COUNTRY MANOR HEALTHCARE
For profit - Limited Liability company
99 Beds
CHARIS TRUST DTD 12/22/16
Data: November 2025
Trust Grade
56/100
#559 of 1155 in CA
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Photo by Margo Bronstein (PurpleTink007)
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Last Inspection: November 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Country Manor Healthcare in Lake View Terrace, California has a Trust Grade of C, which means it is average and in the middle of the pack compared to other facilities. It ranks #559 out of 1155 facilities in California, placing it in the top half, and #100 out of 369 in Los Angeles County, indicating that only a few local options are better. The facility is improving, with the number of issues dropping from 25 in 2024 to just 1 in 2025, which is a positive trend. Staffing is a strong point, earning a 5/5 star rating with a turnover rate of 28%, well below the state average, suggesting that staff are experienced and familiar with residents. However, the facility has faced some serious concerns, including a failure to provide adequate supervision for a resident who subsequently suffered an acute fracture, and issues related to the use of physical restraints without proper consent, which raises significant red flags about resident safety and care.
- Trust Score
- C
- In California
- #559/1155
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ✓ Good
- 28% annual turnover. Excellent stability, 20 points below California's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- $8,018 in fines. Lower than most California facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 42 minutes of Registered Nurse (RN) attention daily — more than average for California. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 61 deficiencies on record. Higher than average. Multiple issues found across inspections.
56/100
Top 48%
Needs review
25 → 1 violations
★★★☆☆
3.0
Overall Rating
★★★★★
5.0
Staff Levels
☆☆☆☆☆
0.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 25 issues
2025: 1 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
Low Staff Turnover (28%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (28%)
20 points below California average of 48%
Facility shows strength in staffing levels, staff retention, fire safety.
The Bad
3-Star Overall Rating
Near California average (3.1)
Meets federal standards, typical of most facilities
Federal Fines: $8,018
Below median ($33,413)
Minor penalties assessed
Chain: CHARIS TRUST DTD 12/22/16
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 61 deficiencies on record
1 actual harm
Jul 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an incident of a physical abuse (deliberately aggressive or ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an incident of a physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1). This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect Resident 1 from further abuse. Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 12/11/2024 and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), schizoaffective disorder bipolar type (a mental illness that can affect thoughts, mood, and behavior), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's History and Physical (H&P), dated 5/14/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 6/7/2025, the MDS indicated Resident 1 had intact cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS further indicated Resident 1 required moderate assistance from staff for upper body dressing and was dependent on staff for toileting hygiene, showers, lower body dressing. During a review of Resident 1's Care Plan (CP), initiated on 7/7/2025, the CP indicated Resident 1 was at risk for injury and emotional distress related to alleged physical abuse by staff. During an interview on 7/21/2025 at 9:15a.m. with Resident 1, Resident 1 stated prior to 6/30/2025 (Resident 1 could not indicate the exact date of the incident), one of the staff members entered the resident's room and pushed Resident 1, who was sitting in his wheelchair into the restroom. Resident 1 further stated he informed the staff member that she was causing him pain, but the staff member continued to push his wheelchair into the restroom while Resident 1 was resisting the transfer by holding the door frame of the restroom door. During an interview on 7/21/2025 at 12:31p.m. with Registered Nurse (RN) 1, RN 1 stated on 7/7/2025, Resident 1 approached RN 1 in the nursing station and reported a staff member knocked him down and pushed his legs intentionally. RN 1 further stated after the abuse report staff members were interviewed as part of facilities internal abuse investigation. During an interview on 7/21/2025 at 1:40p.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated prior to 6/23/2025 (CNA 1 could not indicate the exact date), Resident 1 had informed her that a staff member had pushed him into the restroom causing pain. CNA 1 further stated she did not report the incident. CNA 1 stated pushing a person and causing pain can be considered a potential form of a physical abuse and she should have reported the incident to her supervisor. CNA 1 further stated failure to report the incident could potentially result in Resident 1 experiencing further abuse. During a follow up interview on 7/21/2025 at 3:11p.m. with RN 1, RN 1 stated pushing a person and causing pain was a potential incident of a physical abuse. RN 1 further stated CNA 1 should have reported the incident to the charge nurse and supervision. The RN 1 stated the failure to report the incident had the potential for harm, injury, and further abuse to Resident 1. During an interview on 7/21/2025 at 3:30p.m. with the Administrator, the Administrator stated a report from a resident stating that a person pushed him and caused pain is a potential physical abuse that required investigation. The Administrator stated staff should have reported the incident so the facility could investigate. The Administrator further stated the failure to report the incident on the same day the complaint was made by Resident 1 had the potential for ongoing abuse of Resident 1. During a review of the facility-provided policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, last reviewed on 1/31/202, the P&P indicated, If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to the other officials according to the state law.Physical abuse: Includes, but not limited to hitting, slapping, pinching and kicking.All employees are mandated reporters.
Nov 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0712
(Tag F0712)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the Attending Physician (AP) visited one of three sampled residents (Resident 1) timely.
This deficient practice had the potential t...
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Based on interview and record review, the facility failed to ensure the Attending Physician (AP) visited one of three sampled residents (Resident 1) timely.
This deficient practice had the potential to result in an undetected decline in medical, health or psychosocial condition and can lead to a delay in necessary care, treatment and services.
Findings:
During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 10/25/2019, with diagnoses that included hypertensive (HTN-high blood pressure) chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to filter blood properly.), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and epilepsy (a disorder of the brain characterized by repeated seizures [abnormal electrical activity in your brain that temporarily affects your consciousness, muscle control and behavior].
During a record review of Resident 1's History and Physical (H&P), dated 6/13/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 9/23/2024, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact.
During an interview on 11/25/2024, at 10:21 am with Resident 1, Resident 1 stated he had never seen his AP for a long time.
During a concurrent interview and record review on 11/27/2024, at 3:14 p.m., with Director of Nursing (DON), Resident 1's Physician Nursing Home Visit was reviewed. The Physician Nursing Home Visit indicated the following visits:
1. 5/17/2024- seen by AP.
2. 7/22/2024-seen by Nurse Practitioner (NP)
3. 8/25/2024- seen by NP.
4. 9/20/2024-seen by NP.
5. 10/4/2024- seen by NP.
The DON stated it has been six months since AP last visited Resident 1. The DON stated the NP comes and visit Resident 1 monthly. The DON stated the importance of timely AP visit was to assure Resident 1's health and develop trust with the resident.
During a concurrent interview and record review on 11/27/2024, at 3:29 p.m., with the DON, facility's policy and procedure (PP) titled, Physician Visits, dated 4/2008 and last reviewed on 10/25/2024, the PP indicated, The Attending Physician must visit his or her residents at least once every 30 days for the first 90 days following the resident's admission, and then at least every 60 days thereafter. 2. After the first 90 days, if the Attending Physician determines that a resident need not be seen by him or her every 30 days, an alternate schedule of visits may be established, but not to exceed every 60 days. A physician assistant or nurse practitioner may make alternate visits after the initial 90 days following admission, unless restricted by law or regulation. The DON stated the PP was not followed.
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 F0808
(Tag F0808)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure therapeutic diets (a customized meal plan designed by a healthcare professional to treat a specific medical condition) were served a...
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Based on interview and record review, the facility failed to ensure therapeutic diets (a customized meal plan designed by a healthcare professional to treat a specific medical condition) were served as prescribed by the physician for one of three sampled residents (Resident 2).
This deficient practice can prevent Resident 2 from receiving the benefit of the therapeutic diet.
Findings:
During a record review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 3/4/2024, with diagnoses that included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and essential hypertension (HTN-high blood pressure).
During a record review of Resident 2's History and Physical (H&P), dated 3/5/2024, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions.
During a record review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 9/4/2024, the MDS indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 2 required supervision with eating. The MDS indicated Resident 2 was on therapeutic diet.
During a record review of Resident 2's Physician Order, dated 9/12/2024, the Physician Order indicated controlled carbohydrate diet (carefully monitoring and keeping the amount of carbohydrates you eat each day relatively the same, usually to help manage blood sugar levels, by eating similar portions of carbohydrate rich foods at every meal), regular texture, thin regular liquid consistency, non-fat milk, eight ounces with meals and large portion with all meals.
During a record review of Resident 2's Care Plan related to DM, dated 3/4/2024, the Care Plan indicated an intervention to provide diet as ordered.
During an interview on 11/25/2024, at 9:44 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she (CNA 1) does not inform the charge nurses assigned when Resident 2 requested for a second plate of food because Resident 2 was alert and had a good appetite. CNA 1 stated she (CNA 1) did not know if Resident 2 was diabetic. CNA 1 stated she (CNA 1) should have checked and asked the charge nurse before requesting food in the kitchen.
During an interview on 11/25/2024, at 10:22 a.m., with the Dietary Supervisor (DS), the DS stated Resident 2 will have elevated blood sugar if given extra portion or second plate of food.
During an interview on 11/25/2024, at 10:38 a.m., with Registered Nurse 1 (RN 1), RN 1 stated CNA 1 should notify charge nurses if Resident 2 request extra portion or second plate of food. RN 1 stated Resident 2 had diabetes and if given an extra portion or second plate of food, Resident 2's blood sugar will increase.
During an interview on 11/25/2024, at 11:29 a.m., with the Director of Nursing (DON), the DON stated residents who request extra portion, or second plate of food need to inform the CNAs, then the CNAs would then inform the charge nurse. The DON stated charge nurses would then fill up the Diet Order and Diet Changes form and show it to the kitchen staff. The DON stated Resident 2's blood sugar would be uncontrolled due to extra portion of food.
During a concurrent interview and record review on 11/27/2024, at3:14 p.m., with the DON, the facility's policy and procedure titled, Diet Orders, dated 2023 and last reviewed on 10/25/2024, the PP indicated, Diet orders as prescribed by the Physician will be provided by the Food and Nutrition Services (FNS) Department. Nursing will send a Diet Order Communication slip to the Food and Nutrition Services Department. The FNS Director or [NAME] in charge will make or adjust the diet profile and tray card as prescribed. The diet count is also to be adjusted as needed. The diet profile and tray card will be removed upon discharge or transfer. Any discrepancy in the diet order slip will be clarified by the FNS Director or [NAME] in charge with Nursing. The DON stated it is their policy to follow physician's order.
Nov 2024
21 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0659
(Tag F0659)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure services provided by the facility were provided by qualified persons in accordance with the resident's plan of care fo...
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Based on observation, interview, and record review, the facility failed to ensure services provided by the facility were provided by qualified persons in accordance with the resident's plan of care for one of two sampled residents (Resident 52) investigated under the dignity care area when Activities Assistant (AA) 1 provided hydration to Resident 52.
This failure had the potential to result in Resident 52 aspirating (accidental breathing in of food or fluid into the lungs) during the intake of fluid provided by an unqualified staff member.
Findings:
During a review of Resident 52's admission Record, the admission Record indicated the facility originally admitted Resident 52 on 8/24/2018 and readmitted the resident on 9/8/2020 with diagnoses including dementia (a progressive state of decline in mental abilities) and dependence on wheelchair.
During a review of Resident 52's Minimum Data Set (MDS, a resident assessment tool), dated 8/29/2024, the MDS indicated Resident 52 had short-term and long-term memory problems and severe daily decision-making impairment, and required maximal assistance or was dependent on facility staff for activities of daily living including eating, hygiene, dressing, showering/bathing himself, and surface-to-surface transfers.
During a review of Resident 52's History and Physical (H&P), dated 7/2/2024, the H&P indicated Resident 52 has fluctuating capacity to understand and make informed decisions.
During a review of Resident 52's Order Summary Report, dated 10/12/2023, the Order Summary Report indicated Resident 52 was ordered snacks three times a day for supplements.
During a review of Resident 52's Care Plan titled, [Resident 52] requires assistance with ADL functions secondary to diagnosis: debility, dated 8/24/2018, the Care Plan indicated Resident 52 was dependent on staff to eat. The Care Plan further indicated the position responsible for the intervention are certified nursing assistants (CNA).
During a concurrent observation and interview, on 11/5/2024, at 10:37 a.m., inside the small activity room, AA 1 was standing over Resident 52 while holding a cup next to the resident's face. Resident 52 drank from the cup held by AA 1. AA 1 stated he assists with providing hydration, including thickened liquids, to residents in the activities room.
During an interview with the Director of Staff Development (DSD), on 11/8/2024, at 9:55 a.m., the DSD stated only CNAs and licensed nurses can assist the residents with feeding and/or drinks.
During an interview with the Activity Director (AD), on 11/8/2024, at 12:17 p.m., the AD stated he was not aware that activity staff were not allowed to offer drinks to residents unless they were also a certified nursing assistant.
During a concurrent interview and record review with the Director of Nursing (DON), on 11/8/2024, at 1:52 p.m., Resident 52's Care Plan titled, [Resident 52] requires assistance with ADL functions secondary to diagnosis: debility, dated 8/24/2018, was reviewed and the DON confirmed CNAs were responsible for assisting with feeding. The DON stated it should be the assigned staff according to the care plan that carries out interventions. The DON stated assisting with drinking is included as part of feeding. The DON stated residents in the small activities room have different fluid consistencies with the drinks they are provided. The DON further stated the residents need someone who is trained and qualified to assist the residents with feeding and if the staff is not qualified, there is a potential for the staff to be unaware if the resident is aspirating or not.
During a review of the facility's policy and procedure (P&P) titled, Feeding, Meals, Assisting Residents with, last reviewed 7/19/2024, the P&P indicated each resident receives assistance per individual resident need. The P&P further indicated the responsible discipline are the CNAs.
During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, last reviewed 7/19/2024, the P&P indicated the comprehensive person-centered care plan will identify the professional services that are responsible for each element of care.
During a review of the facility document titled, Job Description: Activities Assistant, dated and signed by AA 1 on 3/3/2022, the facility document indicated essential job duties include following the facility policies and procedures and non-essential duties include observing residents in the dining room as assigned. The facility document did not indicate to feed residents as part of their essential and non-essential duties.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure residents receiving enteral feeding (also known as tube feeding, a method of supplying nutrients directly into the gast...
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Based on observation, interview, and record review the facility failed to ensure residents receiving enteral feeding (also known as tube feeding, a method of supplying nutrients directly into the gastrointestinal tract) received appropriate care and services to prevent complications of enteral feeding for one of one sampled residents (Resident 90) investigated under the tube feeding care area when the facility failed to replace the tubing on the tube feeding set when replacing the resident's tube feeding formula and water flush bag.
This failure had the potential for clogging and harboring bacteria which may result in infection, disrupted delivery of proper nutrition and hydration, and risk for aspiration (happens when food or liquid enters a person's airway by accident when food or liquids come back up from the stomach) if the formula flows improperly.
Findings:
During a review of Resident 90's admission Record, the admission Record indicated the facility originally admitted Resident 90 on 2/22/2024 and readmitted the resident on 9/15/2024 with diagnoses including encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).
During a review of Resident 90's Minimum Data Set (MDS, a resident assessment tool), dated 10/11/2024, the MDS indicated Resident 90 had difficulty understanding and making decisions, required moderate to maximal assistance or was dependent on facility staff for activities of daily living such as eating, hygiene, dressing, showering/bathing, and surface-to-surface transfer, and received tube feeding.
During a review of Resident 90's History and Physical (H&P), dated 9/15/2024, the H&P indicated Resident 90 does not have the capacity to understand and make decisions.
During a review of Resident 90's Order Summary Report, dated 9/15/2024, the Order Summary Report indicated every shift Jevity 1.5 (brand name of a tube feeding formula) at 65 milliliters (ml, a unit of measure for volume) per hour via pump for 20 hours to provide 1300 ml per 1950 kilocalories (kcals, a unit of measurement for energy that is often used in nutrition and exercise) per day, turn pump on at 2 p.m. for 20 hours, may turn pump off for activities of daily living and/or other treatments, and continue feeding until dose limit is met.
During a review of Resident 90's Care Plan titled, Needs tube feeding due to: Impaired swallowing poor oral intake, dated 7/2/2024, the Care Plan indicated to change feeding and tubing as ordered and flush gastrostomy tube with water ordered.
During a concurrent observation and interview with Registered Nurse (RN) 1, on 11/5/2024, at 10:07 a.m., inside Resident 90's room, a container of tube feeding formula, dated 11/4/0224, and timed 6:10 a.m., and a bag containing clear liquid, dated 11/3/2024, and timed 2:00 p.m., hung on a pole next to Resident 90's bed. The tube feeding formula and bag containing clear liquid was attached to tubing that ran through a tube feeding pump and connected to Resident 90's gastrostomy tube. RN 1 stated the tube feeding formula was not changed after 24 hours of being hung and should be changed every 24 hours because the tube feeding formula could potentially expire and cause potential gastrointestinal issues for the resident. RN 1 stated the bag containing clear liquid was water and the bag was not changed after 24 hours of being hung and should be changed every 24 hours to provide fresh water to the resident and prevent potential gastrointestinal problems.
During an interview with RN 5, on 11/8/2024, at 9:14 a.m., RN 5 stated tube feeding formula should be replaced once the ordered dose is completed. RN 5 stated when the tube feeding formula is replaced, the entire tubing set should be changed. RN 5 stated the water bag is part of the tube feeding set and cannot be removed or replaced separately from the tube feeding set. RN 5 stated if a water bag indicated a date two days prior, there is a potential the entire tube feeding set was not replaced when the formula was replaced. RN 5 further stated if the tube feeding set is not replaced when replacing the formula, there is a potential lapse in infection control due to the previously used tubing having residual formula from the previously hung formula.
During an interview with the Director of Nursing (DON), on 11/8/2024, at 1:52 p.m., the DON stated the tube feeding set used by the facility is a closed set and the entire tube feeding set, including the water bag, should be replaced when the formula is replaced to prevent blockages in the tubing and to prevent infection because old tubing can be a potential source for infection.
During a review of facility-provided document titled, [Tube Feeding] Enteral Feeding Pump Instructions for Use, dated 5/2023, the document indicated the tube feeding set should be replaced after 24 hours from initiation of feeding to ensure the pump is operating within specified parameters and prevents bacterial growth that could be a hazard to the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow professional standards of practice for respira...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow professional standards of practice for respiratory care for one of two sampled residents (Resident 13) reviewed under the Respiratory care area by failing to ensure Resident 13 received continuous administration of oxygen as ordered when the resident's oxygen tank (supplemental oxygen) was observed empty.
This deficient practice had the potential to place Resident 13 at risk for respiratory distress.
Findings:
During a review of Resident 13's admission Record (AR), the AR indicated the facility originally admitted the resident on 2/17/2021 and readmitted the resident on 8/22/2024 with diagnoses including sick sinus syndrome (a type of heart rhythm disorder) and chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood), with hypoxia (low levels of oxygen in blood).
During a review of Resident 13's History and Physical (H&P), dated 8/22/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 13's Minimum Data Set (MDS - a federally required assessment tool), dated 8/30/2024, the MDS indicated the resident had the ability to make self understood and understand others. The MDS indicated the resident required assistance from facility staff on activities of daily living including eating, oral hygiene, toileting, bathing, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated the resident received oxygen therapy while a resident in the facility.
During a review of Resident 13's Physician Orders (PO), dated 8/22/2024, the PO indicated the resident with order to administer continuous oxygen at 2 liters per minute (LPM - a unit of measure) via nasal cannula (nasal prongs)/mask to maintain oxygen saturation (amount of oxygen in the blood) above 92 percent (% - one part in every hundred).
During a review of Resident 13's Care Plan (CP) addressing the resident's potentially for ineffective airway clearance, dated 8/23/2024, the CP indicated interventions including to administer medications as ordered and to monitor effectiveness of medications.
During a concurrent observation and interview on 11/6/2024 at 9:10 a.m., inside dining room [ROOM NUMBER], with Registered Nurse 1 (RN 1), RN 1 stated Resident 13's oxygen tank was empty at 0. RN 1 stated she will replace Resident 13's oxygen tank. Observed Resident 13's oxygen setting at 2 liters per minutes (LPM) via nasal cannula.
During an interview on 11/6/2024 at 12:54 p.m., with Registered Nurse 1 (RN 1), RN 1 stated residents with continuous oxygen order are connected to an oxygen tank before leaving their room. RN 1 stated the charge nurses are responsible in checking the oxygen tank so that the resident does not ran out of oxygen. RN 1 stated when oxygen treatment is not given continuously especially to residents who are dependent on oxygen therapy they may show a drop in their oxygen saturation and experience shortness of breath and/or respiratory complications. RN 1 stated the resident should be reassessed and should replace the oxygen tank before it ran out to maintain the resident's oxygen saturation.
During an interview on 11/6/2024 at 1:18 p.m., with the Director of Nursing (DON), the DON stated the resident should not have ran out of oxygen if the order is continuous. The DON stated when the physician order is not followed the resident could potentially drop in their oxygen level and risk for respiratory distress.
During a review of the facility policy and procedure (P&P) titled, Oxygen Therapy, last reviewed 7/19/2024, the P&P indicated it is the policy of the facility that oxygen therapy is administered as ordered by the physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to assess the medical need, evaluate the risks of entrapment (a state in which a person is trapped by the bed rail [also known as...
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Based on observation, interview, and record review the facility failed to assess the medical need, evaluate the risks of entrapment (a state in which a person is trapped by the bed rail [also known as side rails, a type of safety device that can be attached to a bed frame to help prevent falls and provide support for getting in and out of bed] in a position that they cannot move from), and obtain a physician's order and informed consent from the resident or resident representative for one (1) out of 1 sampled resident (Resident 17) investigated under the Accidents care area.
This deficient practice placed the resident at risk for potential accidents such as a body part being caught between the rails; falls if a resident attempts to climb over, around, between, or through the rails; restriction of resident's freedom of movement; decline in physical functioning; psychosocial harm; and death of residents.
Findings:
During a review of Resident 17's admission Record, the admission Record indicated the facility admitted the resident on 3/25/2014 and readmitted in the facility on 5/10/2021 with diagnoses including dementia (a progressive state of decline in mental abilities), abnormalities of gait and mobility, epilepsy (a long-term brain condition where a person has repeated seizures [a sudden uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]).
During a review of Resident 17's History and Physical (H&P) dated 7/19/2024, the H&P indicated the resident did not have the capacity to comprehend and make informed decisions.
During a review of Resident 17's Fall Risk Evaluations, dated 4/11/2024, 7/9/2024, and 10/7/2024, the Fall Risk Evaluations indicated the resident was a high risk for falls due to intermittent confusion and/or forgetfulness, poor vision, and chairbound.
During a review of Resident 17's Care Plan addressing the resident's risk for fall due to possible repeat episodes of seizure, initiated on 11/30/2021 and last revised on 1/16/2024, the Care Plan indicated both upper ¼ side rails up and padded when in bed as one of the interventions to prevent traumatic injuries and manage seizure activity.
During a review of Resident 17s Minimum Data Set (MDS-a resident assessment tool), dated 10/7/2024, the MDS indicated the resident had the ability to usually make self-understood and understand others. The MDS indicated the resident required maximal to total assistance from staff on mobility and activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).
During a review of Resident 17's Physician's Orders, the Physician's Orders dated 10/30/2024 indicated both upper one fourth (1/4 - a unit of measurement) padded side rails up when in bed to aid in mobility and positioning and for seizure precaution.
During a review of Resident 17's informed consent dated 10/30/2024, the informed consent indicated bilateral ¼ siderails up while in bed for mobility and positioning and for seizure precaution.
During a concurrent observation and interview on 11/5/2024 at 10 a.m., inside Resident 17's room with Certified Nursing Assistant 4 (CNA 4), observed Resident 17 asleep in bed with both upper side rails up. CNA 4 stated she thinks the siderails were always used for the resident for safety. CNA 4 stated she was not sure if the siderails were ¼ or one half (1/2 - a unit of measurement). CNA 4 verified there was a gap between the siderails and the mattress and Resident 17's arm can get caught in between and cause injury.
During a concurrent observation and interview on 11/7/2024 at 3:50 p.m., inside Resident 17's room with Registered Nurse 2 (RN 2), RN 2 verified Resident 17 had bilateral siderails up and the current physician's order was bilateral ¼ siderails. RN 2 verified the gap between the siderails and the mattress which can potentially trap Resident 17's arm or any part of the body and cause injury to the resident. RN 2 stated they had bed safety evaluation form but not sure if the evaluation included assessment for risk of entrapment.
During a concurrent observation and interview on 11/8/2024 at 1:30 p.m., inside Resident 17's room with the Director of Nursing (DON), the DON verified Resident 17 had bilateral siderails up and the facility uses only ¼ siderails up as ordered by the physician for resident safety and assists with mobility during ADL care, turning and repositioning, and as a seizure precaution. The DON stated the siderails were fixed attachment on the bed. The DON verified the gap between the mattress and the siderails and it can potentially cause injury when Resident 17's arm or any part of the body gets caught on the gap.
During a follow up concurrent interview and record review on 11/8/2024 at 3:00 p.m., reviewed facility-provided Bed Frame 1 (BF 1) User and Care Manual, Resident 17's physician's orders, informed consent, and bed safety evaluation forms with the DON. The DON stated the user manual indicated BF 1 had photos of the three (3) types of siderails for the bed frame which includes ½ length siderails, 3 position pivoting assist rail, and fixed assist rails. The DON stated based on the previous observation of Resident 17's siderails, Resident 17 had ½ length siderails. The DON stated the facility should have obtained a physician's orders and informed consent from the resident or responsible party indicating the use of bilateral ½ siderails up while in bed instead of ¼ siderails to ensure they were aware of the current plan of care as well as the risks and benefits of the use of ½ length siderails including risk of entrapment. The DON verified the bed safety evaluation forms dated 10/7/2024 and 10/19/2024 did not indicate an assessment for the risk of entrapment and least restrictive measures attempted prior to use of the ½ length siderail. The DON stated the continued use of the ½ length siderails without appropriate assessment resulted in inappropriate use predisposing resident to injury such as entrapment.
During a review of the facility-provided BF 1 User Care and Manual, undated, the manual indicated the following:
-
Use only the proper size mattress that will minimize the gap between the side of the mattress and the side rails. The gap must be small enough to the prevent the patient from getting caught.
-
Always evaluate patients for guard against patient risk of side rail entrapment in accordance with medical protocols. Failure to do so could result in injury and/or death.
During a review of the facility's policy and procedure (P&P) titled, Bed Safety and Bed Rails, last reviewed 7/19/2024, the P&P indicated:
-
Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent:
a.
The assessed medical needs that will be addressed with the use of bed rails.
b.
The resident's risk from the use of bed rails and how these will be mitigated.
c.
The alternatives that were attempted but failed to meet the resident's needs; and
d.
The alternatives that were considered but not attempted and the reasons.
-
Regardless of mattress type, width, length, and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident.
The use of bed rails or side rails is prohibited unless the criteria for use of bed rail rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Residents 22) wa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Residents 22) was free from unnecessary medications by not:
1. Assessing Resident 22's pain level prior to administering Celebrex (a medication referred to as analgesic which is used to decrease pain) on 11/5/2024,
2. Administering Celebrex to Resident 22 daily for a documented pain level of zero (0) (by using a numerical scale used to measure pain with 0 being no pain and 10 being the worst pain) between 11/1/2024 and 11/5/2024, and
3. Following physician orders for non-pharmacological (also known as non-drug, that do not involve medications or drugs) interventions prior to the administration of Celebrex to Resident 22.
As a result, Resident 22 received Celebrex daily between 11/1/2024 and 11/5/2024 against physician order and without adequate assessment and monitoring for pain. This failure had the potential to cause Resident 22 to receive suboptimal (less than the highest standard or quality) care due to not assessing the need and effectiveness of Celebrex, leading to the use of unnecessary medication, potentially increasing the risk of adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) such as gastrointestinal (GI - relating to the stomach) bleeding, pain, diarrhea, vomiting, fever, and nausea, negatively impacting the physical, mental, and psychosocial well-being of Resident 22.
Findings:
During a review of Resident 22's admission Record (a document containing demographic and diagnostic information,) dated 11/5/2024, the admission Record indicated Resident 22 was originally admitted to the facility on [DATE] and readmitted the resident on 10/2/2015 with diagnoses including osteoarthritis (breakdown of bone causing pain and stiffness.)
During a review of Resident 22's Order Summary Report, dated 11/5/2024, the Order Summary report indicated Resident 22 was prescribed the following:
Celebrex 200 milligram ([mg] - a unit of measure of mass) to give one capsule by mouth one time a day for 4 - 6 moderate pain. Give after meals. Chart non-drug intervention/s done as follows: (1) relaxation (2) redirect (3) backrub (4) reposition (5) rest (6) other, prior to Pro Re Nata ([PRN] - as needed) analgesic use. If ineffective give medication as ordered, starting 6/20/2024.
During a review of Resident 22's Medication Administration Record ([MAR] - a record of medications administered to residents) for November 2024, the MAR indicated Resident 22 was prescribed the following:
Celebrex 200 mg to give one capsule by mouth one time a day for 4 - 6 moderate pain. Give after meals. Chart non-drug intervention/s done as follows: (1) relaxation (2) redirect (3) backrub (4) reposition (5) rest (6) other, prior to PRN analgesic use. If ineffective give medication as ordered, daily at 9 a.m. The MAR indicated that between 11/1/2024 and 11/5/2024 Resident 22's pain level was documented zero (0) and Celebrex was administered daily at 9 a.m.
During an observation on 11/5/2024 at 9:33 a.m., in Medication Cart Station 2, Registered Nurse (RN) 3 was observed administering Celebrex 200 mg capsule to Resident 22. Resident 22 was observed swallowing the Celebrex capsule whole with water. RN 3 was observed not asking Resident 22 whether Resident 22 had pain and what the pain level was.
During an interview and concurrent review of Resident 22's MAR on 11/5/2024 11:49 a.m. with RN 3, RN 3 stated that if Resident 22 did not have pain that was moderate between 4 and 6 that Resident 22 should not be administered Celebrex, according to the physician order. RN 3 stated that RN 3 failed to assess Resident 22's pain level and administered Celebrex 200 mg capsule to Resident 22 on 11/5/2024 at 9:33 a.m. without knowing if Resident 22's pain level was moderate between 4 and 6. RN 3 stated that RN 3 administered Celebrex against the physician order, did not follow the directions for non-drug interventions, and documented the MAR that Resident 22 had a pain level of zero (0) on 11/5/2024. RN 3 stated that the MAR indicated that Resident 22 had a pain level of zero (0) and received Celebrex 200 mg every day between 11/1/2024 and 11/5/2024. RN 3 stated that Celebrex could cause GI irritation and Resident 22 may be receiving Celebrex unnecessarily without being assessed and monitored for pain and placed at and increased risk of having adverse effects.
During an interview on 11/7/2024 at 12:57 PM, with the Director of Nursing (DON,) the DON stated that Resident 22 was prescribed Celebrex 200 mg daily for moderate pain between 4 and 6 and when non-drug interventions did not improve the pain. The DON stated if Resident 22 did not have moderate pain between 4 and 6 after non-drug intervention that Resident 22 should not be administered Celebrex. The DON stated that RN 3 failed to assess Resident 22's pain and follow physician orders for non-drug intervention, prior to administering Celebrex 200 mg on 11/5/2024 at 9:30 AM. The DON stated it was unnecessary to administer Celebrex to Resident 22 for pain level of zero (0) or without non-drug interventions or assessment of pain. The DON stated that using Celebrex unnecessarily placed Resident 22 at risk for developing GI adverse effects. The DON stated that licensed nurses should follow facility medication administration guidelines to ensure physician orders are followed and not to place residents at risk of administering unnecessary medications that could result in adverse effects, negatively impacting their health and well-being.
During a review of the facility's policy & procedures (P&P), titled Administering Medications, last reviewed 7/19/2024, the P&P indicated that Medications shall be administered in a safe and timely manner, and as prescribed.
3.
Medications must be administered in accordance with the orders .
8.
The following information must be checked/verified for each resident prior to administering medications:
b.
Vital signs, if necessary.
During a review of the facility's P&P, titled Pain Assessment and Management, last reviewed 7/19/24, the P&P indicated that The purpose of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain.
General Guidelines
6.
Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain .
Steps in Procedure
4.
Ask the resident if he/she is experiencing pain.
Implementing Pain Management Strategies
2. Pharmacological (related to drugs) interventions (i.e. analgesics) may be prescribed to manage pain, however they do not usually address the cause of pain and can have adverse effects on the resident.
6. implement the medication regimen as ordered .
Documentation
1.
Document the resident's reported level of pain with adequate detail.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to store one insulin (medication used to regulate blood s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to store one insulin (medication used to regulate blood sugar levels) Humalog (rapid-acting insulin) vial (a glass bottle that contains the insulin) for Resident 49, in accordance with manufacturer's requirements in one (1) of two (2) inspected medication carts (Medication Cart 3).
This deficient practice increased the risk that Residents 49 could have received insulin that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications resulting in hospitalization or death.
Findings:
During an observation and a concurrent interview on [DATE] at 12:34 p.m., in Medication Cart 3, with Licensed Vocational Nurse 3 (LVN 3), Resident 49's unopened Humalog vial was found stored in a manner contrary to its manufacturer's requirements, and not labeled with an open date as required by its manufacturer's specifications and facility policy and procedures (P&P). Resident 49's unopened Humalog vial was found stored at room temperature without a date indicating when storage or use at room temperature began, with an additional white label affixed to the amber prescription bottle (where the Humalog vial is stored in) indicating to refrigerate. According to the manufacturer's product labeling, unopened Humalog vials should be stored refrigerated between 36 to 46 degrees Fahrenheit (°F - scale for measuring temperature) and if stored at room temperature should be discarded after 28 days. LVN 3 stated that the Humalog vial for Resident 49 was stored at room temperature, not opened, and not labeled with a date indicating when storage at room temperature began. LVN 3 stated the unopened Humalog vial should have been stored in the refrigerator as indicated by the white label affixed to the prescription bottle. LVN 3 stated that multi-dose (containing more than one dose of medication) insulin vials like Humalog needed to be labeled with a date when brought to room temperature to know when to be discarded or needed to be stored in the refrigerator until opened. LVN 3 stated it was unknown when the Humalog vial for Resident 49 was stored at room temperature therefore unknown when it would expire and should be discarded and not to be used in error. LVN 3 stated insulin vials stored at room temperature are usually good for 28 days and lose potency (effectiveness) and sterility (free from contaminants) beyond that date and considered expired. LVN 3 stated administering expired insulin will not be effective in treating residents' blood sugar levels and can harm Resident 49 by causing hyperglycemia (high blood sugar) levels, coma (a life-threatening complication that can result from very high blood sugar or very low blood sugar levels), or potential injection site infections, requiring transfer to a hospital.
During an interview on [DATE] at 12:57 p.m., with the Director of Nursing (DON), the DON stated that the unopened insulin Humalog vial for Resident 49 should be stored in the refrigerator or labeled with a date when it came to storage at room temperate and discarded 28 days later. The DON stated that several licensed nurses failed to refrigerate the unopened Humalog vial for Resident 49 or failed to label the vial with the date when storage at room temperature began. The DON stated without a date labeled on the vial it was unknown when the Humalog vial would expire, which can potentially lead to the administration of expired insulin to Resident 49 leading to medication errors. The DON stated that expired insulin has lost its potency (effectiveness, strength) and administering expired insulin will not be effective in controlling blood sugar levels and can harm Resident 49 by causing hyperglycemia, coma, leading to hospitalization.
During a review of the facility's P&P, titled Storage of Medications, last reviewed [DATE], the P&P indicated:
9. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. All insulin (vials/pens) expire 28 days after opening.
During a review of the facility's P&P titled Medication Storage and Labeling, last reviewed [DATE], the P&P indicated:
1.
Refer to Appendix D for a list of specific medications .with manufacturers' specifications for short expiration dates.
3.
It will be the responsibility of the Nursing Staff to enter the opening date on all manufacturers' labels or blank pharmacy labels.
During a review of the facility-provided guide titled Appendix D - Requirements for Specific Medications and Reagents, [undated], the guide indicated that Humalog insulin expiration opening was 28 days.
During a review of the facility-provided guide titled Insulin Storage Recommendations at Room Temperature, [undated], the guide indicated that Humalog vial stored at room temperature was good for 28 days.
During a review of the facility's P&P, titled Insulin Administration, last reviewed [DATE], the P&P indicated that:
4. Check expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after opening.
During a review of the facility's P&P, titled Administering Medications, last reviewed [DATE], the P&P indicated that:
9. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to maintain documentation of offering advance directive (a legal document indicating resident preference on end-of-life treatment decisions) i...
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Based on interview and record review, the facility failed to maintain documentation of offering advance directive (a legal document indicating resident preference on end-of-life treatment decisions) information to the resident/resident representative and of reviewing the resident's advance directive annually for one of two sampled residents (Resident 86) per facility's policy and procedure (P&P).
This failure had the potential to result in not knowing the resident's wishes regarding end-of-life care and life-sustaining treatments which may lead to unwanted or inappropriate medical interventions.
Findings:
During a review of Resident 86's admission Record, the admission Record indicated the facility admitted the resident on 10/26/2023 with diagnoses including dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and paranoid schizophrenia (a type mental illness that is characterized by disturbances in thought with symptoms of intense feeling of distrust or suspicion towards others).
During a review of Resident 86's History and Physical (H&P) dated 11/1/2023, the H&P indicated the resident had fluctuating capacity to understand and make decisions.
During a review of Resident 86's Minimum Data Set (MDS -a resident assessment tool) dated 9/13/2024, the MDS indicated the resident had the ability to make self understood and understand others. The MDS indicated the resident did not have an advance directive.
During a concurrent interview and record review of Resident 86's Care Conference meeting dated 10/3/2024, on 11/6/2024 at 1:33 p.m., with the Director of Nursing (DON), the DON stated during the care conference the Social Services Director (SSD) discusses the advance directive. The DON stated advance directive is discussed and offered to residents/resident representative upon admission and during quarterly or annual care conferences. The DON stated there should be documentation during the 10/3/2024 that advance directive was discussed and offered to the resident/resident's (Resident 86) representative. The DON stated the purpose of the advance directive is to ensure the resident's wishes are being followed. The DON stated the best person to talk to would be the SSD.
During a follow-up interview and record review of the facility's P&P titled, Advance Directive, on 11/6/2024 at 2:49 p.m., the DON stated per their policy and procedures, the resident's advance directive should be reviewed annually and should be documented on the resident's medical record.
During an interview on 11/6/2024 at 2:51 p.m., with the SSD, the SSD stated when a resident is first admitted , they check if the resident has advance directive and follow-up with family. The SSD also stated they offer advance directive and follow-up annually and/or during quarterly care plan meetings. The SSD stated for Resident 86, she forgot to document the discussion of advance directive. The SSD stated the purpose of documentation is to assure that they discussed it in the meeting with the resident and completed any follow-up. The SSD stated when residents are not offered assistance on formulating an advance directive, they would not know what the resident's wishes are especially if they are self-responsible.
During a review of the facility policy and procedure (P&P) titled, Advance Directive, last reviewed 7/19/2024, the P&P indicated if the resident if the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. The P&P indicated the resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. The P&P indicated the nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. The P&P indicated the Interdisicplinary Team will review annually with the resident his or her advance directive to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (MDS).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits,...
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Based on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to the administration of the pneumococcal vaccine (medication used to prevent pneumonia [serious lung infections caused by streptococcus pneumoniae, a type of bacteria]) and the 2024/2025 influenza vaccine (medication used to prevent a highly contagious respiratory illness, which spreads easily through the air or when people touch contaminated surfaces) for one of five sampled residents (Resident 16) reviewed during the Infection Control task.
This deficient practice had the potential to result in adverse reactions (any unexpected or dangerous reaction) from the vaccines and the denial of the resident's right to refuse vaccines.
Findings:
During a review of Resident 16's admission Record, dated 11/7/2024, the admission Record indicated the facility admitted Resident 16 on 4/10/2024 and readmitted the resident on 9/29/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), and benign prostatic hyperplasia (BPH - enlargement of the prostate gland that may result in urinary retention).
During a review of Resident 16's History and Physical (H&P), dated 9/29/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool), dated 10/14/2024, the MDS indicated Resident 16 had the ability to understand others and the ability to be understood. The MDS further indicated the resident was dependent on staff assistance with eating, oral hygiene, toileting, bathing, dressing, personal hygiene, and mobility.
During a review of Resident 16's Physician Orders, the Physician Orders indicated the following:
- Pneumococcal 20 - Valent Conjugate vaccine (pneumonia vaccine), inject 0.5 milliliters (mL, a unit of measurement) intramuscularly (by way of the muscle) one time only for pneumonia immunization (the process of making a person resistant to disease), monitor site for redness, pain, swelling, bleeding, or any adverse condition for three days, report to the physician when noted, dated 10/17/2024.
- Influenza Virus vaccine, inject 0.5 mL intramuscularly one time only for seasonal flu vaccination, dated 10/16/2024.
During a review of Resident 16's Nursing Clinical Notes, the clinical notes indicated the following:
-On 10/16/2024 at 2:27 p.m., the Infection Preventionist (IP) noted that signed consent for the annual influenza vaccine was obtained, and the vaccine was administered on the left deltoid.
- On 10/18/2024 at 2:29 p.m., the IP noted signed consent for the pneumococcal vaccine was obtained, and the vaccine was administered on the Left Deltoid.
During a review of Resident 16's Informed Consent for Pneumococcal Vaccine form, undated, the form indicated it was not signed by the resident or resident representative, was not marked to indicate that consent was obtained for receiving the vaccine and was not marked to indicate information was received about the risk and benefits of the vaccine.
During a review of Resident 16's Informed Consent for Influenza Vaccine form, undated, the form indicated it was not signed by the resident or resident representative, was not marked to indicate that consent was obtained for receiving the vaccine and was not marked to indicate information was received about the risk and benefits of the vaccine.
During a concurrent interview and record review on 11/7/2024 at 1:28 p.m., with the IP, the IP reviewed Resident 16's physician orders for 10/2024; Informed Consent for Influenza Vaccine form, undated; Informed Consent for Pneumococcal Vaccine form, undated; Nursing Clinical Notes for 10/2024; and Medication Administration Record. The IP stated residents are screened for vaccination upon admission, readmission, and annually for seasonal vaccines. The IP stated if a resident will receive a vaccine, then informed consent is obtained from the resident or resident representative and education is provided regarding the risk and benefits of the vaccine. The IP stated the benefit of vaccines is that they prevent illness. The IP stated the risk of vaccines are there are potential side effects from vaccine administration. The IP stated the influenza vaccine was administered to Resident 16 on 10/16/2024 and the pneumonia vaccine was administered on 10/18/2024. The IP stated he overlooked obtaining informed consent for Resident 16's vaccines and he thought the facility had received the signed consent form during the resident's admission and prior to vaccine administration from the resident's public guardian (a person appointed to be responsible for the care of individuals who are no longer able to make decisions or care for themselves), but they had not received informed consent. The IP stated the importance of obtaining informed consent prior to vaccine administration is that the public guardian makes decisions in the best interest of the resident and is appointed by the court to give consent for medical treatments. The IP stated when vaccines are administered without obtaining informed consent, residents may receive medical treatment they do not want. The IP stated he assumed he had received informed consent for the administration of vaccines to Resident 16, but he never talked with the resident's public guardian.
During a concurrent interview and record review on 11/8/2024 at 11:34 a.m., with the Director of Nursing (DON), the DON reviewed the facility policy and procedures regarding vaccine administration. The DON stated she was made aware that the IP administered vaccines to Resident 16 without obtaining informed consent. The DON stated the facility process is the admission nurse discusses vaccines with the resident or resident representative and obtains consent. The DON stated prior to the administration of the vaccine, consent should be verified by the IP. The DON stated the resident or resident representative have the right to refuse any treatment including vaccines. The DON stated resident rights must be respected. The DON stated when Resident 16's public guardian did not provide consent it could potentially result in harm to the resident from adverse effects of the vaccine or the resident receiving a vaccine they do not want. The DON stated the facility policy regarding vaccine administration was not followed.
During a review of the facility policy and procedures (P&P) titled, Infection Preventionist, last reviewed 7/19/2024, the (P&P) indicated the IP is responsible for coordinating the implementation and updating the infection prevention and control program (IPC). The IP has obtained specialized IPC training beyond initial professional training or education prior to assuming the role, including the prevention of respiratory infections (pneumonia, influenza).
