showed the shelf-life of the test strip is two years from the date of manufacture when stored properly in the original packaging.
According to https://www.preclaboratories.com/knowledge-base/knowledge-base-general-questions/, under Knowledge Based General Questions, the test strips have a minimum shelf-life of two years when stored and handled correctly. In reality, the strips are stable for much longer. We have experienced test strips over 3 years old that still perform to specification. We suggest the test strips be used within one year from the date of opening, given proper storage and handling.
On 11/4/22 at 0930 hours, an observation of sanitation bucket test was conducted with Dietary Aide 1, with the DSS present. Dietary Aide 1 checked the concentration of the sanitizer using a piece of paper strip taken from a container of chlorine test paper. The chlorine test paper container had an expiration date of 9/2022, with no opened date. The DSS verified the chlorine test paper container had expired and no opened date.
4. According to the USDA Food Code 2017, 3-304.14, Wiping Cloths, Use Limitation, cloths in-use for wiping counters and other equipment surfaces shall be held between uses in a chemical sanitizer solution.
According to the USDA Food Code 2017, 4-701.10, Food Contact Surfaces and Utensils, effective sanitization procedures destroy organisms of public health importance that may be present on wiping cloths, food equipment, or utensils after cleaning, or which have been introduced into the rinse solution.
Review of the manufacturer's Safety Information on pH Test Papers/Strips (undated) showed the pH test papers have a shelf life of three years and should be stored dry and protected from sunlight.
According to https://www.microessentiallab.com/help.aspx, under Frequently Asked Question, the shelf life of the pH test paper is three years from the date of manufacture. The color chart is marked with the expiration and lot number for that specific roll. The pH paper will remain accurate until the expiration date listed.
a. On 11/4/22 at 0943 hours, an observation of sanitation bucket test was conducted with Dietary Aide 2, with the DSS present. Dietary Aide 2 checked the concentration of the sanitizer using a paper strip taken from a roll of pH test strips. The pH test strip container had an expiration date of 2/15/21. The DSS verified the pH test strip roll had expired.
b. On 11/4/22 at 0950 hours, an observation of the sanitation bucket test was conducted with Dietary Aide 3, with the DSS present. Dietary Aide 3 checked the concentration of the sanitizer using a paper strip taken from a roll of pH test strips. The pH test strip container had an expiration date of 12/1/17. The DSS verified the pH test strip roll had expired.
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** 2. On 11/1/22 at 0935 hours, 11/3/22 at 1010 hours, and 11/8/22 at 0900 hours, Resident 95 was observed in bed. The outside laye...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 11/1/22 at 0935 hours, 11/3/22 at 1010 hours, and 11/8/22 at 0900 hours, Resident 95 was observed in bed. The outside layer of the bed was observed with multiple torn areas exposing the porous material inside the bed.
Medical record review for Resident 95 was initiated on 11/1/22. Resident 95 was readmitted to the facility on [DATE].
On 11/8/22 at 0910 hours, an observation of Resident 95 and concurrent interview with CNA 5 was conducted. Resident 95 was observed in bed. The outside layer of the bed was observed with multiple torn areas exposing the porous material inside the bed. CNA 5 verified the above findings. CNA 5 stated the tears on the low air loss mattress happened not too long ago. CNA 5 stated she told the charge nurse but could not remember the name of the charge nurse. CNA 5 stated the housekeeping staff cleaned the bed, but she had to call them to clean the bed.
On 11/8/22 at 0929 hours, an observation of Resident 95 and concurrent interview with LVN 15 was conducted. Resident 95 was observed in bed. The outside layer of the bed was observed with multiple torn areas exposing the porous material inside the bed. LVN 15 verified the above findings.
On 11/8/22 at 0958 hours, an observation of Resident 95 and concurrent interview with the Central Supply was conducted. Resident 95 was observed in bed. The outside layer of the bed was observed with multiple torn area exposing the porous material inside the bed. The Central Supply verified the above findings. The Central Supply stated he was responsible in calling the mattress company for bed replacement. The Central Supply stated Resident 95's mattress should not be a concern because the mattress still worked.
On 11/8/22 at 1003 hours, an observation of Resident 95 and concurrent interview with LVN 16 was conducted. Resident 95 was observed in bed. The outside layer of the bed was observed with multiple torn areas exposing the porous material inside the bed. LVN 16 verified the above findings. LVN 16 stated anyone who came in contact with the residents on low air loss mattress were responsible to check the mattress.
On 11/8/22 at 1009 hours, an observation of Resident 95 and concurrent interview with the Maintenance Director was conducted. Resident 95 was observed in bed. The outside layer of the bed was observed with multiple torn areas exposing the porous material inside the bed. The Maintenance Director verified the above findings. The Maintenance Director stated the housekeeping was responsible to deep clean the residents' rooms including the mattress cleaning. The Maintenance Director stated the bed was checked last month and it was not reported the mattress was torn.
Review of the Monthly Bed Checklist dated 10/3/22, showed Resident 95's bed including the motor, remote control, side rails, mattress, and brakes were checked and coded 4 which meant ok.
On 11/9/22 at 0954 hours, a follow-up interview and concurrent medical record review was conducted with LVN 15. When LVN 15 was asked how they ensured the torn surface of low air loss mattress was properly cleaned and sanitized, LVN 15 stated the low air loss mattress needed to be replaced immediately because it could not be properly cleaned.
Based on interview, facility document review, and facility P&P review, the facility failed to implement their infection control program in accordance with the facility's P&P.
* The facility failed to implement their infection control surveillance program for the months of January 2022 through September 2022. The facility conducted surveillance of the resident infections based on whether the residents were prescribed the antimicrobial medications. The facility failed to determine whether the residents who were not prescribed antimicrobial medications met the facility's criteria for infection (utilizing McGeer's Criteria) and thus, failed to include these residents in the facility's infection control surveillance program. This failure posed the risk for not identifying the resident infections and controlling the potential transmission of communicable disease to other residents throughout the facility.
* The facility failed to ensure the low air loss mattress (a mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was free from torn and uncleanable surfaces for one of 33 final sampled residents (Resident 95). This had the potential to cause the growth and spread of bacteria.
Findings:
1. Review of the facility's P&P titled Step-By-Step Surveillance Guide undated, showed all licensed nurses are responsible for participating in the infection control data collection process. On a daily basis, as residents are identified with possible infection events, the licensed nurse identifying the change in the resident's clinical condition must start an assessment sheet (Surveillance Data Collection Form). The IP will oversee this process for accuracy and thoroughness of information collected. Weekly, the IP will review the collected data, individual assessment sheets (if unable to do this on a daily basis) to determine whether the resident's condition is due to community-associated infection (CAI), hospital-associated infection (HAI) or does not meet the criteria category (if criteria for infection according to revised McGeer's Criteria is not met).
Review of the facility's P&P titled Infection Prevention - Surveillance of Infections and Reporting undated, showed it is the policy of the facility to maintain an ongoing system of surveillance, designed to identify possible communicable diseases or infections, to ensure that measures are taken to prevent any potential outbreak. Procedures include, the charge nurse reports any residents displaying any signs/symptoms (of infection) and the nature of the symptoms on the 24 hours report. All potential/actual infections must be treated as a change of condition. An Infection Control Surveillance Log is maintained by the IP. Charge nurses will be responsible to record the information of all residents displaying signs and symptoms of suspected infection on the log. The IP/designee will review the log during the morning routine to ensure all potential/actual infections/outbreaks are being identified. This will be accomplished through review of the 24 hour report, telephone orders, and/or change of condition documentation. The IP/designee will trend all validated infections using McGeer's criteria on a monthly basis.
On 11/8/22 at 1024 hours, an interview and concurrent facility document review was conducted with the IP. The IP was asked to describe the facility's infection surveillance P&P. The IP stated the Surveillance Data Collection Forms were initiated for the residents who exhibited signs and symptoms of infection and who were also prescribed the antimicrobial medications. The Surveillance Data Collection Form contained the information specific to McGeer's Criteria. The IP stated she would review the Surveillance Data Collection Form for each resident in the facility, then make a determination as to whether a resident had a community-associated infection (CAI), hospital-associated infection (HAI) (nosocomial infection) or did not meet the McGeer's Criteria (DNMC) for a true infection. The IP stated she then documented this information on the facility's monthly Infection Prevention Control Surveillance Logs (in order to conduct surveillance of resident infections). The IP stated the identification and surveillance of resident infections in the facility was conducted to identify possible communicable diseases or infections, in order to ensure measures were taken to prevent any potential outbreaks.
Review of the facility's Monthly Infection Prevention and Control Surveillance Logs from January 2022 through September 2022 showed the following resident infection surveillance data for HAIs, CAIs and DNMC.
-1/2022, HAI - 29, CAI - 22, and DNMC - 12
-2/2022, HAI - 21, CAI - 42, and DNMC - 14
-3/2022, HAI - 26, CAI - 6, and DNMC - 16
-4/2022, HAI - 12, CAI - 22, and DNMC - 5
-5/2022, HAI - 25, CAI - 32, and DNMC - 15
-6/2022, HAI - 14, CAI 29, and DNMC -12
-7/2022, HAI - 23, CAI 36, and DNMC 15.
-8/2022, HAI - 19, CAI - 37, and DNMC 14
-9/2022, HAI - 14, CAI - 45, and DNMC 26
Further review of the facility's monthly Infection Prevention Control Surveillance Logs from January 2022 through September 2022 showed documentation that all residents determined to have either an HAI, CAI, or DNMC, were also prescribed antimicrobial medications.
The IP was asked, when the residents in the facility exhibited signs and symptoms of infection and were not prescribed the antimicrobial medication, if the facility made a determination as to whether the resident's condition met the criteria for a CAI, HAI, or DNMC; and if the residents who met McGeer's Criteria (who were not prescribed antimicrobial medication) were also included in the facility's infection surveillance program (for the months of January 2022 through September 2022). The IP stated the facility conducted surveillance of the resident infections based on whether the residents were prescribed the antimicrobial medications. The IP stated the facility failed to determine whether the residents who were not prescribed antimicrobial medications met the facility's criteria for infection (utilizing McGeer's Criteria) and thus, failed to include these residents in the facility's infection control surveillance program (from January 2022 through September 2022).
The IP was asked how many residents in the facility had infections (met McGeer's criteria) and were not prescribed antimicrobial medications (from January 2022 through September 2022). The IP stated she was unable to make that determination.
Jun 2019
20 deficiencies
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** 2. Medical record review for Resident 111 was initiated on 6/9/19. Resident 111 was originally admitted on [DATE], and readmitte...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 111 was initiated on 6/9/19. Resident 111 was originally admitted on [DATE], and readmitted on [DATE]. Resident 111 did not speak or understand English.
Review of Resident 111's History and Physical Examination dated 4/26/19 showed the resident did not have the capacity to understand and make decisions.
Review of the Activity Annual Evaluation dated 3/1/19, showed Resident 111 had a communication board with her and a telephone line in case the resident was unable to make their needs known.
On 6/11/19 at 0852 hours, an observation and concurrent interview was conducted with CNA 4. CNA 4 was asked how she communicated with Resident 111. CNA 4 stated she knew some words and used hand gestures to communicate with Resident 111. CNA 4 was asked to ask Resident 111 if they were cold. CNA 4 stated she did not know how to translate the question in Resident 111's native language. CNA 4 verified the facility did not use any assistive devices to communicate with Resident 111.
On 6/11/19 at 0906 hours, an interview was conducted with Resident 111 using a translator. Resident 111 was asked how they communicated with the staff in the facility. Resident 111 stated she did not understand staff and the staff didn't understand her. Resident 111 was asked if the facility used a communication board or telephone services to communicate to her. Resident 111 stated no.
Based on observation, interview, and medical record review, the facility failed to ensure a communication board (used to communicate basic care needs between nonverbal or non-English speaking residents and the staff) was provided to two of 31 final sampled residents (Residents 50 and 111). This posed the risk for Residents 50 and 111 not being able to communicate their basic care needs.
Findings:
1. On 6/9/19 at 0838 hours, during the initial tour of the facility, an interview was conducted with Family Member 1. Family Member 1 stated Resident 50 spoke her native language and did not speak English. Family Member 1 stated he helped translate if he was at the facility or if he was available by phone. A communication board was not observed at Resident 50's bedside.
Medical record review for Resident 50 was initiated on 6/10/19. Resident 50 was readmitted to the facility on [DATE].
Review of the Social Services Assessment/Evaluation dated 3/4/19, showed Resident 50 had verbalized the need of an interpreter to communicate with a physician or health care staff and her primary language was her native language.
Review of the MDS dated [DATE], showed Resident 50 was cognitively intact.
Review of Resident 50's plan of care showed a care plan problem dated 5/23/19, to address resident-centered care. The interventions included to provide Resident 50 with a communication board.
On 6/11/19 at 0753 hours, an interview was conducted with LVN 5. LVN 5 stated he relied on Resident 50's family to help communicate with the resident. When asked if Resident 50's family was always at the facility, LVN 5 replied no. LVN 5 stated a communication board should be at Resident 50's bedside.
On 6/11/19 at 0757 hours, LVN 5 entered Resident 50's room and informed Resident 50 he was going to look in her bedside drawers for the communication board. Resident 50 looked confused and did not respond. LVN 5 verified Resident 50 did not have a communication board. LVN 5 asked Resident 50 how she was doing. Resident 50 looked confused and stated son, son.
On 6/11/19 at 0800 hours, an interview was conducted with the Activities Supervisor. The Activities Supervisor stated she was responsible for ensuring the residents had a communication board if they needed one. The Activities Supervisor stated she could not find a communication board in Resident 50's native language. The Activities Supervisor stated she relied on Family Member 1 to help translate, but he was not always available.
On 6/11/19 at 0804 hours, an interview was conducted with CNA 7 in Resident 50's room. When asked what language Resident 50 spoke, CNA 7 stated Resident 50 spoke English and Spanish (neither languages are Resident 50's native language). CNA 7 asked Resident 50 how she was doing in English, then again in Spanish. Resident 50 smiled, shook her head, and stated no English. CNA 7 stated she was not aware of the communication board.
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 and interview, the facility failed to provide a comfortable homelike environment for one of 31 final sampled residents (Resident 63).
* Resident 63's cabinet drawers were kept ope...
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Based on observation and interview, the facility failed to provide a comfortable homelike environment for one of 31 final sampled residents (Resident 63).
* Resident 63's cabinet drawers were kept open and the personal hygiene items were not properly arranged in the drawer. This practice negatively affected the resident's well-being.
Findings:
On 6/12/19 at 1021 hours, Resident 63 was observed lying in bed. During an interview with Resident 63, she stated she was paralyzed on her left side. Resident 63 was asked to describe her living conditions in her room. Resident 63 stated she considered her room as her home; however, the staff could not help her in tidying up her room. Resident 63 stated the staff could not even close the drawers of her cabinet. The cabinet across from Resident 63's bed was observed with two open drawers; one each on the top right and top left side of the cabinet. The left drawer extended out about one to two inches and the contents were difficult to identify. The right drawer extended out about four to six inches and contained multiple personal hygiene items not arranged properly in the drawer. A foot rest from a wheelchair was observed on top of the cabinet. Resident 63 stated the foot rest blocked her view of her stuffed animals and plant. Resident 63 stated she felt like she was in a storage room.
On 6/12/19 at 1125 hours, an interview and observation was conducted with LVN 11. LVN 11 acknowledged Resident 63's cabinet drawers were opened. She stated she would follow up with the resident's CNA in keeping the resident's room in order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 106 was initiated on 6/10/19. Resident 106 was readmitted to the facility on [DATE].
Revie...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 106 was initiated on 6/10/19. Resident 106 was readmitted to the facility on [DATE].
Review of Resident 106's MDSs dated 2/6 and 5/9/19, under section B0300 showed resident 106 used a hearing aid or other hearing appliance.
On 6/13/19 at 1134 hours, an interview and concurrent medical record review was conducted with MDS Coordinator 1. MDS Coordinator 1 was unable to locate a hearing consult and stated she was not certain why Resident 106's MDS was coded as using a hearing appliance. The MDS Coordinator 1 verified the assessment was inaccurate. (Cross reference with F685)
Based on interview and medical record review, the facility failed to accurately complete the MDS for two of 31 final sampled residents (Residents 106 and 130).
* The facility failed to accurately code Resident 130 had a fall since admission/entry or reentry to the facility.
* The facility failed to accurately code Resident 106 did not have a hearing aid or other healing appliance.
These failures posed the risk of the residents not receiving an individualized plan of care based on the resident's specific needs.
Findings:
1. Medical record review for Resident 130 was initiated on 6/10/19. Resident 130 was readmitted to the facility on [DATE].
Review of Resident 130's MDS dated [DATE], under fall history showed Resident 130 had no falls since admission/entry or reentry to the facility.
Review of Resident 130's Change in Condition Evaluation dated 5/3/19, showed resident 130 experienced a fall on 5/3/19.
On 6/12/19 at 0945 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator 1. The MDS Coordinator 1 verified Resident 130 had a fall on 5/3/19 and stated the MDS dated [DATE] was not coded accurately.
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 interview and medical record review, the facility failed to ensure the care plans for two of 31 final sampled residents...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the care plans for two of 31 final sampled residents (Residents 59 and 63) were updated to identify and provide for the individual needs of the residents.
* Resident 59's care plan failed to address a care plan problem related to the resident removing a transdermal medication patch.
* Resident 63's care plan failed to include a care plan problem to address the use of an indwelling urinary catheter.
This failure posed the potential of staff not knowing the individual resident's needs to provide resident centered care.
Findings:
1. On 6/10/19 at 1448 hours, resident 59 was observed in her room sleeping in a chair. A round transdermal patch was observed on Resident 59's bedside table. Resident 59 woke up as LVN 4 entered the room. Resident 59 was asked where the patch came from. Resident 59 stated she pulled it off her shoulder. LVN 4 stated the transdermal patch was important for Resident 59's memory.
Medical record review for Resident 59 show Resident 59 was readmitted to the facility on [DATE].
Review of Resident 59's Order Summary Report showed a physician's order dated 3/29/19 for an Exelon (same as rivastigmine) Patch 24 hour 9.5 mg/24 hours transdermally one time a day for dementia.
Review of Resident 59's plan of care showed a care plan problem dated 8/15/16, addressing the risk for impaired cognitive function/dementia or impaired thought processes. The Interventions/Tasks showed to administer medications as ordered. However, the care plan failed to address Resident 59's behavior of removing the medicated transdermal patch.
On 6/11/19 at 1438 hours, an interview was conducted with LVN 4. LVN 4 stated Resident 59 had pulled the transdermal medication patch off about once a week. When asked what alternative might be used to decrease or prevent the Resident 59 from pulling the patch off, LVN stated she could try applying the patch so it was out of the resident's reach. LVN 4 stated the patch had not been placed on Resident 59's back of the shoulder because the resident was usually laying down. During a concurrent medical record review, LVN 4 verified Resident 59's care plan did not address the behavior of removing the transdermal patch.
On 6/17/19 at 1053 hours, a concurrent interview, observation, and medical record review for Resident 59 was conducted with the DSD. Resident 59 was observed with the transdermal patch on the left knee, on top of a pair of blue shorts. After reviewing Resident 59's care plan, the DSD verified the care plan failed to address Resident 59's behavior of removing the transdermal patch.
2. On 6/9/19 0855 hours, during an initial tour, a concurrent observation and interview was conducted with Resident 63. A urinary drainage catheter bag was observed hanging on the resident's bed frame. Resident 63 was asked the reason for having an indwelling urinary catheter. Resident 63 stated she had been using a urinary catheter for a while, since she had surgery to her neck.
Medical record review for Resident 63 was initiated on 6/9/19. Resident 63 was readmitted to the facility on [DATE].
Review of Resident 63's Order Summary Report dated 6/12/19, showed, a physician's order for an indwelling urinary catheter for wound management.
On 6/13/19 at 0815 hours, an interview was conducted with CNA 9. CNA 9 was asked about the use the urinary catheter for Resident 63. CNA 9 stated Resident 63 could not empty her bladder: however, the CNA stated he was not sure if this was the actual reason the resident had a urinary catheter.
Review of Resident 63's plan of care did not show a care plan problem to address Resident 63's use of an indwelling urinary catheter.
On 6/17/19 at 0743 hours, a concurrent interview and medical record review was conducted with LVN 12. LVN 12 verified there was no care plan problem developed to address Resident 63's use of an indwelling urinary catheter.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the comprehensive interdisciplinary plan of care for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the comprehensive interdisciplinary plan of care for one of 31 final sampled residents (Resident 4) was revised to reflect the resident's current care needs and interventions. This posed the risk of not providing Resident 4 with individualized and person-centered care.