During a review of the facility policy and procedures (P&P) titled, Vaccination of Residents, last reviewed 7/19/2024, the (P&P) indicated all residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated, or the resident has already been vaccinated. Prior to receiving vaccinations, the resident or legal representative will be informed and provided information and education regarding the benefits and potential side effects of the vaccinations. Provisions of such education shall be documented in the resident's medical record. The resident or resident's legal representative may refuse vaccines for any reason.
During a review of the facility (P&P) titled, Influenza Vaccine, last reviewed 7/19/2024, the policy indicated all residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. The facility shall provide pertinent information about the significant risks and benefits of vaccines to residents (or residents' legal representatives). Between October 1st and March 31st each year the vaccine will be offered. Prior to the vaccination, the resident (RP) will be provided information and education regarding the benefits and potential side effects of the vaccine. Provision of such education is documented in the resident's medical record. The resident's refusal of the vaccine shall be documented on the informed consent for influenza vaccine and placed in the resident's medical record.
During a review of the facility (P&P) titled, Pneumococcal Vaccine, last reviewed 7/19/2024, the policy indicated all residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents are assessed for eligibility to receive the vaccine and when indicated, are offered the vaccine within 30 days of admission unless medically contraindicated or the resident has already received the vaccine. Prior to receiving the vaccination, the resident (or RP) will be provided information and education regarding the benefits and potential side effects of the vaccine. Provision of such education is documented in the resident's medical record. The resident or resident's legal representative have the right to refuse vaccination.
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** 3. During a review of Resident 94's admission Record, dated 10/29/2024, the admission Record indicated the facility admitted Res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of Resident 94's admission Record, dated 10/29/2024, the admission Record indicated the facility admitted Resident 94 on 10/9/2024 with diagnoses including urinary tract infection (UTI, an infection in the bladder/urinary tract), benign prostatic hyperplasia (BPH, enlargement of the prostate gland that may result in urinary retention) with lower urinary tract symptoms, and dementia.
During a review of Resident 94's H&P, dated 10/10/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 94's MDS, dated [DATE], the MDS indicated Resident 94 had the ability to understand others and the ability to be understood. The MDS further indicated the resident required substantial/maximal assistance with toileting, bathing, dressing, and personal hygiene. The MDS indicated the resident had an indwelling catheter.
During a review of Resident 94's Care Plan regarding bowel incontinence, initiated 10/20/2024, the Care Plan indicated the resident uses disposable briefs that are changed as needed.
During an observation on 11/8/2024 at 9:10 a.m., inside of Resident 94's room, Resident 94 lay in bed while assisted by TN 1 and CNA 2 with indwelling catheter care. Observed Resident 94 wore a disposable brief. While providing catheter care, TN 1 stated to Resident 94 that the resident's diaper would be changed. CNA 2 also stated to Resident 94 that the resident's diaper would be changed. While assisting Resident 94 to change the disposable brief, TN 1 repeated the word diaper three more times and CNA 2 also repeated the word diaper three more times.
During an interview on 11/8/2024, at 9:35 a.m., with CNA 2, CNA 2 stated he changed Resident 94's diaper. CNA 2 stated he knew only the word diaper, and he did not know a different word to refer to the resident's diaper.
During an interview on 11/8/2024, at 9:40 a.m., with TN 1, TN 1 stated normally the staff should use the word disposable instead of diaper while providing care for residents. TN 1 stated he and CNA 2 used the word diaper with Resident 94. TN 1 stated they should have told Resident 94 they were providing dignity care with a disposable, but they did not. TN 1 stated using the word diaper may cause a dignity issue for Resident 94 and the resident may feel bad.
During an interview on 11/8/2024 at 9:55 a.m. with the DON, the DON stated the facility uses the term disposable briefs with residents. The DON stated the staff should not refer to a disposable brief as a diaper because it is a dignity issue. The DON stated the work diaper is used for babies and not adults. The DON stated when staff uses the word diaper with residents it may cause them to feel bad resulting in a self-esteem issue.
During a review of the facility P&P titled, Resident Rights, last reviewed 7/19/2024, the P&P indicated employees shall treat all residents with kindness, respect, and dignity. Federal and state law guarantees certain basic rights to all residents of the facility. These rights include the resident right to a dignified existence.
During a review of the facility P&P titled, Quality of Life, Dignity, last reviewed 7/19/2024, the P&P indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be treated with dignity and respect at all times. Treated with Dignity, means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Staff shall speak respectfully to residents at all times. Demeaning practices that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by addressing the use of incontinent material such as incontinent pad and cloth protector.
Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained a resident's dignity for two of two sampled residents (Resident 3 and Resident 52) investigated under the dignity care area and for one of two sampled residents (Resident 94) investigated under the urinary catheter (also known as an indwelling catheter, a hollow tube inserted into the bladder to drain or collect urine) care area when:
1. Certified Nursing Assistant 6 (CNA 6) failed to sit at eye level with Resident 3 while assisting the resident with feeding.
2. Activities Assistant 1 (AA 1) failed to sit at eye level with Resident 52 while assisting the resident with hydration.
3. Treatment Nurse 1 (TN 1) and CNA 2 did not refer to an incontinence brief as a diaper while providing care to Resident 94.
These failures had the potential to negatively affect the residents' psychosocial wellbeing.
Cross reference F659
Findings:
1. During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 on 3/10/2010 and readmitted the resident on 10/1/2024 with diagnoses including pneumonia (an infection/inflammation in the lungs), abnormal weight loss, and other lack of coordination.
During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 10/25/2024, the MDS indicated Resident 3 had short-term and long-term memory problems and severe daily decision-making impairment, and was dependent on facility staff for activities of daily living including eating, hygiene, dressing, showering/bathing himself, and surface-to-surface transfers.
During a review of Resident 3's History and Physical (H&P), dated 10/17/2024, the H&P indicated Resident 3 does not have the capacity to understand and make decisions.
During a review of Resident 3's Order Summary Report, dated 10/16/2024, the Order Summary Report indicated Resident 3 may have snacks in activities between meals.
During a concurrent observation and interview with CNA 6, on 11/5/2024, at 10:18 a.m., inside Resident 3's room, Resident 3 was lying in bed with the head of the bed elevated to seat Resident 3 upright. CNA 6 assisted Resident 3 with feeding an orange-colored gelatin while standing over the resident. CNA 6 stated she should be sitting at eye level with the resident while assisting the resident with eating to respect the dignity of the resident.
During an interview with Registered Nurse (RN) 5, on 11/8/2024, at 9:14 a.m., RN 5 stated when providing feeding assistance to residents, the facility staff should be sitting down and at eye level with the resident for the dignity of the resident. RN 5 further stated if not done, the residents can feel like they are being rushed and potentially feel disrespected.
During an interview with the Director of Nursing (DON), on 11/8/2024, at 1:52 p.m., the DON stated staff should be sitting down at eye level with the resident while assisting residents with feeding. The DON further stated standing over the residents while feeding them can negatively affect the resident's self-esteem and self-worth and potentially make the residents feel disrespected.
During a review of the facility's policy and procedure (P&P) titled, Assistance with Meals, last reviewed 7/19/2024, the P&P indicated residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity such as not standing over residents while assisting them with meals.
2. During a review of Resident 52's admission Record, the admission Record indicated the facility originally admitted Resident 52 on 8/24/2018 and readmitted the resident on 9/8/2020 with diagnoses including dementia (a progressive state of decline in mental abilities) and dependence on wheelchair.
During a review of Resident 52's MDS, dated [DATE], the MDS indicated Resident 52 had short-term and long-term memory problems and severe daily decision-making impairment, and required maximal assistance or was dependent on facility staff for activities of daily living including eating, hygiene, dressing, showering/bathing himself, and surface-to-surface transfers.
During a review of Resident 52's H&P, dated 7/2/2024, the H&P indicated Resident 52 has fluctuating capacity to understand and make informed decisions.
During a review of Resident 52's Order Summary Report, dated 10/12/2023, the Order Summary Report indicated Resident 52 was ordered snack three times a day for supplements.
During a concurrent observation and interview, on 11/5/2024, at 10:37 a.m., inside the small activity room, AA 1 was standing over Resident 52 while holding a cup next to the resident's face. Resident 52 drank from the cup. AA 1 stated when providing hydration to residents, AA 1 is usually standing over the residents and has not been informed that they should not be standing over the resident while providing hydration.
During an interview with RN 5, on 11/8/2024, at 9:14 a.m., RN 5 stated when providing feeding assistance to residents, the facility staff should be sitting down and at eye level with the resident for the dignity of the resident. RN 5 further stated if not done, the residents can feel like they are being rushed and potentially feel disrespected.
During an interview with the DON, on 11/8/2024, at 1:52 p.m., the DON stated staff should be sitting down at eye level with the resident while assisting residents with feeding. The DON further stated standing over the residents while feeding them can negatively affect the resident's self-esteem and self-worth and potentially make the residents feel disrespected.
During a review of the facility's P&P titled, Assistance with Meals, last reviewed 7/19/2024, the P&P indicated residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity such as not standing over residents while assisting them with meals.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for one (1) out of 1 sampled resident (Resident 60) investigated during a review of physical restraints care area by failing to obtain a physician's order, informed consent from the resident and/or resident representative, and complete a restraint assessment prior to use of the pommel cushion (a cushion for wheelchair designed to maintain proper hip and leg alignment, reduce the risk of inward movement of the legs, and prevent the patient from sliding forward in the seat).
These deficient practices had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment (a state in which a person is trapped by in a position that they cannot move from), and death of residents.
Findings:
During a review of Resident 60's admission Record, the admission Record indicated the facility admitted the resident on 2/16/2023 with diagnoses including dementia (a progressive state of decline in mental abilities) and generalized muscle weakness.
During a review of Resident 60's History and Physical (H&P),dated 7/2/2024, the H&P indicated the resident did not have the capacity to comprehend and make informed decisions.
During a review of Resident 60's Fall Risk Evaluations, dated 7/11/2024, 7/31/2024, and 10/23/2024, the Fall Risk Evaluations indicated the resident was a high risk for falls due to intermittent confusion and/or forgetfulness, poor vision, chair-bound, and requires use of assistive device when ambulating.
During a review of Resident 60's Minimum Data Set (MDS-a resident assessment tool) dated 10/21/2024, the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident required staff assistance on mobility and activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).
During a review of Resident 60's Order Summary Report, the Order Summary Report did not indicate an order for the use of pommel cushion.
During a concurrent observation and interview on 11/5/2024 at 10:37 a.m. inside Dining room [ROOM NUMBER] (DR 1) with Activity Assistant 1 (AA 1), observed Resident 60 sitting on a wheelchair with a cushion with raised center section. Observed Resident 60 making an up and down movement while sitting on the wheelchair. AA 1 verified Resident 60 has been on that type of cushion to prevent the resident from sliding out of the wheelchair due to incidents of falls in the past. AA 1 was unable to tell what the device is called.
During an interview on 11/7/2024 at 9:30 a.m. with Restorative Nursing Assistant 1 (RNA 1), RNA 1 verified the staff have been using the pommel cushion on Resident 60 for a while now but was unable to recall how long the resident had been on the pommel cushion. RNA 1 stated the pommel cushion was used to prevent Resident 60 from sliding out of the wheelchair due to previous history of falls.
During an interview on 11/7/2024 at 9:33 a.m., with Certified Nursing Assistant 3 (CNA 3), CNA 3 verified that they have been using the pommel cushion for Resident 60 to prevent the resident from sliding out of the wheelchair and fall. CNA 3 was unable to recall when the staff started using the pommel cushion on Resident 60, but it had been a while. CNA 3 verified he placed the pommel cushion on 11/5/2024 but was instructed by the supervisor to remove the cushion.
During a concurrent observation and interview on 11/7/2024 at 9:40 a.m., reviewed Resident 60's medical records including physician's orders, care plan, informed consents, and restraint assessments with Registered Nurse 2 (RN 2). RN 2 stated if a device is being used on a resident, there should be a physician's order, informed consent from the resident or resident representative, and restraint assessment prior to use of the pommel cushion. RN 2 verified the pommel cushion restricts Resident 60's movement by preventing the resident from sliding out of the wheelchair. RN 2 verified there was no physician's order, informed consent, and restraint assessment for Resident 60's use of pommel cushion. RN 2 stated a physician's order should have been obtained, informed consent should have been obtained from the resident or resident representative, and restraint assessment completed prior to use of the pommel cushion to determine appropriateness of the device, and for the resident and/or resident representative to be aware of the risks and benefits of the device use. RN 2 stated if there was no physician's order, the staff would not be aware of the resident's plan of care.
During a concurrent interview and record review on 11/8/2024 at 3 p.m., reviewed the facility 's policy and procedure (P&P) titled, Use of Restraints, with the Director of Nursing (DON). The DON stated she asked CNA 3 to remove the pommel cushion on Resident 60 as the resident did not have a physician's order for the device cushion. The DON stated the pommel cushion can restrict Resident 60's movement by preventing the resident from sliding off the wheelchair. The DON stated prior to using a device on a resident, a physician's order, informed consent from the resident and/or resident representative should have been obtained, and a restraint or device use assessment should have been completed prior to use of the pommel cushion. The DON verified the facility did not follow the P&P as evidenced by using the pommel cushion without a physician's order, no informed consent from the resident and/or resident representative, and the restraint or device use assessment was not completed prior to use of the pommel cushion. The DON stated the purpose of a physician's order and informed consent is to ensure staff, resident and/or resident representative were aware of the resident's plan of care, and the risks and benefits of the restraint use. The DON stated purpose of restraint or device use assessment is to determine appropriateness of the use of pommel cushion.
During a review of the facility's P&P titled, Use of Restraints, last reviewed 7/19/2024, the P&P indicated the following:
-
Restraints shall only be used for the safety and well-being of the resident/s and after alternatives have been tried unsuccessfully.
-
Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience, or for the prevention of falls.
-
Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted including placing a resident in a chair that prevents the resident from rising.
-
There shall be a pre-restraining assessment and review to determine the need for restraints prior to placing to placing a resident in restraints.
-
Restraint shall only be used upon the written physician's order and after obtaining consent form the resident and/or resident representative.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for three (3) sampled residents (Residents 60, 17, and 57) investigated under the accidents care area and one (1) out of two (2) sampled residents (Resident 3) investigated under the respiratory care area:
1. By failing to develop a care plan addressing the use of pommel cushion (a cushion for wheelchair designed to maintain proper hip and leg alignment, reduce the risk of inward movement of the legs, and prevent the patient from sliding forward in the seat) for Resident 60.
2. By failing to develop a care plan addressing the use of floor mat (a cushioned floor pad designed to help prevent injury should a person fall) for Resident 17.
3. By failing to develop the Resident 57's care plan addressing the placement of a medical equipment on the resident's floor mat.
4. By failing to address Resident 3's care plan addressing oxygen use.
These failures had the potential to cause a delay in the delivery of necessary care and services the residents need.
Findings:
a. During a review of Resident 60's admission Record, the admission Record indicated the facility admitted the resident on 2/16/2023 with diagnoses including dementia (a progressive state of decline in mental abilities) and generalized muscle weakness.
During a review of Resident 60's History and Physical (H&P), dated 7/2/2024, the H&P indicated the resident did not have the capacity to comprehend and make informed decisions.
During a review of Resident 60's Fall Risk Evaluations, dated 7/11/2024, 7/31/2024, and 10/23/2024, the Fall Risk Evaluations indicated the resident was a high risk for falls due to intermittent confusion and/or forgetfulness, poor vision, chairbound, and requires use of assistive device when ambulating.
During a review of Resident 60's Care Plan addressing the resident's risk for fall related to gait/balance problems, decreased safety judgement initiated on 2/21/2023 and last revised 8/14/2024, the Care Plan did not indicate the use of pommel cushion as one of the interventions.
During a review of Resident 60's Minimum Data Set (MDS-a resident assessment tool), dated 10/21/2024, the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident required staff assistance on mobility and activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).
During a concurrent observation and interview on 11/5/2024 at 10:37 a.m. inside Dining room [ROOM NUMBER] (DR 1) with Activity Assistant 1 (AA 1), observed resident sitting on a wheelchair with a cushion with raised center section. Observed Resident 60 making an up and down movement while sitting on the wheelchair. AA 1 verified Resident 60 has been on that type of cushion to prevent the resident from sliding out of the wheelchair due to incidents of falls in the past.
During a concurrent interview and record review on 11/7/2024 at 2:30 p.m., reviewed Resident 60's medical records including physician orders and care plans with Registered Nurse 2 (RN 2). RN 2 verified Resident 60 did not have a care plan for the use of pommel cushion. RN 2 stated if a device is being used on a resident, a care plan should be developed as it serves as a guide for staff how to provide care to the resident. RN 2 stated a care plan should have been developed for the use of the pommel cushion.
During an interview on 11/8/2024 at 2:49 p.m., with the Director of Nursing (DON), the DON stated she was made aware there was no care plan developed for the continued use of pommel cushion. The DON stated the care plan should have been developed for the continued use of the pommel cushion. The DON stated the purpose of the care plan is to customize the care for the resident. The DON stated when a care plan is not developed, the staff will not have a guide on how to provide care to the resident which can lead to a delay in care.
During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed 7/19/2024, the P&P indicated that a comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
b. During a review of Resident 17's admission Record, the admission Record indicated the facility admitted the resident on 3/25/2014 and readmitted in the facility on 5/10/2021 with diagnoses including dementia, abnormalities of gait and mobility, and muscle wasting and atrophy (the wasting away or shrinkage of an organ or tissue due to lack of use or aging).
During a review of Resident 17's H&P dated 7/19/2024, the H&P indicated the resident did not have the capacity to comprehend and make informed decisions.
During a review of Resident 17's Fall Risk Evaluations, dated 4/11/2024, 7/9/2024, and 10/7/2024, the Fall Risk Evaluations indicated the resident was a high risk for falls due to intermittent confusion and/or forgetfulness, poor vision, and chairbound.
During a review of Resident 17's MDS dated [DATE], the MDS indicated the resident had the ability to usually make self-understood and understand others. The MDS indicated the resident required maximal to total assistance from staff on mobility and activities of daily living.
During a concurrent observation and interview on 11/5/2024 at 10 a.m. inside Resident 17's room with Certified Nursing Assistant 4 (CNA 4), observed Resident 17's wheelchair and overbed table placed on top of the left side floor mat.
During an observation on 11/7/2024 at 3:50 p.m., inside Resident 17's room with Registered Nurse 2 (RN 2). RN 2 verified Resident 17 had floor mat on the left of the bed with the wheelchair left on top.
During a concurrent interview and record review on 11/7/2024 at 3:55 p.m., reviewed Resident 17's Care Plan on risk for fall due to needs assistance with transfers and ambulation related to gait/balance problems initiated on 4/15/2015 and last revised on 2/23/2022. The Care Plan indicated the use of floor mats at the sides of the bed as an intervention was in resolved status on 3/13/2017. RN 2 stated Resident 17 did not have a current intervention in the CP addressing the use of left side floor mat. RN 2 stated the purpose of care plan is so the staff would know what the interventions in place are to minimize resident's risk for falls and prevent delay in care of the resident.
During a concurrent interview and record review on 11/8/2024 at 2:55 p.m., reviewed Resident 17's Care Plan on risk for fall with the DON. The DON verified the Care Plan did indicate floor mat as one of the interventions to prevent resident falls. The DON stated the care plan should have been developed for the continued use of the floor mat. The DON stated the purpose of the care plan is to customize the care for the resident. The DON stated when a care plan is not developed, the staff will not have a guide on how to provide care to the resident which can lead to a delay in care.
During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, last reviewed 7/19/2024, the P&P indicated that a comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
d. During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 on 3/10/2010 and readmitted the resident on 10/1/2024 with diagnoses including pneumonia (an infection/inflammation in the lungs), abnormal weight loss, chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), and other lack of coordination.
During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had short-term and long-term memory problems and severe daily decision-making impairment, and was dependent on facility staff for activities of daily living including eating, hygiene, dressing, showering/bathing himself, and surface-to-surface transfers. The MDS further indicated Resident 3 received oxygen therapy.
During a review of Resident 3's H&P dated 10/17/2024, the H&P indicated Resident 3 does not have the capacity to understand and make decisions.
During a review of Resident 3's Order Summary Report, dated 10/16/2024, the Order Summary Report indicated to administer oxygen at two to three liters (a unit of measure for volume) per minute via nasal cannula or mask to maintain an oxygen saturation (a measurement of how much oxygen the blood is carrying as a percentage) greater than 92 percent (%) every shift for episodes of low oxygen saturation.
During a review Resident 3's Treatment Administration Record (TAR), dated 11/5/2024, the TAR indicated Resident 3 was administered oxygen at two to three liters per minute via nasal cannula or mask to maintain an oxygen saturation greater than 92%.
During an observation on 11/5/2024, at 10:18 a.m., inside Resident 3's room, Resident 3 was lying in bed with a nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) connected to Resident 3's nose. The oxygen concentrator (a medical device that provides extra oxygen) connected to the nasal cannula indicated Resident 3 was receiving oxygen at three liters per minute.
During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC), on 11/8/2024, at 8:52 a.m., Resident 3's Care Plan titled, [Resident 3] is at risk for respiratory distress related to asthma [a chronic lung disease that causes the airways in the lungs to narrow and swell, making it difficult to breathe]/COPD ., initiated 1/3/2015, was reviewed and the MDSC confirmed and stated Resident 3 did not have interventions for oxygen administration. The MDSC stated it is important to include an oxygen administration intervention so that the facility staff know what to do when the resident is experiencing shortness of breath. The MDSC stated the purpose of a care plan is to help guide the facility staff on how to provide care.
During a concurrent interview and record review with Registered Nurse (RN) 5, on 11/8/2024, at 9:04 a.m., Resident 3's care plans, current as of 11/8/2024, were reviewed and RN 5 confirmed Resident 3 did not have current care plans with interventions including administration of oxygen. RN 5 stated it is important for the resident's current conditions to have supporting interventions for nursing staff to be guided on what to do for specific conditions. RN 5 further stated if the interventions are not in place in the care plans there would be a potential delay in care.
During an interview with the DON on 11/8/2024, at 1:52 p.m., the DON stated Resident 3 has a history of COPD and his care plans for COPD should include interventions to administer oxygen. The DON stated the purpose of a care plan is to customize care for the resident and to guide the staff on how to provide care to the resident. The DON further stated without an intervention for Resident 3's COPD, there is a potential for decreased oxygen levels and respiratory failure and case a potential delay in care.
During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered), last reviewed 7/19/2024, the P&P indicated the comprehensive, person-centered care plan will describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, aid in preventing or reducing decline in the resident's functional status and/or functional levels, and reflect currently recognized standards of practice for problem areas and conditions.
c. During a review of Resident 57's admission Record, the admission Record indicated the facility originally admitted the resident on 12/6/2022 and readmitted the resident on 10/25/2024 with diagnoses including hemiplegia (inability to move one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (stroke, loss of blood flow to a part of the brain) affecting left non-dominant side and right dominant side, dementia, and history of falling.
During a review of Resident 57's MDS dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident required staff assistance on mobility and activities of daily living.
During a review of Resident 57's H&P dated 10/25/2024, the H&P indicated the resident had fluctuating capacity to understand and make decisions.
During a review of Resident 57's Fall Risk Evaluation, dated 10/25/2024, the Fall Risk Evaluation indicated the resident had one to two falls in the past three months, was chairbound, and required assistance with elimination.
During a review of Resident 57's Care Plan addressing the resident at risk for fall, dated 10/29/2024, the Care Plan interventions included applying floor mat on both sides of the bed as ordered to decrease injury in the event of a fall.
During an observation on 11/5/2024 at 8:39 a.m., inside Resident 57's room, observed bilateral floor mats by resident's bed and a wheelchair sitting on top of Resident 57's left side floor mat.
During a concurrent observation and interview on 11/5/2024 at 10:28 a.m., inside Resident 57's room, with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated the wheelchair placed on top of Resident 57's left side floor mat belonged to Resident 38. CNA 1 stated she and another CNA have tried before to clear Resident 57's floor mat of Resident 38's wheelchair, but Resident 38 gets angry if his wheelchair was moved so CNA 1 kept it there all the time. CNA 1 stated Resident 38's wheelchair should be off the floor mat because it is used to prevent injury if Resident 57 falls out of bed. When asked if the floor mat would be effective in breaking Resident 57's fall if the wheelchair was kept on top of it, CNA 1 stated she does not know.
During a concurrent observation and interview on 11/6/2024 at 1:04 p.m., inside Resident 57's room, with the DON, the DON stated Resident 38's wheelchair was on top of Resident 57's left side floor mat.
During an interview on 11/6/2024 at 1:12 p.m., with the DON, the DON stated the floor mats are used to minimize injury for fall. The DON stated Resident 38's wheelchair should be removed because it would defeat the function of the floor mat for Resident 57's safety placing the resident at risk for injury. The DON stated it should be care planned if the roommate prefers to have their wheelchair on the side. The DON stated the nursing staff can try to ask Resident 38 if he can use the other side of his bed to place his wheelchair and clear Resident 57's left side.
During a follow-up interview on 11/8/2024 at 2:10 p.m., the DON stated when the care plan is not developed to reflect the current response to the intervention, it can potentially harm the resident because Resident 57 might fall on the wheelchair instead of the floor mat. The DON stated the purpose of a care plan is to customize the care for the resident. The DON stated the care plans guide the staff on how to provide care to the resident and if there is no right intervention, it can cause a delay in care.
During a review of the facility P&P titled, Care Plans, Comprehensive Person-Centered, last reviewed 7/19/2024, the P&P indicated that a comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care in accordance with professional standards for four (4)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care in accordance with professional standards for four (4) of five (5) sampled residents (Resident 14, 37, 56 and 60) investigated for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous ([SQ] -beneath the skin) insulin administration sites.
The deficient practice increased the risk that Residents 14, 37, 56 and 60 could experience adverse effects (unwanted, unintended result) from same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).
Cross Reference F760
Findings:
a. During a review of Resident 14's admission Record, the admission Record indicated the facility admitted the resident on 7/10/2024 with diagnoses including type two diabetes mellitus (DM 2 - a long term condition that causes the level of sugar in the blood to become too high), chronic kidney disease (a long-term condition that occurs when the kidneys are damaged and can't filter blood properly which results in a buildup of excess fluid and waste in the body), and obesity (a condition that occurs when a person has abnormal or excessive fat accumulation that presents a risk to health).
During a review of Resident 14's History and Physical (H&P) dated 7/10/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 14's Minimum Data Set (MDS, a resident assessment tool) dated 9/24/2024, the MDS indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required set up or clean up assistance with eating and assistance from staff with activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 14 had a diagnosis of DM 2 and received insulin.
During a review of Resident 14's Order Summary Report, the Order Summary Report indicated the following physician's order:
- 7/10/2024: insulin aspart (a fast-acting insulin used to treat high blood sugar that starts to work about 15 minutes after injection) injection solution 100 unit per milliliter (unit/ml - a unit of measurement) inject five (5) units SQ before meals and at bedtime for DM 2 hold if blood sugar (BS) less than (< - a unit of measurement) 100 or nothing by mouth (NPO).
- 8/16/2024: insulin aspart injection solution 100 unit/ml inject SQ before meals and at bedtime for fingerstick blood sugar (FSBS). If BS <70 give Glucogel (a product used to treat low blood sugars absorbed through the lining of the mouth and helps increase the blood glucose within 15 minutes) 1 tube, 8 ounces (oz - a unit of measurement) orange juice or light snack if resident alert and able to take by mouth, if with altered level of consciousness give Glucagon (a hormone that increases blood sugar levels by stimulating the liver to release glucose into the bloodstream) 1 ampule (a small, sealed glass container that holds a liquid, usually a medication, that is intended to be injected) intramuscular (IM - injection within or into a muscle) recheck BS and call physician (MD).
Inject as per sliding scale (insulin dosing plan whereby the amount of insulin administered depends on the resident's blood sugar level): if 70 - 150 = zero (0) unit; <70 = Initiate hypoglycemia (low blood sugar) protocol and call MD; 151 - 200 = two (2) units; 201 - 250 = four (4) units; 251 - 300 = six (6) units; 301 - 350 = eight (8) units; 351 - 400 = ten (10) units; more than (>) 400 may give 12 units and call MD, SQ before meals and at bedtime for FSBS.
- 8/16/2024: insulin glargine (a long-acting insulin used to control the amount of sugar in the blood of patients with diabetes) SQ solution 100 unit/ml inject 32 units SQ at bedtime for DM 2.
During a review of Resident 14's Medication Administration Record (MAR) for 8/2024, 9/2024, and 10/2024, the MAR indicated insulin aspart and insulin glargine injection solution were administered as follows:
- Insulin aspart injection solution 100 units/ml:
8/7/2024 4:30 p.m. SQ Abdomen - left lower quadrant (LLQ)
807/2024 9 p.m. SQ Abdomen - LLQ
8/9/2024 9 p.m. SQ Abdomen - right upper quadrant (RUQ)
8/10/2024 6:30 a.m. SQ Abdomen - RUQ
8/10/2024 4:30 p.m. SQ Abdomen - LLQ
8/10/2024 9 p.m. SQ Abdomen - LLQ
8/12/2024 11:30 a.m. SQ Arm - left
8/12/2024 4:30 p.m. SQ Arm - left
8/13/2024 11:30 a.m. SQ Arm - left
8/13/2024 4:30 p.m. SQ Arm - left
8/15/2024 11:30 a.m. SQ Abdomen - left upper quadrant (LUQ)
8/15/2024 4:30 p.m. SQ Abdomen - LUQ
8/23/2024 11:30 a.m. SQ Abdomen - RUQ
8/23/2024 4:30 p.m. SQ Abdomen - RUQ
9/13/24 6:30 a.m. SQ Abdomen - right lower quadrant (RLQ)
9/13/24 11:30 a.m. SQ Abdomen - RLQ
9/21/24 9 p.m. SQ Abdomen - LUQ
9/22/24 6:30 a.m. SQ Abdomen - LUQ
9/23/24 9 p.m. SQ Abdomen - LUQ
9/24/24 6:30 a.m. SQ Abdomen - LUQ
9/27/24 9 p.m. SQ Abdomen - RUQ
9/28/24 6:30 a.m. SQ Abdomen - RUQ
9/21/24 9 p.m. SQ Abdomen - LUQ
9/22/24 6:30 a.m. SQ Abdomen - LUQ
10/19/24 9 p.m. SQ Abdomen - LLQ
10/20/24 6:30 a.m. SQ Abdomen - LLQ
10/25/24 9 p.m. SQ Abdomen - RLQ
10/26/24 6:30 a.m. SQ Abdomen - RLQ
10/26/24 9 p.m. SQ Abdomen - RUQ
10/27/24 6:30 a.m. SQ Abdomen - RUQ
10/25/24 9 p.m. SQ Abdomen - RLQ
10/26/24 6:30 a.m. SQ Abdomen - RLQ
- Insulin glargine injection solution 100 units/ml:
8/12/24 9 p.m. SQ Abdomen - RUQ
8/13/24 9 p.m. SQ Abdomen - RUQ
8/15/24 9 p.m. SQ Abdomen - LUQ
8/16/24 9 p.m. SQ Abdomen - LUQ
10/06/24 9: p.m. SQ Abdomen - RUQ
10/07/24 9 p.m. SQ Abdomen - RUQ
During a concurrent interview and record review on 11/7/2024 at 2:45 p.m., reviewed Resident 14's physician's orders, MAR, and location of administration sites for insulin aspart and insulin glargine injection solution for 8/2024, 9/2024, and 10/2024 with Registered Nurse 2 (RN 2). RN 2 stated insulin administration sites should be rotated. RN 2 verified the insulin administration sites were not rotated for Resident 14. RN 2 stated the insulin administration sites should have been rotated. RN 2 stated not rotating the insulin injection site can damage the tissues such as lumps and bruising.
During a concurrent interview and record review on 11/8/2024 at 3:00 p.m., reviewed Resident 14's location of insulin administration sites for insulin aspart and insulin glargine for 8/2024, 9/2024, and 10/2024, policy and procedure (P&P) on insulin administration, and manufacturer's guideline for insulin aspart and glargine with the Director of Nursing (DON). The DON stated insulin administration sites should be rotated. The DON verified the nurses did not rotate the insulin administration sites on multiple occasions from 8/2024 to 10/2024. The DON verified the facility's P&P indicate to rotate injection sites. The DON verified the manufacturer's guideline for aspart and glargine indicated to rotate injection sites to prevent lipodystrophy and amyloidosis. The DON stated the injection sites should have been rotated to prevent lumps, bruising, and tenderness affecting the absorption of the medication.
b.1. During a review of Resident 37's admission Record (a document containing demographic and diagnostic information) dated 11/7/2024, the admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including DM 2.
During a review of Resident 37's Order Summary Report, dated 11/7/2024, the Order Summary Report indicated Resident 37 was prescribed Novolog (fast-acting insulin) to inject per sliding scale subcutaneous ([SQ] - under the skin) before meals and at bedtime, starting 5/16/2024.
During a review of Resident 37's Medication Administration Record ([MAR] - a record of mediations administered to residents), for November 2024, the MAR indicated Resident 37 was prescribed Novolog per sliding scale SQ before meals and at bedtime, at 6:30 a.m., 11:30 a.m., 4:30 p.m. and 9 p.m.
During the same review, the MAR indicated Novolog SQ was administered by the following licensed nurses, on the following days, times, and sites:
11/6/2024 four (4) units ([un] - a measure of dosage for insulin) at 11:30 a.m. on Left Upper Quadrant ([LUQ] - upper left side of abdomen) by Licensed Vocational Nurse (LVN) 3
11/6/2024 six (6) un at 4:30 p.m. on LUQ by LVN 4
b.2. During a review of Resident 56's admission Record dated 11/6/2024, the admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including DM 2.
During a review of Resident 56's Order Summary Report, dated 11/6/2024, the Order Summary Report indicated Resident 56 was prescribed Fiasp (rapid-acting insulin) to inject per sliding scale SQ before meals and at bedtime related to DM 2, starting 3/22/2024.
During a review of Resident 56's MAR for November 2024, the MAR's indicated Resident 56 was prescribed Fiasp to inject per sliding scale SQ before meals and at bedtime related to DM 2, at 6:30 a.m., 11:30 a.m., 4:30 p.m. and 9 p.m.
During the same review, the MAR indicated Fiasp SQ was administered by the following licensed nurses, on the following days, times, and sites:
11/4/2024 two (2) un at 9 p.m. on left arm by Registered Nurse (RN) 4
11/5/2024 two (2) un at 11:30 a.m. on left arm by RN 3
b.3. During a review of Resident 60's admission Record dated 11/6/2024, the admission Record indicated the resident was originally admitted to the facility on [DATE] with a diagnosis including DM 2.
During a review of Resident 60's Order Summary Report, dated 11/6/2024, the Order Summary Report indicated Resident 60 was prescribed Lantus (long-acting insulin) to inject five (5) un SQ in the morning for DM related to DM2, starting 8/9/2023.
During a review of Resident 60's MAR for November 2024, the MAR indicated Resident 60 was prescribed Lantus (long-acting insulin) to inject five (5) un SQ in the morning for DM related to DM 2, at 6:30 a.m.
During the same review, the MAR indicated Lantus SQ was administered by the following licensed nurses, on the following days, times, and sites:
11/2/2024 five (5) un at 6:30 a.m. on Right Lower Quadrant ([RLQ] - lower right side of abdomen) by LVN 5
11/3/2024 five (5) un at 6:30 a.m. on RLQ by LVN 5
During a concurrent interview and record review on 11/7/2024 at 12:57 p.m., with the DON, the DON reviewed Resident 37's, 56's and 60's MAsR for November 2024. The DON stated that for Residents 37, 56 and 60, the MARs indicated there were instances where the insulin administration sites were not rotated by several licensed nurses, as expected by facility policy, standard of practice, and manufacturer guidelines. The DON stated the failure of the licensed nurses to rotate insulin administration sites could cause harm to Resident 37, 56 and 60 by causing lipodystrophy (skin abnormalities such as lumps in the skin or thickened skin) at the repeated administration sites.
During a review of the facility's policy & procedures (P&P,) titled Adverse Consequences and Medication Errors, last reviewed 7/19/2024, the P&P indicated:
2.
An 'adverse consequence' is defined as an unpleasant symptoms or event that is due to or associated with a medication, such as an impairment or decline in an individual's mental or physical condition or functional or psychosocial status. An adverse consequence may include:
a.
adverse drug/medication reaction
3.
An adverse drug reaction (ADR), a form of adverse consequences, is defined as a secondary and usually undesirable effect of a drug .
4.
The staff and practitioner shall strive to minimize adverse consequences by:
a.
Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication.
During a review of facility's P&P titled, Insulin Administration, last reviewed 7/19/2024, the P&P indicated: To provide guidelines for the safe administration of insulin to residents with diabetes.
16.b. injection sites should be rotated, preferably within the same general area.
During a review of facility provided manufacturer's guide Instructions for Use for Fiasp, dated September 2017, the manufacturer's guide indicated to Change (rotate) your injection sites for each injection. Do not use the same injection site for each injection.
During a review of facility-provided manufacturer's guide Instructions for Use for Novolog, dated February 2023, the manufacturer's guide indicated to If you inject Novolog, change (rotate) your injection sites within the area you choose for each dose to reduce your risk of getting lipodystrophy (pits in skin or thickened skin) at the injection sites. Do not use the same injection site for each injection. Do not inject where the skin has pits, is thickened, or has lumps. Do not inject where the skin is tender, bruised, scaly or hard, or into scars or damaged skin.
During a review of manufacturer's guide for Injecting Lantus with a vial and syringe, dated 2022, the manufacturer's guide indicated to Change (rotate) your injection sites within the area you chose with each dose to reduce your risk of getting lipodystrophy (pitted or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites. Do not use the same spot for each injection or inject where the skin is pitted, thickened, lumpy, tender, bruised, scaly, hard, scarred or damaged.
During a review of facility-provided manufacturer's guideline on insulin glargine, last revised 6/2022, the manufacturer's guide indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. the guideline indicated adverse reactions commonly associated with insulin glargine include hypoglycemia (low blood sugar), allergic reactions, injection site reactions, lipodystrophy, pruritus (itchiness), rash, edema (swelling), and weight gain.
During a review of facility-provided manufacturer's guideline on insulin aspart, last revised 2/2023, the manufacturer's guide indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. the guideline indicated adverse reactions commonly associated with insulin glargine include hypoglycemia, allergic reactions, injection site reactions, lipodystrophy, pruritus, rash, edema, and weight gain.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0678
(Tag F0678)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their policy and procedure on cardiopulmonary resuscitati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their policy and procedure on cardiopulmonary resuscitation (CPR, an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) by failing to maintain American Red Cross (an organization led by volunteers that provide relief to victims of disasters and help people prevent, prepare for and respond to emergencies) or American Heart Association (AHA, a non-profit organization that aims to reduce disability and death from cardiovascular diseases and stroke) CPR certification for three (3) of five (5) sampled employees (Activity Assistant 1 [AA1], Certified Nursing Assistant 3 [CNA 3], CNA 4) during a review of employee files under Sufficient and Competent Nurse Staffing care area.
This deficient practice had the potential of delayed provisions of emergency care for current residents who wishes to have full treatment in a life-threatening situation.
Findings:
During a record review of employee files on [DATE] at 9:55 a.m., with the Director of Staff Development (DSD), the employee files of AA1, CNA 3, and CNA 4 indicated their basic life support (BLS, a set of essential emergency procedures designed to sustain life in victims experiencing cardiac arrest) Provider Card certification from National CPR Foundation, dated [DATE] for AA 1, [DATE] for CNA 3, and [DATE] for CNA 4, indicated, the mentioned student is now certified in the mentioned course by demonstrating proficiency by successfully passing the examination in accordance with the Terms and Conditions of National CPR Foundation (NCPRF). Valid for 2 Years.
During an interview on [DATE] at 10:20 a.m., AA 1 verified that the CPR training dated [DATE] was an online training. AA 1 stated participants were just given a lecture and shown videos in different ways how to perform CPR in infants, children, and adults and when a person is in danger due to choking. AA 1 stated, there was no hands-on training provided to participants. AA 1 stated the last time he took an in-person CPR training was [DATE].
During a review of the facility-provided job description for Activities Assistant (AA) form, undated, the form indicated to follow the facility policies and procedures as one of the essential job duties.
During a review of the facility-provided job description for CNA form, undated, the form indicated to follow all established P&P, to include nursing procedures, safety regulations, and personnel policies as one of the major duties and responsibilities as a CNA.
During a follow-up interview on [DATE] at 12:00 p.m. with AA 1, AA 1 stated he was not aware CPR training should be hands-on or in-person training from ARC/AHA. AA 1 stated hands-on training in performing CPR during emergency is important so the staff would feel confident or competent and effective in performing CPR.
During a concurrent interview and record review on [DATE] at 3:30 p.m. with the DSD, the DSD stated he was previously made aware hands-on training was not required or obtaining CPR training from ARC/AHA. The DSD verified the facility policy and procedure (P&P) titled, Emergency Procedure - Cardiopulmonary Resuscitation, indicated CPR certification should be obtained and/or maintained thru ARC/AHA for key clinical staff members who will direct resuscitative efforts including non-licensed personnel. The DSD stated the facility did not follow the P&P regarding CPR certification.
During a concurrent interview and record review on [DATE] at 3:00 p.m., reviewed AA and CNA job descriptions and the facility P&P titled, Emergency Procedure - Cardiopulmonary Resuscitation, with the Director of Nursing (DON). The DON stated all staff whether licensed on non-licensed are required to have CPR certification. The DON stated CPR initial certification and recertification should be in-person and includes hands-on training for all staff from a certified instructor thru ARC/AHA. The DON verified the P&P indicated CPR certification should be obtained and/or maintained thru ARC/AHA for key clinical staff members who will direct resuscitative efforts including non-licensed personnel. The DON stated the staff did not follow the facility P&P to maintain or obtain CPR certification thru ARC/AHA certified providers to prevent delay in performing CPR in emergency situations. The DON stated, as indicated in the job description, AA 1, CNA 3, and CNA 4 should have followed the facility P&P to maintain their CPR certification thru ARC/AHA certified provider so they would competent and effective in performing CPR in emergency situations.
During a review of the facility's P&P titled, Emergency Procedure - Cardiopulmonary Resuscitation, last reviewed [DATE], the P&P indicated a policy statement that personnel have completed training on the initiation of to obtain and/or maintain ARC or AHA certification in CPR for key clinical staff members who will direct resuscitative efforts including non-licensed personnel.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for two of four sampled residents (Residents 17 and 57) investigated under accidents by:
1. Failing to ensure Resident 17's floor mat (a cushioned floor pad designed to help prevent injury should a person fall) did not have the wheelchair and overbed table on top of it.
2. Failing to ensure Resident 17's floor mat was placed properly as indicated in the application instructions.
3. Failing to ensure Resident 57's floor mat did not have a medical equipment on top of it observed multiple times.
These deficient practices increased the risk of Resident 17 and Resident 57 incurring an injury such as falls with fracture (a break or crack in a bone) and even death.
Findings:
a. During a review of Resident 17's admission Record (AR), the AR indicated the facility admitted the resident on 3/25/2014 and readmitted on [DATE] with diagnoses dementia (a progressive state of decline in mental abilities), abnormalities of gait and mobility, and muscle wasting and atrophy (the wasting away or shrinkage of an organ or tissue due to lack of use or aging).
During a review of Resident 17's History and Physical (H&P), dated 7/19/2024, the H&P indicated the resident did not have the capacity to comprehend and make informed decisions.
During a review of Resident 17's Fall Risk Evaluations, dated 4/11/2024, 7/9/2024, and 10/7/2024, the Fall Risk Evaluations indicated the resident was a high risk for falls due to intermittent confusion and/or forgetfulness, poor vision, and chair bound.
During a review of Resident 17's Care Plan (CP) addressing the resident's risk for fall due to needs assistance with transfers and ambulation related to gait/balance problems initiated 4/15/2015 last revised 2/23/2022, the CP indicated the use of floor mats at the sides of the bed as an intervention in resolved status on 3/13/2017.
During a review of Resident 17s Minimum Data Set (MDS - a federally required assessment tool), dated 10/7/2024, the MDS indicated the resident had the ability to usually make self-understood and understand others. The MDS indicated Resident 17 required maximal to total assistance from staff on mobility and activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).
During a review of Resident 17's Physician's Orders (PO), the PO did not indicate an order for the use of floor mat.