Findings:
On 6/9/19 at 1037 hours, during an initial tour, a concurrent observation and interview was conducted with Resident 4. Resident 4 was sitting in a wheelchair at the bedside. A yellow star cardboard was observed hanging below Resident 63's left arm rest of the wheelchair. Resident 63 was asked to explain the yellow star hanging on the left armrest of the wheelchair. Resident 63 stated he fell in the bathroom few months ago. The resident explained his legs felt weak and he lost his balance while getting up from the toilet seat.
Medical record review for Resident 4 was initiated on 6/9/19. Resident 4 was re admitted to the facility on [DATE].
Review of Resident 4's care plan showed a care plan problem dated 12/29/18, addressing the risk for falls. Review of the Interventions/Tasks showed revisions dated 3/27/19, addressing the need for a safe environment: floors free of spills and/or clutter, adequate, glare-free light, a working reachable call light, bed in the low position at night, side rails as ordered, handrails on the walls, and personal items within reach.
On 6/11/19 at 1447 hours, a concurrent interview and facility document review was conducted with the DON. The DON acknowledged the facility's document showed Resident 4 had a fall on 3/25/19, while the resident was in the bathroom. The DON was asked about Resident 4's care plan addressing preventing a fall. The DON stated the interdisciplinary team discussed fall prevention measures for Resident 4. The DON explained the fall prevention measures discussed during the meeting was an OT evaluation. The DON stated Resident 4 had been evaluated by an OT. The DON was asked about the outcome of the OT's evaluation. The DON stated there was no recommendation from the OT. The DON acknowledged Resident 4's plan of care did not show an OT evaluation outcome related to fall prevention measures for Resident 4.
Review of the OT Discharge Summary dates 3/26/19 - 4/22/19, showed Resident 4 showed a baseline assessment dated [DATE], the resident would safely perform toileting tasks using a grab bar and a standard commode with supervised assistance.
On 6/12/19 at 0836 hours, a concurrent interview and record review was conducted with the Rehabilitation Services Director. The Rehabilitation Services Director verified the above findings. The Rehabilitation Services Director stated the use of a grab bar and a standard commode should have been included in Resident 4's plan of care to prevent falls by the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and medical record review, the facility failed to ensure one of 31 (Resident 63) final sampled r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and medical record review, the facility failed to ensure one of 31 (Resident 63) final sampled residents who was unable to carry out activities of daily living received the necessary services to maintain good nutrition. This failure to provide the necessary care posed a risk to the resident's nutritional status and negatively impact the resident's psychosocial well-being.
Findings:
On 6/9/19 at 0859 hours, during an initial tour, a concurrent interview and observation was conducted with Resident 63. Resident 63 was in bed with her left arm was resting on her chest and the head of the bed was elevated. Resident 63 was asked to describe her activities in the facility. Resident 63 stated she was paralyzed on the left side. Resident 63 explained she had surgery to her neck.
On 6/12/19 at 1021 hours, a concurrent interview and observation was conducted with Resident 63. Resident 63 was observed in her bed, A white small cup was on her chest in a tilted position. Resident 63 was holding a spoon with a full-fisted grip, and a small amount of brown thick liquid was observed on the resident's left hand. Resident 63 was asked what she was eating. Resident 63 stated it was ice cream. Resident 63 stated one of the staff served her the ice cream and left her room. Resident 63 stated she could not eat the ice cream by her herself. The resident stated she could not use her left hand to hold the cup and use the right hand to scoop out the ice cream from the cup at the same time.
Medical record review for Resident 63 was initiated on 6/9/19. Resident 63 was initially admitted to the facility on [DATE], and readmitted on [DATE]
Review of Resident 63's History and Physical dated 3/29/19, showed the resident had the capacity to understand and make decisions.
Review of Resident 63's Progress Notes showed an entry dated 12/7/18, by the DSS addressing Resident 63's food preferences. The note showed Resident 63 was agreeable to a snack twice a day between meals, nutritional ice cream.
On 6/13/19 at 0815 hours, an interview was conducted with CNA 9. CNA 9 was asked to describe the care required by Resident 63. CNA 9 stated Resident 63 was totally dependent on care, including eating. CNA 9 stated Resident 63 could not move the left side of her body. CNA 9 was asked to describe how Resident 63 ate. CNA 9 stated Resident 63 could only use the right hand to hold on to items such as silverware and a cup. CNA 9 stated Resident 63 could not use the left hand to hold onto items. CNA 9 was asked if Resident 63 was able to eat ice cream in a cup. CNA 9 stated Resident 63 would not be able to eat the cup of ice cream independently.
Review of Resident 63's Treatment Encounter Notes dated 6/10/19, showed the resident would benefit from OT services including to increase independence with self-feeding.
Review of Resident 63's OT Evaluation and Plan of Treatment dated 6/10/19, showed, the resident had impaired range of motion of the left upper extremity, and impaired strength of both upper extremities.
On 6/13/19 at 1353 hours, a concurrent interview and medical record review was conducted with OT 1. OT 1 was asked to describe the care provided to Resident 63's. OT 1 stated Resident 63 was being treated for improving her ADLs, including feeding. OT 1 stated Resident 63 was having difficulty manipulating eating utensils with her right hand. OT 1 stated Resident 63's left arm was non-functional had had paralysis of the left side of her body. OT 1 stated Resident 63 could not eat independently; she needed assistance from the staff to eat.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure sennosides (stimulant laxative...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure sennosides (stimulant laxative medication) was held as per the physician's order, when the resident had episodes of loose stool, for one nonsampled resident (Resident 52). This had the potential to cause Resident 52 to have additional episodes of loose stool/diarrhea.
Findings:
Medical record review for Resident 52 was initiated on 6/12/19. Resident 52 was admitted to the facility on [DATE].
Review of the Order Summary Report showed a physician's order dated 9/13/18, for sennosides 8.6 mg by mouth twice a day for bowel maintenance. The physician's order showed to hold the sennosides for loose stools.
Review of the Medication Administration Record for May 2019 and June 2019 showed sennosides 8.6 mg was administered orally to Resident 52 at 0900 hours on 5/20, 5/21, 5/27, and 6/4/19, and at 1700 hours on 6/9/19.
Review of the Documentation Survey Report for May 2019 and Point Click Care Response History for June 2019 (used to document the consistency of Resident 52's bowel movements) showed Resident 52's most recent bowel movement was loose stool/diarrhea, prior to the administration of sennosides 8.6 mg at 0900 hours on 5/20, 5/21, 5/27, and 6/4 and at 1700 hours on 6/9.
On 6/12/19 at 1457 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 verified the findings and stated the sennosides should have been held.
Review of the Medication Administration Record for April 2019 showed sennosides 8.6 mg was administered to Resident 52 at 0900 hours on 4/3, 4/14, and at 1700 hours on 4/7, 4/17, and 4/24/19.
Review of the Documentation Survey Report for April 2019 showed documentation Resident 52's most recent bowel movement was loose stool/diarrhea, prior to the administration of sennosides 8.6 mg at 0900 hours on 4/3, 4/14, and at 1700 hours on 4/7, 4/17, and 4/24/19.
On 6/13/19 at 1150 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 verified the findings and stated the sennosides should have been held.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to assist one of 31 final sampled residents (Res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to assist one of 31 final sampled residents (Resident 106) with a hearing device to facilitate better communication. This had the potential to impede Resident 106 in maintaining and/or achieving independent function, dignity, and made Resident 106 feel lousy.
Findings:
On 6/10/19 at 1232 hours, an attempt was made to interview Resident 106. During the attempted interview, Resident 106 repeatedly asked the speaker to repeat what they said. Resident 106 was asked if he had a hearing aid. Resident 106 answered No. When asked if he would like a hearing aid, Resident 106 answered Yes.
On 6/10/18, medical record review was initiated for Resident 106. Resident 106 was admitted to the facility on [DATE], and readmitted to the facility on [DATE].
Review of the MDSs dated 5/9/19, and 2/6/19, showed Resident 106 was assessed as having a hearing aid or other hearing appliance used while at the facility.
On 6/10/19 at 1358 hours, on observation was conducted with LVN 13 and Resident 106. Resident 106 was heard telling LVN 13 multiple times to repeat her self because Resident 106 could not hear what was being said.
On 6/11/19 at 1450 hours, an interview was conducted with LVN 4. LVN 4 stated Resident 106 was heard of hearing and they had to speak to him slowly.
On 6/12/19 at 1017 hours, an interview and concurrent medical record review was conducted with the SSA. The SSA stated she documented on 5/7/19 at 1516 hours, staff reached out to Family Member 3 regarding a hearing consult, and Family Member 3 stated the resident had hearing aids but did not like to wear them, so the family took them home. When asked if Resident 106 would like a hearing aid or assistive hearing device, the SSA stated No.
On 6/17/18 at 1010 hours, an interview was conducted with resident 106. When asked about his hearing, Resident 106 stated he could not hear people, It makes me feel lousy. Resident 106 stated he would like someone to make an appointment for him for a hearing aid. Resident 106 stated, Sometime I just look at people and smile and laugh when I can't understand what they are saying because I can't hear them.
On 6/17/19 at 1043 hours, an interview was conducted with CNA 10. CNA 10 stated Resident 106 had a very hard time hearing and it has gotten worse. CNA 10 stated sometimes he just laughs and shakes his head.
On 6/18/19 at 0954 hours, a telephone interview was conducted with Family Member 3. Family Member 3 stated Resident 106 never had a hearing aid in the facility; his hearing had been pretty bad for several years. Family Member 3 stated someone from the facility contacted him about an auditory consult for hearing earlier this year. Family Member 3 told the facility staff member the V.A. issued a hearing aid to resident 106 about seven years ago, but he didn't use them very often. It may have been resident 106 forgot to put them in. Family Member 3 stated he told the staff during the conversation Resident 106 seemed to do better with a pocket talker (device with headphones used to amplify surrounding sounds).
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** Based on observation, interview, and medical record review, the facility failed to ensure the environment was free from accident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the environment was free from accident hazards for two of 31 final sampled residents (Residents 15 and 53).
* The facility failed to ensure Resident 53 was accurately assessed and failed to implement bilateral floor mats as ordered by the physician and recommended by the IDT after Resident 53 sustained a fall.
* The facility failed to ensure a caution sign was placed in a high traffic area to alert residents, staff, and visitors of the wet floors.
* The facility failed to ensure the staff did not leave Resident 15 unattended in the bathroom. Resident 15 was left unattended in the bathroom, which resulted in a fall.
These failures posed the risk for injury to the residents, staff, and visitors.
Findings:
1a. On 6/9/19 at 0920 hours, during the initial tour of the facility, Resident 53 was observed lying in bed. Floor mats were observed folded and tucked in between Resident 53's bed and the nightstand.
On 6/9/19 at 1250, 1457, and 1618 hours, Resident 53 was observed lying in bed with a floor mat in place on the right side of the bed. A floor mat was not observed in place on the left side of the bed. The floor mat was observed folded and tucked in between Resident 53's bed and the nightstand.
Medical record review for Resident 53 was initiated on 6/10/19. Resident 53 was readmitted to the facility on [DATE].
Review of the Progress Notes showed a nursing entry dated 5/29/19, showing Resident 53 was found on the floor holding on to the privacy curtains at the bedside.
Review of the Order Summary Report showed a physician's order dated 5/29/19, to have bilateral floor mats in place.
Review of Resident 53's plan of care showed a care plan problem dated 5/29/19, to address an actual fall related to poor balance and poor comprehension. The interventions included to have bilateral floor mats in place.
On 6/10/19 at 0747 hours, Resident 53 was observed lying in bed. A floor mat was not observed in place on the left side of the bed. The floor mat was observed folded and tucked in between Resident 53's bed and the nightstand.
On 6/10/19 at 0927 hours, an interview was conducted with CNA 8. CNA 8 stated Resident 53 was supposed to have bilateral floor mats in place. CNA 8 verified Resident 53's floor mat on the left side of the bed was not in place earlier in the morning when she started her shift.
On 6/10/19 at 1425 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 stated the IDT recommended to have bilateral floor mats in place after Resident 53 sustained a fall to prevent injuries should the resident have another fall.
b. Review of the Fall Risk Evaluation dated 5/29/19, completed after Resident 53 sustained a fall, inaccurately showed Resident 53 had no falls in the past three months.
On 6/10/19 at 1425 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 stated a Fall Risk Evaluation was completed annually, quarterly, and after each fall. LVN 5 verified the Fall Risk Evaluation dated 5/29/19, was inaccurate and did not include Resident 53's fall from that day. When asked if omitting the fall from the Fall Risk Evaluation could change the Fall Risk Score and category (low, moderate, or high risk for falls), LVN 5 stated yes.
On 6/10/19 at 1454 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the Fall Risk Evaluation conducted after the resident sustained a fall should include all falls within the past three months, including the most current fall that prompted the post fall evaluation.
2. On 6/9/19 at 1607 hours, the floor across from Room A and by Station 3's nurses' station was observed wet. The air conditioning vent on the ceiling directly above the wet floor was observed with condensation on the vent and was actively leaking fluid onto the floor. LVN 3 was observed wiping the wet floor and stated she would notify the maintenance department. LVN 3 left the area without placing a caution sign to alert the residents, other staff, and visitors of the wet floors, as fluid was still leaking from the air conditioning vent.
On 6/9/19 at 1611 hours, the Maintenance Supervisor arrived and placed a chair under the air conditioning vent and stood on the chair to wipe the outside of the air conditioning vent. The Maintenance Supervisor stated he needed to go to the roof to check the air conditioning unit. The Maintenance Supervisor left the area without placing a caution sign and without asking another staff member to place a caution sign to warn of the wet floors. Resident 32 was observed ambulating in the hallway with the wet floors and a second resident was observed self-propelling himself in his wheelchair in the same hallway.
On 6/9/19 at 1634 hours, an interview was conducted with LVN 3. LVN 3 verified fluid was still leaking from the air conditioning vent and the floor below it was wet. LVN 3 was asked how the facility alerted the residents, staff, and visitors of the wet floors to minimize falls. LVN 3 stated the staff was supposed to notify housekeeping to place the caution sign up.
3. Medical record review for Resident 15 was initiated on 6/9/19. Resident 15 was readmitted to the facility on [DATE] with diagnoses including a history of falling.
Review of Resident 15's Fall Risk Evaluation dated 2/12/19, showed Resident 15 was at high risk for falls.
Review of Resident 15's MDS dated [DATE], showed Resident 15 required one person's extensive assistance for toileting (how resident uses the toilet room including transfer on/off toilet).
Review of Resident 15's Change in Condition Evaluation dated 3/25/19, showed Resident 15 had a fall in the facility on 3/25/19.
Review of Resident 15's Progress Note dated 3/26/19 at 1407 hours, showed the Fall Committee IDT met to discuss Resident 15's above fall. On 3/25/19 around 1600 hours, Resident 15 was assisted to the toilet by a CNA. The CNA then left Resident 15 unattended on the toilet, resulting in Resident 15 attempting to get up on her own, losing her balance, and falling.
On 6/12/19 at 1027 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 15 fell on 3/25/19, and stated the CNA left the resident on the toilet unsupervised. When asked if Resident 15 should have been left alone on the toilet, the DON stated no, Resident 15 was at high risk for falls and should not have been left alone. The DON stated Resident 15 had a history of getting up unassisted.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to provide necessary services to restore as much normal bladde...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to provide necessary services to restore as much normal bladder and bowel function as possible for one of 31 final sampled residents (Residents 3). This posed the risk for further decline in the resident's bladder and bowel function.
Findings:
Review of the CMS 672 Resident Census and Conditions of Residents form completed by the DON and dated 6/9/19 showed; 110 of the 158 residents in the facility were occasionally or frequently incontinent of bladder, 96 of the 110 residents were occasionally or frequently incontinent of bowel, and there were no residents on a urinary and bowel toileting program.
On 6/10/19 at 0910 hours, during an initial tour of the facility, a concurrent interview and observation was conducted with Resident 3. Resident 3 was in bed and responded appropriately when greeted by his name. Resident 3 was asked to describe his bladder and bowel pattern. Resident 3 stated he had been using incontinence briefs for urination and bowel movements.
Review of Resident 3's medical record was initiated on 6/10/19. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE].
On 6/12/19 at 1426 hours, a follow-up interview was conducted with Resident 3. Resident 3 was asked if he could use the bathroom for urination and bowel movements. Resident 3 stated he could use the bathroom for urination and bowel movements; however, the resident stated he was not able to go to the bathroom by himself. Resident 3 was asked if the staff had offered to take him to the bathroom to urinate and to have bowel movements. Resident 3 stated the staff had not recently offered to take him to the bathroom. The resident stated he was offered to use the bathroom a couple of times since he was admitted to the facility. Resident 3 explained he would prefer to use the bathroom to urinate and to have a bowel movement.
Review of Resident 3's MDS dated [DATE], showed the resident was cognitively intact.
Review of Resident 3's plan of care showed a care plan problem was initiated on 5/1/19, for ADL Self Care Performance deficit including toilet use. However, the plan of care did not show an intervention addressing the resident's deficit for toilet use.
On 6/13/19 at 0840 hours, an interview was conducted with CNA 10. CNA 10 acknowledged she was familiar with the care and needs of Resident 3. CNA 10 was asked to describe Resident 3's performance with bladder and bowel movements. CNA 10 stated Resident 3 was incontinent of bowel and bladder. CNA 10 was asked if she had offered to take Resident 3 to the bathroom. CNA 10 stated she never offered to take Resident 3 to the bathroom. CNA 10 stated Resident 3 used incontinence briefs for urination and bowel movements.
On 6/17/19 at 0907 hours, a concurrent interview and medical record review was conducted with MDS Coordinator 2. MDS Coordinator 2 was asked when Resident 3 was evaluated for toileting program. MDS Coordinator 2 stated the recent bowel and bladder evaluation for Resident 3 was performed on 4/5/19, and 4/30/19.
Review of the Bowel and Bladder Evaluation form dated 4/5 and 4/30/19, showed the resident had occasional bowel and bladder incontinence, and the resident was likely a candidate for a bowel and bladder re-training program.
MDS Coordinator 2 was asked if a toileting program was implemented based on the bowel and bladder evaluation performed as described above. MDS Coordinator 2 stated a three-day voiding pattern task was initiated on 4/30/19. MDS Coordinator 2 stated a three-day voiding pattern was a trial for a bladder retraining program. MDS Coordinator 2 was asked what the outcome of the three-day voiding pattern was. MDS Coordinator 2 failed to show documentation of the three-day voiding pattern outcome. MDS Coordinator 2 stated the licensed nurses should had followed up on the outcome of the three-day voiding pattern. MDS Coordinator 2 stated the outcome of the three-day voiding pattern would guide licensed nurses to reassess Resident 3 for a bladder retraining program. MDS Coordinator 2 was asked if Resident 3 was offered a bowel retraining program based on the bowel and bladder evaluation performed as described above. MDS Coordinator 2 stated she was not sure if a bowel retraining program for Resident 3 was implemented.
On 6/17/19 at 0948 hours, a telephone interview was conducted with Family Member 2. Family Member 2 was asked if the facility had offered Resident 3 bladder and bowel retraining. Family member 2 stated bowel and bladder retraining was not offered to Resident 3 until a few days ago.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to at...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to attain or maintain the highest physical well-being for two of 31 final sampled residents (Residents 53 and 505) who required dialysis.
* The facility failed to ensure the medications scheduled to be administered to Residents 53 and 505 the days the residents had dialysis treatments had physicians' orders to be held or were rescheduled.
* The facility failed to ensure the staff did not obtain Resident 53's blood pressure on the right arm per the physician's order.
These failures posed the risk for Residents 53 and 505 not being provided with appropriate care and treatment.
Findings:
1a. On 6/10/19 at 1346 hours, Resident 53 was not observed in her room.
On 6/10/19 at 1347 hours, LVN 8 stated Resident 53 was at her dialysis appointment. LVN 8 stated Resident 53 had dialysis on Mondays, Wednesdays, and Fridays. LVN 8 stated Resident 53 was just picked up for her dialysis appointment and usually returned to the facility before 1900 hours.
Medical record review for Resident 53 was initiated on 6/10/19. Resident 53 was readmitted to the facility on [DATE].
Review of the Order Summary Report showed the following physician's orders dated 5/17/19:
- Dialysis every Monday, Wednesday, and Friday with a chair time of 1430 hours (pickup time by the ambulance was 1345 hours),
- Administer one tablet of metoprolol (blood pressure medication) 25 mg two times a day at 0900 and 1700 hours,
- Administer one tablet of ascorbic acid (vitamin C) 500 mg two times a day at 0900 and 1700 hours,
- Administer one tablet of hydralazine (blood pressure medication) 25 mg three times a day at 0900, 1300, and, 1700 hours, and
- Administer insulin (diabetes medication) regular human solution 100 units/ml per the sliding scale at 0630, 1130, and 1630 hours.