During a concurrent observation and interview on 11/5/2024 at 10 a.m. inside Resident 17's room with Certified Nursing Assistant 4 (CNA 4), observed Resident 17's wheelchair and overbed table placed on top of the left side floor mat, and the sign on the floor mat, This Side Down, was facing up. CNA 4 verified the floor mat was not placed correctly as indicated in the sign. CNA 4 stated the side facing up should have been facing the floor as it can cause a slip and fall accident. CNA 4 stated they always place the wheelchair and overbed table on top of the floor mats. When CNA 4 moved the wheelchair and overbed table off the floor mat, CNA 4 verified the indentation left by the wheelchair and overbed table. CNA 4 stated the purpose of the floor mat is to protect the resident in case of a fall. CNA 4 stated the floor mat gets thinner if the wheelchair and table stays on top of the floor mat for a long time and lessens the protection for the resident in case of a fall. CNA 4 the wheelchair and overbed should have not been left on top of the floor mat. CNA 4 stated Resident 17 can get injured when the resident tries to get out of bed, loose balance, and hit the wheelchair or table placed on top of the floor mat.
During a concurrent observation and record review on 11/7/2024 at 3:50 p.m., inside Resident 17's room with Registered Nurse 2 (RN 2) reviewed a photo of Floor Mat 1 (FM 1) taken on 11/5/2024 at 10:00 a.m. RN 2 verified Resident 17 had floor mat on the left of the bed with the wheelchair left on top. RN 2 verified the sign on the photo indicated, This Side Down, and should have been placed correctly as indicated on FM 1. RN 2 stated the wheelchair and overbed table should not have been placed on top of the floor mat as the resident can get injured in case of a fall. RN 2 stated the floor mat is used on residents who are high risk for falls by lessening the impact of a fall. RN 2 stated leaving the wheelchair and table on top of the floor for a long time defeats the purpose of using the floor mat and can cause injury to the resident during a fall. RN 2 stated not placing the floor mat with the label facing the floor can potentially cause a slip and fall accident which may lead to injuries.
During a concurrent interview and record review on 11/8/2024 at 2;55 p.m., reviewed the facility provided FM 1 Application Instructions, photo of FM 1 taken on 11/5/2024 at 10:00 a.m., and facility policy and procedures (P&P) titled, Safety and Supervision of Residents, and Hazardous Areas, Devices, and Equipment, with the Director of Nursing (DON). The DON stated the floor mats are used to minimize injuries to the resident in case of a fall. The DON stated the wheelchair and table should not be placed or left for an extended period as it defeats the purpose of placing a floor mat for resident safety placing the resident at risk for injury. The DON verified FM 1 was placed incorrectly as indicated in the photo. The DON stated FM 1 application instruction indicated the non-skid bottom helps prevent slipping when stepping into the cushion and to make sure the This Side Down label is facing the floor. The DON stated Resident 17 can slip and get injured if FM 1 label was not facing the floor.
During a review of the facility provided Floor Mat 1 (FM 1) Application Instructions, dated 7/30/2024, the FM 1 indicated:
-
FM 1 helps to minimize injuries from a fall. The FM 1 indicated the foam creates a low profile that is easy for patients to step on and off.
-
The non-skid bottom helps prevent slipping when stepping onto the cushion.
-
Make sure the This Side Down label is facing the floor.
-
Inform resident and staff to take care when stepping on or off the cushion to avoid tripping.
During a review of the facility policy and procedure (P&P) titled, Falls - Clinical Protocol/Interventions, last reviewed 7/19/2024, the P&P indicated the staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling.
During a review of the facility's P&P titled, Safety and Supervision of Residents, last reviewed 7/19/2024, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accident are facility-wide priorities.
During a review of the facility's P&P titled, Hazardous Areas, Devices, and Equipment, last reviewed 7/19/2024, the P&P indicated all hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible.
b. During a review of Resident 57's admission Record (AR), the AR indicated the facility originally admitted the resident on 12/6/2022 and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (stroke, loss of blood flow to a part of the brain) affecting left non-dominant side and right dominant side, dementia, and history of falling.
During a review of Resident 57's History and Physical (H&P), dated 10/25/2024, the H&P indicated the resident had fluctuating capacity to understand and make decisions.
During a review of Resident 57's Fall Risk Evaluation, dated 10/25/2024, the Fall Risk Evaluation indicated the resident had one to two falls in the past three months, was chair bound and required assistance with elimination.
During a review of Resident 57's Care Plan (CP) addressing the resident at risk for fall, dated 10/29/2024, the CP indicated the resident with interventions including applying floor mat on both sides of the bed as ordered to decrease injury in the event of a fall.
During a review of Resident 57's MDS, dated [DATE], the MDS indicated the resident had the ability to make self understood and understand others. The MDS indicated the resident required staff assistance on mobility and ADLs.
During an observation on 11/5/2024 at 8:39 a.m., inside Resident 57's room, observed bilateral floor mats by resident's bed and a wheelchair sitting on top of Resident 57's left side floor mat.
During an observation on 11/5/2024 at 10:21 a.m., inside Resident 57's room, observed Resident 57 lying in bed, floor mats placed on both sides of the resident's bed, and noted a wheelchair placed on the resident's left side of the bed.
During a concurrent observation and interview on 11/5/2024 at 10:28 a.m., inside Resident 57's room, with CNA 1, CNA 1 stated the wheelchair placed on top of Resident 57's left side floor mat belongs to Resident 38. CNA 1 stated she and another CNA have tried before to clear the resident's floor mat with Resident 38's wheelchair, but Resident 38 and does get angry if his wheelchair was moved so she keeps it there all the time. CNA 1 stated the wheelchair should be off the floor mat because it is used to prevent injury if the resident falls out of bed. When asked if the floor mat would be effective in breaking the resident's fall if the wheelchair was kept on top of it, CNA 1 stated she does not know.
During a concurrent observation and interview on 11/6/2024 at 1:04 p.m., inside Resident 57's room, with the Director of Nursing (DON), the DON stated Resident 38's wheelchair was on top of Resident 57's left side floor mat.
During a follow-up interview on 11/6/2024 at 1:12 p.m., with the DON, the DON stated the floor mats are used to minimize injury for fall. The DON stated the wheelchair should be removed because it would defeat the function of the floor for the resident's safety placing the resident at risk for injury.
During a review of Floor Mat 1 (FM 1) Application Instructions, dated 7/30/2024, the FM 1 indicated the FM 1 helps to minimize injuries from a fall. The FM 1 indicated the foam creates a low profile that is easy for patients to step on and off.
During a review of the facility policy and procedure (P&P) titled, Falls - Clinical Protocol/Interventions, last reviewed 7/19/2024, the P&P indicated the staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors (me...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for four (4) of five (5) sampled residents (Resident 14, 37, 56 and 60) investigated for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous ([SQ] -beneath the skin) insulin administration sites.
The deficient practice increased the risk that Residents 14, 37, 56 and 60 could experience adverse effects (unwanted, unintended result) from same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).
Cross Reference F658
Findings:
a.1. During a review of Resident 14's admission Record, the admission Record indicated the facility admitted the resident on 7/10/2024 with diagnoses including type two diabetes mellitus (DM 2 - a long term condition that causes the level of sugar in the blood to become too high), chronic kidney disease (a long-term condition that occurs when the kidneys are damaged and can't filter blood properly which results in a buildup of excess fluid and waste in the body), and obesity (a condition that occurs when a person has abnormal or excessive fat accumulation that presents a risk to health).
During a review of Resident 14's History and Physical (H&P) dated 7/10/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 14's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/24/2024, the MDS indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required set up or clean up assistance with eating and assistance from staff with activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 14 had a diagnosis of DM 2 and received insulin.
During a review of Resident 14's Order Summary Report, the Order Summary Report indicated the following physician's order:
- 7/10/2024: insulin aspart (a fast-acting insulin used to treat high blood sugar that starts to work about 15 minutes after injection) injection solution 100 unit per milliliter (unit/ml - a unit of measurement) inject five (5) units SQ before meals and at bedtime for DM 2 hold if blood sugar (BS) less than (< - a unit of measurement) 100 or nothing by mouth (NPO).
- 8/16/2024: insulin aspart injection solution 100 unit/ml inject SQ before meals and at bedtime for fingerstick blood sugar (FSBS). If BS <70 give Glucogel (a product used to treat low blood sugars absorbed through the lining of the mouth and helps increase the blood glucose within 15 minutes) 1 tube, 8 ounces (oz - a unit of measurement) orange juice or light snack if resident alert and able to take by mouth, if with altered level of consciousness give Glucagon (a hormone that increases blood sugar levels by stimulating the liver to release glucose into the bloodstream) 1 ampule (a small, sealed glass container that holds a liquid, usually a medication, that is intended to be injected) intramuscular (IM - injection within or into a muscle) recheck BS and call physician (MD).
- Inject as per sliding scale: if 70 - 150 = zero (0) unit; <70 = Initiate hypoglycemia (low blood sugar) protocol and call MD; 151 - 200 = two (2) units; 201 - 250 = four (4) units; 251 - 300 = six (6) units; 301 - 350 = eight (8) units; 351 - 400 = ten (10) units; more than (>) 400 may give 12 units and call MD, SQ before meals and at bedtime for FSBS.
- 8/16/2024: insulin glargine (a long-acting insulin used to control the amount of sugar in the blood of patients with diabetes) SQ solution 100 unit/ml inject 32 units SQ at bedtime for DM 2.
During a review of Resident 14's Medication Administration Record (MAR) for 8/2024, 9/2024, and 10/2024, the MAR indicated insulin aspart and insulin glargine injection solution were administered as follows:
- Insulin aspart injection solution 100 units/ml:
8/7/2024 4:30 p.m. SQ Abdomen - left lower quadrant (LLQ)
807/2024 9:00 p.m. SQ Abdomen - LLQ
8/9/2024 9:00 p.m. SQ Abdomen - right upper quadrant (RUQ)
8/10/2024 6:30 a.m. SQ Abdomen - RUQ
8/10/2024 4:30 p.m. SQ Abdomen - LLQ
8/10/2024 9:00 p.m. SQ Abdomen - LLQ
8/12/2024 11:30 a.m. SQ Arm - left
8/12/2024 4:30 p.m. SQ Arm - left
8/13/2024 11:30 a.m. SQ Arm - left
8/13/2024 4:30 p.m. SQ Arm - left
8/15/2024 11:30 a.m. SQ Abdomen - left upper quadrant (LUQ)
8/15/2024 4:30 p.m. SQ Abdomen - LUQ
8/23/2024 11:30 a.m. SQ Abdomen - RUQ
8/23/2024 4:30 p.m. SQ Abdomen - RUQ
9/13/24 6:30 a.m. SQ Abdomen - right lower quadrant (RLQ)
9/13/24 11:30 a.m. SQ Abdomen - RLQ
9/21/24 9:00 p.m. SQ Abdomen - LUQ
9/22/24 6:30 a.m. SQ Abdomen - LUQ
9/23/24 9:00 p.m. SQ Abdomen - LUQ
9/24/24 6:30 a.m. SQ Abdomen - LUQ
9/27/24 9:00 p.m. SQ Abdomen - RUQ
9/28/24 6:30 a.m. SQ Abdomen - RUQ
9/21/24 9:00 p.m. SQ Abdomen - LUQ
9/22/24 6:30 a.m. SQ Abdomen - LUQ
10/19/24 9:00 p.m. SQ Abdomen - LLQ
10/20/24 6:30 a.m. SQ Abdomen - LLQ
10/25/24 9:00 p.m. SQ Abdomen - RLQ
10/26/24 6:30 a.m. SQ Abdomen - RLQ
10/26/24 9:00 p.m. SQ Abdomen - RUQ
10/27/24 6:30 a.m. SQ Abdomen - RUQ
10/25/24 9:00 p.m. SQ Abdomen - RLQ
10/26/24 6:30 a.m. SQ Abdomen - RLQ
-Insulin glargine injection solution 100 units/ml:
8/12/24 9:00 p.m. SQ Abdomen - RUQ
8/13/24 9:00 p.m. SQ Abdomen - RUQ
8/15/24 9:00 p.m. SQ Abdomen - LUQ
8/16/24 9:00 p.m. SQ Abdomen - LUQ
10/06/24 9:00 p.m. SQ Abdomen - RUQ
10/07/24 9:00 p.m. SQ Abdomen - RUQ
During a concurrent interview and record review on 11/7/2024 at 2:45 p.m., reviewed Resident 14's physician's orders, MAR, and location of administration sites for insulin aspart and insulin glargine injection solution for 8/2024, 9/2024, and 10/2024 with Registered Nurse 2 (RN 2). RN 2 stated insulin administration sites should be rotated per standards of practice. RN 2 verified the insulin administration sites were not rotated. RN 2 stated the insulin administration sites should have been rotated. RN 2 stated not rotating the insulin injection site can damage the tissues such as lumps and bruising.
During a concurrent interview and record review on 11/8/2024 at 3:00 p.m., reviewed Resident 14's location of insulin administration sites for insulin aspart and insulin glargine for 8/2024, 9/2024, and 10/2024, policy and procedure (P&P) on insulin administration, and manufacturer's guideline for insulin aspart and glargine with the Director of Nursing (DON). The DON stated insulin administration sites should be rotated as a standard of practice. The DON verified the nurses did not rotate the insulin administration sites on multiple occasions from 8/2024 to 10/2024. The DON verified the facility's P&P indicate to rotate injection sites. The DON stated the nurses did not follow the manufacturer's guideline and the standards of practice. The DON stated the insulin administration sites should have been rotated as it can affect the absorption of insulin and can also cause skin lumps and bruising. The DON stated not rotating insulin administration site is considered a medication error per the manufacturer's guideline and standards of practice.
a.2. During a review of Resident 37's admission Record (a document containing demographic and diagnostic information,) dated 11/7/24, indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including Type 2 Diabetes Mellitus 2 ([DM2] - a condition where there are high blood sugar levels.)
During a review of Resident 37's Order Summary Report, dated 11/7/24, indicated Resident 37 was prescribed Novolog (fast-acting insulin) to inject per sliding scale (insulin dosing plan whereby the amount of insulin administered depends on the resident's blood sugar level,) subcutaneous ([SQ] - under the skin) before meals and at bedtime, starting 5/16/24.
During a review of Resident 37's Medication Administration Record ([MAR] - a record of medications administered to residents), for November 2024, the MAR indicated Resident 37 was prescribed Novolog per sliding scale SQ before meals and at bedtime, at 6:30 a.m., 11:30 a.m., 4:30 p.m. and 9 p.m.
During the same review, the MAR indicated Novolog SQ was administered by the following licensed nurses, on the following days, times, and sites:
11/6/24 four (4) units ([un] - a measure of dosage for insulin) at 11:30 a.m. on Left Upper Quadrant ([LUQ] - upper left side of abdomen) by Licensed Vocational Nurse (LVN) 3
11/6/24 six (6) un at 4:30 p.m. on LUQ by LVN 4
a.3.During a review of Resident 56's admission Record dated 11/6/24, indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including DM2.
During a review of Resident 56's Order Summary Report, dated 11/6/24, indicated Resident 56 was prescribed Fiasp (rapid-acting insulin) to inject per sliding scale SQ before meals and at bedtime related to DM2, starting 3/22/24.
During a review of Resident 56's MAR for November 2024, the MAR's indicated Resident 56 was prescribed Fiasp to inject per sliding scale SQ before meals and at bedtime related to DM2, at 6:30 a.m., 11:30 a.m., 4:30 p.m. and 9 p.m.
During the same review, the MAR indicated Fiasp SQ was administered by the following licensed nurses, on the following days, times, and sites:
11/4/24 two (2) un at 9 p.m. on left arm by Registered Nurse (RN) 4
11/5/24 two (2) un at 11:30 a.m. on left arm by RN 3
a.4. During a review of Resident 60's admission Record dated 11/6/24, indicated the resident was originally admitted to the facility on [DATE] with a diagnosis including DM2.
During a review of Resident 60's Order Summary Report, dated 11/6/24, indicated Resident 60 was prescribed Lantus (long-acting insulin) to inject five (5) un SQ in the morning for DM related to DM2, starting 8/9/23.
During a review of Resident 60's MAR for November 2024, the MAR indicated Resident 60 was prescribed Lantus (long-acting insulin) to inject five (5) un SQ in the morning for DM related to DM2, at 6:30 a.m.
During the same review, the MAR indicated Lantus SQ was administered by the following licensed nurses, on the following days, times, and sites:
11/2/24 five (5) un at 6:30 a.m. on Right Lower Quadrant ([RLQ] - lower right side of abdomen) by LVN 5
11/3/24 five (5) un at 6:30 a.m. on RLQ by LVN 5
During a concurrent interview and record review on 11/7/24 at 12:57 p.m., with the Director of Nursing (DON,) the DON reviewed Resident 37's, 56's and 60's MAR for November 2024. The DON stated that for Resident 37, 56 and 60 the MARs indicated there were instances where the insulin administration sites were not rotated by several licensed nurses, as expected by facility policy, standard of practice and manufacturer guidelines. The DON stated the failure of the licensed nurses to rotate insulin administration sites could cause harm to Resident 37, 56 and 60 by causing lipodystrophy (skin abnormalities such as lumps in the skin or thickened skin) at the repeated administration sites. The DON stated not rotating insulin administration sites was considered a significant medication error.
During a review of the facility's policy & procedures (P&P,) titled Adverse consequences and Medication Errors, last reviewed 7/19/24, the P&P indicated:
2.
An 'adverse consequence' is defined as an unpleasant symptoms or event that is due to or associated with a medication, such as an impairment or decline in an individual's mental or physical condition or functional or psychosocial status. An adverse consequence may include:
a.
adverse drug/medication reaction
3.
An adverse drug reaction (ADR), a form of adverse consequences, is defined as a secondary and usually undesirable effect of a drug .
4.
The staff and practitioner shall strive to minimize adverse consequences by:
a.
Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication;
5.
A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services.
5.
Examples of medication error include:
h.
Failure to follow manufacturer instructions and/or accepted professional standards.
During a review of facility's P&P titled, Insulin Administration, last reviewed 7/19/24, indicated: To provide guidelines for the safe administration of insulin to residents with diabetes.
3. The type of insulin, .and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order.
16.b. injection sites should be rotated, preferably within the same general area.
During a review of facility-provided manufacturer's guide Instructions for Use for Fiasp, dated September 2017, the guide indicated to Change (rotate) your injection sites for each injection. Do not use the same injection site for each injection.
During a review of facility-provided manufacturer's guide Instructions for Use for Novolog, dated February 2023, the guide indicated to If you inject Novolog, change (rotate) your injection sites within the area you choose for each dose to reduce your risk of getting lipodystrophy (pits in skin or thickened skin) at the injection sites. Do not use the same injection site for each injection. Do not inject where the skin has pits, is thickened, or has lumps. Do not inject where the skin is tender, bruised, scaly or hard, or into scars or damaged skin.
During a review of manufacturer's guide for Injecting Lantus with a vial and syringe, dated 2022, the guide indicated to Change (rotate) your injection sites within the area you chose with each dose to reduce your risk of getting lipodystrophy (pitted or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites. Do not use the same spot for each injection or inject where the skin is pitted, thickened, lumpy, tender, bruised, scaly, hard, scarred or damaged.
During a review of facility-provided manufacturer's guideline on insulin glargine, last revised 6/2022, indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. the guideline indicated adverse reactions commonly associated with insulin glargine include hypoglycemia (low blood sugar), allergic reactions, injection site reactions, lipodystrophy, pruritus (itchiness), rash, edema (swelling), and weight gain.
During a review of facility-provided manufacturer's guideline on insulin aspart, last revised 2/2023, indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. the guideline indicated adverse reactions commonly associated with insulin glargine include hypoglycemia, allergic reactions, injection site reactions, lipodystrophy, pruritus, rash, edema, and weight gain.
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, and record review, the facility failed to follow the menu and did not meet the nutritional needs of 17 of 96 residents on puree texture diets (diet with pudding-like c...
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Based on observation, interview, and record review, the facility failed to follow the menu and did not meet the nutritional needs of 17 of 96 residents on puree texture diets (diet with pudding-like consistency foods used for individuals with difficulty chewing or swallowing) when:
a.
Polenta (a grainy dish made from boiled cornmeal) was watery and could not hold its shape on the plate on 11/5/2024 for lunch.
b.
Puree carrots were runny and could not hold its shape on the plate on 11/6/2024 for lunch.
This failure had the potential to result in difficulty in eating, chewing, and swallowing to the residents and decrease food and nutrient intake resulting to unintended (not done on purpose) weight loss.
Findings:
a.
During a review of the facility's daily spreadsheet titled Fall Menus, dated 11/5/2024, the spreadsheet indicated residents on puree and International Dysphagia Diet Standardization 4 ([IDDSI] a global standard to describe texture modified foods and thickened drinks for individuals with swallowing difficulties in all ages, in all settings) Level 4 (pureed foods with extremely thick fluids) portions would get the following food items:
Puree lemon chicken piccata (pan-fried chicken cutlet), half (1/2) cup (c, household measurement)
Puree polenta ½ c
Puree spinach au gratin (a baked dish of spinach covered in a cheese sauce and breadcrumbs) ½ c
Parsley flakes
Puree fresh green salad with dressing ½ c
Puree gelatin 2.7 ounces (oz, household measurement)
Milk 4 oz
During an observation on 11/5/2024 at 11:05 a.m. at the trayline area (an area where foods were assembled on the trays), the puree chicken and polenta looked runny with weeping liquids.
During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) for puree diet and interview on 11/05/2024 at 12:44 p.m. with the Dietary Supervisor (DS), DS stated the polenta was runny. The DS stated puree foods should hold its form on the plate and have a pudding-like consistency. The DS stated residents could have difficulty picking up runny foods with their utensils and might not eat the food causing them to lose weight as a potential outcome.
During a review of the facility's standardized recipe titled RECIPE: POLENTA, dated 2024, the standardized recipe indicated 4. Polenta is done when texture is creamy, and the individual grains are tender. Pureeds/dysphagia (difficulty swallowing): Puree to ensure no lumps. Puree following the puree recipes in the Food Safety/Misc. section of Book #1.
During a review of the facility's standardized recipe titled Pureed (IDDSI Level 4) Starch (Rice, Pasta, Polenta, Potatoes, etc.), the standardized recipe indicated, The finished puree items should be smooth and free of lumps, hold it shape, while not being too firm or sticky, and should not weep. The finished pureed item must pass IDSSI level 4 testing requirements.
b.
During a review of the facility's daily spreadsheet titled Fall Menus, dated 11/6/2024, the spreadsheet indicated residents on puree portions would get the following food items:
Pure apple glazed meat balls 2 pieces (pcs)
Puree brown rice Florentine 1/3 cup (c, household measurement)
Puree carrots with parsley 1/3 c
Puree wheat roll ¼ c
Margarine 1 teaspoon
Mousse Dessert 1/3 c, no chocolate chips
Milk 4 ounces (oz, unit of measurement)
During an interview on 11/06/2024 at 11:19 a.m. with Registered Dietitian (RD), RD stated puree diets was used for those residents with chewing and swallowing problems. RD stated puree food should have a texture of mashed potato and should form and hold it shape on the plate. RD stated if the puree food was runny, it could get mixed up with other food and residents would have difficulty to scoop out their food using their utensils. RD stated the cook probably added more water to the puree food and it would lessen the nutrients causing residents to lose wight as a potential outcome. RD stated standardized recipe should be followed exactly.
During concurrent observation and interview on 11/6/2024 at 11:55 a.m. with RD, RD stated the carrots was a little watery for puree.
During a review of the facility's standardized recipe titled Recipe: Carrots with Parsley, dated 2024, the standardized recipe indicated, Pureeds: Puree #12 scoop. Puree following the pureed recipes in the Food Safety/Misc. section of Book #1.
During a review of the facility's standardized recipe titled Recipe: Pureed (IDDSI Level 4) Vegetables, dated 2024, the standardized recipe indicated 5. The finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished puree must pass IDDSI level 4 testing requirements (i.e. the fork drip, fork pressure, and spoon tilt test.
During a review of the facility's Diet Manual titled Regular Pureed Diet/IDDSI Level 4, dated 2024, the Diet Manual indicated, DESCRIPTION: the pureed diet is a regular diet that has been designed for residents who have difficulty chewing/and or swallowing. The texture of the prepared pureed food items included on this diet should be smooth and free of lumps, hold their shape, while not being too firm or sticky, and should not weep.
During a review of the facility's policies and procedures (P&P) titled Food Preparation, dated 7/19/2024, the P&P indicated, POLICY: Food shall be prepared by methods that conserve nutritive value, flavor, and appearance. PROCEDURE: (1) The facility will use approved recipes, standardized to meet the resident census.
During a review of IDSSI website titled IDDSI dated 7/2019, the IDSSI website indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance when:
a.
The polenta (a grainy dish made from boiled cornmeal)...
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Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance when:
a.
The polenta (a grainy dish made from boiled cornmeal) was watery, runny, and touching other foods on the plate for Resident 10.
b.
Fresh green salad with dressing was served frozen and wilted for Resident 10.
These failures had the potential to result in 95 of 96 facility residents getting food from the kitchen, including Resident 10 at risk of unplanned weight loss, a consequence of poor food intake.
Findings:
During a review of Resident 10's admission Record, the admission Record indicated the facility originally admitted Resident 10 on 3/11/2010 and readmitted the resident on 5/19/2024 with diagnoses including chronic kidney disease ([CKD] a long term condition where the kidneys are damaged and cannot filter blood properly), Type II diabetes mellitus ([DM 2] a chronic disease that occurs when the body does not produce enough insulin (hormone that lowers the level of glucose [sugar] in the blood) or does not use it properly, resulting in high blood sugar levels) and dysphagia (difficulty swallowing).
During a review of Resident 10's Minimum Data Set (MDS, a resident assessment tool), dated 9/18/2024, the MDS indicated Resident 10 was moderately intact (process of thinking and reasoning) with daily decision making. The MDS indicated Resident 10 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity) and assistance throughout or intermittently when eating.
During a review of Resident 10's Order Summary Report, dated 5/19/2024, the Order Summary Report indicated Resident 10 was ordered a consistent carbohydrate ([CCHO] a therapeutic diet with the same amount of carbohydrates per meal that helps control blood sugar levels), no added salt ([NAS] no salt packet served on the tray) with regular liquid (fluids with no restriction) consistency.
During a concurrent observation and interview on 11/6/2024 at 12:40 p.m. with Resident 10, it was observed that the salad looked wilted, and the polenta was runny on the plate. Resident 10 stated he did not like the food and did not like the way how it looked. Resident 10 stated he could did not even know what the food was.
During a review of the facility's daily spreadsheet titled Fall Menus, dated 11/5/2024, the spreadsheet indicated residents on regular diet (diet with no restriction) would get the following food items:
Lemon chicken piccata (pan-fried chicken cutlet), 3 oz (oz, unit measurement)
Polenta half (½) cup (c, household measurement)
Spinach au gratin (a baked dish of spinach covered in a cheese sauce and breadcrumbs) ½ c
Parsley flakes
Fresh green salad with dressing ½ c
Gelatin 2.7 oz with whip topping 1 tablespoon.
Milk 4 oz
During a concurrent observation and interview on 11/5/2024 at 12:27 p.m., of the test tray (a process of tasting, temping, and evaluating the quality of food) with the Dietary Supervisor (DS), the DS stated the polenta was watery and runny. The DS stated the salad was frozen and the tray was not presented well as the polenta was touching other food items on the plate. The DS stated frozen salad could lose its nutrients and change its flavor. The DS stated a good tray presentation enhanced residents to eat. The DS stated residents would not eat the food resulting to weight loss as a potential outcome for the residents.
During an interview on 11/06/2024 at 11:19 a.m. with the Registered Dietitian (RD), the RD stated the standardized recipes must be followed for the food to looked appetizing and so that food would not change its flavor. The RD stated residents would not have an appetite because the food did not look good resulting to weight loss as a potential outcome.
During a review of the facility's policies and procedures (P&P) titled Food Preparation, dated 7/19/2024, the P&P indicated, POLICY: Food shall be prepared by methods that conserve nutritive value, flavor, and appearance. PROCEDURE: (1) The facility will use approved recipes, standardized to meet the resident census.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices were followed in the kitchen when:
a. Garbanzo (chickpe...
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Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices were followed in the kitchen when:
a. Garbanzo (chickpea) salad and sherbert were not labeled with product names.
b. Three eggs and hash brown (staff food) in a Styrofoam container was sitting on the countertop by the thawing spinach container.
c. Staff walked around inside the walk-in refrigerator while drinking from an open coffee tumbler.
d. Domes and pans were stacked wet.
e. Ice machine internal parts had brown and black slimy dirt when wiped with paper towel.
f. Internal parts of the mixer had dry food residues and buildup.
g. Staff's cellphone was stored on top of the pot in the clean area.
These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 95 of 96 medically compromised residents who received food and ice from the kitchen.
Findings:
a. During an observation on 11/5/2024 at 8:14 a.m. of the reach-in freezer, frozen items had no product name label.
During an observation on 11/5/2024 at 8:20 a.m., in the walk-in refrigerator, prepared food item had no product name label.
During a concurrent observation and interview on 11/05/2024 at 8:34 a.m. with Dietary Supervisor (DS) and Assistant Dietary Supervisor (ADS), DS stated their process of labeling food was, once the food was opened, the staff had to cover it, label it with open date, expiration dates and the name of the food item. DS stated the prepared food item was not labeled with name. ADS stated the prepared food item was pinto beans but had to double check and it was garbanzo beans. DS stated the ice cream and sherbert individually portioned on dishes were not labeled with product names. DS stated the staff must label the food with the product name so that staff were aware what they were serving the residents. DS stated if food items were not labeled with name, the wrong food could be given to residents and could cause allergic reactions to some residents who had allergies as a potential outcome.
During a review of facility's Policies and Procedures (P&P) titled, Labeling and Dating of Foods, dated 7/19/2024, the P&P indicated, POLICY: All food items in the storeroom, refrigerator, and freezer needed to be labeled and dated. All prepared food needed to be covered, labeled, and dated. Items can be dated individually or in bulk on a tray with masking tape if going to be used for meal service (i.e. salads, drinks, and other miscellaneous items for tray line).
During a review of Food Code 2022, the Food Code 2022 indicated, 3-501.17 Commercially processed food, open and hold cold, (B) except specified in (E) - (G) of this section, refrigerated, ready-to-eat time/temperature control for food safety food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacture's use-by- date if the manufacturer determined the use-by date based on food safety.
b. During an observation on 11/5/2024 at 8:19 a.m. in the preparation area where spinach was thawing, there was a Styrofoam bowl container with three boiled eggs and one hash brown near the thawing spinach.
During an interview on 11/5/2024 at 8:51 a.m. with DS, DS stated the Styrofoam bowl container with eggs and hash brown were food from the tray line for [NAME] 1's breakfast and it should not be in the preparation area as it could cause cross-contamination.
During a review of facility's P&P titled, Employee Meals, dated 7/19/2024, P&P indicated, POLICY: Food brought by employees outside the facility shall not be kept in the facility's refrigerator in the kitchen nor prepared or reheated in the facility's kitchen. All containers should be labeled with employee's name and the date it was brought in.
c. During an observation on 11/5/2024 at 8:20 a.m. near the walk-in freezer, a staff walked around while drinking coffee from a coffee tumbler without a cover.
During an interview on 11/5/2024 at 8:42 a.m. with DS, DS stated staff could not eat in the working area and they could not bring drinks in the kitchen unless it was covered. DS stated staff needed to go to the lunch area to eat and drink. DS stated staff went in the walk-in refrigerator and got some milk and the coffee tumbler was not covered. DS stated walking and drinking in the walk-in refrigerator was not okay due to cross contamination. DS stated residents could have vomiting and diarrhea as a potential outcome of cross-contamination.
During a review of the facility's P&P titled Employee Meals, dated 7/19/2024, the P&P indicated, Staff must eat in designated meal areas. Eating in the kitchen is not allowed.
During a review of the facility's P&P titled, Cross-Contamination, dated 7/19/2024, the P&P indicated, Cross-contamination is the process by which bacteria or other microorganisms are transferred from one food to another. Hazards are present when preparing, storing, and serving foods. The residents are counting on each one of you to protect their health by proper food handling.
During a review of the facility's P&P titled, Phone/Personal Belongings of Employee Storage Area, dated 7/19/2024, the P&P indicated, Not allowed activities such as eating in the kitchen production area, chewing gum, spitting, smoking, or chewing tabaco. These activities cause you to bring your hands to your mouth, thus contaminating them with saliva that contains harmful germs.
During a review of Food Code 2022,, the Food Code 2022 indicated 2-401 Food Contamination Prevention. 2-401.11 Eating, Drinking, or using Tabaco Products (A) Except as specified in (B) of this section, an employee shall eat, drink, or use any form of tobacco products only in designated areas where the contamination of exposed food; clean equipment, utensils, and linens; unwrapped single-service and single-use articles; or other items needing protection cannot result. (B) A food employee may drink from a closed beverage container if the container is handled to prevent contamination of: (1) the employee's hands; (2) the container; and (3) Exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.
d. During an observation on 11/5/2024 at 10:58 a.m. the domes by the dishwashing area were stacked wet.
During a concurrent observation and interview on 11/6/2024 at 2:55 p.m. with ADS near the three-compartment sink, ADS stated the pans were stacked wet. ADS stated it was important to air dry the pots and pans before stacking them for storage as wet pans grow bacteria when stacked wet. ADS stated residents could get sick of vomiting and diarrhea as a potential outcome.
During a review of facility's P&P titled Dishwashing, dated 7/19/2024, the P&P indicated, Dishes are to be air dried in rack before stacking and storing.
During a review of Food Code 2022, the Food Code 2022 indicated, 4-901.11 Equipment and Utensils, air-drying required. After cleaning and sanitizing equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food and; (B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry.
e. During an observation on 11/5/2024 at 11:09 a.m. of ice machine 2, the internal parts of the ice machine 2 had brown and black slimy dirt when wiped with paper towel.
During an interview on 11/5/2024 at 11:12 a.m. with ADS, ADS stated ice machine 2 was last cleaned two months ago by an outside vendor and the staff only cleaned the external parts daily. ADS stated they used ice for nourishments and water every mealtime for residents. ADS stated ice machine 2 internal parts looked like brown and black dirt. ADS stated it was not okay for the Ice machine 2 to have dirt because residents might get sick due to the bacteria in the ice machine upon consumption of the ice.
During an interview on 11/5/2024 at 11:23 a.m. with DS and Maintenance Supervisor (MS), DS stated maintenance personnel was responsible for cleaning ice machine 2. MS stated the last time Ice machine 2 was last cleaned last Saturday. DS stated it was not okay for the ice machine to have dirt as residents could have food borne illnesses after consuming ice as a potential outcome.
During a review of the facility's vendor invoice titled, Invoice, dated 9/16/2024, the invoice indicated ice Machines 1 and 2 were cleaned by an outside vendor on 9/16/2024.
During a review of facility's P&P titled, Ice Machine Cleaning Procedures, dated 7/19/2024, the P&P indicated, POLICY: The ice machine needs to be cleaned and sanitized monthly. The internal components cleaned monthly or per manufacturer's recommendations, and the date recorded when cleaned. Procedure: Clean inside of ice machine with sanitizing agent per manufacturer's instructions. Rinse the inside again with clear warm water several times to be certain that all traces of sanitizer have been removed.
During a review of Food Code 2022, the Food Code 2022 indicated, 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or storing a food temperature measuring device, and (5) At the time during the operation when contamination may have occurred.
During a review of Food Code 2022, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.
f. During an observation on 11/6/2024 at 9:55 a.m. the mixer internal parts had dried up food buildup.
During an interview on 10/8/2024 at 10:17 a.m. with ADS, ADS stated they last used the mixer yesterday at dinner time to mix the pudding. ADS stated it was the cooks and cook assistant's responsibility to clean the mixer after each use and a cleaner comes in once a week to detail clean. ADS stated the mixer internal parts had dried food buildup and it was not okay as it should have been cleaned yesterday after use. ADS state the potential outcome to residents would be vomiting and diarrhea as the mixer could have bacteria in it.
During a review of facility's cleaning schedule titled, Daily Cleaning Schedule, dated 7/19/2024, the P&P indicated, there was not a schedule for cleaning the mixer.
During a review of Food Code 2022, the Food Code 2022 indicated, 4-602.12 Cooking and Baking Equipment. (A) The food contact surfaces of cooking and baking equipment shall be cleaned at least every 24 hours. This section does not apply to hot oil cooking and filtering equipment if it is cleaned as specified subparagraph 4-602.11 (D)(6).
g. During a concurrent observation and interview on 11/6/2024 at 10:28 a.m. with DS in the pot storage area, there was a cellphone on top of the pot. DS stated it was a personal cellphone of [NAME] 1.
During an interview on 11/6/2024 at 10:31 a.m. with DS, DS stated staff could not use or store their cellphone in the working area as it would be a distraction for them and there could be cross-contamination of food as phones could be dirty. DS stated residents could get sick of foodborne illnesses as a potential outcome.
During a review of the facility's P&P titled, Phone/Personal Belongings of Employee Storage Area, dated 7/9/2024, the P&P indicated Handling your cellphone can pass along bacteria. The phone may have germs from your mouth or hands. (Recommend use of cellphone be limited to breaks unless an emergency, as well as personal belongings, and emphasis washing hands after touching or using cellphone and personal belongings).
During a review of Food Code 2022, the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301-3-306.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to enforce its policy and procedures of storing food brought in by family or visitors in a way that it was either separate or eas...
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Based on observation, interview, and record review the facility failed to enforce its policy and procedures of storing food brought in by family or visitors in a way that it was either separate or easily distinguishable from facility food when there was no designated refrigerator space.
This failure had the potential to result in a decrease food intake resulting to unintentional (without trying) weight loss, frustrations, and psychosocial harm to 95 of 96 facility residents.
Findings:
During an interview on 11/7/2024 at 2:12 p.m. with the Dietary Supervisor (DS), the DS stated they allowed family to bring food for the residents; however, family were not allowed to bring food for more than a meal. The DS stated if family brought food for more than one (1) meal, they must throw everything away because there was no designated refrigerator for residents in the kitchen and in the nurses' station. The DS stated this was not a good practice because residents could feel angry and feel bad. The DS stated she could store the food in the kitchen's refrigerator; however, would not be a good sanitary practice as it could cause cross-contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another).
During an interview on 11/7/2024 at 2:34 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated they do not have a refrigerator in the nurses' station so if there were foods from the outside needing refrigerator they must refer to the DS. LVN 1 stated they could not let food requiring refrigeration just hanging out as it could spoil. LVN 1 stated he would suggest having a designated refrigerator for residents outside food to make it favorable for residents. LVN 1 stated residents may or may not feel bad as a potential outcome.
During an interview on 11/7/2024 at 3:15 a.m. with the Director of Nursing (DON), the DON stated they do not have storage for extra food requiring refrigerator beyond one meal for the food of the residents coming from an outside source. The DON stated they used to have a refrigerator in Station 2; however, the refrigerator was used and labeled for staff use only. The DON stated they did not have a refrigerator designated for resident's food from the outside. The DON stated residents would feel deprived as a potential outcome of not being able to keep or store their food coming from their family or friends.
During a review of the facility's policies and procedures (P&P) titled Food from Outside Sources, dated 7/19/2024, the P&P stated Food brought in from outside the facility kitchen for resident's consumption will be monitored. This is done to measure the effectiveness of this intervention in residents with low food intake, to be sure the food is within the guidelines of the diet order, and to better assess nutrient intake. Nursing and/or Admissions will provide the family of new admits with the information sheet Bringing in food for our residents. Procedure: Prepared foods, beverages, or perishable food that requires refrigeration, can be stored for the resident in the facility kitchen, nursing station's refrigerator or in the residents' personal refrigerator. In the food service department, the policy on the food storage will apply. Otherwise, if unopened, refrigerated, or frozen items will be disposed of by the expiration date on the container. If opened, the food must be sealed, dated to the date opened a disposed of in 2 days after opening. Frozen items such as ice cream, will be disposed in 30 days.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to:
1.Ensure the indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) drainage bag was not touching the floor for one of five sampled residents (Resident 16) reviewed during the Infection Control task.
2. Ensure Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics] that uses targeted gown and glove use during high contact resident care activities) were implemented by Housekeeper 1 (HSK 1) and Certified Nursing Assistant 5 for one of five sampled residents (Resident 16) reviewed during the Infection Control task.
3. Ensure resident nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) tubing was not touching the floor while connected to the resident for one of two sampled residents (Resident 3) reviewed under the respiratory care area.
These failures had the potential to spread infections and illnesses among residents and staff.
Findings:
1.a.During a review of Resident 16's admission Record, dated 11/7/2024, the admission Record indicated the facility admitted Resident 16 on 4/10/2024 and readmitted the resident on 9/29/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), benign prostatic hyperplasia (BPH - enlargement of the prostate gland that may result in urinary retention), and encounter for a urinary device.
During a review of Resident 16's History and Physical (H&P), dated 9/29/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. The H&P further indicated the resident had recently been hospitalized for severe sepsis (a potentially life-threatening complication of an infection) and a complicated urinary tract infection.
During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool), dated 10/14/2024, the MDS indicated Resident 16 had the ability to understand others and the ability to be understood. The MDS further indicated the resident was dependent on staff assistance with eating, oral hygiene, toileting, bathing, dressing, personal hygiene, and mobility.
During a review of Resident 16's Order Summary Report, dated 11/1/2024, the Order Summary Report indicated the following orders:
-Indwelling catheter for diagnosis of obstructive and reflux uropathy (interruption of urinary outflow at any level in the urinary tract), dated 10/15/2024.
-Indwelling catheter: monitor every shift for signs and symptoms of infection such as pain, redness and drainage at the site; urine output for cloudiness, bleeding and sedimentation, dated 9/30/2024.
During a review of Resident 16's Care Plan regarding an indwelling catheter, initiated 4/11/2024, the Care Plan indicated a goal that the resident would show no signs or symptoms of infection.
During an observation on 11/5/2024 at 9:44 a.m., inside Resident 16's room, Resident 16 lay in bed. Observed the indwelling catheter drainage bag inside of a privacy bag (pouch designed to easily slip over and discreetly conceal urine in a drainage bag from public view), the drainage bag inside the privacy bag was touching the floor.
During a concurrent observation and interview on 11/5/2024 at 9:48 a.m., Certified Nursing Assistant 6 (CNA 6) entered Resident 16's room and stated the catheter bag was touching the floor. CNA 6 stated the drainage bag inside of the privacy bag should not be touching the floor to prevent infection in the resident. CNA 6 stated the drainage bag should be placed in a clean basin to create a barrier between the bag and the dirty floor.
During an observation on 11/7/2024 at 11:45 a.m., Resident 16 lay in bed with the bed in the lowest position, observed the indwelling catheter drainage bag inside of a privacy bag and touching the floor.
During a concurrent observation and interview on 11/7/2024 at 11:51 a.m., CNA 5 entered Resident 16's room and stated the resident's indwelling catheter drainage bag in the privacy bag was on the floor. CNA 5 stated she had removed the basin that was under the drainage bag because it was dirty. CNA 5 stated she was going to get a clean basin and lowered the resident's bed because she didn't want him to fall, but the drainage bag was left on the floor. CNA 5 stated she should have brought the clean basin to the room prior to removing the dirty basin so the drainage bag was not left on the floor.
During an interview on 11/7/2024 at 1:28 p.m., with the Infection Preventionist (IP), the IP stated indwelling catheter drainage bags should be placed in a privacy bag and should not be on the floor. The IP stated drainage bags inside of privacy bags should be off the floor because dirt and germs from the floor can get on the drainage bag then travel to the resident causing an infection like a UTI.
During an interview on 11/8/2024 at 11:34 a.m., with the Director of Nursing (DON), the DON stated indwelling catheter drainage bags in a privacy bag should not be on the floor. The DON stated if a drainage bag is on the floor, bacteria may travel from the floor to the resident potentially causing an infection.
During a review of the facility policy and procedures (P&P) titled, Catheter Care, Urinary, last reviewed 7/19/2024, the (P&P) indicated the purpose of this procedure is to prevent catheter associated urinary tract infections. Be sure the catheter tubing and drainage bag are kept off the floor.