Review of the Order Summary Report did not show an order to hold Resident 53's medications on dialysis days.
Review of the Medication Administration Records dated May and June 2019 showed the following medications were held and not administered to Resident 53:
- metoprolol 25 mg at 1700 hours on dialysis days,
- ascorbic acid 500 mg at 1700 hours on dialysis days,
- hydralazine 25 mg at 1700 hours on dialysis days, and
- insulin regular human solution 100 units/ml per the sliding scale at 1630 hours on dialysis days.
On 6/11/19 at 1525 hours, an interview was conducted with the Pharmacy Consultant. The Pharmacy Consultant stated medications could not be held without a physician's order. The Pharmacy Consultant stated Resident 53's medications scheduled to be administered during the dialysis appointments should have been communicated to the physician so the medication administration schedule could have been adjusted or to obtain a physician's order to hold the medications.
On 6/12/19 at 0815 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 verified there was no physician's order to hold Resident 53's medications on dialysis days. LVN 5 verified there was no documentation to show the physician was notified Resident 53 was routinely out of the facility three days a week when the medications were ordered to be administered. LVN 5 stated he needed to clarify with the physician to determine whether Resident 53's medications needed to be held during the dialysis appointments or be rescheduled.
b. Review of the Order Summary Report showed a physician's order dated 5/18/19, showing Resident 53 had a non-tunneled central line catheter to the right upper chest used for dialysis access. The order also showed not to obtain the blood pressure on Resident 53's right arm.
On 6/12/19 at 0833 hours, a medication administration observation for Resident 53 was conducted with LVN 10. Prior to the medication administration, LVN 10 stated she was going to check Resident 53's blood pressure. LVN 10 was observed obtaining Resident 53's blood pressure on the right arm.
On 6/12/19 at 0903 hours, an interview was conducted with LVN 10. LVN 10 stated Resident 53 had a central line catheter to the right upper chest used for dialysis access. LVN 10 verified she obtained Resident 53's blood pressure on the right arm, but was not supposed to obtain the blood pressure on Resident 53's right arm to avoid causing complications to the central line catheter.
2. Medical record review for Resident 505 was initiated on 6/12/19. Resident 505 was admitted to the facility on [DATE], with diagnoses including acute kidney failure (a condition in which the kidneys cannot get rid of waste products from the blood), requiring dialysis.
Review of Resident 505's Order Summary Report showed a physician's orders for dialysis every Tuesday, Thursday, and Saturday with a chair time of 0600 hours. Resident 505's dialysis communication forms showed the resident was out of the facility for dialysis between 0445 and 1119 hours.
Review of Resident 505's Medication Administration Records for 5/30/19, showed for 0900 hours, the following medications were not administered as ordered: amlodipine, chlortalidone, clonidine, metoprolol (medications to treat high blood pressure), and aspirin (antiplatelet medication to reduce the risk of heart attack).
Review of Resident 505's Medication Administration Records for 6/6/19, and 6/11/19, for 0900 hours showed the following medications were not administered as ordered: amlodipine, chlortalidone, clonidine, metoprolol, and aspirin. The Medication Administration Record for the date 6/11/19 at 0900 hours showed Rena Vite (a dietary supplement for people with end stage renal disease), and zinc sulfate (dietary supplement).
On 6/12/19 at 1015 hours, an interview was conducted with LVN 1 regarding the medications not administered as ordered on 5/30, 6/6, and 6/11/19, for 0900 hours. LVN 1 stated the medications were not administered to Resident 505 because the resident was out of the facility for dialysis treatments. LVN 1 stated she did not notify the physician to obtain an order to hold the medications on dialysis days, or to adjust the time for medication administration on dialysis days.
On 6/12/19 at 1030 hours, an interview was conducted with RN 2. RN 2 verified there was no order to hold the medications on the days Resident 505 was out of the facility for dialysis.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 6/9/19 at 1122 hours, Resident 50 was observed in bed with bilateral side rails elevated by the head of the bed.
Medical r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 6/9/19 at 1122 hours, Resident 50 was observed in bed with bilateral side rails elevated by the head of the bed.
Medical record review for Resident 50 was initiated on 6/10/19. Resident 50 was readmitted to the facility on [DATE].
Review of Resident 50's medical record failed to show documentation alternatives were attempted prior to the use of the elevated side rails.
On 6/10/19 at 1357 hours and on 6/13/19 at 0932 hours, Resident 50 was observed in bed with bilateral side rails elevated by the head of the bed.
On 6/13/19 at 0953 hours, an interview and concurrent medical record review was conducted with the ADON. Review of the Bed Rail Safety assessment dated [DATE], and review of Resident 50's medical record failed to show documentation alternatives were attempted prior to the use of the elevated side rails. The ADON verified the above findings and stated the facility did not always attempt alternatives prior to using the elevated side rails and did not document the alternatives attempted.
Based on observation, interview, and medical record review, the facility failed to ensure one of 31 final sampled residents (Resident 50) and one nonsampled resident (Resident 406) remained free from accident hazards due to the use of side rails.
* The facility failed to attempt alternatives prior to the use of side rails for Residents 50 and 406. This had the potential to place the residents at risk for entrapment and serious injury.
Findings:
The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail itself. Inappropriate positioning or other care related activities could contribute to the risk of entrapment.
1. Medical record review for Resident 406 was initiated on 6/9/19. Resident 406 was admitted to the facility on [DATE].
Review of Resident 406's Order Summary Report showed a physician's order dated 6/9/19, for elevated side rails to aid in bed mobility.
Review of a care plan problem dated 6/9/19, titled Potential for Injury/Entrapment related to side rail used showed a goal to minimize the risk of injuries and entrapment related to side rail use.
On 6/13/19 at 0855 hours, an observation was conducted of Resident 406. Resident 405 was observed transferring out of bed. Resident 406's bed was observed with bilateral side rails elevated at the middle of the bed extending to the head of the bed.
On 6/17/19 at 0932 hours, an observation was conducted of Resident 406. Resident 406 was observed lying in bed watching television. Resident 406's bed was observed with bilateral side rails elevated at the middle of the bed extending to the head of the bed.
Review of Resident 406's medical record failed to show alternatives to side rails were attempted prior to the use of side rails.
On 6/13/19 at 0932 hours, an interview was conducted with RN 2. RN 2 stated Resident 406 used the side rails as an enabler. RN 2 verified alternatives prior to the use of side rails were not attempted for Resident 406.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
2. On 6/13/19 at 0933 hours, an interview and concurrent narcotic reconciliation was conducted with the DON. Review of Resident 455's Narcotic and Antibiotic Drug Record showed 24 tablets of lorazepam...
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2. On 6/13/19 at 0933 hours, an interview and concurrent narcotic reconciliation was conducted with the DON. Review of Resident 455's Narcotic and Antibiotic Drug Record showed 24 tablets of lorazepam 0.5 mg (antianxiety) were left, and 23 tablets were disposed of on 3/24/19. The DON stated she could not explain one dose of lorazepam missing. The DON verified the finding.
Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide pharmaceutical services to one of 31 final sampled residents (Resident 60) and one nonsampled resident (Resident 455) to assure the accurate administration, reconciliation, and disposition of all drugs to meet the needs of the residents. This had the potential for drug diversion for Residents 60 and 455.
* The facility failed to remove a Norco (controlled pain medication) bubble pack (a card where medications are placed in individual, clear, and sealed bubbles) for Resident 60 from the medication cart after the medication was discontinued by the physician. A licensed nurse removed a Norco tablet from the bubble pack after the medication had been discontinued and failed to document the disposition of the medication.
* The facility failed to ensure the accuracy of the disposition and reconciliation of all controlled medication for Resident 455.
Findings:
1. Review of the facility's P&P titled Controlled Medication Storage dated 09/10 showed any discrepancy in controlled medications counts is reported to the DON immediately. The DON investigates and makes every reasonable effort to reconcile all reported discrepancies.
On 6/17/19 at 1050 hours, an inspection of Medication Cart 1 was conducted with LVN 7.
Inspection of Medication Cart 1 showed Resident 60's bubble pack for Norco 5-325 mg contained 10 tablets. Review of the label on the bubble pack showed to administer one tablet by mouth every six hours as needed for pain management.
Review of Resident 60's Controlled Drug Record for Norco 5-325 mg tablets, showed one Norco 5-325 mg tablet was obtained by LVN 9 on 5/28/19 at 0900 hours.
Review of Resident 60's medical record showed the physician discontinued Resident 60's order for Norco 5-325 mg tablets on 4/6/19.
Review of Resident 60's medical record failed to show documentation a Norco 5-325 mg tablet was administered to Resident 60 on 5/28/19 at 0900 hours, or documentation a Norco 5-325 mg tablet was wasted by licensed nursing personnel on 5/28/19 at 0900 hours.
LVN 7 verified the findings. LVN 7 stated, per the facility's practice, when the physician discontinued Resident 60's order for Norco 5-325 mg, the medication should have been removed from Medication Cart 1 and given to the DON for disposition.
On 6/17/19 at 1354 hours, an interview was conducted with the DON. The DON stated the facility's practice of removing discontinued controlled medications from the medication cart was to prevent the possibility of administering discontinued medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 6/12/19 at 0833 hours, a medication administration observation for Resident 53 was conducted with LVN 10. LVN 10 administe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 6/12/19 at 0833 hours, a medication administration observation for Resident 53 was conducted with LVN 10. LVN 10 administered the following medications to Resident 53:
- one tablet of ascorbic acid 500 mg,
- one tablet of aspirin 81 mg,
- one tablet of zinc sulfate 220 mg,
- one tablet of multivitamins with minerals,
- one tablet of hydralazine 25 mg, and
- one tablet of metoprolol 25 mg.
Review of the Order Details showed the physician ordered one capsule of Culturelle Probiotics one time a day at 0900 hours, but it was not administered to Resident 53.
On 6/12/19 at 1002 hours, an interview was conducted with LVN 10. LVN 10 verified she did not administer the Culturelle Probiotics to Resident 53. LVN 10 stated she did not see the orders earlier.
Based on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 7.69%. Two of three licensed nurses (LVNs 4 and 10) were found to have made errors during the medication administration observations.
* Resident 52 had a physician's order for sennosides (stimulant laxative medication); however, LVN 4 administered Senna-S, a combination medication containing sennosides and docusate sodium (stool softener medication). This failure had the potential to cause Resident 52 to have loose stools/diarrhea.
* LVN 10 failed to administer one of Resident 53's medications as ordered by the physician.
These failures had the potential to negatively affect the residents' health.
Findings:
1. On 6/12/19 at 0929 hours, a medication administration observation for Resident 52 was conducted with LVN 4. LVN 4 prepared and administered Resident 52's medications, which included one tablet of Senna-S (sennosides 8.6 mg and docusate sodium 50 mg).
Medical record review for Resident 52 was initiated on 6/12/19. Resident 52 was admitted to the facility on [DATE].
Review of the Order Summary Report dated 6/12/19, showed a physician's order dated 9/13/18, for sennosides 8.6 mg, give one tablet orally twice a day for bowel maintenance. The physician's order showed to hold the sennosides for loose stools.
On 6/12/19 at 1009 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 verified she administered Senna-S (sennosides 8.6 mg and docusate sodium 50 mg) to Resident 52; however, the physician's order was for sennosides 8.6 mg. LVN 4 verified she administered the incorrect medication and should have administered sennosides 8.6 mg. (cross reference F 684)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to ensure medications and biologics labeled as expired were removed from the general use supply. This posed the risk of residents being administ...
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Based on observation and interview, the facility failed to ensure medications and biologics labeled as expired were removed from the general use supply. This posed the risk of residents being administered these medications and the staff using the biologicals which may have altered effectiveness due to being expired.
Findings:
On 6/11/19 at 0755 hours, an inspection of the medication room on Station 1 was conducted with LVN 2. The following expired medications and biologicals were observed:
- Eight tubes of Xpert Nasopharyngeal Sample Collection Kit for Virus with the expired date of 11/18, and two tubes with expired dates marked 4/19.
- One bag of nasogastric feeding tube formula with expired date marked 2/19.
- One glucometer kit (solutions used to check the accuracy of the machines used to check blood sugar levels) with the expired date marked 12/18.
LVN 2 verified the findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen.
* The facility failed to ensure proper labeling and dating o...
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Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen.
* The facility failed to ensure proper labeling and dating of foods in the kitchen and refrigerator used for residents' foods brought in by visitors.
* The facility failed to ensure proper sanitation of the ice machine.
* The facility failed to ensure kitchen equipment and utensils were clean.
* The facility failed to air dry equipment.
* The facility failed to ensure the desserts were covered while being transported from the meal carts to the residents' rooms.
These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.
Findings:
Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 6/9/19, showed 149 of 158 residents in the facility received food prepared in the kitchen.
1a. Review of the facility's P&P titled Food storage in nursing and resident refrigerators 2011, showed food items without manufacturer expiration, will be labeled and dated by designated facility staff, and will be thrown away after three days.
On 6/9/19 at 0800 hours, an initial tour of the kitchen was conducted with the DSS. While observing the walk in refrigerator, a green produce bag containing two raw potatoes were observed on the resident's food shelf. The DSS stated the bag should have been labeled and dated before the item was placed into the refrigerator.
b. On 6/9/19 at 0830 hours, an observation and concurrent interview was conducted with RN 1. RN 1 was asked to open the refrigerator used to store resident's food brought in by visitors. A bag labeled with a resident's name and dated 6/5/19, was observed containing two plastic trays of deli meat and two plastic trays of cheese. The individual trays were observed undated, unlabeled, and without a manufacturer's expiration date. RN 1 was asked about the residents' food items. RN 1 stated the licensed nurses checked the temperature of the refrigerator and checked the contents of the refrigerator daily. RN 1 stated they kept food in the refrigerator for a week before it was discarded.
2. On 6/11/19 at 1016 hours, an observation and interview was conducted with the Maintenance Director. During the ice machine inspection, a pink substance was removed with a white paper towel from the door of the ice harvester (an area in the machine where ice is made), and black and pink debris was removed with a white paper towel from the edges of the ice harvester. The Maintenance Director was asked about the accumulation of the pinkish black substances on the edges and the cover of the ice making area. The Maintenance Director stated it was normal. The Maintenance Director verified the above findings.
3. According to the USDA Food Code 2017, 4-601.11 Equipment, Food- Contact Surfaces, Nonfood Contact Surface, and Utensils, the food- contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; Nonfood-contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.
According to the USDA Food Code 2017, 4-602.13, Non-Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.
On 6/9/19 at 0800 hours an observation and interview was conducted with the DSS. One scoop was observed with dried food particles on the scoop, and one scoop was observed with a syrup-like substance on its handle.
The DSS verified the above findings and stated they should have been properly cleaned, sanitized, or replaced.
4. According to the USDA Food Code 2017, 4-901.11, Equipment and Utensils, Air-Drying Required, items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms.
Review of the facility's P&P titled Dishwashing procedures (dishmachine) dated 2011 showed all racks of dishes/trays/utensils to air dry. If drying space is not ample for dishes to air dry, use utility carts. Do not rack and stack wet dishes or trays.
On 6/11/19 at 0938 hours, an observation and interview was conducted with the DSS and Dietary Aide 1. Dietary Aide 1 was observer removing 10 heat keeper bases from the dishwasher and stacking them onto the table. Dietary Aide 1 was also observed removing 10 plates from the dishwasher, and stacking the plates into the plate warmers on top of each other. When the plates and bases were lifted, they were wet. The DSS stated they should have been air dried before stacking.
5. On 6/9/19 at 1230 hours, CNA 1 was observed taking a lunch tray from Station 3' s meal cart and delivering the tray to a resident's room. The slice of pie on the tray was uncovered in the hallway, as it was transported from the cart to the resident's room.
On 6/9/19 at 1233 hours, Station 3's meal cart was observed with eight lunch trays with slices of pies uncovered.
On 6/9/19 at 1240 hours, Station 2's meal cart was observed with one lunch tray, unpassed, with the slice of pie uncovered.
On 6/9/19 at 1241 hours, Station 4's meal cart was observed with 10 lunch trays, unpassed, with the slices of pie uncovered.
On 6/9/19 at 1245 hours, CNA 3 was observed taking two lunch trays with slices of uncovered pie from Station 4's meal cart, down the hallway, and to the residents' rooms.
On 6/9/19 at 1236 hours, an interview was conducted with CNA 2. CNA 2 stated the desserts were usually covered with plastic, and were supposed to have been covered.
On 6/9/19 at 1237 hours, an interview was conducted with LVN 1. LVN 1 stated the desserts were supposed to be covered with plastic.
On 6/10/19 at 1350 hours, an interview was conducted with the DSS and the RD Consultant. The DSS and RD Consultant stated desserts served in a plastic dessert bowl were covered with lids. Desserts that did not fit in a plastic bowl, such as slices of pie, were to be placed in Styrofoam bowls covered with cellophane or Saran wrap. The RD Consultant verified the desserts should have been covered.
CONCERN
(D)
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 medical record review, the facility failed to ensure the medical record was accurately documented for two...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the medical record was accurately documented for two of 31 final sampled residents (Residents 130 and 505) and two nonsampled residents (Residents 12 and 139).
* The facility failed to accurately complete Resident 130's fall risk evaluation after the resident had a fall. This failure had the potential of Resident 130 not receiving necessary precautions to prevent further falls.
* The facility failed to obtain a signed statement from the physician to show she was the only one who had the signature stamp to use for signing the residents' records. This failure had the potential for unauthorized use of the physician's signature stamp.
Findings:
1. Medical record review for Resident 130 was initiated on 6/10/19. Resident 130 was readmitted to the facility on [DATE].
Review of Resident 130's Change in Condition Evaluation dated 5/3/19, showed Resident 130 fell in the facility on 5/3/19.
Review of Resident 130's Fall Risk Evaluations dated 5/3/19, and 5/16/19, showed Resident 130 had no falls in the past three months.
On 6/12/19 at 1007 hours, an interview and concurrent medical record review was conducted with the DON. The DON was asked when fall risk evaluations were completed. The DON stated fall risk evaluations were completed upon admission and after a fall. The DON stated the purpose of the fall risk evaluation was to assess if the resident was at risk for falls. The DON verified the fall risk evaluations dated 5/3/19, and 5/16/19, were not accurate, and should have shown Resident 130 had one to two falls in the past three months. When asked the risk of an inaccurate fall evaluation, the DON stated other staff might not be aware of the resident's risk for falls.
2. Medical record reviews were initiated on 6/12/19, for Residents 12, 139, and 505. Review of the medical records showed a stamped signature was used by the physician to sign the residents' medical records.
On 6/12/19 at 1430 hours, an interview was conducted with the Administrator. The Administrator stated he was not aware of a signature stamp used by the physician to sign the residents' medical records. The Administrator verified there was no signed statement on file, from the physician, to inform the facility she was the only one who had the signature stamp to sign the residents' medical records. The facility did not have a policy and procedure in place regarding the use of signature stamps.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and facility used product manufacturer recommendations, the facility failed to ensure the appropriate infection control practices designed to help prevent the developm...
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Based on observation, interview, and facility used product manufacturer recommendations, the facility failed to ensure the appropriate infection control practices designed to help prevent the development and transmission of infections were implemented for one of 31 final sampled residents (Resident 106). This failure had the potential to result in the transmission of disease-causing microorganisms.
Findings:
Review of the facilities P&P titled Infection Control Prevention and Control Practices dated 9/17 showed aseptic practices are to be followed by personnel performing procedures and disinfecting equipment.
Review of the facility's cleaning product labeled Sani-Cloth Bleach, showed under the section: to clean, disinfect, and deodorize: treated surface must remain visibly wet for four (4) minutes.
On 6/10/19 at 1358 hours, a concurrent observation and interview was conducted with LVN 13. LVN 13 was observed to remove a white cloth like substance and proceeded to wipe down a bed side table with it. LVN 13 identified the cloth like substance as a Sani-Cloth Bleach wipe. At 1400 hours, LVN 13 was observed placing a paper drape over the table and began setting up supplies for a dressing change procedure. LVN 13 stated the wet time for the bleach wipe was 3-5 minutes. When asked if LVN 13 knew how long the bedside table had been wet from the bleach, LVN 13 stated it had been about two minutes.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. On 6/10/19 at 1002 hours, a resident group interview was conducted with residents 3, 8, 29, 44, 57, 69, 107, and 115. When as...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. On 6/10/19 at 1002 hours, a resident group interview was conducted with residents 3, 8, 29, 44, 57, 69, 107, and 115. When asked about getting their call lights answered, all the residents stated they waited anywhere between one to three hours for a staff member to answer a call light. The residents explained this wait occurred on all shifts. The residents stated, during this one to three-hours time frame, they had to sit in urine and feces while they waited for assistance. The residents stated staff came to their rooms and turned off the call light without providing the assistance the resident needed. Resident 69 stated staff sometimes came into the room and assisted the roommate in bed A, who asked for something; however, that resident may not have been the one who activated the call light. Resident 107 stated sometimes the staff turned off the call light and said they will be right back, but do not return.