During a review of the facility's (P&P) titled, Surveillance for Infections, last reviewed 7/19/2024, the policy and procedure indicated the infection preventionist will conduct ongoing surveillance for healthcare associated infections and other epidemiologically (relating to the study of how diseases and disorders are spread, controlled, and impact populations) significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions.
1.b. During a concurrent observation and interview on 11/5/2024 at 9:39 a.m., with HSK 1, observed an Enhanced Standard Precaution sign posted at the entrance to Resident 16's shared room. Observed HSK 1 mopped the floor, touched a chair, and touched a wheelchair in the shared resident room. Observed HSK 1 did not don (put on) a gown while cleaning the environment. HSK 1 stated she should be wearing a gown while cleaning the room of an EBP resident.
During an interview on 11/5/2024 at 9:40 a.m., with the Quality Assurance Nurse (QA), the QA stated she observed HSK 1 cleaning Resident 16's shared room and HSK 1 was not wearing a gown. The QA stated HSK 1 should have donned a gown while cleaning the environment to prevent the spread of infection.
During a concurrent observation and interview on 11/7/2024 at 11:51 a.m., with CNA 5, observed an Enhanced Standard Precaution sign posted at the entrance to Resident 16's share room. Observed CNA 5 entered Resident 16's room and stated the resident's indwelling catheter drainage bag was on the floor. CNA 5 exited the room and then returned with a clean privacy bag and a clean basin. CNA 5 donned gloves, pulled the resident's covers up to access the drainage bag, removed the drainage bag from the dirty privacy bag, placed the clean privacy bag on the indwelling catheter drainage bag, then placed the drainage bag in the clean basin on the floor. Observed CNA 5 did not don a gown while accessing the indwelling catheter.
During a follow interview on 11/7/2024 at 12:04 p.m., with CNA 5, CNA 5 stated Resident 16 was on EBP. CNA 5 stated EBP means staff must use a gown when changing the resident and changing his linens for infection control and to protect the resident. Observed CNA 5 refer to the EBP sign posted at Resident 16's room entrance. CNA 5 stated the EBP sign indicated to don a gown when providing care for an indwelling device. CNA 5 stated she did not wear a gown when she accessed Resident 16's indwelling catheter drainage bag. CNA 5 stated she did not don a gown because she was nervous, but she should have.
During a concurrent interview and record review on 11/7/2024 at 1:28 p.m., with the IP, the IP reviewed the facility provided Enhanced Standard Precaution Sign and policy and procedure regarding EBPs. The IP stated the facility (P&P) indicates to don a gown for high contact resident care activities. The IP stated the Enhanced Standard Precautions sign is used for residents on EBPs. The IP stated the sign indicates that all staff must don gloves and a gown when cleaning the environment or accessing an indwelling device. The IP stated gowns are worn to minimize the spread of MDROs from staff members clothing to susceptible residents with indwelling devices like an indwelling catheter. The IP stated CNAs should don a gown and gloves when touching the indwelling catheter drainage bag because the catheter tubing could transmit bacteria to the resident causing an infection. The IP Stated housekeepers should also don a gown and gloves when cleaning the room of a resident on EBPs because there are other residents in the shared room and the gown and gloves prevents the transmission of bacteria from one resident to another resident potentially causing infection.
During a interview on 11/8/2024 at 11:34 a.m., with the DON, the DON stated EBP is a technique to protect residents prone to infection, including residents with indwelling catheters, from cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) of MDROs. The DON stated HSK 1 and CNA 5 did not follow the facility policy when they did not don gowns while providing care and while cleaning the environment for a resident on EBP.
During a review of the facility-provided Los Angeles County Department of Public Health Enhanced Standard Precautions sign, dated 9/8/2021, the sign indicated to wear gloves and a gown for high contact resident care activities including activities of daily living, caring for devices, and cleaning the environment.
During a review of the facility (P&P) titled, Enhanced Barrier Precautions, last reviewed 7/19/2024, the (P&P) indicated EBPs are an infection prevention and control intervention and are utilized to prevent the spread of MDROs to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity and PPE is changed before caring for another resident. Examples of high contact resident care activities requiring providing hygiene, assisting with toileting, device care or use (urinary catheter). EBPs are indicated for residents with wounds or indwelling medical devices regardless of MDRO colonization.
2. During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 on 3/10/2010 and readmitted the resident on 10/1/2024 with diagnoses including pneumonia (an infection/inflammation in the lungs), abnormal weight loss, and other lack of coordination.
During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had short-term and long-term memory problems and severe daily decision-making impairment, and was dependent on facility staff for activities of daily living including eating, hygiene, dressing, showering/bathing himself, and surface-to-surface transfers. The MDS further indicated Resident 3 received oxygen therapy.
During a review of Resident 3's H&P, dated 10/17/2024, the H&P indicated Resident 3 does not have the capacity to understand and make decisions.
During a review of Resident 3's Order Summary Report, dated 10/16/2024, the Order Summary Report indicated to administer oxygen at two to three liters (a unit of measure for volume) per minute via nasal cannula or mask to maintain an oxygen saturation (a measurement of how much oxygen the blood is carrying as a percentage) greater than 92 percent (%) every shift for episodes of low oxygen saturation.
During a review of Resident 3's Treatment Administration Record (TAR), dated 11/5/2024, the TAR indicated Resident 3 was administered oxygen at two to three liters per minute via nasal cannula or mask to maintain an oxygen saturation greater than 92%.
During a concurrent observation and interview with CNA 6, on 11/5/2024, at 10:24 a.m., inside Resident 3's room, CNA 6 confirmed Resident 3's nasal cannula tubing was touching the floor while connected to Resident 3's nose. CNA 6 stated Resident 3's nasal cannula tubing should not be touching the floor because the floor is dirty and can cause cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another) between the floor and the tubing. CNA 6 further stated if cross-contamination occurs, there is potential for Resident 3 to get an infection.
During an interview with the DON, on 11/8/2024, at 1:52 p.m., the DON stated nasal cannula tubing should not be touching the floor to prevent infection. The DON further stated the floor is a potential area for infection and residents can potentially get sick when their nasal cannula is touching the floor while connected to the resident.
During a review of the facility's (P&P) titled, Surveillance for Infections, last reviewed 7/19/2024, the P&P indicated the infection preventionist will conduct ongoing surveillance for healthcare associated infections and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide education about the risks and benefits of, obtain consent o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide education about the risks and benefits of, obtain consent or refusal for, and/or administer the 2023/2024 coronavirus disease 2019 vaccine (medication used to prevent complications from COVID-19 [a highly contagious viral infection that can trigger respiratory tract infection]) for three of five sampled residents (Resident 16, 57, and 91) reviewed during the Infection Control task by failing to:
1. Ensure informed consent was obtained prior to the administration of the 2024/2025 COVID-19 vaccine to Resident 16.
2. Offer and/or clarify with the physician the appropriateness for the administration of the 2024/2025 COVID-19 vaccine for Resident 57.
3. Ensure vaccine education was provided and documented per the facility policy and procedures prior to the administration of the 2024/2025 COVID-19 for Resident 91.
These deficient practices had the potential to result in adverse reactions (any unexpected or dangerous reaction to a drug) to receiving vaccines, denial of the resident's right to refuse vaccines, and an increased risk of residents developing complications from COVID-19 including acute respiratory failure (a serious condition that occurs suddenly when the lungs cannot get enough oxygen).
Findings:
1.During a review of Resident 16's admission Record dated 11/7/2024, the admission Record indicated the facility admitted Resident 16 on 4/10/2024 and readmitted the resident on 9/29/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), and benign prostatic hyperplasia (BPH - enlargement of the prostate gland that may result in urinary retention).
During a review of Resident 16's History and Physical (H&P) dated 9/29/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool) dated 10/14/2024, the MDS indicated Resident 16 had the ability to understand others and the ability to be understood. The MDS further indicated the resident was dependent on staff assistance with eating, oral hygiene, toileting, bathing, dressing, personal hygiene, and mobility.
During a review of Resident 16's Physician Orders, the Physician Orders indicated:
- COVID - 19 vaccine inject 0.3 milliliters (mL, a unit of measurement) intramuscularly (by way of the muscle) one time only for COVID - 19 bivalent booster vaccine (a seasonal COVID-19 vaccine), observe resident and administration site for fifteen minutes after vaccine administration, dated 10/4/2024.
During a review of Resident 16's Nursing Clinical Notes, the clinical notes indicated the following:
- On 10/7/2024 at 3:56 p.m., the Infection Preventionist (IP) noted that signed consent for the COVID-19 vaccine was obtained, and the vaccine was administered on the left deltoid (muscle in the arm).
During a concurrent interview and record review on 11/7/2024 at 1:28 p.m., with the IP, the IP reviewed Resident 16's physician orders for 10/2024, Nursing Clinical Notes for 10/2024, and Medication Administration Record. The IP stated residents are screened for vaccination upon admission, readmission, and annually for seasonal vaccines. The IP stated if a resident will receive a vaccine, then informed consent is obtained from the resident or resident representative and education is provided regarding the risk and benefits of the vaccine. The IP stated the benefit of vaccines is that they prevent illness. The IP stated the risk of vaccines are there are potential side effects from vaccine administration. The IP stated the COVID-19 vaccine was administered to Resident 16 on 10/7/2024. The IP stated he overlooked obtaining informed consent for Resident 16's COVID-19 vaccine. The IP stated he thought the facility had received the signed consent form during the resident's admission process and prior to vaccine administration from the resident's public guardian (a person appointed to be responsible for the care of individuals who are no longer able to make decisions or care for themselves), but they had not received consent. The IP stated the importance of obtaining informed consent prior to vaccine administration is the public guardian makes decisions in the best interest of the resident and is appointed by the court to give consent for medical treatments. The IP stated when vaccines are administered without obtaining informed consent, residents may receive medical treatment they do not want. The IP stated he assumed he had received informed consent for the administration of vaccines to Resident 16, but he never talked with the resident's public guardian.
During a concurrent interview and record review on 11/8/2024 at 11:34 a.m., with the Director of Nursing (DON), the DON reviewed the facility policy and procedures regarding vaccine administration. The DON stated she was made aware that the IP administered vaccines to Resident 16 without obtaining informed consent. The DON stated the facility process is the admission nurse discusses vaccines with the resident or resident representative and obtains consent. The DON stated prior to the administration of the vaccine, consent should be verified. The DON stated the resident or resident representative have the right to refuse any treatment including vaccines. The DON stated resident rights must be respected. The DON stated when Resident 16's public guardian did not provide consent it could potentially result in harm to the resident from vaccine adverse effects or the resident receiving a vaccine they do not want. The DON stated the facility policy regarding vaccine administration was not followed.
During a review of the facility policy and procedures (P&P) titled, Infection Preventionist, last reviewed 7/19/2024, the (P&P) indicated the IP is responsible for coordinating the implementation and updating the infection prevention and control program (IPC). The IP has obtained specialized IPC training beyond initial professional training or education prior to assuming the role, including the prevention of respiratory infections.
During a review of the facility (P&P) titled, Vaccination of Residents, last reviewed 7/19/2024, the policy indicated all residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated, or the resident has already been vaccinated. Prior to receiving vaccinations, the resident or legal representative will be informed and provided information and education regarding the benefits and potential side effects of the vaccinations. Provisions of such education shall be documented in the resident's medical record.
During a review of the facility (P&P) titled, Coronavirus Disease (COVID-19) - Vaccination of Residents, last reviewed 7/19/2024, the policy indicated each resident is offered the COVID - 19 vaccine unless the immunization is medically contraindicated, or the resident has already been immunized. The resident or RP has the opportunity to accept or refuse a COVID-19 vaccine. COVID - 19 vaccine education and documentation are overseen by the IP and coordinated by his or her designee. Before the COVID-19 vaccine is offered, the resident is provided with education regarding the benefits, risks, and potential side effects associated with the vaccine. Residents must sign a consent to vaccinate form prior to receiving the vaccine. Select adverse events for COVID-19 vaccines are reported, including serious adverse events, multisystem inflammatory syndrome (a group of symptoms linked to swollen, inflamed, organs or tissues) in adults, and cases of adverse events that result in hospitalization or death.
2. During a review of Resident 57's admission Record dated 10/28/2024, the admission Record indicated the facility admitted Resident 57 on 12/6/2022 and readmitted the resident on 10/25/2024 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body), cerebral infarction (stroke, when blood flow to the brain is blocked or there is sudden bleeding in the brain ), and dementia (a progressive state of decline in mental abilities).
During a review of Resident 57's H&P, dated 10/25/2024, the H&P indicated the resident had fluctuating capacity to understand and make decisions. The H&P further indicated the resident was re-admitted from the hospital and was in stable condition.
During a review of Resident 57's MDS dated [DATE], the MDS indicated Resident 57 had the ability to understand others and the ability to be understood. The MDS further indicated the resident required partial/moderate assistance with dressing and personal hygiene, and required substantial/maximal assistance with toileting and bathing.
During a review of Resident 57's Physician Orders, the Physician Orders indicated:
- May have COVID - 19 vaccine, dated 10/25/2024.
During a review of Resident 57's Immunization Audit Report, dated 11/7/2024, the audit report indicated the COVID-19 vaccine was last administered on 12/16/2023.
During a concurrent interview and record review on 11/7/2024 at 1:28 p.m., with the IP, the IP reviewed Resident 57's physician orders for 10/2024 and Immunization Audit Report. The IP stated residents are screened for vaccination upon admission, readmission, and annually for seasonal vaccines including the COVID-19 vaccine. The IP stated the COVID-19 vaccine was last administered to Resident 57 on 12/16/2024 and the resident had not received the 2024/2025 COVID-19 vaccine. The IP stated the resident was recently hospitalized and the IP decided the resident should not receive the COVID-19 vaccine. The IP stated he did not contact the resident's physician regarding the COVID-19 vaccine. The IP stated the resident's physician should have been notified to make the decision regarding the appropriateness for the administration of the COVID - 19 vaccine, but the physician was not contacted. The IP stated the resident's physician knows the resident's medical condition and the physician should be the one to decide to give an order to give or not give the COVID-19 vaccine. The IP stated when he decided to not give Resident 57 the COVID-19 vaccine and did not consult with the resident's physician it could potentially result in the resident becoming ill from pneumonia caused by COVID-19.
During a concurrent interview and record review on 11/8/2024 at 11:34 a.m., with the DON, the DON reviewed the facility policy and procedures regarding vaccine administration. The DON stated Resident 57's physician and family should make the decision whether to give the COVID-19 vaccine. The DON stated it is a medical decision to not give a vaccine and medical decisions are made by physicians. The DON stated it was not within the IP's scope of practice to decide that COVID-19 vaccine was not appropriate for Resident 57. The DON stated vaccines are administered for the prevention of illness or to lesson the effects of the illness. The DON stated when a vaccine is not administered it may result in resident's being more prone to illness.
During a review of the facility (P&P) titled, Vaccination of Residents, last reviewed 7/19/2024, the policy indicated all residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated, or the resident has already been vaccinated. Certain vaccines may be administered per the physician approved facility protocol after the resident has been assessed by the physician for medical contraindications for each vaccine.
During a review of the facility (P&P) titled, Coronavirus Disease (COVID-19) - Vaccination of Residents, last reviewed 7/19/2024, the policy indicated each resident is offered the COVID - 19 vaccine unless the immunization is medically contraindicated, or the resident has already been immunized. Residents who are eligible to receive the vaccine are strongly encouraged to do so. Residents are screened for contraindications to the vaccine, medical precautions and prior vaccination before being offered the vaccine.
3. During a review of Resident 91's admission Record dated 7/17/2024, the admission Record indicated the facility admitted Resident 91 on 2/29/2024 and readmitted the resident on 7/16/2024 with diagnoses that included severe sepsis (a life-threatening blood infection), urinary tract infection (an infection in the bladder/urinary tract), osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of the sacral region (region at the bottom of the spine), and infection of the skin and subcutaneous (below the skin) tissue.
During a review of Resident 91's H&P, dated 7/16/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 91's MDS, dated [DATE], the MDS indicated Resident 91 had the ability to understand others and usually had the ability to be understood. The MDS further indicated the resident was dependent on staff for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, and mobility.
During a review of Resident 91's Nursing Clinical Notes for 10/2024, the clinical notes indicated on 10/7/2024 at 3:21 p.m., the IP noted that verbal consent for the COVID vaccine was obtained, and the vaccine was administered on the left deltoid. The Nursing Clinical Notes did not indicate that education regarding the risk and benefits of the vaccine were provided.
During a concurrent interview and record review on 11/7/2024 at 1:28 p.m., with the IP, the IP reviewed Resident 91's physician orders for 10/2024, Nursing Clinical Notes for 10/2024, and Medication Administration Record. The IP stated residents are screened for vaccination upon admission, readmission, and annually for seasonal vaccines. The IP stated if a resident will receive a vaccine, then informed consent is obtained from the resident or resident representative and education is provided regarding the risk and benefits of the vaccine. The IP stated the benefit of vaccines is that they prevent illness. The IP stated the risk of vaccines are there are potential side effects from vaccine administration. The IP stated the COVID-19 vaccine was administered to Resident 91 on 10/7/2024. The IP stated he could not find an Informed Consent form for the COVID-19 vaccine for Resident 91. The IP stated he received verbal consent and documented it in the Clinical Notes. The IP stated there was no documented evidence that education regarding the risk and benefits of the COVID-19 vaccine was discussed with the resident's representative. The IP stated the importance of providing education regarding vaccines is so the family is aware the benefits and the risks of vaccination.
During a concurrent interview and record review on 11/8/2024 at 11:34 a.m., with the DON, the DON reviewed the facility policy and procedures regarding vaccine administration and Resident 91's Nursing Clinical Notes dated 10/7/2024. The DON stated the IP did not document that education regarding the risk and benefits of the COVID-19 vaccine were discussed prior to the administration of the vaccine. The DON stated the importance of documenting that education was provided was to ensure the family was aware of reason for receiving the vaccine and the possible side effects because the family has the right to refuse the vaccine after hearing the potential side effects.
During a review of the facility (P&P) titled, Vaccination of Residents, last reviewed 7/19/2024, the policy indicated all residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated, or the resident has already been vaccinated. Prior to receiving vaccinations, the resident or legal representative will be informed and provided information and education regarding the benefits and potential side effects of the vaccinations. Provision of such education shall be documented in the resident's medical record.
During a review of the facility (P&P) titled, Coronavirus Disease (COVID-19) - Vaccination of Residents, last reviewed 7/19/2024, the policy indicated each resident is offered the COVID - 19 vaccine unless the immunization is medically contraindicated, or the resident has already been immunized. COVID - 19 vaccine education and documentation are overseen by the IP and coordinated by his or her designee. Before the COVID-19 vaccine is offered, the resident is provided with education regarding the benefits, risks, and potential side effects associated with the vaccine.
May 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure that the physician was notified when one of three sampled residents (Resident 1) had a change in condition.
This deficient practice ...
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Based on interview and record review, the facility failed to ensure that the physician was notified when one of three sampled residents (Resident 1) had a change in condition.
This deficient practice had the potential for delayed medical interventions for Resident 1.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 4/30/2024 with diagnoses that included urinary tract infection (UTI - an infection in any part of the urinary system [kidneys, bladder, or urethra]), benign prostatic hyperplasia ((BPH - a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream), and obstructive and reflux uropathy (occurs when urine cannot drain through the urinary tract and backs up into the kidney).
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 5/15/2024, indicated the resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills was intact. The MDS indicated Resident 1 was dependent on facility staff for toileting hygiene. The Bladder and Bowel section indicated Resident 1 had an indwelling catheter and was incontinent of bowel.
A review of Resident 1 ' s Bowel (a long tube in the body which digested food passes from the stomach to the anus) and Bladder (a hallow organ that stores urine in the body) Evaluation, dated 5/3/2024, indicated the resident had an indwelling catheter for urinary retention or bladder outlet obstruction.
A review of Resident 1 ' s History and Physical, dated 5/8/2024, indicated the resident had the capacity to understand and make decisions.
A review of Resident 1 ' s Physician ' s Order, dated 5/8/2024, indicated to monitor every shift for signs and symptoms of infection such as cloudiness, bleeding, and sedimentation of the urine output.
A review of Resident 1 ' s Care Plan on indwelling urinary catheter, initiated on 5/12/2024, indicated the resident ' s goal to be free from catheter related trauma and will not show signs and symptoms of urinary infection. The Care Plan Interventions included checking catheter tubing for kinks every shift and as needed. The Care Plan Intervention indicated to monitor, record, and report to the physician for sign and symptoms of urinary tract infection which included urine cloudiness.
A review of Resident 1 ' s Progress Notes, dated 5/24/2024, indicated the resident had a yellow urine output with whitish sediments. There was no documentation that Resident 1 ' s attending physician was notified about the sediments in the urine output.
On 5/28/2024 at 10:38 a.m., during a concurrent observation and interview, observed Resident 1 lying in bed, facing the right side, with white sheet covering the resident from chest down to toes, and an indwelling catheter tubing hanging on the right side of the bed frame. Certified Nursing Assistant 1 (CNA 1) removed the white sheet and Resident 1 ' s black pants and noted the catheter did not have a securement device (strap free devise which locks the catheter in place, stabilizes the catheter and eliminates any chance of sudden pull). Resident 1 was observed with feces in the disposable brief and on the bed cover. CNA 1 removed Resident 1 ' s disposable brief and picked up the pieces of feces from the resident ' s bed. Licensed Vocational Nurse 1 (LVN 1) stated that Resident 1 ' s indwelling urinary catheter output was white and cloudy.
On 5/28/2024 at 10:50 a.m., during a concurrent observation and interview, observed Resident 1 ' s indwelling urinary catheter with Registered Nurse 1 (RN 1). RN 1 stated that Resident 1 ' s indwelling urinary catheter was not secured with a securement device and the resident ' s urine output was white to yellow in color, thick, and cloudy. RN 1 stated that Resident 1 ' s indwelling urinary catheter should be anchored on the resident's leg to prevent dislodgment and bleeding. RN 1 stated that Resident 1 ' s movement with an unsecured urinary catheter tubing had the potential to cause UTI. RN 1 stated that Resident 1 ' s urine output was a change of condition and the resident ' s attending physician was not notified.
On 5/28/2024 at 11:23 a.m., during an interview, RN 2 stated that on 5/28/2024 at 8:30 a.m., LVN 1 reported to him that Resident 1 ' s urine output was cloudy. RN 2 stated that Resident 1 ' s urine output was not reported to the attending physician. RN 2 stated that Resident 1 ' s attending physician should be notified as soon as the resident ' s change of condition was identified.
On 5/28/2024 at 12:36 p.m., during a concurrent interview and record review, the facility ' s policy and procedure titled, Urinary Catheter Care, dated 12/8/2023, was reviewed with the Director of Nursing (DON). The DON stated Resident 1 ' s indwelling urinary catheter should be anchored on the resident's leg to prevent pulling of the catheter, accidental dislodgement, and infection. The policy indicated to report findings to the physician or supervisor immediately.
A review of the facility ' s policy and procedure titled, Change in a Resident ' s Condition or Status, dated 12/8/2023, indicated the facility promptly notifies the resident, his attending physician, and the resident representative of changes in the resident ' s medical/mental condition and/or status.
A review of the facility ' s policy and procedure titled, Notification of Attending Physician, dated 12/8/2023, indicated the attending physician will be notified promptly by the licensed nurse by any sudden and/or marked adverse changes in signs, symptoms, or behavior exhibited by the resident. Examples of changes included . g. infections. The policy indicated that any attempts to notify the physician will be noted in the licensed nurses notes to include date, time, method of communication, specific information given to the physician based on the assessment of the resident ' s condition, person acknowledging contact, signature, and title of person who made the notification.
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
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to secure a resident's urinary indwelling catheter (a flexible plastic tube inserted into the bladder that helps provide continuo...
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Based on observation, interview and record review, the facility failed to secure a resident's urinary indwelling catheter (a flexible plastic tube inserted into the bladder that helps provide continuous urinary drainage) with a securement device (strap free device which locks the catheter in place, stabilizes the catheter and eliminates any chance of sudden pull) for one of one sampled residents.
This deficient practice had the potential to result in urinary catheter dislodgement (forcefully pulled out of a secure position) causing urethral (the tube through which urine leaves the body) tearing resulting to possible pain, bleeding, and infection.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 4/30/2024 with diagnoses that included urinary tract infection (UTI - an infection in any part of the urinary system [kidneys, bladder, or urethra]), benign prostatic hyperplasia ((BPH - a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream), and obstructive and reflux uropathy (occurs when urine cannot drain through the urinary tract and backs up into the kidney).
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 5/15/2024, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills was intact. The MDS indicated Resident 1 was dependent on facility staff for toileting hygiene. The Bladder and Bowel section indicated Resident 1 had an indwelling catheter and was incontinent of bowel.
A review of Resident 1 ' s Bowel (a long tube in the body which digested food passes from the stomach to the anus) and Bladder (a hallow organ that stores urine in the body) Evaluation, dated 5/3/2024, indicated the resident had an indwelling catheter for urinary retention or bladder outlet obstruction.
A review of Resident 1 ' s History and Physical, dated 5/8/2024, indicated the resident had the capacity to understand and make decisions.
On 5/28/2024 at 10:38 a.m., during a concurrent observation and interview, observed Resident 1 lying in bed, facing the right side, with white sheet covering from chest down to toes, and an indwelling catheter tubing hanging on the right side of the bed frame. Certified Nursing Assistant 1 (CNA 1) removed the white sheet and Resident 1 ' s black pants and noted the catheter did not have a securement device(strap free device which locks the catheter in place, stabilizes the catheter and eliminates any chance of sudden pull) on Resident 1. Resident 1 was observed with feces in the disposable brief and on the bed cover. CNA 1 removed Resident 1 ' s disposable brief and picked up the pieces of feces from the resident ' s bed. Licensed Vocational Nurse 1 (LVN 1) stated that Resident 1 ' s indwelling urinary catheter should be anchored on the resident's leg with a securement device.
On 5/28/2024 at 10:50 a.m., during a concurrent observation and interview, observed Resident 1 ' s indwelling urinary catheter with Registered Nurse 1 (RN 1). RN 1 stated that Resident 1 ' s indwelling urinary catheter did not hvae a securemnet device. RN 1 stated that Resident 1 ' s indwelling urinary catheter should be anchored on the resident's leg to prevent dislodgment and bleeding. RN 1 stated that Resident 1 ' s movement with an unsecured urinary catheter tubing had the potential to cause UTI.
On 5/28/2024 at 12:36 p.m., during a concurrent interview and record review, the facility ' s policy and procedure titled, Urinary Catheter Care, dated 12/8/2023, was reviewed with the Director of Nursing (DON). The DON stated Resident 1 ' s indwelling urinary catheter should be anchored on the resident to prevent pulling of the catheter, accidental dislodgement, and infection. The Changing Catheter section of the policy and procedure indicated to ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site.
Nov 2023
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had three f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had three falls at the facility since admission and needed moderate assistance from staff (helper does less than half the effort; helper lifts, hold, or supports trunk or limbs and provides more than half the effort while walking between 10 to 50 feet) when walking, was free of accidents and injury. The facility failed to provide Resident 1 supervision and assistance in accordance with the assessment and plan of care.
As a result, on 11/16/2023, Resident 1 sustained an acute fracture (sudden break of a bone) of the femoral component (generally made of metal, and curves around the end of the femur [thigh bone]) of the right total hip arthroplasty (damaged femoral head is removed and replaced with a metal stem that is placed into the hollow center of the femur).
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 1/6/2023 with diagnoses including essential (primary) hypertension (high blood pressure that does not have a known cause), muscle weakness, history of fall, personal history of (healed) fractures, bilateral (both) hip replacement, cancer of the throat and lungs, and Alzheimer ' s disease (brain condition that causes a worsening decline in memory, thinking, learning, and organizing skills).
A review of Resident 1 ' s History and Physical exam, dated 3/23/202,3 indicated Resident 1 did not have the capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 11/3/2023, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were moderately impaired. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort; helper lifts, hold, or supports trunk or limbs and provides more than half the effort while walking between 10 to 50 feet). The MDS also indicated resident had one episode of fall with injury since admission and had a bed alarm (device that contains sensors that trigger an alarm or warning light when they detect a change in pressure; the sensor pads are generally placed either under the shoulder area, or under the hip area, underneath the sheets on the mattress).The MDS also indicated Resident 1 was receiving active (resident participated) range of motion (ROM, moving the joints) exercises and walking exercises by restorative nursing assistant (RNA, nursing assistant trained to provide interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible). The MDS indicate Resident 1 did not use assistive devices with walking (cane or walker).
A review of Resident 1 ' s Care Plan developed for the resident ' s fall risk, dated 1/11/2023, included in the interventions assisting Resident 1 with activities of daily living (ADL- such as walking, dressing and personal hygiene), providing a safe environment, observing / anticipating / intervening for factors causing prior falls (e.g., bowel and bladder urgency, mobility problem (standing, transferring, walking); ROM exercises or assist with ambulation if ordered.
A review of Resident 1 ' s Care plan for potential for complications, dated 1/11/2023, indicated an intervention to observe, anticipate (expect), intervene for factors causing prior falls (example given bowel/bladder urgency [sudden], mobility problem- standing, transferring, walking) and range of motion exercises or assists ambulation as ordered.
A review of Resident 1 ' s Situation-Background-Assessment-Recommendation (SBAR) Communication Form and Progress Note (communication form between members of the health care team about a resident ' s condition), dated 1/13/2023, indicated Resident 1 claimed he fell on 1/13/2023 at noon. The SBAR indicated resident was assessed with yellowish to bluish discoloration to right hand.
A review of Resident 1 ' s SBAR, dated 3/17/2023, indicated that around 4:45 p.m., Resident 1 was found on the floor, by his bed, lying on his left side with a bump on the left forehead.
A review of the Physician ' s Order for Resident 1, dated 3/22/2023, indicated to apply a bed alarm to remind Resident 1 to ask for assistance when getting out of bed.
A review of Resident 1 ' s SBAR, dated 9/22/2023, indicated Resident 1 was found at 7 a.m. lying on the floor, near the foot of the bed. Resident 1 had redness and scratched skin to back. The SBAR documentation did not include if the bed alarm was in place and functioning.
A review of Resident 1 ' s Care Plan for the actual fall sustained on 9/22/2023, included in the interventions monitoring effectiveness / response to the plan of care.
A review of Resident 1 ' s Fall Risk Evaluation, dated 11/3/2023, indicated resident had one to two episodes of fall in the past three months.
A review of Resident 1 ' s SBAR, dated 11/16/2023, indicated Certified Nursing Assistant 2 (CNA 2) reported to Registered Nurse 1 (RN 1) that resident was found lying on the floor, in the hallway, and was complaining of right hip pain. The SBAR indicated the attending physician was notified and ordered X-rays (type of radiation used to create a picture of the inside of the body) of both hips.
A review of Resident 1 ' s SBAR, dated 11/17/2023, indicated resident had worsening right hip pain, the severity was six of ten (6/10, in a pain scale for zero to 10; zero indicating no pain and 10 the worst pain possible). The Nurse Practitioner (NP) ordered to transfer Resident 1 to General Acute Care Hospital 1 (GACH 1).
A review of Resident 1 ' s Progress Note, dated 11/18/2023, indicated RN 3 from General Acute Care Hospital 1 (GACH 1) notified the Director of Nursing (DON) Resident 1 was diagnosed with had a right femur fracture (break in the thigh bone).
During an interview on 11/27/2023 at 8:10 a.m., RN 1 stated Resident 1 was ambulatory with unsteady gait (unstable pattern of walking) and had previous history of fall. RN 1 stated on 11/16/2023 he worked in the unit for residents with Coronavirus Disease - 2019 (COVID-19, - highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks) which had 40 residents, including Resident 1. RN 1 stated he had documented CNA 2 informed him of finding Resident 1 on the floor, during the interview, RN 1 stated that around 9:30 a.m. to 10 a.m., he was at the end of the hallway in front of Room A about to give medications when he saw Resident 1 falling on his right side while walking in the hallway by himself using a straight cane. RN 1 stated resident fell in front of Room F while CNA 2 was coming out of Room E. RN 1 stated the fall could have been avoided if CNA 2 stayed with the resident while he was walking in the hallway. RN 1 stated CNA 2 should have stayed with the resident and asked another staff to look for the resident ' s eyeglasses instead of leaving him by himself.
During a concurrent interview and record review on 11/27/2023 at 10:32 a.m., with the Director of Nursing (DON), Resident 1 ' s MDS, dated [DATE], and SBARs, dated 1/13/2023, 3/17/2023, 9/22/2023 and 11/16/2023, were reviewed. The MDS, dated [DATE], indicated resident needed moderate assistance and the SBARs all indicated Resident 1 ' s fall. The DON stated moderate assistance means resident should walk with a staff beside him. The DON stated CNA 2 should have stayed with him while he was walking in the hallway. The DON stated they were not able to provide supervision that day to resident 1 causing his fall.
During a concurrent interview and record review on 11/27/2023 at 11:12 a.m., with Physical Therapist 1 (PT 1), Resident 1 ' s Physical Therapist Discharge Summary (DC Summary), dated 3/23/2023 to 4/20/2023, was reviewed. The DC Summary indicated on 4/20/23 resident was able to ambulate 150 feet with standby assists from staff using a single point cane (SPC). PT 1 stated standby assists meant staff should be next to the resident while walking.
During an interview on 11/27/2023 at 11:44 a.m., the Administrator (ADM) stated fall was avoidable if CNA 2 stayed with Resident 1 while he was walking in the hallway.
A review of Resident 1 ' s GACH 1 History and Physical Reports, dated 11/20/2023, indicated Resident 11 was admitted because of a right hip fracture after a fall and the orthopedic surgeon (doctor who specializes in surgery of bones, joints, and muscles) was consulted and no surgery was indicated.
A review of Resident 1 ' s GACH 1 Final Report, dated 11/20/2023, indicated a Computed Tomography (CT scan - an imaging procedure that uses special x-ray equipment to create detailed pictures, or scans, of areas inside the body) of the right hip showed acute fracture of the femoral component of the right total hip arthroplasty with multiple fractures involving the greater trochanter (a four-sided bony prominence located at the upper part of the femur) and extending inferiorly (lower part).
A review of facility ' s policy and procedure titled, Safety and Supervision of Residents, dated 7/2017 and reviewed on 3/9/2023, indicated, Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Employees shall be trained on potential accidents hazards and demonstrate competency on how to identify and report accidents hazards and try to prevent avoidable accidents. Resident supervision is a core component of the systems approach to safety. They type and frequency of resident supervision is determined by the individual residents assessed needs and identified hazards in the environment.
Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had three falls at the facility since admission and needed moderate assistance from staff (helper does less than half the effort; helper lifts, hold, or supports trunk or limbs and provides more than half the effort while walking between 10 to 50 feet) when walking, was free of accidents and injury. The facility failed to provide Resident 1 supervision and assistance in accordance with the assessment and plan of care.
As a result, on 11/16/2023, Resident 1 sustained an acute fracture (sudden break of a bone) of the femoral component (generally made of metal, and curves around the end of the femur [thigh bone]) of the right total hip arthroplasty (damaged femoral head is removed and replaced with a metal stem that is placed into the hollow center of the femur).
Findings:
A review of Resident 1's admission Record indicated the facility admitted the resident on 1/6/2023 with diagnoses including essential (primary) hypertension (high blood pressure that does not have a known cause), muscle weakness, history of fall, personal history of (healed) fractures, bilateral (both) hip replacement, cancer of the throat and lungs, and Alzheimer's disease (brain condition that causes a worsening decline in memory, thinking, learning, and organizing skills).
A review of Resident 1's History and Physical exam, dated 3/23/202,3 indicated Resident 1 did not have the capacity to understand and make decisions.
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 11/3/2023, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were moderately impaired. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort; helper lifts, hold, or supports trunk or limbs and provides more than half the effort while walking between 10 to 50 feet). The MDS also indicated resident had one episode of fall with injury since admission and had a bed alarm (device that contains sensors that trigger an alarm or warning light when they detect a change in pressure; the sensor pads are generally placed either under the shoulder area, or under the hip area, underneath the sheets on the mattress).The MDS also indicated Resident 1 was receiving active (resident participated) range of motion (ROM, moving the joints) exercises and walking exercises by restorative nursing assistant (RNA, nursing assistant trained to provide interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible). The MDS indicate Resident 1 did not use assistive devices with walking (cane or walker).
A review of Resident 1's Care Plan developed for the resident's fall risk, dated 1/11/2023, included in the interventions assisting Resident 1 with activities of daily living (ADL- such as walking, dressing and personal hygiene), providing a safe environment, observing / anticipating / intervening for factors causing prior falls (e.g., bowel and bladder urgency, mobility problem (standing, transferring, walking); ROM exercises or assist with ambulation if ordered.
A review of Resident 1's Care plan for potential for complications, dated 1/11/2023, indicated an intervention to observe, anticipate (expect), intervene for factors causing prior falls (example given bowel/bladder urgency [sudden], mobility problem- standing, transferring, walking) and range of motion exercises or assists ambulation as ordered.
A review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR) Communication Form and Progress Note (communication form between members of the health care team about a resident's condition), dated 1/13/2023, indicated Resident 1 claimed he fell on 1/13/2023 at noon. The SBAR indicated resident was assessed with yellowish to bluish discoloration to right hand.
A review of Resident 1's SBAR, dated 3/17/2023, indicated that around 4:45 p.m., Resident 1 was found on the floor, by his bed, lying on his left side with a bump on the left forehead.
A review of the Physician's Order for Resident 1, dated 3/22/2023, indicated to apply a bed alarm to remind Resident 1 to ask for assistance when getting out of bed.
A review of Resident 1's SBAR, dated 9/22/2023, indicated Resident 1 was found at 7 a.m. lying on the floor, near the foot of the bed. Resident 1 had redness and scratched skin to back. The SBAR documentation did not include if the bed alarm was in place and functioning.
A review of Resident 1's Care Plan for the actual fall sustained on 9/22/2023, included in the interventions monitoring effectiveness / response to the plan of care.
A review of Resident 1's Fall Risk Evaluation, dated 11/3/2023, indicated resident had one to two episodes of fall in the past three months.
A review of Resident 1's SBAR, dated 11/16/2023, indicated Certified Nursing Assistant 2 (CNA 2) reported to Registered Nurse 1 (RN 1) that resident was found lying on the floor, in the hallway, and was complaining of right hip pain. The SBAR indicated the attending physician was notified and ordered X-rays (type of radiation used to create a picture of the inside of the body) of both hips.
A review of Resident 1's SBAR, dated 11/17/2023, indicated resident had worsening right hip pain, the severity was six of ten (6/10, in a pain scale for zero to 10; zero indicating no pain and 10 the worst pain possible). The Nurse Practitioner (NP) ordered to transfer Resident 1 to General Acute Care Hospital 1 (GACH 1).
A review of Resident 1's Progress Note, dated 11/18/2023, indicated RN 3 from General Acute Care Hospital 1 (GACH 1) notified the Director of Nursing (DON) Resident 1 was diagnosed with had a right femur fracture (break in the thigh bone).
During an interview on 11/27/2023 at 8:10 a.m., RN 1 stated Resident 1 was ambulatory with unsteady gait (unstable pattern of walking) and had previous history of fall. RN 1 stated on 11/16/2023 he worked in the unit for residents with Coronavirus Disease - 2019 (COVID-19, - highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks) which had 40 residents, including Resident 1. RN 1 stated he had documented CNA 2 informed him of finding Resident 1 on the floor, during the interview, RN 1 stated that around 9:30 a.m. to 10 a.m., he was at the end of the hallway in front of Room A about to give medications when he saw Resident 1 falling on his right side while walking in the hallway by himself using a straight cane. RN 1 stated resident fell in front of Room F while CNA 2 was coming out of Room E. RN 1 stated the fall could have been avoided if CNA 2 stayed with the resident while he was walking in the hallway. RN 1 stated CNA 2 should have stayed with the resident and asked another staff to look for the resident's eyeglasses instead of leaving him by himself.
During a concurrent interview and record review on 11/27/2023 at 10:32 a.m., with the Director of Nursing (DON), Resident 1's MDS, dated [DATE], and SBARs, dated 1/13/2023, 3/17/2023, 9/22/2023 and 11/16/2023, were reviewed. The MDS, dated [DATE], indicated resident needed moderate assistance and the SBARs all indicated Resident 1's fall. The DON stated moderate assistance means resident should walk with a staff beside him. The DON stated CNA 2 should have stayed with him while he was walking in the hallway. The DON stated they were not able to provide supervision that day to resident 1 causing his fall.
During a concurrent interview and record review on 11/27/2023 at 11:12 a.m., with Physical Therapist 1 (PT 1), Resident 1's Physical Therapist Discharge Summary (DC Summary), dated 3/23/2023 to 4/20/2023, was reviewed. The DC Summary indicated on 4/20/23 resident was able to ambulate 150 feet with standby assists from staff using a single point cane (SPC). PT 1 stated standby assists meant staff should be next to the resident while walking.
During an interview on 11/27/2023 at 11:44 a.m., the Administrator (ADM) stated fall was avoidable if CNA 2 stayed with Resident 1 while he was walking in the hallway.
A review of Resident 1's GACH 1 History and Physical Reports, dated 11/20/2023, indicated Resident 11 was admitted because of a right hip fracture after a fall and the orthopedic surgeon (doctor who specializes in surgery of bones, joints, and muscles) was consulted and no surgery was indicated.
A review of Resident 1's GACH 1 Final Report, dated 11/20/2023, indicated a Computed Tomography (CT scan - an imaging procedure that uses special x-ray equipment to create detailed pictures, or scans, of areas inside the body) of the right hip showed acute fracture of the femoral component of the right total hip arthroplasty with multiple fractures involving the greater trochanter (a four-sided bony prominence located at the upper part of the femur) and extending inferiorly (lower part).
A review of facility's policy and procedure titled, Safety and Supervision of Residents, dated 7/2017 and reviewed on 3/9/2023, indicated, Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Employees shall be trained on potential accidents hazards and demonstrate competency on how to identify and report accidents hazards and try to prevent avoidable accidents. Resident supervision is a core component of the systems approach to safety. They type and frequency of resident supervision is determined by the individual residents assessed needs and identified hazards in the environment.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure an allegation of abuse was reported immediately, but no later than two hours after the allegation was made, to the State Survey Agen...
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Based on interview and record review, the facility failed to ensure an allegation of abuse was reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency (SSA) for one of three sampled residents (Resident 1). On 11/16/2023 Resident 1 reported to Registered Nurse 1 (RN 1) that someone pushed him causing him to fall to the ground. The facility did not investigate and reported the allegation of abuse to the SSA.
This deficient practice had the potential to result in harm to residents from uninvestigated allegations of abuse.
Findings:
A review of Resident 1 ' s admission Record (Face Sheet) indicated the facility admitted the resident on 1/6/2023 with diagnoses that included pneumonitis (inflammation of lung tissue) due to inhalation (the process by which air enter your lungs) of food and vomit (the involuntary, forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose), hypotension (uncontrolled low blood pressure), muscle weakness and Alzheimer ' s Disease (brain condition that causes a worsening decline in memory, thinking, learning and organizing skills).
A review of Resident 1 ' s History and Physical dated 3/23/2023 indicated the resident had no capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 11/3/2023, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 1 required moderate assistance from staff while walking between 10 to 50 feet.
A review of Resident 1 ' s Situation-Background-Assessment-Recommendation (SBAR) Communication Form and Progress Note (communication form between members of the health care team about a resident ' s condition), dated 11/16/2023 indicated Resident 1 reported to Registered Nurse 1 (RN 1) that a resident pushed him.
A review of Resident 1 ' s Interdisciplinary Team (IDT- professionals from various disciplines who work in collaboration to address a patient with multiple physical and psychological needs) Note dated 11/17/2023 indicated Resident 1 initially stated that someone pushed him.
During an interview on 11/27/2023 at 8:10 a.m., RN 1 stated on 11/16/2023 between 9:30 a.m. to 10 a.m., he was at the end of the hallway in front of Room A when he saw Resident 1 falling on his right side while walking in the hallway by himself using a cane. RN 1 stated resident fell in front of Room F while Certified Nursing Assistant 1 was coming out of Room E.
During a concurrent interview and record review on 11/27/2023 at 10:32 a.m., with the Director of Nursing (DON), Resident 1 ' s SBAR dated 11/16/2023 was reviewed. The SBAR indicated a resident pushed Resident 1. The DON stated they did not report the incident to the State Survey Agency (SSA), the Ombudsman and local law enforcement because the incident was witnessed by RN 1 that no one pushed the resident on 11/16/2023.