7. On 6/11/19 at 1019 hours, an observation and interview was conducted with resident 16. Resident 16 explained there were times when they waited up to an hour for staff to respond once the call light button was pressed. Resident 16 stated they had to wait over an hour when calling for pain medication or to be cleaned up. Resident 16 stated, sometimes they needed to be changed and had to just lay in their mess (resident clarified fecal incontinence) for a while before staff came to provide care. Resident 16 stated they sometimes called for pain medication and it took staff a long time. Resident 16 stated they felt neglected, and it made them feel very angry, .they don't understand what it's like. Resident 16 stated they looked at the clock in front of their bed; that was how they knew how long it took the staff to answer the call light.
On 6/13/19 at 0952 hours, an interview was conducted with the Administrator. The Administrated stated, when a resident turns on their call light, the call light system activates a light over the resident's doorway and at the nurses' station on the call light board. The call light system also activates a repeated dinging sound until it is deactivated by someone entering the resident's room and deactivates the light. The Administrator stated the staff was to answer call lights within 10 minutes.
During this interview and a concurrent review of the recorded security surveillance camera dated 6/4/19, between 0731 hours and 0754 hours, staff was observed walking past resident 16's room, with the call light activated, more than 15 times during the course of 22 minutes before responding to the activated call light. Review of the recorded security surveillance camera dated 6/8/19 between 0627 hours and 0703 hours, Resident 16's call light was confirmed to be activated for 35 minutes before staff arrived at resident 16's room. The Administrator confirmed the above findings.
On 6/17/19 at 1029 hours, an interview was conducted with CNA 6. CNA 6 stated Resident 16 was incontinent of bowel and could not get out of bed on his own. CNA 6 stated Resident 16 was totally dependent on staff for care.
5. On 6/9/19 at 0920 hours, during the initial tour of the facility, an interview was conducted with Resident 84. When asked about the care she received at the facility, Resident 84 stated there were times when the staff did not answer her call light, or the staff would enter the room to turn off the call light and not provide the care she needed. Resident 84 stated approximately two weeks ago, towards the end of May, she pressed her call light button so she could be changed, but the staff did not answer the call light for approximately two to three hours. Resident 84 stated she was left sitting in urine and feces for two to three hours making, her feel ashamed, dirty, and embarrassed. Resident 84 stated she kept track of the time by using her cellphone and by looking at the clock across from her bed. Resident 84 stated she was in tears by the time the staff answered her call light.
Medical record review for Resident 84 was initiated on 6/10/19. Resident 84 was readmitted to the facility on [DATE].
Review of Resident 84's MDS dated [DATE], showed Resident 84 was cognitively intact and required extensive assistance from two or more staff members for bed mobility, dressing, and toilet use (including how the resident cleaned herself or was cleaned after eliminating).
Review of Resident 84's plan of care showed a care plan problem dated 6/10/19, to address the risk for urinary tract infections. The interventions included to provide good hygiene practices, clean the perineal area well after each bowel movement, and to provide clean underwear.
Review of the Nurse Call Activity Report showed the following call light activities for Resident 84's room:
- On 5/23/19 at 2312 hours, the call duration (the amount of time it took the staff to answer the call light) was 37 minutes.
- 5/24/19 at 1403 hours, the call duration was 1 hour and 44 minutes.
- 5/24/19 at 2301 hours, the call duration was 1 hour and 32 minutes.
- 5/25/19 at 1317 hours, the call duration was 52 minutes. The call light was answered or turned off at 1410 hours, but at 1411 hours, the call light was activated with a call duration of 46 minutes.
- 5/25/19 at 1501 hours, the call duration was 1 hour and 7 minutes.
- 5/25/19 at 1704 hours, the call duration was 1 hour and 27 minutes.
- 5/25/19 at 1906 hours, the call duration was 1 hour and 48 minutes.
- 5/25/19 at 2157 hours, the call duration was 1 hour and 50 minutes.
- 5/26/19 at 0849 hours, the call duration was 59 minutes.
- 5/26/19 at 1037 hours, the call duration was 1 hour and 19 minutes.
- 5/26/19 at 1403 hours, the call duration was 2 hours and 29 minutes.
- 5/27/19 at 1102 hours, the call duration was 54 minutes.
- 5/27/19 at 1529 hours, the call duration was 59 minutes.
- 5/27/19 at 1726 hours, the call duration was 2 hours and 12 minutes.
- 5/27/19 at 2050 hours, the call duration was 1 hour and 1 minute.
- 5/27/19 at 2220 hours, the call duration was 1 hour and 37 minutes, and on
- 5/28/19 at 0318 hours, the call duration was 1 hour and 44 minutes.
On 6/12/19 at 1017 hours, a follow-up interview was conducted with Resident 84. Resident 84 stated she had a stroke and could not walk or care for herself. Resident 84 stated sometimes when it took too long for the staff to answer her call light, she would call the facility using her cellphone and would ask the receptionist to call for help.
On 6/12/19 at 1029 hours, an interview was conducted with CNA 5. CNA 5 stated Resident 84 was incontinent and required assistance with ADL care. CNA 5 stated Resident 84 was able to make her needs known. CNA 5 stated when the resident pushed the call light button, the light above the resident's door and a light went on at the call light panel at the nurses' station. CNA 5 was asked if she was providing care for a resident, would she know if another resident's call light was on. CNA 5 replied no, she would have to rely on someone being at the nurses' station or in the hallway to see the call light. CNA 5 stated the licensed nurses sometimes helped answer the call lights and informed the CNAs what the resident needed.
On 6/12/19 at 1036 hours, an interview was conducted with Receptionist 1. Receptionist 1 stated part of her duties included to answer the incoming calls. Receptionist 1 was asked if she ever received calls from the residents residing at the facility. Receptionist 1 replied yes, and stated some residents called for help if their call light was not answered. Receptionist 1 stated she notified the staff by calling the nurses' station.
2. On 6/9/19/ 0855 hours, during the initial tour of the facility, an interview was conducted with Resident 63. Resident was asked to describe the care she received in the facility. Resident 63 stated staff took a while to answer her call light. Resident 63 stated she needed assistance, including changing her incontinence brief and repositioning in bed; however, Resident 63 stated she had to wait approximately 45 minutes to one hour before staff answered her call light. Resident 63 stated she was not able to move her left side. Resident 63 stated she was frustrated not receiving assistance from the staff in a timely manner.
Medical record review for Resident 63 was initiated 6/9/19. Resident 63 was readmitted to the facility on [DATE].
Review of Resident 63's History and Physical dated 3/29/19, showed Resident 63 had the capacity to understand and make decisions.
Review of Resident 63's plan of care showed a care plan problem dated 6/9/19, addressing ADL self-care performance deficit related to left hemiparesis (weakness).
Review of the Nurse Call Activity Report for Resident 63's room showed the following call light activities, for example:
- On 5/2/19 at 2137 hours, the call duration (the amount of time it took the staff to answer the call light) was 22 minutes;
- On 5/3/19 at 1747 hours, the call duration was 23 minutes;
- On 5/4/19 at 1029 hours, the call duration was 22 minutes;
- On 5/4/19 at 1503 hours, the call duration was 1 hour and 6 minutes;
- On 5/5/19 at 0905 hours, the call duration was 41 minutes;
- On 5/5/19 at 1053 hours, the call duration was 46 minutes;
- On 5/9/19 at 0646 hours, the call duration was 39 minutes;
- On 5/9/19 at 0946 hours, the call duration was 55 minutes;
- On 5/30/19 at 1023 hours, the call duration was 25 minutes;
- On 5/30/19 at 2107 hours, the call duration was 26 minutes;
- On 6/1/19 at 2146 hours, the call duration was 39 minutes;
- On 6/4/19 at 1456 hours, the call duration was 24 minutes;
- On 6/9/19 at 0538 hours, the call duration was 40 minutes.
On 6/13/19 at 0815 hours, an interview was conducted with CNA 9. CNA 9 was asked to describe the care he provided to resident 63. CNA 9 stated Resident 63 was totally dependent for all care. CNA 9 stated Resident 63 needed assistance with transfers, dressing, and eating. CNA 9 stated Resident 63 could not move the left side of her body.
On 6/13/19 at 0952 hours, a concurrent interview, facility record review and review of the recorded security surveillance camera was conducted with the Administrator. The Administrator was asked to describe how the staff responded when a resident's call light was activated. The Administrator stated all of the staff was responsible for answering a residents' call lights. The Administrator stated staff should respond to a resident's call light within 10 minutes, and the staff should keep the call light turned on if the assistance was not provided to the resident. The Administrator verified if a call light was activated by a resident, a light would turn on outside the resident's room and on the call light board located in the nurses' station. An audible sound can be heard within the unit when the call light was activated by the resident. The Administrator verified the call light could only be turned off in the resident's room.
During a concurrent review of the recorded video camera and the Nurse Call Activity Report for Room C, for example, the report showed on 5/30/19 at 1023 hours, the call light was activated and at 1049 hours, the call light was answered. A video camera was located in the hallway with the view of the entrance to Room C. On the date and time documented on the Nurse Call Activity Report for Room C, the recorded surveillance video camera footage showed multiple staff walking by Room C, and a staff parked a medication cart right outside of Room C. At approximately 1049 hours, staff entered Room C (an approximate 25 minutes response time). These findings were acknowledged by the Administrator.
3. On 6/9/19 at 0910 hours, during the initial tour of the facility, an interview was conducted with Resident 3. Resident 3 was asked to describe the care she received in the facility. Resident 3 stated there were times he felt frustrated with his care, especially when he needed staff to change his incontinence brief. Resident 3 stated the staff took a while to respond to his call light. Resident 3 stated he had to sit in a wet and dirty incontinence brief; he felt a burning sensation on the skin of his private area.
Medical record review for Resident 3 was initiated 6/9/19. Resident 3 was readmitted to the facility on [DATE].
Review of Resident 3's MDS dated [DATE], showed the resident was cognitively intact. Resident 3 required extensive assistance with toilet use and personal hygiene.
Review of Resident 3's plan of care showed a care plan problem dated 6/9/19, addressing ADL self-care performance deficit.
Review of the Nurse Call Activity Report for Resident 3's room showed the following call light activities:
- On 5/2/19 at 1923 hours, the call duration was 15 minutes;
- On 5/2/19 at 1943 hours, the call duration was 16 minutes;
- On 5/3/19 at 0701 hours, the call duration was 31 minutes;
- On 5/5/19 at 2108 hours, the call duration was 34 minutes;
- On 5/6/19 at 1904 hours, the call duration was 38 minutes;
- On 5/6/19 at 2306 hours, the call duration was 29 minutes;
- On 6/2/19 at 1743 hours, the call duration was 18 minutes;
- On 6/8/19 at 1803 hours, the call duration was 14 minutes.
On 6/12/19 at 1426 hours, a follow-up interview was conducted with Resident 3. Resident 3 stated he was not receiving consistent care. Resident 3 stated sometimes the staff responded to his call light and provided assistance in a timely manner; however, there were times he had to wait for a while for staff to respond to his call light. Resident 3 stated he kept track with the time using his watch. Resident 3 stated he had to call Family Member 2 to contact the staff at the facility to answer his call light.
On 6/13/19 at 0840 hours, an interview was conducted with CNA 10. CNA 10 was asked to describe the care he provided to Resident 3. CNA 10 stated Resident 3 needed assistance with his ADLs, particularly when his incontinence brief was dirty, and the resident was dependent when transferring in and out of his bed. CNA 10 explained Resident 3 used his call light when the resident needed help from the staff.
On 6/13/19 at 0952 hours, a concurrent interview, facility record review, and review of the recorded security surveillance camera was conducted with the Administrator. During the review of the recorded video camera and the Nurse Call Activity Report for Room with the Administrator, for example; the report showed on 6/2/19 at 1743 hours, the call light to Room D was activated, and at 1801 hours, the call light was answered. A video camera was located in the hallway with a view of the entrance to Room D. During the date and time described above, the recorded video camera footage showed there was facility staff who walked by Room D without stopping at Room D. At approximately 1801 hours, a staff member entered Room D (an approximate 18 minutes of response time), and the staff came out carrying a meal tray. These findings were acknowledged by the Administrator.
On 6/17/19 at 1011 hours, a telephone interview was conducted with Family Member 2. Family Member 2 acknowledged Resident 3 called her on a Sunday night; however, she did not remember the date when the resident made the call. Family Member 2 stated Resident 3 informed her he was wet, and the staff was not answering his call light. Family Member 2 contacted the facility after speaking to Resident 3, and the family member spoke to staff and requested to check on the resident
4. On 6/9/19 0837 hours, during the initial tour of the facility, an interview was conducted with Resident 17. Resident 17 was asked to describe the care he received in the facility. Resident 17 stated the staff did not respond to his call light in a timely manner. Resident 17 stated there were times he did not get additional food items he wanted from the kitchen because the staff took forever to answer his call light. Resident 17 stated this made him frustrated and angry. Resident 17 stated he was able to keep track of the time waiting for staff to answer his call light by pointing at the clock mounted on the wall across from his bed. The digital clock had a font about 10 - 12 inches in height.
Medical record review for Resident 17 was initiated 6/9/18. Resident 17 was readmitted to the facility on [DATE].
Review of Resident 17's History and Physical dated 1/16/19, showed the resident had the capacity to understand and make decisions.
On 6/10/19 at 1412 hours, an interview was conducted with CNA 11. CNA 11 was ask to describe the care provided to Resident 17. CNA 11 stated he assisted changing Resident 17's incontinence brief, transferring the resident in and out of bed, helping the resident put on his clothes, and getting extra food items from the kitchen as requested by the resident. CNA 11 stated Resident 17 used his call light when he needed assistance.
Review of the Nurse Call Activity Report for Resident 17's room (Room E) showed the following call light activities:
- On 5/18/19 at 0830 hours, the call duration was approximately 27 minutes;
- On 5/19/19 at 0547 hours, the call duration was approximately 20 minutes;
- On 5/20/19 at 2040 hours, the call duration was approximately 23 minutes;
- On 5/23/19 at 1925 hours, the call duration was approximately 22 minutes;
- On 5/19/19 at 2049 hours, the call duration was approximately 29 minutes;
- On 5/25/19 at 1228 hours, the call duration was approximately 21 minutes.
Based on observation, interview, medical record review, and facility document review, the facility failed to promote dignity and respect by failing to answer resident call lights in a timely manner for seven of 31 final sampled residents (Residents 3, 4, 16, 17, 63, 84, and 405) and seven nonsampled residents (Residents 8, 29, 44, 57, 69, 107, and 115) which resulted in residents feeling demeaned, frustrated, ashamed, neglected, angry, and embarrassed. The residents were housed in different resident rooms located throughout the facility.
Findings:
1. Medical record review for Resident 405 was initiated on 6/9/19. Resident 405 was admitted to the facility on [DATE].
On 6/10/19 at 1630 hours, an observation and interview was conducted with Resident 405. A bed pan was observed adjacent to Resident 405's bed. Resident 405 stated the bed pan used to be stored in his cabinet; however, when he needed to have a bowel movement it took the CNAs too long to answer his call light, therefore, he kept the bed pan at the bedside. Resident 405 stated he was admitted to the facility on [DATE], and on two occasions he soiled himself because it took approximately 30 minutes for the CNAs to answer his call light. Resident 405 stated he used the clock on the wall in his room to determine the call light response time. Resident 405 stated the first incident took place in the evening a couple of days after his admission to the facility, and the second incident took place in the evening several days thereafter. Resident 405 stated he felt demeaned and felt it was not his fault he needed assistance.
Review of the Nurse Call Activity Report for Room B (Resident 405's room) showed the following call light information; date of call, time of call, time answered, and call duration:
- On 6/6/19, the time of call showed 2351 hours, and on 6/7/19 the time answered showed 0022 hours (call duration showed 31 minutes and 33 seconds).
- On 6/9/19, the time of call showed 1947 hours, and on 6/9/19, the time answered showed 2019 hours (call duration showed 31 minutes and 31 seconds).
On 6/11/19 at 1429 hours, an observation, interview, and facility record review, was conducted with the Administrator. The facility had video cameras located throughout the facility. The Administrator stated the facility video cameras stored two weeks of footage available for review. A video camera was located in the hallway with a view of the entrance to Room B.
Review of video footage for the entrance to Room B showed the following staff response times, after the call light was activated in Room B:
- On 6/6/19 at approximately 2351 hours, a call light in Room B was activated and on 6/7/19 at 0022 hours, staff entered Room B (an approximate 31 minute response time).
- On 6/9/19 at 1947 hours, a call light in Room B was activated and at 2015 hours, staff entered Room B (an approximate 27 minute response time).
The Administrator verified the findings and stated the facility P&P for call light response times was to answer resident call lights within a reasonable amount of time (up to ten minutes).
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0577
(Tag F0577)
Minor procedural issue · This affected multiple residents
Based on interview, the facility failed to ensure four nonsampled residents (Residents 8, 44, 69, and 57) and one of 31 final sampled residents (Resident 3) were aware of the location and results of t...
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Based on interview, the facility failed to ensure four nonsampled residents (Residents 8, 44, 69, and 57) and one of 31 final sampled residents (Resident 3) were aware of the location and results of the facility's most recent survey results. This had the potential of residents not being informed of the State survey findings and showing the plans of correction the facility was to implement to correct the concerns identified during the most recent surveys.
Findings:
On 6/10/19 at 1002 hours, a group resident interview was conducted with residents 3, 8, 29, 44, 57, 69, 107, and 115. The residents were asked if they knew the location of the most recent survey without having to ask staff. Five of the eight residents responded, No. Two of the five residents stated they have attended resident council meetings before.
On 6/12/18 at 1047 hours, an interview was conducted with the Activities Director. The Activities Director stated residents who do not attend resident council would be told were the survey binder was only if they asked.
On 6/12/19 at 1101 hours, an interview was conducted with the Admissions Assistant. When asked if they provided information to newly admitted residents regarding the location of the most recent survey results, the Admissions Assistant stated they had never been told specifically to tell the residents about the survey binder. The Admissions Assistant state she was not sure who was responsible for telling the residents about the survey binder.
On 6/12/18 at 1514 hours, an interview was conducted with the Administrator. The Administrator stated they were not sure who was to inform the residents about the survey binder and was not aware of a time, other than during admission, when the residents would be told.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most California facilities.
- • 24% annual turnover. Excellent stability, 24 points below California's 48% average. Staff who stay learn residents' needs.
Concerns
- • 96 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 65/100. Visit in person and ask pointed questions.
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About This Facility
What is Sea Cliff Healthcare Center's CMS Rating?
CMS assigns SEA CLIFF HEALTHCARE CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within California, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Sea Cliff Healthcare Center Staffed?
CMS rates SEA CLIFF HEALTHCARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 24%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Sea Cliff Healthcare Center?
State health inspectors documented 96 deficiencies at SEA CLIFF HEALTHCARE CENTER during 2019 to 2025. These included: 89 with potential for harm and 7 minor or isolated issues. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.
Who Owns and Operates Sea Cliff Healthcare Center?
SEA CLIFF HEALTHCARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by THE ENSIGN GROUP, a chain that manages multiple nursing homes. With 182 certified beds and approximately 167 residents (about 92% occupancy), it is a mid-sized facility located in HUNTINGTON BEACH, California.
How Does Sea Cliff Healthcare Center Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, SEA CLIFF HEALTHCARE CENTER's overall rating (3 stars) is below the state average of 3.1, staff turnover (24%) is significantly lower than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Sea Cliff Healthcare Center?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Sea Cliff Healthcare Center Safe?
Based on CMS inspection data, SEA CLIFF HEALTHCARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in California. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Sea Cliff Healthcare Center Stick Around?
Staff at SEA CLIFF HEALTHCARE CENTER tend to stick around. With a turnover rate of 24%, the facility is 21 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.
Was Sea Cliff Healthcare Center Ever Fined?
SEA CLIFF HEALTHCARE CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Sea Cliff Healthcare Center on Any Federal Watch List?
SEA CLIFF HEALTHCARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.