During an interview on 11/27/2023 at 11:27 a.m., RN 1 stated Resident 1 had history of confusion and initially reported he was pushed by a resident and then later reported he fell by himself. RN 1 stated it was not allegation of abuse because he witnessed no one pushed Resident 1.
During an interview on 11/27/2023 at 11:37 a.m., the Director of Staff Development (DSD) stated he reviewed the SBAR dated 11/16/2023 that indicated Resident 1 reported to RN 1 that he was pushed. The DSD stated the allegation of abuse should have investigated and reported to SSA, the Ombudsman and local law enforcement within two hours. The DSD stated RN 1 should have reported the incident as soon as the resident reported that someone pushed him.
During an interview on 11/27/2023 at 11:44 a.m., with the Administrator, the (ADM) stated a resident reporting someone pushed him is an allegation of abuse.
A review of facility ' s policy and procedure titled, Abuse Investigation and Reporting dated 12/24/2020 and reviewed on 11/15/2023, indicated, All alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of property will be reported by the facility Administrator or designee, or his/her designee, to the following persons or agencies:
a. State licensing/certification agency responsible for surveying/ licensing the facility.
b. the local Ombudsman.
e. Law enforcement officials.
Based on interview and record review, the facility failed to ensure an allegation of abuse was reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency (SSA) for one of three sampled residents (Resident 1). On 11/16/2023 Resident 1 reported to Registered Nurse 1 (RN 1) that someone pushed him causing him to fall to the ground. The facility did not investigate and reported the allegation of abuse to the SSA.
This deficient practice had the potential to result in harm to residents from uninvestigated allegations of abuse.
Findings:
A review of Resident 1's admission Record (Face Sheet) indicated the facility admitted the resident on 1/6/2023 with diagnoses that included pneumonitis (inflammation of lung tissue) due to inhalation (the process by which air enter your lungs) of food and vomit (the involuntary, forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose), hypotension (uncontrolled low blood pressure), muscle weakness and Alzheimer's Disease (brain condition that causes a worsening decline in memory, thinking, learning and organizing skills).
A review of Resident 1's History and Physical dated 3/23/2023 indicated the resident had no capacity to understand and make decisions.
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 11/3/2023, indicated resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 1 required moderate assistance from staff while walking between 10 to 50 feet.
A review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR) Communication Form and Progress Note (communication form between members of the health care team about a resident's condition), dated 11/16/2023 indicated Resident 1 reported to Registered Nurse 1 (RN 1) that a resident pushed him.
A review of Resident 1's Interdisciplinary Team (IDT- professionals from various disciplines who work in collaboration to address a patient with multiple physical and psychological needs) Note dated 11/17/2023 indicated Resident 1 initially stated that someone pushed him.
During an interview on 11/27/2023 at 8:10 a.m., RN 1 stated on 11/16/2023 between 9:30 a.m. to 10 a.m., he was at the end of the hallway in front of Room A when he saw Resident 1 falling on his right side while walking in the hallway by himself using a cane. RN 1 stated resident fell in front of Room F while Certified Nursing Assistant 1 was coming out of Room E.
During a concurrent interview and record review on 11/27/2023 at 10:32 a.m., with the Director of Nursing (DON), Resident 1's SBAR dated 11/16/2023 was reviewed. The SBAR indicated a resident pushed Resident 1. The DON stated they did not report the incident to the State Survey Agency (SSA), the Ombudsman and local law enforcement because the incident was witnessed by RN 1 that no one pushed the resident on 11/16/2023.
During an interview on 11/27/2023 at 11:27 a.m., RN 1 stated Resident 1 had history of confusion and initially reported he was pushed by a resident and then later reported he fell by himself. RN 1 stated it was not allegation of abuse because he witnessed no one pushed Resident 1.
During an interview on 11/27/2023 at 11:37 a.m., the Director of Staff Development (DSD) stated he reviewed the SBAR dated 11/16/2023 that indicated Resident 1 reported to RN 1 that he was pushed. The DSD stated the allegation of abuse should have investigated and reported to SSA, the Ombudsman and local law enforcement within two hours. The DSD stated RN 1 should have reported the incident as soon as the resident reported that someone pushed him.
During an interview on 11/27/2023 at 11:44 a.m., with the Administrator, the (ADM) stated a resident reporting someone pushed him is an allegation of abuse.
A review of facility's policy and procedure titled, Abuse Investigation and Reporting dated 12/24/2020 and reviewed on 11/15/2023, indicated, All alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of property will be reported by the facility Administrator or designee, or his/her designee, to the following persons or agencies:
a. State licensing/certification agency responsible for surveying/ licensing the facility.
b. the local Ombudsman.
e. Law enforcement officials.
Nov 2023
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 5 (CNA 5) was not standing over a resident while feeding the resident for one (Resident 70...
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Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 5 (CNA 5) was not standing over a resident while feeding the resident for one (Resident 70) out of one sampled resident investigated for dignity.
This deficient practice had the potential to affect the residents' sense of self-worth and self-esteem.
Findings:
A review of Resident 70's admission Record indicated the facility admitted the resident on 8/28/2020, with diagnoses including multiple left rib fractures, psychosis (a mental health condition when there is a loss of contact with reality), vascular dementia (a condition that refers to changes with memory, thinking, and behavior caused by reduced blood flow in the brain), and lack of coordination.
A review of Resident 70's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 01/21/2021, indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required extensive assistance with bathing, limited assistance with dressing, toilet use, and personal hygiene, and supervision with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During an observation on 11/1/2023 at 8:28 a.m., observed Certified Nursing Assistant 5 (CNA 5) standing over Resident 70, who was in bed, while assisting the resident with feeding.
During an interview on 11/1/2023 at 8:38 a.m., CNA 5 stated Resident 70 required assistance with feeding as the resident did not want to move due to pain on the left side of the stomach. CNA 5 stated she should have been sitting down at eye level with Resident 70 while feeding the resident.
During an interview on 11/1/2023 at 3:34 p.m., with Registered Nurse 3 (RN 3), RN 3 stated CNA 5 should have been sitting down at eye level while feeding Resident 70 to maintain Resident 70's self-esteem and self-worth.
During an interview on 11/3/2023 at 9:53 a.m., with the Director of Nursing (DON), the DON stated CNA 5 should have been sitting down at eye level while feeding Resident 70 to maintain Resident 70's self-esteem, and self-worth.
A review of the facility's policy and procedure titled, Dignity, last reviewed 3/9/2023 indicated a policy statement that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. The policy indicated the following:
1.
Residents shall be treated with dignity and respect at all times.
2.
Treated with dignity, means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure the call light is within the resident's reach for two of two sampled residents (Resident 36 and Resident 50).
This def...
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Based on observation, interview, and record review, the facility failed to ensure the call light is within the resident's reach for two of two sampled residents (Resident 36 and Resident 50).
This deficient practice had the potential for delaying care and services requested by the residents and placing the residents at risk for falls and injuries.
Findings:
A review of Resident 36's admission Record indicated the facility admitted the resident on 9/13/2021, with diagnoses including schizoaffective disorder, depressive type (a mental health disorder with symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
A review of Resident 36's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/8/2023, indicated Resident 36 had the ability to make self-understood and understand others. The MDS indicated the resident required supervision with bed mobility, transfer, walk in room, walk in corridor, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene.
A review of Resident 36's Care Plan, dated 9/14/201 , indicated Resident 36 was at risk for falls related to multiple medications use, decreased safety judgment secondary to psychiatric issues. The interventions included to encourage the resident to use call light for assistance as needed and to respond promptly to all requests for assistance.
During a concurrent observation and interview on 10/31/2023 at 10:30 a.m., with Activity Assistant 3 (AA 3), observed Resident 36's call light hanging on the wall behind the resident's bed. AA 3 stated the call light should be within the resident's reach and not hung on the wall because there is a potential for the resident to fall while trying to reach for the call light.
A review of Resident 50's admission Record indicated the facility admitted the resident on 7/22/2022, with diagnoses including hemiplegia and hemiparesis affecting the left side (a condition in which one side of the body is weak and not able to move), and legal blindness (having only 10% of your vision).
A review of Resident 50's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/28/2023, indicated Resident 50 had the ability to make self-understood and understand others. The MDS indicated Resident 50 required supervision with bed mobility, transfer, walk in room, locomotion on and off unit, and eating.
A review of Resident 50's Care Plan, dated 7/10/2020, indicated Resident 50 was at high risk for falls related to history of fall, legal blindness, and getting up unassisted. The interventions included to maintain call light within reach and answer promptly.
During a concurrent observation and interview on 10/31/2023 at 10:21 a.m., with Certified Nursing Assistant 6 (CNA 6), observed Resident 50's call light on the floor. CNA 6 stated it is important that the call light is within reach so the resident can call for assistance. CNA 6 stated the resident can fall while trying to reach for the call light.
During an interview on 11/2/2023 at 1:33 p.m., with the Director of Development (DSD), the DSD stated the call light is the resident's lifeline and should have been placed within reach so the residents can communicate their needs to the staff. The DSD stated not having the call light within the resident's reach had the potential for the residents hurting themselves trying to reach for the call light.
During an interview on 11/3/2023 at 10:28 a.m., with the Director of Nursing (DON), the DON stated the call light should be within reach, so the residents are able to ask staff for assistance. The DON stated not having the call light within reach had the potential for residents' needs not being met and may result in fall related injuries.
A review of a facility policy and procedure titled, Call System, last revised on 03/2023, indicated to provide a mechanism for residents to communicate to staff a need for assistance and make sure all cords are placed within the resident's reach at all times.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide a written notice of bed hold (holding or reserving a resident's bed while the resident is absent from the facility fo...
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Based on observation, interview, and record review, the facility failed to provide a written notice of bed hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) policy and return for one out of five residents (Resident 70) investigated addressing the care area of hospitalization. Resident 70 was transferred from the facility to a general acute care hospital (GACH) on 10/30/2023.
This deficient practice had the potential to deny Resident 70's timely return to the facility due to no available bed.
Findings:
A review of Resident 70's admission Record indicated the facility admitted the resident on 8/28/2020, with diagnoses including multiple left rib fractures, psychosis (a mental health condition when there is a loss of contact with reality), vascular dementia (a condition that refers to changes with memory, thinking, and behavior caused by reduced blood flow in the brain), and lack of coordination.
A review of Resident 70's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 01/21/2021, indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required extensive assistance with bathing, limited assistance with dressing, toilet use, and personal hygiene, and supervision with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
A review of Resident 70's physician's order dated 10/30/2023, indicated a telephone order to send the resident to the emergency room (ER) secondary to left ninth (9th) rib fracture, for further evaluation and treatment.
A review of Resident 70's Progress Notes dated 10/30/2023, indicated the resident was transferred to general acute care hospital (GACH) due to fracture of the 9th left rib.
During a concurrent interview and record review on 11/1/2023 at 3:50 p.m., with Registered Nurse 3 (RN 3), Resident 70's medical record was reviewed. RN 3 stated he was unable to provide documented evidence of the notice of bed hold policy provided to the resident. RN 3 stated the licensed nurse should have provided the resident or the resident's representative the notice at the time of transfer of the resident to GACH.
During an interview on 11/3/2023 at 9:59 a.m., with the Director of Nursing (DON), the DON stated per facility policy, a written bed hold notification should have been provided to the resident or the resident's representative responsible party upon transfer to GACH to make them (resident and the resident's representative) aware that the bed would still be available upon the resident's return to the facility within seven days.
A review of the facility's policy and procedure titled, Bed-Holds and Returns, last reviewed on 3/9/2023, indicated all residents/representatives are provided written information regarding the facility and state bed-hold policies which holds or reserves a resident's bed during periods of absence (hospitalization of therapeutic leave)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer (injury to skin and underlying tiss...
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Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one of one sampled resident (Resident 77) by failing to ensure Resident 77's bilateral heel protectors were placed on the resident's heels as ordered.
This deficient practice had the potential for development and worsening of pressure ulcer/injuries to the resident.
Findings:
A review of Resident 77's admission Record indicated the facility originally admitted the resident on 5/12/2023 and readmitted the resident on 8/7/2023, with diagnoses including chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys [filter waste and excess fluid from the blood]), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and non-pressure chronic ulcer of right heel and midfoot limited to skin breakdown.
A review of Resident 77's History and Physical, dated 8/7/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 77's Order Summary Report, dated 8/7/2023, indicated an order to apply heel protectors to bilateral heel every shift for skin integrity management every shift.
A review of Resident 77's Certified Nursing Assistant (CNA) Documentation Survey Report (tasks only) for 10/2023, indicated on 10/31/2023 7 a.m. to 3 p.m. shift, the resident required moderate assistance with lying to sitting on side of bed, rolling left and right, sit to lying, and dependent with personal hygiene and toileting hygiene.
During an observation on 10/31/2023 at 8:58 a.m., observed Resident 77 lying in bed with no heel protectors on.
During an observation on 11/2/2023 at 9:06 a.m., observed Resident 77 lying in bed with no heel protectors on.
During an observation on 11/2/2023 at 10:23 a.m., observed Resident lying in bed with no heel protectors on.
During a concurrent observation and interview on 11/2/2023 at 10:40 a.m., with Nurse Aide 1 (NA 1), observed Resident 77 lying in bed. Nurse Aide 1 (NA 1) stated she does not know where the resident's heel protectors are. NA 1 stated the resident did not have heel protectors on when she started her shift. During an observation of the resident's closet, observed the resident's heel protectors inside the closet. NA 1 stated she did not place the heel protectors in the closet.
During a concurrent observation and interview on 11/3/2023 at 8:40 a.m., with Registered Nurse 5 (RN 5), in Resident 77's room, observed resident in the wheelchair wearing heel protectors. RN 5 stated the resident is supposed to wear the heel protectors while in bed unless the resident's family requested for the resident to wear the heel protectors while the resident is up on the wheelchair. RN 5 stated it is the facility's to use the heel protectors while the resident is in bed to offload (minimizing or removing weight placed on the foot to help prevent and heal ulcers) the resident's pressure points on the heels. RN 5 stated there is a risk of skin breakdown when the resident is not wearing it.
A review of the facility's policy and procedure titled, Prevention of Pressure Injuries, reviewed 3/9/2023, indicated that the purpose of this procedure is to provide information regarding identification of pressure injury (ulcer) risk factors and the interventions for specific risk factors. The procedure indicated the support surfaces and pressure redistribution with selected appropriate support surfaces based the resident's risk factors, in accordance with current clinical practice.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide catheter care (reduces the risk of complications such as infections) in a manner to prevent odors, and infection for ...
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Based on observation, interview, and record review, the facility failed to provide catheter care (reduces the risk of complications such as infections) in a manner to prevent odors, and infection for one of one sampled resident (Resident 77) investigated under the urinary catheter (a tube that is inserted into the bladder, allowing urine to drain freely) or urinary tract infection (UTI, an infection that affects part of the urinary tract-kidneys, ureters, urinary bladder and the urethra) care area.
This deficient practice had the potential for residents to develop catheter associated urinary tract infection (CAUTI, an infection of the urinary tract caused by a tube [urinary catheter] that has been placed to drain urine from the bladder).
Cross reference to F726 and F728.
Findings:
A review of Resident 77's admission Record indicated the facility originally admitted the resident on 5/12/2023 and readmitted the resident on 8/7/2023 with diagnoses including chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys [filter waste and excess fluid from the blood]), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and encounter for surgical aftercare following surgery on the genitourinary system (organs of the reproductive system and the urinary system).
A review of Resident 77's History and Physical, dated 8/7/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 77's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/4/2023, indicated the resident understood others and made self-understood. The MDS indicated the resident had an indwelling catheter (urinary catheter).
A review of Resident 77's Order Summary Report, dated 8/20/2023, indicated the order for indwelling catheter for diagnosis urinary retention.
A review of Resident 77's care plan titled, Requires assistance with Activities of Daily Living (ADL, describe fundamental skills required to independently care for oneself), initiated date of 5/15/2023, indicated the goals of meeting the resident's needs. The care plan interventions indicated the resident required up to extensive assistance by Certified Nursing Assistant (CNA) with personal hygiene and oral care, toilet use, and physical assistance by CNA with bathing/showering and as necessary.
A review of Resident 77's Certified Nursing Assistant (CNA) Documentation Survey Report (tasks only) 10/2023, indicated on 10/31/2023 7 a.m. to 3 p.m. shift, the resident required moderate assistance with lying to sitting on side of bed, rolling left and right, sit to lying, and dependent with personal hygiene and toileting hygiene.
During a concurrent observation and record review on 11/2/2023 at 10:40 a.m., with Nurse Assistant 1 (NA 1) at Resident 77's bedside, observed Resident 77 lying in bed wearing a hospital gown. Nurse Aide 1 (NA 1) stated she will give care to the resident and have the resident ready for the day. Observed NA 1 at Resident 77's left side with gloves on. NA 1 stated CNA 2 will assist her in turning the resident. CNA 2 provided privacy by drawing the curtains fully closed.
CNA 2 took two (2) dry wash cloths to the toilet sink. CNA 2 stated he soaked the washcloths in warm water. CNA 2 folded the two soaked washcloths into one bundle. Observed NA 1 provide catheter care to Resident 77. CNA 2 handed two wash cloths soaked in warm water from the toilet sink. CNA 2 was standing at Resident 77's right side with gloves on and removed the fasteners/tape off the resident's briefs. Observed the urinary catheter tubing connected to Resident 77 and draining clear, yellow urine. NA 1 used the bundled washcloth to clean the resident's left groin, right groin, and on top surface of the resident's genital area with a total of three wipes. NA 1 was not observed cleaning the area at the resident's catheter insertion and did not observe the resident was dried after the wash cloths were used. NA 1 and CNA 2 repositioned the resident to his right side to clean his backside. NA 1 used cleaning wipes to clean the resident's back area. NA 1 placed clean briefs on Resident 77.
On 11/2/2023 at 10:52 a.m., observed CNA 2 empty Resident 77's urinary drainage bag. CNA 2 stated there is 320 millimeters (unit of measurement) of urine inside. CNA 2 removed gloves, performed hand hygiene, and put on new gloves. NA 1 and CNA 2 put on resident's long-sleeve shirt and pants.
On 11/2/2023 at 11:02 a.m., NA 1 and CNA 2 transferred Resident 77 on his wheelchair. NA 1 stated she is done providing peri-care to the resident.
During an interview on 11/2/2023 at 11:20 a.m., with CNA 2, CNA 2 stated he was helping NA 1 with providing care to Resident 77 because the resident is totally dependent. CNA 2 stated they are supposed to clean the resident's catheter insertion area but did not observe NA 1 do it. CNA 2 stated NA 1 did not dry the resident after providing perineal care.
During an interview on 11/2/2023 at 11:33 a.m., CNA 2 stated it is important to clean the resident's perineal area well and gently because the resident's skin is sensitive and fragile which can result in infection or skin tears and sores.
During an interview on 11/2/2023 at 1:35 p.m., with NA 1, NA 1 stated this is the first-time she provided care to Resident 77. NA 1 stated she is supposed to clean the catheter insertion area. NA 1 stated she thought CNA 2 cleaned the resident's catheter insertion area. NA 1 stated she does not remember if she did it.
During an interview on 11/3/2023 at 3:20 p.m., with Registered Nurse 2 (RN 2), RN 2 stated it is important that licensed nurses and CNAs provide catheter care well to the residents to prevent infections.
A review of the facility's policy and procedure titled, Catheter Care, Indwelling Catheter, reviewed 3/9/2023, indicated the purpose of this procedure is to prevent infection and reduce irritation. The procedure indicated the following:
1. Position resident in semi-Fowler's position on bed pan if tolerated or use alternate position.
2. Put on gloves.
3. Pour warm water over perineal area.
4. Wash perineum well with soap and warm water, taking care to wash from front to back.
5. Cleanse area well at catheter insertion, taking care not to pull on catheter or advance further into urethra.
6. All debris must be removed from catheter at insertion site.
7. Rinse well with warm water and pat dry gently with clean towel.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards of practice to one of twenty-four sampled residents (Resident ...
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Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards of practice to one of twenty-four sampled residents (Resident 41) by failing to ensure:
1. The nasal prongs of the nasal cannula (a lightweight tube which on one end splits into two prongs which are placed in the nostrils to provide supplemental oxygen to the body) were inserted on both nostrils of Resident 41.
The deficient practice had the potential for Resident 41 not to get enough oxygen in the system causing shortness of breath leading to hypoxia (low levels of oxygen in the body).
2. The nasal cannula tubing was labeled with the date it was last changed.
The deficient practice had the potential for Resident 41's nasal cannula tubing to grow bacteria that could cause respiratory infections.
Findings:
A review of Resident 41's admission Record indicated the facility admitted Resident 41 on 8/13/2015 and readmitted Resident 41 on 8/26/2023, with diagnoses including acute respiratory failure (a serious condition that makes it difficult to breathe on your own) with hypercapnia (a buildup of carbon dioxide in the body), acute pulmonary edema (a buildup of fluid in the lungs), and dependence on supplemental oxygen.
A review of Resident 41's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/6/2023, indicated Resident 41 had the ability to make self-understood and understand others. The MDS indicated Resident 41 was on oxygen therapy (a treatment that provides extra oxygen to breathe).
A review of Resident 41's Order Summary Report, dated 8/26/2023, indicated an order to administer oxygen at 2 liters per minute (LPM, a measurement of the velocity at which air flows into the sample probe) via nasal cannula/mask to maintain oxygen (O2) saturation (a measurement of how much oxygen in the blood is carrying a percentage of the maximum it could carry) greater than ( > ) 92% every shift for low O2 saturation and to change and label oxygen cannula, oxygen tubing, humidifier (medical device to humidify supplemental oxygen), and bag weekly on Saturdays 11-7 shift every night shift every Sat.
A review of Resident 41's Care Plan indicated Resident 41 has a care plan addressing oxygen therapy, if necessary (PRN) related to (r/t) episode of low O2 saturation after hemodialysis (a treatment to filter wastes and water from the blood), initiated on 8/12/2022.
During a concurrent observation and interview on 10/31/2023, at 10:14 a.m., with Licensed Vocational Nurse 2 (LVN 2), observed Resident 41's nasal cannula prong not inserted on both nostrils of the resident and the oxygen tubing was not labeled with the date it was last changed. LVN 2 stated the nasal cannula prong should be inserted on both resident's nostrils to get the right amount of oxygen in the body. LVN 2 stated the incorrect placement of the nasal cannula to the resident's nose could lead to shortness of breath and hypoxia to resident. LVN 2 also stated the oxygen tubing was not labeled with the date it was last changed. LVN 2 stated the failure to date the tubing could lead to infection because you do not know when it was last changed.
During an interview on 11/2/2023, at 1:33 p.m., with the Director of Staff Development (DSD), the DSD stated the resident was not receiving proper dosage of oxygen due to the improper placement of the nasal cannula on the resident that could lead to shortness of breath. The DSD stated the oxygen tubing should be labeled with the date it was last changed for infection control. The DSD stated after the oxygen tubing sat for a long time, it could grow bacteria in the tubing that resident can breathe in. The DSD stated labeling the oxygen tubing helps to know when to replace it.
During an interview on 11/3/2023, at 10:31 a.m., with the Director of Nursing (DON), the DON stated the nasal cannula prong should sit on both nostrils of the resident to get the prescribed amount of oxygen to the resident. The DON stated failure of the staff to place the nasal cannula could lead to shortness of breath on the resident. The DON stated the oxygen tubing should be labeled with the date it was last changed so the staff know when to change the tubing and for infection control.
A review of the facility's recent policy and procedure titled, Oxygen Equipment, last reviewed on 3/9/2023, corroborated with the DSD on 11/2/2023, at 1 p.m., indicated the facility will use disposable pre-filled humidifiers, tubing, mask, and cannulas for residents receiving oxygen. The equipment is to be discarded after use. Tubing should be replaced every week.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0728
(Tag F0728)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure Nurse Aide 1, who was employed as a Certified Nursing Assistant, had successfully completed the state's Certified Nursing Assistant ...
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Based on interview and record review, the facility failed to ensure Nurse Aide 1, who was employed as a Certified Nursing Assistant, had successfully completed the state's Certified Nursing Assistant (CNA) competency evaluation examination (a standardized assessment that measures the knowledge and skills of individuals seeking certification as a CNA). The facility failed to provide NA 1's CNA certificate number.
This deficient practice had the potential to result in the residents receiving substandard care, leading to potential health risks and complications.
Cross reference to F690 and F728.
Findings:
During an interview and record review on 11/3/2023 at 9:43 a.m., with the Assistant Administrator (AADM), reviewed NA 1's employee file. The AADM stated the facility hired NA 1 on 7/28/2023 as full time CNA. The AADM stated NA 1's certificate number and orientation checklist was not on file.
During a concurrent interview and record review on 11/3/2023 at 1:44 p.m., with the Director of Staff Development (DSD), reviewed NA 1's training program certificate. The DSD stated the training program certificate indicated NA 1 completed the training program on 4/9/2021.
During an interview on 11/3/2023 at 4:52 p.m., with the DSD, the DSD stated NA 1 an education (training program) certificate but did not have a certificate number to work as a CNA. The DSD stated NA 1 did not complete the CNA state competency evaluation examination. The DSD stated it was an oversight on his part.
A review of the facility's policy and procedure titled, Credentialing of Nursing Service Personnel, reviewed 3/9/2023, indicated that a nursing service personnel who require a certification to provide resident care or treatment without direction or supervision within the scope of the individual's certification must present verification of such certification prior to or upon employment. The procedure indicated nursing personnel requiring a certification are not permitted to perform direct resident care services until all licensing/background checks have been completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one of five sampled residents (Residents 81) reviewed for unnecessary medications was free from unnecessary psychotropic medications...
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Based on interview and record review, the facility failed to ensure one of five sampled residents (Residents 81) reviewed for unnecessary medications was free from unnecessary psychotropic medications (medications capable of affecting the mind, emotions, and behavior) by failing to provide documented diagnosis for administering Olanzapine (antipsychotic medication, drug used to manage abnormal condition of the mind described as involved a loss of contact with reality) to Resident 81.
This deficient practice had the potential to result in ineffective treatment and placed the resident at risk for receiving unnecessary psychotropic medication and adverse effects (unwanted effects that a medication may have) including sedation, fatigue, death typically occurred due to heart failure (a progressive heart disease that affects pumping action of the heart muscles), or sudden death.
Findings:
A review of Resident 81's admission Record indicated the facility admitted the resident on 2/17/2022, with diagnoses including vascular dementia (a type of dementia that occurs when there is damage to the blood vessels in the brain, leading to problems with cognition and memory), unspecified psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), and delusional disorders (type of mental health condition in which a person cannot tell what is real from what is imagined).
A review of Resident 81's History and Physical, dated 7/21/2023, indicated the resident does not have the capacity to understand and make decisions.
A review of Resident 81's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/17/2023, indicated the resident made self-understood and understood others. The MDS indicated the resident did not have an active diagnosis of schizophrenia in the last seven days.
A review of Resident 81's Order Summary Report, dated 9/5/2023, indicated an order for Olanzapine tablet, give 2.5 milligrams (mg, a unit of measure) by mouth at bedtime for schizophrenia (mental disorder in which people interpret reality abnormally) manifested by auditory hallucinations as evidenced by talking to unseen being.
During a concurrent interview and record review on 11/2/2023 at 3:23 p.m., with Registered Nurse 4 (RN 4), reviewed Resident 81's physician orders, progress notes, psychiatric progress notes, H & P, and diagnosis list. RN 4 stated the resident has an order for Olanzapine for which the resident was receiving for diagnosis of schizophrenia. Resident 81's Psychiatric Progress Notes dated 8/22/2023, 9/13/2023, and 10/11/2023, H&P, and Diagnosis List did not indicate the resident has a diagnosis of schizophrenia.
During a concurrent interview and record review, on 11/3/2023 at 9:53 a.m., reviewed Resident 81's Pharmacy Discharge Note, dated 2/17/2022, with RN 4. RN 4 stated the resident has the following orders for Olanzapine:
-
Olanzapine tab 5 mg by mouth (PO) every six hours as needed for mil-moderate agitation, olanzapine not to exceed 40 mg total daily dose.
-
Olanzapine tab 5 mg PO at bedtime for thought organization/mood.
During a concurrent interview and record review, on 11/3/2023 at 5:12 p.m., with the Director of Nursing (DON), reviewed the facility's policy and procedure (P&P) titled, Psychoactive Drug Monitoring, The DON stated the use of anti-psychotic medications should include a diagnosis with description of symptoms, discussion of the psychiatrist and medical differential diagnosis to show justification for the continued use.
A review of the facility's P&P titled, Psychoactive Drug Monitoring, reviewed 3/9/2023, indicated that it is the facility's policy that every effort is made to ensure that residents receiving these medications obtain the maximum benefit with the minimum of untoward effects. The procedure indicated that the resident's physician provides a justification for the continued use of the drug and dosage as clinically appropriate, and this justification appears somewhere in the resident's record. The procedure indicated the justification to include:
a.
A diagnosis with description of symptoms.
b.
A discussion of the psychiatrist and medical differential diagnosis (a systematic process used to identify the proper diagnosis from a set of possible competing diagnoses).
c.
A description of the rationale for the choice of a particular treatment(s).
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, interview, and record review the facility failed to maintain safe and proper temperatures for all medications for one of two medication room refrigerators (Med Ref 1) by:
1. Fail...
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Based on observation, interview, and record review the facility failed to maintain safe and proper temperatures for all medications for one of two medication room refrigerators (Med Ref 1) by:
1. Failing to ensure the medication refrigerator freezer did not have ice buildup.
2. Failing to ensure the refrigerator temperature was maintained between 36 Fahrenheit (F, a unit of measure) to 46 F.
This deficient practice had the potential to result in degradation or alteration of the medications, rendering them ineffective or even potentially harmful.
Cross reference to F908.
Findings:
During a concurrent observation and interview, in Med Ref 1, on 11/1/2023 at 2:44 p.m., with Licensed Vocational Nurse 2 (LVN 2), observed medication refrigerator with temperature reading at 28 F. LVN 2 stated there is ice buildup inside the fridge and will ask maintenance to clean the refrigerator. LVN 2 stated the medication refrigerator's temperature should be between 36 F to 46 F.
During a concurrent observation and interview, inside Med Ref 1, on 11/1/2023 at 3:55 p.m., with the Registered Nurse 1 (RN 1), observed ice buildup inside the medication refrigerator. RN 1 stated the medication refrigerator's temperature reading is at 29 F. RN 1 stated 29 F is below the appropriate temperature for medications that needs refrigeration. RN 1 stated the temperature of the refrigerator should be between 36 F to 46 F because it may affect the medications and render the medications ineffective. RN 1 stated there is a risk for harm to the residents who received ineffective medications. RN 1 stated the medication refrigerator's ice buildup should have been reported it to the maintenance. Observed inside the medication refrigerator the following medications:
-
One insulin (a hormone that lowers the level of sugar in the blood) glargine (a hormone for Resident 48
-
One Humulin R (an insulin medication) vial for Resident 96
-
Two (2) insulin aspart injectable pens for Resident 34
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Three (3) vials of Tuberculin Purified Protein Derivative, Diluted Aplisol (a sterile aqueous solution of a purified protein fraction for intradermal [done within the layers of skin] administration as an aid in the diagnosis of tuberculosis [disease caused by germs that are spread from person to person through the air]).
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One semaglutide (a medication that works by increasing insulin levels in your body, which decreases your blood sugar [glucose]) injectable pen for Resident 296
-
One Risperdal (an antipsychotic medication that affects chemicals in the brain) injection for Resident 12
During a concurrent interview and record review 1on 11/1/2023 at 4:06 p.m., with RN 1, the maintenance log for Nursing Station 1 was reviewed. RN 1 stated there was no documentation for a request to fix the medication refrigerator inside the medication room for 11/2023.
A review of the facility's policy and procedure titled, Medication Storage and Labeling, reviewed 3/9/2023, indicated it is the facility's policy that drugs requiring refrigeration shall be stored in a refrigerator between 36F and 46F. The procedure indicated that drugs shall be stored in appropriate temperatures and drugs requiring refrigeration shall be stored in a refrigerator between 36 F and 46 F.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to provide food that accommodates resident preferences for one out of twenty-four sampled residents (Resident 36) by failing to e...
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Based on observation, interview, and record review the facility failed to provide food that accommodates resident preferences for one out of twenty-four sampled residents (Resident 36) by failing to ensure Resident 36's preferences were updated per facility's policy and procedure.
The deficient practice had the potential for resident to have poor appetite that could potentially result in weight loss.
Findings:
A review of Resident 36's admission Record indicated the facility admitted Resident 36 on 9/13/2021, with diagnoses including protein-calorie malnutrition (an imbalance between the nutrients the body needs and the nutrients it gets), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and lymphedema (tissue swelling caused by an accumulation of protein-rich fluid drained through the body's lymphatic system [part of the immune system]).
A review of Resident 36's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/8/2023, indicated Resident 36 had the ability to make self-understood and understand others.
A review of Resident 36's Order Summary Report, dated 8/9/2023, indicated an order for NAS (No Added Salt) diet, regular texture, thin/regular liquid consistency, small portions.
A review of Resident 36's admission Nutritional Assessment, dated 9/15/2021, indicated Resident 36 was on NAS, regular texture food. The Nutritional Assessment indicated resident liked over easy eggs, regular milk, and mixed vegetables. No food dislikes were indicated on the assessment.
A review of Resident 36's Quarterly Nutritional Assessment, dated 9/8/2023, indicated Resident 36 was on NAS diet, regular texture, thin/regular liquid consistency. No indication of food likes and dislikes noted on the assessment note.
During an interview on 10/31/2023, at 10:40 a.m., Resident 36 stated she has not seen a dietician for a long time. Resident stated she wanted to update her food preferences.
During an interview and record review on 11/2/2023, at 1:59 p.m., with the Registered Dietician (RD), reviewed Resident 36's medical record. The RD stated Resident 36's diet was NAS, regular consistency, and regular texture. The RD stated the resident had her quarterly nutritional assessment on 9/8/2023. The RD stated that the Dietary Supervisor (DS) oversaw the updating of the resident's preferences. The RD stated the DS should have followed up with Resident 36 after her quarterly nutritional assessment to update Resident 36's food preferences.
During an interview and record review on 11/3/2023, at 9:28 a.m., with the DS, reviewed Resident 36's medical record. The DS stated the last time she saw the resident was 9/8/2023. The DS stated that she should have updated Resident 36's food preferences during her quarterly nutritional assessment. The DS further stated they should not wait for the quarterly nutritional assessment to update the food preferences of the residents especially if they were losing weight. The DS stated she needed more help in seeing residents more frequently to update resident's food preferences. The DS stated not seeing the residents regularly to update food preferences could lead to weight loss due to residents not eating the diet trays served to them.
During an interview on 11/3/2023, at 10:31 a.m., the Director of Nursing (DON) stated that the dietary department should have asked the resident for food preferences daily. The DON stated it was important to consider food preferences because sometimes residents refuse the food if they do not like them and if they want the food being served to them, they will eat more, thus improving their nutrition.
A review of the facility's policy and procedure titled, Nutritional Screening/Assessments/Resident Care Planning, last reviewed on 3/9/2023, indicated the Food and Nutrition Services (FNS) Director will complete the Dietician Assessment & Monitoring Sheet on a daily basis and give this sheet to the Consultant Dietician on each visit.
A review of the facility's recent policy and procedure titled, Food Preferences, last reviewed on 3/9/2023, indicated updating of food preferences will be done as residents' needs change and/or during quarterly review.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain one of two medication room refrigerators (Med Ref 1) in safe operating condition by:
1. Failing to ensure the medica...
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Based on observation, interview, and record review, the facility failed to maintain one of two medication room refrigerators (Med Ref 1) in safe operating condition by:
1. Failing to ensure the medication refrigerator freezer did not have ice buildup.
2. Failing to ensure the refrigerator temperature was maintained between 36 Fahrenheit (F, a unit of measure) to 46 F.
This deficient practice had the potential to result in degradation or alteration of the medications, rendering them ineffective or even potentially harmful.
Cross reference to F761.
Findings:
During a concurrent observation and interview, in Med Ref 1, on 11/1/2023 at 2:44 p.m., with Licensed Vocational Nurse 2 (LVN 2), observed medication refrigerator with temperature reading at 28 F. LVN 2 stated there is ice buildup inside the fridge and will ask maintenance to clean the refrigerator. LVN 2 stated the medication refrigerator's temperature should be between 36 F to 46 F.
During a concurrent observation and interview, inside Med Ref 1, on 11/1/2023 at 3:55 p.m., with the Registered Nurse 1 (RN 1), observed ice buildup inside the medication refrigerator. RN 1 stated the medication refrigerator's temperature reading is at 29 F. RN 1 stated 29 F is below the appropriate temperature for medications that needs refrigeration. RN 1 stated the temperature of the refrigerator should be between 36 F to 46 F because it may affect the medications and render the medications ineffective. RN 1 stated there is a risk for harm to the residents who received ineffective medications. RN 1 stated the medication refrigerator's ice buildup should have been reported it to the maintenance. Observed inside the medication refrigerator the following medications:
Observed inside the medication refrigerator the following medications for:
-
One insulin (a hormone that lowers the level of sugar in the blood) glargine (a hormone for Resident 48
-
One Humulin R (an insulin medication) vial for Resident 96
-
Two (2) insulin aspart injectable pens for Resident 34
-
Three (3) vials of Tuberculin Purified Protein Derivative, Diluted Aplisol (a sterile aqueous solution of a purified protein fraction for intradermal [done within the layers of skin] administration as an aid in the diagnosis of tuberculosis [disease caused by germs that are spread from person to person through the air]).
-
One semaglutide (a medication that works by increasing insulin levels in your body, which decreases your blood sugar [glucose]) injectable pen for Resident 296
-
One Risperdal (an antipsychotic medication that affects chemicals in the brain) injection for Resident 12
During a concurrent interview and record review 1on 11/1/2023 at 4:06 p.m., with RN 1, the maintenance log for Nursing Station 1 was reviewed. RN 1 stated there was no documentation for a request to fix the medication refrigerator inside the medication room for 11/2023.
During an interview on 11/3/2023 at 4:14 p.m. with the Maintenance Supervisor (MS), the MS stated he was only notified yesterday, 11/2/2023, about the medication refrigerator in nursing station 1 medication room not working. The MS stated he had the medication refrigerator in the medication room replaced because it had ice buildup. The MS stated the medication refrigerator rooms are not part of his daily checks. The MS stated he will only check the medication refrigerator when the licensed nurses notify him either verbally or by writing on the maintenance log.
A review of the facility's policy and procedure titled, Refrigerators and Freezers, reviewed 12/15/2022, indicated that the facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation. The procedure indicated the supervisor takes immediate action if temperatures are out of range, actions that are necessary to correct the temperatures are recorded on the tracking sheet, including the repair personnel and/or department contacted.
A review of the facility's policy and procedure titled, Medication Storage and Labeling, reviewed 3/9/2023, indicated it is the facility's policy that drugs requiring refrigeration shall be stored in a refrigerator between 36 F and 46 F. The procedure indicated that drugs shall be stored in appropriate temperatures and drugs requiring refrigeration shall be stored in a refrigerator between 36 F and 46 F.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record, the facility failed to provide an environment that is restraint-free as indicated in the facility's policy for three (3) of 3 sampled residents (Residents ...
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Based on observation, interview, and record, the facility failed to provide an environment that is restraint-free as indicated in the facility's policy for three (3) of 3 sampled residents (Residents 51, 53, and 55) investigated under the Restraint care area by:
1.
Failing to ensure least restrictive measures were attempted prior to use of self-release belt alarm and sensor pad alarm in bed to ensure the alarms were used to treat medical symptoms and not for discipline or convenience, for Resident 51.
2.
Failing to ensure least restrictive measures were attempted prior to use of self-release belt alarm and failing to ensure the informed consent was clarified with the physician for the use of self-release belt alarm, to ensure the self-release belt alarm was used to treat medical symptoms and not for discipline or convenience, for Resident 53.
3.
Failing to ensure least restrictive measures were attempted prior to use of pressure alarm in wheelchair and failing to ensure the informed consent for the use of pressure alarm in wheelchair and in bed was clarified with the physician prior to use, to ensure the alarms were used to treat medical symptoms and not for discipline or convenience, for Resident 55.
These deficient practices placed Residents 51, 53, and 55 at risk for affecting their self-worth for being restricted with movement and had the potential to violate the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms.
Findings:
a. A review of Resident 51's admission Record indicated the facility admitted the resident on 5/21/2018 and readmitted the resident on 9/27/2021 with diagnoses including cerebral infarction (also known as a stroke which occurs due to damage to tissues in the brain due to a loss of oxygen), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks(, and history of falling.
A review of Resident 51's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 10/26/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required substantial assistance from staff eating, persona hygiene, and bed mobility, and total assistance from staff with other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
A review of Resident 51's Order Summary Report indicated the following orders:
1.
Resident may have self-release belt alarm in wheelchair to alert staff if trying to stand up unassisted. Check for placement and functionality every shift dated 9/28/2021.
2.
Resident may have sensor pad alarm in bed, to alert staff in unassisted transfer. Check for placement and functionality every shift dated 9/27/2021.
A review of Resident 51's care plan indicated Resident was a high risk for further falls related to impaired cognition, and Alzheimer's initiated 5/22/2018 with target date of 1/24/2024, indicated the resident's last documented fall incident was 3/7/2022. The care plan indicated use of appropriate device as ordered, self-release belt alarm in wheelchair to alert staff if trying to stand up unassisted.
A review of Resident 51's Facility Verification of Informed Consent to Physical Restraints, Psychotherapeutic Drugs or Prolonged Use of a Device dated 9/28/2021, indicated the following:
1.
May have self-release belt alarm in wheelchair to alert staff if trying to stand up unassisted.
2.
May have sensor pad alarm in bed to alert staff in unassisted transfer.
A review of resident 51's quarterly Restraints-Physical Assessments dated 10/31/2022, 1/27/2023, 10/26/2023 did not indicate restraint reduction strategies and alternatives attempted prior to use of the self-release belt alarm and sensor pad alarm in bed. The restraint assessments indicated self-release belt alarm in wheelchair and sensor pad alarm in bed to remind himself or alert staff if Resident 51 attempts to get up by himself. The restraint assessments did not indicate restraint reduction strategies and alternatives attempted prior to use of the self-release belt alarm while in wheelchair and sensor pad alarm in bed.
During a concurrent observation and interview on 10/31/2023 at 9:45 a.m., with Activity Assistant 1 (AA 1), observed Resident 51 in the wheelchair in the activity room with belt attached to an alarm box on the backrest of the wheelchair. Activity Assistant 1 (AA 1) stated the belt was an alarm to alert staff in case Resident 51 slides off the wheelchair.
During an interview on 11/3/2023 at 8:00 a.m., with the Minimum Data Set Assistant (MDSA), the MDSA stated she may have forgotten to indicate in Resident 51's restraint assessments that restraint reduction strategies and alternatives have been attempted prior to use of the self-release belt alarm. The MDSA stated she should have indicated in the restraints assessments the least restrictive measures attempted prior to use of the self-release belt alarm and sensor pad alarm.
During a concurrent interview and record review on 11/3/2023 at 9:13 a.m., with the Director of Nursing (DON), Resident 51's informed consent, care plan, and quarterly restraint assessments were reviewed. The DON stated the informed consents for the self-release belt alarm in wheelchair and sensor pad alarm in bed indicated the reason for use of the alarms is to alert staff of Resident 51's attempts of standing up and transferring unassisted. The DON stated there was no documented evidence in the care plan and restraint assessments that restraint reduction strategies and alternatives were attempted prior to use of the self-release belt alarm and sensor pad alarm. The DON verified the reason for the use of self-release belt alarm and sensor pad alarm was not due to a medical symptom. The DON stated the care plan and the quarterly restraint assessments should have indicated the least restrictive measures attempted to evaluate the need for continued use of the alarm. The DON stated continued use of the alarm may affect Resident 51's self- worth as his movement was restricted. The DON stated the informed consent should have been clarified with the physician to ensure the use of alarms was to treat the resident's medical condition.
b. A review of Resident 53's admission Record indicated the facility admitted the resident on 6/4/2021 with diagnoses including hemiplegia (complete paralysis of one side of the body) and hemiparesis (partial weakness of one side of the body) affecting the right dominant side, dysphagia (difficulty swallowing), and dependence on wheelchair.
A review of Resident 53's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 8/30/2023, indicated the resident had severely impaired cognition ((mental action or process of acquiring knowledge and understanding) and required total assistance from staff with locomotion on and off unit, unable to walk, and required extensive assistance with other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
A review of Resident 53's Order Summary Report indicated an order, the resident may have self-release belt alarm in wheelchair, check for placement and functionality every shift dated 8/8/2023.
A review of Resident 53's Facility Verification of Informed Consent to Physical Restraints, Psychotherapeutic Drugs or Prolonged Use of a Device dated 11/4/2021, indicated may use self-release belt alarm in wheelchair to alert staff if trying to stand up unassisted, check for placement and functionality every shift.
A review of Resident 53's care plan on risk for falls related to general muscle weakness, impaired cognition, right hemiplegia, and history of falls prior to admission initiated on 6/4/2021 and with target date of 2/27/2024, indicated an intervention may have self-release belt alarm when in wheelchair.
A review of Resident 53's quarterly Restraints-Physical Assessments dated 12/2/2022, 3/2/2023, 6/2/2023, and 8/28/2023 did not indicate restraint reduction strategies and alternatives were attempted prior to use of the self-release belt alarm. The restraint assessments indicated self-release belt alarm in wheelchair use to alert staff of resident's activity as patient is non-ambulatory.
During a concurrent observation and interview on 10/31/2023 at 9:08 a.m., with Activity Assistant 1 (AA 1), observed Resident 53 in the wheelchair in the activity room with belt attached to an alarm box. Activity Assistant 1 (AA 1) stated the belt was a self-release alarm to alert staff in case Resident 53 slides off the wheelchair.
During an interview on 11/3/2023 at 8:00 a.m., with the Minimum Data Set Assistant (MDSA), the MDSA stated she may have forgotten to indicate in Resident 53's restraint assessments that restraint reduction strategies and alternatives have been attempted prior to use of the self-release belt alarm. The MDSA stated she should have indicated in the restraints assessments the least restrictive measures attempted prior to use of the self-release belt alarm.
During a concurrent interview and record review on 11/3/2023 at 9:13 a.m., with the Director of Nursing (DON), Resident 53's informed consent, care plan, and quarterly restraint assessments were reviewed. The DON verified the self-release belt alarm informed consent indicated the use of self-release belt alarm in wheelchair was to alert staff if the resident was trying to stand up unassisted. The DON stated there was no documented evidence in the care plan and restraint assessments that restraint reduction strategies and alternatives were attempted prior to use of the self-release belt alarm. The DON verified the reason for the use of self-release belt alarm was not treat a medical symptom. The DON stated the care plan and the quarterly restraint assessments should have indicated the least restrictive measures attempted to evaluate the need for continued use of the alarms. The DON stated continued use of the alarm may affect Resident 53's self- worth as his movement was restricted. The DON stated the informed consent should have been clarified with the physician to ensure the use of alarms was to treat the resident's medical symptom.
c. A review of Resident 55's Face Sheet indicated the facility admitted the resident on 5/16/2022 with diagnoses including vascular dementia (a condition that refers to changes with memory, thinking, and behavior caused by reduced blood flow in the brain), including human immunodeficiency virus (HIV - a condition that weakens a person's immune system by destroying important cells that fight disease and infection), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
A review of Resident 55's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/27/2023, indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision with eating and locomotion in the unit, extensive assistance from staff with bed mobility, personal hygiene, and dressing, and totally dependent to staff with other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
A review of Resident 55's Order Summary Report indicated the following:
1.
Resident may have alarm in bed to alert staff if resident was getting out of bed unassisted. Check for placement every shift dated 8/8/2023.
2.
Resident may have pressure alarm in wheelchair to remind resident to call staff when in need of assistance and to alert staff of getting up unassisted.
A review of Resident 55's Facility Verification of Informed Consent to Physical Restraints, Psychotherapeutic Drugs or Prolonged Use of a Device dated 2/19/2023, indicated wheelchair/bed alarm.
A review of Resident 55's care plan on risk for falls related to gait/balance problems, decrease safety judgement, and history of falls prior to admission initiated on 5/22/2022 with a target date of 2/8/2024, indicated an intervention for bed alarm and wheelchair alarm to alert staff and to remind resident to ask for assistance.
A review of Resident 55's quarterly Restraints-Physical Assessments dated 11/17/2022, 2/15/2023, 5/16/2023, and 8/16/2023 did not indicate restraint reduction strategies and alternatives attempted prior to use of the self-release belt alarm. The restraint assessments indicated there was no behavioral problem, and restraint was not recommended.
During a concurrent observation and interview on 10/31/2023 at 9:18 a.m., observed Resident 55 sitting in the wheelchair without a wheelchair alarm. Resident 55 stated he does not need a wheelchair alarm as he can get in and out of bed to the wheelchair safely.
During a concurrent observation and interview on 10/11/2023 at 1:00 p.m., with Licensed Vocational Nurse 3 (LVN 3), observed Resident 55's sensor pad alarm with blinking green light attached to the right side of the bed. LVN 3 stated the bed alarm alerts the staff if the resident is trying to get up unassisted.
During an interview on 11/3/2023 at 8:00 a.m., with the Minimum Data Set Assistant (MDSA), the MDSA stated that she may have forgotten to indicate in Resident 55's restraint assessments that restraint reduction strategies and alternatives have been attempted prior to use of the bed alarm. The MDSA stated she should have indicated in the restraints assessments the least restrictive measures have been attempted prior to use.
During a concurrent interview and record review on 11/3/2023 at 9:13 a.m., with the Director of Nursing (DON), Resident 55's informed consent, care plan, and quarterly restraint assessments were reviewed. The DON verified the informed consent indicated wheelchair/bed alarm. The DON stated there was no documented evidence in the care plan and restraint assessments that restraint reduction strategies and alternatives have been attempted prior to use of the pressure alarm in wheelchair and bed alarm. The DON verified the reason for the use of pressure alarm in wheelchair and bed alarm was not to treat a medical symptom. The DON stated the care plan and the quarterly restraint assessments should have indicated the least restrictive measures attempted to evaluate the need for continued use of the alarms. The DON stated continued use of the alarm may affect Resident 55's self- worth as his movement was restricted. The DON stated the informed consent should have been clarified with the physician to ensure the use of alarms was to treat the resident's medical symptom.
A review of the facility's policy and procedure titled, Informed Consent for Physical/Chemical Restraints, last reviewed 3/9/2023, indicated the resident's attending physician has to inform the resident or surrogate of the risks and potential benefits of the use of chemical restraints, physical restraints, or devices that may lead to the inability to regain use of a normal bodily function. The policy indicated use of devices that may lead to the inability to regain normal bodily function will be only on written physician's order.
A review of the facility's policy and procedure titled, Use of Restraints, last reviewed 3/9/2023, indicated the following:
1.
Restraints shall only be used after other alternatives have been tried unsuccessfully.
2.
Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by less restrictive intervention and a restraint is required to treat the medical symptom.
3.
Prior to placing a restraint, there shall be a pre-restraint assessment to review the need for restraint, to determine underlying causes of the medical symptom, and if there are less restrictive interventions that may improve the symptoms.
4.
Restraints shall only be used upon the written order of a physician and after obtaining consent and shall include the specific reason related to the medical symptoms, and how the restraint will be used to benefit the resident's medical symptoms.
A review of the facility's policy and procedure titled, Alarms, Personal Use of, indicated that the facility use the least restrictive method of ensuring resident safety to provide the highest degree of resident independence possible.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident 34's admission Record indicated the facility admitted Resident 34 on 9/3/2015 and readmitted the residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident 34's admission Record indicated the facility admitted Resident 34 on 9/3/2015 and readmitted the resident on 4/1/2021 with diagnoses including hemiplegia (one-sided muscle paralysis or weakness) and hemiparesis (weakness or the inability to move on one side of the body) following cerebrovascular disease (a condition that affects the blood vessels that supply blood to the brain), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and diabetes type 2 (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly).
A review of Resident 34's History and Physical (H&P), dated 5/3/2023, indicated Resident 34 did not have the capacity to understand and make decisions.
A review of Resident 34's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/27/2023, indicated Resident 34 required one-to-two-person physical assistance with bed mobility, transfer, dressing, eating, toileting, and personal hygiene.
A review of Resident 34's Order Summary Report indicated the following orders:
- Xarelto 20 milligrams (mg - a unit of mass or weight) 1 tablet by mouth in the evening for deep vein thrombosis (DVT- a blood clot in a deep part of the leg)
-Anticoagulants medication monitoring for hematuria, black tarry stools, coffee-ground emesis, sudden headache, nausea, vomiting, lethargy, bruising, sudden changes in mentals
During a concurrent interview and record review on 10/2/2023, at 12:05 p.m., with Registered Nurse 4 (RN 4), Resident 34's care plan and physician orders were reviewed. RN 4 stated Resident 34 was receiving Xarelto (anticoagulant medication). RN 4 stated that the resident did not have a care plan for the use of Xarelto. RN 4 stated that it was important to have a care plan for the use of Xarelto to ensure the staff know what adverse side effects to monitor.
During a concurrent interview and record review on 10/3/2023, at 10:55 a.m., with Registered Nurse 2 (RN 2), Resident 34's care plan and physician orders were reviewed. RN 2 stated Resident 34 is receiving Xarelto. RN 2 stated Resident 34 did not have a care plan for the use of Xarelto. RN 2 stated care plans are important for the resident's optimal well-being.
During an interview on 1/3/2023, at 3:03pm., with the Director of Nursing (DON), the DON stated that the facility should create care plans for residents who are on anticoagulant medications. The DON stated that care plans are developed in order to evaluate if the implemented interventions are effective.
A review of the facility's policy and procedure titled Care Plans - Comprehensive, last reviewed on 3/2023, indicated, A comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, psychosocial needs shall be developed for each resident.
Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan (a written or electronic record containing all the information the resident needs to effectively manage their own health) for three out of 31 sampled residents (Residents 80, 93, 34, and 20) by failing to ensure:
1.
Resident 80 had a care plan addressing the use of an anticoagulant (Eliquis, a drug to treat and prevent dangerous blood clots).
2.
Resident 93 had a care plan addressing the resident's discharge to home.
3.
Resident 34 had a care plan addressing the use of an anticoagulant (Xarelto, anticoagulant [blood thinner medication] used to lower the risk of stroke [occurs when something blocks blood supply to part of the brain)
4.
Resident 20's echocardiogram (EKG, a noninvasive test that records the electrical signal from the heart to check for different heart conditions) was done per physician's order.
This deficient practice had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services.
Findings:
1.
A review of Resident 80's admission Record indicated the facility admitted Resident 80 on 2/25/2023, with diagnoses including transient ischemic attack (TIA, a temporary disruption in the blood supply to the brain), cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area), and peripheral vascular disease (an accumulation of plaque [fats and cholesterol] in the arteries in the legs or arms).
A review of Resident 80's History and Physical (H&P), dated 2/28/2023, indicated Resident 80 had fluctuating capacity to understand and make decisions.
A review of Resident 80's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/25/2023, indicated Resident 80 had the ability to make self-understood and understand others. The MDS indicated Resident 80 was receiving an anticoagulant (a medication used to prevent the formation of blood clots).
A review of Resident 80's Order Summary Report indicated the following orders:
-Anticoagulant/hemolytic meds monitoring- Monitor every (q) shift for hematuria (blood in the urine), black tarry stools, coffee-ground emesis (the act of vomiting), sudden severe headache, nausea and vomiting (N&V), lethargy (lack of energy), bruising, sudden changes in mental status, and or vital signs (v/s, essential body functions, including your heartbeat, breathing rate, temperature, and blood pressure), shortness of breath (SOB), nose bleeds, unusual skin discolorations every shift on 3/22/2023.
-Eliquis oral tablet (Apixaban). Give 2.5 milligrams (mg, a unit of mas or weight) by mouth two times a day for deep vein thrombosis (DVT, a medical condition that occurs when a blood clot forms in a deep vein) on 2/25/2023.
During a concurrent interview and record review on 11/1/2023, at 8:19 a.m., with the Director of Staff Development (DSD), Resident 80's care plan was reviewed. The DSD stated there was no care plan for the use of Eliquis. The DSD stated the care plan guides the staff on how to take care of the residents safely.
During an interview on 11/3/2023, at 3:40 p.m., with the pharmacist (PHARM), the PHARM stated the use of the anticoagulant medication should be care planned.
2. A review of Resident 93's admission Record indicated the facility admitted Resident 93 on 9/8/2023, with diagnoses including legal blindness (visual impairment), sensorineural hearing loss (damage to the inner ear), and history of falling.
A review of Resident 93's MDS, dated [DATE], indicated Resident 93 had the ability to make self-understood and understand others. The MDS indicated the Resident 93 had severely impaired cognitive impairment (trouble remembering, learning new whings, concentrating, or making decisions that affect everyday life). The MDS indicated Resident 93 participated in the assessment and goal setting.
A review of Physician's Orders, dated 10/3/2023, indicated may discharge home . on October 5, 2023, after he returns from 2:30 p.m. appointment at general acute care hospital 1 (GACH 1) with 2 weeks supply of medication.
During a concurrent interview and record review on 11/3/2023, at 1:30 p.m., with the DSD, Resident 93's care plan was reviewed. The DSD stated Resident 93 did not have a discharge care plan. The DSD stated the care plan for discharge was important to ensure safety and readiness of Resident 93's discharge from the facility.
A review of the facility's recent policy and procedure titled Discharge Planning, last reviewed on 3/9/2023, corroborateA review of Physician's Orders, dated 10/3/2023, indicated may discharge home . on d with the DSD on 11/2/2023, at 1 p.m., indicated establishment of discharge plans and post discharge care prior to enhance continuity of resident care. It is the policy of this facility to provide ongoing evaluation and discharge planning for all residents while in the facility. Document status in discharge planning section of Care Plan.
A review of the facility's recent policy and procedure titled, Care Planning- Interdisciplinary Team, last reviewed on 3/9/2023, indicated the care planning/Interdisciplinary Team shall develop a comprehensive care plan for each resident. A comprehensive care plan is developed within seven (7) days of the resident assessment (MDS).
A review of the facility's recent policy and procedure titled, Care Plans- Comprehensive, last reviewed on 3/9/2023, indicated the resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS). Care plans are revised as changes in the resident's condition dictates. Reviews are made at least quarterly.
4. A review of Resident 20's admission Record indicated the facility admitted the resident on 10/29/2015, with diagnosis including chronic obstructive pulmonary disease (COPD, a common lung disease causing restricted airflow and breathing problems) with acute exacerbation (the process of making something that is already bad even worse), schizoaffective disorder (a mental illness that affects thoughts, mood, and behavior) and vascular dementia (a type of dementia that occurs when there is damage to the blood vessels in the brain, leading to problems with cognition and memory).
A review of Resident 20's History and Physical, dated 4/5/2023, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 20's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/13/2023, indicated the resident understood others and able to make self-understood. The MDS indicated the resident required setup assistance with eating and upper body dressing, and required supervision assistance with oral hygiene, toileting hygiene, lower body dressing, personal hygiene, and putting on/taking off footwear.
A review of Resident 20's Physician Order, dated 9/16/2022, indicated annual EKG in September 2023, for Zyprexa (an antipsychotic medication that affects chemicals in the brain).
During a concurrent interview and record review on 11/3/2023 at 8:23 a.m. with Registered Nurse 2 (RN 2), Resident 20's Progress Notes, dated 10/4/2023 at 3:30 p.m., and care plans were reviewed. RN 2 stated the resident refused EKG three times. RN 2 stated there was no care plan developed for the resident's refusal of the EKG.
A review of the facility's policy and procedure titled, Goals and Objectives, Care Plans, reviewed 3/9/2023, indicated that care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. The procedure indicated care pan goals and objectives are defined as the desired outcome for a specific resident problem.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility licensed nursing staff failed to provide care in accordance with professional...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility licensed nursing staff failed to provide care in accordance with professional standards to one out of twenty-four sampled residents (Residents 71) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that lowers the level of sugar in the blood) administration sites to Resident 71.
This deficient practice had the potential to place the resident at increased risk of developing lipodystrophy (a group of conditions characterized by a complete or partial loss of fat tissue) and amyloidosis (when an abnormal protein called amyloid builds up in the tissues and organs).
Findings:
A review of Resident 71's admission Record indicated the facility admitted Resident 71 on 9/15/2020 and the facility readmitted Resident 71 on 1/8/2021, with diagnoses including type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high) with diabetic neuropathy (nerve damage cause by diabetes) and type 2 diabetes mellitus with diabetic retinopathy (an eye condition that can cause vision loss and blindness in people with diabetes).
A review of Resident 71's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/5/2023, indicated Resident 71 had the ability to make self-understood and understand others. The MDS indicated the resident was receiving insulin injections.
A review of Resident 71's Order Summary Report, indicated the following orders:
-Insulin glargine solution 100 units per milliliter (unit/ml, concentration of insulin per milliliter of solution). Inject 27 units subcutaneously one time a day for diabetes mellitus (DM) on 9/12/2023.
-Insulin glargine solution. Inject 42 units subcutaneously at bedtime related to type 1 diabetes mellitus without complications on 9/12/2023.
-Novolog solution (Insulin Aspart). Inject 5 unit subcutaneously three times a day for diabetes. Only give if eating meal on 8/9/2023.
-Novolog solution (Insulin Aspart). Inject as pers sliding scale: if 70-150= none. Give oral gel for blood sugar (B.S.) less than (<) 70 and call MD, if unconscious, give glucagon 1 milligram (mg, a unit of weight) intramuscular (IM, within or into the muscle) then call MD; 151-200= 2 units; 201-250= 4 units; 251-300= 6 units; 301-350= 8 units; 351-400= 10 units; 401+ = 12 and call MD, subcutaneously before meals and at bedtime for diabetes. If BS <70 glucogel (a fast-acting dextrose gel that gives an instant sugar boost) 1 tube, 8 ounces (oz, a unit of weight) orange juice (OJ) or light snack if resident alert and able to take orally, if altered level of consciousness (ALOC) give glucagon 1 ampule (amp, a small glass vessel used to hold a solution) IM recheck B.S. and call MD on 8/9/2023.A review of Resident 71's Location of Administration for Insulin from 8/2023 to 11/1/2023 indicated:
8/2023
Insulin Glargine Solution
8/3/2023 at 8:08 p.m. at the Abdomen-LLQ
8/5/2023 at 8:53 p.m. at the Abdomen- left lower quadrant (LLQ)
8/11/2023 at 8:50 a.m. at the Abdomen-LLQ
8/12/2023 at 11:20 a.m. at the Abdomen-LLQ
8/17/2023 at 9:10 a.m. at the Abdomen-right upper quadrant (RUQ)
8/18/2023 at 8:19 a.m. at the Abdomen-RUQ
8/23/2023 at 8:59 a.m. at the Arm-left
8/24/2023 at 9:30 a.m. at the Arm-left
8/25/2023 at 10:47 a.m. at the Arm-left
8/27/2023 at 8:59 a.m. at the Abdomen-right lower quadrant (RLQ)
8/28/2023 at 10:44 a.m. at the Abdomen-RLQ
Novolog Solution
8/4/2023 at 11:20 a.m. at the Abdomen- left upper quadrant (LUQ)
8/4/2023 at 4:36 p.m. at the Abdomen-LUQ
8/7/2023 at 8:41 p.m. at the Abdomen-RLQ
8/8/2023 at 6:52 a.m. at the Abdomen-RLQ
8/11/2023 at 9:53 p.m. at the Abdomen-RLQ
8/12/2023 at 6:54 a.m. at the Abdomen-RLQ
8/15/2023 at 6:31 p.m. at the Abdomen-RLQ
8/16/2023 at 5:59 a.m. at the Abdomen-RLQ
8/19/2023 at 4:58 p.m. at the Arm-left
8/19/2023 at 9:04 p.m. at the Arm-left
8/21/2023 at 5:04 p.m. at the Abdomen-RUQ
8/22/2023 at 7:04 a.m. at the Abdomen-RUQ
8/27/2023 at 9:42 p.m. at the Abdomen-RLQ
8/28/2023 at 6:54 a.m. at the Abdomen-RLQ
9/2023
Insulin Glargine Solution
9/6/2023 at 10:44 a.m. at the Abdomen-RUQ
9/7/2023 at 8:24 a.m. at the Abdomen-RUQ
9/9/2023 at 9:19 a.m. at the Abdomen-LLQ
9/10/2023 at 9:28 a.m. at the Abdomen-LLQ
9/16/2023 at 8:37 p.m. at the Abdomen-LUQ
9/17/2023 at 8:35 p.m. at the Abdomen-LUQ
9/18/2023 at 9:41 a.m. at the Arm-right
9/19/2023 at 10:19 a.m. at the Arm-right
9/23/2023 at 9 p.m. at the Abdomen-RUQ
9/24/2023 at 8:22 p.m. at the Abdomen-RUQ
9/25/2023 at 9:23 a.m. at the Abdomen-LLQ
9/26/2023 at 10:40 a.m. at the Abdomen-LLQ
Novolog Solution
9/30/2023 at 5:49 p.m. at the Abdomen-LUQ
9/30/2023 at 9:37 p.m. at the Abdomen-LUQ
10/2023 to 11/1/2023
Insulin Glargine Solution
10/1/2023 at 8:37 a.m. at the Abdomen-LLQ
10/2/2023 at 10 a.m. at the Abdomen-LLQ
10/22/2023 at 8:19 a.m. at the Abdomen-RLQ
10/23/2023 at 10:39 a.m. at the Abdomen-RLQ
10/24/2023 at 11:10 a.m. at the Abdomen-RUQ
10/25/2023 at 8:56 a.m. at the Abdomen-RUQ
11/1/2023 at 8:14 p.m. at the Abdomen-LLQ
11/1/2023 at 8:42 a.m. at the Abdomen-LLQ
Novolog Solution
10/29/2023 at 8:57 p.m. at the Abdomen-RLQ
10/30/2023 at 6:50 a.m. at the Abdomen-RLQ
10/31/2023 at 6:30 a.m. at the Abdomen-RUQ
10/31/2023 at 4:30 p.m. at the Abdomen-RUQ
During a concurrent interview and record review on 11/3/2023, at 9:32 a.m., with Registered Nurse 2, Resident 71's Location of Administration of insulin was reviewed. RN 2 stated there were repeated administration of insulin on the same site from 8/2023 to 11/1/2023. RN 2 stated licensed nurse must change administration sites to prevent bruising, discoloration, and lipodystrophy.
During an interview on 11/3/2023, at 10:31 a.m., with the Director of Nursing (DON), the DON stated insulin administration sites should be rotated to prevent lipodystrophy.
During an interview on 11/30/2023, at 3:40 p.m., with the Pharmacist (PHARM), the Pharm stated insulin administration sites should be rotated on the following sites: outer arm, outer legs and thigh, and the abdominal areas to prevent blood clot at the site of administration.
A review of the copy of Physician's Desk Reference (PDR, a thick volume that provides a guide to prescription drugs available in the United States) Nurse's Drug Handbook, no date, provided by the facility, indicated Lantus administration should alternate injection sites (upper arm, thigh, abdomen).
A review of the copy of PDR Nurse's Drug Handbook, no date, provided by the facility, indicated to watch for adverse reactions: Hypoglycemia, hypokalemia, lipodystrophy, hypersensitivity reaction, injection site reactions, pruritus, rash.
A review of the Manufacturer's Recommendation of Use for Humulin N KwikPen, US License Number 1891, manufactured by [NAME] Lily and Company, Indianapolis, IN 46285, USA, corroborated with the PHARM on 11/3/2023, at 3:40 p.m., indicated to change (rotate) your injection sites within the area you choose for each dose to reduce risk of getting lipodystrophy (pits in skin or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 7's admission Records indicated the facility admitted Resident 7 on 8/28/1995 and readmitted the residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 7's admission Records indicated the facility admitted Resident 7 on 8/28/1995 and readmitted the resident on 03/31/2023, with diagnoses including achalasia cardia (a rare swallowing disorder), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), and deaf nonspeaking (deaf people who cannot speak on oral language).
A review of Resident 7's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/8/2023, indicated Resident 7 had mild cognitive impairment (when someone has symptoms showing changes in their memory or their thinking, but the changes do not affect their ability to do day to day activities).
The MDS indicated that Resident 7 required maximal assistance from staff with toileting, dressing, showering, and personal hygiene. MDS also indicated that Resident 7 required supervision while eating and used a wheelchair as a mobility device.
A review of Resident 7's care plan, dated 2/16/2018, indicated that the resident was at high risk for injury related to smoking and required an apron during supervised smoke breaks to minimize the risk of smoking burns.
A review of Resident 7's Smoking Safety evaluation, dated 10/16/23, indicated to use a smoking apron while smoking as a safety requirement.
3. A review of Resident 29's admission Records indicated the facility admitted Resident 29 on 4/1/2019 and readmitted him on 5/7/2021 with diagnoses including bipolar type of schizoaffective disorder (a serious mental illness that affects that affects how a person thinks, feels, and behaves) and diabetes type 2 (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly).
A review of Resident 29's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/8/2023, indicated Resident 29 had mild cognitive impairment (when someone has symptoms showing changes in their memory or their thinking, but changes do not affect their ability to do day -to day activities).
The MDS indicated Resident 29 required one person assistance from staff with toileting, dressing, showering, and personal hygiene. The MDS also indicated that Resident 29 required supervision while eating and used a wheelchair as a mobility device.
A review of Resident 29's care plan, dated 5/10/2021, indicated that the resident was at high risk for injury related to smoking and required an apron during supervised smoke breaks to minimize the risk of smoking burns.
During a concurrent observation and interview on 11/1/2023 at 1:47 p.m., with Certified Nursing Assistant (CNA 4), observed Resident 7 and Resident 29 were observed not wearing smoking aprons while smoking on the patio. Certified Nursing Assistant 4 (CNA 4) stated she was only helping the Activities Assistant (AA) supervise the smoking area and was not sure why the residents were not wearing smoking aprons.
During an observation and interview on 11/3/2023 at 1:55 p.m., Resident 29 was observed not wearing a smoking apron while smoking on the patio. Resident 29 stated, I would love to wear a smoking apron if someone offered it to me.
During an interview on 11/1/2023 at 2:41 p.m., with the Activity Director (AD), the AD stated that an apron should be offered to residents before they smoke for the residents' safety.
During an interview on 11/1/2023 at 2:51 p.m., the Director of Staff Development (DSD) stated that all Certified Nursing Assistants (CNAs) have assigned residents to supervise during smoking breaks. The DSD stated that CNAs should provide residents with an apron before they start smoking.
During an interview on 1/3/2023 at 3:03 p.m., with the Director of Nursing (DON), the DON stated that if residents are not wearing an apron during smoking it puts the residents at risk for injury and burns.
A review of the facility's policy titled Country Manor Healthcare Smoking Policy and Procedure-Residents, last revised on 3/9/2023, indicated that residents will be provided with smoking aprons as necessary.
Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and implemented measures to prevent accidents for five of five sampled residents, by failing to:
1. Ensure smoking aprons were provided or offered to four of four sampled residents (Resident 7, 29 36, 55).
This deficient practice had the potential for placing the residents at risk for sustaining injuries related to cigarette burns.
2. Ensure bilateral floor mats (high-impact foam and are designed to help prevent injury from potential falls) were provided for Resident 77 as ordered by the physician.
This deficient practice had the potential to result in fall related injuries.
Findings:
1. A review of Resident 36's admission Record indicated the facility admitted the resident on 9/13/2021, with diagnoses including schizoaffective disorder, depressive type (a mental health disorder with symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
A review of Resident 36's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/8/2023, indicated Resident 36 had the ability to make self-understood and understand others.
A review of Resident 36's Smoking Safety Evaluation, date 9/8/2023, indicated apron as a safety requirement during smoking.
During a concurrent observation and interview on 11/1/2023 at 1:47 p.m., with Certified Nursing Assistant 4 (CNA 4), observed Resident 36 smoking on the patio without a smoking apron. Certified Nursing Assistant 4 (CNA 4) stated she was only helping the Activities Assistant supervise the smoking area and was not sure why the resident was not wearing a smoking apron.
During an interview on 11/1/2023 at 1:47 p.m., Activities Assistant (AA 2), AA 2 stated he had not given out the aprons because he was passing out cigarettes and lighting the cigarettes for the residents. AA2 stated the aprons should have been offered to the residents prior to lighting the cigarettes. AA 2 stated the aprons should have been offered to the residents for safety.
During an interview on 11/1/2023 at 2:41 pm., with the Activities Director (AD), the AD stated the staff supervising the smoking patio should make sure ashtrays and aprons are always present, so the residents do not burn themselves.
During an interview on 11/1/2023 at 2:51 p.m., with the Director of Staff Development (DSD), the DSD stated the staff supervising the smoking patio should provide residents with aprons and ashtrays.
A review of the facilities recent Policies and Procedures(P&P) titled, Country Manor Healthcare Smoking Policy and Procedure-Residents, last revised on 3/9/2023, indicated Residents will be provided with smoking apron as necessary.
4. A review of Resident 55's Face Sheet indicated the facility admitted the resident on 5/16/2022 with diagnoses including vascular dementia (a condition that refers to changes with memory, thinking, and behavior caused by reduced blood flow in the brain), including human immunodeficiency virus (HIV - a condition that weakens a person's immune system by destroying important cells that fight disease and infection), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
A review of Resident 55's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/27/2023, indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision with eating and locomotion in the unit, extensive assistance from staff with bed mobility, personal hygiene, and dressing, and totally dependent to staff with other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
A review of Resident 55's Smoking Safety Evaluation dated 5/16/2022, 8/19/2022, 11/17/2022, 2/15/2023, 5/16/2023, 8/16/2023, indicated the resident required smoking apron and supervision when smoking for safety.
A review of Resident 55's care plan on smoking initiated 5/25/2022 with target date 2/8/2024, indicated a goal that resident will not suffer injury from unsafe smoking practices thru the review date. The policy indicated the following interventions:
1.
Resident 55 requires supervision while smoking.
2.
Staff will continue to offer/provide a smoking apron while smoking to minimize risk of injury while smoking.
During an observation on 11/1/2023 at 1:45 p.m., observed Resident 55 sitting in the wheelchair smoking without an apron. When asked, Resident 55 stated the staff usually offer aprons but unsure why it was not offered today prior to smoking. Resident 55 stated he knew he needed it for safety to prevent cigarette burns.
During an interview on 11/1/2023 at 1:47 p.m., with Certified Nursing Assistant 9 (CNA 9), CNA 9 stated that she was just assisting to supervise the residents while smoking. CNA 9 stated she was unsure why the residents were not wearing the smoking aprons. CNA 9 stated the residents should have been wearing the smoking aprons to prevent injuries such as cigarette burns.
During an interview on 11/1/2023 at 1:47 p.m., with Activity Assistant 1 (AA 1), AA 1 stated the residents should have been offered the apron and before handing out the cigarettes.
During an interview on 11/1/2023 at 2:41 p.m., with the Activity Director (AD), the AD stated all residents should be offered the smoking aprons prior to smoking. AD stated the residents were supervised by an activity staff and CNAs and failure to offer the smoking aprons prior to smoking can cause harm to the residents.
During an interview on 11/1/2023 at 2:51 p.m., with the Director of Staff Development (DSD), the DSD stated CNAs have assigned residents to supervise during smoke breaks. The DSD stated the CNAs should have offered the apron to the residents before the smoking break started.
During an interview on 11/3/2023 at 9:55 a.m., with the Director of Nursing (DON), the DON stated smoking breaks are supervised by the activity department staff and CNAs. The DON stated smoking aprons should have been offered or provided to the residents prior to start of smoking breaks because it placed the residents at risk for injuries such as cigarette burns. The DON stated, if the residents refused, the licensed nurse (LN) should have been notified of the refusal so the LN can offer the apron again to the residents. The DON stated if the resident continues to refuse, the LN will document in the care plan.
A review of the facility's policy and procedure titled, Smoking Policy and Procedures, last reviewed 3/9/2023, indicated the residents will be provided with smoking aprons, as necessary.
5. A review of Resident 77's admission Record indicated the facility originally admitted the resident on 5/12/2023 and readmitted the resident on 8/7/2023 with diagnoses including chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys [filter waste and excess fluid from the blood]), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and non-pressure chronic ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of right heel and midfoot limited to skin breakdown.
A review of Resident 77's History and Physical, dated 8/7/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 77's Order Summary Report, dated 8/20/2023, indicated the resident may have floor mats at the side of the bed.
A review of Resident 77's care plan titled, Risk for falls, initiated date 5/15/2023, indicated the resident with goals of free of falls and interventions of maintaining a safe environment with floor mats if ordered.
A review of Resident 77's Fall Risk Evaluation, dated 9/4/2023, indicated a score of 11, indicating the resident was at risk for falls. The evaluation indicated the resident had poor vision and the resident was not able to perform standing on both feet without holding onto anything, walk straight forward, walk through a doorway, and make a turn.
A review of Resident 77's MDS, dated [DATE], indicated the resident understood others and made self-understood. The MDS indicated the resident had a recent fall with no injury.
A review of Resident 77's Interdisciplinary Note, dated 10/11/2023 at 1:39 p.m., indicated the weekly fall meeting or 90-day fall review discussed the fall incident on 8/20/2023 on 7 a.m. to 3 p.m. shift with interventions in place, floor mats on both sides of the bed.
During observations on 10/31/2023 at 8:58 a.m., and on 11/12/2023 at 9:06 a.m., and at 10:23 a.m., Resident 77 was observed lying in bed with no floor mats placed at the side of the resident's bed.
During a concurrent observation and interview on 11/3/2023 at 8:41 a.m., with Certified Nursing Assistant 10 (CNA 10), inside Resident 77's room. Observed Resident 77 sitting up in wheelchair. CNA 10 stated the resident has one floor mat that she folded and placed by the window. CNA 10 stated the floor mat should be in place at the resident's left side for the resident's safety.
During an interview on 11/3/2023 at 4:05 p.m., with the Director of Nursing (DON), the DON stated residents at risk for falls have a care plan with interventions including floor mats at side of the bed for the residents' safety. The DON stated the floor mats should be in place because residents may fall and result injury.
A review of the facility's policy and procedure titled, Falls and Fall Risk, Managing, reviewed 3/9/2023, indicated that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The procedure indicated the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure one of one Nursing Aide (Nursing Aide 1 [NA 1]) was competent to provide indwelling catheter care (reduces the risk of...
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Based on observation, interview, and record review, the facility failed to ensure one of one Nursing Aide (Nursing Aide 1 [NA 1]) was competent to provide indwelling catheter care (reduces the risk of complications such as infections) for one of one sampled resident (Resident 77), who had physician order for indwelling urinary catheter (a tube that is inserted into the bladder, allowing urine to drain freely).
This deficient practice had the potential for residents to develop catheter associated urinary tract infection (CAUTI, an infection of the urinary tract caused by a tube [urinary catheter] that has been placed to drain urine from the bladder).
Cross reference to F690 and F728.
Findings:
A review of Resident 77's admission Record indicated the facility originally admitted the resident on 5/12/2023 and readmitted the resident on 8/7/2023 with diagnoses including chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys [filter waste and excess fluid from the blood]), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and encounter for surgical aftercare following surgery on the genitourinary system (organs of the reproductive system and the urinary system).
A review of Resident 77's History and Physical, dated 8/7/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 77's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/4/2023, indicated the resident understood others and made self-understood. The MDS indicated the resident had an indwelling catheter (urinary catheter).
A review of Resident 77's Order Summary Report, dated 8/20/2023, indicated an order for indwelling catheter for diagnosis urinary retention.
A review of Resident 77's care plan titled, Requires assistance with Activities of Daily Living (ADL, describe fundamental skills required to independently care for oneself), with initiated date of 5/15/2023, indicated the goals of meeting the resident's needs. The care plan interventions indicated the resident required up to extensive assistance by Certified Nursing Assistant (CNA) with personal hygiene and oral care, toilet use, and physical assistance by CNA with bathing/showering and as necessary.
A review of Resident 77's Certified Nursing Assistant (CNA) Documentation Survey Report (tasks only) 10/2023, indicated on 10/31/2023 7 a.m. to 3 p.m. shift, the resident required moderate assistance with lying to sitting on side of bed, rolling left and right, sit to lying, and dependent with personal hygiene and toileting hygiene.
During a concurrent observation and record review on 11/2/2023 at 10:40 a.m., with Nurse Assistant 1 (NA 1) at Resident 77's bedside, observed Resident 77 lying in bed wearing a hospital gown. Nurse Aide 1 (NA 1) stated she will give care to the resident and have the resident ready for the day. Observed NA 1 at Resident 77's left side with gloves on. NA 1 stated CNA 2 will assist her in turning the resident. CNA 2 provided privacy by drawing the curtains fully closed. CNA 2 took two (2) dry wash cloths to the toilet sink. CNA 2 stated he soaked the washcloths in warm water. CNA 2 folded the two soaked washcloths into one bundle. Observed NA 1 provide catheter care to Resident 77. CNA 2 handed two wash cloths soaked in warm water from the toilet sink. CNA 2 was standing at Resident 77's right side with gloves on and removed the fasteners/tape off the resident's briefs. Observed the urinary catheter tubing connected to Resident 77 and draining clear, yellow urine. NA 1 used the bundled washcloth to clean the resident's left groin, right groin, and on top surface of the resident's genital area with a total of three wipes. NA 1 was not observed cleaning the area at the resident's catheter insertion and did not observe the resident was dried after the wash cloths were used. NA 1 and CNA 2 repositioned the resident to his right side to clean his backside. NA 1 used cleaning wipes to clean the resident's back area. NA 1 placed clean briefs on Resident 77.
On 11/2/2023 at 10:52 a.m., observed CNA 2 empty Resident 77's urinary drainage bag. CNA 2 stated there is 320 millimeters (unit of measurement) of urine inside. CNA 2 removed gloves, performed hand hygiene, and put on new gloves. NA 1 and CNA 2 put on resident's long-sleeve shirt and pants.
On 11/2/2023 at 11:02 a.m., NA 1 and CNA 2 transferred Resident 77 on his wheelchair. NA 1 stated she is done providing peri-care to the resident.
During an interview on 11/2/2023 at 11:20 a.m., with CNA 2, CNA 2 stated he was helping NA 1 with providing care to Resident 77 because the resident is totally dependent. CNA 2 stated they are supposed to clean the resident's catheter insertion area but did not observe NA 1 do it. CNA 2 stated NA 1 did not dry the resident after providing perineal care.
During an interview on 11/2/2023 at 11:33 a.m., CNA 2 stated it is important to clean the resident's perineal area well and gently because the resident's skin is sensitive and fragile which can result in infection or skin tears and sores.
During an interview on 11/2/2023 at 1:35 p.m., NA 1 stated this is the first-time she provided care to Resident 77. CNA 1 stated she is supposed to clean the catheter insertion area. NA 1 stated she thinks CNA 2 cleaned the resident's catheter insertion area. NA 1 stated she does not remember if she did it.
During an interview on 11/3/2023 at 3:20 p.m., Registered Nurse 2 (RN 2) stated it is important that licensed nurses and CNAs provide catheter care well to the residents to prevent infections.
A review of the facility's policy and procedure titled, Catheter Care, Indwelling Catheter, reviewed 3/9/2023, indicated the purpose of this procedure is to prevent infection and reduce irritation. The procedure indicated the following:
1. Position resident in semi-Fowler's position on bed pan if tolerated or use alternate position.
2. Put on gloves.
3. Pour warm water over perineal area.
4. Wash perineum well with soap and warm water, taking care to wash from front to back.
5. Cleanse area well at catheter insertion, taking care not to pull on catheter or advance further into urethra.
6. All debris must be removed from catheter at insertion site.
7. Rinse well with warm water and pat dry gently with clean towel.
During an interview and record review on 11/3/2023 at 9:43 a.m., with the Assistant Administrator (AADM), reviewed NA 1's employee file. The AADM stated the facility hired NA 1 on 7/28/2023 as full time CNA. The AADM stated NA 1's certificate number and orientation checklist was not on file.
During an interview on 11/3/2023 10:09 a.m., the DSD stated on the first day of the CNA's orientation checklist is completed. The DSD stated once the orientation checklist is completed it will be filed in the employee's file. The DSD stated he does not know why NA 1's orientation checklist was not on her employee file.
A review of the facility's policy and procedure titled, Credentialing of Nursing Service Personnel, reviewed 3/9/2023, indicated that a nursing service personnel who require a certification to provide resident care or treatment without direction or supervision within the scope of the individual's certification must present verification of such certification prior to or upon employment. The procedure indicated nursing personnel requiring a certification are not permitted to perform direct resident care services until all licensing/background checks have been completed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow proper sanitation and food handling practices b...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow proper sanitation and food handling practices by:
1. Failing to store food in accordance with professional standards for food service safety by failing to discard:
A. [NAME] cooking wine, which expired on 7/28/2022 and was observed in the dry storage room on 10/31/2023.
B. [NAME] pie shell wrapped in plastic wrap, dated 9/9/2023, with no expiration date, which was observed in the dry storage room.
C. Traditional Stuffing mix, with no expiration date, which was observed in the dry storage room on 10/31/2023.
D. Thawing ground beef, dated 10/28/2023, which was observed in the refrigerator on 10/31/23.
E. Ground beef, dated 10/28/2023, and ground chicken, dated 10/31/2023, thawing in the same pan, which were observed in the refrigerator on 10/31/2023.
F. Pancakes, prepared on 10/25/2023, with an expiration date of 10/28/2023, which were observed in the refrigerator on 10/31/2023.
G. A box of unopened sliced ham with a sell by date of 9/23/2023, which was observed in the refrigerator on 10/31/2023.
H. 12 blocks of margarine with no expiration date, which were observed in the refrigerator on 10/31/2023.
2. Failing to ensure that the dry produce storage room was used for food only. On 10/31/2023, HP cartridges for ink and gloves were observed being stored in the dry produce storage room. Observed on top of the HP cartridges were observed two boxes of a lemonade soft drink mix and one box of fruit mix in pear juice.
3.Failing to ensure that a food thermometer was being used properly by failing to sanitize the thermometer between dishes during the meal tray line on 11/01/2023, at 11:40 a.m.
These deficient practices had the potential to result in foodborne illnesses (also called food poisoning, illness caused by eating contaminated food) for residents living in the facility.
Findings:
During a concurrent observation of the storage room and refrigerator and interview on 10/31/2023, at 8:25 a.m., with the Dietary Supervisor (DS), the DS stated that the white [NAME] cooking wine, pancakes, and sliced ham should have all been discarded before their expiration date. The DS stated that the graham pie shell wrapped in plastic wrap, traditional stuffing mix, and 12 blocks of margarine should have been labeled with the received date, open date, and best by date to ensure that the food items were not expired. The DS stated that the staff should indicate the received date, open date, and best by date for all food products transferred to other containers so the staff know when to discard them. The DS stated that the thawed ground beef should not have been stored in the same container with the ground chicken to prevent cross contamination. The DS stated that according to facility policy, the dry produce storage room should be used for storage of food only, and the HP cartridges for ink and boxes of gloves should have been stored separately from the food supply to prevent cross contamination.
During a concurrent observation and interview on 11/1/2023 at 11:40a.m., with the DS, during the food tray line, Dietary [NAME] 1 (DC1) was observed using a digital thermometer to check the temperature of beef cubes with mushroom. DC1 wiped the thermometer with a white paper napkin and used the thermometer to check the temperature of the pasta. DC1 then wiped the thermometer with a white paper napkin again and proceeded to take the temperature of the seasoned spinach with the same thermometer. The DS stated that DC1 used a regular two-ply dinner napkin (DN300-2) to clean the thermometer. DS stated that the dinner napkin (DN300-2) does not contain any sanitizing agent and that these napkins are not supposed to be used for sanitizing the thermometer. The DS stated that DC1 is supposed to use an alcohol swab or a food-grade sanitizer to prevent cross contamination of dishes.
During an interview on 11/3/2023 at 3:03 p.m., with the Director of Nursing (DON), the DON stated that the staff should be checking the food items for expiration dates, open dates, and best by dates because expired food products may harm the residents. The DON stated that the kitchen staff should have removed all expired food items and items that were not properly dated and labeled. The DON stated that the dry storage room should be used to store food items only to prevent cross contamination. The DON stated that thermometer should be sanitized between dishes to prevent cross contamination of food allergens.
A review of the facility's recent policy and procedure titled, Storage of food and supplies, last reviewed on 3/9/2023, indicated: Food storage areas should be used only for food . All food products will be dated- month, date, year .Food in unlabeled . containers .not be retained or used.
A review of the facility's recent policy and procedure titled, Procedure for refrigerated storage, last reviewed on 3/9/2023, indicated: Individual packages of refrigerated or frozen food taken from original packing box need to be labeled and dated.
A review of the facility's recent policy and procedure titled, Thermometer use and calibration, last reviewed on 3/9/2023, indicated: Wipe the clean thermometer with the sanitizing solution using a clean cloth or paper towel.
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
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to screen and/or offer the pneumococcal vaccine (a drug that helps the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to screen and/or offer the pneumococcal vaccine (a drug that helps the immune system develop immunity from pneumococcal pneumonia [an infectious bacterial lung disease]) for three of five sampled (Resident 1, Resident 3, and Resident 4) when the following occurred:
A. Resident 1 ' s immunization record (document that indicates the type of vaccine administered and when the vaccine was administered) did not indicate if Resident 1 received the pneumococcal vaccine.
B. Resident 3 was not screened for pneumococcal vaccine eligibility and was not offered the pneumococcal vaccine.
C. Resident 4 was not screened and offered the pneumococcal vaccine upon admission to the facility.
These deficient practices resulted in Resident 1, Resident 3, and Resident 4 to not make an informed decision regarding the pneumococcal vaccine and potentially increase the risk of acquiring and transmitting pneumococcal pneumonia in the facility.
Findings:
A. A review of Resident 1 ' s admission Record indicated the facility originally admitted the resident to the facility on [DATE] and readmitted the resident on 1/23/2023, with diagnoses including dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change) and Human Immunodeficiency Virus Disease (HIV - a virus that attacks the body ' s immune system).
A review of Resident 1 ' s Minimum Data Set (MDS - an assessment and care screening tool), dated 7/5/2023, indicated Resident 1 had severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions).
A review of Resident 1 ' s Order Summary Report, dated 1/23/2023, indicated an order for Pneumococcal vaccine 0.5 milliliters (ml - a unit of measure) when available.
During a concurrent interview and record review with the Infection Preventionist (IP), on 8/30/2023, at 3:44 PM, Resident 1 ' s Immunization Record, undated, was reviewed and indicated there was no evidence of pneumococcal vaccine administration for Resident 1. The IP confirmed Resident 1 ' s immunization record did not indicate whether Resident 1 received the vaccine or not. The IP stated it is important to have the record of pneumococcal vaccination administration to track and to know when to give the vaccine next.
B. A review of Resident 3 ' s admission Record indicated the facility originally admitted the resident to the facility on 5/1/1986, with diagnoses including hypertensive heart disease without heart failure (heart problems that occur because of high blood pressure without a long-term condition in which the heart does not pump blood as well as it should) and is [AGE] years old.
A review of Resident 3 ' s MDS, dated [DATE], indicated Resident 3 was unable to complete the interview to determine Resident 3 ' s cognitive (relating to the mental process involved in knowing, learning, and understanding things) status.
A review of Resident 3 ' s Order Summary Report, dated 7/9/2019, indicated an order for Pneumococcal vaccine 0.5 ml when available.
During a concurrent interview and record review with the IP, on 8/30/2023, at 3:49 PM, Resident 3 ' s Immunization Record, undated, was reviewed and indicated Resident 3 received Pneumovax Dose 1 (a type of pneumococcal vaccine) on 6/14/2012. The IP confirmed Resident 3 received Pneumovax Dose 1 and stated Resident 3 is due for Prevnar 13 (PCV13 - a type of pneumococcal vaccine) or Polysaccharide 20 (PCV20 - a type of pneumococcal vaccine). The IP stated residents that have been vaccinated for pneumococcal pneumonia are offered the vaccine every five years. The IP further stated it is important to have Resident 3 ' s immunizations updated to prevent pneumonia.
C. A review of Resident 4 ' s admission Record indicated the facility originally admitted the resident to the facility on 5/12/2023 and readmitted the resident on 8/7/2023 with diagnoses including chronic kidney disease (long term disease affecting the body part responsible for filtering waste materials out of the blood and passing them out of the body as urine) and chronic obstructive pulmonary disease (COPD - a group of lung [body part located in the chest responsible for adding oxygen and removing carbon dioxide from the blood] diseases that block airflow and make it difficult to breathe).
A review of Resident 4 ' s MDS, dated [DATE], indicated Resident 4 had severe cognitive impairment.
A review of Resident 4 ' s Order Summary Report, dated 8/7/2023, indicated an order for Pneumococcal vaccine 0.5 ml when available.
During a concurrent interview and record review with the IP, on 8/30/2023, at 3:54 PM, Resident 4 ' s Immunization Record, undated, was reviewed and indicated Resident 4 received PPSV 23/Pneumonia Vaccine 23 (PPSV23 - a type of pneumococcal vaccine) on 4/28/2015, around the time when Resident 4 turned [AGE] years old. Resident 4 ' s Immunization Record further indicated Pneumococcal conjugate PCV20 was recommended for administration on 8/8/2017. The IP confirmed Resident 4 received their pneumococcal vaccine prior to their admission to the facility and more than five years ago. The IP further stated the facility should have offered Resident 4 the pneumococcal vaccine upon his admission to help prevent Resident 4 from getting pneumonia.
A review of the facility ' s policy and procedure (P&P) titled, Pneumococcal Vaccine, reviewed 12/15/2022, indicated all residents will be offered the pneumococcal vaccine to aid in preventing pneumococcal infections, for example, pneumonia. The P&P indicated prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine and when indicated, will be offered the vaccination within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. The P&P indicated the assessments of pneumococcal vaccination status will be conducted within five working days of the resident ' s admission if not conducted prior to admission. The P&P further indicated administration of the pneumococcal vaccination or revaccination will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.
A review of the CDC ' s document titled, Pneumococcal Vaccination: Who and When to Vaccinate, reviewed 2/13/2023, indicated adults aged 19 through [AGE] years old who have received PCV13 and one dose of PPSV23 recommends giving one dose of PCV20 at least five years after the last pneumococcal vaccine. The document further indicated adults 65 years or older who have received PCV13 at any age and PPSV23 before [AGE] years old, the CDC recommends giving one dose of PCV20 at least five years after the last pneumococcal vaccine or to give one dose of PPSV23 at least one year after PCV13 dose and at least five years after the last PPSV23 dose.
Based on interview and record review, the facility failed to screen and/or offer the pneumococcal vaccine (a drug that helps the immune system develop immunity from pneumococcal pneumonia [an infectious bacterial lung disease]) for three of five sampled (Resident 1, Resident 3, and Resident 4) when the following occurred:
A. Resident 1's immunization record (document that indicates the type of vaccine administered and when the vaccine was administered) did not indicate if Resident 1 received the pneumococcal vaccine.
B. Resident 3 was not screened for pneumococcal vaccine eligibility and was not offered the pneumococcal vaccine.
C. Resident 4 was not screened and offered the pneumococcal vaccine upon admission to the facility.
These deficient practices resulted in Resident 1, Resident 3, and Resident 4 to not make an informed decision regarding the pneumococcal vaccine and potentially increase the risk of acquiring and transmitting pneumococcal pneumonia in the facility.
Findings:
A. A review of Resident 1's admission Record indicated the facility originally admitted the resident to the facility on [DATE] and readmitted the resident on 1/23/2023, with diagnoses including dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change) and Human Immunodeficiency Virus Disease (HIV – a virus that attacks the body's immune system).
A review of Resident 1's Minimum Data Set (MDS – an assessment and care screening tool), dated 7/5/2023, indicated Resident 1 had severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions).
A review of Resident 1's Order Summary Report, dated 1/23/2023, indicated an order for Pneumococcal vaccine 0.5 milliliters (ml – a unit of measure) when available.
During a concurrent interview and record review with the Infection Preventionist (IP), on 8/30/2023, at 3:44 PM, Resident 1's Immunization Record, undated, was reviewed and indicated there was no evidence of pneumococcal vaccine administration for Resident 1. The IP confirmed Resident 1's immunization record did not indicate whether Resident 1 received the vaccine or not. The IP stated it is important to have the record of pneumococcal vaccination administration to track and to know when to give the vaccine next.
B. A review of Resident 3's admission Record indicated the facility originally admitted the resident to the facility on 5/1/1986, with diagnoses including hypertensive heart disease without heart failure (heart problems that occur because of high blood pressure without a long-term condition in which the heart does not pump blood as well as it should) and is [AGE] years old.
A review of Resident 3's MDS, dated [DATE], indicated Resident 3 was unable to complete the interview to determine Resident 3's cognitive (relating to the mental process involved in knowing, learning, and understanding things) status.
A review of Resident 3's Order Summary Report, dated 7/9/2019, indicated an order for Pneumococcal vaccine 0.5 ml when available.
During a concurrent interview and record review with the IP, on 8/30/2023, at 3:49 PM, Resident 3's Immunization Record, undated, was reviewed and indicated Resident 3 received Pneumovax Dose 1 (a type of pneumococcal vaccine) on 6/14/2012. The IP confirmed Resident 3 received Pneumovax Dose 1 and stated Resident 3 is due for Prevnar 13 (PCV13 - a type of pneumococcal vaccine) or Polysaccharide 20 (PCV20 - a type of pneumococcal vaccine). The IP stated residents that have been vaccinated for pneumococcal pneumonia are offered the vaccine every five years. The IP further stated it is important to have Resident 3's immunizations updated to prevent pneumonia.
C. A review of Resident 4's admission Record indicated the facility originally admitted the resident to the facility on 5/12/2023 and readmitted the resident on 8/7/2023 with diagnoses including chronic kidney disease (long term disease affecting the body part responsible for filtering waste materials out of the blood and passing them out of the body as urine) and chronic obstructive pulmonary disease (COPD – a group of lung [body part located in the chest responsible for adding oxygen and removing carbon dioxide from the blood] diseases that block airflow and make it difficult to breathe).
A review of Resident 4's MDS, dated [DATE], indicated Resident 4 had severe cognitive impairment.
A review of Resident 4's Order Summary Report, dated 8/7/2023, indicated an order for Pneumococcal vaccine 0.5 ml when available.
During a concurrent interview and record review with the IP, on 8/30/2023, at 3:54 PM, Resident 4's Immunization Record, undated, was reviewed and indicated Resident 4 received PPSV 23/Pneumonia Vaccine 23 (PPSV23 - a type of pneumococcal vaccine) on 4/28/2015, around the time when Resident 4 turned [AGE] years old. Resident 4's Immunization Record further indicated Pneumococcal conjugate PCV20 was recommended for administration on 8/8/2017. The IP confirmed Resident 4 received their pneumococcal vaccine prior to their admission to the facility and more than five years ago. The IP further stated the facility should have offered Resident 4 the pneumococcal vaccine upon his admission to help prevent Resident 4 from getting pneumonia.
A review of the facility's policy and procedure (P&P) titled, Pneumococcal Vaccine, reviewed 12/15/2022, indicated all residents will be offered the pneumococcal vaccine to aid in preventing pneumococcal infections, for example, pneumonia. The P&P indicated prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine and when indicated, will be offered the vaccination within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. The P&P indicated the assessments of pneumococcal vaccination status will be conducted within five working days of the resident's admission if not conducted prior to admission. The P&P further indicated administration of the pneumococcal vaccination or revaccination will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.
A review of the CDC's document titled, Pneumococcal Vaccination: Who and When to Vaccinate, reviewed 2/13/2023, indicated adults aged 19 through [AGE] years old who have received PCV13 and one dose of PPSV23 recommends giving one dose of PCV20 at least five years after the last pneumococcal vaccine. The document further indicated adults 65 years or older who have received PCV13 at any age and PPSV23 before [AGE] years old, the CDC recommends giving one dose of PCV20 at least five years after the last pneumococcal vaccine or to give one dose of PPSV23 at least one year after PCV13 dose and at least five years after the last PPSV23 dose.
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
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Fall Risk Evaluation tool (a rapid and simple method of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Fall Risk Evaluation tool (a rapid and simple method of assessing resident ' s likelihood of falling in the skilled nursing facility) accurately reflected the fall risk status of one of three sampled residents (Resident 1).
The deficient practice had the potential to formulate and implement a care plan not appropriate to current fall risk status of Resident 1 that could lead to further falls with injury.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 4/1/2019 and the facility readmitted the resident on 5/7/2021 with diagnoses including fracture (a partial or complete break in bone) of greater tuberosity (the bump of bone) of left humerus (left upper rm bone), disorders of bone density (measurement of how tightly a material is packed together) and structure, and abnormalities of gait (a manner of walking) and mobility.
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/8/2023, indicated the resident had the ability to make self-understood and understand others. The MDS indicated Resident 1 needed supervision on bed mobility, transfer, locomotion on and off the unit, and toilet use. The MDS also indicated Resident 1 used a cane/crutch and a wheelchair.
A review of Resident 1 ' s Situation, Background, Assessment, and Recommendation (SBAR, provides a framework for communication between members of the healthcare team about a resident ' s condition), dated 8/11/2023, at 6:20 a.m., indicated Resident 1 was found on his right side, lying on the floor at the foot of his bed. Resident 1 was assessed by two licensed nurses. Resident 1 complained of 10/10 pain (a score of 10 using the pain scale from 0 to 10 means the most severe or worst pain you have ever experienced) on the left upper extremities (limbs), dizziness, and shortness of breath. Resident 1 was given 1000 milligrams (mg, a unit of weight) of Tylenol, administered oxygen at 3 liters per minute (LPM) via nasal cannula (a medical device to provide supplemental oxygen therapy to residents who have lower oxygen levels). Resident 1 was assisted back to bed. Resident 1 stated that he was coming back from his bed after using the restroom and slipped. He lost balance and ended up on the floor. Resident 1 was not able to tolerate the pain and cannot wait for the regular ambulance to come. Registered Nurse (RN) called 911 and Resident 1 was [NAME] to general acute care hospital 1 (GACH 1). Resident 1's representative and MD were made aware.
During a concurrent interview and record review on 8/17/2023, at 11:15 a.m., reviewed Resident 1 ' s Fall Risk Evaluation, dated 8/11/2023, at 6:43 a.m. with Registered Nurse 1 (RN 1), RN 1 stated Resident 1 had a score of 5, indicating the resident was a low risk for fall. RN 1 stated that on the Fall Risk Evaluation tool, Resident 1 was scored a 0 on history of falls, however, the resident had a fall within the past 3 months. RN 1 stated Resident 1 should have been scored a 2. RN 1 stated on gait/balance the Resident 1 should have been scored a 6 as the resident required assistive devices such as a cane and a wheelchair. Lastly, RN 1 stated on the predisposing diseases, Resident 1 should have been scored a 4 because the resident had Parkinson ' s disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes), and fractures. RN 1 stated the total score should have been 17, a score of 10 and above constitutes high-risk for fall. RN 1 stated that the inaccuracy in the assessment could affect the formulation of the care plan as the care plan was developed to implement interventions geared towards a low risk for fall resident.
During an interview on 8/17/2023, at 3:33 p.m., the Director of Nursing stated the inaccurate assessment could affect the formulation of the care plan. The DON stated that based on the assessment they developed a care plan for a low risk for fall resident that could possibly predispose a resident to accidents.
A review of the facility ' s recent policy and procedure titled, Fall Risk Assessment, last reviewed on 12/15/2022, indicated the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Upon admission, the nursing staff and the physician will review a resident ' s record for history of falls, especially in the last 90 days and the recurrent or periodic bouts of falling over time. Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls (such as osteoporosis).
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
Based on observation and interview, the facility failed to maintain an infection prevention and control program by failing to label the urinal with name of the resident to one of three sampled residen...
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Based on observation and interview, the facility failed to maintain an infection prevention and control program by failing to label the urinal with name of the resident to one of three sampled residents (Resident 1).
This deficient practice had the potential for cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) of infection among residents.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 4/29/2019 and the facility readmitted the resident on 5/7/2021 with diagnoses including benign prostatic hyperplasia (a condition in men in which the prostate gland [a gland below the bladder and in front of the rectum in men] is enlarged and not cancerous), neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems), and Coronavirus Disease 2019 (COVID-19 -a highly contagious disease spread from person to person through droplets released when an infected person coughs, sneezes, or talks).
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/8/2023, indicated the resident had the ability to make self-understood and understand others. The MDS indicated Resident 1 needed supervision on toilet use and limited assistance on personal hygiene.
During a concurrent observation and interview on 8/17/2023, at 9:47 a.m., observed Resident 1 ' s urinal hanging on the drawer ' s handle beside the resident ' s bed without a label. Certified Nursing Assistant 1 (CNA 1) stated the urinal should be labeled so they do not cross contaminate other residents. CNA 1 stated that if the urinal was not labeled there was a potential to mix other residents ' urinal with each other causing contamination and spread of infection.
During an interview on 8/17/2023, at 3:10 p.m., the Infection Preventionist (IP) stated the staff should place the name of the resident, so they could identify the urinal who belongs to for infection purposes.
During an interview on 8/17/2023, at 3:33 p.m., the Director of Nursing (DON) stated the staff should place the room number and the name of the resident on the urinal for infection control issues. The DON stated the deficient practice could spread infection among residents.
During an interview on the phone on 8/23/2023, at 11:38 a.m. the Asst. ADM (Assistant Administrator) stated she cannot provide the revised policy and procedure for labeling of urinals to prevent cross contamination because the QAPI has not approved them yet. The Asst. ADM stated from the beginning it was their practice to label the urinal with name to prevent switching urinals among residents that could cause infection.
Jul 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazard...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards to two out of four sampled residents (Residents 2 and 3) by failing to ensure Resident 2 and 3's low bed (a bed that can go 9 to 10 inches off the floor to help prevent injuries due to falls) were left in the lowest position.
This deficient practice had the potential for the residents sustaining injuries as a result of a fall.
Findings:
A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 2/15/2022 and readmitted the resident on 11/21/2022, with diagnoses including history of falling, muscle weakness, and nontraumatic intracranial hemorrhage (bleeding into the substance of the brain in the absence of trauma or surgery).
A review of Resident 2 ' s History and Physical (H&P), dated 11/21/2022, indicated the resident had the capacity to understand and make decisions.
A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 6/5/2023, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident had impaired vision. The MDS also indicated the resident required extensive assistance on bed mobility, dressing, and personal hygiene, and total dependence on transfer, locomotion on and off the unit, and toilet use. The MDS further indicated the resident was unsteady on surface-to-surface transfer and had impairment on both upper and lower extremities. The MDS indicated the resident used a wheelchair to move around.
A review of Resident 2 ' s Order Summary Report, dated 11/21/2022, indicated an order of resident may have low bed, check for placement and usage every shift.
A review of Resident 2 ' s Fall Risk Evaluation, dated 6/5/2023, indicated the resident was high risk for fall.
A review of Resident 2 ' s Care Plan, initiated on 2/16/2023, indicated the resident was at risk for falls and injury and the care plan indicated an intervention to provide a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position etc.
During a concurrent observation and interview on 7/27/2023, at 10:27 a.m., with Licensed Vocational Nurse 1 (LVN 1), observed Resident 2 ' s bed was not left in the lowest position. The bed was measured with a measuring tape that indicated the bed was 23 inches off the floor. LVN 1 stated the bed should be placed in the lowest position to prevent falls with injury.
A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 2/1/2017 and the facility readmitted the resident on 5/9/2021 with diagnoses including other symptoms and signs involving cognitive functions following a cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), epilepsy (along-term disease that causes repeated seizures due to abnormal electrical signals produced by damaged brain cells), and dependence on wheelchair.
A review of Resident 3 ' s H&P, dated 4/22/2023, indicated the resident had fluctuating capacity to understand and make decisions.
A review of Resident 3 ' s MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident had impaired vision. The MDS also indicated the resident required extensive assistance on bed mobility, dressing, toilet use, and personal hygiene, and total dependence on transfer, and locomotion on and off the unit. The MDS further indicated the resident was unsteady on moving from seated to standing position and surface-to-surface transfer. The MDS indicated the resident used a wheelchair to move around.
A review of Resident 3 ' s Order Summary Report, dated 5/9/2021, indicated an order of resident may have low bed, check for placement and usage every shift.
A review of Resident 3 ' s Fall Risk Evaluation, dated 6/14/2023, indicated the resident was high risk for fall.
A review of Resident 3 ' s Care Plan, initiated on 5/11/2017, indicated the resident was at high risk for further unpreventable falls and potential for injuries due to behavior of getting up unassisted and comorbidities. The care plan indicated an intervention to continue fall precautions- low bed, alarm in wheelchair (w/c) and bed, and floor mats (a mat placed at the side of the resident ' s bed to help prevent injury from potential falls), call MD with any changes.
During a concurrent observation and interview on 7/27/2023, at 10:47 a.m., with Certified Nursing Assistant 4 (CNA 4), observed Resident 3 ' s low bed in the high position. The bed was measured with a measuring tape and registered at 24 inches off the floor. CNA 4 stated the bed should be placed on the lowest position to prevent injury when resident falls.
During an interview on 7/27/2023, at 10:56 a.m., the Director of Staff Development (DSD) stated low beds should be one foot from the floor so that residents who were deemed high risk for fall with injury will have less chances of incurring injury.
During an interview on 7/27/2023, at 1:11 p.m., the Director of Nursing (DON) stated Resident 2 and 3's bed should have been placed in the lowest position to prevent falls with injury.
A review of the facility ' s recent policy and procedure titled Falls and Fall Risk, Managing, last reviewed on 1/1/2023, indicated based on previous evaluations and current data, the staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Environmental factors that contribute to the risk of falls include:
a. Wet floors;
b. Poor lighting;
c. Incorrect bed height or width;
d. Obstacles in the foot path;
e. Improperly fitted or maintained wheelchairs; and
f. Footwear that is unsafe or absent.
Resident- centered approaches to managing falls and fall risk include a systematic evaluation of a resident ' s fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once).
Nov 2022
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to obtain informed consent (permission granted by a resident or resident representative to proceed with treatment after the physician had full...
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Based on interview and record review, the facility failed to obtain informed consent (permission granted by a resident or resident representative to proceed with treatment after the physician had fully explained the benefits and possible risks or consequences) from the resident's responsible party prior to:
1. Implementing the bed alarm (a physical or electronic device that monitors resident movement and alerts the staff when movement is detected while the resident is in bed) once the order was received from the physician for one of one sampled resident (Resident 44).
2. Increasing the dose for Trazodone (medication used to treat depression) from 50 milligrams (mg - unit of weight measurement) to 100 mg for one of five sampled residents (Resident 44) investigated under the care area of unnecessary medications.
These deficient practices violated the resident's right to be fully informed and consent to the proposed care and treatment.
Findings:
a. A review of Resident 44's admission Record indicated the facility admitted the resident on 6/30/202, with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), dementia (loss of thinking, remembering, reasoning, and behavioral abilities to such an extent that it interferes with a person's daily life and activities.), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest).
A review of Resident 44's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/29/2022, indicated the resident's cognitive skills (thought processes) for daily decision making was severely impaired.
A review of Resident 44's physician's order, ordered on 8/31/2022, indicated the resident may have alarm in bed to remind resident to ask for assistance when getting out of bed and to check for placement and functionality every shift.
During a concurrent interview and record review, on 11/9/2022 at 8:30 a.m., Registered Nurse Supervisor 2 (RN Sup 2) reviewed Resident 44's physician's order and verified an order for bed alarm. RN Sup 2 stated an informed consent is obtained by the physician from the resident or responsible party and the licensed nurse who received the order would follow up with the resident or the responsible party to verify the consent was obtained. RN Sup 2 stated Resident 44 is incapable of making decisions and the consent would need to be obtained from the resident's conservator (a person appointed by the court to make decisions for an adult who is mentally or physically disabled and incapable of caring fully for themselves). RN Sup 2 reviewed Resident 44's chart and confirmed there was no consent regarding the use of bed alarm. RN Sup 2 stated the licensed nurse receiving the order should have verified with Resident 44's responsible party that informed consent was obtained to notify the responsible party of what is going on including the benefits and risks and the rationale for placing the bed alarm.
During a concurrent interview and record review, on 11/9/2022 at 8:37 a.m., the Medical Records Supervisor (MRS/LVN) reviewed Resident 44's entire chart and confirmed there is no informed consent for Resident 44's bed alarm order in the chart.
During an interview, on 11/10/2022 at 11:15 a.m., the Director of Nursing (DON) confirmed an informed consent should have been obtained from the Resident 44's conservator for the bed alarm since it is considered a physical restraint (any manual method, physical or mechanical device, or equipment that restricts resident's freedom of movement or normal access to his or her body). The DON stated the doctor would explain the benefits and risks of the bed alarm and the licensed nurses would call the conservator to verify that they are giving consent. The DON further stated the importance of obtaining informed consent for the resident and the responsible party to be informed of the proposed care including the benefits and risks, thereby allowing them to make a choice based on the information they received.
A review of the facility's policy and procedure titled, Informed Consent for Physical/Chemical Restraint, last reviewed on 12/9/2021, indicated the resident's attending physician will inform the resident or surrogate of the risks and potential benefits of the use of chemical restraints, physical restraints or devices that may lead to the inability to regain use of a normal bodily function. The policy and procedure further indicated the nurse receiving the order for a physical or chemical restraint will verify with physician that resident/surrogate decision maker has consented to the use of chemical/physical restraint and two licensed nurses will verify with the resident or authorized representation that informed consent has been obtained prior to initiating an order.
b. A review of Resident 44's physician's orders indicated the following:
- Trazodone Hydrochloride (Hcl) tablet 50 mg, give one tablet by mouth at bedtime for dementia with psychotic feature manifested by agitation, ordered on 6/30/2021.
- Discontinue all previous order of Trazodone, start Trazodone 100 mg every night at bedtime (QHS) for depression manifested by difficulty sleeping, ordered on 8/6/2021.
- Trazodone Hcl tablet, give 100 mg by mouth at bedtime related to major depressive disorder, recurrent, unspecified manifested by inability/difficulty to sleep, ordered on 8/19/2021.
During a concurrent interview and record review, on 11/9/2022 at 12:18 p.m., Charge Nurse 1 (CN 1) reviewed Resident 44's physician's order and verified the resident is currently receiving trazodone 100 mg every night at bedtime which was increased from a previous dose of 50 mg. CN 1 stated a new informed consent needs to be obtained either from the resident or from the responsible party for newly ordered psychotropic medications (drugs that affects behavior, mood, thoughts, or perception) or if there is a change in dosage in which the dose is increased. CN 1 explained the consent is obtained from the resident if he or she is self-responsible. CN 1 stated if the resident does not have the capacity to make decisions, then the consent is obtained from the resident's responsible party. CN 1 stated the licensed nurse would speak with the resident or call the responsible party and explain the purpose, the dosage, the frequency, and the benefits and risks of the psychotropic medication. CN 1 reviewed Resident 44's chart and verified an informed consent was obtained for the previous trazodone 50 mg order. However, CN 1 confirmed there was no informed consent for trazodone when the dosage of the medication was increased from 50 mg to 100 mg every night. CN 1 stated an informed consent should have been obtained from Resident 44's conservator when the dosage for trazodone was increased. CN 1 stated the importance of obtaining consent for psychotropic medications when there is a change in dosage for the conservator to know and understand what is exactly happening with the care of the resident and to allow the conservator to make an informed decision to accept or refuse treatment.
During an interview, on 11/10/2022 at 11:22 a.m., the Director of Nursing (DON) stated a new consent is required to be obtained any time the dosage of psychotropic medications is increased and confirmed that a consent should have been obtained from Resident 44's conservator when the dose for trazodone was increased from 50 mg to 100 mg. The DON explained the physicians would explain the benefits and risks including side effects of psychotropic medications to the family or conservator and stated the licensed nurse should have followed up to verify the consent was obtained. The DON stated the completed consent form is then placed in the physical chart under the psychotropic medication tab. The DON further stated the importance of obtaining and verifying consent for psychotropic medications including changes in dosage to ensure the goals of treatment are explained to the resident's family or conservator and to allow them to make a decision upon reviewing the benefits and risks associated with the medication.
A review of the facility's policy and procedure titled, Informed Consent for Physical/Chemical Restraint, last reviewed on 12/9/2021, indicated the resident's attending physician will inform the resident or surrogate of the risks and potential benefits of the use of chemical restraints, physical restraints or devices that may lead to the inability to regain use of a normal bodily function. The policy and procedure further indicated the nurse receiving the order for a physical or chemical restraint will verify with physician that resident/surrogate decision maker has consented to the use of chemical/physical restraint and two licensed nurses will verify with the resident or authorized representation that informed consent has been obtained prior to initiating an order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure resident call light was within reach for one of one sampled resident (Resident 43).
This deficient practice had a pote...
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Based on observation, interview and record review, the facility failed to ensure resident call light was within reach for one of one sampled resident (Resident 43).
This deficient practice had a potential for the resident not able to call for assistance as needed.
Findings:
A review of Resident 43's admission Record indicated the facility admitted Resident 43 on 08/13/2015, with diagnosis including dementia (memory disorders, personality changes, and impaired reasoning that interferes with daily functioning) and epilepsy (a neurological disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness).
A review of Resident 43's History and Physical dated 11/02/2022 indicated Resident 43 does not have the capacity to understand and make decisions.
A review of Resident 43's Minimum Data Set (MDS-an assessment and care screening tool) dated 06/22/2022 indicated Resident 43 with clear speech, made self-understood, and understood others. The MDS indicated Resident 43 required limited assistance (resident highly involved in activity; staff provide guided maneuvering) with transferring and personal hygiene, extensive assistance (resident involved in activity, staff provide weight-bearing support) with toilet use and dressing with one-person physical assistance.
A review of Resident 43's Care Plan titled Risk for Falls/Injury, revised date 07/29/2020, indicated interventions to maintain call light within reach.
During an observation on 11/08/2022 at 9:29 a.m., Resident 43 lying in bed with eyes closed but easily awoken, observed Resident 43's call light hanging on the wall.
During a concurrent observation and interview on 11/08/2022 at 9:31 a.m., the Registered Nurse Supervisor 1 (RN Sup 1) at Resident 43's bedside confirmed Resident 43's call light was clipped to the padded board hung on the wall and out of Resident 43's reach. RN Sup 1 stated call light is used when residents need assistance. RN Sup 1 stated she will move the call light within Resident 43's reach.
During an interview on 11/10/2022 at 10:37 a.m., the Director of Nursing (DON) stated call light should be within reach. DON stated all facility staff should ensure call light is easily accessible such as placing on top of the resident's pillowcase. DON stated if the resident prefers his or her call light at a certain place it is indicated in the care plan. DON stated it should not be clipped to the wall for resident's safety.
A review of the facility's policy and procedure titled Call Light, Use of, reviewed and approved on 12/09/2021, indicated that it is the basic responsibility of the licensed nurse, nursing assistant, and all facility staff to be sure all call lights are placed on the bed at all times, never on the floor or bedside stand.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility licensed nurses failed to evaluate and revise the care plan for one of four sampled resident (Resident 32) who was at risk for contracture and decreas...
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Based on interview and record review the facility licensed nurses failed to evaluate and revise the care plan for one of four sampled resident (Resident 32) who was at risk for contracture and decreased range of motion of extremities.
This deficient practice had the potential to cause debilitation and contractures to Resident 32.
Findings:
A review of Resident 32's admission Record, indicated that the facility admitted the resident on 2/15/2022, and readmitted the resident on 9/9/2022, with diagnoses including polyosteoarthritis (is a term used when at least five joints are affected with arthritis), muscle wasting (a weakening shrinking, and loss of muscle) and atrophy (decrease in size of a body part), and other abnormalities of gait (the way a person walks and move around) and mobility.
A review of Resident 32's History and Physical, dated 9/9/2022, indicated that the resident had fluctuating capacity to understand and make decisions.
A review of Resident 32's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/12/2022, indicated that the resident had the ability to make self-understood and had the ability to understand others. The resident was totally dependent on bed mobility, transfer, and toilet use. The resident required extensive assistance on dressing and personal hygiene. The resident had an impairment on both sides of the upper and lower extremity. The resident uses a wheelchair.
A review of Resident 32's Physical Therapy (PT) Evaluation & Plan of Treatment, dated 9/11/2022 to 10/10/2022, indicated notable weakness and increased physical exertion with activity, presents with better prior level of function (PLOF), good participation with initial assessment/treatment, and good potential for established realistic goals.
A review of Resident 32's Order Summary Report, dated 10/17/2022, indicated the following orders:
-Order date: 10/17/2022
Restorative Nursing Aide (RNA- are health-care professionals who are responsible for providing restorative and rehabilitation care for residents to maintain or regain physical, mental, and emotional well-being) for Active Assisted Range of Motion (AAROM- an exercise in which manual or mechanical external force assists specific muscles and joints to move through their available excursion) exercises to both lower extremities (BLE), 5 times per week as tolerated. Every day shift every Mon, Tue, Wed, Thu, Sun for maintenance. Monitor for change in condition and participation, report to charge nurse accordingly.
-Order date: 10/14/2022
RNA for AAROM exercises to both upper extremities (BUE) 5 times per week as tolerated. Every day shift every Mon, Tue, Wed, Thu, Fri for maintenance.
A review of Resident 32's Care Plan, with a revision date of 8/20/2022, indicated a plan of RNA program for AAROM exercises to LUE 3 times per week as tolerated for maintenance. RNA for AAROM exercises to BUE 5 times per week for Mondays through Fridays for maintenance RNA for AAROM exercises to BLE, 3 times per week as tolerated, while patient is sitting at edge of bed (EOB) or edge of wheelchair without leaning on backrest.
During an interview and record review on 11/10/2022, at 7:40 a.m., Registered Nurse Supervisor 1 (RN Sup 1), stated that the care plan still indicated AAROM to left upper extremity (LUE) 3 times per week. RN Sup 1 stated that it should have been updated with the new order of AAROM exercises to BUE 5 times per week as tolerated. RN Sup 1 stated that it was important to update the care plan to make sure the therapy being provided was per doctor's order. RN Sup 1 validated that the care plan was not revised and reviewed for effectiveness of interventions. The care plan was last reviewed 8/29/2022, and interventions were all dated 5/27/2022.
During an interview on 11/10/2022, at 11:16 a.m., with the Director of Nursing (DON), the DON stated that the care plan for RNA therapy should have been updated within seven (7) days of the date of the new therapy ordered. The DON stated that it was important to update, revise, review and evaluate the effectiveness of the care plan to determine if the resident had decreasing range of motion (ROM- is the capability of a joint to go through its complete spectrum of movements) and if other interventions were needed.
A review of the facility's recent policy and procedure titled Care Plans- Comprehensive, dated 12/9/2021, indicated that the comprehensive care plans are based on a thorough assessment that includes, but is not limited to, the MDS. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS).The care planning/interdisciplinary team is responsible for the periodic review and updating of care plans: (a) when there has been a significant change in the resident's condition; (b) when the desired outcome is not met; (c) when the resident has been readmitted to the facility from a hospital stay; and (d) at least quarterly.
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 observation, interview, and record review, the facility failed to identify and provide necessary care and treatment for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify and provide necessary care and treatment for two of two residents (Resident 46 and Resident 43), by:
1. Failing to ensure an identification band was placed for one out of one resident who expired (Resident 46) in the facility on [DATE].
The deficient practice had the potential for misidentification of the resident's cadaver (a dead body) that could lead to family anguish and distress.
2. Failing to thoroughly assess Resident 43's reasons for Restorative Nursing Assistant (RNA) Treatment Program refusal from [DATE] to [DATE].
This deficient practice had the potential to delay necessary care and services and could result in a decline in the residents' medical condition.
Findings:
a. A review of Resident 46's admission Record, indicated that the facility admitted the resident on [DATE], with diagnoses including Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements such as shaking, stiffness, and difficulty with balance and coordination), obstructive sleep apnea (a disorder in which a person frequently stops breathing during his or her sleep), and age-related physical debility (is an age-related, multidimensional state of decreased physiologic reserves).
A review of Resident 46's Veterans Affairs (VA) Advance Directive Durable Power of Attorney for Health Care and Living Will (is a legal document that tells your doctor your wishes about your health care if you cannot make the decisions yourself), dated [DATE], indicated Family Member 1 (FM 1) was appointed on behalf of Resident 46 to make decisions about Resident 46's health care.
A review of Resident 46's Physician Orders for Life-Sustaining Treatment (POLST- is a medical order that helps give people with serious illness more control over their care during a medical emergency), dated [DATE], indicated that the resident had orders for:
-Do Not Attempt Resuscitation (DNR- it instructs health care providers not to do emergency life-saving procedures if they stop breathing or their heart stops)
-Allow natural death.
-Comfort-focused treatment, with primary goal of maximizing comfort.
The document was signed by FM 1 on [DATE].
A review of Resident 46's Situation, Background, Assessment, and Recommendation (SBAR- to aid in facilitating and strengthening communication between nurses and prescribers) Communication Form, dated [DATE], at 5:30 a.m., indicated that during medication pass, the resident was noted unresponsive. The Registered Nurse Supervisor (RN Sup) was informed. Resident 46's vital signs was taken but unappreciated. The RN Supervisor called 911 (the telephone number used to reach emergency medical services), the primary physician and the family member. The paramedics (a person who is trained to give medical help, especially in an emergency) came in and pronounced resident death. The staff provided post-mortem care (the care given once death has occurred through transfer to a funeral provider).
During an observation on [DATE], at 9:15 a.m., observed the resident in the room, covered with a blanket. At 9:50 a.m., the mortuary representative informed the surveyor that the resident did not have identification band on. The surveyor went inside the room and verified that the resident did not have an identification band.
During a concurrent observation and interview on [DATE], at 9:55 a.m., observed MRS/LVN place an identification band on the resident. The Director of Staff Development (DSD) and the Medical Record Supervisor/Licensed Vocational Nurse (MRS/LVN) both stated that the staff should have placed an identification band on the resident after post-mortem care for identification.
During an interview and on [DATE], at 9:30 a.m., with Charge Nurse 1, CN 1 stated that when a resident passes away in the facility, the licensed nurses check the code status of the resident, if the resident is a full code, they call 911 right away. They notify the police, the doctor and the family members of the resident's death. The Certified Nursing Assistants (CNAs) provide the post-mortem care. CN 1 further stated that before the mortuary picks up the body from the facility, the resident should have an identification band to confirm resident identity.
During an interview on [DATE], at 10:43 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated that two CNAs provide post-mortem care. The CNAs clean the resident, change the clothes and the linens to make sure that the resident is presentable before the family arrives. CNA 1 stated that after post-mortem care they make sure that the resident has an identification band.
During an interview on [DATE], at 11:16 a.m., with Director of Nursing (DON), the DON stated that the staff should have placed an identification band on the expired resident. She stated that it is important to have the identification band on the expired resident for identification of the cadaver.
A review of the facility's recent policy and procedure titled Identification Band, Resident, dated [DATE], indicated that that purpose of the identification band on the resident is to ensure positive identification of every resident and to prevent errors in care and treatment. Checking of identification bands is the ongoing responsibility of all facility staff to be sure bands are legible and in place at all times. All residents are to wear identification bands at all times unless contraindicated.
A review of the recent facility policy and procedure titled Post-Mortem Care, dated [DATE], indicated that the purpose of the policy is to prepare the deceased resident prior to release to the mortuary. The equipment needed for post-mortem care included identification tag per facility procedure.
b. A review of Resident 43's admission Record indicated the facility admitted Resident 43 on [DATE], with diagnosis including dementia (memory disorders, personality changes, and impaired reasoning that interferes with daily functioning) and epilepsy (a neurological disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness).
A review of Resident 43's History and Physical dated [DATE] indicated Resident 43 does not have the capacity to understand and make decisions.
A review of Resident 43's Minimum Data Set (MDS-an assessment and care screening tool) dated [DATE] indicated Resident 43 with clear speech, made self-understood, and understood others. The MDS indicated Resident 43 required limited assistance (resident highly involved in activity; staff provide guided maneuvering) with transferring and personal hygiene, extensive assistance (resident involved in activity, staff provide weight-bearing support) with toilet use and dressing with one-person physical assistance.
A review of Resident 43's Physician Order indicated the following orders:
- RNA for Active-Assisted Range of Motion (AAROM-a joint receiving partial assistance from an outside force) exercises to bilateral upper extremities five times per week as tolerated every day shift Mon, Tue, Wed, Thu, Fri for maintenance, ordered date of [DATE].
- RNA for Active ROM (AROM-how far a joint move without assistance) exercises to bilateral lower extremities five times per week as tolerated, every day shift Mon, Tue, Wed, Thu, Sun for maintenance, ordered date [DATE].
- RNA for sit-to-stand exercises using parallel bars or handrail in hallway, five times per week as tolerated, every Mon, Tue, Wed, Thu, Fri, ordered date of [DATE].
A review of Resident 43's Restorative Exercise Documentation Report for the following months indicated the following:
- [DATE] to [DATE], Resident 43 refused 11 out of 11 RNA sit-to-stand exercises
- [DATE] to [DATE], Resident 43 refused seven out of seven RNA sit-to-stand exercises
During an interview on [DATE] at 8:50 a.m., the Family Member 2 (FM 2) stated she is concerned with Resident 43 not receiving rehab services and was discharge from physical therapy because the resident has been refusing exercises. FM 2 stated she wanted to know what the reasons were behind Resident 43's refusal of exercises and what approaches the facility has taken but no one could explain to her.
During an observation on [DATE] at 4:19 p.m., Resident 43 sitting outside the main dining room by the door, asleep.
During an interview on [DATE] at 4:22 p.m., RNA 1 stated RNA 2 is assigned to Resident 43 today and if resident has been offered and declined RNA then they document on the resident's chart. RNA 1 stated Resident 43 can verbalize if he allows the RNAs to provide exercises or not and recently has been refusing to have exercises.
During an interview on [DATE] at 9:00 a.m., RNA 2 stated Resident 43 refused RNA treatment yesterday, [DATE] and he documented it on the RNA notes and informed his charge nurse. RNA 2 stated he is the RNA assigned to Resident 43 today and Resident 43 usually have his exercises around 2 p.m.
During an observation on [DATE] at 1:53 p.m., Resident 43 sitting on his wheelchair in the patio area. RNA 2 asked Resident 43 if he would like to do some exercises. Resident 43 stated he does not want to and will do it when he wants to. RNA 2 explained to Resident 43 to do leg strengthening exercises. Resident 43 stated his legs are fine and does not want to do it at this time. RNA 2 offered to come back in an hour and will offer him again.
During an observation on [DATE] at 3:06 p.m., observed Resident 43 self-propelling using his legs and his right arm holding the right handrails in the hallway going to his room. RNA 2 approached Resident 43 and offered Resident 43 if he would like to do some exercises. Resident 43 stated he does not want to do it and to leave him alone. Resident 43 stated he knows how to sit-stand using the handrails, but he does not want to do it. RNA 2 asked Resident 43 what time would be best for him to do exercises. Resident 43 stated he does not want to do it and to leave him alone.
During a concurrent interview and record review of Resident 43's Interdisciplinary Team (IDT- when different disciplines meet to address resident's problem) Care Plan Conference Record on [DATE] at 8:18 a.m., the MDS Nurse stated she is part of the IDT and had offered Resident 43's family member to participate to encourage Resident 43 participation in the rehab/RNA treatment. The MDS Nurse stated this should be part of Resident 43's care plan interventions. The MDS Nurse confirmed the IDT Note dated [DATE] did not indicate other areas such as behavioral aspect or addressing resident 43's preferences or timing with the treatment. The MDS Nurse stated the IDT documents on the IDT Note on what topics were discussed at that time.
A review of the IDT Note dated [DATE] indicated Resident 43 was on skilled Occupational Therapy/Physical Therapy until [DATE] included refusal of treatments and offered Resident 43's family member to encourage Resident 43.
During a concurrent interview and record review of Resident 43's Episodes of Choosing not to participate with rehab/RNA and receive prescribed treatments Care Plan on [DATE] at 9:14 a.m., Licensed Vocational Nurse 1 (LVN 1) confirmed there were no care plans developed prior to [DATE] with Resident 43's multiple episodes of refusal of RNA treatments. LVN 1 stated interventions included allowing resident to vent his feelings, offering care and assistance, respecting his choice, informing the responsible party, providing time, and monitoring any acute health changes in the resident's condition. LVN 1 stated the purpose of the care plan is to address the resident's problem, goal, and review interventions if they are effective or not. LVN 1 stated the care plan serves as a guide on how to care for the residents.
During an interview on [DATE] at 10:41 a.m., the DON stated IDT meetings are done as scheduled such as PPS (PPS - a method of Medicare [health insurance] reimbursement), Quarterly MDS Assessment, or Annual MDS Assessment, and impromptu meetings include weight variances, fall meeting and scheduled meetings. The DON stated during scheduled meetings all resident care and treatment areas including discharge planning, medical issues, rehabilitation therapy, etc. are discussed. The DON stated the MDS Nurse Coordinator also a Registered Nurse attends the scheduled meetings. DON stated the facility honors when a resident request not to receive medical treatment as ordered by his or her physician. The DON stated there should be documentation of the refusal and explain to the resident the consequences and offer alternative treatments, and resident's primary physician and responsible party should be informed. The DON stated the refusal should be care planned and discussed by the IDT about the resident's refusal.
During a concurrent interview and record review on [DATE] at 1:30 p.m., the MRS/LVN verified Resident 43's last psychology visit was on [DATE] and latest Social Services Progress Notes is dated [DATE].
A review of the facility's policy and procedure titled Refusal of Treatment, reviewed and approved on [DATE], indicated if a resident refuses treatment, the Unit Manager, Charge Nurse, or Director of Nursing Services will interview the resident to determine what and why the resident is refusing to try to address the resident's concerns and explain the consequences. The Care Plan Team will assess the resident's needs and offer the resident alternative treatments, if available and pertinent, while continuing to provide other services outlined in the care plan. Should the resident refuse to accept treatment detailed information relating to the refusal must be entered into the resident's medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
b. A review of Resident 44's admission Record indicated the facility admitted the resident on 6/30/202, with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and t...
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b. A review of Resident 44's admission Record indicated the facility admitted the resident on 6/30/202, with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), dementia (loss of thinking, remembering, reasoning, and behavioral abilities to such an extent that it interferes with a person's daily life and activities.), and restless legs syndrome (a condition that causes an uncontrollable urge to move the legs).
A review of Resident 44's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/29/2022, indicated the resident's cognitive skills (thought processes) for daily decision making was severely impaired. The MDS indicated Resident 44 required supervision with bed mobility and transfers and required one-person extensive assistance with toilet use and personal hygiene. The MDS further indicated the resident had one fall with injury since admission.
A review of Resident 44's Situation, Background, Assessment, Recommendation (SBAR - system for identifying, evaluating, and reporting deterioration in resident's condition) Communication Form, dated 8/30/2022, indicated the resident had an unwitnessed fall in which the resident reported he rolled over from his bed.
During a concurrent interview and record review, on 11/9/2022 at 11:38 a.m., Charge Nurse 1 (CN 1) stated a fall risk assessment is conducted upon admission, quarterly, and post fall whenever a fall incident occurs and is documented on Point Click Care (PCC - electronic health record). CN 1 stated Resident 44 had an unwitnessed fall on 8/30/2022 upon reviewing Resident 44's SBAR, dated 8/30/22, and verified that a fall risk assessment should have been done after the resident fell. CN 1 reviewed all of Resident 44's fall risk assessments in PCC since admission and confirmed there was no fall risk assessment done after Resident 44 fell on 8/30/22, stating the last fall risk assessment was completed on 7/1/2022 which indicated that the resident was a high fall risk. CN 1 stated the charge nurse or registered nurse (RN) supervisor should have conducted a fall risk assessment post fall for Resident 44 which includes assessing for orientation, behaviors, ambulatory status, vision, balance, gait (person's pattern of walking), medications, and predisposing diseases. CN 1 further stated the importance of conducting a fall risk assessment post fall to assess the resident, update the care plan, and start new interventions to prevent further falls.
During an interview, on 11/10/2022 at 11:26 a.m., the Director of Nursing (DON) stated fall risk assessments are conducted for all residents upon admission, quarterly, annually, and post fall. The DON explained the residents are assessed for risk factors that can contribute to a fall including the resident's diagnosis, cognitive status, activities of daily living (ADL - daily self-care tasks), gross motor, medications, and behaviors. The DON confirmed a fall risk assessment should have been completed immediately within 72 hours for Resident 44 when the resident fell on 8/30/2022. The DON stated the importance of conducting a fall risk assessment post fall for the resident's safety to mitigate and prevent further episodes of falls.
A review of the facility's policy and procedure titled, Falls Management System, last reviewed on 12/9/2021, indicated each resident is assessed using the Falls Risk Assessment to determine his or her risk for sustaining a fall and residents will be reassessed for risk upon decline or improvement which meets criteria for signification change in functional status or development of behavioral symptoms that increase the risk for falls as well as with a comprehensive MDS.
Based on interview and record review, the facility failed to ensure residents safety for two of two residents (Resident 43 and 44) investigated under the falls care area by:
1. Failing to reassess and revise a person-centered fall care plan for Resident 43 who had two episodes of unwitnessed falls out in the facility patio.
2. Failing to conduct and complete a fall risk assessment after a fall incident occurred for Resident 44.
These deficient practices placed Residents 43 and 44 at risk for further falls and serious injuries including possible fractures.
Findings:
a. A review of Resident 43's admission Record indicated the facility admitted Resident 43 on 8/13/2015, with diagnosis including dementia (memory disorders, personality changes, and impaired reasoning that interferes with daily functioning) and epilepsy (a neurological disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness).
A review of Resident 43's History and Physical dated 11/02/2022, indicated Resident 43 does not have the capacity to understand and make decisions.
A review of Resident 43's Minimum Data Set (MDS-an assessment and care screening tool) dated 06/22/2022 indicated Resident 43 with clear speech, made self-understood, and understood others. The MDS indicated Resident 43 required limited assistance (resident highly involved in activity; staff provide guided maneuvering) with transferring and personal hygiene, extensive assistance (resident involved in activity, staff provide weight-bearing support) with toilet use and dressing with one-person physical assistance.
A review of Resident 43's Fall Risk Evaluations indicated the following:
- On 06/22/2022, indicated Resident 43 with score of 9 and Fall Management Plan included interventions: anticipate needs, ensure adequate lighting, free of clutters, bed in low position, safety instruction to call for assistance, call light within easy reach and answer promptly, and frequent visual check.
- On 09/11/2022, indicated Resident 43 with score of 11 and Fall Management Plan did not indicate any new fall prevention interventions.
- On 09/20/2022, indicated Resident 43 with score of 11 and Fall Management Plan did not indicate any new fall prevention interventions.
During an interview on 11/08/2022 at 8:50 a.m., the Family Member 2 (FM 2) stated Resident 43 fell more than once out in the patio. FM 2 stated no one could tell her how long Resident 43 was on the floor while out in the patio and what interventions the facility has differently since Resident 43's first fall out in the patio. FM 2 stated she is concerned with the Resident 43's multiple falls out in the patio.
During a concurrent interview and record review on 11/10/2022 at 8:03 a.m., with Registered Nurse Supervisor 1 (RN Sup 1), Resident 43's Situation, Background, Assessment, Recommendations (SBAR-system for identifying, evaluating, and reporting deterioration in resident's condition) Communication Forms were reviewed. The SBAR form indicated the resident had status-post fall out in the patio on 06/20/2022 and 09/11/2022. RN Sup 1 confirmed both incidents were unwitnessed, and Resident 43 was found on the ground by facility staff.
During a concurrent interview and record review of Resident 43's Risk for Falls/Injury Care Plan on 11/10/2022 at 9:07 a.m., the Licensed Vocational Nurse 1 (LVN 1) confirmed he was the charge nurse assigned to Resident 43 on 09/11/2022. LVN 1 stated the MDS Nurse found Resident 43 on the ground and notified him, and he went and checked on Resident 43. LVN 1 stated upon arrival he saw Resident 43 on the ground in front of his wheelchair, sitting down with his left hand supporting him. LVN 1 stated there were no other facility staff or residents present at that time of the incident. LVN 1 confirmed there was no non-slip mat or cushion observed on Resident 43's wheelchair. LVN 1 confirmed this is the second time that Resident 43 has been found on the ground out in the patio area. LVN 1 confirmed Resident 43's Risk for Falls/Injury care plan, initiated date 07/29/2022, did not have revised or updated interventions to include a non-slip mat or cushion while Resident 43 is in wheelchair.
During an interview on 11/10/2022 at 11:00 a.m., the Director of Nursing (DON) stated when a resident has a fall, witnessed or unwitnessed, the IDT team should reevaluate the residents at risk for falls care plan interventions. DON stated this is done to further mitigate further falls. DON stated one of the interventions licensed nurses can implement is the use of non-slip wheelchair cushion to prevent Resident 43 from further falls.
A review of the facility's policy and procedure titled Fall Management System, reviewed and approved on 12/09/2021, indicated it is the facility's policy to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if fall occurs. The procedure indicated that when a resident sustains a fall, an assessment will include investigation . to determine probable causal factors considering environmental factors, resident medical conditions, resident behavioral manifestation/s, and medical or assistive devices that may be implicated in the fall. The investigation and appropriate interventions will be initiated at the time of fall . Results of investigation will be documented in the resident's clinical record including recommendations.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain an acceptable parameter of nutritional status of a desirable body weight range for one of three sampled residents (R...
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Based on observation, interview, and record review, the facility failed to maintain an acceptable parameter of nutritional status of a desirable body weight range for one of three sampled residents (Resident 11) by failing to offer and/or provide meals from outside the facility twice weekly as part of a therapeutic diet.
This deficient practice had the potential to result in Resident 11 not meeting weight and nutritional goals and placed the resident at an increased risk of malnutrition (the state of inadequate intake of food).
Findings:
A review of Resident 11's admission Record indicated the facility admitted the resident on 9/30/2016 and readmitted the resident on 6/28/2022 with diagnoses that included hypo-osmolarity and hyponatremia syndrome (low sodium concentration in the body) of inappropriate secretion of antidiuretic hormone (a condition characterized by the body retaining too much water and commonly leads to hyponatremia) and unspecified protein-calorie malnutrition.
A review of Resident 11's History and Physical, dated 7/6/2022, indicated Resident 11 did not have the capacity to understand and make decisions.
A review of Resident 11's Minimum Data Set (MDS- an assessment and care screening tool) dated 8/26/2022 indicated Resident 11 was sometimes able to make self-understood and usually able to understand others. The MDS indicated the resident required limited assistance with mobility, dressing, and personal hygiene and required supervision for eating. The MDS further indicated Resident 11 had a loss of 5% (a measurement of weight loss) or more in the last month or loss of 10% or more in the last six months and was not on a physician-prescribed weight-loss regimen.
A review of Resident 11's Physician's Orders, indicated the following:
-May have outside food twice a week per resident's request, dated 6/28/2022.
-Fortified (added nutrients) regular diet, mechanical soft (a type of texture for people who have difficulty chewing) with finely chopped meat and veggies texture, thin/regular liquid consistency. Provide food containing potassium - banana, oranges, apricots, etc. (to help increase potassium level), dated 7/2/2022.
-May have weekly weights for nutritional stability monitoring, dated 6/28/2022.
A review of Resident 11's Care Plan (CP) titled, Nutrition Continued, initiated on 9/6/2021, with latest date of 7/14/2022, indicated Resident 11 had weight loss of 10 pounds (lbs, a measurement of weight) / 6.1 % in one month, 14 lbs. / 8.4 % in 3 months, indicated the resident would maintain adequate nutritional status with a goal weight of 170 lbs. The CP indicated (to provide) outside food twice a week as per physician order.
A review of Resident 11's Weights and Vitals Summary form indicated the following:
-On 6/30/2022, Resident weighed 135 lbs. (an 18.2% weight loss change compared to 1/4/2022, a 16.7% weight loss change compared to 4/1/2022, and an 11.8 % weight loss change compared to 6/6/2022).
-On 7/14/2022, Resident weighed 128 lbs.
-On 8/11/2022, Resident weighed 134 lbs.
-On 9/15/2022, Resident weighed 133 lbs.
-On 10/13/2022, Resident weighed 128 lbs.
-On 11/3/2022, Resident weighed 132 lbs.
During an interview on 11/10/2022 at 10:47 a.m., the Social Services Director (SSD) stated she ordered food for Resident 11 once a week on Food Fridays. The SSD stated Resident 11 liked Asian food. The SSD stated the resident had lost weight and his conservator (a person appointed by the court to make decisions and handle affairs on behalf of someone who is unable to) requested the outside food. The SSD reviewed Resident 11's physician's order and stated she did not know the Resident should be offered and/or purchased outside food twice a week. The SSD stated she had worked at the facility for about a year and had never purchased outside food for Resident 11 twice a week, only one time per week. The SSD stated the Dietary Supervisor (DS) attended Resident 11's weight variance meetings and told her to order outside food one time per week.
During an interview on 11/10/2022 at 11:01 a.m., the DS reviewed Resident 11's Physician Orders, Weights and Vitals Summary form, CPs for nutrition and weight loss, and Weight Variance Meeting's notes and stated Resident 11 had significant unplanned weight loss and was on weekly weight measurements. The DS stated the resident's weights were currently stable at 132 lbs, but the resident was not at his goal weight. The DS stated the SSD should always order outside food on Mondays and Fridays. The DS stated the outside food is ordered because the conservator requested the outside food twice a week, there was an order for outside food twice a week, and it was in the resident's CP for twice a week. The DS stated the importance of ordering the outside food twice per week was that the resident was Asian and the conservator stated the resident liked ethnic food (foods associated with a particular culture). The DS stated she was responsible to notify the SSD to order the outside food twice per week and she did.
During an interview on 11/10/2022 at 11:40 a.m., the Director of Nursing (DON) reviewed Resident 11's clinical records and stated the resident had significant weight loss. The DON stated the importance of Resident 11 being offered and receiving outside food twice per week was the psychosocial element that could lead to an increase in appetite. The DON stated the resident liked Asian food and the gustatory (concerned with tasting or the sense of taste) element was important to get the resident back to his goal weight. The DON stated the SSD should have been ordering outside food twice a week for Resident 11. The DON stated the resident did not have the ability to ask for food and it must be offered twice per week. The DON stated she was disappointed the SSD was not offering and ordering outside food twice per week.
During an interview on 11/10/2022 at 2:35 p.m., the Registered Dietician (RD) stated Resident 11 had not reached his goal weight after significant weight loss. The RD stated the importance of providing outside food twice a week, on Mondays and Fridays, was because his conservator knows he likes it, and it would help reach his goal weight.
During an interview on 11/10/2022 at 3:39 p.m., the DON reviewed the facilities policy and procedures and stated there was not a specific policy that indicated orders should be followed to maintain gustatory elements, but the physician's orders should be followed, and the CP also stated outside food should at least be offered two times a week.
A review of the facility policy and procedure titled, Diet Orders, last reviewed 12/9/2021, indicated diet orders as prescribed by the physician will be provided by the Food and Nutrition Services department.
A review of the facility policy and procedure titled, Weight Loss, last reviewed 12/9/2022, indicated unplanned weight loss will be considered avoidable unless the facility documented an appropriate assessment, a CP with implemented interventions and evaluated the outcomes with CP revisions as appropriate. The policy indicted weight loss may result when one or more of the following factors are present: depression or dementia, therapeutic and mechanically altered diet, drug therapy that may contribute to nutritional deficiencies, and lack of access to culturally acceptable foods.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure a resident received prescribed therapeutic diet (a meal plan that controls the intake of certain foods or nutrients) f...
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Based on observation, interview, and record review, the facility failed to ensure a resident received prescribed therapeutic diet (a meal plan that controls the intake of certain foods or nutrients) for one of one sampled resident (Resident 4).
This deficient practice had the potential to result in further weight loss and adverse resident outcome, such as aspiration (foods or fluids that get into the airway that can lead to trouble breathing or lung infections) or dehydration (a condition that occurs when the body loses too much water and other fluids that it needs to work normally).
Findings:
A review of Resident 4's admission Record indicated the facility admitted the resident on 08/30/2006, and readmitted the resident on 11/11/2011, with diagnoses including oropharyngeal (part of the throat at the back of the mouth behind the oral cavity) phase, dysphagia (difficulty in swallowing), and dementia (memory disorders, personality changes, and impaired reasoning that interferes with daily functioning).
A review of Resident 4's History and Physical dated 08/29/2022 indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 4's Minimum Data Set (MDS-an assessment and care screening tool) dated 09/22/2022 indicated the resident had unclear speech, rarely/never understood others, and rarely/never made self-understood. The MDS also indicated Resident 4 had with highly impaired vision (object identification in question, but eye appear to follow objects). The MDS indicated Resident 4 required extensive assistance with eating with one-person physical assist.
A review of Resident 4's Physician Order indicated an order for fortified (the process of adding micronutrients to food) regular diet, pureed texture, thin/regular liquid consistency; provide additional water, juice, or other fluids with meals; ice cream with benecalorie (a calorie and protein supplement) at lunch and dinner; pudding with benecalorie with breakfast, 8-ounce whole milk with meals; double entrée with meals, ordered date: 01/10/2022.
A review of Resident 4's Care Plan titled Nutritional Risk, initiated date 07/11/2020, indicated the goals of consuming 75% of each meal and included interventions such as to provide supplements as ordered.
During concurrent observation and interview on 11/08/2022 at 12:33 p.m., Licensed Vocational Nurse 2 (LVN 2) reviewed Resident 4's lunch meal ticket and confirmed the resident's meal tray did not have ice cream with benecalorie on tray. LVN 2 stated the kitchen forgot to provide the resident the ice cream on her tray. LVN 2 stated Resident 4 ate 75% of her lunch meal.
During an interview on 11/10/2022 at 10:34 a.m., the Director of Nursing (DON) stated if the resident has a prescribed therapeutic diet, it should be followed. The DON stated the physician's order is received by the licensed nurses then communicated to the kitchen where the Dietary Supervisor receives it. The DON stated before the tray is passed, the kitchen staff checks it, and the licensed nurses check the meal cart once it arrives at the stations and dining rooms. The DON stated the importance of ensuring residents received the prescribed diet is to ensure the residents receive the correct nutrition, to ensure their meal trays are of proper consistency and texture for safety, and if resident has a weight loss to prevent further weight loss.
A review of the facility's policy and procedures titled Diets, Dysphagia, and Thickened Liquids, reviewed and approved on 12/09/2021, indicated the purpose of providing appropriate food and fluid consistencies to residents suspected of having dysphagia in a manner that will avoid adverse resident outcome, such as aspiration or dehydration. The policy and procedures also indicated it is their policy to provide interdisciplinary assessments and interventions to enhance the safety and nutritional status of residents suspected of or having dysphagia.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility staff failed to document the name and title of the individual pronouncing the resident's death and the cause of death for one of three sampled reside...
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Based on interview and record review, the facility staff failed to document the name and title of the individual pronouncing the resident's death and the cause of death for one of three sampled residents (Resident 46) investigated addressing closed records.
This deficient practice had the potential to result in an inaccurate information placed on the death certificate of Resident 46.
Findings:
A review of Resident 46's admission Record indicated the facility admitted the resident on 9/27/2016, with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements such as shaking, stiffness, and difficulty with balance and coordination), obstructive sleep apnea (a disorder in which a person frequently stops breathing during his or her sleep), and age-related physical debility (is an age-related, multidimensional state of decreased physiologic reserves).
A review of Resident 46's Physician Orders for Life-Sustaining Treatment (POLST- is a medical order that helps give people with serious illness more control over their care during a medical emergency), dated 10/13/2016, indicated Do Not Attempt Resuscitation (DNR- it instructs health care providers not to do emergency life-saving procedures if they stop breathing or their heart stops) and allow natural death. The resident was on comfort-focused treatment with primary goal of maximizing comfort.
A review of Resident 46's Situation, Background, Assessment, and Recommendation (SBAR- to aid in facilitating and strengthening communication between nurses and prescribers) Communication Form, dated 11/7/2022, the resident was unresponsive. The vital signs (measurements of the body's most basic functions: pulse rate, rate of breathing, body temperature, and often blood pressure) were unappreciated. Registered Nurse Supervisor (RN Sup) called 911 (the telephone number used to reach emergency medical services), the primary physician, and Family Member 1 (FM 1). The paramedics (a person who is trained to give medical help, especially in an emergency) came in and pronounced the resident's death.
During an interview and record review on 11/10/2022, at 12:50 p.m., with Registered Nurse Supervisor 1 (RN Sup 1), RN Sup 1, stated that the name and title of the individual pronouncing the death of Resident 46 was not documented on the chart. RN Sup 1 also stated that she did not find the physician's documentation about the cause of death of the resident. RN Sup 1 stated that sometimes the doctor documents them on the death certificate of the resident which the medical records department might have.
During an interview and record review on 11/10/2022, at 3:20 p.m., with Medical Records Supervisor/Licensed Vocational Nurse (MRS/LVN), the MRS/LVN stated that they don't have the death certificate of Resident 46. The MRS/LVN did not find the physician's documentation of the cause of death of Resident 46. The MRS/LVN stated that they usually had to follow up with the doctor about this documentation. The MRS/LVN stated that they have 24 hours to follow up with the physician to document the cause of death of Resident 46. The licensed nurses and himself were responsible for following up with the physician. The physician also has 24 hours to complete his documentation.
A review of the facility's recent policy and procedure titled Death of a Resident, Documenting, dated 12/9/2021, indicated that all information pertaining to a resident's death (i.e., date, time of death, the name and title of the individual pronouncing the resident dead, etc.) must be recorded on the nurses' notes. The Attending Physician must record the cause of death in the progress notes and must complete and file a death certificate with the appropriate agency within twenty-four (24) hours of the resident's death or as may be prescribed by state law.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
b. During an observation and interview on 11/7/2022, at 9:35 a.m., in the hallway of Nursing Station 1, with the Director of Staff Development (DSD), observed a clothing cart left opened by Laundry St...
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b. During an observation and interview on 11/7/2022, at 9:35 a.m., in the hallway of Nursing Station 1, with the Director of Staff Development (DSD), observed a clothing cart left opened by Laundry Staff 1 (LS 1) and left unattended exposed to the environment. The DSD stated that the clothing cart should not be left opened and unattended to prevent them from environmental contaminants. LS 1 also stated that the clothing carts should always be covered for infection control purposes.
During an interview on 11/9/2022, at 10:35 a.m., with the Laundry Supervisor (LS), the LS stated that clothing/linen carts should always be closed to prevent infection.
During an interview on 11/10/2022, at 11:16 a.m., with the Director of Nursing (DON), the DON stated that clothing/linen carts should always be replaced with the cover when unattended and when not in use. The DON stated that the importance of keeping the carts covered was to protect them from dust and environmental contaminants.
A review of the facility's recent policy and procedure titled Linen Handling, dated 12/9/2021, indicated that the purpose of the policy was to protect linens against the transmission of organisms from one location to another through the use of proper linen handling techniques.
A review of the facility's recent policy and procedure titled Laundry Services, dated 12/9/2021, indicated that clean linens are transported by methods that ensure cleanliness, e.g. protect from dust and soil.
Based on observation, interview, and record review, the facility failed to implement infection control policy and procedure by failing to:
1. Ensure Activities Assistant 1 (AA 1) wore a mask at all times while in the facility, while sitting at a table with residents in the dining room.
This deficient practice had the potential to transmit infectious microorganisms and placed the residents and staff at risk for infection.
2. Keep clothing/linen carts covered and free from environmental contaminants.
This deficient practice had the potential to contaminate the clothes and linens and placed the residents at risk for infection.
Findings:
a. During a concurrent observation and interview on 11/10/2022 at 2:54 p.m., observed Activities Assistant 1 (AA 1) in the dining room sitting at a table with residents with his N95 mask (a particulate-filtering facepiece respirator that filters at least 95% of airborne particles) under his chin. AA 1 stated the purpose of the mask is to protect from infection and need to have it on at all times. AA 1 stated he lowered the mask to speak to a resident who is hard of hearing. AA 1 stated it defeats the purpose of why he is to be wearing the mask.
During an interview on 11/10/2022 at 3:03 p.m., with the Director of Staff Development (DSD), the DSD stated the purpose of wearing a mask is to protect yourself from Coronavirus disease-2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) and including any other virus. The DSD stated by protecting yourself, you are also protecting others and limit the spread of viruses. The DSD stated staff are to keep their mask on at all times especially when talking to residents because the staff member can spread the transmission of the virus.
During an interview on 11/10/2022 at 4:36 p.m., with the Director of Nursing (DON), the DON stated staff members should have their masks on at all times. The DON stated the purpose of masks is to not spread any viruses.
A review of the facility's policy and procedure titled, Coronavirus Disease 2019 (COVID-19) Mitigation Plan (a plan to reduce loss of life and impact of COVID-19 in the facility), revised 9/28/2022, indicated, All facility personnel are wearing a facemask while at the facility .All staff, regardless of vaccination status, must wear a medical-grade surgical/procedure mask or N95 respirator for universal source control at all times while they are in the facility .In the [NAME] Cohort (this cohort is reserved for residents who do not have COVID-19), medical-grade surgical/procedure masks or higher (N95 respirators) must be worn indoors at all times in areas where resident care is provided and/or residents may have access for any purpose including but not limited to resident rooms, dining rooms, rehab gyms, hallways, etc.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
b. A review of Resident 62's admission Record indicated the facility admitted the resident on 3/1/2019, and most recently readmitted the resident on 5/20/2022, with diagnoses that included schizoaffec...
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b. A review of Resident 62's admission Record indicated the facility admitted the resident on 3/1/2019, and most recently readmitted the resident on 5/20/2022, with diagnoses that included schizoaffective disorder bipolar type (mental health disorder characterized by hallucinations [experience involving perceiving things that are not there) or delusions [false belief] and episodes of extreme mood swing that include emotional highs and lows) and insomnia (sleep disorder).
A review of Resident 62's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/23/2022, indicated the resident had the ability to make self understood and had the ability to understand others. The MDS further indicated Resident 62 required supervision from staff with bed mobility, transfers, eating, and toilet use and required one-person limited assistance with personal hygiene.
A review of Resident 62's physician's orders indicated the following orders:
- Haldol solution (antipsychotic medication), give five milligrams (mg - unit of measure) by mouth two times a day for auditory hallucinations related to schizophrenia, unspecified, as evidenced by hearing voices stating, we got you there, ordered on 6/27/2022.
- Antipsychotic drug use: monitor every shift for dry mouth, constipation, blurred vision, disorientation/confusion, lethargy, drooling, difficulty voiding and dark urine output, yellow skin, nausea/vomiting, hypotension (low blood pressure), hyperthermia (abnormally high body temperature) with extrapyramidal (involuntary movements of the tongue, face, trunk, and extremities including tremors, facial stiffness, and restlessness causing an urge to tap finger, fidget, or jiggle legs) and autonomic (system of nerves that control automatic body functions) disturbances that may result in death. Chart + if noted symptom and document in notes or - if none observed in shift every shift.
A review of Resident 62's Medication Administration Record (MAR) for the month of 11/2022 indicated documentation that no symptoms were observed related to antipsychotic drug use from 11/1/2022 to 11/9/2022.
During a concurrent observation and interview, on 11/7/2022 at 9:54 a.m., observed Resident 62 with tremors of both hands and fidgeting of fingers. Resident 62 stated he does not know what is causing the tremors and that he cannot control them.
During an observation, on 11/8/2022 at 4:33 p.m., observed Resident 62 sitting in a chair watching television. Observed resident with tremors of both hands and arms and shaking both legs restlessly.
During an observation, on 11/9/2022 at 9:23 a.m., observed Resident 62 with tremors to both hands and arms.
During a concurrent interview and record review, on 11/10/2022 at 11:43 a.m., Registered Nurse Supervisor 1 (RN Sup 1) reviewed Resident 62's physician orders and verified an order for Haldol for which the resident was receiving for diagnosis of schizophrenia. RN Sup 1 stated the licensed nurses monitor all residents on antipsychotic medications for side effects and document on the MAR every shift. RN Sup 1 explained that residents are also monitored for tardive dyskinesia (a movement disorder that is characterized by uncontrollable, abnormal, and repetitive movements of the face, torso, and/or other body parts), cognitive symptoms, akathisia (movement disorder that makes it hard for person to stay still and causes an urge to move that cannot be controlled), and Parkinsonism (brain conditions that cause slowed movements, rigidity, and tremors) (TCAP) every week on Sundays. RN Sup 1 stated -'' is documented for no symptoms and + is documented if symptoms are noted on the MAR. RN Sup 1 reviewed Resident 62's MAR for the month of 11/2022 and stated the resident has had no side effects related to Haldol use from 11/1/2022 to 11/9/2022.
During a concurrent observation and interview, on 11/10/2022 at 12:11 p.m., observed Resident 62 in the dining room with tremors to bilateral hands and arms in the presence of RN Sup 1 who confirmed the tremors. RN Sup 1 verified Resident 62 does not have a diagnosis or condition such as Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and stated tremors can result from antipsychotic use. RN Sup 1 stated Resident 62 receiving Haldol is the only reason that makes sense as to why the resident is having tremors of both hands and arms. RN Sup 1 stated the licensed nurse should have documented + on the MAR to indicate the presence of a side effect from antipsychotic use as well as document on the progress note the assessment of the symptom, the severity, the affected function, any interventions that were done, and notify the physician. RN Sup 1 stated it is important to accurately monitor residents on antipsychotic medications for side effects to see if the medication is effective and to know if the medication needs to be changed or stopped since antipsychotics can result in changes in conditions and behaviors and may even cause death. RN Sup 1 further stated the physician would need to be notified for presence of any adverse side effects related to antipsychotic use.
During a concurrent interview and record review, on 11/10/2022 at 2:53 p.m., the Director of Nursing (DON) confirmed Resident 62 has resting tremors from long time use of Haldol and psychiatrist is aware. The DON stated residents on antipsychotic medications are monitored every shift for side effects and document on the MAR. If any side effects are observed, the DON stated the licensed nurse will enter a skilled note, complete a Situation, Background, Assessment, Recommendation (SBAR - system for identifying, evaluating, and reporting deterioration in resident's condition) Communication Form, and notify the physician. The DON stated since Resident 62 is exhibiting tremors, the presence of symptoms from antipsychotic drug use should have been documented as + on Resident 62's MAR and confirmed that the assessment on Resident 62's MAR indicating there are no side effects from Haldol use is not accurate. The DON stated the importance of monitoring residents for side effects if receiving antipsychotics to prevent residents from receiving unnecessary medication and to determine if a gradual dose reduction (stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) is necessary.
A review of the facility's policy and procedure titled, Psychoactive Drug Monitoring, last reviewed on 12/9/2021, indicated residents who are receiving antipsychotic drug therapy are adequately monitored for significant side effects of such therapy.
A review of the facility's policy and procedure titled, Antipsychotic Medication Use, last reviewed on 12/9/2021, indicated nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician including neurologic symptoms: akathisia dystonia (movement disorder that causes the muscles to contract involuntarily), extrapyramidal effects, akinesia (absence of movement), or tardive dyskinesia.
Based on interview and record review, the facility failed to ensure two of six sampled residents (Residents 62 and 191) reviewed for unnecessary medications were free from unnecessary psychotropic medications (medications capable of affecting the mind, emotions, and behavior) by failing to:
1. Ensure Resident 191's side effects were being monitored for the use of sertraline (medication used to treat depression [mood disorder that causes a persistent feeling of sadness and loss of interest]).
2. Ensure there was a specific diagnosis for the use of risperidone (medication used to treat schizophrenia [mental disorder in which people interpret reality abnormally], bipolar disorder [mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks], or irritability associated with autistic disorder [developmental disability caused by difference in the brain]) for Resident 191.
3. Accurately monitor and document the side effects related to Haldol (antipsychotic medication - drug used to manage abnormal condition of the mind described as involved a loss of contact with reality) use for Resident 62.
These deficient practices had the potential to result in adverse reaction (any unexpected or dangerous reaction to a drug) or impairment in the residents' mental or physical condition.
Findings:
a. A review of Resident 191's admission Record indicated the facility admitted the resident on 10/17/2013 with a readmission date of 10/22/2022 with diagnoses that included unspecified dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Alzheimer's disease (type of dementia that affects memory, thinking, and behavior), and major depressive disorder.
A review of Resident 191's Minimum Data Set (MDS - an assessment and care screening tool) dated 10/31/2022 indicated the resident rarely/never made self-understood and rarely/never understood others.
A review of Resident 191's physician orders indicated the following:
- Sertraline give 50 milligrams (mg-unit of measure) via percutaneous endoscopic gastrostomy tube (PEG tube - feeding tube placed through the abdominal wall and into the stomach) one time a day for depression manifested by episodes of crying, ordered on 10/22/2022.
- Risperidone 1 mg give 1 tablet via PEG tube two times a day for episodes of mumbling and screaming, ordered on 10/22/2022.
During a concurrent interview and record review on 11/9/2022 at 4:07 p.m., with Registered Nurse Supervisor 3 (RN Sup 3) and Medical Records Supervisor/Licensed Vocational Nurse (MRS/LVN), reviewed Resident 191's physician orders and Medication Administration Record (MAR). RN Sup 3 and the MRS/LVN verified there was no side effect monitoring for the use of sertraline. The MRS/LVN stated it is important to monitor for side effects because if there are any adverse side effects they would need to call the physician and taper down the medication or discontinue it altogether. RN Sup 3 verified Resident 191's risperidone medication does not have a diagnosis for the use of the medication. RN Sup 3 stated risperidone should have a diagnosis for the medication and should be given for an actual psychiatric diagnosis. RN Sup 3 stated it is important to give medication for an actual diagnosis and shouldn't be given just for behaviors.
During an interview on 11/10/2022 at 11:08 a.m., with the Director of Nursing (DON), the DON stated antipsychotic medications should have a diagnosis associated with the medication. The DON stated the medication order needs a diagnosis because of regulations and it will be an unnecessary medication if the physician order doesn't have a specific diagnosis especially with psychotropic medications. The DON stated the physician order should also have a target behavior. The DON stated they should be monitoring for antidepressant side effects because of the black box warning (highest safety-related warning intended to alert the public and health care providers to serious side effects, such as injury or death) and antidepressant medications are potent. The DON stated they need to monitor for side effects because the resident can overdose.
A review of the facility's policy and procedure titled, Depression-Clinical Protocol, last reviewed on 12/9/2021, indicated, The staff and physician will monitor the resident/patient carefully for side effects of any medications used to treat a mood disorder as well as interactions between antidepressants and other classes of medications.
A review of the facility's policy and procedure titled, Antipsychotic Medication Use, last reviewed on 12/9/2021, indicated, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective .Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident .Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders: schizophrenia; schizoaffective disorder (mental health condition including schizophrenia and mood disorder symptoms), schizophreniform disorder (type of psychotic illness), delusional disorder (type of mental health condition in which a person can't tell what's real from what's imagined), mood disorders, psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) in the absence of dementia, medical illnesses with psychotic symptoms and/or treatment-related psychosis, Tourette's disorder (neurological disorder characterized by sudden, repetitive, rapid, and unwanted movements or vocal sounds called tics), Huntington's disease (condition in which nerve cells in the brain break down over time), hiccups (not induced by other medications); or nausea and vomiting associated with cancer or chemotherapy (drug treatment that uses powerful chemicals to kill fast-growing cells in the body).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:
1. Discard expired insulin (hormone that lowers the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:
1. Discard expired insulin (hormone that lowers the level of glucose [sugar] in the blood) vial for one resident (Resident 49) that was observed in one of two medication carts (Station 1 Medication Cart) reviewed during the facility task Medication Storage and Labeling.
2. Label one opened insulin pen with the date it was opened for one resident (Resident 70) that was observed in one of two medication carts (Station 1 Medication Cart) reviewed during the facility task Medication Storage and Labeling.
These deficient practices had the potential to compromise the therapeutic effectiveness of the stored medications.
3. Label one opened glucometer (medical device for determining the approximate concentration of glucose in the blood) test strip (an absorbent strip that soaks up blood to be read by the glucometer) container with the date it was opened found in one of two medication carts (Station 1 Medication Cart) reviewed during the facility task Medication Storage and Labeling.
This deficient practice had the potential to compromise the therapeutic effectiveness of the stored glucometer test strips and inaccurate blood glucose readings.
Findings:
a. A review of Resident 49's admission Record indicated the facility admitted the resident on [DATE] with diagnoses that included unspecified dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), type 2 diabetes mellitus (DM - a chronic condition that affects the way the body processes blood sugar [glucose]), and long term use of insulin.
A review of Resident 49's Minimum Data Set (MDS - an assessment and care screening tool) dated [DATE] indicated the resident had the ability to make self-understood and had the ability to understand others.
A review of Resident 49's physician orders indicated an order for Lantus (long-acting insulin) insulin glargine inject 25 unit subcutaneously (SQ - administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) at bedtime for DM ordered on [DATE].
During a concurrent observation and interview on [DATE] at 1:21 p.m., with the Director of Staff Development (DSD), observed and reviewed Station 1 Medication Cart. Observed with the DSD, Resident 49's Lantus insulin vial with an open date of 10/6. The DSD stated insulin is good for 28 days after opening and verified the vial has been opened for over 28 days. The DSD stated the medication should be reordered. The DSD stated after 28 days of opening, it can affect the effectiveness of the medication.
During an interview on [DATE] at 11:01 a.m., with the Director of Nursing (DON), the DON stated insulin is good for 28 days after opened. The DON stated after 28 days the medication should be discarded because it can affect the efficacy of the medication.
A review of the facility's policy and procedure titled, Medication Storage and Labeling, last reviewed on [DATE], indicated, All drugs will be labeled and stored in a manner consistent with manufactures' published specifications, federal and state regulations, and to enhance accurate and safe medication administration by the facility staff .Drugs shall not be kept in stock after the expiration date on the label and no contaminated or deteriorated drugs shall be available for use .Date open stickers- certain products have limited expiration dates after the product has been mixed or opened for the first time. The policy and procedure also indicated Lantus insulin expires 28 days after opening.
b. A review of Resident 70's admission Record indicated the facility admitted the resident on [DATE] with diagnoses that included chronic kidney disease (gradual loss of kidney function), heart failure (heart is not pumping as well as it should be), and type 2 diabetes mellitus.
A review of Resident 70's Minimum Data Set (MDS - an assessment and care screening tool) dated [DATE] indicated the resident had the ability to make self-understood and had the ability to understand others.
A review of Resident 70's physician orders indicated an order for insulin glargine (generic name for Lantus-long-acting insulin) inject 10 unit subcutaneously at bedtime for DM, ordered on [DATE].
During a concurrent observation and interview on [DATE] at 1:21 p.m., with the Director of Staff Development (DSD), observed and reviewed Station 1 Medication Cart. Observed with the DSD, Resident 70's glargine insulin pen opened and not labeled with an open date. The DSD stated it should be labeled with date when it was opened. The DSD stated after 28 days of opening, it can affect the effectiveness of the medication.
During an interview on [DATE] at 11:01 a.m., with the Director of Nursing (DON), the DON stated insulin is good for 28 days after opened. The DON stated after 28 days the medication should be discarded because it can affect the efficacy of the medication. The DON stated it is important to label insulin once opened with the open date because they need to know the expiration date and use by date.
A review of the facility's policy and procedure titled, Medication Storage and Labeling, last reviewed on [DATE], indicated, All drugs will be labeled and stored in a manner consistent with manufactures' published specifications, federal and state regulations, and to enhance accurate and safe medication administration by the facility staff .Drugs shall not be kept in stock after the expiration date on the label and no contaminated or deteriorated drugs shall be available for use .Date open stickers- certain products have limited expiration dates after the product has been mixed or opened for the first time .It will be the responsibility of the Nursing Staff to enter the opening date on all manufactures' labels or blank Pharmacy labels.
c. During a concurrent observation and interview on [DATE] at 1:21 p.m., with the Director of Staff Development (DSD), observed and reviewed Station 1 Medication Cart. Observed with the DSD, one opened glucometer test strip container not labeled with an open date. The DSD stated it should be labeled once opened.
During an interview on [DATE] at 11:01 a.m., with the Director of Nursing (DON), the DON stated the glucometer test strip container should be labeled once opened. The DON stated important to label with open date because staff need to know when it will expire and should be used by.
A review of the facility-provided manufacture's guidelines titled, Assure Platinum Blood Glucose Monitoring System Quality Assurance/Quality Control (QA/QC) Reference Manual, revised 6/20212, indicated, Assure Platinum Test Strips- Storage and Handling: When you first open the bottle, write the date on the bottom label. Use the test strips within 3 months of first opening the bottle.
MINOR
(B)
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** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a standardized assessment and ca...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a standardized assessment and care screening tool) was coded accurately to reflect the severity of the fall for one of two sampled residents (Resident 44).
This deficient practice had the potential to negatively affect Resident 44's plan of care and delivery of necessary care and services.
Findings:
A review of Resident 44's admission Record indicated the facility admitted the resident on 6/30/2021, with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), dementia (loss of thinking, remembering, reasoning, and behavioral abilities to such an extent that it interferes with a person's daily life and activities.), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest).
A review of Resident 44's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/29/2022, indicated the resident's cognitive skills (thought processes) for daily decision making was severely impaired. The MDS indicated Resident 44 required supervision with bed mobility and transfers and required one-person extensive assistance with toilet use and personal hygiene. The MDS further indicated the resident had one fall with injury since admission.
A review of Resident 44's After Visit Summary indicated the resident was transferred to a hospital on 8/30/2022 due to a fall and was diagnosed with left orbital (bony cavity that contains the eyeball) laceration (a deep cut or tear in skin) and closed fracture (broken bone that does not penetrate the skin) of left elbow.
During a concurrent interview and record review, on 11/10/2022 at 2:31 p.m., the Minimum Data Set Nurse (MDS Nurse) stated Resident 44 had a fall on 8/30/2022 that involved closed fracture of the left elbow. The MDS Nurse explained falls resulting in bone fractures are considered falls with major injury. The MDS Nurse reviewed Resident 44's most recent MDS dated [DATE] and confirmed the fall was incorrectly coded as fall with injury except major. The MDS Nurse stated it should have been coded as fall with major injury since the resident suffered a bone fracture that meets the criteria for major injury. The MDS Nurse further stated the MDS assessment provides an overall picture and therefore should accurately reflect the resident and the plan of care.
A review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, dated October 2019, defined fall with major injury to include bone fractures, joint dislocations, closed head injuries with altered consciousness, or subdural hematoma (serious condition where blood collects between the skull and the surface of the brain). The RAI manual further indicated coding instructions to code 1 if the resident had one major injurious fall since admission/entry or reentry or prior assessment under Section J1900C.
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
- • 28% annual turnover. Excellent stability, 20 points below California's 48% average. Staff who stay learn residents' needs.
Concerns
- • 61 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade C (56/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 56/100. Visit in person and ask pointed questions.
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About This Facility
What is Country Manor Healthcare's CMS Rating?
CMS assigns COUNTRY MANOR HEALTHCARE 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 Country Manor Healthcare Staffed?
CMS rates COUNTRY MANOR HEALTHCARE's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 28%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Country Manor Healthcare?
State health inspectors documented 61 deficiencies at COUNTRY MANOR HEALTHCARE during 2022 to 2025. These included: 1 that caused actual resident harm, 59 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Country Manor Healthcare?
COUNTRY MANOR HEALTHCARE 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 CHARIS TRUST DTD 12/22/16, a chain that manages multiple nursing homes. With 99 certified beds and approximately 95 residents (about 96% occupancy), it is a smaller facility located in LAKE VIEW TERRACE, California.
How Does Country Manor Healthcare Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, COUNTRY MANOR HEALTHCARE's overall rating (3 stars) is below the state average of 3.1, staff turnover (28%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Country Manor Healthcare?
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 Country Manor Healthcare Safe?
Based on CMS inspection data, COUNTRY MANOR HEALTHCARE 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 Country Manor Healthcare Stick Around?
Staff at COUNTRY MANOR HEALTHCARE tend to stick around. With a turnover rate of 28%, the facility is 17 percentage points below the California average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 23%, meaning experienced RNs are available to handle complex medical needs.
Was Country Manor Healthcare Ever Fined?
COUNTRY MANOR HEALTHCARE has been fined $8,018 across 1 penalty action. This is below the California average of $33,159. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Country Manor Healthcare on Any Federal Watch List?
COUNTRY MANOR HEALTHCARE 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.